At this point it is important to check the vascularization of the flap that has been created. If there is any doubt, one should change the surgical plan, discarding the inferior flap, leaving the upper pole intact, and performing Peixoto's technique. If no vascular impairment is noted, the mammary tissue is resected from the upper pole until it reaches the desired size (Figs. li.ii, 11.10).
Mounting of the breast is done with the patient in the horizontal position. Fixing the pedicle is done first. It should drop naturally, and the number and location of the stitches necessary to fix it will vary by patient (Figs. 11.1j, 11.11). With the entire upper pole pulled upwards the breast is closed, joining the skin edgeBD to CD and making the vertical incision. The suture starts from point D and goes until it is 4 to 7 cm from it, depending on the size of the breast (Figs. 11.1k, 11.12). The nipple-areola complex is sutured in such a way as to compensate for the excess skin. No skin resection is required.
A hook should be placed at the junction of the vertical incision to the areola and pulled upwards. In most instances, a dog ear is present in the inferior part of the vertical incision and must be excised, taking care not to extend beyond the submammary sulcus (Figs. 11.1l, 11.1m, 11.13-11.15). The breast is then immobilized. This is done by applying adhesive microp-orous tape with an upward traction of the breast (Fig. 11.16). It is the equivalent to nasal immobilization after rhinoplasty and is based on skin retraction. The tape should remain in place for 10 days, after which it is substituted by a brassiere. Drainage is accomplished through a suction drain, which should emerge from the axillary area, never from the incision.
The most frequent complication is excess skin on the inferior pole of the breast, which occurs in approximately 10% of cases. It can be caused by two factors: (1) A too high positioning of the pedicle, producing a dead space in the inferior pole and consequently an area of skin excess; and (2) an insufficient excision of skin in the inferior end of the vertical incision. It is absolutely essential to be on the lookout during the operation for the presence of a dog ear at this point. Revision is accomplished through a vertical excision that should not extend beyond the submammary sulcus. If such a maneuver cannot be performed, a T-shaped outline is made to permit the correction without adversely risking the aesthetic result.
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