Disclosure
Mammaplasty has improved so much over time that this operation currently boasts one of the greatest numbers of surgical techniques. Authors have introduced certain modifications for surgical improvements, leading to a gradual development of techniques reminiscent of the evolution of species. However, this evolution introduced some avant-garde techniques that were eventually abandoned and condemned. Because they were used without an associated safety procedure, the techniques were deemed dangerous and had the potential for various complications. History of the Procedure: The purpose of mammary reduction is to decrease breast volume. With it, in the past, came the aesthetic need to add a grafted nipple in a trompe l'oeil fashion. That technique remains in use in some surgical centers, but it has fortunately been replaced in most of them by reductions with transposition of the nipple, with consequent conservation of the nipple as a flap based on a vascular pedicle. The quality of a transposed nipple is clearly superior to that of a grafted one. A large pedicle was not required to keep the nipple alive; often, but not always, a thin strip of subcutaneous fat was sufficient. If the nipple survived the ischemia of fragile transposition, it remained inert, congestive for a long while, and insensitive, with its neighboring position being the only relation to underlying tissues. Innovators, attempting to increase the safety of the nipple by thickening its pedicle, recommended increasingly thicker fatty flaps. Survival of the nipple increased, yet the torsion of the pedicle, necessary for the new positioning of this important complex, often produced surprises. These pedicles were always of superior origin (at the 12-, 10-, or 2-o'clock position), lateral origin (at the 3- or 9-o'clock position), or bifid but they were never of inferior origin. Resections were performed in the inferior quadrant of the breast, automatically cutting all bridges for a glandular pedicle of that quadrant. Because the transposition was always made toward the top, these glandular pedicles could not be very thick; if they were, displacement and torsion would be more damaging (see Image 1). The advantage of creating a nipple of superior quality by adding a glandular bridge to the fatty pedicle was clear. Surgeons who were convinced of that principle also quickly understood that a thick pedicle cannot be soft enough to allow displacement of the nipple in all directions and without any constraint at will if that pedicle was superior, oblique, or lateral. They also understood that such a mobile pedicle cannot originate from close surrounding tissues to avoid mechanical constraints with mobilization of the nipple. Thus, it now appears obvious that such a pedicle should originate somewhere in the mass of breast tissue, allowing its displacement in all directions. This eliminates all limitations to the mobilization of the nipple-areola complex. Evolution In 1971, McKissock improved the pedicle of the nipple-areola complex by choosing 2 glandular bridges. Between them, the inferior is quite large and connects the nipple to deep glandular tissue to allow vascularity of the nipple by perforating vessels emanating from the pectoralis major. Contrary to the previous techniques, McKissock's technique based the nipple on a mass of the breast gland that could represent 10-15% of the total mass of the remaining breast after reduction (see Image 2A). Only a Biesenberger reduction based the nipple on a larger mass of the remaining breast; unfortunately, the Biesenberger method had too many problems inherent in the detachment of the breast from the pectoralis major, consequently causing interruption of the perforating vessels and a high rate of breast tissue necrosis. Thus, this type of reduction was abandoned. In 1976, Robbins, carrying on McKissock's work, based the nipple on a simple inferior pedicle, probably a little larger than McKissock's. Mammary mass in connection with the nipple had to represent 15-25% of the remaining mammary volume (see Image 2B). Since 1979, the author has used 100% of the remaining gland as vascular support for the nipple-areola complex. This pedicle initially was in a posterior and inferior position, but eventually it occupied the entire height of the gland. Care is always taken to include 100% of the remaining breast. This is the total dermoglandular posterior pedicle (see Image 2C). Problem: Breast surgery, either lifting or reduction, consists of more than displacing an inert mass or simply reducing as in other resection surgery on undesirable tissue. Indeed, one must also be greatly concerned with how the breast will appear afterward and with the other functions of the remaining breast tissue. Reducing the breast tissue and not taking care of the nipple, its position, and its relationship with the remaining volume of the breast has already been suggested by some authors, but, in the author's opinion, these are inelegant gestures that discount the talent of plastic surgeons and their potential to achieve artful results. The surgeon must preserve the most important functions of a woman's breast, such as the quality of sensation of the nipple, contractility, and breastfeeding ability. Plastic surgeons also must be very demanding in terms of shape, proportion, volume, and scarring. Obtaining a nicely shaped breast on a normally built woman with minimal scars; harmonious features; and a well-placed, sensitive, contractile nipple is now the standard in mammaplasty. Etiology: The origin of hypertrophies is multiple. Most breast hypertrophies do not have a precise etiology but seem to occur more frequently in some families. Hypomastia also seems to occur more frequently in some families. Apart from this majority of unexplained hypertrophies, a large number of hormones act on breast development, either by enlarging them or by reducing them. Among these are estrogen, progesterone, testosterone, glucocorticoids, insulin, prolactin, growth hormone, thyroid hormone, and oxytocin. Clinical: Characteristics This technique is performed openly on a breast completely stripped on its anterior aspect. Resection is performed at the periphery, and the entire remaining gland is in direct contact with the nipple and acts as the pedicle. Thus, the pedicle of the nipple-areola complex is composed of the entire remaining breast that extends from the lowest to the highest limit of the breast, hence the term total pedicle. This characteristic lends the technique of the total pedicle all its other peculiarities and advantages, described below.
Relevant Anatomy: The breast extends from the second to the seventh rib. Its horizontal limits are the sternal bone medially and the frontal axillary line laterally. The breast glandular tissue is primarily vascularized by the perforating vessels arising from the internal mammary artery and intercostal arteries. According to different authors, this posterior vascularization provides 60-70% of the breast blood supply. This has been the very determinant factor in the choice of using a total posterior pedicle mammaplasty. Innervation of the nipple originates from the intercostal nerves, mainly the fourth, fifth, and sixth, which run along the aponeurosis of the chest muscles and, once in the central area of the breast, proceed ventrally through the breast tissue to the nipple-areola complex. This allows the total posterior pedicle to preserve the continuity of these very important nerves in order to conserve nipple sensitivity (see Image 11).
Lab Studies:
Imaging Studies:
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Preoperative details: Sketches The total pedicle is by no means limited to a drawing and can adapt to all sorts of incisions of preestablished drawings, yet the author favors a manner of drawing for reasons of simplicity, standardization, and, most importantly, conservation of reasonable scar length. The author divides the breast into 3 categories (see Image 3).
Begin with the drawing of the keyhole described by Aufricht, with certain modifications. Draw with the patient in a sitting position; the axis of each breast passes through the marked nipple, which is not necessarily the midclavicular line. Then, choose the keyhole position at the level of the inframammary fold (see Image 4). This position appears lower than that recommended in previous literature. This is because the position is measured on skin already stretched down by the weight of hypertrophy. Once the hypertrophy is treated, the new nipple site spontaneously rises 1-2 cm. The upper curved part of the keyhole is not a circle, but an oval with a longer horizontal axis, for 2 reasons. First, upon closing (A joins C), it has a tendency to look circular, whereas a circle would lead to a vertical oval figure when closed. Second, the natural tendency of tissues, caused by weight and trimming, is a vertically elongating effect on the nipple-areola complex. The opening of the keyhole arms (angle AB/CD) is 90° for category I, 140° for category II, and 180° for category III (see Image 3). See Advantages in Postoperative Details for a description of why this technique allows such wide-angle openings of the keyhole. After 5 cm, keyhole arms curve toward each other to join on the inframammary fold (see Images 5-6). Intraoperative details: Incisions With the patient positioned supine, make the circular periareolar incision 5 cm in diameter to definitively fit a 4-cm space. This imparts a particular conical projection on the nipple-areola complex. Perform an inverted-U incision to delimit the dermal pedicle. With a width of 6 cm, it extends from the superior part of the nipple-areola complex to the inframammary line. The interior area of that inverted U is deepithelialized. Then, perform full-thickness incisions of the skin based on preestablished drawings (see Image 7). Undermining flaps and exposure of gland Detach skin and subcutaneous fat flaps from the breast gland up to the aponeurosis of the pectoralis major muscle. Upon completion of the undermining, the breast is fully exposed on the frontal aspect, while the posterior aspect remains entirely attached to the pectoralis major aponeurosis (Image 8). Technically, undermining is performed quite easily by holding the internal, then superior, and then external flaps separately with skin hooks, successively placed in 2 positions at the same time in points A and B, A and C, and, finally, C and D. The assistant raises these points. The surgeon then can easily, by putting some pressure with a sponge on the gland with one hand, define with the other hand with a No. 10 scalpel blade the cleavage plane that is established between glandular tissue and subcutaneous fatty tissue. This allows for a practically bloodless dissection (see Image 8). Pay special attention to detachment of the exterior flap in the subaxillary region. Avoid cutting the areolar tissue at the extremity of the external quadrant of the breast to preserve intercostal nerves. Note the fifth in particular; these nerves run along the aponeurosis of the pectoralis, through that areolar tissue, medially toward the center of the breast, and then ascend through the mammary gland anteriorly to join the nipple-areola complex (see Image 11). Resection One realizes immediately the advantage of working openly on a breast. Resection is performed easily in areas most in need. Large hypertrophies typically are characterized by a particular excess of glandular tissue spreading quite far in the subaxillary region for which resection in the external quadrant is the most important. Save that areolar tissue for the same reason one safeguards the intercostal nerves. No resection is performed in the inferior or superior quadrants. These 2 quadrants are the protected zones of the total dermoglandular pedicle. Resection in the internal quadrant is quite small (see Images 9-10). Reconstitution The nipple is set in its new position in the circle obtained by the closing of the curved line through the junction of A and C corners. Technically, begin by joining the upper limit of the areola to the center of curved line AC with a stitch (see Image 12). The second stitch in 1 stage brings the lower limit of the areola against points A and C. The third cardinal stitch of the reconstitution brings points B and D together to close the vertical line (see Image 13). If the vertical line is too long (>6 cm), reduce it by retaining an elliptical horizontal area in the lower part of the line to create an inverted T with a very short horizontal arm (2-5 cm) (see Image 14). Pay special attention at the closure of the 2 corners at the junction of the vertical line, with the circular one around the areola and the horizontal one in the inframammary fold. To avoid a small loss of skin at these corners, keep a small excess of skin in a deerfoot fashion (see Image 15). Because of skin undermining and centralization of all remaining glandular mass, this technique avoids the classic anchor scar that traditionally results from most techniques using preestablished sketches (see Image 16). Tissue disposition The 6-cm-wide dermal pedicle, which, according to the case, is originally from 2-5 times the length of the AB/CD vertical line, must now occupy a 4-5 cm length at the end of the operation and, consequently, must intensively pucker. This creates a dermal inferior vault all the more resistant to traction and elongation; thus it is thicker and doubled-up by the dermis of the cutaneous flaps that cover it. This provides the total pedicle a certain capacity to resist stretching and, consequently, classic pseudoptosis, by lengthening of the vertical line, slipping of the gland in a subnipple position, and upper orientation of the nipples (see Image 17). Postoperative details: Advantages
Follow-up care: The patient is usually seen the second day after surgery. The static drain (Penrose), which drains the outer dead space secondary to the external quadrant resection, is removed, and the bandage is exchanged for the patient's bra over some sponges. Follow-up visits occur 1 week, 1 month, 3 months, and 6 months after surgery. The patient is seen once a year thereafter. The patient is seen once a year thereafter.
The deerfoot closure adapts within a month as the excess skin heals and overlapping at the flap corners disappears. Disadvantages First sketches can be considered difficult. This difficulty eases and eventually disappears with repetition. General prejudice against cutaneous flaps can be considered a disadvantage. Surgeons are famously apprehensive about completely undermining real cutaneous fatty flaps as far as the aponeurosis because of the fear of skin loss in the flaps. However, this is completely unfounded. Skin has its own vascular network, and circulation does not depend on vessels coming from the gland.
Twenty-five years of experience From 1979-2005, the author performed 5000 bilateral reduction mammaplasties using the total dermoglandular pedicle technique. Patient ages ranged from 14-72 years, and the average age was 30 years. Resection ranged from 100-1600 g per breast; transposition ranged from 3-32 cm. The author experienced no nipple loss in 5000 patients (see Images 20-25). In 2% of patients, the author encountered skin healing problems, chiefly at the junction of horizontal and vertical incisions and mainly in the first 7 years. Wounds, which resulted in a certain amount of skin loss, eventually healed spontaneously without skin grafting. In the last 18 years, this problem has diminished, as the deerfoot closing technique at the junction of these incisions was adopted (see Image 15). Curiously, a great number of these patients were surprisingly amenable to having ameliorated nipple sensation, either because of diminution of traction on the nerves or possibly because of psychological factors. After mammaplasty, 500 patients became pregnant. All carried their pregnancy to term normally and had normal lactation. The psychological impact on these patients is estimated as positive in 99% of cases.
When the total posterior pedicle was presented in the early 1990s, criticisms from traditional surgeons were experienced because of their fear of losing the undermined skin. The evolution of the technique over time has proved the safety of such skin flaps divided from the gland tissue. The inclusion of the entire remaining gland in the pedicle of the nipple-areola complex and the preservation of the intercostal innervation of the nipple make this technique superior in terms of functionality. Conservation of a whole and unique block of gland enveloped by a gland-free bag of elastic skin without any constraint due to the presence of sequestrated parcels of breast tissue under the skin allows the realization of achieving very attractive and natural-looking breasts.
Breast Reduction, Moufarrège Total Posterior Pedicle excerpt | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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