Durability of Shape with a Combined Technique
The correct execution of modern techniques in reduction mammoplasty produces excellent and immediate results.
The surgeon who operates respecting anatomical and physiological precepts of the breast, and with a proper knowledge of an affirmed technique, can adjust the skin with precision, modelling it to the reduced glandular contents, in conformity with the various patterns that have been proposed.
However, the ultimate evaluation of the operative result is does not depend on the immediate outcome: the prognosis must be deferred for at least one year, by which time the new shape of the breast will reveal eventual merits or defects of the technique employed.
The crucial point of reductive breast surgery is neither the volumetric reshaping nor the glandular modelling, which should conform to specific aesthetic canons, but the guarantee of the durability of the result.
Thus it is necessary that the technique utilised exploit valid devices in order to offset the force of gravity which, in the course of the months following the operation, may again cause the breast to sag.
The goal to be achieved – to limit the gradual drooping of the gland – pays no consideration to the pathogenesis of mammary sagging and must therefore be predetermined both when reducing hypertrophic breasts, in which sagging is the result of increased weight and volume, as well as in breasts that droop due to parenchymal hypotrophy and tissue lassitude.
In either case it is simply a question of fashioning the breast to regular proportions, providing resistance to the forces of gravity.
Pursuing this aim, and with a knowledge of the principles of embryology, anatomy and physiology of the breast, we have ascertained that in order to achieve a good substantial result in reductive mammoplasty, at least three conditions are necessary:
A – Maximum conservation of the dermis.
B- Vertical direction of the flaps.
C- Maximum mobility of the pedicle bearing the nipple.
Based on these assumptions, we have long rejected techniques which involve extensive undermining and generous removal of the skin, and so compromise the suspensory ligaments of Cooper and subtract the dermis, which is the most reliable and resistant tissue.
If dermal preservation is a necessary condition to maintain suspension and trophism, the direction of the cutaneous and glandular flaps is indispensable for the future stability and shape of the breast.
A horizontal arrangement of the flaps is prejudicial to achieving a conical shape and also offers a larger surface to the action of gravity.
This produces breasts that tend to flatten and slide downwards, forcing the nipple into an upward position, owing to an anchorage that is not adequate for the flap proportions.
Flaps with vertical direction are more in harmony with the goal of achieving a conical shape.
We utilise vertical dermal flaps in association with a quadrangular dermal-fat flaps (Ribeiro), obtained from the lower part of the breast, based on the submammary fold. This flap, inserted into the retromammary space, presents the following advantages:
- It consists of tissue that is not susceptible to sagging thanks to its firm anchorage to the pectoralis muscle, and therefore it is preferable to glandular tissue, which is heavier and more difficult to stabilise. -
- Its median and vertical collocation respects the intent of creating a cone-shaped breast.
- It can be curved along its upper edge, in order to carry more substance in the case of hypotrophic breasts, nevertheless forming a conical shape.
- It does not resorb but, on the contrary, gains in volume with the increased weight acting on it, since it is provided with its own circulation.
- With its extensive de-epithelialised surface it favours adhesion and suspension of the gland.