Mammaplasty With L-Incision

Abstract

Background: The cutaneous sequelae resulting from mastopexy and reduction mammaplasty are serious drawbacks for patients, particularly young women, and physicians who are dissatisfied with extensive postoperative scarring.

Objective: The author reports on an L-incision technique that involves a base resection with an upper transposition of the nipple-areolar complex (NAC) to yield good shape and projection, short scars, and preservation of lactation.

Methods: Preoperative markings were made to aid estimation of the amount of breast tissue to be excised, to establish anatomic landmarks ensuring breast symmetry, and to position the scars. Breast reduction was performed by means of perpendicular excision of the lower pole and transverse amputation of the base from the pectoral aspect of the breast. In wider breasts, a vertical keel was excised to decrease the circumference of the base. In mastopexy, the lower pole was preserved as a superiorly based flap and used to fill the upper pole. The new site of the NAC was marked bilaterally, slightly lower than the apex of the new mammary cone, with the downward rotation of the breast during the early postoperative period taken into consideration.

Results: The described L-incision procedure was performed in more than 500 patients between 1996 and 2003, with good results and a low rate of complications. Nipple sensitivity was generally preserved unless lesions of the lateral branches of the intercostal nerves were present. No lactation problems were reported by the 9 patients who breastfed babies after undergoing surgery. Twenty-seven patients underwent revision procedures to correct scar hypertrophy, areolar enlargement, asymmetry, persistent ptosis, or correction of “dog-ear.”

Conclusions: The L-incision technique is a safe, reliable procedure that results in good breast shape and projection with inconspicuous scars. It can be used in a wide variety of applications, including correction of breast hypertrophy, ptosis, and asymmetries.

Mastopexy and reduction mammaplasty are aimed at obtaining a compromise between improved breast shape and the inevitable resultant scarring. However, cutaneous sequelae of mammaplasties have always been a major drawback for patients, particularly young women,^{1, 2} and surgeons are also dissatisfied with long visible scars on the breast. The goals of modern surgery of the breast are improved shape, symmetry, retention of function and sensation, and minimal visible scarring. During mammaplasty, surgeons must address the management of excess skin or parenchyma and the safe transposition of the nipple-areolar complex (NAC), taking into account the control of shape and appearance of scars.³ Common mammaplasty approaches include the inverted T, periareolar, vertical, and L-techniques.

In recent years, surgeons have focused on minimizing scarring resulting from mammaplasty. The T-shaped scar is long, and the lateral or medial extents of the inframammary incision may result in dog-ears whose removal may result in a longer scar. The medial scar may also be conspicuous, resulting in a square breast.⁴ Use of the periareolar technique to achieve a conical breast shape can make it difficult to deal with the management of excess skin, especially in larger breasts. This often results in a flattened appearance and areolar enlargement.^5–7 The vertical techniques can leave long scars that overset the mammary crease.^8–10

Since the first description of mammaplasty with an oblique incision by Hollander in 1924,¹¹ many authors have referred to the L-techniques. With the L-technique, a good shape, shorter scars, and avoidance of a scar over the medial thoracic wall can be achieved.^{1–3,12–14} In this paper a safe and reliable L-technique is presented that includes simple preoperative marking and a base resection with an upper transposition of the NAC. This technique produces good shape and projection, shorter scars, and preservation of lactation and sensation. It has wide application,^{13, 15} and the results are satisfactory, with low rates of complication.

Methods

Markings

Initial measurements were carried out with the patient in an upright position. First, the midclavicular hemimammary line and inframammary crease were drawn (Figure 1) The hemimammary line usually crossed the nipple, if the nipple was not shifted.

Points A, B, and C were marked with the use of the Pitanguy maneuver.¹⁵ Point A was placed on the hemiclavicular line, at a level slightly lower than the projection of the inframammary crease (Figure 2). To determine points B and C, the surgeon grasped the skin in the central infraareolar region to estimate the amount of skin it would be necessary to remove to achieve a firm and well-positioned cone while including as much skin as possible. Such points should be placed below a transverse line passing through the NAC (Figure 3, A and B). Points A and B and points A and C were connected by curved lines. The distances from A to B and from A to C usually varied from 6 to 10 cm but were sometimes much longer.

Measurements were then taken with the patient in the supine position. A line representing the neosulcus was drawn 1.5 cm above the inframammary fold (Figure 4). The intersection of the hemimammary line with the neosulcus was designated point I (Figure 5). With the breast supported laterally, a dotted line was drawn from point B and parallel to the midclavicular line (see Figure 1). Point D was marked at the intersection of this line and the neosulcus. A curved line, drawn from point B, met the neosulcus at a location between points I and D, depending on the amount of skin to be excised, which the surgeon estimated by grasping the skin at point C and moving it toward point D using bidigital pinching maneuvers. This curved line should not be placed medially to point D or laterally to point I (Figures 6 and 7). Point E was marked laterally, on the new fold at the end of a wrinkle formed by the bidigital pinching maneuvers. This point should never overstep the anterior axillary line. Point C was connected to point E in a curved, upwardly convex line that varied in length and height according to the requirements of each case (Figure 8). The same procedure was then carried out on the other breast.

Surgical technique

After the areolar diameter was set, the periareolar tissues between points A, B, and C were denuded down to the deep dermis with the use of the Schwarzmann maneuver¹⁶(Figure 9). The breast marks were incised and the tissues elevated from the pectoral fascia. Careful skin undermining in a deep subcutaneous layer all around the lower pole was then performed. This step involved slight skin elevation. The glandular flap, which was going to be excised, had to be separated from the skin and fat along the mammary fold medially and laterally.¹

Breast reduction was performed by way of perpendicular excision of the lower pole inferior to the areola, including all the skin encircled by the markings inferior to B–C, and by transverse amputation of the base of the breast from the pectoral aspect to reduce breast height. The larger the breast, the larger the transverse segment excised to attain the desired size and height.¹⁰ In wider breasts, it was necessary to excise a vertical keel to decrease the circumference of the base (Figures 10 and 11).^{2, 15}

Care was taken to preserve the full thickness of the subcutaneous tissue around the periphery of the base in an attempt to avoid damaging the neurovascular supply to the residual breast tissues.² In mastopexy, the lower pole was preserved as a superiorly based flap and used to fill the upper pole. The glandular flap was turned under the NAC and sutured to the pectoral fascia or the superior parenchyma.

Closure

Deep sutures were used to bring together the lateral and medial pillars to yield a conical shape (Figure 12). The skin at point C was pulled toward the neosulcus and sutured between points I and D. Bidigital pinching maneuvers were useful in moving the lateral flap to determine the optimal suture location. The lateral flap was brought medially and slightly downward, whereas the medial flap was taken laterally and slightly upward (Figures 13 and 14). The breast tissue was rotated slightly from lateral to medial.

Suturing of the wound was begun at the lateral sulcus and finished at the apex. Inequality in the length of the skin edges was compensated for so that the medial edge was longer than the lateral one. Any skin excess was brought medially and upward toward the apex, ending in a round purse suture, which allowed resection of the skin excess during transposition of the NAC. Some wrinkling along the longer skin edge may occur. Any wrinkles that appear unavoidable should not cause concern because they always disappear within a few weeks (Figure 15).^{2, 12}

The new site of the NAC was marked bilaterally slightly lower than the apex of the new mammary cone, with the downward rotation of the breast during the early postoperative months (which would shift the areola to a slightly higher position) taken into consideration.¹⁵ After the removal of intradermal skin, the areolar transposition was easily achieved by means of peripheral incision of the dermis (Figure 16).

Results

This technique has been used for the past 8 years in more than 500 patients undergoing reduction mammaplasty, mastopexy, or correction of breast asymmetry. Patients ranged in age from the teens to the 60s. Breast reduction ranged from 200 to 1200 g per breast, with an average tissue removal of 500 g per breast. The shape of the breast was usually satisfactory, scars were inconspicuous, and patient satisfaction was high (Figures 17–19).

A telephone research questionnaire was used to assess patient satisfaction, nipple sensation, breastfeeding potential, and any complaints concerning scars, hypertrophy, persistent ptosis, under- or overreduction of breast volume, areolar enlargement, asymmetries, and other problems. We were able to reach 295 patients, or 59% of the patients operated on between 1996 and 2003. Patient satisfaction was recorded on a scale of A to C, in which A represented “extremely satisfied,” B “satisfied,” and C “not satisfied.” More than 90% percent of patients reported that they were satisfied with the results of surgery (Table 1).

Patients were asked to rate nipple sensation on a scale in which A represented “normal sensation,” B “sensation present but abnormal,” and C “no sensation.” Nipple sensitivity was generally preserved unless lesions of the lateral branches of the intercostal nerves, especially of the fourth intercostal nerve, were present. More than 76% of patients reported normal sensation; another 22% indicated that nipple sensation was present but abnormal (Table 2). Only 9 patients breastfed babies after surgery. Although all reported that lactation was possible without any problems, this issue requires further investigation.

The type and incidence of complications are listed in Table 3. Note that 2 or more complications arose in some patients. No large postoperative hematomas requiring surgical evacuation occurred, but small fluid collections required conservative drainage. No skin slough was noted in the wounds. Twenty-seven patients underwent minor revisions to correct scar hypertrophy, areolar enlargement, asymmetry, persistent ptosis, or dog-ear (Table 4). In almost all cases, revisions were performed with the basic design of the L-technique or the scar line for additional excisions (Figure 20).

Discussion

Many L-techniques have been described since the first report, by Hollander in 1924, of mammaplasty with an oblique scar.^{11, 17} Mammaplasty with an L-incision requires more technical expertise than does mammaplasty with an inverted-T incision because the skin closure demands more accuracy. However, the L-technique results in shorter scars because there are just 2 points of compensation. One is located at the lateral mammary crease; the other is on the apex of the new cone, where it ends in a large dog-ear and consumes extensive skin in the performance of the areola-nipple transposition. In contrast, in the inverted-T technique there are 3 linear points of compensation, 2 of them at the mammary fold, often ending in dog-ears. The excision of these dog-ears results in longer scars over the medial and lateral thoracic wall.²

The L-technique does not require rigid preoperative demarcation. The preoperative marks are made for orientation so that the surgeon may estimate the amount of tissue to be excised by using anatomic landmarks for symmetry and positioning of the scars. The nipple is never marked beforehand because its final position is set up in accordance with the newly formed breast cone.¹⁵ Moreover, tissue viability is never threatened because the only vessels interfered with are those originating from the pectoral fascia directly beneath the breast. The base resection preserves the neurovascular supply and enables the NAC to be carried on a total breast tissue pedicle. The anatomic continuity of the residual breast tissues with the nipple is maintained, thereby preserving a functioning organ and providing normal potential for lactation.¹³ Its preferential indication is moderate hypertrophy (500 g), which is found in most candidates for the procedure, but it can also be used in severe hypertrophy or even gigantomastia.¹⁸

Conclusion

The L-incision technique is a safe, reliable procedure that can be used to treat a wide variety of conditions, including breast hypertrophy, ptosis, and asymmetries, with emphasis on good shape and projection, short and inconspicuous scars, and preservation of sensation and function.

I extend special thanks to Haroldo Santos Lacerda, MD, the anesthesiologist for our operative team, for his support.

References