Vertical Scar Mammaplasty with a Superior Pedicle

Albert De Mey

Ohe best of men is he who acquires learning but better than him is he who transmits it.

Folk Tradition, by M. Hamdi in training who performed the operation in the university hospital. The same unfavorable results were published by Pickford [15]. Therefore, we tried to make the technique safer, keeping in mind the basic principles of the vertical scar mammaplasty.

Operative Technique (Figs. 5.1-5.12)

Drawings

Introduction

The goal of breast reduction is the correction of the volume, shape, and symmetry of the breast while preserving nipple sensitivity. Since the early days of breast surgery, many surgical techniques have been proposed to reach this goal, but over the two last decades, new techniques have been published that attempt to minimize the scars. The periareolar scar is unavoidable as the nipple-areola complex has to be repositioned, but the vertical scar has proved to be avoidable in mastopexies [6], as has the horizontal submammary scar in the majority of cases, even in large reductions [3]. Following the description of Dar-tigues in 1925 and the publication of Lassus in 1970 [8], in the early 1990s Lejour popularized a technique derived from Lassus [9].

The Lejour vertical mammaplasty is a technique that combines a superior pedicle for the areola and a central resection for the breast reduction associated with liposuction and wide undermining of the skin along the vertical scar. Despite the results reported on large series [12], many surgeons are still reluctant to apply the Lejour vertical mammaplasty as a standard technique. This can be due to the use of a superior pedicle for the NAC, an inferomedial resection, and different approaches to the skin and to the glandular tissue. Moreover, the result is not obtained immediately.

The Lejour technique has been used in our department as the only technique for breast reduction since 1990. The first reports of Lejour were encouraging and confirmed by long series and late results [13]. However, at the university hospital, using the same procedure we observed up to 30% minor complications and 15 % major complications [3]. This difference was probably due to the different populations (larger breasts, obese patients) and to the lack of experience of the surgeons

The preoperative drawings are done the day before surgery, according to the description of Lejour [11], in a standing position. The future nipple site is positioned on a line joining the suprasternal notch with the nipple slightly lower than the inframammary fold (IMF) as projected onto the face of the breast by the index finger (Fig. 5.1).

The areolar circumference is then defined by marking the upper pole on the line drawn from the nipple to the sternal notch 2 cm above the nipple site. This distance between the sternal notch and the areo-lar site is 18 to 22 cm. The internal limit is positioned at 9 to 10 cm of the midline based on the width of the

Superior Pedicle Breast Reduction
Fig. 5.1. The index finger maneuver to determine the future nipple site
Superior Pedicle Breast ReductionBreast Domes
Fig. 5.3. The drawing is complete with the dome-shaped areola

chest and the external limit 7 to 8 cm externally of this point on a horizontal line drawn 3 to 4 cm below the upper marking. These three points are joined and mark the superior areolar circumference.

The inframammary fold is marked, as is the vertical axis of the breast. The lateral markings are made pushing the breast laterally and medially with an upward rotation movement, in continuity with the vertical axis drawn below the breast (Fig. 5.2a, b). The lower limits of the areola are then delineated by drawing a slightly curved line between the previous areolar points and the vertical lines. The total circumference of the areola should measure between 14 and 16 cm to match the 4.2-cm areola template (Fig. 5.3). The same markings are made on the opposite breast. To check the symmetry of the drawings, both breasts can be gently pushed together toward the midline, making the medial markings touch.

Surgical Technique

Under general anesthesia, the patient is positioned in a semisitting position, with hands placed under the buttocks. The base of the breast is constricted with an autofixed band mammostat, and the periareolar area is deepithelialized (Fig. 5.4). Two points are then marked on each vertical line 7 to 8 cm below the lower areolar point in order to determine the height of the remaining glandular pillars (Fig. 5.5a, b). A skin hook is placed at this point and another at the lowest part of the drawings near the inframammary fold. This allows for undermining of the lower part of the breast subdermally, leaving a little adipose/glandular tissue attached to the dermis down to the inframammary fold (Fig.5.6a,b). This dissection is performed both medially and laterally in the same position.

The dissection continues upward on the pectoralis fascia centrally, in the retromammary space, toward the subclavicular area. This dissection should not be extended laterally so as to preserve the blood supply and the innervation. A hand is then placed in the retromammary space and the breast tissue is incised vertically along the medial and lateral skin marks (Fig. 5.7). Doing this creates two glandular pillars. In a

Fig. 5.4. Deepithelialization of areolar pedicle

Fig. 5.5 a, b. 7-cm mark along vertical scar to determine dimensions of glandular pillar large ptotic breast, the surgeon must be very conservative in the incision of the medial pillar and resect more on the lateral pillar in order to correct the inferior lateral excess of breast tissue.

A skin hook is then positioned at the low portion of the deepithelialized area around the areola, and the central portion of breast tissue is resected in a conical fashion (Fig. 5.8). The closure starts with a first stitch positioned at the upper pole of the areola with 4-0 nonabsorbable sutures and the second at the lower pole of the areola. Then, two last stitches are placed at 3h and 9h to finish the positioning of the areola (Fig. 5.9).

No sutures are placed on the pectoralis fascia except in very large fatty breasts in order to facilitate the shaping of the breast by releasing some tension. The parenchymal sutures are then inserted with heavy absorbable sutures starting at the upper part of the glan-

Fig. 5.5 a, b. 7-cm mark along vertical scar to determine dimensions of glandular pillar

Pedicle Breast IncisionVertical Scar Breast ReductionBreast Revision Marking

dular pillars, from deep to superficial, to achieve the desired conical shape of the breast (Fig. 5.10). If necessary, some additional resection can be performed laterally and medially at the lower end of the pillars to obtain a more curved shape of the breast at the infra-mammary fold. Finally, a suture is placed at the lowest part of the pillars including the chest wall tissue.

A very conservative undermining of the skin is performed along the vertical scar in a triangular fashion in order to release tension on the subdermal stitches (Fig. 5.11a,b). These are done with 3.0 absorbable sutures starting at the upper end of the vertical scar as a running suture, creating multiple fine wrinkles evenly distributed along the vertical scar. The end of this suture is attached at the base of the glandular pillars after placement of a suction drain (Fig. 5.12a, b).

There is no true contraindication for the vertical mammaplasty. However, as in any breast reduction technique, care must be taken in special occasions. The superior pedicle technique has proved reliable in large breasts. However, in elderly obese patients needing a large reduction, the Thorek amputation is probably more advisable. In large reductions, care must be taken to widen the areolar pedicle in accordance with

Fig. 5.11 a, b. Subcutaneous suture along vertical scar with even puckering of excess of skin

Fig. 5.11 a, b. Subcutaneous suture along vertical scar with even puckering of excess of skin

Fig. 5.12 a, b. Final aspect of breast at end of operation
Dog Ears Breast Reduction

its length. This can be easily done during the preoperative drawings: after positioning the internal border of the areola, the external limit can be placed 8 to 9 cm from the first mark. This allows for a very safe 16- to 18-cm-long areolar pedicle.

In some large resections (looog/breast), a small horizontal skin excision is performed in the infra-mammary fold at the end of the vertical suture in order to avoid crossing the inframammary fold or leaving a dog ear (Fig. 5.15.). This is recommended in patients with redundant skin and limited skin elasticity or presenting risk factors such as smoking or diabetes. The skin is then sutured with 3.0 nonabsorbable stitches. A light dressing is applied on the wounds, with an additional roll of gauze placed in the lower part of the breast to avoid a dead space in the under mined areas. This technique differs from the original technique, as proposed by Lejour, in the absence of liposuction and of skin undermining on the glandular pillars. Moreover, skin puckering is limited and thick skin folds or dog ears are avoided at the level of the inframammary fold.

Results

From 1996 to 2002, 261 patients were operated on at the university hospital using the vertical mammaplas-ty as described above. The mean age was 34 years (14-68 years). The average weight resection was 530 g (0 to 3480 g) per breast, and the mean BMI was 26.6 UI (18 to 45 UI).

Extreme Breast Growth TeensVertical Scar Breast Reduction
Fig. 5.14. a Twenty-year-old patient who had a resection of 670 g on right and 590 g on left breast. a, b Preoperative views. c, d One-year postoperative views

The best indication for the vertical scar mamma-plasty is a young patient with elastic skin and up to 500 g resection per breast (Figs. 5.13, 5.14). It is the shape that matters: a conical shape and narrow base are best. The long-term results are guaranteed by the inferior midline suture of the glandular pillars. Reduced scarring is an additional benefit of the procedure.

Testicular
Fig. 5.15 a-c. A patient who had 770-g resection on right and 810-g resection on left breast with a primary horizontal excision in the inframammary fold. a Preoperative condition. b,c Postoperative views at 1-year follow-up.

Sensitivity

Breast sensation after reduction is a major concern. The superior pedicle technique has often been criticized because of the potential damage to the nerve supply of the nipple-areola complex. In a prospective study [7], we showed that recovery of breast sensation was observed in moderate breast hypertrophy. In large breasts, pressure sensibility recovered after lyear, but temperature and vibration sensitivity decreased on the nipple-areola complex.

Complications

At the university hospital, the rate of complications decreased significantly with the technical modifications to the original technique. When we compared the results of patients operated on between 1996 and 2002 using the revised technique with results obtained in a series of patients operated on with the original technique (liposuction and wide skin under mining) between 1991 and 1994, we observed a dramatic decrease of seroma (27% to 4%) and hematoma (12% to 5%). Wound healing along the vertical scar was also improved,with less than 15 % of delayed healing, down from 46 %. Finally, the steatonecrosis rate was nearly eliminated, decreasing from 22.4 to 1.3 %.

Nevertheless,secondary corrections were still needed in 16% of cases, mostly on the lowest part of the vertical scar. The need to correct this area was unfortunately not completely eliminated by a primary excision in the submammary fold. The only problematic cases are patients with inelastic skin, because in these patients, even if the reduction is moderate, there is a high risk of a residual excess of skin and the patient has to be informed that a small scar might be necessary in the inframammary fold to obtain a nice redraping of the skin. This condition does not depend on the resected volume or on the age of the patient. But in large reductions (more than 1000 g/breast), the risk of a residual excess of skin in the lower breast is high (Fig. 5.12a-c).

In our series, the main risk factors for complications were the BMI and the amount of resection.

When the BMI was between 15 and 25 UI,the total rate of complication was 9 % but increased to 65 % if the BMI was over 30 UI. Similarly, 8% of patients presented some complications in resections of less than 250 g, but 50 % of complications were observed after resection of more than 1000 g per breast.

Revision Procedures

Among the specific complications of the vertical scar mammaplasty, an excess of skin in the submammary fold is by far the most frequent indication for secondary revision. In the majority of cases, the correction can be performed under local anesthesia as an ambulatory procedure at least 6 months after the primary operation. It consists of a horizontal resection of the dog ear. The scar can be positioned exactly in the in-framammary fold, is always hidden by the breast, and is shorter than what would have resulted after Wise pattern skin resection (Fig. 5.16 a,b).

Discussion

Breast reduction is a highly effective procedure with a high degree of patient satisfaction. There is probably no single technique for all breast reductions. Inverted T techniques based on various areolar pedicles have proved to be safe and reproducible for nearly all kinds of breasts. However, techniques have evolved over the last 30 years that attempt to reduce scars [8]. The main change has been in the understanding that the skin and the breast parenchyma can be handled independently. Most vertical techniques use superior or lateral areolar pedicles as described long ago by Pitanguy [16] and Skoog [17]. This can be a concern for surgeons who are used to the inferior pedicle technique, which may then lengthen the learning curve. Another concern surrounding the technique comes from the description of Lassus [9], who relies on an artistic approach without precise preoperative markings. This problem has been avoided by the description of the standard pattern by Lejour or a modified pattern by Findlay-Hall [5].

Concerning the rest of the operation, glandular resection is quite easy as it follows the skin markings along the vertical scar and extends laterally and inferi-orly as in the traditional Wise pattern excision without the skin resection. Suturing of the glandular pillars has proved to be an important step in reshaping the gland and maintenance of a good long-lasting result.

The only problem remaining is the risk of secondary revision of the lower end of the vertical scar. This has been reported by several authors [16]. In our experience, if needed, this has always been possible under local anesthesia as an ambulatory procedure. How-

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