History and introduction

Regardless of the technique for breast reduction to be utilized, in most patients skin resection and tissue removal is necessary. The length of the incisions will vary, depending on the size of the breast and the amount of skin to be excised. The greater the skin excess, the more skin needs to be removed, so the longer the final scar will be.

Every patient who asks for a breast reduction knows she will have a scar after the procedure. When a woman asks for a mammaplasty, it is because she is displeased with the appearance of her breasts in terms of volume, shape, or consistency. Therefore, when a breast reduction is performed the surgeon should strive to attain breasts with a pleasing appearance, with adequate size and form, with minimal scarring and a low rate of complication. On many occasions, when you try to reduce the extension of the scar you will compromise the aspect of the breast. The appearance of the scar is much more important than its length. Most of the patients illustrated in this chapter have an inverted-T scar after the mammaplasty.

The inverted-T incision became popularized in the early 1960s when Pitanguy published his technique for breast reduction. In this period, two other procedures played a very important role in the history of mammaplasty: the Wise pattern and Strömbeck technique. As a result of these improvements the demand for breast reduction increased, the complications decreased, and aesthetic results were enhanced.

Physical evaluation

Anatomy

This technique maintains the relationship between skin and breast tissue. There is no skin dissection or skin undermining, decreasing the probability of seroma, hematoma and skin slough. The tissue resection avoids the fourth intercostal nerves, thus preserving the innervation to the gland, so that in following these principles there will rarely be alterations of sensation.

The elevation of the nipple areola complex is performed without tension, so that necrosis in this area also is extremely rare.

Technical steps

Patients are operated on under general anesthesia in a semi-seated position. Two sutures, one at the sternal notch and another at the xyphoid appendix, are placed. The hemiclavicular line is then marked. In this line, in the projection of the submammary crease, a point called “A” is marked (Figs 47.1 and 47.2). This point corresponds to the new site of the areola. From point A we mark points “B” and “C”, which will determine the new position of the breasts. These points depend on the relationship between skin and breast tissue. The lines A–B and A–C should not exceed 7 cm. The points B and C are then linked to the medial and lateral extremities of the breasts.

Fig. 47.1 Marking the point A at the level of the inframammary fold.

Fig. 47.2 Point A in both breasts.

Fig. 47.3 Patient in the operating room. Semi-seated position. Rechecking height and position of points A.

Fig. 47.4 Testing the tension that will be applied to the skin flaps.

Fig. 47.5 Utilizing the hooks for final checking.

Fig. 47.6 Final markings.

After the breasts are marked, an infiltration of a solution with adrenaline (epinephrine) 1/100,000 is placed in the areas that will be incised.

The incisions start at the areola with de-epithelialization of the surrounding areas in order to maintain innervation and vascularization. Excess skin is then removed. Tissue removal will be performed depending on the size of the breast, the relationship between skin and tissue, and experience and skill of the surgeon. This removal may focus on certain areas of parenchyma, or in some cases only skin is removed. The breasts are then compared and sutured without tension so that after 8–18 months, the scars are largely inconspicuous.

Most of the sutures are intradermal. Sutures in the skin are removed around the tenth day after the operation.

Fig. 47.7 Checking the efficacy of tissue removal and comparing the remaining tissue.

Fig. 47.8 The different types of resection that can be used depending on each breast.

Fig. 47.9 A, B, C, Preop view of a 26-year-old patient presenting hypertrophic and ptotic breasts. D, E, F, Appearance 10 months after inverted-T breast reduction with plane resection of 145 g from left breast and 235 g from right breast.

Postoperative care

In Brazil, the patient is discharged the day after surgery when the dressing is removed and a brassiere is applied. In the US this procedure is often done on an outpatient basis. The patient is asked to stay at home for only one day after the operation. The external sutures along the vertical line are removed around the tenth day. A tape remains over the scar for about 30–45 days.

The patient is advised to avoid major movements with the arms such as swimming, tennis and weight-lifting with the upper extremities, for three months.

A brassiere is worn to provide compression.

Complications