Mammoplasty with bipedicled flap from the pectoral muscle : 30 years of experience

Introdução: Existem inúmeras técnicas de mamoplastia com objetivo de evitar a ptose tardia. Observamos em todas estas técnicas que a forma da mama após a sua báscula permaneceu com perda de preenchimento do seu polo superior. A associação da mamoplastia com o uso do retalho de base torácica associado ao retalho bipediculado de músculo peitoral maior tem sido utilizada devido ao bom resultado que é mantido num pós-operatório tardio. Método: Foram feitos mais de 4000 procedimentos utilizando a técnica do autor. Foi realizada a marcação de mamoplastia tradicional e confecção de retalho de pedículo inferior conforme descrito por Ribeiro. Divulsiona-se uma faixa do músculo peitoral e realiza-se a passagem completa do retalho torácico através da alça muscular com posterior fixação do retalho à parede torácica. Os retalhos muscular e glandular são envolvidos pelo tecido do polo superior fazendo se a sutura dos pilares laterais. Resultados: Com a utilização da técnica de um retalho torácico, fixado por uma alça de músculo peitoral, obtivemos uma báscula mínima que forneceu um melhor resultado estético a longo prazo. Com esta técnica, o tecido mamário é dividido e reposicionado para o local desejado, mantendo a forma da mama e não dependendo do fechamento dérmico para se obter o contorno final. Conclusão: Observamos nos casos operados a manutenção do polo superior da mama mesmo tardiamente, redução da tensão sobre a cicatrização com consequente melhora do aspecto, ausência do movimento de báscula (ptose) pós-operatória, sem aumento significativo no tempo cirúrgico. ■ RESUMO


INTRODUCTION
The objectives of mammoplasty are to reduce excess glandular tissue and hypertrophy; remodeling of the breast cone to treat ptosis (mammary reduction) focuses on maintaining breast volume, while mastopexy addresses breast elevation and shape 1 .
Several breast augmentation techniques have been developed to avoid late ptosis.These various efforts have sutured the breast to the costal cartilages (Gaillard, 1882; Girard, 1910) or to the periosteum or fascia of the greater pectoral muscle (Micheland  Pousson, 1897; De Quervain, 1926; Rangnell, 1946), fixing the gland to the pectoral muscle; other methods used silicone lamina to support the breast (Bustus, 1992).However, the pendulum movement persisted in all of these techniques, with loss of filling of the upper pole 2 .

OBJECTIVE
The objective of this study was to demonstrate results obtained after 30 years of experience with breast augmentation surgery using the muscle flap technique described by Milton Daniel.

METHODS
More than 4,000 procedures were performed using the author's technique.We present pre-and late post-operative (minimum three years) images.

Technique
The mammoplasty was marked with a periareolar inverted "t" or "L" construction of the inferior pedicle flap as described by Ribeiro.The flap was between 4 and 5 cm wide, extended up to 1 to 2 cm from the     The muscle and glandular flaps were wrapped around the tissue of the upper pole and the lateral breast pillars were sutured with nylon 3-0 sutures.
On the eighth day, the patients started exercises to contract the pectoral muscle so that the breast was pulled up, thus controlling the weight on the scars.Normal activities were permitted on the 15th day postoperation.
The senior surgeon performed the operations in all cases.

RESULTS
Figure 1 -Thoracic flap and dissected muscle strap for flap passage.Side: schematic drawing of the technique.
Figure 3 -Pre-operative and two-year postoperative aspects.
Figure 4 -Pre-operative and six-year postoperative aspects.

DISCUSSION
Several common techniques used to prevent ptosis after mammoplasty utilize static mechanisms to correct breast ptosis.The breast is thus subject to the adverse and continuous action of gravity.A muscle flap involving the lower pole of the breast raises the breast when the muscle is contracted, thus dynamically counter-acting the effects of gravity and preventing ptosis.
The thoracic wall flap, maintained by a loop of the greater pectoral muscle and sutured in a top position, maintains the fill in the upper breast pole.The thoracic flap technique maintains the modified breast shape above the level of the new submammary crease, resulting in better long-term results.
The weight of glandular tissue on the vertical surgical scar increases the vertical length of the scar, leading to varied results according to technique.Thus, each pedicle type and location will press the lower pole differently and uniquely stretch each vertical scar 5 .Contraction of the pectoral muscle elevates the breast through the muscle strap, thus avoiding the action of gravity and preventing mammary ptosis.This technique prevents breast pendulum and decreases the weight of the breast on the scar, thus reducing its enlargement and hypertrophy.
Use of a thoracic flap supported by a pectoral muscle strap resulted in minimum pendulum, which provided better long-term aesthetic results.With this technique, the breast tissue is divided and repositioned in the desired location, thus maintaining the shape of the breast without relying on the dermal closure for the final shape.

CONCLUSION
Even many years after the operations, we observed preserved volume of the upper breast pole, reduced scar tension with consequent aspect improvement, and absence of post-operative pendulum movement (ptosis); furthermore, this technique can be performed without significant increase in surgical time.

Figure 1 .
Figure 1.A: Construction of the dermofat flap and marking of the bipedicled muscular flap with methylene blue; B: Opening of the tunnel under the muscle strap to allow passage of the flap, and passage of the flap under the strap; C: Positioned flap.

Figure 5 .
Figure 5. Sequence of images from right to left: preoperative, one-, nine-, and 19-year postoperative images.