INTRODUCTION
The rates of breast volume reduction surgery or ptosis correction have increased in
Brazil. In 2019, 202,029 surgeries were performed, representing 13.38% of aesthetic
plastic surgeries. Several surgical techniques have been developed to correct these
breast deformities. The objective is always to achieve increasingly efficient results
and offer a better quality of life for patients with fewer complications. The resulting
scars have been the object of special attention, especially their extent and location.
All breast surgery that requires a change in the spatial situation of the nipple-areolar
plate involves tissue remodeling and skin incisions, which defines the term mastopexy.
Mastopexy is indicated in breast hypertrophy and the correction of breast ptosis.
The history of mastopexy is full of very different techniques. From the description
by Wise in 1956, who introduced the previous demarcation and the ending in an inverted
T, this has been a constant in this type of procedure1. With the description by Pitanguy, 1960, the use of pedicles spread with different
variations2.
However, there is a technique that does not use the previous demarcation, nor is it
based on pre-established pedicles, widely used in our country, devised by Dr. Roberto
Antônio Barjas Millan, a physician of extraordinary importance in the history of the
development of plastic surgery in Brazil and, in particular, in São Paulo, being co-founder
of the Regional of the Sociedade Brasileira de Cirurgia Plástica in 1966 and responsible for the formation of care and teaching services in this specialty.
Dr. Millan, as he is known in our specialty, has admittedly developed and improved
several surgical techniques. However, for reasons of an intimate nature, he never
set out to transform them into scientific documents, being enough for him to teach
and, above all, to obtain a result, the best possible, to the wishes of the patients.
The mastopexy technique he developed differs essentially from the others in that it
is not pre-marked and allows for a change in the shape of the breasts until almost
the end of the surgery, when the necessary tissue resection takes place, especially
skin flaps3.
OBJECTIVE
This research aims to describe the treatment technique standardized by Dr. Millan
without prior marking and assess the level of patient satisfaction after the procedure.
METHODS
This is a primary, cross-sectional, comparative, observational, analytical study developed
at Faculdade de Medicina do ABC, in Santo André-SP, between May 1 and October 1, 2019.
The determinations of Resolution 466/12 of the National Health Council, which provides
guidelines and standards that regulate research involving human beings, were followed
to conduct this project.
The project was analyzed and approved by the Ethics and Research Committee of Faculdade
de Medicina do ABC under protocol CAAE 09088918.8.0000.0082, Opinion number: 3,315,883.
Forty consecutive female patients were selected, 20 of whom were about to undergo
surgery (Control Group) and 20 already operated using the Millan technique (Operated
Group) for at least 6 months and at most 12 months. The patients had grade II and
III breast ptosis according to the Regnauld4 classification, or breast hypertrophy, defined by the criteria of Sacchini5 and Franco & Rebello6. The indications were all primary surgery aged between 18 and 60 years.
All patients were clinically evaluated and were in good health, with no comorbidities.
Body Mass Index (BMI) values ranged from 20 to 29.9 kg/m2. Patients with pregnancy or delivery for less than one year, those undergoing investigation
or diagnosis of breast pathologies and those with other clinical comorbidities were
excluded.
The same surgeon performed the surgeries.
To analyze the women’s level of satisfaction after the procedure, the Breast-Q®7 questionnaire was applied. The following four subscales were used to compare the
two groups: breast satisfaction, psychosocial well-being, sexual well-being, and physical
well-being. The satisfaction with the overall result (postoperative version) subscale
was applied to the mammoplasty group using the Millan technique.
The answers to the items of each subscale were transformed, using the Q-Score® scoring
software, into a total score that ranges from zero to 100. The higher the score, the
greater the satisfaction, or the better the quality of life.
Measures of central tendency and dispersion, as well as absolute and relative frequencies,
were used to describe the variables. Because of the non-normality of some of the study
variables (Shapiro-Wilk test, p<0.05), it was decided to compare them with the second group (control versus postoperative)
through the test of MannWhitney. The association of the group with qualitative variables
was performed using the chi-square. The statistical package STATA 11.0 was used.
Technique
Patients were placed in dorsal decubitus, in a supine position, with the trunk maintaining
an angle of 45° with the pelvis and the hands kept under the gluteal region, with
the arms in a semiflexed position (Figure 1).
Figure 1 - Position of flexed arms, trunk and shoulders during the operation.
Figure 1 - Position of flexed arms, trunk and shoulders during the operation.
The size of the neo-areola was chosen with the aid of areolotomes that varied in three
sizes (Figure 2). Next, the excess areola skin was decorticated (Figure 3).
Figure 2 - Demarcation of the areola reduction.
Figure 2 - Demarcation of the areola reduction.
Figure 3 - Decortication of the areola skin.
Figure 3 - Decortication of the areola skin.
A 3-0 nylon monofilament thread was passed through the areola to keep the breast under
gentle traction, and the projection of the areola was marked in the submammary groove.
The length of the horizontal incision in the sulcus was 5 to 7 cm and the midpoint
projected by the nipple. The incision was made, and the skin and subcutaneous tissue
were sectioned until reaching the supra-aponeurotic plane of the pectoralis major
muscle (Figure 4). The dissection progressed, in this plane, in a superior direction until the projection
of the areola.
Figure 4 - Outcome of areola skin decortication.
Figure 4 - Outcome of areola skin decortication.
The vertical incision site was marked from the lower limit of the decorticated area
of the areola to the midpoint of the incision in the submammary groove, reaching the
mammary gland tissue (Figure 5). From this depth, two flaps, medial and lateral, skin and subcutaneous, were dissected
with sufficient thickness to maintain vitality, which provided ample exposure to the
mammary gland. The dissection did not exceed the median limit of the breast (Figure 6).
Figure 5 - Demarcation and vertical incision.
Figure 5 - Demarcation and vertical incision.
Figure 6 - Exposure of the mammary gland.
Figure 6 - Exposure of the mammary gland.
After demarcation, the glandular tissue segment corresponding to the reduction in
breast height was resected. Next, the area of central tissue considered to be excess
of the gland was demarcated and removed. After this resection, two flaps, medial and
lateral, of glandular tissue resulted. The actual reduction was evaluated when approaching
the flaps mentioned above (Figure 7). The medial and lateral flaps were brought together with a 2-0 nylon monofilament
thread to contain the glandular tissue. The breast was positioned in a new situation
and adjusted to the skin tension by bidigital manipulation. This position was maintained,
and the skin and subcutaneous flaps were transfixed by five U-shaped stitches, with
a distance of approximately 1.5 cm between them. The new position of the breast in
the thorax concerning the contralateral one not yet operated on was observed.
Figure 7 - Glandular resection.
Figure 7 - Glandular resection.
The same demarcation and resection procedures were used in the contralateral gland.
After modeling the flaps of the other breast, the symmetry was adjusted (Figure 8).
Figure 8 - Breast modeling.
Figure 8 - Breast modeling.
Excess skin and subcutaneous tissue were demarcated and resected with a #22 scalpel
blade. Tubular suction drains with a diameter of 4.8 mm were placed, with internal
access at the level of the horizontal incision, exteriorization in the anterior axillary
line bordering the chest, and fixed with 3-0 cotton threads transfixed into the skin
and then tied to the tube. The horizontal and vertical incision was approximated in
planes with absorbable synthetic monofilament thread. The subcutaneous tissue is approximated
by simple stitches separated with 4-0 thread. The skin was initially sutured with
juxtadermal stitches, inverted knots, with 4-0 thread, and, finally, the skin was
sutured with an intradermal stitch with 4-0 absorbable monofilament thread.
To make the neo-areola, the same molds used at the beginning of the operation were
positioned symmetrically at the apex of the breasts. After demarcation, this area
was resected, and the areola was exteriorized. For the approximation of the edges,
they were distributed with four cardinal points, kept for presentation. A juxtadermal
approximation was performed, with 5-0 stitches inverted, followed by a classic Allgower
suture (Figure 9).
Figure 9 - Positioning of the neo-areola.
Figure 9 - Positioning of the neo-areola.
The sutured incisions were covered with cut gauze and fixed with Micropore® tape.
Then, the area was covered with layers of hydrophilic cotton, bandaging and placement
of the drains.
The patients returned in the first and second postoperative periods with the removal
of the drain in the second postoperative period, oriented regarding the dressing,
and the returns were performed at one week, 15 days, 30 days, 3 months, 6 months and
1 year.
RESULTS
Satisfaction level
It is observed that there were no significant differences between the women who underwent
surgery (post-surgical group) when compared to those who did not undergo surgery (control
group) concerning the variables age (p=0.357), BMI (p=0.695), degree of hypertrophy (p=0.799) and degree of breast ptosis (p=0.391). Regarding the variables of satisfaction with the breasts, psychosocial, sexual
and physical all showed higher values in women with surgery than in the group without
surgery (p<0.009) (Table 1).
Table 1 - Anthropometric characteristics and variables of the Breast-Q questionnaire of patients
before and after surgery.
| Variables |
Control group |
Post-Surgical Group |
p |
| Mean (SD) |
| Median (P25-P75) |
| Age (years) |
33.5 (10.7)
33.5 (23.5 - 40.5)
|
36.4 (10.5)
37.0 (26.0 - 45.0)
|
0.357 |
| BMI (Kg/m2)
|
26.4 (2.4)
26.6 (24.2 - 28.5)
|
26.2 (1.7)
26.0 (25.1 - 27.7)
|
0.695 |
| Satisfaction with the breasts |
25.6 (12.6)
27.5 (18.0 - 36.0)
|
83.7 (14.9)
84.5 (71.0 - 100.0)
|
<0.001 |
| Psychosocial well-being |
30.4 (17.7)
29.0 (18.5 - 43.0)
|
89.7 (11.5)
89.5 (78.5 - 100.0)
|
<0.001 |
| Sexual well-being |
31.8 (15.6)
30.5 (23.5 - 39.0)
|
86.9 (15.0)
91.0 (73.0 - 100.0)
|
<0.001 |
| Physical well-being |
63.5 (18.7)
70.0 (49.0 - 79.0)
|
79.9 (10.0)
78.0 (72.5 - 89.5)
|
0.009 |
| Degree of Hypertrophy (n=27) |
|
n (%) |
|
| 1 |
3 (23.1) |
2 (14.3) |
0.799 |
| 2 |
6 (46.2) |
8 (57.1) |
| 3 |
4 (30.8) |
4 (28.6) |
| Degree of Breast Ptosis (n=13) |
|
|
|
| 2 |
4 (57.1) |
2 (33.3) |
0.391 |
| 3 |
3 (42.9) |
4 (66.7) |
Table 1 - Anthropometric characteristics and variables of the Breast-Q questionnaire of patients
before and after surgery.
DISCUSSION
Although mastopexy is a highly satisfactory surgery, complications and unfavorable
results can occur, such as wound dehiscence, hypertrophic scars, infections, fatty
necrosis, hematomas and partial or total necrosis of the nipple-areolar complex, in
addition to asymmetries and position abnormalities8. The multiplicity of techniques described reveals the intense search for the best
technique to reduce complications and improve women’s quality of life. In addition,
it has to be easier to be instructed in learning services such as medical residency
and passed on to new generations of already trained professionals.
For these reasons, the great advantage of the technique developed by Dr. Millan is
to be able to evaluate the result of the assembly of the breast cone even before the
skin resection, which allows adaptations, especially in cases of breast asymmetry
avoiding unfavorable outcomes.
The detachment of the lateral and medial skin flaps is always the minimum necessary,
and the horizontal scar is always the smallest possible, which makes it very appropriate
for those patients in which the risk of circulatory compromise is expected, such as
patients who are smokers, elderly or with controlled chronic pathologies, or also
that they can be carriers of damage to the microcirculation, such as diabetes, hypertension
and inflammatory diseases involving collagen.
In cases where the distribution of breast parenchyma and adipose tissue is very heterogeneous,
this technique offers the visibility and freedom to promote changes in the shape and
size of both breasts until the final moments of the surgery, ensuring the best possible
symmetry.
The positioning of the lateral and medial skin flaps, leading to the compensation
of the skin resection towards the apex of the mammary cone, generates a greater resection
of the periareolar skin, which reduces the compensation in the access route in the
inframammary fold, reducing its length. As the skin resection is performed based on
the definitive coneshaped assembly of the breast tissues, there is no resulting tension,
which avoids the flattening of the breast shape as reported in periareolar techniques9, 10, 11.
The techniques that follow demarcations and the making of pedicles can serve as a
guide and are based on previous personal experiences. However, there are situations
in which predictability is difficult, such as accentuated asymmetries or when the
skin conditions of the breasts are uneven, as in the presence of numerous stretch
marks or scars from previous burns, factors that change the malleability of the tissues
unpredictably. In these cases, a technique that allows adaptations during the surgical
procedure can be much more efficient and safer.
However, it is worth considering that in breast surgeries that involve large reductions,
in which the horizontal scar in the groove will be extensive, techniques with prior
marking optimize the surgical time since they are faster and the difference in scar
size may not be significant.
The technique is ideal for ptosis, asymmetries and augmentation mammaplasties associated
with the resection of a large excess of skin because it takes into account, in addition
to the quality of the skin, also the consistency of the breast tissue. This is different
from previous demarcation techniques that often follow inflexible patterns that may
not be suitable for all cases and, in particular, may not accurately calculate the
amount of skin that will be resected.
Body image represents a person’s physical appearance, resulting from a combination
of perceptualneural processes, environmental, social and psychological factors and
can manifest through the degree of care and satisfaction with the body12. Thus, concerning women’s level of satisfaction with the procedure performed, the
results showed that mastopexy standardized by Millan’s technique brought a significant
improvement in satisfaction with the breasts: in psychosocial well-being, sexual well-being
and physical well-being. These results converge with similar studies that evaluated
the level of satisfaction with another mastopexy techniques13,14.
When comparing the results of the Breast-Q® questionnaire from the Operated Group
to those from the Control Group, it becomes more evident that the request for breast
correction goes beyond the physical aspects. Women who perform such procedures are
looking to improve their quality of life, which may represent an ingroove in self-esteem,
an improvement in appearance and social acceptance, and an improvement in the context
of sexual relationships.
CONCLUSION
The mastopexy technique standardized by Dr. Roberto Antônio Barjas Millan has a high
level of satisfaction and seems to fulfill patients’ expectations once confronted
with the evaluations of women who have not yet undergone surgery. It is a technique
that does not use the previous demarcation and provides greater flexibility in surgical
times, allowing adjustments until the final moments of the surgery, which can favor
the result, especially in asymmetrical breasts and with large excesses of skin.
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1. Centro Universitário Saúde ABC, Faculdade de Medicina do ABC, Santo André, S P,
Brazil.
2. Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
Corresponding author: Pablo Eduardo Elias Rua Elvira Ferraz 250, CJ 309, Vila Olímpia, São Paulo, S P, Brazil Zip Code: 04552-040
E-mail: contato@drpabloelias.com.br
Article received: February 25, 2021.
Article accepted: December 13, 2021.
Conflicts of interest: none.
Institution: Centro Universitário Saúde ABC, Faculdade de Medicina do ABC, Departamento
de Cirurgia Plástica, Santo André, S P, Brazil.
