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.

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