INTRODUCTION
During the aging process and consequent breast ptosis, emptying of the upper pole
occurs. The breast loses its anatomically beautiful shape and its base becomes transversal,
inverting its diameters1. The more the horizontal direction is elongated, the greater the ptosis. In the frontal
view, the vertical diameter of the breast should be aesthetically perfect and longer
than the horizontal in the proportion of 1.3:1. This is a frequent complaint in the
postoperative period because the possible flaps for upper pole projection and elongation
of the vertical diameter and horizontal reduction do not offer full filling in all
cases because they do not reach the highest horizontal breast line (HHBL), the connection
between the two anterior axillary folds1.
Breast tissue flaps are used for this purpose. The most commonly used is the lower
pedicle axial flap described by Ribeiro et al. in 20022 in its various forms2,3. However, in some cases, it does not reach the upper pole when the measurement between
the submammary groove (at the vascular pedicle) and the areola is insufficient for
its end under the breast to reach the HHBL1. This excellent flap fills the upper and lower poles, not changing the proportion
between them. Crossed flaps of the medial and lateral sides of the breast would have
the same purpose: one would fill the upper breast pole and the other assuming the
position of the first4,5,6.
In the breast ptosis process, on breast profiles (Figure 1), the measurement between the cone’s apex and the groove expands, while that between
the apex and the upper pole ridge shortens. The ratio of the proportion between the
lower and upper measurement that should be from 1:1.6 to 1:1.41; as it approaches 1, the breast becomes more flaccid. It also occurs in postoperative
techniques that do not model and structure the cone’s breast as a fundamental principle
with appropriate proportions and measures and use the skin’s traction and resistance
to provide shape. In the medium term, the breast acquires the shape left by the surgeon
and the flap distends the skin, acting as an expander. This elongates the vertical
scar even if it is initially short and under tension. The proportion between the upper
and lower poles is inverted and the breast loses its original shape in the early postoperative
period.
Figure 1 - Breast with ptosis and larger volume below the areola; inversion of the measurements
between point A to the groove and from it to the upper ridge.
Figure 1 - Breast with ptosis and larger volume below the areola; inversion of the measurements
between point A to the groove and from it to the upper ridge.
In cases of secondary mammoplasty, where there is enough volume to recreate the proper
shape and the proportion between the lower and upper segments is inverted, the proposed
tactic will be indicated. This is also true in primary breasts with the same inversion,
which is sometimes called pseudoptosis7.
OBJECTIVE
To describe use of the upper pedicle flap to fill the upper breast pole.
METHODS
There is a fundamental principle governing the flap’s vascular anatomy. The breasts
are considered deeply modified sweat glands that are fundamentally ectodermic, that
is, fixed to the skin.
At birth, the mammary glands show the same development in both sexes. In females at
puberty or during pregnancy and breastfeeding, they change under hormonal influence.
During female puberty, breast buds develop and distend the skin and subcutaneous tissue,
decreasing their thickness from the peripheral adjacent thorax to the gland to the
areola. It is in this tissue that blood vessels, lymphatic vessels, and nerves run
in a converging network up to the nipple–areola complex (NAC). Degree of breast growth
depends on both hormone dosage and number of buds.
Breast shape depends on the skin’s distensibility. The more resistant the skin, the
less projected the breast will be with a wider base. The thinner the skin, the narrower
the base. Therefore, the base’s extension and breast cone’s projection can be classified
into 4 groups of hypertrophies and 4 groups of hypomastia8,9.
The upper vascularization originates from the perforators of the internal thoracic
artery, with its branches of the second and third more calibrous veins. They irrigate
the upper internal portion from the subcutaneous tissue inward toward the mammary
tissue. In the upper lateral portion, the mammary branches penetrating the gland from
the subcutaneous tissue originate from the lateral thoracic artery, an axillary branch.
In the upper pole, irrigation comes from the pectoral branches of the thoracoacromial
artery, penetrating the gland in the same way as the others through the subcutaneous
tissue (Figures 2A, 2B, and 2C)10.
Figure 2 - Vascularization scheme of the breast from the surface to the depth with pedicles in
all quadrants in network to the papilla.
Figure 2 - Vascularization scheme of the breast from the surface to the depth with pedicles in
all quadrants in network to the papilla.
The thickness of the subcutaneous tissue in the thorax changes only with changes in
body weight. It serves as a guide for obtaining flaps or detaching glands without
damaging the arterial irrigation, venous drainage, lymphatic system, or innervation.
Surgery
Excess skin markings for resection to correct ptosis should be performed according
to the surgeon’s experience. This can appear as an inverted T, L, or vertical line
depending on the degree of ptosis.
In the breast meridian, the measurement between point A and the upper glandular ridge
is equal to or less than that from point A to the submammary groove. In primary or
secondary cases, with sufficient volume, the proposed tactic is indicated except in
secondary cases in which the primary surgery was performed by techniques that detached
the skin from the gland.
The excess skin is de-epidermized from the demarcated area to the submammary groove.
Both periareolar and subareolar, this lower region can be removed.
Using Kocher forceps, point A is pulled perpendicular to the thorax until the gland
is cone-shaped (Figure 3A).
Figure 3 - A. Marking of the breast flap to be obtained while preserving the thickness of the subcutaneous
tissue equal to that of the adjacent thorax. B. The breast’s base detached from the pectoral muscles and the flap obtained by preserving
the thickness of the subcutaneous tissue of the adjacent thorax. C. View of the flap where the excess was removed from its medial and lateral parts and
wedge removal at the lower pole to reduce the lateral–lateral diameter. D. The flap dipped under the breast with the end reaching the highest horizontal breast
line.
Figure 3 - A. Marking of the breast flap to be obtained while preserving the thickness of the subcutaneous
tissue equal to that of the adjacent thorax. B. The breast’s base detached from the pectoral muscles and the flap obtained by preserving
the thickness of the subcutaneous tissue of the adjacent thorax. C. View of the flap where the excess was removed from its medial and lateral parts and
wedge removal at the lower pole to reduce the lateral–lateral diameter. D. The flap dipped under the breast with the end reaching the highest horizontal breast
line.
In the mammary meridian, at point A, the lower measurement is marked for the desired
side (6–8 cm) toward the submammary groove. It is from this point to the groove that
the possible flap thickness is obtained (it can be reduced if necessary). This represents
how much it is possible to increase the upper pole by reducing the lower pole. Mathematically,
the proportions can be inverted by transporting tissue from the lower pole to the
upper pole and the proportion between 1:1.4 to 1:1.6 can be offered between the lower
and upper measurements based on the A point of the future papilla.
The breast should be detached from the pectoral muscles. The medial and lateral thickness
of the peripheral subcutaneous tissue should be preserved without detachment, avoiding
lesions to the vessels that irrigate it. In the upper pole, it detaches until it reaches
the upper horizontal breast line without reaching the upper nutrient vessels present
in the subcutaneous tissue. In the lower pole, at the meridian, a mini lower pedicle
described by Ribeiro et al. in 20022 is left to recompose it (Figure 3A). The mammary tissue is detached from the flap at the lateral and medial sides, in
the skin and subcutaneous tissue, again preserving the thickness equal to the adjacent
thorax (Figure 3B).
The gland is transversally incised where the flap thickness was marked, directing
it to the upper pole until just above the transversal diameter of the breast cone
base (Figure 3C).
This glandular flap is obtained in a slightly cylindrical way; if reduced in its lateral
and medial ridges (Figures 3B, 3C), it resembles a half moon (Figures 4A, 4B). It is turned into what is termed a “book leaf,” with the transversal axis of the
pedicle above half of the breast base. It is introduced through the upper detached
area reaching the HHBL1 (Figures 3D, 4C, and 4D), where its end is fixed. It redoes the upper breast pole, filling it, reducing the
lower one and inverting the measurements between the two segments (Figures 5A and 5B). If there is a need to reduce the lateral diameter of the mammary cone, a vertical
wedge can be made in the remaining mammary tissue of the lower pole up to before the
flap pedicle (Figures 3C, 3D).
Figure 4 - The same half-moon-shaped flap without removal of its lateral and medial parts.
Figure 4 - The same half-moon-shaped flap without removal of its lateral and medial parts.
Figure 5 - Profile scheme of breast tissue transfer from the lower to upper pole in the form
of a mixed axial glandular and randomized flap.
Figure 5 - Profile scheme of breast tissue transfer from the lower to upper pole in the form
of a mixed axial glandular and randomized flap.
If further volume reductions are required, part of the flaps or tissue of the bottom
base will be resected. In all tactical maneuvers, the thickness of the subcutaneous
should be preserved equal to that of the thorax except in the upper pole where the
flap will be implanted.
RESULTS
The authors operated on six patients at the Base Hospital of the Medical School of
São José do Rio Preto. All patients signed an informed consent form prior to participating.
The results showed that the upper pole was filled through inversion of the lower and
upper pole measurements as well as adequate projection (Figures 6A–6F) and (Figures 7A–7F), and the consequent breast shape improvement. There were no complications related
to breast tissue vascularization. This remained natural on palpation without hardening
or clinical signs of steatonecrosis. In one case, the implants were removed, the fibrous
capsule was recent with no signs of a calcium deposit; its anterior portion was fixed
to the flap, facilitating its suture to the upper pole (Figures 8A–8F). Additional cases are needed to analyze the long-term results of the mammary forms
obtained as well as possible complications since this is an innovative rather than
technical surgical tactic of mammoplasty.
Figure 6 - Pre- and postoperative photos of the use of the described procedure.
Figure 6 - Pre- and postoperative photos of the use of the described procedure.
Figure 7 - Pre- and postoperative photos of the use of the described procedure.
Figure 7 - Pre- and postoperative photos of the use of the described procedure.
Figure 8 - Pre- and postoperative photos of a patient who no longer wished to use implants, which
were removed. A flap was made in conjunction with the anterior fibrous capsule.
Figure 8 - Pre- and postoperative photos of a patient who no longer wished to use implants, which
were removed. A flap was made in conjunction with the anterior fibrous capsule.
DISCUSSION
Using our knowledge of ectodermic embryology and breast anatomy, we can make any flap
with or without the NAC if the thickness of the subcutaneous is preserved progressively
thinner as it approaches it. Glandular flaps can also be created if their pedicles
are based on the subcutaneous tissue and skin. They can be axial if they follow the
vascular path and are randomized or mixed (flap of Ribeiro et al. in 20022). If randomized, the appropriate proportions between their widths and lengths are
maintained around 1:1.
The mammary gland embryologically originates from the ectoderm, so it is fixed to
the skin that covers it. The preservation of the peripheral subcutaneous tissue equal
to the thickness of the subcutaneous thorax is fundamental to preserving the vessels
and nerves that converge in a network to the NAC because they irrigate and enervate
the mammary tissue and the remaining skin surface.
The length of the proposed flap does not exceed its width, so its irrigation is satisfactory,
running from top to bottom and from the surface to its depth. Its blood supply is
derived from the branches of the pectoral artery of the thoracoacromial artery and
the perforating vessels of the internal thoracic artery, the second and third intercostal
spaces, and the branches of the thoracic-lateral artery, as long as the subcutaneous
of the thorax peripheral to the gland is preserved, without detachments, except the
upper area where the flap will be introduced.
When the breast tissue includes more adipose than glandular tissue, the flap should
be shorter with a thick pedicle. This is generally enough to fill the upper mammary
pole. If less consistent, it is more difficult to attach it to the appropriate place
and may lead to low-quality results.
There were no major complications denoting a lack of adequate irrigation of the proposed
flap.
In the frontal view, if the areolas are positioned close to the ideal measurements
from the sternal furcula, thus appear too high, the proposed procedure corrects the
visual distortion of the inverted proportions between the upper and lower breast poles.
This tactic was developed by observing the breasts’ vascular behavior during skin-preserving
mastectomies and by making flaps with or without NAC transport performed for over
45 years by the authors.
CONCLUSION
The described flap is proposed to fill the upper breast pole and invert the measures
and proportions between the upper and lower breast segments in primary or secondary
cases, promoting improved breast esthetics.
COLLABORATIONS
ARB
|
Final manuscript approval
|
ACB
|
Analysis and/or data interpretation
|
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1. Faculdade de Medicina de São José do Rio Preto, São José do Rio Preto, SP, Brazil.
Corresponding author: Antonio Roberto Bozola Avenida José Munia 7075, São José do Rio Preto, SP, Brazil. Zip Code: 15085-350.
E-mail: ceplastica@hospitaldebase.com.br
Article received: June 21, 2018.
Article accepted: October 21, 2019.
Conflicts of interest: none.