A Personal Technique: Mammaplasty With J Scar

A Personal Technique: Mammaplasty With J Scar Carlo Gasperoni, MD* Marzia Salgarello, MD† Paolo Gasperoni, MD†

Mastopexy and reduction mammaplasty techniques have evolved with time, pursuing the aim of an effective and reliable technique that produces a well-shaped breast and reduces the amount of scarring. The authors believe that the L mammaplasty achieves the best results in terms of a short scar and a good, stable shape. They present their technique of a modified L mammaplasty with a resulting scar in the shape of a J, which implies a central breast resection with the nipple–areola complex transposed on a superior pedicle. The correct execution of the preoperative markings and the shaping of the gland tissue are mandatory to obtaining the desired result. The technique has been used during the past 7 years on 326 patients, providing satisfactory results with short scars and virtually no complications. Gasperoni C, Salgarello M, Gasperoni P. A personal technique: mammaplasty with J scar. Ann Plast Surg 2002;48:124 –130 From the *Plastic Surgery Center, Casa di Cura Quisisana; and the †Department of Plastic and Reconstructive Surgery, Catholic University of Sacred Heart, Largo Gemelli 8-00168 Rome, Italy. Received Apr 27, 2001, and in revised form Aug 3, 2001. Accepted for publication Aug 3, 2001. Address correspondence and reprint requests to Dr Salgarello, Via della Pineta Sacchetti 484, 00168 Rome, Italy.

the breast up to its boundaries with the thoracic wall, resulting in an unnatural transition between the breast and the thorax. The search for a reliable technique to produce the best shape possible with few scars has led many surgeons to shift toward other procedures. Many techniques other than those with an inverted T scar have been described: periareolar,7–12 vertical,13–18 oblique,19 –21 Z,22 and L.23–33 Each of these techniques has advantages and disadvantages. Based on our experience, we think that a good compromise between a better shape and short scars may rely on the L technique. We propose our approach to the L technique, which results in a J-shaped scar. We present our experience with J scar mammaplasty, which has been used on 326 patients, operated during the past 7 years.

Materials and Methods

The goal of any mastopexy and reduction mammaplasty is to obtain correction of the ptotic breast or excessive size, a good and long-lasting shape, symmetry, satisfactory function and sensation, and acceptable breast scars. Therefore, any mastopexy and reduction mammaplasty has to face the management of excess skin alone or both skin and parenchyma, the safe transposition of the nipple and the areola, the management of the shape of the breast, and the amount of scarring. The first and second points may be managed with most of the pedicled techniques: The more popular ones are those derived from Wise pattern markings1 and result in an inverted T scar.2– 6 The third and fourth points (i.e., obtaining a good shape with a reduced amount of scarring) are not optimal with the inverted T technique because they allow breast molding with an unsightly horizontal inframammary scar. Moreover, the skin resection is carried in the inferior pole of 124

Copyright © 2002 by Lippincott Williams & Wilkins, Inc.

Markings The patient lies on the operating table in a semisitting position. The median sternal line is marked with methylene blue dye. The inframammary line is marked bilaterally. A line is then marked bilaterally, connecting the clavicle to the inframammary fold and dividing the breast into two halves. This line is called the hemimammary line. This line starts at the clavicle, approximately 6 cm from the jugular notch, and crosses the inframammary fold at point F (F for fold). It usually crosses the nipple, but it does not necessarily cross it (in which case the nipple is shifted slightly medially or laterally). The symmetry of this line is checked by measuring the distance between the median sternal line and point F on both breasts. Point A (the future site of the nipple) is determined on the right breast. It is marked on the hemimammary line 1 cm over the projection of the inframammary crease on the anterior skin

Gasperoni et al: Mammaplasty With J Scar

Fig 1. Point B is marked on the medial aspect of the breast in the inferior pole while pushing the breast laterally. It is aligned with the point on the clavicle where the hemimammary line starts, with point F on the inframammary fold.

surface of the breast, using the Pitanguy maneuver.3 The distance from the clavicle to point A is transferred to the contralateral breast as point A'. Pushing the breast laterally with the hand, point B is marked on the medial aspect of the breast in the inferior pole, and it is aligned with the point on the clavicle where the hemimammary line starts and with point F on the inframammary fold (Fig 1). Then the breast is shifted medially and point C is marked, aligned with the point on the clavicle where the hemimammary line starts and with point F, this time on the lateral–inferior aspect of the breast. Point A is connected with a line to points B and C. The position of points B and C is checked as: While keeping point A projected forward in a high position, the surgeon pinches the skin at point B and C, approximating point B and point C. Keeping point B and C together, the two segments AB and AC must coincide with the hemimammary line (Fig 2). Point D is drawn on the hemimammary line 1 cm above the inframammary fold. Point E is drawn in the inferior lateral quadrant of the breast approximately 3 cm above the inframammary fold and 3 cm from the anterior axillary line. The lateral vertical limb (segment AC) is curved downward with an upward concavity to reach point E. The medial vertical limb (segment AB) continues in a curve with an upward concavity to point D and then to point E (Fig 3A). The

Fig 2. The position of points B and C is checked by pinching the skin at points B and C and approximating them. Keeping points B and C together, segments AB and AC must coincide with the hemimammary line.

skin encircled by the markings has the shape of a J (Fig 3B). The markings are double checked by the surgeon while the assistant is holding point A forward in a high position: The surgeon pinches the skin, which is already marked, bringing together the main lines AB and AC and lines BDE and CE to include the skin area to resect. With a compass point on the medial sternal line at the height of the areola, point B' is marked symmetrically with point B on the left breast. Then points D' and E' are marked on the left breast. Line A'B' is then drawn. Point C' is marked by shifting the left breast medially in the same way as point C on the right breast. Line A'C' is drawn. Finally, lines C'E' and B'D'E' are marked in a circular fashion to meet each other at point E', symmetrical to the right breast. The surgeon checks the markings of this breast while the assistant pinches point A in a high position. If breast asymmetry is present, the skin areas encircled by the markings will be different, wider on the bigger breast. Because the length of the curved lines CE and BDE is different, when suturing the skin at the end of the procedure, gathering of the skin along the longer skin edge will occur. Therefore, we use methylene blue dye to mark and tattoo several reference points to make the sutures easier to place. The curved lines CE and BDE are divided into three parts of the same length: At the end of the operation, each of the longer segments of line BDE will be sutured to each of the shorter seg125

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Fig 4. (A, B) Because the length of the curved lines CE and BDE are different, we divide lines BDE and CE into three parts of equal length. At the end of the operation, each of the longer segments of line BDE is sutured to each of the shorter segments of line CE.

Fig 3. (A) After drawing point D 1 cm above the inframammary fold on the hemimammary line and point E in the inferior lateral quadrant of the breast, the medial vertical limb (segment AB) continues in a curve with an upward concavity up to point D and then to point E. (B) The skin encircled by the markings has the shape of a J.

ments of line CE (Fig 4). The same markings are drawn on the contralateral breast. Breast Incision Both breast markings are incised. The areolar diameter is set at approximately 4 cm and is incised. Skin in the upper region is deepithelialized down to 1 cm below the areola. 126

Breast Reduction When a breast reduction is planned, the gland resection starts 1 cm below the inferior edge of the areola perpendicular to the thorax to reach the pectoral fascia. The gland resection has the shape of a vertical wedge, with a keel under the areola. The width of the wedge includes all skin and gland encircled by the markings (Fig 5). The glandular resection retains the glandular tissue in the upper pole, beneath the nipple–areola complex and in the two inferior pillars located laterally and medially to the resected gland. The remaining breast parenchyma is now undermined widely in the prepectoral plane. Mastopexy For mastopexy, all skin encircled by the markings is deepithelialized. An inferiorly based dermoglandular flap may be planned to increase the projection of the upper pole of the breast (Fig 6).

Gasperoni et al: Mammaplasty With J Scar

Fig 5. The gland resection has the shape of a vertical wedge with a keel under the areola with a width that includes all skin and gland encircled by the markings.

Fig 7. The bases of the medial and lateral pillars of the mammary parenchyma are sutured together with deep stitches to obtain a conical shape of the breast.

upper part of the retromammary dissection, creating a central fold with medial and lateral pillars of mammary parenchyma. The bases of the two pillars are sutured together with two to three deep stitches to obtain a conical shape of the breast (Fig 7).

Fig 6. An inferiorly based dermoglandular flap is marked to increase the projection of the upper pole of the breast.

In this case a horizontal incision of the gland is made 1 cm below the inferior edge of the areola, cutting through the gland in a direction perpendicular to the thorax, and ends at the pectoral fascia. Below this incision the gland maintains its connection with the prepectoral plane. The breast tissue above the incision is freed from the prepectoral fascia, and the inferiorly based flap slides under the mammary gland and is fixed with sutures to the pectoralis major muscle behind the upper pole. The skin edges are divided minimally from the mammary tissue to facilitate their approximation when suturing. Breast Shaping The lower central border of the remaining breast tissue is elevated and fixed with stitches to the

Closure The deep dermis is sutured with interrupted sutures along the curved lines CE and BDE, following the reference points marked previously. After the suture of the dermis, the J scar is shortened notably. After both breasts are sutured, the new position of the nipple–areola complex is marked bilaterally in a position slightly lower than the apex of the mammary cone, considering the postoperative change of shape of the breast (Fig 8). Because during the postoperative period the breast parenchyma will settle and fill the lower pole, the areolar position is shifted slightly higher. The skin of the areolar site is removed and the areola is sutured in its new position. A continuous subcuticular suture is used to gather the skin further up along the full length of the J. Some wrinkles will result in the central portion of the J scar, but these will fade completely in 1 to 2 months. The areola is also sutured with a subcuticular running suture. Patients are asked to wear a sports bra for the first 1 to 2 months postoperatively. Scars are taped continuously with paper tape for 2 to 3 months. 127

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Fig 8. After both breasts are sutured, the new position of the nipple–areola complex is marked bilaterally.

Results We have used this technique since 1985 and report our experience with this procedure applied during the last 7 years to 326 patients who ranged in age from 14 to 71 years (average age, 34 years). This approach was used to correct breast ptosis of any degree in 218 patients, to correct breast hypertrophy in 108 patients whose reduction was less then 1,000 g per breast, and was used in 26 cases of asymmetry. The average amount of breast tissue removed was 340 g (Fig 9). No seromas or hematomas have occurred. No skin slough of the areola nor of the J wound has occurred. Patients refer to no changes in nipple sensitivity. Although few patients tried to breastfeed their babies because of fear of breast deformity, lactation in those who tried was possible. A few patients (N ⫽ 6) underwent a minor revisional procedure to correct an enlarged areolar scar or vertical segment of the J scar. Underreduction of the breast volume occurred in some cases of breast reduction: This was the only side effect we encountered.

Discussion The search for a reliable mammaplasty technique that produces a good, stable breast shape with fewer scars has led to vertical13–18 and L techniques.23–29,31–33 The vertical scar allows one to 128

obtain a conical-shaped breast and avoids excessive tension on the areolar skin, contrary to the periareolar technique, whose main drawbacks are the flat shape of the breast and the widening of the areola with time. If we analyze the scars that result from using the inverted T technique, we note that the inframammary scar is the worst, the periareolar scar is variable, and the vertical scar is usually quite good and surely the best of the three. The search for an ideal technique that avoids the inframammary scar (especially its medial portion) starts at the beginning of the history of reduction mammaplasty. The first description of mammaplasty with an oblique scar was published by Hollander21 in 1924. Others used his technique of lateral mammary resection in the years thereafter,20 but it was not until 1961 that Dufourmentel and Mouly19 included in the lateral resection technique the principle of deepithelialization to move the nipple–areola complex safely. In 1957, Arie13 introduced mammaplasty with a vertical scar, using the original idea of Lotsch30 proposed in 1923. This technique was reviewed by others,15,17,18 who pursued the possibility of breast reduction and mastopexy using a vertical technique. In 1971, Meyer31 presented the first paper on reduction mammaplasty using an L scar, followed by reports by Elbaz and Verheecke,27 and Regnault.33 The lateral approach was improved further by several Brazilian surgeons.23–26,29 Our J scar mammaplasty arises from the procedure performed by Arie13 and is applied to the ptotic breast of any degree, as well as to minor, moderate, and large hypertrophy and asymmetry (Figs 8 and 9). In case of very large breasts, the amount of reduction is limited by the extreme size of the breast. In fact, if we consider the breast as an envelope of skin and subcutaneous tissue (the container) covering the mammary gland cone (the content), the reduction of the volume (content) should be adequate to the reduction of the skin (container). In other words, the degree of the reduction of the mammary parenchyma is influenced by the extent of the cutaneous resection. Because it is sometimes difficult to reduce an enormous amount of skin, we prefer to restrict the use of this technique to reductions not exceeding 1,000 g per breast. In case of a very large

Gasperoni et al: Mammaplasty With J Scar

Fig 9. (A, C) Preoperative view of a 38-year-old woman with breast ptosis of a severe degree. (B, D) Postoperative view 8 months after a J scar mammaplasty.

breast, we can limit the amount of the resection and produce a reduced but still large breast, or can choose to use an inverted T technique for further reduction. An other important point concerns the inframammary fold-to-nipple distance. In case of the reduction of moderate and large hypertrophy as well as of mastopexy of a severe degree, the inframammary fold-to-nipple distance at the end

of the surgery surely exceeds the standard measure of 5 cm. Lassus16 clearly pointed out that many attractive normal breasts demonstrate an inframammary fold-to-nipple distance that ranges from 4.5 to 10 cm. Thus, the tenet of 5 cm should be scrutinized. Breast shape does not rely on the skin: The suture of the two pillars of the residual gland in a higher position determines the shape of the 129

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breast. With regard to mastopexy, we make an inferiorly based dermoglandular flap that is pedicled up beneath the upper pole of the breast to perform an “autoaugmentation.” This technique obtains stable fullness of the upper pole. The J scar technique has a short operative time (less than 2 hours), implying minimal blood loss and speedy recovery. The only difficulty with the technique lies in the correct execution of the preoperative markings, which are not based on a predetermined pattern but follow the individual characteristics of each breast. The J scar mammaplasty is reliable, and complications are rare. Because there is no cutaneous undermining, complications such as woundhealing problems are avoided. Nipple–areola necrosis has never been encountered. The hemostasis is accurate and the undermining of the gland from the pectoralis major muscle is made in a relatively avascular plane, therefore no drains are needed, and no seroma or hematomas developed. The glandular resection is made in the inferior and middle portion of the breast, preserving the lateral neurovascular pedicle. The postoperative sensitivity of the nipple–areola complex is usually unchanged. Because the lactiferous ducts located beneath the nipple–areola complex are not interrupted, the potential for lactation is preserved.

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