Aesthetic Breast Surgery with Inverted-T Scar Placed above the Inframammary Sulcus
 
Jair José Pereira, M.D.
Fax: 55-019-2420923
 
 
Abstract. This article describes the inverted-T incision technique with the scar placed above the inframammary sulcus for cases of pexy, breast reduction, and argumentation-reduction mammaplasty. This technique preserves the inframammary fold as na important factor in naturalbreast suspension; the breast mound is easily shaped independent of the skin tension. The gland- and skin sutures are placed separately and independently. This technique has been used on 380 patients in the last 13 years.

Key words: Breast - Mammaplasty - Inverted-T technique

    Breasts vary in their shape and volume during a woman's life due to the againg process, body weight variations, lactation, hormone changes, biotype, skin texture, glandular-fat proportions, chest asymmetry, etc. Breast asymmetry, present in more than 90% of women, can range from inconspicuous to obvious. Based on these many factors, aesthetic breast surgery is considerei one of the most difficult surgical procedures from which to obtain acceptable long-tenn symmetry and lasting results.
    Medical literatura is rich in techniques with different approaches to glandular-fat resection and to the size and shape of the resulting scar. Georgiade et al. [1] do not consider that any one "all-season" technique is able to solve all types of breast problems.
    The most common criticisms reported during longten-n followup are unnatural contour, elevation (bascule) of the areola-nipple complexo ptosis of the lower quadrants, remaining axillary prolongation, flatness of the breast cone, scars visible out of bathing suit edges, inframammary scar adhesion to the deep muscular plane, and breast shape distortions due to attempts to reduce scar length.
    Our initial experience with reduction mammaplasty was based on Pitanguy's [3] and Pontes' [4] techniques. Personal modifications were gradually introduced in the inverted-T scar, until it was placed above the inframammary sulcus.
    Maintenance of the inframammary fold beyond the gland's base, lateral and medial undermining, and the separate and independent planes of suture, are other important details measured among final results' quality. Long-term results related to the natural breast shape and positioning improved, based on our aesthetic consensus and the patient's general acceptance.

Surgical Technique

    The breasts are demarcated with the patient in a sitting or standing position. A midclavicular-nipple line is drawn caudally below the inframammary sulcus which is also demarcated. Point A, representing the definitive areola-nipple upper level is determined by measuring 17 to 21 cm from the medium clavicular projection. As in Pontes' breast procedures, points B and C are placed 6 to 8 cm equidistant from point A, and are placed bilaterally, describing the areola inside a triangular area (Fig. 1).
 

Fig. 1. Preoperative marking. Points A, D, and E are placed on the midclavicular line.

    The distance between B and C varies according to the amount of skin/gland resection relative to the breast rnound. Points B and C should join point D, in the breast mound maneuver; point E is where the midclavicular lines intersect with the inframammary lines. Point D is usually 2 cm above point E. Points F and G represent the medial and lateral extremities of the horizontal inverted-T line.
    ln symmetric breasts, points A-G are symmetrically transferred to the opposite breast. ln asymmetric breasts, only A, D, and E in both breasts are equidistant from the vertical midsternal line.
    The patient is operated upon in the supine and elevated trunk position. After areola demarcation, the triangular periareolar area (within the triangular limits of the points A-B-C) is de-epithelized. The skin along the horizontal F-D-G line is incised to the pectoralis muscle fascia, contouring the gland, and the breast is undermined at its base (Fig. 2).
 

Fig. 2. Undermining the gland at its base just above the pectoralis fascia.
    The gland is sufficiently undermined, laterally and medially, to allow a reduction in its radius and to obtain a better contour.
    A hook placed at point A elevates the whole breast, giving volume to the upper pole and to expose the excess to be resected at its base.
    The areola-nipple complex is dissected to its deepithelized limits and bearing by an upper mono-pedicle flap.
    According to the breast problem being treated, there are four specific techniques available: (1) In cases of ptosis only there is no tissue resection. The mastopexy is performed by folding and suturing the breast's inferior quadrants over themselves, along their vertical line. (2) For ptosis plus augmentation, the same maneuver as for ptosis is done, with the prosthesis inserted behind the gland. (3) ln small and medium hypertrophies (from 50 gm to 350 gm of resection from each side), a glandular wedge is resected between the two inferior quadrants (Fig. 3);
 
Fig. 3. Skin and glandular resection, for cases of small and medium hypertrophies.
(4) For large hypertrophies (over 350 gm of resection from each side), a larger but similar glandular wedge resection is performed and combined with glandular wedge resections in the breast base (Fig. 4).
 
Fig. 4. Skin and glandular resection, for cases of large hypertrophies.
    Skin and gland are resected as a block.
    ln both small and large resections, while the hook still holds and sustains the breast, the two glandular pillars left at the lower quadrants are sutured together from the upper to the lower level with 2-0 nylon separated stitches. The breast base is then sutured to the pectorallis fascia with 2-0 nylon separated stitches. Skin closure is performed with intradermal 4-0 Vycril or 5-0 nylon separated stitches. The areolas are placed in their definitiva position routinely.
    The horizontal line is placed 2 cm above the inframammary sulcus at point D, and goes obliquely to both sides. The horizontal suture line runs above the sulcus, and tends to match the sulcus at its medial and lateral edges (Figs. 5 and 6).
 
Fig. 5
 
Preoperative marking. (A) The final desired volume is defined, and
(B) the opposite side is marked. Marking the medial skin flap
(C) and the lateral skin flap
(D) to be resected.
 
 
Fig. 6
 
Intraoperative views. (A) Evaluation and resection of the gland and skin.
(B) As the breast is held by the hook, the remaining glandular pillars are joined up, from up to down.
After mounting the gland, (C) skin closure is begun and
(D) the new areola-nipple site is ready to be marked.
 

    Dressing

    A Penrose drain is inserted in all cases. Slightly compressive dressing is placed on the breasts during the first postoperative day, followed by the use of a common brassiere.
    The skin suture is completely covered by micropore brassiere, which is changed each 2 weeks and maintained for 10 weeks.
 
    Results

    ln the last 13 years (from February 1982 to August 1994), 380 patients have undergone this procedure. No areola-nipple complex graft was necessary, even in wide resections (maximum 1,900 gm from each side). Except in cases of ptosis only routine pathological examination was performed in all surgical specimens. One case of carcinoma was disclosed. Another case of unilateral diffuse breast carcinoma was detected 2 years later, even though those breast specimens were normal immediately after surgery.
    No patient has complained about undesirable aesthetic aspects of either volume or shape.
    Complications (Table 1) were similar to those from other techniques described in the literatura.
 

Table 1. Complications.
 
Types
Number of cases
%
Infection 0 0
Total Areola Necrosis 0 0
Partial Areola Necrosis 7 1.8
Unilateral Hematorna 1 0.26
Bilateral Areola Loss of Sensation 1 0.26
Unilateral Areola Loss of Sensation 1 0.26
Scar Hypertrophy 15 3.9
Fat Necrosis (Lipolysis) 15 3.9
Areola Partial Epitheliolysis 20 5.2
 

Five representative cases are presented (Fig. 7-11).