Keywords

1 Introduction

Mastoplasty is an extremely popular and very common surgical procedure in Brazil compared with other countries. A highlight for the development and progress resulting from the effort, commitment, and creativity of surgeons all over the world, seeking new approaches to creating an organ with immense significance for women’s personal lives. As long as a surgeon respects the anatomy, physiology, and basic surgical principles, it is possible to develop new approaches to reshaping the breasts.

Breast hypertrophy is a very common problem for physical reasons, but also for psychological conditions. Patients complaint of the unaesthetic appearance of the breasts; quite often, they refer to back pain, sulcus on the shoulders caused by the brassiere, bad posture because of the overweight of the breasts, cutaneous irritation on the submammary crease caused by constant contact of the breast with the skin of the upper abdominal wall.

Because of the progress and development of our specialty, technical improvement has taken place in mastoplasty with the significance that it is safe to perform surgery, even in young patients. In fact, the basic technical principles and anatomical knowledge allow us to perform surgery on patients with marriage prospects, and on those who are pregnant or breast-feeding children.

The resulting scars after reduction mastoplasty are extensive according to skin resection, which may bother patients because of the unaesthetic appearance. Usually, surgeons are very concerned about the final scars and several procedures have been presented to suggest how to perform the operation leaving reduced scars. As I had the privilege to be Prof. Pitanguy’s resident, I learned his technique in detail, which has been of fundamental importance in my practice. Nevertheless, as soon as I started my private activities, some modifications were introduced to achieve reduced scars after mastoplasty. Thus, the area of skin on the internal and external sides of the breast have a similar shape to the glandular columns to be created after “keel” resection. In my mind, it is like two arms hugging.

2 Method

2.1 Surgical Planning

According to Pitanguy’s publications (Pitanguy 1960; Pitanguy and Garcia 1972), surgical planning is the basic step before performing mastoplasty. As in any other field, surgical planning must be a fundamental stage before all surgeries, as I have already described in my previous publications (Avelar 2013, 2016). The surgeon must talk peacefully with patient who comes to the office to seek a surgical solution for breast hypertrophy. In a subsequent stage, the physical examination is valuable step in analyzing the breasts and preparing the operative plan. If there is hypertrophy with or without ptosis, the recommended treatment is surgical resection, as there is no other effective therapy.

Nevertheless, there are several aspects that should not be forgotten by a surgeon when examining a patient. First, any asymmetry can be seen and the surgeon should note this and advise the patient to observe her own body. Second, the surgeon should check if there is only ptosis with sagging but without hypertrophy. and third, if there is hypertrophy combined with ptosis. The surgical technique used is different and the patient should be advised of the position, location, and size of the scars.

Although there are many techniques, the surgeon should employ the one that he or she is used to performing and over which he or she has total control. Excessive disclosure on the subject may give false information to the public causing professional problems. However, the doctor may evaluate the problem of each patient and prepare a specific operative plan for each case.

Often patients may opt for surgery that leaves one vertical scar or even a periareolar one, thinking that such a procedure is an updated one to correct her problem. In fact, she wants the best for her, but her intellectual capacity cannot exceed that of the doctor who will perform it.

If we have a patient with bilateral breast hypertrophy, the technique is aimed at reducing the volume, but she also deserves explanations about the position and other characteristics of the scars.

2.2 Surgical Technique

Among several techniques for the treatment of breast hypertrophy, my description basically addresses the one that I am most convinced of. My methodology is developed from Pitanguy’s technique, with whom I had the privilege to be his resident during my specialization and training. Some of the improvements I added to the original technique are due to my own style, attention to detail, and surgical refinements, especially in the long-term observation of my patients.

At the beginning of my practice, I concluded that it would be possible to reduce it without any damage to the aesthetic characteristics of the operated breast. In fact, achieving small scars should not be given priority over the shape, harmony, and symmetry of the breasts. Patients are basically concerned about the shape of the breasts and their harmony with the body contour. The surgeon may be concerned about reducing the size of the scars, but should not jeopardize the shape of the breasts.

2.3 Surgical Marking

Surgical marking is an essential and fundamental procedure before mastoplasty to provide adequate orientation during surgery concerning skin and glandular resection. As Prof. Pitanguy had so much experience, he usually did it with the patient on the operating table under general anesthesia in a semi-sitting position. However, I prefer to do the surgical pre-marking on my patients 1 day before the operation.

2.3.1 Pre-Marking

Reference points are marked with the patient standing in front of two vertical mirrors placed strategically one in front of the other in my examination room at my clinic (Fig. 7.1). Initially, a point is marked on the center of sternal notch. Afterward, another two points are marked laterally 7 cm away on each side on the midclavicular point. Those vertical lines are not parallel as they diverge in a lateral direction through the nipples. The inframammary crease is marked by gently elevating the breast. Afterward, I follow Pitanguy’s description, such as placing my index finger of one hand under and behind the breast up to the inframammary crease (Fig. 7.1). The opposite index finger palpates through the breast to determine the level of the tip of my finger in the inframammary crease, and the surface of the breast is marked at this point (Fig. 7.1). It is the approximate site of the new nipple, which is shown to the patient in front of the mirror. This is the Pitanguy’s point A, which is marked to give adequate orientation during surgical marking in the operating room. There is no fixed position for the new nipple site, but to show that it allows for upward migration. In fact, the nipples are projected onto the vertical lines depending upon the height of the patient, the size of the breasts, and the dimensions of the thorax, in addition to the age of the patient. When the breasts are very large and the skin is stretched, the nipples may move up after the weight and stretch have been reduced. Correction of mild ptosis may only require a small amount of upward nipple movement. For this reason, I consider pre-marking a useful procedure to determine the reference points before surgery.

Fig. 7.1
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Pre-marking 1 day before the operation at my clinic with a patient in front of two vertical mirrors. (a) Photo with the patient in a standing position: Pitanguy’s point A is demarcated. (b) Drawing shows the position of fingers to mark points B and C, which are always below the nipple–areolar complex (NAC). (c) Photo shows the breasts already demarcated

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These reference points are marked with ink and the patient is recommended to preserve them until next day. She can take a shower, but must be careful to maintain those points to help the surgical marking during the operation.

I found those pre-markings to be very useful, as the patient is awake and observes my work in the mirrors. At this time, I have one more chance to examine all the surgical details that were registered during the first consultation. I check the blood tests, heart and clinical examination, ultrasound or mammography of patients over 30 years of age. Also, the patient signs the consent form.

The next day, when the patient is in the operating room, the references points previously marked are useful for determining the surgical marking. My preference is to perform reduction mastoplasty under local anesthesia combined with intravenous sedation under the care of an anesthesiologist. A stitch is made in the sternal notch and another one on xyphoid process for surgical marking (Fig. 7.2). With the patient placed in the supine position, the operating table is raised to about 45°, with elevation of the chest so that the breasts show the ptotic position and the inframammary creases are marked (Fig. 7.2). At this moment, Pitanguy’s point A is a fundamental reference for the marking of the surgery. The submammary folds are drawn to determine the location of the final scars after surgery.

Fig. 7.2
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Drawing to demonstrate surgical marking during surgery. (a) Two medial long stitches are made on the sternal notch and on the xyphoid process. (b) A vertical line is drawn from the midclavicular point, passing the nipple. The two long stitches showed in (a) are useful as a compass for a comparison of the two breasts before, during, and after the operation as well

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I have never employed any of the prefabricated patterns advocated a long time ago by several authors (Wise 1956; Strömbeck 1960), as Prof. Pitanguy did not use them. My marking presents some modifications of Pitanguy’s original descriptions. First, I changed the position of points B and C, which were placed lower than a horizontal line with the nipple (Fig. 7.1b). As these points are marked below, this resulted in a smaller area of skin resection. Consequently, the lower final scar is shorter and the area for skin resection is shaped like a rocket (Fig. 7.3b). This time, the horizontal segments on the medial and lateral breast are reduced, thereby leading to a decrease in the dimensions of the scars (Fig. 7.4). However, my goal has always been to achieve a good shape, with symmetrical volume and the nipple–areola complex (NAC) in harmony with the breast, but with short scars (Fig. 7.5).

Fig. 7.3
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Surgical marking in the operating room. (a) Photo of the patient with pre-marking to demonstrate my evolution: the points B and C are marked at the same level of the NAC according to Pitanguy’s technique, but I make them much lower so that they cannot see them on the breast. (b) On the drawing, the points B1, C1, D1, and E1 can be seen marked according to my approach, in which the area for skin resection is similar to a rocket

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Fig. 7.4
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A 20-year-old girl with hypertrophic breasts before and after reduction mastoplasty using my approach. (a), (c), and (e) Preoperative photos. (b), (d), and (f) Postoperative photos

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Fig. 7.5
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A 34-year-old patient with large and ptotic hypertrophic breasts. (a) and (c) Preoperative photos. (b) and (d) Photos of the same patient after reduction mastoplasty

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Currently, the technical design of my surgery plays a part in the skin approaches and required glandular resection without much accuracy in the dimensions of the initial design. In fact, the demarcated area for skin resection is always smaller than I would like, as the excess skin is removed afterward.

Finally, it is worth saying that my method of marking allows me more freedom, with no fixed numbers and distances, but that all I have in mind is to create the volume and shape of the breast (Fig. 7.3).

Often, during mastoplasty, it is possible for me to perform extensive resections, leaving only a scar on the vertical line (Fig. 7.4). However, I have no desire to pursue such a result, or even promise to the patient that she will have only one scar. I am aware of the technical limitations and, above all, the huge variations in each case; thus I do not promise something that impossible to accomplish.

2.3.2 Anesthesia

Since the earliest years of my practice, I have performed mastoplasty employing local anesthesia combined with intravenous sedation under the care of an anesthesiologist. Even for large breasts, I have performed mammary gland resection of 1000 g on each side, following the same methodology. Currently, I do not face any difficulty in employing my methodology, as the patients themselves are informed by others before they come to the clinic for consultation.

2.4 Anesthetic Infiltration

The anesthetic infiltration is performed after the technical marking of the skin is done. My anesthetic solution is:

  • Lidocaine (2%) 40 mL

  • Distilled water 160 mL

  • Adrenaline (1/1000) 1 mL

  • Total solution 201 mL

This amount of anesthetic volume is enough to infiltrate both breasts, even in the case of large hypertrophy. It is worth emphasizing that the breast parenchyma should not be infiltrated, but only the base and at the subcutaneous level underneath the markings. For this reason, there is no relationship between breast volume and amount of anesthetic to be injected (Avelar 1993).

The first point to be infiltrated is the central segment of the inframammary crease followed by the subcutaneous layer of the external border of the breast. The lateral side of the chest and external border of the breasts are mainly innervated by the external branches of the intercostobrachial nerve.

Following the procedure, the base of the breast is then infiltrated, which means between the mammary tissue and the level of the pectoralis muscle. For good infiltration, I clamp the breast with one hand and at the same time a long needle is inserted using the other hand (Fig. 7.6a and b). This maneuver is very useful as the surgeon should feel the penetration of the needle at once. If there is any difficulty, insertion of the needle into the breast parenchyma should not continue, as it should be easily introduced into the connective tissue. Nevertheless, it is worth emphasizing that the parenchyma is heavily vascularized and any infiltration could reach a vessel and create an unpleasant situation.

Fig. 7.6
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Transoperative photos showing local infiltration on reduction mastoplasty. (a) Subcutaneous infiltration on external border of the breast to block endings of the intercostal branchial nerve as well as of the intercostal; (b) the breast is pulled foreword and using a long needle infiltration is done below the mammary gland and above the pectoralis muscle; (c) subdermal infiltration is done following surgical marking

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As a final step, the subcutaneous plane corresponding to the technical markings below the areola are infiltrated, which is the most sensitive region (Fig. 7.6c). It is important to state that after infiltration, the period of analgesia lasts for a long time and the patient is not exposed to any suffering (Avelar 1993).

The other breast is infiltrated after the glandular resection has been performed on the first one. Following this systematization, infiltration is not overloaded, avoiding any risk of complications relevant to the methodology.

2.5 Glandular Resection

The base of the breast is grasped by the surgeon’s assistant with two hands, but my preference is to employ an elastic rubber band all around to tie it up (Fig. 7.7).

Fig. 7.7
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Surgical marking is carried out and the base of the breast is held at its base to perform Schwartzmann’s maneuver. (a) Drawing shows two hands holding the breast. (b) An elastic tape holding the breast while the maneuver is being performed with a knife

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I start the operation by making an incision circumscribing the areola followed by Schwartzman’s (1930) procedure creating a massive and composite flap of the nipple–areola segment and mammary gland for maintenance of the blood supply to the nipple. Afterward, a 4-cm cutaneous incision is made with a knife into the submammary crease followed by dissection with scissors until the border of the glandular tissue is separated from the aponeurosis (Fig. 7.8). From this point, by gently digital undermining, the mammary gland is totally separated from the pectoralis muscle. This digital maneuver allows examination of breast tissue by direct palpation. Then, a wet compress is introduced through the opening to avoid bleeding during glandular resection. The breast is suspended by its top corner using a strong hulk, which is kept in the ideal position for glandular resection (Fig. 7.9). A curved incision is made below the nipple–areola region followed by two vertical incisions upward to separate the upper segment of the parenchyma, creating Pitanguy’s “keel” with two wedges on each side (Fig. 7.9). Thus, consequently, two glandular columns are created, one medial and the other on the lateral side of the breast tissue (Fig. 7.10). The width of the “keel” and the thickness of the wedges at the base of the two columns show the degree of glandular resection provided (Fig. 7.11).

Fig. 7.8
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Peroperative photos showing the area of skin, which is preserved according to my marking in comparison with Pitanguy’s technique. The photos the undermining of the breast tissue from the pectoralis muscle. (a) A small incision is made in the submammary sulcus. (b) With a finger, undermining is carried out all over the submammary level. (c) Afterward, wet gauzes are introduced. (d) It can be seen that the skin is resected and the gauzes are placed below the mammary tissue and above the pectoralis muscle to avoid bleeding during surgery

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Fig. 7.9
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Peroperative photos showing breast tissue resection as a “keel” following Pitanguy’s technique. (a) Breast tissue to be resected is outlined. (b) The breast tissue is incised with a knife. (c) The “keel”-shaped resection. (d) Drawing shows the marking of breast tissue for a “keel” resection

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Fig. 7.10
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Pitanguy’s “keel” resection. (a) Drawing shows a “keel” resection held by forceps. (b) Drawing shows the breast after “keel” resection with my Z instrument introduced inside and pulling the breast upward. (c) Photo of the “keel” of mammary tissue and skin already removed

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Fig. 7.11
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Pitanguy’s “keel” resection. (a) Drawing shows a perspective of the breast after “keel” resection in the center of the breast. (b) Drawing from the frontal view showing that through my marking, an extensive area of skin is not resected. (c) Per-operative photo from the frontal view where the inside of the breast can be seen after “keel” resection without any bleeding. The points B1, C1, D1, and E1 are marked according to my approach. The amount of skin that is not resected can be seen

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After glandular resection of one breast, anesthetic infiltration is performed on the opposite one according to the above description. Despite there being very little bleeding during such a procedure owing to anesthetic infiltration and to the digital dissection, hemostasis should be carefully performed. Following this systematization, no time is wasted and the volume of anesthetic infiltration is injected in two doses.

After careful hemostasis, the two columns are sutured. To facilitate closure my Z instrument is introduced under the remaining glandular tissue between the two columns (Fig. 7.12). The assistant pulls it up to suture the two columns to the aponeurosis of the pectoralis muscle. Afterward, a cutaneous temporary stitch is inserted to approximate points B and C on the midline of the submammary crease. Thus, it is possible to evaluate the size and shape of the future breast (Figs. 7.13 and 7.14). The excess skin is then pulled forward using special forceps to evaluate the amount to be removed (Fig. 7.13). I learned this maneuver from Pitanguy and Garcia (1972), as described by Noël (1928) and it is a very useful procedure for adjusting content and container. I do not expect skin retraction, as described by Peixoto (1979).

Fig. 7.12
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Suturing of the two Pitanguy’s columns created after resection of mammary tissue. (a) and (b) Drawings showing suture of the two columns. (c) and (d) Peroperative photos show the suturing of the two Pitanguy’s columns created after breast tissue resection. (e) Scheme shows the suturing of the columns from the frontal view

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Fig. 7.13
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Using my Z instrument introduced inside the breast, the NAC is pulled upward and the skin is de-epithelialized on both sides on vertical segment of the breast to create the dermal flap to be sutured. (a) Photo, oblique view of the right breast showing that the excess of skin was pulled forward and held by special forceps

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Fig. 7.14
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Marking of the new NAC. (a) Drawing showing the technical marking. (b) On a peroperative photo the NAC can be seen already demarcated and a small scar on the submammary crease. Also, the extent of the skin that is preserved is demarcated

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Following the operation, I move to the other side of the operating table to perform the same procedure on the opposite breast. After inserting the temporary stitch on the opposite breast, it is mandatory to evaluate the two breasts concerning the size, shape, and position.

2.6 Repositioning the New Nipple–Areola Region

After temporary sutures are inserted, I perform dissection of the dermis to create two dermal flaps on each side of the vertical wound. The dermal flaps are sutured with isolated stitches, creating a dermal structure that works as a reinforcement of the vertical suture to adjust content and container (Avelar 1980, 1993). The dermal structure works as a plane to support the weight of the breast like a new skin brassiere. Afterward, using special forceps, the skin is pulled forward to evaluate the exact amount of excess to be resected according to Noël (1928) (Fig. 7.13). A running intra-dermal suture is inserted to close the wound. Afterward, the nipple–areola region is drawn on the vertices of the new breast using a special round marker. The new areolar area is de-epithelialized and the nipple–areola segment is then pulled from deep inside to the outside for suturing (Fig. 7.14).

2.6.1 Dressing After Surgery

Adhesive tapes are placed on the wound after internal suturing. Elastic tapes are applied covering both breasts similar to a brassiere and a garment is placed over it all. No drainage is used as there is no bleeding during surgery or “dead space”. Patients usually go home the next day with all postoperative instructions to avoid any strain on the upper limbs for at least 2 weeks. They return to my clinic 1 week after surgery when the first bandaging is removed and another one is placed and it is changed every 1 or 2 weeks for 2 months. No stitches are to be removed, as only internal suturing is performed.

3 Discussion

Every patient with breast abnormalities is looking for a better shape and size. On the other hand, it is a natural desire for a surgeon to expect to achieve those anatomical characteristics with reduced scars. It is important to emphasize that performing a mastoplasty with reduced scars should not jeopardize the size and shape of the breast after surgery. In fact, it is a balance between short scars and outstanding surgical results, as patients’ are concerned about the shape of the breast and the surgeon is concerned with suitable final scars (Figs. 7.15 and 7.16).

Fig. 7.15
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Preservation of skin during reduction mastoplasty according to my approach in comparison with Pitanguy’s technique. (a) Peroperative photo shows that reduction mastoplasty of the right breast has already been performed and on the left breast surgical marking can be seen. (b) Both breasts have been operated on, showing that an extensive area of skin has not been resected. (c) Same patient 1 week after the operation showing a very small scar on the submammary crease

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Fig. 7.16
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A patient with very flabby, ptotic, and hypertrophic breasts before and after reduction mastoplasty. (a) and (c) Preoperative photos. (b) and (d) Photos of the same patient after the operation

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Mastoplasty is an important field of plastic surgery that is constantly evolving, to fulfil not only the demands of the patients, but also the creativity of the plastic surgeons. Indeed, many past generations have left behind a fabulous arsenal of methods so that we can offer improved results. Among the range of relevant factors, the struggle to reduce the scars resulting from mastoplasty can be highlighte. Nevertheless, despite the meritorious work and effort, a surgeon should not prioritize only one factor at the expense of achieving a good shape, external configuration, and especially preserving the functional aspects, where the sensitivity and lactation emerge with unusual meaning in the lives of patients (Figs. 7.17 and 7.18). Fortunately, this is bringing the universal notion of plastic surgeons who devote every effort to finding new operative solutions.

Fig. 7.17
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A 21-year-old patient with very large hypertrophic breasts. (a) and (c) Preoperative photos. (b) and (d) Photos of the same patient after reduction mastoplasty showing a small scar on the submammary folds

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Fig. 7.18
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A 24-year-old patient with hypertrophic breasts. (a) and (c) Preoperative photos. (b) and (d) Postoperative photos after reduction mastoplasty with small scars on the submammary folds

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Blood transfusion used to be employed a long time ago, as heavy operative bleeding was reported by Maliniac (1945). However, since I started to employ local anesthesia combined with intravenous sedation under the care of an anesthesiologist 35 years ago, I have not performed a blood transfusion. Another favorable situation is that I am not used to performing associated procedures through which patients may bleed too much during the operation.

No matter what the technique to be employed, the surgeon should aim to achieve harmony between the NAC and the breast, and this should be kept tightly balanced with the chest, and especially with the opposite breast. Here is a great challenge that is presented to us at each surgery and we need to achieve it every time. It is worth emphasizing that one failure in a single case may represent a small percentage in the wide sample of a surgeon, but for that patient it means 100%. Thus, we must work bearing in mind that it must always be achieved and that there are not many chances to repair any mistakes. Our great opportunity is the first time, and as such we incorporate all our knowledge, skill, attention, and care into all our surgical procedures.

4 Complications

I described above that any surgeon may develop a new technique, but it is important to evaluate both the immediate postoperative complications and the long-term results. Fortunately, I had the privilege to be Prof. Pitanguy’s resident during the period of my specialization when I had the opportunity to certify the efficiency of his technique. Thus, I bear testimony to the high level of his excellent results, which impressed me when I started my own practice. Therefore, some of the improvements in reduction mastoplasty I developed were based on his technique, which provided me with good surgical results. Probably for this reason, most of the major complications described in the medical literature did not occur in my patients. Among 1642 patients operated on during 43 years of my practice, some of the minor complications that occurred were: small hematoma formation (although careful hemostasis is achieved in all cases) and there is no “dead space,” as there is never any undermining of skin flaps or other tissues; few patients presented sloughing of the areola (which healed secondarily, but in three patients, a skin graft from internal tissue as a donor area was performed); two patients with very fatty breasts presented nipple necrosis (which required reconstruction); some patients with very flabby breasts with excessive striae presented some degree of recurrent ptosis at later follow-up. Postoperative infection and dehiscence of the wound occurred in a few cases, although it has having take much care during surgery in addition to the routine use of prophylactic antibiotics.

Hypertrophic scars used to occur when I started my practice, but nowadays it is very rare because of the smooth suturing with no tension owing to internal stitches. Asymmetric breasts may occur after mastoplasty, but it is very rare among my patients, as surgical planning and marking are carefully carried out. A patient presented temporary alterations on the left arm due to too much stretching causing distention of the motor nerve, as the anesthesiologist exaggerated the position of the arms. The patient recovered all movement after a few days. It is advisable that the surgeon be attentive to the position of the arms during the operation.

As I have never utilized prefabricated patterns in my method, my final results achieve a good balance between the two breasts at the end of the operation, even in cases of severe asymmetry. I do not recommend employing prefabricated patterns as they do not take into consideration the individuality of the patients and the asymmetry of the skin, subcutaneous panniculus, and mammary gland.

Conclusions

The aesthetic appearance of the size and shape of the breasts in harmony with body contouring is the aim of mastoplasty procedures. These aspects of the breasts are related to historical and cultural factors of the time and to individual criteria. In this sense, when analyzing the aesthetic concept of the mastoplasty, which is performed to modify the shape of the breast, the focus should be on the subjective point of view of the patient and the surgeon’s artistic creativity.

Reduction mastoplasty is performed under local anesthesia combined with intravenous sedation under the care of an anesthesiologist. The procedure is a variation of Pitanguy’s technique leaving a short scar on the submammary crease, another vertical one with reinforcement of the dermis to provide adequate support of the weight of the breasts, and a periareolar scar. Resection of the mammary gland is performed as Pitanguy’s “keel” in the central part of the breast and another segment on the base. There is no undermining of the panniculus and no “dead space”. For this reason, there is no bleeding during or after the operation. No drainage is employed.