Breaking Paradigmes about Breast Reduction – Axillary Approach

Introduction

In the last 10 years many papers were published in world literature about Breast Silicone Implants, but less papers about Breast Reduction.

Recently Kaiser from Zurich, Switzerland and Klepetko from Vienna, Austria [1] published interesting paper about Breast reduction Mammoplasty a review of literature and presentation of novel technique dual vascular supply. Schlenz et al. analyzed this hypothesis and described that any breast reduction technique avoiding a resection of the central parenchyma, detachment of the central part of the breast from thoracic wall, or injury of the lateral part of the pectoral fascia had a low risk of injury to the dominant nerve of the nipple-areola complex [2].

Felicio, Y [3] published in 1993 about Mammary Plasty of reduction without scarring, with radio-surgery” and in 1997, Felicio Y. [4] publication about Axillary reduction Mammaplasty proved that this technique preserved de Central Breast. Until today a few colleagues know this technique.

In spite of the author showed in different Congress conducted in all the continents of the world, but it is not popular yet. Hence it is necessary to divulge more.

D’Artigue in 1924 [5], registered in the literature about axillary breast reduction but, only a few colleagues and patients know that it is even possible to reduce the breast avoiding scar on breast.

Many women don’t submit the breast reduction because of extension of the scar.

The author believes that now it is a new moment about breast reduction and also it is the final era, about big breast. Even it is beginning to appear in publications about the breast silicone implants used after cancer treatment.

During 1960, the Twigg model influenced many women to have little breast. In my service at this time, the most number of surgeries were breast reduction, but after 1990, approximately 30 years later due to strong media effect mostly change happened in the USA as the patients want more and big breasts. As a result, many breast silicone implant surgeries are made in the world, not only by plastic surgeons, but also by different doctors, sometimes not qualified to do it.

Nowadays, it is causing many problems such as capsula, asymmetry, infections, desconfortbal, artificial results and even leading to cancer. Thus sometimes implant needs to be changed.

In my private service, we are receiving patients who wants middle breast, no more little, no more big in great majority.

Materials and Methods

Since march 1993 to march 2016, 514 breast operations were registered by Felicio Y [6] on axillary reduction mammaplasty technique in which 66.14% were breast hypertrophy, 14.98% ptosis, 9.72% asymmetry, 7.79% mastopexy associated with breast silicone implant and 1% tumor resection associated with breast reduction. The age varied between 16-58 years old and the quantity of breast tissue resected varied between 50-1500g. The greater percentage was 36.77%, between 200-300g. Two decades ago, we had removed more quantity about 500-1000g. Complications were registered at about 3.30% low when compared with the other techniques. In conclusion, among 514 breast operations about 17 complications, 6 keloids, 6 hypertrophy scars with seroma, 3 hematomas, with short dehiscence, and 2 cases of arm hypersensitivity disappeared after 30 days with physiotherapy.

Surgical Procedure

The procedure is performed under local and/or peridural anesthesia and sedation. The patient remain lay down, not to be sitted, and the arms are in abducted position.

It is marked with one fusiform incision contouring all the axilla not superficial and not down, approximately 4cm from skin until subcutaneous tissue. After five minutes all the gland is set free with a few trauma and a few blooding, exactly at the inter mammary gland and begin to remove the breast tissue little by little until there is no more breast tissue up the muscle, this moment finishes the remotion if any necessary breast and fat tissue is removed.

To reduce the time of surgery, if the bleeding is more or low, here radiowave surgery is used because cutting and coagulation occurs at the same time.

It is necessary to put one drain in lateral and inferior breast position and maintains this during 48 hours.

The sutures are only four sutures for both the breasts: one vicryl3 zeros, two mononylon 4 zeros and one mononylon 5 zeros. The sutures are made in three planes: in gland, in sub-cutaneo and in the skin, continue suture and separated sutures in the skin.

The compressive dressing in axilla for 24 hours and the patient begin to use the bras immediately after finishing the surgery and it is necessary to use the bras during three months.

The sutures only are removed after 15 days, because the axilla is a region that has much mobility. Beginning to open the arms very slowly.

Figure 1: Preoperative drawing.

Figure 2: Removing fusiform skin in all axilla.

Figure 3: Detachment by Hegar valve.

Figure 4: Using radiowave surgery removing breast tissue little by little.

Figure 5: Final suture and drain.

Results

Table 3: Amount of the breast tissue resected in 514 breast operated.

Table 4: Complications (3.30%)

Figure 6: Patients with 22 years old, was removed 500g for each breast, in total 1000g forthe both breast, post operative after one year later.

Figure 7: The same patient, the result after 20 years later.

Discussion

The philosophy based on the axillary breast reduction is very different than other techniques of breast reduction, because axillary approach is closed procedure while the others are open.

The final result is best in axillary while the others are good for three months. But after one year, the gland has one bascule and if the superior pole is removed, it will be concave in the axillary approach so the superior pole is maintained, or full and the breast tissue is removed around the central part (CAM: Complex Areole-Mamilar), more in lateral and inferior quadrants. Thus the great majority of the women want convex the superior pole.

Ritwik Grover [7] described in Advances in Plastic & Reconstructive(APRS) journal Why supercharging a Wise-Pattern Might Be
Wise in a select group of large Breast Reduction” and was cited the big problem about T-junction in inverted T-technique as described by Pitanguy, I [8] the more popular technique used in the world during the five decades. The author for two decades used axillary approach for more than 500 cases operated in different types of the breast such as glandular, fat breast and mixed breast, but the best results are being in glandular breast.

It is proved that it is possible to reduce large breasts, removing 1500g or more, avoiding the problem from T-junction ischemia. The result will confirm the type of the breast but not depend on the technique and personal experience.

Closure

This procedure is more economical than the others, use only four sutures in both breasts, the others use ten or more sutures. The performed time is approximately 1hr 45min or two hours in axillary approach, from skin to skin, and the other techniques take lot more time in my hands.

It is necessary to break paradigms and to divulge, that it is possible to reduce the breast with only one scar hidden in axillary pleats, avoiding any scar on breast.

Many women like to undergo breast reduction, but they avoid because of the size of the scars.

Rehabilitation

The surgeons in the world do breast reduction with one, two or three scars on the breast, yet it is necessary to find one more high level of satisfaction to the part of the patients and the good way is avoiding a scar on the breast.

The PIA flap usually provides good skin coverage with excellent cosmetic appearance and is seldom bulky or needs defatting, as the dorsal forearm subcutaneous fat layer is usually thin [Figure 8a, 8b]. In one study, 50/50 consecutive flaps survived with mild edema and minimal complications [12]. Known complications of this procedure include: flap necrosis, hematoma, infection, and donor site morbidity[1, 2, 12-15].

Dear colleague when you want to cut one breast, remember that the mamma is a sexual symbol of the woman, if you need to cut the breast of your daughter or your spouse or your girlfriend, one should make self-reflection.

what the scar it will be??? The best impediment in breast surgery is the scar.

Conclusion

During five decades all the plastic surgeons in the world made breast reduction with one, two or three scars on the breast, but the great majority of the women want to reduce the breast but they don’t want a scar on the breast.

It is possible to do it by axilla and to avoid the scar on breast, only one scar will remain inside axilla pleats and it is easier to do corrections when a bad scar is in axilla than on breast.

It is an economic procedure and with a few trauma, more than the others, it is possible to do it through local and peridural anesthesia.

This procedure reduces the parenchyma, preserve the sensitivity, up the breast, but does not change the original shape.

Depend on the quality of tissue of each patient, this procedure has good retraction of the skin and add more elevation of the breast.

The principal advantages remain only one scar in the axilla, avoiding any scar on the breast.

References

1. Kaiser SF and Klepetko H. Breast Reduction Mammoplast a Review of Literature and Presentation of a Novel Technique with Dual Vascular Supply. Adv Plast Reconstr Surg. 2017; 1:136-143. [Crossref]
2. Schlenz I, Rigel S, Schemper M, Kuzbari R. Alteration of nipple and areola sensivityby reduction mammaplasty a prospective comparison of five techniques. Plast Reconst Surg. 2005; 115:743-751. [Crossref]
3. Felicio,Y. Plastie mammaire de réduction sans cicatrice mammaire, avec radiochirugie. La Revue de Chirurgie Esthétique de Langue Française; XVIII,N:1993;73:53-58. [Crossref]
4. FelicioY. Axillary Reduction MammaplaSchlenz I, Rigel S, Schemper M, Kuzbari R.Alteration of nipple and areola sensivity by reduction mammaplasty a prospective comparison of five techniques. Plast Reconst Surg. 2005; 115:743-751.sty-Yhelda Felicio´s technique. Aesthetic Plast Surg. 1997: 21:268-275. [Crossref]
5. D’Artigues. Chirurgie Répatrice, Plastique et esthétique de la Poitrine, et de l’abdomen. R.Lépine Éditeur, Paris; VIII, 1924; 44-47. [ [Crossref]
6. Felicio,Y. Redução mamária axilar, por Yhelda Felicio. Ebook, Novas Edições Acadêmicas, www.get-morebooks.com code: 978-613-0-16890-2 2015. [Crossref]
7. Ritwik Grover. Why Supercharging a Wise-Pattern Might Be Wise in a Select Group of Large Breast Reductions. Adv Plast Reconstr Surg, 2017; 1:117-118. [Crossref]
8. Pitanguy I. Surgical Treatment of breast hypetrophy. Br J Plast Surg. 1967; 22: 78-85. [Crossref]