INTRODUCTION

The increased number of bariatric surgeries brought technical challenge to the universe of plastic surgery. Regarding mammaplasty after massive weight loss, developing an acceptable breast contour with better and long-lasting results is always an issue¹.

After massive weight loss most patients present an important fat tissue reduction resulting in flattened breast, redundant skin envelope, grade 3 breast ptosis and asymmetry². The patient's refuse to put on prosthesis, either for personal reasons or for the cost itself, makes the surgeon preserve maximum breast tissue to give back a satisfactory shape^3,4,5.

On breast reconstruction after cancer, flap confections challenges the surgeon to achieve a harmonic shape. On aesthetic mastopexies, achieving good volume and symmetry is even more desired.

The procedure to be presented has the benefit to fill the deficient upper pole with an inferior-lateral flap and has a higher inframammary fold as final outcome.

METHODS  

5 patients were treated between June 2008 and February 2009, within six months average evaluation time on Federal University of Săo Paulo.

Surgical Technique:

Skin Markings:

·         The patient is marked on standing position with points A, B and C as on classic skin markings by Pitanguy. Point A corresponds to the inframammary fold's anterior projection onto the breast which is about 18 -21 cm from the jugular notch and points B and C about 5 cm laterally that will determine the resected skin area (picture 1).      

·         The flap that will have its excess skin excised on inferior-lateral breast side is marked from lateral point B to the inframammary fold without redundant skin or “ear dog” in order to obtain as much tissue as possible from the axilar region.   

Surgical Technique

A periareolar incision is made with the confection of the Schwartzman maneuver. Another incision is made from the areola towards the pectoralis muscle superiorly creating a wide superior paddle as Liacyr Ribeiro¹ keeping appropriate blood supply to the nipple-areola complex.

The inferior pole is prolonged laterally and its skin is resected releasing the lateral chest inferiorly pedicled flap (pictures 2 and 3), based on thoracic axillar flap, our reference. The inferior flap is attached to the superficial pectoral fascia with inverted U stitches to fill the medial pole. The inferior flap is folded to the upper medial pole through its rotation and attached to the superficial pectoral fascia providing major projection to that area (picture 4).

Points B, C and D are brought together to form the lateral and medial columns (point D corresponds to the union of points B and C to the inframammary fold).  The columns are closed plane by plane and vacuum drains are located on subcutaneous (picture 5). 

Figure Legends

Pictures 1: Skin Markings.

Pictures 2 and 3: Initial aspect after the inferior flap and the lateral flap are released, both pedicled inferiorly.

Picture 4: Inferior flap is attached to the superficial pectoral fascia and lateral flap placed to a superiorly position and attachment to the superficial pectoral fascia.

Picture 5: Final result with a T scar.