INTRODUCTION
Reduction mastoplasty is a challenging procedure for plastic surgeons, although
many techniques explaining how to perform it have been described in the
literature1-5. The methods that are usually cited are
empiric and mostly based on a surgeon’s intuition. Several techniques can be
used to mark the skin, remove breast tissue, and perform a skin incision and
resection, presenting their own advantages and disadvantages. Some can be
applied only to small breasts or breasts with specific characteristics. However,
none of the techniques can be applied in procedures for repairing breast
morphological changes induced by different etiological causes.
The first surgical technique for breast reduction was developed by Paulus
Aegenita, who in the 7th century, described in detail a procedure used to
correct gynecomastia. More-reliable methods were described in the 1920s by
Thorek, Aubert, and Passot. Improvements of the techniques were then reported by
Schwartzmann and De Biesenberger in the 1930s. The technique described by Dr.
Schwartzmann is still used nowadays.
The era of modern mastoplasty started in the 1960s with the works of Strombeck
and Pitanguy, who published their technique based on the information reported by
Lexer (1912), Kraske (1923), and Arié (1957). The contributions of Skoog (1963),
in relation to the lateral dermal pedicle, and Mackissock (1972), concerning the
popular procedure of areola reconstruction with bipedicled dermal flaps, are
also worth mentioning6.
The surgical technique known as single marking (SM) was developed by Pessoa7 in 1989 at the Service of Plastic Surgery
and Reconstructive Microsurgery of Walter Cantídio University Hospital of the
Federal University of Ceará. The technique was presented at the competition for
the Georges Arié award, and promoted by the Brazilian Society of Plastic
Surgery, in 2009, where it received honorable mention.
This technique was developed by taking into consideration breast morphology,
known worldwide to be conical, and its anatomical relationship with the chest
wall. Therefore, the development of this method was based on the assumption that
when operating a breast, the surgeon aims to achieve a cone-shaped breast in
conditions in which the patient’s breast has total or partial loss of integrity.
The technique is based on anatomical and geometric principles, which could be
applied to all types of procedures for maintaining, repairing, or reconstructing
the breast. This method can be used to treat all types of breasts (small,
medium, large, and giant).
When planning to use this technique, the size of the breast must first be
determined. According to the International System of Units, cubic meter is used
as the standard volume unit. One cubic meter (1 m³) corresponds to a volume of
1,000 L. Therefore, breasts can be deemed small or large just by observing and
calculating the ratio between the space they occupy on the chest divided by the
space they occupy on the abdomen.
The Lalardrie and Jouglard classifications8
were also used. According to the authors, breast size could be represented by 5
categories based on the height (base of the breast) and frontal projection of
the breast. Thus, breasts are divided as follows: having 1. an ideal volume
(250-300 cm3), 2. moderate hypertrophy
(400-600 cm3), 3. significant hypertrophy
(600-800 cm3), and 4. very significant
hypertrophy (800-1000 cm3).
In this article, to be able to use breast volume as the measurement to define
breast size, the Web Calculator9 was used
preoperatively.
To calculate the breast volume that was surgically removed, Archimedes’ principle
(Syracuse, Sicily, 287 BC)10,11 was applied
intraoperatively.
The principle states that
a. All bodies immersed in fluid displaces a determined weight of liquid,
whose volume is equal to the volume of the submerged body.
b. A body immersed in fluid “loses” a fraction of its weight that is equal
to the weight of the fluid, which in turn is equal to the submerged
volume of the object.
The principle was not used in the original technique of Pessoa7 but was applied in the present study.
Moreover, on the basis of the above-mentioned statement, “any surgeon performing
breast surgery aimed at repairing or reconstructing the breast must create,
maintain, or reconstruct the cone shape regardless of any change that totally or
partially compromises the breast anatomy.”
OBJECTIVE
The objective of this study was to demonstrate the effectiveness of the single
marking technique proposed by Pessoa7 and
performed while training new plastic surgeons. Herein, we report the results
obtained in patients with different degrees of breast hypertrophy and ptosis who
underwent the procedure.
METHODS
We conducted a retrospective and descriptive study based on the data collected
from the medical records of women diagnosed as having breast ptosis,
hypertrophy, gigantomastia, and/or breast asymmetry who underwent reduction
mastoplasty.
Ninety-five patients were evaluated by analyzing and comparing the breast before
and after surgery. The outcomes of the procedures performed between January 2014
and May 2017 by first-, second-, and third-year residents (R1,
R2, and R3, respectively) were assessed.
This study was approved by the research ethics committee of the institution
(opinion no. 69467517.5.0000.5045).
Surgical procedures were preceded by anamnesis, physical examination, laboratory
tests, cardiac examinations, and screening of breast abnormalities by
ultrasonography and mammography, conducted in patients aged >35 years.
The inclusion criteria were as follows:
1. Patients aged >21 years.
2. Patients with breast volumes > 300 cm3.
3. Patients whose main preoperative complaints were physical discomfort, bad
posture, back pain, and premenstrual pain.
4. Patients with an outpatient postoperative follow-up of 1 year.
5. Patients who signed the informed consent form.
The exclusion criteria were as follows:
1. Patients with a body mass index (BMI) ≥ 28.
2. Patients with psychological disorders.
3. Patients with indication for prosthesis implantation without skin and/or
areola reduction.
To evaluate the results, the opinions of both the surgeons (residents) and the
patients were considered.
All the patients were monitored postoperatively, on dates scheduled in the
outpatient clinic of the above-mentioned service. All the women were monitored
for a period of 1 year, after which we collected the data to conduct this
study.
The data analyzed were age, degree of patient satisfaction, appearance of the
scars, volume of the resected breast tissue per surgery, type of resulting scar,
and early and late complications.
On their visit at 1 year after the procedure, the patients were given a survey
questionnaire, with topics listed in Chart 1 and referring to the quality of the treatment result, final volume,
breast shape and ptosis, aesthetic quality of the nipple-areola complex (NAC),
breast symmetry, scar quality, and degree of satisfaction (very satisfied,
satisfied, poorly satisfied, and dissatisfied).
Chart 1 - Patients' satisfaction with the procedure.
| 1. Degree of satisfaction with breast volume |
| a) Note 0 b) Note 1 c) Note 2 |
| 2. Degree of satisfaction with form and degree of
ptosis
|
| a) Note 0 b) Note 1 c) Note 2 |
| 3. Degree of satisfaction with CAP quality |
| a) Note 0 b) Note 1 c) Note 2 |
| 4. Degree of satisfaction with symmetry of
breasts
|
| a) Note 0 b) Note 1 c) Note 2 |
| 5. Degree of satisfaction with scar quality |
| a) Note 0 b) Note 1 c) Note 2 |
Chart 1 - Patients' satisfaction with the procedure.
To calculate the volume of the cone and define the desired breast size
preoperatively, we used the Web Calculator9 along with measurements of the radius of the breast base and its
projection.
Figures 1 and 2 show how the measurements were taken. Figure 3 shows an example of the Web
Calculator used to determine the volume of the straight cone.
Figure 1 - Measurements to calculate breast volume. (h) - breast height or
projection, the distance between the chest midline and the
nipple-areola complex; (r) - radius of the base of the breast (known
as foot print in the English literature), half the
diameter measured between the second and sixth ribs.
Figure 1 - Measurements to calculate breast volume. (h) - breast height or
projection, the distance between the chest midline and the
nipple-areola complex; (r) - radius of the base of the breast (known
as foot print in the English literature), half the
diameter measured between the second and sixth ribs.
Figure 2 - Measurements to calculate the breast volume: (h) - breast height
or projection, distance between the chest midline and the
nipple-areola complex; (r) - radius of the base of the breast (known
as foot print in the English literature), half the
diameter, measured between the second and sixth ribs.
Figure 2 - Measurements to calculate the breast volume: (h) - breast height
or projection, distance between the chest midline and the
nipple-areola complex; (r) - radius of the base of the breast (known
as foot print in the English literature), half the
diameter, measured between the second and sixth ribs.
Figure 3 - Web Calculator used to calculate the volume of the straight cone.
Figure 3 - Web Calculator used to calculate the volume of the straight cone.
The principle of Archimedes of Syracuse, Sicily, was used to determine the volume
of the breast tissue removed intraoperatively, and the method used for this
purpose is shown in Figure 4.
Figure 4 - Determination of the breast volume removed intraoperatively using
Archimedes’ principle.
Figure 4 - Determination of the breast volume removed intraoperatively using
Archimedes’ principle.
This principle was applied using 2 disposable plastic containers. One was filled
with saline or distilled water. The resected tissue was placed in the other
container, which presented the same capacity and was filled with fluid from the
first container. This allowed the calculation of the volume of resected tissue,
which was equal to the volume of fluid that remained in the first container.
The following observation criteria were used to establish the qualitative
parameters of the results obtained from the mastoplasty procedures:
Ideal breast:
a. Conical shape, between the second and sixth intercostal spaces;
b. Ideal volume: 250-300 cm3;
c. Areolas with a diameter of 4 cm;
d. Distance between the upper limit of the areola and the sternal wishbone:
≤19 to 23 cm;
e. Distance between the midline and the lateral limit of the areola: 9 to 11
cm;
f. Breast symmetry;
g. NAC with everted nipples and preserved sensitivity;
h. Preservation of the ability to breastfeed;
i. Scars well positioned within the folds; scars that remain on the breasts
should be barely visible.
In the present study, the responses given by the residents to the anonymous
structured questionnaire were analyzed, including variables referring to the
single marking technique proposed by Pessoa7, the self-assessment of the technique, and the received training.
The responses to the survey were scored in an odd ordinal scale from 1 to 3,
with a fourth negative option that did not measure the variable (Chart 2). In addition, the residents’
satisfaction with the final outcomes of the procedure was assessed using the
same questionnaire as that given to the patients (Chart 1).
Chart 2 - Questionnaire about the difficulties experienced by the residents
during the surgical procedure.
| 1. Demarcation |
| a) Average b) Few c) None |
| 2. Access to the gland and choice of pedicle |
| a) Average b) Few c) None |
| 3. Breast Modeling |
| a) Average b) Few c) None |
| 4. Symmetrization |
| a) Average b) Few c) None |
| 5. Breast Closure - Suture |
| a) Average b) Few c) None |
Chart 2 - Questionnaire about the difficulties experienced by the residents
during the surgical procedure.
The variables and graphs were entered into Microsoft Excel.
The statistical analysis was performed using the EPIINFO 6.0 software.
RESULTS
The patients’ ages ranged from 21 and 61 years (Graph 1).
Graph 1 - Age distribution of the patients who underwent reduction
mastoplasty.
Graph 1 - Age distribution of the patients who underwent reduction
mastoplasty.
The main postoperative complaints were physical discomfort (100%), bad posture,
and back pain (81%).
The inferior and superior pedicle techniques were used in 93 (97.89%) and 2
(2.11%) of the patients, respectively.
The final breast volumes were calculated using the formula of the breast cone as
previously described. The results ranged from 315 to 690 cm3.
The types of resulting scars were as follows: T-shaped (98.95%) and L-shaped
(1.05%). The mean surgical time was 3 hours.
The observed complications were divided as follows:
a. Early complications: occurring up to 30 days after the procedure, and
divided into epidermolysis (11.58%), suture dehiscence (9.47%), necrosis
of the NAC (1.05%), and infections (0%; Graph 2).
Graph 2 - Early complications of reduction mastoplasty.
Graph 2 - Early complications of reduction mastoplasty.
b. Late complications: occurring during the patient follow-up period and
divided into significant asymmetry (1.05%) and ptosis recurrence of
Regnault grade ≤ II (5.26%). No other types of late complications
were reported.
Graph 3 shows the degree of patient
satisfaction with the procedure, which was assessed by scoring (2, 1, and 0) the
following 5 aspects: resected volume, breast shape and degree of ptosis, quality
of the NAC, breast symmetry, and scar quality.
Graph 3 - Degree of patient satisfaction with the procedure in relation to
the resected volume, breast shape and degree of ptosis, quality of
the nipple-areola complex, breast symmetry, and scar quality.
Graph 3 - Degree of patient satisfaction with the procedure in relation to
the resected volume, breast shape and degree of ptosis, quality of
the nipple-areola complex, breast symmetry, and scar quality.
The following results were obtained in relation to the degree of patient
satisfaction: 90.53% of the patients were very satisfied; 5.26%, satisfied;
3.16%, poorly satisfied; and 1.05%, dissatisfied (Graph 4).
Graph 4 - Analysis of the patients’ degree of satisfaction with the
procedure.
Graph 4 - Analysis of the patients’ degree of satisfaction with the
procedure.
Among the 9 residents who answered the questionnaires to evaluate the
difficulties experienced during the surgical procedure, 3 were R1 (33.3%), 3
were R2 (33.3%), and 3 were R3 (33.3%); 6 were men (66.7%), and 3 (33.3%) were
women.
Among the residents, 11.11% reported intermediate difficulties in the surgical
marking step (1 R1); 33.33%, some difficulties (2 R1 and 1 R2); and 55.56%, no
difficulties (2 R2 and 3 R3).
Regarding the access to the gland and the choice of pedicle, 44.44% reported some
difficulty (3 R1 and 1 R2) and 55.56% reported no difficulty (2 R2 and 3
R3).
Regarding breast reshaping, 11.11% of the residents reported intermediate
difficulties (1 R1); 33.33%, some difficulty (2 R1 and 1 R2); and 55.56% (2 R2
and 3 R3), no difficulty.
Regarding breast symmetry, 44.44% of the residents reported intermediate
difficulty (3 R1 and 1 R2); 22.22%, some difficulty (2 R2); and 33.33%, no
difficulty (3 R3).
Regarding breast closure, 44.44% of the residents reported some difficulty (3 R1
and 1 R2); and 55.56% (2 R2 and 3 R3) no difficulty (Graph 5).
Graph 5 - Degree of difficulty experienced by R1, R2, and R3 residents in
executing the steps of the surgical procedure.
Graph 5 - Degree of difficulty experienced by R1, R2, and R3 residents in
executing the steps of the surgical procedure.
The degree of resident satisfaction with the results of the procedure was
assessed by scoring the 5 aspects (on a scale of 2, 1, and 0) shown in Graph 6.
Graph 6 - Degree of satisfaction of the residents in performing the
procedure in relation to the resected volume, breast shape and
degree of ptosis, quality of the NAC, breast symmetry, and scar
quality.
Graph 6 - Degree of satisfaction of the residents in performing the
procedure in relation to the resected volume, breast shape and
degree of ptosis, quality of the NAC, breast symmetry, and scar
quality.
Example cases are shown in Figures 5 and
6.
Figure 5 - Outcomes obtained after reduction mastoplasty performed with the
single marking technique.
Figure 5 - Outcomes obtained after reduction mastoplasty performed with the
single marking technique.
Figure 6 - Outcomes obtained after reduction mastoplasty performed with the
single marking technique.
Figure 6 - Outcomes obtained after reduction mastoplasty performed with the
single marking technique.
DISCUSSION
Reduction mastoplasty is one of the most common surgical procedures performed by
plastic surgeons12. When choosing the
type of procedure, one of the surgeon’s major concerns is safe transposition of
the NAC and achieving a breast cone that meets the patient’s expectations.
Advances in the understanding of vascular anatomy since the 1980s, in
particular, allowed plastic surgeons to plan a safe transposition of the NAC on
the following 4 pedicles with axial extensions: superior, inferior,
mediolateral, and lateral.
Mastering the single marking technique allows the surgeon to safely transpose the
NAC within the indication and needs of each patient, which is one of the major
advantages of using the method.
The concept of single marking broke the paradigm that no universal technique has
been established for breast surgery, as its principles can be applied to all
types of breast procedures, provided that the intention is to maintain, repair,
or reconstruct the breast cone. From a mathematical point of view, this
technique respects the individuality of patients.
The definition of an ideal outcome could be easily modified by establishing, when
planning the surgery, whether the resulting cone will be maintained, reduced, or
increased with the removal of the skin or breast tissue or with the insertion of
silicone implants.
Another important point is the possibility of not making a prior skin removal,
which is unnecessary before the planned cone is defined. This technical feature
can define the type of resulting scar as circumferential, racket-shaped,
L-shaped, T-shaped, or anchor-shaped. Many articles in the literature describe
how to create the cone with different scar results.
The possibility of using mathematical concepts allows obtaining completely
predictable results, especially when associated with glands and skin reshaping,
which is performed in distinct stages. This practice prevents errors such as the
removal of excess glands and skin, which cannot be corrected afterward.
An individualized approach is used for each patient.
Unnecessary scars are prevented, and planning a skin pocket can avoid the
occurrence of asymmetries.
Another important point to consider is the infiltration of anesthetic and
adrenaline solutions to aid in reducing bleeding, which spares the patient from
complications, reduces the surgical time without increasing the incidence of
bleeding or hematoma, and provides a low-risk postoperative period with lower
risk of infection.
The technique does not involve resections below the NAC, which should be located
10 cm above the breast tissue.
In this study, the incidence of NAC necrosis caused by procedures performed to
correct gigantomastia (very significant hypertrophy) was up to 85-90%, which is
in agreement with the reports in the literature13-15. In the
present study, the NAC viability was 98.95%.
A high degree of patient satisfaction (90.53%) was observed, with outcomes rated
between satisfactory and excellent, similar to the findings published by Ronconi
et al.16, Cho et al.17 and Rohrich et al.18, who used well-established surgical techniques among the national
and international communities of plastic surgery.
In the study that described the opinions of the plastic surgery residents
regarding the training and self-learning of the surgical technique, the
technique was highly favorable, presenting a short learning curve.
Although the residents were highly or moderately satisfied with the outcomes of
the procedures performed, they all identified several aspects they wished to
improve in relation to breast surgery training/learning. This finding highlights
the importance of anonymity in questionnaires to prevent unreliable results.
The above-mentioned observations were not made by the R3 group.
Pessoa’s single marking technique is a recently developed method; therefore, its
increasing use by surgeons and improved description will undoubtedly lead to its
evolution and better outcomes.
CONCLUSION
In this study, the use of the single marking technique proposed by Pessoa7 was highly effective.
A high degree of satisfaction was reported both by the patients and the
residents. The outcomes were rated as good and excellent. The position and shape
of the scars were satisfactory, and their sizes were reduced to minimum.
Moreover, the results presented herein confirm that the technique is effective
for training residents, proving to be an easy-to-learn, safe, and predictable
method.
COLLABORATIONS
|
SGPP
|
Analysis and/or data interpretation, data curation, formal analysis,
methodology, visualization.
|
|
AM
|
Analysis and/or data interpretation, conception and design study,
data curation, final manuscript approval, methodology, project
administration, writing - original draft preparation.
|
|
JADL
|
Conception and design study, final manuscript approval, project
administration, supervision.
|
REFERENCES
1. Schartzman E. Die technik der mammaplastik. Der Chirurg.
1930;2:932.
2. Ariê G. Nova técnica em mastoplastia. Rev Latinoam Cir Plast.
1957;3:22-8.
3. Strombeck JO. Reduction mammaplasty. In: Grabb WC, Smith JW, eds.
Plastic surgery. Boston: Little, Brown and Co; 1968.
4. Pitanguy I. Hipertrofias mamárias: estudo crítico da técnica
pessoal. Rev Bras Cir. 1966;56:263.
5. Skoog T. Plastic surgery: new methods and refinements. Philadelphia:
Saunders; 1974.
6. Neligan PC, Grotting JC. Cirurgia Plástica: Técnicas de
CirurgiaEstética de Mama. Rio de Janeiro: Elsevier; 2015. p.
153-64.
7. Pessoa SGP, Dias IS, Pessoa LMGP. Mastoplastia com marcação única:
uma abordagem pessoal. Rev Bras Cir Plást. 2009;24(4):509-20.
8. Lalardrie JP, Jouglard JP. Plasties Mammaries pour Hypertrophie et
Ptose. Paris: Masson; 1973.
9. WebCalc. Área/Volume do Cone Reto. [acesso 2018 Out 2]. Disponível
em: http://webcalc.com.br/Matematica/form/cone_reto
10. Guimarães ABAB. O velho princípio de Arquimedes. Cad Bras Ens Fís
(Florianópolis). 1999;16(2):170-5.
11. Martins TF, Rodrigues FL, Malafaia PAM, Cruz FAO. Princípio de
Arquimedes: do treinamento virtual a execução experimental. Vivências.
2015;11(21):199-205.
12. Cammarota MC, Camara Filho JPP, Daher JC, Benedik Neto A, Faria
CADC, Borgatto MS, et al. Aplicação estética e reconstrutora da mamoplastia com
pedículo areolado. Rev Bras Cir Plást. 2014;29(2):237-42.
13. Bostwick J. Plastic and Reconstructive Breast Surgery. St Louis:
QMP; 1990. DOI:
https://doi.org/10.1097/00006534-199104000-00034
14. Hefter W, Elvenes OP, Lindholm P. A retrospective quantitative
assessment of breast sensation after lateral pedicle mammaplasty. Br J Plast
Surg. 2003;56(7):667-73. DOI:
https://doi.org/10.1016/S0007-1226(03)00308-4
15. Graf R, Biggs TM. In search of better shape in mastopexy and
reduction mammoplasty. Plast Reconstr Surg. 2002;110(1):309-17. DOI:
https://doi.org/10.1097/00006534-200207000-00053
16. Ronconi RC, Vieira FA, Boechat CEJ, Nunes PSMR, Aboudib JHC, Castro
CC. Estudo Retrospectivo de 730 Pacientes Submetidas a Mamaplastia Redutora. Rev
Bras Cir Plást. 2004;19(2):58-62.
17. Cho BC, Yang JD, Baik BS. Periareolar reduction mammoplasty using an
inferior dermal pedicle or a central pedicle. J Plast Reconstr Aesthet Surg.
2008;61(3):275-81. PMID: 18037359 DOI:
https://doi.org/10.1016/j.bjps.2007.10.024
18. Rohrich RJ, Gosman AA, Brown SA, Reisch J. Mastopexy preference: a
survey of board-certified plastic surgeons. Plast Reconstr Surg.
2006;118(7):1631-8. PMID: 17102738 DOI:
https://doi.org/10.1097/01.prs.0000248397.83578.aa
1. Universidade Federal do Ceará, Fortaleza, CE,
Brazil.
2. University of Belgrade, Belgrado,
Sérvia.
Corresponding author: Salustiano Gomes de Pinho
Pessoa, Avenida Parnamirim,1001 - Cs 05, Centro, Eusebio, CE, Brazil.
Zip Code 61760-000. E-mail: salustianogpessoa@gmail.com
Corresponding author: Aleksandra Markovic, Avenida
Beira Mar, 4260, Praia de Mucuripe, Fortaleza, CE, Brazil. Zip Code 60165-121.
E-mail: 19quepasa19@gmail.com
Article received: July 05, 2018.
Article accepted: April 21, 2019.
Conflicts of interest: none.
