Keywords

1 Introduction

From the aesthetic point of view, we believe that contemporary plastic surgery has reached perfection with regard to volume, shape, positioning of the breasts and the quality of the scars, thanks to the generous contributions of numerous techniques, among which we highlight, Arié’s (1957), Strombeck’s (1960/61), and Pitanguy’s (1963). However, from a subjective point of view in daily contact with the patients, many patients are dissatisfied with the scars of the inverted T technique, especially with regard to the medial segment, despite the professing satisfaction with the overall result.

Facing this concern, plastic surgeons, especially those of the Brazilian School, were motivated to develop and improve surgical techniques and tactics to minimize the stigma of scars, which was already part of our daily work.

Authors such as Geraldo Peixoto in 1980 published a personal technique that reduced the size of the inverted T. Eulalio José Neiva 1984 proposed a pentagonal resection to reduce the horizontal line of the T. Yhelda de A. Felicio (1984) presented a technique with one areolar scar, and then other authors such as Ricardo Bustos (1985), Sampaio Goes (1989) and Pedro Martins (1989), contributed to the improvement of periareolar mastoplasty. Based on the techniques of Arié (1957) and Dufourmental and Mouly (1961), there was an increase in the number of techniques with lateral incisions such as that of Horibe (1976), and the J technique published in 1981 by Sepulveda. In Bozola (1992), Bozola published his L technique.

Inspired by the work of Bozola, we began to perform this technique in 1983, at first in patients with simple ptosis and small hypertrophy. Enthusiastic with regard to the good aesthetic results and the apparent acceptance of our patients, we were also encouraged to practice it in cases of medium and large hypertrophy; today, it is the technical procedure that has been almost exclusively adopted to treat different presentations of aesthetic breast deformities (Merriman 1984; Hakme et al. 1983).

2 Materials and Methods

After 33 years spent performing mastoplasty using the L technique in patients with small hypertrophy and ptosis, we gradually started to employ this technique in medium and large hypertrophy. The ages ranged between 12 and 68 years.

In isolated cases, we apply the same technique for sequelae correction as for other techniques to reduce the medial segment of the T at the time of silicone prosthesis insertion when there was a need to correct mammary ptosis, offer better accommodation of the content and container, and give rise to a better aesthetic configuration.

In our assessment, we consider hypertrophy:

Small: when the breasts fit comfortably into a brassiere of Brazilian size 42 or 44, or when it was necessary to resect up to 400 g of dermo-glandular tissue.

Medium: when the breast fit into a size 46 brassiere, or when 400–800 g was resected.

Large: when the breast fit into a for a brassiere above size 48, or there is resection of more than 800 g.

3 Surgical Technique

We proceeded to mark the skin of the cutaneous resection area (simple ptosis) or dermo-glandular (hypertrophy), calculating the excess through interdigital pinching of the lower pole of the breast, trying to model the future breast cone using this maneuver (see Fig. 33.2). At the apex of this cone or slightly below, point A of the future location of the nipple–areola complex (NAC) is marked. From there we go down with a curved line toward the medial pole meeting the midclavicular line with the inframammary crease, point B” always going above that point and proceeding toward the anterior axillary line, stopping before the skinfold limit of the submammary groove that originates from the interdigital clamping point D. Then we went down with another curved line by the lateral pole to a point C, which when approaching it from point B, these two curved lines form a perfect angle, with the points A and B as the vertices (see Fig. 33.3).

Starting from point C, we draw a line that can be straight or curved toward point D. The final alignment results in a shape resembling a comma viewed in the right breast and after resection and subsequent suturing in a U, viewed in the left breast (Figs. 33.1, 33.2 and 33.3).

Fig. 33.1
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Intermamario Canyon free of scars

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Fig. 33.2
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Marking

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Fig. 33.3
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Marking

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We resect the excesses of atypical breast contents without following patterns standards, according to the need and the individuality of each case, the first withdrawal being only the necessary excess, either wedge-shaped or “watermelon cut” according to Arié, now as a keel shape, as Pitanguy advocated, and sometimes combining techniques such as those of Pitanguy and Peixoto to reduce the volume and height of the breast cone (in large hypertrophy).

The remaining breast content in the upper, medial, and lateral poles should be sufficient to allow the breast to be filled that favors the shape of a cone in height and diameter in perfect proportionality with the contour of the patient’s torso.

In any resection technique, we are always careful to leave more content in the lateral pole, making a greater resection of the medial pole to avoid flattening of the lateral pole (Fig. 33.4). The structure is made of a breast approaching the lateral pole towards the medial pole, fixing them to one or more points with non-absorbable sutures (Mononylon 3–0), Transfixing the weight of the chest in a slightly higher position to compensate for future chest fall (as a “bridge”). The skin sutures are made with sparse intradermal points of absorbable suture (braided polyglycolic acid) and poliglecaprone thread in an intradermal continuous suture without removal. The areolas are sutured with nylon 5–0 at separate points. We do not use drains and the dressing of gauze pad and cotton and crepe bands is applied for 24 or 48 h placed in a brassiere (Figs. 33.5, 33.6, 33.7, 33.8, 33.9, 33.10, 33.11, 33.12, 33.13, 33.14, 33.15, 33.16., 33.17, 33.18, 33.19, 33.20, 33.21, 33.22 and 33.23).

Fig. 33.4
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(a, b) Surgical resection

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Fig. 33.5
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Scars (a, b) and (c) - post operative

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Fig. 33.6
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Before and after small hypertrophy

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Fig. 33.7
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Before and after small hypertrophy

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Fig. 33.8
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Before and after small hypertrophy

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Fig. 33.9
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Before and after small hypertrophy

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Fig. 33.10
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Before and after small hypertrophy

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Fig. 33.11
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Before and after small hypertrophy

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Fig. 33.12
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Before and after medium hypertrophy

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Fig. 33.13
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Before and after medium hypertrophy

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Fig. 33.14
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Before and after medium hypertrophy

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Fig. 33.15
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Before and after medium hypertrophy

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Fig. 33.16
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Before and after medium hypertrophy

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Fig. 33.17
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Before and after large hypertrophy

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Fig. 33.18
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Before and after large hypertrophy

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Fig. 33.19
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Before and after large hypertrophy

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Fig. 33.20
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Before and after large hypertrophy

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Fig. 33.21
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Before and after large hypertrophy

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Fig. 33.22
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Before and after large hypertrophy

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Fig. 33.23
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Before and after large hypertrophy

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4 Discussion

The L technique is a versatile procedure that can be performed easily and in a shorter surgical time, in patients with ptosis, small and medium hypertrophy, and, with skill and some tactical resources, in large hypertrophy.

At first, we noticed a certain flattening of the lateral pole, which was corrected when we came to resect more content of the medial pole, preserving sufficient breast tissue in the lateral pole, which when pulled and rotated medially, filled the space created, favoring the frame of the breast cone with effective filling of the upper pole, eliminating excess volume and allowing a graceful setting of the intermammary space. We usually call it INTERMEDIATE CANYON, which is very often required by patients who intend to display it at the neckline of their clothes.

After 33 years of working with this technique, we make 1600 g of reductions in each breast and never had difficulties with the elevation of the NAC, we do not feel the need to resort to the dermoglossous flap by Ribeiro (1975), or the interbreeding of flaps suggested by Sperli 1977 and Farid in 1983 with the intention of better filling the upper pole and providing better support.

More than 4000 patients were operated on using this technique and in a recent survey a sample of 100 patients found that a good aesthetic configuration was maintained, preserving the upper pole, with a small degree of ptosis, and inapparent scars. We only had one case of reoperation for ptosis correction at 6 years postoperatively, in a patient who became pregnant soon after surgery.

5 Complications

We had no severe complications, except in one case in which a subareolar hematoma caused suffering and complete necrosis of the areola and nipple, which had to be properly rebuilt. There were no complaints of loss of sensitivity. A few patients had hypertrophic scars and were treated with intracicatricial infiltration with corticosteroids. There were no cases of infection.

Conclusion

In our current routine, besides the Arié technique or the Arié–Pitanguy version for small ptosis, the L technique seems to be the best option for mastoplasties, because of both the objective aspects of aesthetic presentation that it offers, as in the fulfilment of the artistic sense of the surgeon and the great satisfaction of the patients that we have increasingly witnessed.

The resection of a greater volume of glandular content in the medial pole to be advanced to the lateral pole to fill the space, this allows the excess underarm extension to be corrected to sufficiently fill the upper pole and provide good fixation of the breast. It has been proven by 33 years of follow-up that these effects can be long-lasting.