Operative technique (inverted T)

With the patient in a half-sitting position, the new areolae are drawn 4 cm in diameter with an areolar marker (Figs 15.2A and 15.3). A vertical line is drawn from the midclavicular line to the upper edge of the areolae, and point A is marked corresponding to the projection of the inframammary fold on the upper pole of the breast (Figs 15.2B and 15.4). By means of a pinching maneuver and the surgeon’s judgment, points B and C are marked, determining the amount of skin to be resected horizontally (Figs 15.2C and 15.5). The points are linked to the inframammary fold with curving lines, as in Pitanguy’s technique (Figs 15.2D, E, 15.6 and 15.7).

Fig. 15.2 A Marking of the new areola with a diameter of 4 cm. B Marking of point A. It corresponds to the projection of the submammary fold. C Points B and C are marked by the pinching maneuver, determining the amount of skin to be resected horizontally. D A line is drawn connecting points B, A and C. E The points B and C are linked to the inframammary fold with curving lines, as in Pitanguy’s technique. The inferior flap is drawn along the meridian of the breast, beginning in the submammary sulcus and ending 1 to 2 cm from the lower border of the new areola. Its width is approximately 4 to 5 cm. F and G Preparation of the inferior flap with de-epithelialization of the segment of skin. Incisions are made on its edge, downward to the muscular plane. Its thickness is about 3 cm. H Resection of the lateral and medial segments of the inferior quadrants (lateral and medial to the flap). I After resection of the excess breast tissue in the upper quadrants, the inferior flap is fixed to the pectoralis fascia with separate stitches of a non-absorbable suture. The distal edge of the flap is folded over itself to give the upper pole tissue more projection. J Points B and C are fixed in the middle point of the flap base. K Elevation of the breast is finished. The new areola is marked. L Final result after the completion of the suture.

Fig. 15.3 Marking of the new areola with a diameter of 4 cm.

Fig. 15.4 Marking of point A. It corresponds to the projection of the submammary fold in the hemiclavicular line.

Fig. 15.5 Points B and C are marked by the pinching maneuver, determining the amount of skin to be resected horizontally.

Fig. 15.6 A line is drawn connecting points B, A, and C.

Fig. 15.7 The points B and C are linked to the inframammary fold with curving lines, as in Pitanguy’s technique. The inferior flap is drawn along the meridian of the breast, beginning in the submammary sulcus and ending 1 to 2 cm from the lower border of the new areola. Its width is approximately 4 to 5 cm.

With the breast lifted so that the lower pole can be seen, the drawing of the flap is started at the central portion beginning in the inframammary sulcus and extending to 1 to 2 cm below the inferior edge of the areola. Its width is approximately 4 to 5 cm (Figs 15.2E and 15.7). The outlined flap is de-epithelialized (Fig. 15.2F), and an incision is made on its edges downward to the muscular plane to allow the shaping of a dermolipoglandular flap, supplied by the fourth, fifth, and sixth intercostal perforating vessels. It is important that the flap be 2 to 3 cm thick (Figs 15.2G and 15.8).

Fig. 15.8 Start of the preparation of the inferior flap. After de-epithelialization of the segment of skin, incisions are made on its edge, downward to the muscular plane. Its thickness is about 3 cm.

Incision of the new areolar marking is done and is followed by the Schwartzmann maneuver. The excess breast tissue is resected, laterally and medially to the inferior flap and in the upper hemisphere (Figs 15.2H, 15.9 and 15.10). After the resection is completed, the inferior flap is attached to the pectoralis fascia with nylon 3-0 separate stitches. The distal edge of the flap is bent over itself to give the upper pole tissue more projection and to bring the remaining mammary tissue close to the retroglandular area (Figs 15.2I, 15.11 and 15.12). We believe that this procedure ensures the recanalization of the glandular tissue and can allow normal breast feeding.

Fig. 15.9 After the inferior flap is prepared, the lateral segments of the inferior quadrants (lateral and medial to the flap) are resected.

Fig. 15.10 The excess breast tissue in the upper quadrants is resected until the desired volume (size) is reached.

Fig. 15.11 The inferior flap is fixed to the pectoralis fascia with separate stitches of a non-absorbable suture. The distal edge of the flap is folded over itself to give the upper pole tissue more projection.

Fig. 15.12 Lateral view of the inferior flap fixed into position.

Points B and C are joined at the middle point of the flap base (Figs 15.2J and 15.13), and the breast is finished (Figs 15.2K and 15.14). Suturing is done with separate nylon 4-0 stitches. Skin suturing is continuous using nylon 5-0. The areola is placed at its new position and is sutured with nylon 5-0 U stitches (Gillies/Perseu techniques) (Figs 15.2L and 15.15).

Fig. 15.13 Points B and C are fixed in the middle point of the flap base.

Fig. 15.14 Elevation of the breast is finished. The new areola is marked.

Fig. 15.15 Final result with the completion of the suture.

Operative technique (lozenge)

The technique is advised only for young patients with elastic skin and mild to moderate hypertrophy, even though we have made resections of up to 900 g on each side. Mild to moderate ptosis and as an adjunct in breast augmentation with correction of ptosis are also good indications. The shape of a lozenge, which gave the name to the technique, was slightly changed: the upper edge gained a round shape to allow removal of more periareolar skin. The surgical sequence was similar to that described above.

The new areola is marked (Figs 15.16A and 15.17), and point A is determined by the projection of the inframammary fold on the upper pole of the breast. Points B and C are marked by means of a pinching maneuver and the surgeon’s judgment to determine the amount of skin to be resected horizontally (Figs 15.16B and 15.18). Point D is marked 3 cm above the inframammary fold and 10 to 11 cm from the middle line (Fig. 15.19). A curved line is drawn to join points A, B, and C (Fig. 15.18), and points B and C are linked to point D by straight lines (Figs 15.16C and 15.20).

Fig. 15.16 A The new areola is outlined, with a 3.5 cm diameter. B Points B and C are marked by pinching the skin at the level of the nipple and seeing the amount of skin possible to resect in the horizontal plane. The position of point A is confirmed by the projection of the upper pole over the submammary sulcus. C Point D is marked 3.0 cm above the submammary sulcus and approximately 10.0 cm from the xiphoid appendix. Points A, B, C and D are joined in curved and straight ways achieving a lozenge shaped outline. D The inferior based pedicle is outlined. E De-epithelialization within the markings. F A horizontal incision is done below the areola and carried down to the pectoralis fascia. G, H After undermining of the inferior pole the inferior flap is created. I Resection of the lateral and medial prolongations of the flap.J The creation of the inferior flap is finished. The excess breast tissue in the upper quadrants is resected until the desired volume (size) is reached. K Lateral view of the fixation of the flap on the pectoralis fascia. L The closure of the breast begins by closing the vertical incision until it reaches 4 to 6 cm from the point D, depending on the size of the breast. M, N Checking for the presence of ‘dog-ears,’ which are marked and resected. O Areola and vertical suturing are completed.

Fig. 15.17 The new areola is outlined, with a 3.5 cm diameter.

Fig. 15.18 Points A, B and C are marked (see text) and joined with a curved line.

Fig. 15.19 Point D is marked 3.0 cm above the submammary fold on the meridian line of the breast.

Fig. 15.20 Points B, D and C are joined with straight lines, producing a lozenge shaped outline; hence the designation ‘lozenge technique.’ Point D is located approximately 10.0 cm from the xiphoid process.

After de-epithelialization of the outlined area (Figs 15.16E and 15.21), a transverse incision is made below the areola, within the de-epithelialized area, downward to the muscular plane, dividing the breast into two halves (Figs 15.16F and 15.22), so keeping the nipple–areola in the superior half. The shaping of the flap starts by undermining the lower quadrants of the breast (Figs 15.16G, H and 15.23) and resecting both its lateral and medial edges, with care taken not to jeopardize the perforating vessels that will provide the blood supply to the inferiorly based flap (Figs 15.24). The tissue on the superior hemisphere is resected until the desired volume is achieved (Figs 15.16J and 15.25), leaving enough of it to maintain the safety of the vascular complex. The inferior based flap is attached to the pectoralis fascia with separate stitches of nylon 3-0 (Figs 15.16K and 15.26). With the breast pulled upwards, the closure is started bringing segments BD and CD together. They are sutured with separate stitches up to 4 to 6 cm from point D (Figs 15.16L and 15.27). The areola is sutured to the segment BAC in such a way as to compensate for the excess of skin. No extra resection of skin is necessary. A Gillies hook is positioned in the transition of the areola and vertical scar to help push the breast upward, a dog-ear might be noted at the inferior portion, in which case its excision is required (Figs 15.16M, N, 15.28 and 15.29). The areola is sutured with separate stitches (Gillies/Perseu) (Figs 15.16O and 15.30).

Fig. 15.21 De-epithelialization of the lozenge area and marking of the inferiorly based pedicle.

Fig. 15.22 A horizontal incision within the de-epithelialized area is carried down to the pectoralis fascia dividing the breast in two halves.

Fig. 15.23 The whole inferior pole of the breast is freed.

Fig. 15.24 The inferiorly based flap is formed after resection of the lateral and medial segments.

Fig. 15.25 Excess breast tissue is resected from the central area of the superior pole until it reaches the desired size.

Fig. 15.26 The pedicle is left to drop naturally over the pectoralis fascia and fixed with non-absorbable sutures.

Fig. 15.27 With the entire upper pole pulled upwards, closing the breast starts by joining edges BD to CD with sutures from point D until it reaches 4 to 6 cm from it. The areola is sutured in a way to compensate for the excess skin.

Fig. 15.28 It is important to check for the presence of skin excess in the inferior end of the incision.

Fig. 15.29 The excess is marked and care should be taken not to extend the line of resection beyond the submammary fold.

Fig. 15.30 The end result. Areola and vertical suturing is completed. The vertical scar does not extend beyond the submammary fold.