REDUCTION MAMMAPLASTY WITH AN L-SHAPED SUTURE LINE Development of Different Techniques RODOLPHE MEYER, M.D,, No ULRICH K. KESSELRING, MD. Lausanne, Switzerland Because the breast deformities requir- ing surgical correction appear in many different types, the plastic surgeon log- ically employs different procedures. We have tried in Figure 1 to demonstrate roughly the main tendencies and de- velopments in reductive plastic surgery of the breast. The sectorshaped excision, which can still be seen today in various methods, was used by Lexer,1? Kraske,° May,'4 and many others in the early 1920's. In 1938, Nedkoff introduced the now classic keyhole excision, extended into a sickleshaped resection above the inframam- mary fold. He was not aware of the possibili ties that the “deepithelization”* technique of- 1960 Serémbeck*+ showed that, with ns, the vascularity of "the surrounding skin area as a “bridge this was largely an extension of the maneuver of Schwarzmann® and allowed him to trans- port the nipple on a bipedicled flap, one which would not have provided sufficient blood supply if deprived of its entire cutis layer. In the years that followed, Tamerin#* (1968), Skoog? (1968), and Pitanguy'* (1967) developed their own variations of the princi ples of Nedkoff and Strémbeck.** ‘The lateral-resection technique is also not new. In 1924 Hollander’ described such a *Editorial note. As we all know, about the only way to de-epithelize skin is with trypsin or some other enzyme. When the thinnest possible layer is removed with a knife, one has a splitkin graft containing some dermis, With the denudation technique usually used in these “dermal pedicle” ‘mammaplasties, it is probable that all of the der- mis is removed—unless someone can demonstrate skin appendages, elastic fibrils, ete, in the remain: ing bed. Accordingly, we shall use quote marks around “de-epithelize” until the situation is clark fied. method, but like many of his contemporaries he moved the nipple to its new place on the top of a pillar consisting of subcutaneous and glandular tissue and fat. It has since been proven (as Schwarzmann®? maintained in 1980) that the main blood supply to the nipple does not come perpendicularly from the thoracic wall, but horizontally through the cutis. In 1961 Dufourmentel and Mouly? applied the principle of “de-pithelization” to method with lateral incision. A later vari tion was reported by Elbaz and Verheecke® in 1972; they brought the lateral incision to ower level, to join the submammary fold later- ally. ‘The idea of displacing the nipple on a verti- cal bipedicled flap may have come from Joseph,® who performed a two-stage operation to ensure the viability of the nipple. McKissock'* had the same idea and he advo- cated a vertical nipple-bearing flap, using “de- epithelization” to improve the blood supply and allow a one stage operation. Related proce- dures were reported in 1972 by Lalardriet and in 1973 by Weiner. Single pedicled “bridges” were also tried suc cessfully by the pioneers of mammaplasty Schwarzmann?? applied his “de-epithelizing’ maneuver to a single pedicle. In 1980, he rec- ‘ommended a “de-epithelized” transposition flap for the transport of the nipple; this preceded Skoog’s#® 1968 method, which adapted this early technique to a more modern concept of reduc- tion in which the “de-pithelized” single pedi cle was quite large and thin. Many recent techniques, then, were conceived quite early but without knowledge of the “de-epithelization” technique. Today there are probably some 50 variations of this principle, cul- minating in the giant “de-epithelized” area of the Garcia-Padron technique (1972).PLASTIC & RECONSTRUCTIVE SURGERY, February 1975 Ce Cig / coun 122 eso, eur 12 Ce vo ge Cay ee” Lal Ce (above) The main trends in mammaplasty developed from the sector excisions, which were gradually changed into keyhole excisions. (center) Later, the “de-epithelized” bridges were developed to leave more blood supply to the areola and nipple, (lower) Some of the methods eventuating in lateral scars, with their predecessors. OUR METHOD While we appreciate the methods of Strémbeck," Pitanguy,* and Skoog which have made it possible to operate on even extreme cases of mammary hy- pertrophy with acceptable results, we try whenever possible to avoid the tech- niques which produce unattractive scar- ring beyond the mammillary line medially. It is a bit surprising that, apart from the Dufourmentel and Mouly* oblique method and the recent modification of Elbaz and Verheecke,* very few surgeons have produced meth- ods which leave unspoiled décolletés. In our opinion, and in our practice, only extremely long, flabby, and sack- like breasts, or broad heavy obese breasts (classified by Rees as Type I, 1-8), require procedures such as Strém- beck’s,** Pitanguy's** or Skoog’s® in which the suture line must reach theVol. 55, No. 2 | REDUCTION MAMMAPLASTY sternum. In the other cases—and partic- ularly in young women with virginal hypertrophy, slight ptosis, or asymmetry (Rees Type I, 4)—we feel nowadays that the use of inverted ‘T-incisions should be avoided. We use a technique which leads to an. L-shaped suture line, with the vertical component extending from the lower border of the areola down to a new sub- mammary crease, 3 to 5 cm higher; the horizontal component conforms with the new submammary fold laterally. We gradually developed our tech- nique about 10 years ago when we mod- ified Lotsch and Gohrbandt’s* method (Meyer and Martinoni," 1971). Gohrbandt’s 1928 procedure is similar to that of Biesenbergert (1981), with blunt dissec- tion in a deep subcutaneous layer all around the mammary gland—but with a wedge Tesec- in the upper median part instead of in the lateral part of the breast. The suture line starts at the nipple but goes down across the submammary fold. In our modification (shown in a film at the Fifth International Congress of Plastic Surgery at Melbourne in 1971, we carry the vertical incision only down, to the submammary fold, and then go laterally. Thus we obtain an L-shaped suture line. New oo ‘SUBHAINARY FOLD 144 As this method and its modifications, as well as Biesenberger's' technique, can compromise the blood supply of the nipple, we had to limit its use to easy cases, We used other methods, noted above, for the treatment of severe hyper- trophy and ptosis. Gradually, however, we started to combine this esthetic lateralization of the incisions with a huge “de-epitheli- zation" and developed our recent method. The latter is similar to the technique of Elbaz and Verheecke,* yet its origin and development are quite different. We know that a good many plastic surgeons use lateral suture lines (Winkler and Regnault?* for exam- ple) but we do not know of any other procedure which leads to the same kind of L-shaped scar. We sometimes use our older Gobr- bande variation now in easy cases of slight ptosis, when a young woman de- sires especially conic breasts. Our new method, however, is useful for the correction of a larger spectrum of de- formities. OPERATIVE TECHNIQUE ‘The 3 important principles of this ap- proach are (1) the L-shaped suture line, (2) the “de-epithelization,” and (3) the creation of a new submammary fold. We ew FOLD Fic, 2 Moderately ptotic breasts (first degree) are treated by a keyhole ““de-epithelization” with subsequent closure to tighten the skin brassiere. ‘The region of the future submammary fold is defatted, to put the new crease at a higher level142 First the new site of the nipple is de- termined. The average distance from its upper border to the middle of the clavicle measures between I] and 15 cm, the average distance from the midline of the sternum is between 8 and 10 cm. The experience and the sense of propor- tion of the surgeon will find the right positions in each individual case. A keyhole incision is made, nearly concentric to the arcola, and going down on either side toward the planned new submammary crease. ‘The medial branch joins the new crease in a curve, at 8 to 10 cm from the midline, A lat. eral triangular excision completes the confined Small Ptotic Breasts In patients with not large but moderately ptotic and flabby breasts (first degree), we ‘de-epithelize” the circumscribed area and defat in the region of the future submammary fold, to facilitate the creation of a new and higher crease. When the skin edges are now Drought together, the breast is lifted, rounded, and has become firm again (Figs. 2, 8). If there is too little fatty and glandular tissue available to achieve the desired shape, we add an implant as a supplementary procedure (Fig. 3). In these cases, it is important to mark the area to be ‘“de-epithelized” after the prosthesis is inserted (and inflated, if an inflatable model is used) Slightly Enlarged Breasts In slightly heavier and longer breasts (sec- ond degree), the periareolar “de-epitheliza- DeerrTexization XQ ou ay MRT FO PLASTIC & RECONSTRUCTIVE SURGERY, February 1975 tion” is extended upward, and a fusiform fat skin excision is performed in the lower lateral quadrant (Figs. 4, 9) Large Breasts In really big breasts (third degree) , this exci- sion can include the central parts of both lower quadrants—sometimes forming a huge in the Strdmbeck,?* Pitanguy,!* and Skoog’ procedures (Figs. 5, 10). Completing the Operation In all types a new inframammary fold is cre- ated at a higher level. This is done by under- ining the breast skin on the medial lower side of our incision, and by removing subcuta- Sg MAMMARY PROSTHESIS Fic. $, In the treatment of ptotic breasts which are also flabby and flat, lacking in substance, an implant is added. The marking and the “de- are done after the prosthesis has Le FORWER BREAST SKIN NOM OEFATED Fic 4. Second degree (moderate) hypertrophies require a larger “de-epithelized” area, so a fusion excision of skin and fat is performed in the lower lateral quadrant.Vol. 55, No. 2 [ REDUCTION MAMMAPLASTY se-prne.raio8 Fic. 5. Large (third degree) hypertrophies require extensive ex 143 Fer east 0 ww OFATED faions, including the cen: tral area of the lower part of the breast. The skin on the lower side of the breast, close to the submammary fold, is defatted and sutured to the pectoral fascia. In this manner 2 new, higher, submammary crease results. This technique can also be employed in the treatment of first degree and second degree cases. neous fat in that triangular area. In the same way we defat the skin flap just above the infra- ‘mammary crease, The new inframammary fold is then completed by excising the lateral “dog- As the next step, we pull the areola into its new position by 4 to 6 Donati (half-buried, horizontal) sutures tied within its margin (Fig. 6). In other words, we perform a dermopexy from the areolar border to the edge of the “‘deepithelized” zone, placing the nipple on the top of the new cone, The mobilized and raised submammary skin, as well as the skin of the Keyhole incision and triangular excision areas, has to be fixed tightly to the thoracic wall with subcutaneous sutures. By this techni- cal detail the circumference of the base of the breast becomes much smaller. (Basically, we cannot agree with those authors who claim that, in mammary hypertrophy and ptosis, this circumference can be left intact by the correc- tive surgery.) All the skin closures are done by intradermal sutures, with only a few single skin sutures added at critical points (Fig. 7). DISCUSSION We have started to perform two-stage operations in extreme cases, where ob- viously one of the above-mentioned techniques was indicated but where the patient desired a scar-free median sub- mammary crease. If such a patient is young and is willing to undergo two op- erations, we think this is justified (Fig. 11). Once a scar is set, whether slight or not, it will be visible all the patient's Fic, 6, The nipple and areola are pulled into their new location by Donati half-buried, horizon: tal, mattress sutures. The circumference of the skin at the outer border of the defect is always a trifle longer than the circumference at the correspond- ing inner border (areola) INTRACUTICULAR < NYLON SUTURE WALE-BURIED HORIZONTAL MATTRESS. SUTURES Fic, 7. All the skin closures are done with intra- dermal running sutures, plus 2 few interrupted sutures at critical points.144 PLASTIC & RECONSTRUCTIVE suRcERY, February 1975 Fic, 8. A first degree case, where only a “de-epithelization” was performed,Vol. 55, No, 2 | REDUCTION MAMMAPLASTY 145 Fic. 9. A second degree case, where a new submammary crease was created.146 PLASTIC & RECONSTRUCTIVE SURGERY, February 1975 Fic, 10. Probably the largest extent of third degree hypertrophy that can be operated fon by our method in one stage. The result is shown two weeks postoperatively. The still rather voluminous breasts were the wish of this patientVol. 55, No. 2 | REDUCTION MAMMAPLASTY 147 Fic. 1. Extreme hypertrophy and ptosis required 2 two-stage procedure. life. We believe this is one of the most important reasons why some women are afraid to have surgery done on their breasts SUMMARY A technique for reduction mamma- plasty, with emphasis on obtaining a scarfree median part of the submam- mary fold, is reported. It produces an L-shaped suture line and an elevation of the submammary fold. Different incisions and resections are adapted to the different forms and de- na 20-year-old woman. The result shown grees of mammary hypertrophy and pto- sis. Rodolphe Meyer, MD. 15 Av, Rambert 1005 Lausanne, Switzerland Dr. Meyer is Associate Professor of Plastic Sur- {ery at the University Hospital in Lausanne. REFERENCES enberger, H.: Deformititen und Kosme- tische Operationen der Weiblichen Brust. Mandrich, Wien, 1931 2 Dufourmentel, C., and Mouly, R: Plastic mammaire par la méthode oblique. Ann. chit, plast,, 6: 43, 1961,148 3. | Goulian, D., Jr, and MeDivitt, R. W. 1 Joseph, J Ne PLASTIC & Dufourmentel, C., and Mouly, R Développe- ‘ments récents de la plastie mammaire par la méthode oblique latérale. Ann. chir. plast 10: 227, 1965. |. Dufourmentel, C., and Mouly, R.: Modification fof “periwinkleshell” operation for small totic breast, Plast. & Reconstr, Surg., #1: 52, 1968 Elbaz, J. §., and Vetheecke, G.: La cicatrice en L dans les plasties mammaires. Ann, chir, plast,, 17: 285-288, 1972. Subeu taneous mastectomy with immediate recon: struction of the breasts, using the dermal mastopexy technique. Plast. & Reconstr. Surg., 50: 211, 1972. Hinderer Meise, U.: Remodeling mammaplasty with superficial and retromammary dermo: pexy.In Tyansacta der 3. Tagung der Verein- figung der Deutschen Plastischen Chirurgen, Koln, 1972. s. Hollinder, E.: Die Operation der Mammahy. pertrophie wnd der Hangebrust, med. Wehnschr., 50: 1400, 1924. enplastik wid Sonstige Gesichts- plastik, nebst-Mammaplastik. C. Kabitseh, Leipaig, 1928. Kraske, H.: Die Operation der atrophischen ‘und hypertrophischen Hangebrust. Miinchen med. Wehnschr., 70: 672, 1928. Lalardrie, J. P Reduction mammaplasty for hypertrophy with ptosis. In Transacta der 3. Tagung der Vereinigung der Deutschen Plas tischen Chirurgen, Kéla, 1972. Lexer, E: Ptosis operation. Kli ‘Augen, 70: 464, 1925, Lotich, G.'M., and Gohrbandt, E.: Operationen an der weiblichen Brustdriise, In Chirur- iiche Operationsiehre, Edited by Bier, Braun, and Kummel, A Barth Verlag, Leip: zig, 1955. May, H. Breast plasty in the fen Reconstr. Surg. 17: $51, 1956. MeKissock, P. K: Reduction _mammaplasty with a’ vertical dermal flap. Plast. & Re Deutsche Monatsbl le, Plast, & 16. 21 2 24 2. a |. Winkler, E.: RECONSTRUCTIVE SURGERY, February 1975 constr. Surg. 49: 245, 1972. Meyer, R.. and Kesselring, U. Kz Mamma- plasty. Internat. Microf. J. Aesth. Plast. Surg, 1974. Meyer, "R., and Martinoni, G.: Mastoplastica di riduzione. 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L, Alache, A. E, Silver, L., and nonda, TA’ single dermal pedicle nipple transposition in subcutaneous mastectomy, reduction mammaplasty, oF mastopexy. Plast. & Reconstr. Surg., 31: 115, 1978, Korrekturoperationen der _wei- Dlichen Brust. Klin. Med. (Wien), 20: 308, 1965. Regnault, P.: Reduction mammaplasty by the “BR” technique. Plast. & Reconstr. Surg., 53: 19, 1974