SURGICAL T R E A T M E N T OF B R E A S T H Y P E R T R O P H Y

By Ivo PITANGOY
Chief of Plastic Surgery Department, Catholic University, Rio de Janeiro, Brasil

APART from physical discomfort, large and heavy breasts adversely affect the functions
of the respiratory, circulatory, as well as locomotor systems, particularly when old age
approaches. In this day and age the rationale for surgical treatment is no longer under
discussion. In many of our cases we have observed that big breasts may cause feelings
Of inferiority in patients who may develop serious psychological problems.
The aim at physical normality is legitimate, and refutes any qua}ification of vanity.
A well-adjusted patient who wishes to surmount such problems should be treated by a
technique which minimises complications, and efficiently reduces the breast, giving it
normal shape and contour, and preserving all its function.
Literature on breast reduction during the last 15 years has been enriched by many
publications (Biesenberger, 1931 ; Gillies and McIndoe, 1939 ; Thorek, 1942 ; Malbec,
1951 ; Conway, 1952 ; Marino and Uriburu, 1957 ; Str6mbeck, 196o, 1964). In these
writings there is a marked tendency to use one-stage procedures for many reasons,
including reduction of the anmsthetic and surgical risk, and minimisation of social and
economic difficulties.
In previous papers (Pitanguy, 196o ; I96Ia, b ; I962a, b ; I963a, b ; I964a, b) a
series of cases was analysed, studying the results, complications and pathological
findings. For the last six years in breast hypertrophies from average to large size, we
have been using a keel technique which has given better results on the functional and
aesthetic level than the others that we used before, and which represents a simple approach
to breast reduction.
It is also interesting to note that our incidence of free grafts has dropped from
8 per cent. to I per cent. since the development of this technique. The free graft has
been restricted to massive hypertophies of long duration where functional mammary
tissue is practically non-existent. The techniques previously used, like the Biesenberger
technique, involve some risks as nutrition of the nipple depends entirely on the internal
mammary network and a few intercostal vessels. It also requires long and extensive
flaps, creating dead spaces which not only jeopardise the welfare of the nipple but also
hamper the fashioning of the breast.
When observed after long post-operative periods, breasts reconstructed in this
manner frequently have large inferior poles, and nipples which project upward. Mal-
position of the nipple occurs even in cases where the nipple was originally placed below
its ideal height. We noted that after a few months the nipple rotates into an abnormal,
vertical position, primarily because the inferior pole moves downward causing the
superior pole to flatten. This observation has also been made in our other cases where
techniques with extensive undermining were performed (Pitanguy, 196o).
We have published a previous series of 19o cases (Pitanguy, I96Ib) in which the
keel technique was employed and no complications of importance found, and compared
it to an analysis of results and complications of a previous personal series of 245 in
which we used techniques with extensive underminings (Pitanguy, 196o).
Our object was to find a technique which would yield a well-shaped breast and allow
considerable reduction of volume and this resulted in the method illustrated in this
article.
78
 S U R G I C A L T R E A T M E N T OF BREAST H Y P E R T R O P H Y 79

FIG. I

FIGS. I a n d 2 . - - A C B shows the lateral re-

section o n b o t h sides a n d t h e d e e p e n i n g o f t h e
knife b e t w e e n t h e two c o l u m n s o f breast tissue
w h i c h are s t e p - l a d & r e d to t h e u p p e r pole.
Here t h e a m o u n t r e m o v e d varies w i t h each
case~ b u t t h e resection n e v e r goes b e y o n d t h e
adipose capsule.
FIG. 3 . - - S p o n g e m o d e l s h o w i n g dissection.

FIG. 3

The problem of not using flaps, and not interfering with the pedicles of the mam-
mary arteries, has been approached by Str6mbeck (196o, 1964) in the large hypertrophies.
Philosophically these problems have been similarly approached by us, but conceived in a
different way technically, in which we remove the upper pole from beneath, preserving
the adipose capsule that contains the vessels and nerves important to innervation of
and circulation in the nipple. The preservation of this capsule allows a fullness of the
upper pole later when the capsule is pleated over itself enabling the preserved lateral
columns of breast tissue to effect the upward movement of the nipple. The resection
is performed in a manner that resembles the escalation of a step ladder ; the advance-
ment of the lateral columns allows a rotation of tissue which fills the dead space, moves
the nipple upwards, introducing it to a position which it will occupy naturally with no
tendency to be pulled downward, and allows the nipple to be the centre of the cone of
the breast with certain freedom of movement for a final matching (Figs. 1-7).
80 BRITISH ~OURNAL OF PLASTIC SURGERY
L

FIG. 4
FIGS. 4 and 5.--The breast is not cut square, but as an infundibulum, and s such that when C
and B (the columns of breast tissue) are joined together there is a tendency to push the nipple
upwards rather than to pull it downwards.

FIG. 6 FIG. 7
FIG. 6.--While the nipple is supported upwards, the lower stitch is made in breast tissue to
eliminate the dead space that may exist at the juncture of the scars. It could also be done
by anchoring the breast to the chest wall if desired.
FIG. 7.--The breast is folded over itself and the nipple directed upwards.

So t h a t t h e s k i n will p e r f o r m its real f u n c t i o n as l i g a m e n t , it is n e c e s s a r y t h a t its

c o n t i g u i t y w i t h t h e r e m a i n i n g s e g m e n t s , t h r o u g h t h e a d i p o s e capsule, b e m a i n t a i n e d .
F o r t h e m o s t p a r t t h e r e s e c t i o n o f t h e g l a n d i n t h e keel t e c h n i q u e is t h e s a m e as for t h e
skin, a n d p r o t e c t s t h e f u n d a m e n t a l u n i o n o f g l a n d a n d s k i n b y a series o f f i b r o u s t r a c t s
o v e r all its surface. I n this w a y t h e s u s p e n s i o n o f t h e n e w l y r e s e c t e d g l a n d d e p e n d s u p o n
 SURGICAL TREATMENT OF BREAST HYPERTROPHY 8I

FIG. 8 FIG. 9
FIG. 8.--Point A is placed on the hemiclavicular line, always lower than the
projection of the submammary sulcus as indicated by the finger. It does not
represent the centre of the nipple, but a place where the nipple will be, slightly
upwards and lateral allowing for a finer placement in the end.
FIG. 9.--Points C and B are calculated by holding the breast and figuring
the amount of tissue to be resected according to the indications of each case.
They should not be placed higher than a transverse line passing through the
nipple.

~IG. IO
FIG. I o . - - T h e distance AB or AC should not be longer than 6-7 cm.
FIG. i I.---Line C D is a resection of the axillary prolongation, and will vary in height and length
according to the necessities of each case. Then line BE is similarly traced.
IF
82 B R I T I S H J O U R N A L OF P L A S T I C SURGERY

the skin, the organ to which it is embryologically joined (as the mammary gland is
nothing but a sudoriferous gland).

C o m m e n t s . m T h i s paper is based upon a personal experience of 8oo breasts, 317 of

which were done by the technique which this article illustrates. The technique pro-
duces a good aspect from the msthetic point of view with the tendency to improve with
time. This improvement and the lack of mammary ptosis during the post-operative

FIG. 12 FIG. 13

FIG. : 2 . - - F o l l o w i n g t h e incision of t h e areola, note t h e area o f intact dermis.

FIG. I 3 . - - I n s o m e cases, if t h e r e is m o r e skin to be r e m o v e d t h a n gland, or i f t h e gland does n o t easily

fold over itself, a small u n d e r m i n i n g is m a d e , a n d t h e excess o f tissue resected.

period are linked to the fact that the newly formed gland does not suffer any torsion,
traction or accommodation. Sensibility has been very good, which is attributed mostly
to the complete preservation of the nerves contained in the adipose capsule of the upper
pole. Likewise there has been no interference with breast feeding.
This technique does not depend on a previous and rigid demarcation. We mark
in the operating room, simply for our orientation, and according to the deformity
(Figs. 8-II).
The nipple is never marked beforehand, because we find that its position is governed
by the newly-formed breast, its situation being the logical consequence of a well-oriented
glandular resection. We do not trace it on the original planar surface, but situate it in
the vertex of a cone, because it seems preferable to us to conceive a cone, in the vertex of
which the nipple takes the integral part. Its final detailed placement is always done
by comparing one side with the other, and after the initial stitches (Figs. 12-14).
The entire resection is done from the under side of the breast, and for suspension
we depend on the skin only, not upon muscles, threads, etc., to sustain the shape of the
breast.
It is our practice to operate on the second breast before completing the reconstruc-
tion of the first in order to facilitate timely comparison of their resection, which appears
more prudent than doing one after the other is entirely finished. The results of this form
of mammaplasty in two patients are illustrated in Figures 15-2o.
 SURGICAL TREATMENT OF BREAST HYPERTROPHY 83

FIG. 14 FIG. I5

FIG i6 FIG x7
F i t . i 4 . - - T h e final placing of the nipple is facilitated by its position at the upper
pole of the cone.
FIGs. IS-I7.--Case I.
84 BRITISH JOURNAL OF PLASTIC SURGERY

FIo. I8
Case I.

FIG. 19 FIG. 20
FIGS. I 9 - 2 o . - - C a s e 2 .
 S U R G I C A L T R E A T M E N T OF BREAST H Y P E R T R O P H Y 85

CONCLUSIONS

In all mammary hypertrophies it appears to us that the problem of surgical techni-

ques should not be considered separately from the pathology of the gland. All the
resected parts should be analysed.
The histopathological examinations of the asymptomatic cases revealed lesions
very similar to those obtained from patients that demonstrated clinical symptoms. The
study of some cases afforded us the discovery of incipient tumours which otherwise would
have gone unnoticed (Pitanguy and Torres, I964).
It is our opinion that the correction of hypertrophied and ptosed glands can provide,
besides functional and msthetic benefits, improvement of the mammary physiology,
impeding perhaps, if improvement of the circulatory condition and diminution of the
proportions are taken into account, the incidence of carcinoma.

REFERENCES
BIESENBERGER, H. H. (I93I). " Deformitiiten und kosmetische Operationen der weiblichen
Brust." Vienna : Mandrich.
CONWAY, H. (1952). Plastic reconstr. Surg., IO, 3o3.
GILLIES, H., and MCINDOE, A. (1939). Surgery Gynec. Obstet., 68, 658.
MALBEC, E. (1951). Dia mdd., 23, 2056.
MARINO, H., and URIBURU, J. V. (1957)- " La M a m a . " Buenos Aires : Cientifica Argentina.
PITANGUY, I. (I960). Trans. int. Soc. plast. Surg. 2nd Congress, Lon:lon, I959. E d i n b u r g h :
E. & S. Livingstone.
• (I96Ia). Revta bras. Cirurg., 4 x, 179.
(I96Ib). Revta bras. Cirurg., 4 ~, 2oi.
(I962a). ~Esthetische Medizin, 3, 65.
- - . (I96zb). Annls Chit. plast., 7, 199.
(I963a). Revta lat.-am. Cirurg. plast., 7, 77.
(I963b). Revta lat.-am. Cirug. plast., 7, 142.
(1964). Trib. todd., 4, 3.
- - - - , and TORRES, E. T. (I964). Br. ft. plast. Surg., 17, z97.
STR6MBECK, J. O. (196o). Br. ft. plast. Surg., I3, 79.
- - - (1964). Reduction mammaplasty. I n " Modern Trends in Plastic Surgery."
Vol. I. Ed. T. Gibson. London : Butterworths.
THOREK, M. (1942). " Plastic Surgery of the Breast and Abdominal Wall." Springfield, II1.:
C. C. Thomas.