Pitanguy breast reduction

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CHAPTER 49 Pitanguy breast reduction

Ivo Pitanguy, Henrique N. Radwanski

History

Until the first half of the 1950s, breast reduction, such as the Biesengberger approach, included extensive skin undermining, resulting in poor upper pole definition and ptosis in the postoperative follow-up, along with a high rate of complications. I was already familiar with Lexer’s, Prudente’s and Arié’s procedures, among others, and I felt that with my experience, I could contribute with my own principles for breast reduction.

My modification of Arié’s technique, presented at the London meeting of 1959, described point A as the initial landmark, from which the other points are developed. With this concept, following adequate resection and closing approximation of the two pillars, the lower pole undergoes a rotation to the upper pole, filling up the breast and assuring a long-term aesthetic result. Later, when the limitations of the single vertical scar (i.e. the Pitanguy rhomboid technique) were perceived in breasts of larger size, a further development was presented utilizing the inverted keel resection, called the classic Pitanguy technique. This approach was indicated for larger reduction mammaplasties, where a greater amount of skin and parenchyma are safely removed, assuring the ascension of the nipple to a new position – where point A is located. In both approaches, the resection saves all the functional part of the breast, and there is no separation of the gland from the skin, minimizing complications.

Interestingly, the rhomboid approach has currently become more useful with the popularization of breast augmentation, where patients seek specifically a fuller upper pole. It is often not possible to achieve this fullness if excess skin is not removed appropriately from the ptotic breast, together with the inclusion of an implant.

Physical evaluation

Physical evaluation of the patient presenting for breast reduction includes:

With patient standing up

• Overall evaluation of patient’s biotype: height, weight, chest girth.

• Examination of breast skin (elasticity, signs of dermal fragility such as striae, maceration or infection from intertrigo).

• Inspection of degree of flaccidity by checking level of nipple with respect to the submammary sulcus.

• Estimation of breast volume (visual and by palpation).

• Verification of excess parenchyma with a two-handed pinching maneuver, also noting distance the nipple–areolar complex (NAC) will have to rise.

• Examination of other breast deformities, such as inverted nipple.

With patient lying down

• Palpation of breast parenchyma.

• Maneuver to check for any secretion from nipple.

Finally, examination is not complete without interacting with the patient, to determine her desires regarding breast volume, either in a reduction or an augmentation. A lucid body should participate in the decisions, expressing itself and suggesting what is its ideal self-image.

Anatomy

The personal techniques for breast reduction developed from comprehension of, and respect for, breast embryology. Breast buds develop from vertical thickening of the ectoderm, so there is an intimate relationship between skin and gland. The continuity between breast parenchyma and skin should be preserved in all breast reduction operations. This principle may be stated as such: the “continent” should not be separated from the “content”.

Sound anatomical principles and respect for physiology are the basis for these procedures. In breast reduction, resection of breast tissue is restricted to the lower pole, so that the vascularity and innervation of the NAC are preserved, and all dead space is closed with the approximation of remaining tissue. There is also little risk of flap or nipple ischemia, because breast parenchyma is not separated from overlying skin.

Postoperative anatomy of the breast is also important. All resected tissues are sent to the pathology laboratory for close inspection. As has been published previously, it is interesting to note that the segment where most of breast pathology arises – the lower pole – is exactly the region that is removed in both of the techniques to be described.

The classic Pitanguy breast reduction technique

Indicated for large hypertrophy

See Figs 49.1–49.10.

Fig. 49.1 Point A (also called Pitanguy’s point) is found at the level of the submammary sulcus, along the mid-clavicular line. This is where the final position of the nipple–areolar complex will be situated.

Fig. 49.2 A pinching maneuver allows the surgeon to estimate how much parenchyma should be removed.

Fig. 49.3 Final demarcation is checked with long sutures and a compass.

Fig. 49.4 Lines of resection are curved to permit removal of excess skin.

Fig. 49.5 Two strong hooks are pulled together to ascertain that demarcation is correct.

Fig. 49.6 A straight resection is indicated in breasts that are mostly fatty in nature.

Fig. 49.7 The inverted keel resection should be applied to breasts that are mainly composed of glandular tissue.

Fig. 49.8 With the inverted keel resection, the surgeon creates two pillars; this also allows the NAC to rise to its new position.

Fig. 49.9 Closing of the pillars eliminates all dead space.

Fig. 49.10 The final position of the NAC, which will lie around Point A, is not a fixed measurement, but depends on the aesthetic feeling of the surgeon.

• Patient is placed in a semi-sitting position.

• Two long sutures are placed along the midline, to help the surgeon check for symmetry during demarcation and at the end of the procedure.

• Midclavicular line is drawn, through the NAC all the way to the sulcus. Point A is determined along this line, at or slightly lower than the breast sulcus. (This point determines the future position of the NAC.)

• By pinching excess skin points B and C are determined.

• Two points, D and E, define the medial and lateral extension of the horizontal incision, not extending beyond the midline and the anterior axillary line. The lines uniting these points are curved when excess skin is present.

• The area between points A–B–C is de-epithelialized (Schwartzman’s maneuver). This assures the maintenance of the dermal capsule of the superior pole, which is considered the third neurovascular pedicle of the CAM.

• Glandular resection is always restricted to the inferior pole, and is straight when the breast is composed mainly of fatty tissue or in an inverted ship’s keel fashion if the parenchyma is more glandular.

• Two pillars, medial and lateral, are created with both forms of resection. The upper-pedicled NAC will slide upwards as the pillars are approximated, and all dead space is eliminated.

• The operated breast is wrapped in moist towels and the same procedure is done on the opposite breast. The two are then lifted by the assistant, and inspected from a distance to compare remaining parenchyma, one side with the other.

• Tissues are now brought together with one main suture, bringing points A–B–C to the midline. Sutures are done from deep to superficial planes.

• The new position of the NAC is now determined by inspection, and demarcated on both sides. Symmetry is checked once again, using the two long sutures. A main advantages of this technique is that the surgeon feels that he is free to demarcate the new position of the NAC, and is not bound to fixed measures as in other techniques.

A mold made of plaster is placed over the dressing, which guarantees the immobilization of the breasts. It has been noted that this firm pressure has resulted in a very low rate of serosanguineous collection over the years. This plaster shield is removed in 24 hours, when the breast is inspected. Placement of drains is not routinely used, as all dead space has been closed.

See Clinical cases 1–6 (Figs 49.C1–49.C6).

Fig. 49.C1 Clinical case 1: The Pitanguy technique is usually applied to moderate-size breasts, as in this 32-year-old woman. A rhomboid approach could also have resulted in a pleasing aesthetic result.

Fig. 49.C2 Clinical case 2: Young women, such as this 29-year-old patient with larger breasts and asymmetry, will benefit from the same procedure.

Fig. 49.C3 Clinical case 3: Reducing very large breasts is feasible with the classic Pitanguy approach, as in this 41-year-old woman; she has taken part in outdoor activities, showing her sun marks.

Fig. 49.C4 Clinical case 4: Asymmetry together with cumbersome breasts, as shown in this 25-year-old woman, is corrected with the same operation as the previous patient.

Fig. 49.C5 Clinical case 5: Older women (in this case, a patient 65 years old) often demand reduction of breast volume, and the classic technique with an inverted keel approach is the indicated procedure.

Fig. 49.C6 Clinical case 6: The classic Pitanguy approach to breast reduction, using the inverted keel resection, was indicated in this 58-year-old woman with heavy breasts.

The rhomboid Pitanguy breast reduction technique

Indicated in small to medium hypertrophy and breast ptosis

See Figs 49.11–49.13.

Fig. 49.11 The Pitanguy rhomboid technique has an elliptical shape of demarcation.

Fig. 49.12 In smaller breasts, resection is restricted to skin.

Fig. 49.13 Positioning of the NAC is done after checking for symmetry of the breasts.

• The initial demarcation is elliptical or rhomboid and finishes with a single vertical scar.

• Point A is determined as previously described.

• The surgeon estimates how much skin must be removed by pinching the medial and lateral skin on either side of the nipple, and points B and C are determined.

• Point D, which should not be lower than the sulcus, will complete the elliptical demarcation. The final incision is a vertical scar, ending at (or slightly below) the submammary sulcus.

• Resection can be restricted to skin when simple ptosis is present, or can include a variable amount of breast tissue from the lower pole, when the patient desires reduction of volume.

• As described in the classic technique, the inverted keel resection, when indicated, creates two pillars or columns. Once these are approximated, the superior pole is defined and the nipple will rise to the new position.

• An appropriate areola demarcator is chosen for placement of the NAC, around the area of point A.

• The final vertical incision may be complemented with a small horizontal component, converting the single scar into an “L” or inverted “T” so as not to extend the scar beyond the sulcus.

See Clinical cases 7–9 (Figs 49.C7–49.C9).

Fig. 49.C7 Clinical case 7: Mastopexy in this 26-year-old woman was done through the Pitanguy rhomboid procedure; only excess skin is removed, and an aesthetic final shape is attained.

Fig. 49.C8 Clinical case 8: Whenever the single scar becomes too long, the surgeon may convert this into a final small inverted “T” scar, as in this 34-year-old woman.

Fig. 49.C9 Clinical case 9: The placement of a breast implant through the rhomboid technique allows for removal of excess skin, and projection of the breast mound.

Postoperative care

• Patients submitted to reduction mammoplasty are discharged either 24 or 48 hours postoperative.

• Dressings are changed and the breasts are inspected for hematoma collection and skin ischemia.

• The patient returns for follow-ups every 4–7 days until last sutures are removed.

• Silicone sheeting is used routinely, unless there is history of allergy.

• The patient must refrain from physical exercises or strenuous activities that use the upper limbs for the first month.

• Monthly revisions are done until the 6th month and then at one year postoperative. At this time, postoperative photographs are done and touch-ups may be planned.

Complications

• The rate of complications following breast reduction using the classic or rhomboid Pitanguy techniques is very low. This is due to no dissection of breast parenchyma, and preservation of the vascular pedicle of the NAC. Also, the inverted keel resection assures that, on closure, all dead space is eliminated.

• Most dehiscences are small and self-limiting; blood collections are very infrequent and rarely require drainage. Vascular insufficiency to the NAC, although rare, is usually transitory, and mostly limited to the epidermis.

See Table 49.1.

Table 49.1 Breast hypertrophy complications (1957–2006)

In five decades of breast reduction, almost 10,000 cases have been performed at the author’s private clinic and at the Santa Casa General Hospital, a charity institution where most of the procedures are done by the senior residents, under the supervision of the attending staff.

See Table 49.2.

Table 49.2 Breast hypertrophy operations (1957–2006)

Idade	IPC	SC
10–19 years	4.0	11.0
20–29 years	26.0	33.0
30–39 years	32.0	29.0
40–49 years	21.0	17.0
50–59 years	14.0	7.0
≥60 years	3.0	3.0

Ivo Pitanguy Clinic: 3476 cases.

38th Ward Santa Casa: 6403 cases.

Total cases: 9879.

Summary of steps

The classic Pitanguy breast reduction technique

1. Patient is placed in a semi-sitting position. Two long sutures are placed along the midline.

2. Midclavicular line is drawn, through the NAC all the way to the sulcus. Point A is determined along this line, at or slightly lower than the breast sulcus.

3. By pinching excess skin, points B and C are determined.

4. Two points, D and E, define the medial and lateral extension of the horizontal incision, not extending beyond the midline and the anterior axillary line.

5. The area between points A–B–C is de-epithelialized (Schwartzman’s maneuver).

6. Glandular resection is always restricted to the inferior pole.

7. Two pillars, medial and lateral, are created with both forms of resection.

8. The operated breast is wrapped in moist towels and the same procedure is done on the opposite breast.

9. Tissues are now brought together with one main suture, bringing points A–B–C to the midline. Sutures are done from deep to superficial planes.

10. The new position of the NAC is now determined by inspection.

The rhomboid Pitanguy breast reduction technique

1. The initial demarcation is elliptical or rhomboid and finishes with a single vertical scar.

2. Point A is determined as previously described.

3. The surgeon estimates how much skin must be removed by pinching the medial and lateral skin on either side of the nipple, and points B and C are determined.

4. Point D, which should not be lower than the sulcus, will complete the elliptical demarcation.

5. The inverted keel resection, when indicated, creates two pillars or columns. Once these are approximated, the superior pole is defined and the nipple will rise to the new position.

6. An appropriate areola demarcator is chosen for placement of the NAC, around the area of point A.

7. The final vertical incision may be complemented with a small horizontal component, converting the single scar into an “L” or inverted “T” so as not to extend the scar beyond the sulcus.

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Pitanguy breast reduction

History

Physical evaluation

With patient standing up

With patient lying down

Anatomy

The classic Pitanguy breast reduction technique

Indicated for large hypertrophy

The rhomboid Pitanguy breast reduction technique

Indicated in small to medium hypertrophy and breast ptosis

Postoperative care

Complications

Pearls

Pitfalls

The classic Pitanguy breast reduction technique

The rhomboid Pitanguy breast reduction technique

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