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Correction of extensive hypertrophy and ptosis of the breast with a long distance between the jugular notch of the sternum and the nipple presents a number of surgical challenges: Maintaining adequate nipple-areola perfusion, preserving sensation and function, minimising scars, and forming a juvenile breast shape. The curtain type bipedicled mammoplasty with internal suspension combines the following procedures: the surface of the new breast is built entirely by a cranially based flap, thus avoiding a vertical scar and stabilising the periareolar wound. The nipple-areola is pedicled caudally as well as centrally, thus optimizing perfusion and maintaining sensation and the capacity for lactation. Fixing of deepithelialized skin stabilises the residual breast tissue at the thoracic wall and forms an internal suspension.
to eliminate the vertical incision is a modern concept. A further development of these techniques is described to enhance nipple-areola blood supply and perhaps improve the shape of the breast. This seems of special interest for pendulous breasts which are narrow at the top and have a long nipple-jugular distance.
2. Indications
This method can be successfully applied in patients with a minimal distance of about 7–10 cm between the proposed new nipple position and the upper border of the original areola. This distance is necessary to build the lower aspects of the newly formed breast.
This method is favored in younger patients, where lactation is a consideration.
The best aesthetic results will be achieved in breasts having the shape of a hanging pear, where the upper quadrants are small and, therefore, the base of the newly formed breast is narrow.
3. Method
With the patient standing, the new site of the nipple is provisionally marked at about 19 cm from the jugular notch of the sternum in the direction of the nipple. The original submammary fold is marked medially as far as it is hidden by the breast. A corresponding point within the submammary fold is marked laterally at the same level. In the submammary fold a distance of 9–10 cm from the midline is marked as the center of the lower deepithelialised flap. In most patients this corresponds with the distance of the new nipple position from the midline.
The lower end of the cranial, medially and laterally based upper flap is marked in a curved line, connecting the medial and lateral endpoints of the marks in the submammary fold and a central point, about 7–10 cm below the provisional marking of the new nipple position. The medial and lateral parts of the curved line show the form of a lazy S.
The skin between the submammary fold and the nipple-areola complex is deepthelialized in a width of about 8 cm, equivalent to 4 cm laterally and medially from the previous central markings in the submammary fold. The area of the deepithelialized skin is enlarged beneath and at both sides of the areola like wings. The breast tissue under the nipple areola complex is preserved centrally beneath the deepithelialized skin. At the endings of the wings the tissue is thinned out. Except for a small remnant of tissue above the pectoral fascia and beneath the cranial flap, all breast tissue is removed, including the upper, medial and the lateral excess of breast tissue.
At about the level of the endpoints of the submammary incision the endings of the wings are attached to the pectoral fascia, using absorbable suture material. Thus, the reconstructed breast gets internal support.
The upper flap is then brought down to the submammary fold like a curtain, hiding the breast. The excess flap is arranged in such a manner, that the length of the flap and the submammary fold are equivalent at the medial and lateral corners whereas the central part of the flap is pleated, thus forming a central fullness.
If the shape of the new breast is satisfactory, the position of the new nipple is marked, a hole is made in the flap exposing the hidden areola-nipple complex, which is then sutured in the hole.
The construction of the breast is finished by running sutures after insertion of suction tubes (Figure 1, Figure 2) .
Figure 1The operative procedure (A) cranially based upper flap (like a curtain), caudally and centrally based nipple-areola complex with deepithelialized skin (lateral view, section), (B) upper edges of the deepithelialized skin attached to the thoracic wall (frontal view), (C) upper flap is fixed to the submammary fold, residual breast tissue is formed and fixed to the thoracic wall, new nipple position is determined in a sitting position of the patient, (D) nipple-areola complex fixed.
Figure 2Operative steps, (A) deepithelialization of skin, marking of the caudal incisionline of the upper flap, provisional marking of the nipple position, (B) the upper flap is elevated, resection of upper, medial and lateral surplus of breast tissue together with skin, (C) edges of the deepithelialised skin fixed to the thoracic wall, formation of the shape of the breast, (D) the nipple-areola-complex is exposed through a circular incision after positioning in sitting patient at the end of the forming procedure. Upper flap pleated, especially centrally beneath the breast.
From March 1999 to November 2000, 20 breasts in 10 patients were treated by the curtain type reduction mammoplasty with internal suspension. The youngest patient was 24, the oldest 66 years old; the mean age was 40 years.
The amount of reduction ranged between 620 and 1120 g per breast. All nipples survived with no partial or full necrosis of the nipple-areola complex.
Sensation of the nipple was absent in only one patient in one side. Some patients even reported an increase in sensation after the procedure.
In one patient, postsurgical pain occurred in one breast due to limited fat necrosis. A revisional operation with removal of a small amount of necrotic fat and fibrous tissue resolved this problem. The shape of the breast was not altered by this procedure.
In one patient there was a delayed healing of the submammary wound on one side due to skin inflammation. This healed without further intervention. In two patients minor scar revisions were performed on an outpatient basis.
The 26 year old patient had an extensive ptosis and a hypertrophy of the breasts. The reduction in weight was 600 g on each side (Fig. 3) .
Figure 3Example of excessive ptosis in a 26 years old patient (A) preoperative frontal view, (B) frontal view 6 months after operation, (C) preoperative lateral view, (D) lateral view 6 months after operation.
Plastic surgical procedures for breast reduction try to minimise scars. It is necessary to differentiate two main features: the total length, and the visibility of the scar when the patient is upright.
The periareolar approach has the best results in terms of scar-length, but is restricted to relatively mild hypertrophy.
Techniques forming a scar between the nipple-areola and the submammary fold, avoid the scar in the submammary fold, although this scar is relatively inconspicuous. The vertical scar itself is prominent in the center of the lower quadrants.
The curtain type reduction mammoplasty avoids this vertical scar, with the scar in the submammary fold, which is not visible in the upright patient.
The most important aspect of reduction mammoplasty is the vitality, sensation and function of the nipple-areola complex. The longer the sternal notch nipple distance the higher is the risk for complications, because of the need for a long pedicle or free nipple grafting.
The proposed method combines two pedicles, which make the procedure safe for the nutrition, sensation and possible lactation. Several patients reported increased sensation of the nipple-areola after operation.
The use of two pedicles is possible by eliminating the cranial block of tissues within the upper flap as described by Yousif.
was that the breast does not have enough projection. It seems necessary to create an inner solid form of the breast, firmly attached to the thoracic wall around which the curtain is draped.
It improves the shape of the breast, if both endings of the upper incision are made in a lazy S-fashion, together with a relatively short incision in the submammary fold.
What had been considered a handicap for breast reduction—pronounced surplus of breast tissue together with marked ptosis—may on the contrary offer advantages. Except for a relatively inconspicuous circumareolar incision and scar, breast reduction is possible without another visible scar in the front-view of the upright patient.
References
Spear S.L
Mijidian A
Reduction mammaplasty and mastopexy general considerations.
in: Spear S.L Little J.W Lippman M.E Wood W.C Surgery of the Breast: Principles and Art. Lippincott-Raven Publishers,
Philadelphia1998: 673-684
Prof. Dr Ruediger G. H. Baumeister, Head Division of Plastic-, Hand-, Micro-Surgery
Division of Plastic-, Hand-, Micro-Surgery, Department of Surgery, Klinikum der Universitaet Muenchen, Großhadern, Marchioninistr, 15 D-81377 Muenchen, Germany
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