All efforts to reduce the size of the breast or to improve the shape of the ptotic

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1 Reduction Mammaplasty and Mastopexy with Shorter Scar and Better Shape Ruth Maria Graf, MD; André Auersvald, MD; Afranio Bernardes, MD; and Thomas M. Biggs, MD Background: Efforts to reduce the size or improve the shape of the ptotic breast have resulted in long, obtrusive scars or a shape that lacks upper-pole fullness and projection. Objective: The goal of the present study was to evaluate the short-term and long-term results of a modified procedure that was designed to provide long-lasting upper-pole fullness and reduce visible scarring. Methods: As a result of the use of a shortened oblique incision and the elevation of an inferior chest wall-based flap, divided at its inferior subcutaneous attachment and maintained in the cephalad position by a loop of pectoral muscle, the scar is unobtrusive and the shape is optimal, with lasting fullness in the upper pole. Results: From 1984 to 1998, 1521 women underwent breast reduction or mastopexy. Long-term follow-up (4 years) indicates maintenance of the full upper pole of the breast and satisfaction of nearly all of the patients. All complications, which included steatonecrosis and skin dehiscence below the areola, resolved without additional surgery within 6 months postoperatively. Conclusions: An aesthetically pleasing breast requires a proper shape and adequate skin cover, with a nipple-areola complex at the apex of the mound. The technique presented achieves these goals with an unobtrusive lateral scar that does not extend beyond the anterior axillary line. All efforts to reduce the size of the breast or to improve the shape of the ptotic breast involve incisions and subsequent scars. Early attempts in contemporary surgery used an inverted-t incision with a resulting anchor-type scar and a scar around the areola. 1 Methods designed to avoid the medial component of the scar have incorporated an oblique incision or a completely vertical scar that originates below the inframammary fold and terminates at the fold, redundant skin being defatted and allowed to contract Other authors have approached the removal of redundant skin and reshaping of the mound with a totally circumareolar incision. 11,17 In all of these techniques, we have found deficiencies. Either the scar was too long and obtrusive or, far too often, the shape of the mound lacked projection or upper-pole fullness after settling. To address these deficiencies, we developed an alternative procedure. In particular, this article describes 2 distinct maneuvers that have improved results: (1) Instead of an inverted-t incision, we use a lateral oblique incision that results in a shortened and less From a private practice in Paraná, Brazil (Drs. Graf, Auersvald, and Bernardes), and a private practice in Houston, TX (Dr. Biggs). Accepted for publication January 28, Reprint requests: Ruth Graf, MD, R. Solimões, 1184, Curitiba Paraná, Brazil Copyright 2000 by The American Society for Aesthetic Plastic Surgery, Inc /2000/$ /1/ doi: /maj A ESTHETIC S URGERY J OURNAL ~ MARCH/ APRIL

2 Figure 1. Evolution of breast surgery techniques in groups I, II, and III shows an increase in use of the lateral oblique incision technique over the last 15 years. Figure 2. Evolution of the use of an inferior submuscular pedicle flap in breast surgery over the last 5 years (group III). obtrusive scar. (2) Instead of using imbrication or plication for breast mound shape, we use an inferior chest wall based pedicle of breast tissue 18 that has been divided at its inferior attachment and passed under and maintained in position by a loop of pectoral muscle, 19 thereby establishing longer-lasting upper-pole fullness. Materials and Methods From 1984 to 1998, 1521 patients underwent breast reduction or mastopexy in the first author s practice. This population was subdivided into 3 groups on the basis of chronology (Figure 1). Group I was composed of 213 women who underwent surgery between 1984 and 1988; group II of 488 women who underwent surgery between 1989 and 1993, and group III of 721 women who underwent surgery between 1994 and In group I, 226 patients (72%) received an inverted-t incision and 86 (28%) a minimal lateral oblique incision. In group II, 273 (56%) were treated with the inverted-t approach and 215 (44%) with the lateral oblique approach. In group III, 325 (45%) had the inverted-t incision and 396 (55%) the lateral oblique incision. Group III encompasses those patients who had the inferior pedicle flap divided and passed under the loop of pec- 100 A ESTHETIC S URGERY J OURNAL ~ MARCH/APRIL 2000 Volume 20, Number 2

3 Figure 3. Demarcation of the midline, mammary midline, and points A1 and M. Figure 5. Medial point from pinching maneuver must be 10 cm from the midline. C E Figure 4. Oblique manual pinching of the breast. Figure 6. Demarcation of lines A1-B, A1-C, C-E and B-D. toral muscle. Of the 325 women who received the inverted-t incision, 114 had this pectoral flap, and of the 396 patients who received the lateral oblique incision, 174 had the flap. As the procedure evolved, there was greater use of a lateral oblique incision, with a pedicle of breast tissue maintained in the upper pole by a pectoral muscle loop (Figure 2). Surgical Technique Similar skin markings can be used to perform either mastopexy or breast reduction. The only difference will be in tissue removal, which is necessary in breast reduction. The shortened oblique incision is indicated for reduction up to 600 g. For larger reductions, the inverted-t incision should be considered. Skin laxity is another limitation of this technique. If skin elasticity is poor (too many striae and thin skin), an inverted-t incision should be considered, because this type of skin may not accommodate the breast mound. 1. A line is drawn from the sternal notch to the xiphoid process. 2. An oblique line is drawn from the midclavicle to the nipple-areola complex (NAC) and continues inferiorly parallel to the midline of the inframammary fold, point M, creating an inferior vertical line (Figure 3). Reduction Mammaplasty and Mastopexy with A ESTHETIC S URGERY J OURNAL ~ MARCH/APRIL Downloaded from Shorter Scar and Better Shape

4 Figure 7. Demarcation of lines D-X and E-X. Figure 9. Inferior pedicle flap. Figure 8. Superomedial rotation of the breast. Point A2 and the measures A2-B and A2-C will be similar. 3. A point is marked 20 cm from the clavicle on the oblique line, which will be the new upper pole of the areola (A1). This can be adjusted at the surgeon s discretion in patients with very high or very low inframammary folds. 4. With a bimanual pinching technique (Figure 4), the amount of skin to be removed and the upper rotation of breast tissue are determined, the inferior vertical line being used as a reference between the 2 points. The medial point should not be less than 10 cm from the midline (Figure 5). 5. A 5 to 7-cm curved line is drawn superiorly from a point (E) 2 cm above the inframammary fold at the inferior vertical line (line E-C). 6. A curved line, 6 to 7 cm long, is drawn from A1 to C. Figure 10. Bipedicle muscular flap. 7. A curved line is drawn from A1 to B (3 cm) and continues 5 cm to end at the new point D, passing through the pinching lateral marking (Figure 6). 8. Two curved lines are drawn from E and from D that intersect at X, 1.5 cm above the inframammary fold and never beyond the anterior axillary line (Figure 7). 9. As C-E and B-D are placed together, the breast tissue rotates so that the NAC will rotate and A2 will replace A1. A2B and A2C become equal in length (11 to 13 cm; Figure 8). Once demarcation is completed, surgery begins with the Schwartzman maneuver, all of the skin within the demar- 102 A ESTHETIC S URGERY J OURNAL ~ MARCH/APRIL 2000 Volume 20, Number 2

5 Figure 11. Passage of the inferior pedicle flap under the muscular flap loop. Figure 12. Suture of points B-C and D-E. cated areas being de-epithelialized. The NAC is incised with a diameter of 4.2 cm. The dermis is not incised along the superior portion of the areola, as this will be the areolar pedicle. The dermis is incised 2 cm under the areola horizontally, in a plane perpendicular to the thorax, all the way to the pectoral muscle at the level of the fourth intercostal space. The medial and lateral incisions are made in the dermis and continue through the breast to the chest wall. Great care is taken to dissect in an outward fashion to leave an ample base for the pedicle. Both the base and the flap are 5 to 6 cm in breadth (Figure 9). The upper portion of the breast is undermined to the second rib. The dissection of the inferior flap is carried out in meticulous fashion to keep intact the chest wall perforators nourishing this flap. After the superior, lateral, and medial borders of the flap are created, the dermis is incised at the inferior portion and the incision is carried straight through to the rectus abdominus fascia, the entire block of tissue thus being divided in all 4 borders. No longer an inferiorly based flap, it is now a flap that is totally free and based on the chest wall itself. Just superior to this flap, a loop of pectoral muscle is isolated; this loop is 3 cm wide (Figure 10) and long enough to give passage to the inferior flap with no constrictive tightening (Figure 11). After the flap has been passed under the pectoral loop, the superior portion of the flap is secured at the second rib with a suture from the dermis of the flap to the pectoral fascia. Additional sutures are placed around the periphery of the flap to the fascia. Placement of this block of tissue in the upper pole of the breast, held firmly by the loop of pectoral muscle and secured by multiple Figure 13. Shape of the breast after suturing. sutures from dermis to pectoral fascia, creates an autoaugmentation of 100 to 200 ml. If it is not necessary to remove tissue, the lateral columns are sutured together; otherwise, excess tissue can be excised from these columns before closure. The columns of breast tissue are then sutured together, giving projection to the NAC. The skin is closed, points B and C being brought together, points D and E being brought together (Figure 12), and the breast tissue being rotated into position so that the 12 o clock position on the NAC is now at A2. D-X and E-X are closed with a smooth, curved closure that never passes beyond the anterior axillary line (Figure 13). Results and Comments In the last 4 years, we have standardized the techniques to be used according to breast shape. In young patients Reduction Mammaplasty and Mastopexy with A ESTHETIC S URGERY J OURNAL ~ MARCH/APRIL Downloaded from Shorter Scar and Better Shape

6 A B C D Figure 14. A and C, Preoperative views of a 43-year-old woman with mammary flaccidity. B and D, Postoperative views shown at 6 months after mastopexy with lateral oblique incision and submuscular inferior pedicle flap. with hypertrophic glandular parenchyma and good skin quality, we prefer to perform breast reduction with the lateral oblique incision. We began using Meyer s technique years ago for small hypertrophies and later applied this technique to larger hypertrophies once we became more comfortable with the technique. During this period, some modifications were made to Meyer s original procedure, which evolved to become our lateral oblique incision mastopexy. As we became more familiar and confident with the technique, we felt more comfortable recommending it to patients with greater laxity or small glandular hypertrophy, and further modifications were made to the markings and the surgical technique, making this an original technique. Skin marking is similar to that used in Pitanguy s 16 method inasmuch as the amount of skin resection is subjective, but there is a difference in the pinching technique. Pitanguy uses a bimanual, horizontal pinching of skin, whereas the L shape requires a bimanual oblique lateral pinching of skin. This maneuver rotates the breast superomedially. Elderly patients with excessive skin laxity or significant weight loss, who have less glandular parenchyma, still require an inverted-t incision. In these patients, there is a great deal of skin in the medial aspect of the breast, which must be removed. Pitanguy s inverted-t technique is one of the most commonly used throughout the world. A submuscular inferior pedicle flap was used in all of the patients described in this article except those requiring secondary mammaplasty. It has produced better results in the long term because of improved maintenance of the upper pole. A total of 1521 patients underwent breast reduction or mastopexy from 1984 to 1998; these have been divided into 3 groups. The division helps to demonstrate the evolution of our technique. In group I ( ), 86 (28%) breast surgeries with lateral oblique incision were performed; in group II ( ), 215 (44%) such surgeries were performed; and in group III ( ), 396 (55%) were performed. The trend toward the use of a lateral 104 A ESTHETIC S URGERY J OURNAL ~ MARCH/APRIL 2000 Volume 20, Number 2

7 A B C D Figure 15. A and C, Preoperative views of a 38-year-old woman with mammary hypertrophy and flaccidity. B and D, Postoperative views shown at 2 years after mastopexy and breast reduction with lateral oblique incision and submuscular inferior pedicle flap. oblique incision is evident, and this is related to the surgeon s gain in experience. In group III, we began using the inferior pedicle flap as described by Ribeiro 21 and modified by Daniel. 19 The length of this inferiorly based breast pedicle varies among individuals, but all of them are long enough to reach the upper pole to provide fullness, because the pedicle is based at the fourth and fifth intercostal spaces. On occasion, the flap may be too long, requiring trimming at its superior end. This flap can vary in length from 8 to 10 cm, but the base should never be shorter than 6 cm. The flap extends from the fourth and fifth intercostal spaces to the second rib. Three hundred twenty-five women received an inverted-t mammaplasty. In 211 of these procedures, the standard Pitanguy technique was used, whereas in 114 (35%) procedures, the submuscular inferior pedicle flap was used. Three hundred ninety-six women received lateral oblique incisions, and 174 (44%) of these patients had the submuscular inferior pedicle flap. Two hundred twenty-two (66%) of these patients underwent the procedure with standard technique because of their youth. Of the group of patients who received the lateral oblique incision and inferior submuscular flap (174 patients), 126 (72.4%) underwent breast reduction and 48 (27.6%) underwent mastopexy. The lateral oblique incision has been used more often because of the reduction in the scar s length and its improved position. The submuscular inferior flap has proved to be a superior technique because of its improved long-term maintenance of upper-pole fullness. Patient satisfaction after these new improvements has risen considerably, especially in the late follow-up (Figures 14 and 15). This technique, with the measurements described, may be used for mastopexy alone when there is no need to remove breast tissue. However, when a reduction Reduction Mammaplasty and Mastopexy with A ESTHETIC S URGERY J OURNAL ~ MARCH/APRIL Downloaded from Shorter Scar and Better Shape

8 mammaplasty is necessary, we remove breast tissue from the lateral columns. In cases of extensive hypertrophy (requiring more than 600 g per breast removal) and in cases of significant weight loss and skin laxity, an inverted-t incision is still preferred, but the inferior submuscular flap is used in all cases. Long-term follow-up (4 years) demonstrates maintenance of the full upper pole of the breast and the satisfaction of most patients. There were no complications during longterm follow-up. All complications occurred during the initial weeks after surgery and were resolved within a 6- month postoperative period. Complications arose with the short oblique scar and inferior submuscular flap in 9 (5.17%) of 174 patients the first patients of group III who underwent this procedure. Three patients had steatonecrosis, which resolved with serial aspirations, and 6 patients had skin dehiscence below the areola. In the present study, patients were followed for at least 1 year. Three criteria were analyzed in the late follow-up: 1. Upper-pole fullness was analyzed with the patient in the erect position, and there was a persistence of fullness in the upper breast aspect (second, third, and fourth ribs). Photographs were taken to document this conclusion. 2. Breast projection is a constant in all patients when they are lying in the supine position. The areola maintains its projection upward, with little tilting laterally. 3. Scars resulting from a lateral oblique incision have better quality because there is less tension over the scar, and the skin in the lower lateral aspect of the breast heals with less tendency to hypertrophy. Conclusion An aesthetically pleasing breast requires a proper shape and adequate skin cover with the NAC at the apex of the mound. Our technique achieves these goals with an unobtrusive lateral scar that does not extend beyond the anterior axillary line. In older techniques, breast shape was determined by skin tightening, and as the skin stretched, the shape was lost. With the technique described, a block of breast tissue that remains attached to the chest wall is made mobile and moved in a cephalad direction under a loop of pectoral muscle, thus providing fullness in the upper pole of the breast. This fullness is maintained permanently by the restraint of the pectoral loop and thus creates a shape that does not depend on skin closure for contour. References 1. Peixoto G. Reduction mammaplasty: a personal technique. Plast Reconstr Surg 1980;65: Arié G. Una nueva técnica de mastoplastia. Rev Lat Am Cir Plast 1957;3: Biesenberg H. Deformitäten und Kosmetische Operationen der Weiblichen Brust. Vienna: Mandrich; Bozola AR. Mamoplastia em L - contribuição pessoal. Rev AMRIGS 1982;26: Chiari AJ. The L short-scar mammaplasty: a new approach. Plast Reconstr Surg 1992;90: Dufourmentel C, Mouly R. Plastic mamaire par la méthode oblique. Ann Chir Plast 1961;6: Elbaz JS, Verheecke G. La cicatrice en L dans les plasties mammaires. Ann Chir Plast 1972;17: Ely JF. Guidelines for reduction mammaplasty. Ann Plast Surg 1981;6: Erol O, Spira M. A mastopexy technique for mild to moderate ptosis. Plast Reconstr Surg 1980;65: Holländer E. Die operation der mamahypertrophie und der hangebrust. Deutsche Med Wochenschr 1924;50: Horibe K, Spina V, Lodovici O. Mamaplastia redutora: nuovo abordaje del método lateral oblícuo. Cir Plast Ib Latinoamer 1976;11: Lassus C. Breast reduction: evolution of a technique a single scar. Aesthetic Plast Surg 1989;11: Lejour M, Abboud M, De Clety A, Kertesz P. Reduction des circatrices de plastie mammaire: de l ancre courte a la verticale. Ann Chir Plast Esthet 1990;35: Lexer E. Ptosis operation. Clin Monatsbl Augenh 1923;70: Meyer R, Kesselring UK. Reduction mammaplasty with an L-shaped suture line. Plast Reconstr Surg 1975;55: Pitanguy I. Surgical treatment of breast hypertrophy. Br J Plast Surg 1967;20: Benelli L. A new periareolar mammaplasty: round block technique. Aesthetic Plast Surg 1990;14: Regnault P. Reduction mammaplasty by the B technique. Plast Reconstr Surg 1974;53: Daniel M. Mammaplasty with pectoral muscle flap. Paper presented at: 64th American Annual Scientific Meeting; 1995; Montreal. 20. Lotsch GM, Gorhbandt E. Operationen an der weibliche brustdrüse. Chir Oper Ribeiro L, Backer E. Mastoplastia com pediculo de seguridad. Rev Espan Cir Plast 1973;6: A ESTHETIC S URGERY J OURNAL ~ MARCH/APRIL 2000 Volume 20, Number 2

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