Mastopexy and Breast Reduction: Breast Shape and Scar Quality Are Most Important

Abstract

The author describes his preferred technique for mastopexy and reduction mammaplasty. He contends that patients are accepting of a longer scar if it results in improved breast appearance and that scar quality, more than length, is an important factor in achieving patient satisfaction.

The goal of a mastopexy or a reduction mammaplasty is to achieve aesthetically pleasing breasts with adequate firmness, size, and form and to create the least possible scarring. With every breast reduction surgery, there is skin resection and tissue removal. Correct assessment of skin excess and the amount of tissue removal needed is key to achieving good results. The evaluation of skin resection and tissue removal is unique to each patient.

Patients who seek breast reduction know that there will be a scar after surgery. In my view, it is the appearance of the scar that matters, not its length.

Planning

When planning a mammaplasty, I consider these factors: (1) size and consistency of the breasts, (2) level of ptosis, (3) distance between the suprasternal notch and nipples, (4) skin quality and, most importantly, (5) the relationship between breast tissue and skin. Because of these individual variations I do not use a pattern. Instead, I customize skin markings.¹ The more skin excess relative to breast tissue, the longer the resulting scar will be. Attempts to reduce scar length usually result in compromise of breast form and appearance.

Markings

I first draw a line from the midclavicle to the submam-mary sulcus passing through the nipple. I mark point “A” at the projection of this line on the submammary fold to indicate the new position of the nipple areo-lar complex. Point A can be placed lower if it appears that it will be difficult to raise the nipples. The next maneuver is the most important: the marking of points “B” and “C” (Figure 1). The location of these points is determined by the relationship between skin and breast tissue and also depends on the surgeon's skill, experience, and common sense. Points B and C define the form and firmness of the new breast. These points should not be more than 7 cm from point A. If they exceed 7 cm, the distance from the lower extremity of the areola to the submammary fold tends to lengthen, and the long-term appearance of the breasts will suffer. These lines will be more or less curved, depending on the skin excess.² I then link points B and C to the lateral and medial extremities of the infra-mammary fold (Figure 2). The length of the inframam-mary scar depends not only on breast size but also primarily on the relationship between skin and breast tissue (Figure 3).

With Pitanguy's principles,^3,4 there are 3 different types of skin markings. Therefore there are 3 different types of final scars: (1) classic inverted T, (2) inverted T with a small compensation at the inframammary fold, and (3) vertical scar (Figure 4).

I have used the periareolar approach⁵ for select cases (mild hypertrophy with good skin quality). Because indications for the periareolar technique are uncommon, I will not discuss this procedure here.

Tissue Resection

The type of tissue resection depends on the size, consistency, and form of the breast. I have been using 3 different types of breast tissue resection: plane resection,⁶ posterior resection,⁶ and keel resection.³

The plane resection has been recommended for hyper-trophic breasts in patients with a flat superior pole (Figure 5). The posterior resection achieves good results in patients with hypertrophic breasts who have excess tissue in the superior pole (Figure 6). The keel resection is the best option for an overall breast reduction.

Patient Satisfaction

In the service of plastic surgery of the Hospital of the University of the State of Rio de Janeiro, more than 4000 breast reductions and mastopexies were performed during the period from 1974 to 2001. My experience has been that when a woman requests mammaplasty, she is more concerned with the overall appearance of her breasts than with reducing the length of the scar. I have, in fact, never had complaints regarding the length of the scar. I have, on the other hand, had patients who complained about the size or shape of their breasts.

Based on my experiences I believe that Pitanguy's^3,4 principles are the state of the art in mastopexy and reduction mammaplasty. These principles are simple, reliable, easy to learn, and can be applied in every type of breast to achieve a high degree of patient satisfaction.

References