ISSN Online: 2177-1235 | ISSN Print: 1983-5175

Comparison of the Inflammatory Response to Trauma in the Inverted T Technique and Axillary Access Technique for Breast Reduction Surgery
Estudo Comparativo da Resposta Inflamatória do Trauma em Cirurgias de Redução Mamária, Técnica T Invertido versus Técnica por Via Axilar

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Articles - Year2002 - Volume17 - Issue 2

Yhelda Felício

ABSTRACT

Eighteen patients with hypertrophy and bilateral breast ptosis were operated on for breast reduction: ten were submitted to axillaiy access mammaplasty and eight it to the inverted T technique. Sixteen patients, eight of which submitted to axillary access breast reduction and eight submitted tn the inverted T technique, received interleucin-1β and TNF-α pnt-iuflammatory cytokines. The mean length of surgery was 36 minutes, less for the axillary technique. The mean cost for the operating room was twice as much for the inverted T technique. The recovery period for patients to return to all activities was approximately 80 days for the inverted T technique, and forty days less for the axillaiy technique. The dosage of pro-inflammatory cytokines showed a significant difference (p<0.05) in levels of IL-Iβ of patients submitted to the axillary surgical route compared to those of patients submitted to the inverted T technique, in which the fonner had higher levels of IL-1β than the latter. Regarding the dosage of TNF-α, a certain upward trend was observed, although without statistical significance, in patients submitted to the inverted T technique, for most of the periods studied (preoperative, 24,48 and 72 hours postoperative). Although a significant decrease in the levels of IL-1β in patients submitted to the inverted T technique was observed in comparison to the axillaiy route, one cannot conclude that there was actually less trauma associated to the former technique, considering that the levels of TNF-α, on the other hand, tended towards the opposite direction. Nonetheless, it can lie said that the serum level of pro-inflammatory cytokines does not seem to be an ideal method for identifying a greater or lesser degree of trauma to breast tissue, and it would be necessary to measure other pro-inflammatoiy mediators or even increase the study sample.

Keywords: Inflamatory response to trauma; axillary reduction vs. inverted T mammaplasty.

RESUMO

Dezoito pacientes portadoras de hipertrofia e ptose mamária bilateral foram operadas para redução mamária, sendo que dez submeteram-se à mamaplastia por via axilar e oito pela técnica do T invertido. Dezesseis pacientes, oito das quais submetidas à redução mamária por via axilar e oito pela técnica do T invertido, foram submetidas à dosagem de citocinas pro-inflamatórias interleucina-1β e TNF-α.
O tempo médio de cirurgia foi 36 minutos, menor na técnica axilar. O custo médio de gasto de sala de cirurgia foi o dobro na técnica do T invertido. O período de recuperação das pacientes para retornarem a todas as suas atividades foi de aproximadamente 80 dias na técnica do T invertido, enquanto na técnica axilar foi quarenta dias menor.
A dosagem de citocinas pro-inflamatórias demonstrou diferença significante (p< 0,05) entre os níveis de IL-1β das pacientes submetidas a cirurgia por via axilar e os das pacientes do T invertido, sendo que as primeiras tiveram maiores níveis de IL-1β que as segundas. Quanto à dosagem TNF-α, observou-se uma certa tendência a elevação, embora sem significância estatística, naquelas pacientes submetidas à técnica do T invertido, na maioria dos tempos estudados (pré-cirúrgico, 24, 48 e 72 horas pós-cirúrgico). Embora tenha sido observada uma diminuição significante nos níveis IL-1β nas pacientes submetidas à técnica do T invertido em comparação com a realizada pela via axilar, não se pode concluir que houve de fato menor trauma na primeira técnica, já que a análise dos níveis de TNF-α, por outro lado, tenderam a uma observação contrária. Pode-se, entretanto, afirmar que a dosagem sérica de citocinas pro-inflamatórias parece não se constituir num método ideal para identificar menor ou maior trauma no tecido mamário, sendo necessária, possivelmente, a dosagem de outros mediadores pro-inflamatórios ou mesmo aumentar a amostragem experimental.

Palavras-chave: Resposta inflamatória ao trauma; mamaplastia redutora axilar versus T invertido

INTRODUCTION

The tirst description of reduction mammaplastv in the literature was in the VII century A.D. Durstan(1), in 1669, also described breast reduction surgery Beisenberg(2) treated gynecomastia, but it was onlv in the beginning of the past century that the major contributions related to the issue began to be cited in the literature, as, for example, studies by Arié(3), Mouly and Dufourmcntel(4), Strombcck(5), Pitanguy(6), Andrews(7) and Peixoto(8), among others. These authors brought new contributions to the development of breast reduction techniques. According to many authors, the surgical technique for treating breast hypertrophy and ptosis should be the one the surgeon is best at. The negative aspects pointed out for classical reduction mammaplasty are the size of scars, a fact with which most patients agree.

The results of an interactive survey on mastoplastv carried out at the XXI São Paulo Plastic Surgery Dav in Campos do Jordão - São Paulo, in June 2001, showed that patients" major complaint referred to inappropriate scars (59.4%), 5.1% did not choose anyone of the given alternatives, 7.6% had breast asymmetry, 11.4% inadequate shape, and 16,5% late postoperative ptosis.

We considered the comments above as a starting point to begin to perform, as of January 1984, a new, less aggressive reduction mammaplastv with an areolar access technique, that preserves a larger number of central mammary lobules and presents a sole areolar scar. The experience with the technique has been described both in Brazilian(9, 10) and international(11, 12, 13, 14, 15, 16) literature.

Over a period of nine years, the technique was performed on five-hundred patients that is a thousand breasts. After this period, the conclusion was that breasts could be submitted to a mammaplastv utilizing the axillary route with out any scar at the end. The experience with the technique was initially described in 1993(17) in La Revue de Chirurgic Hsthetique de Languc Francaise.

The new technique has the following advantages:

1. It is less aggressive when compared to classical techniques, because any breast quadrant may be approached by the axillary route. Moreover, resection is mainly approached by lateral quadrants, as they are responsible for the inelegant aspect of most patients in the late postoperative period.

2. It can be performed either under local or epidural anesthesia.

3. It is more economical, since it only requires four sutures for both armpits.

4. Its major advantage is it avoids any scar in the breast, because the axillary scar is hidden by natural folds.

5. Less trauma is believed to occur in the axillary route technique if compared to the inverted T technique, mainly due to immediate patient recovery (forty days less, minimum) and due to the absence of breast scars, yielding a single axillary scar of approximately a third of the size of inverted T surgery scars.

Axillary access breast reduction surgerv was described in the literature as early as 1924, by D'Artigues(18). Mam publications have described it, although the technique has not become popular to date.

A higher satisfaction rate was obtained with two hundred breasts operated on by the axillary route reduction technique and followed for five years, when compared to the rates obtained when the inverted T technique or priareolar technique were used. We obtained 160 of 240 blood samples of patients submitted to breast reduction. Eight patients were submitted to the inverted T technique and eight patients to the axillary route technique. An assay for detecting serum pro-intlammatory cytokines- Tumor Necrosis Factor (TNF-α) and Interleucine-lβ (IL-lβ) - was performed on eighty 5 ml blood samples from each group of patients. The literature has widely described cytokines, mainly IL-1β and TNF-α that are a link between cell injury, recognition of non-self and the development of local and systemic signs, in addition to signs of inflammation, such as cell migration, edema, fever and hyperalgesia (Dinarello 1986(19), Hopkins 1990(20) and Dinarello 1996(21). To that purpose, the present study assessed serum levels of TNF-α and IL-1β as possible markers of the level of tissue damage, in two kinds of breast reduction surgical techniques: axillary route and breast route (inverted T technique).


OBJECTIVES

The objective of the present pre iject was to widen the knowledge on the new reduction mammaplastv technique by the axillary route, bv comparing the inflammatory response to trauma that follows breast reduction surgery In order to reach the objective, two techniques were compared from a quantitative and qualitative standpoint: classical inverted T and axillaiy route.

The scientific proof of less trauma or similarities may contribute to the knowledge and promotion of the technique in the medical milieu, in addition to financial and psychological advantages to women who need this kind of intervention.


EXPERIMENTAL PROTOCOL

Eighteen female patients, ranging from 18 to 52 years of age, with breast hypertrophy, discomfort due to breast weight benefited from reduction. Random criteria were used to select the patients. All patients were assessed by an anesthetist in the preoperative period and the following lab tests, in addition to the conventional ones, were performed: dosage of inflammatory agents, cytokines, interlcucine-lβ and TNF-α in all patients operated on, in addition to epidural anesthesia. Patients accepted by the protocol remained in the hospital for 72 hours and had blood drawn five times (15 ml each time, separated in 3 samples kept in 5ml tubes, at the following moments: preoperative, 6, 24, 48 and 72 hours after surgery, approximately in order to measure cytokines, interleucin-lβ and TNF-α.


Fig. 1 - Standard TNF-α curve (30 min).


Fig. 2 - Standard IL-lβ curve (30 min).


Fig. 3 - Comparison of trauma inflammatory response to axillary vs. inverted T technique breast reduction surgery, using the results of the standard-curve IL-lβ in two independent samples.


Fig. 4 - Comparison of trauma inflammatory response to axillary vs. inverted T technique breast reduction surgery, using the results of the standard-curve TNF-α in two independent samples.






METHOD

ASSAY FOR DETECTING SERUM PROINFLAMMATORY CYTOKINES

Blood samples obtained from patients in the preoperative period, 6 hours, 24, 48 and 72 hours after surgerv, were centrifuged (2,400 rpm for 10 minutes), freezing cell-free supernadant at -70º C, to later dose cytokines, according to Thonson, 1996(2). Specific kits were used for dosing cytokines. In this fashion, concentrations of interleucin-β (IL-1β) and Tumor Necrosis Factor (TNF-α), were determined by ELISA assays, specific to each cytokine (human interleukin-lβ - Enzyme Immunoassay Kit and TNF-α Human Enzyme Immunoassay Kit, both from CAYMAN Chemical Company, Ann Arbor, MI 48108 USA).

The kits for IL-1β and TNF-&açpha; were used according to manufacturer's instructions, and each sample was assayed three times. In this fashion, plates were initially washed with a standardized buffer solution which was removed before beginning the assay. Then 100 microlitres of the samples to be tested were added in each well. In some wells, standard TNF-α (or IL-lη standard) was added to obtain a standard-curve (Graphs I and II). Then 100 microliters of anti-TNF-α antibody conjugate (or anti-IL-β conjugate) was added to each well, except for Blank wells (controls). Plates were incubated for a whole night in a refrigerator at 4ºC. On the following day wells were emptied and washed 5 to 6 times with a standard buffer solution. Two-hundred microliters of Ellman's reagent with chromogen were added to each well and the plate-was covered with plastic wrap and left in die dark for thirty minutes. Afterwards, plates were read on an EL1SA reader using a 420 nm filter. These assays detect a minimum limit of l.Spg/ml of TNF-α and IL-lη. The standard-curves determined in diese experimental protocols were the following: y = 0.0014x+0.0116; R2 = 0.9954 and y = 0.0024x+0.0291; R2 = 0.9936 for TNF-α and IL-1β, respectively

Two statistical assessment techniques were performed.

A non-parametric test (Mann-WhirnevTest) (Graphs III and IV) is recommended for statistical analysis, instead of Student's T test due to the requirements of die latter; that is to say, a normal distribution of the variable (TNF-α or IL 1β), although Student's T test was performed as exploratory as was analysis of variance (longitudinal for times), the results of which should be interpreted with caution. Therefore, conclusions actually derived from the Mann-Whitney test. An alpha significance level of 5% was considered; hypothesis rest established alpha = 5%, or equal to: 0.05.


RESULTS

All surgeries were performed at the same hospital, by the same team and with the same epidural anesthesia.

Patient's age varied between 18 and 52 years, and the average age of patients that chose the axillary technique was 30 years. Eor those who preferred the conventional technique the average age was 34 years; thus, a four year difference (Table I). According to Table II, the amount of resected breast tissue varied between 200 and 1,500 g.






Histological findings were: adipose hypertrophy, cvst, fibroadenocystic mastopathy, chronic lymphadenitis and bilateral ductal ectasia (Table III). The average surgical time for the axillary route pnjeedure was three hours and nine minutes, and three hours and fortv-five minutes for the inverted T technique. The average time for the axillary technique was 36 minutes less.




The mean expense with operating room material was RS 209.60 for the axillary technique and RS 418.57 for the inverted T technique. So, the axillary technique represented a fifty percent cost reduction in relation to the conventional technique.

Tible IV shows that the anesthetic material used was practically the same for both techniques.

A total of four sutures were used for both breasts in the two-hundred breasts operated on using the axillary mute, although in the present study, in which 18 patients were operated on in a public hospital, the average number of sutures used for the technique totaled nine for both breasts, and totaled twice as many, 18, for both breasts in the inverted T technique.

Despite the current concept that little skin is removed in the axillary route, by comparing the average amount of resected skin in both techniques, the study proves that practically the same amount is removed. Axillary technique, right breast: 9 x 5.8 x 4 and left ba-ast: 8.5 x 5.9 x 3.9. Inverted T technique, right breast: 7.6 x 5.8 x 4.9 and left breast: 7.6 x 5.8 x 4.8. In order to perform a qualitative study to assess both techniques, a questionnaire was answered bv patients, (responses were given four months and one year after surgery), with the following questions: assess the result as satisfactory, unsatisfactory or if more was expected, rating the procedure from zero to ten. Results: none considered the result unsatisfactory; two in each technique expected more; axillary technique satisfactory: 8 patients and inverted T: 6 patients. The average mark for the axillary technique was 9.5, and 7.0 for the inverted T.

Regarding pro-inflammatory cytokine dosages, a significant difference (p<0.05) was observed between the levels of IL-1β of patients submitted to axillary mure surgery and those submitted to the inverted T technique, pointing nut that the former had higher levels of IL-1β than the latter. On the other hand, no significant differences were observed between the levels of TNF-α in both groups of patients studied, although it is possible to say that there seems to be a certain upward trend for TNF-&apha; levels in patients submitted to the inverted T technique for most of the times studied (pre-surgical, 24, 48 and 72 hours after surgery). The small number of patients in each group in: 8) certainly may have contributed to not obtaining statistical significance.

Complications: two patients operated on by the axillary technique had a seroma and the same number was legistered in the inverted T technique: two. Keloids: one in the axillary technique and four in the inverted T. Herpes: one-case, only in the axillary technique. Hypertrophic scar: one in the axillary and two in the inverted T. Dehiscence: two in T and none in the axillary (Table V).






DISCUSSION OF RESULTS

Various routes may be chosen in order to reduce the mammary gland. The present study shows that the inverted T technique does not invalidate the axillary technique or vice-versa. Both techniques can reduce the gland, and only size and site of scars vary. The final result does not depend solely on the technique, but also on the quality of the tissue (glandular, tatty or mixed) of each breast.


CONCLUSION

The comparison of both techniques leads to the conclusion that neither one invalidates the other, although, ni.mv advantages could be linked to the axillary technique.

The axillary technique provides faster recovery so patients may return to normal activities approximately 40 days sooner and at a lower cost, a very important factor nowadays. The level of satisfaction was higher for patients submitted to the axillary route technique.

The present study also proves that mammary tissue memory will only change a year after surgical treatment. Breasts operated on bv the axillary route, at six months postoperative, presented little scarring retraction and a similar memory to the aspect of the initial breast. Only after a year, complete scarring retraction and a very different aspect from the original breast, approximately 50% smaller than the initial volume, are observed.

Conversely, in the inverted T technique, there is a complete scar retraction at six months postoperative and breast seesawing bascule only occurs a year after surgery. Both are believed to differ as to follow-up because the axillary tech-nique is a closed technique while the inverted T is open.

In relation to cytokine dosages: interleucine-Iβ and TNF-α, only 16 patients were studied, eight of axillary technique and eight of the inverted T technique, and samples from two patients could not be performed.

Results differed: IF-lβ levels presented a significant difference (p<0.05) between patients submitted to axillary route surgery and those submitted to the inverted T technique, where the former had higher levels of IL-1β than the latter. There were no significant differences between TNF-α levels for both groups studied, but there was a certain upward trend for TNF-α levels in patients operated on by the inverted T technique, in most of times studied (preoperative, 24, 48 and 72 hours postoperative). It can be said that the serum dosage of 1L-1β and TENF-α does not seem to be an ideal method for identifying the level of trauma in healthy mammary tissue, that is to say; without infection or cancer; it may be necessary to dose other pro-inflammatory mediators or, maybe, the small number of patients studied may have contributed to the statistical non-significance.


REFERENCES

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16. Felicio Y. Thruth fulness and unthruth fulness of the periarolar mammaplasty by Yhelda Felicio. In: Actualites de chirurgie esthétique, sous la direction de Bernard Mole, 2e. série. Mansson 1993; p.161-75.

17. Felicio Y. Plastic mammaire de réduction sans cicatice mammaire, avec radio-chirurgie. La Revue de Chirurgie Fsthetique de Langue Francaise. 1993; XVIII(73):53-8.

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19. Dinarello CA, Cannon JG, Wolff SM, Bernheim HA, Beutler B, Cerami A, et al. Tumor necrosis (cachectin) is a endogenous pyrogen and induces production of interleukin-1. 1986; J Hxp Med. 163:1443-9.

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22. Thonson A. The cytokine Hanoi book.2. ed. New York:Academic Press; 1996.










I. Senior Member of the Brazilian Society of Plastic Surgery.

Address for correspondence:
Yhelda Felicio, MD
R. Prof. Dias da Rocha, 1200 - Aldeota
60170-310 - Fortaleza - CE Brazil
Fhone: (55 851 261-7744

Summary of the Dissertation presented to the Post Graduation Program in Experimental Surgery of the Department of Surgery of the School of Medicine of Universidade Federal do Ceará for obtaining a Master's Degree

 

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