Breast reduction in Brazil: the Pitanguy technique

Breast reduction

Dr. Zamarian is experienced and recognized by his reduction mammoplasty, and he can help the patients to regain their youth vigour back through this surgery. Voluminous breasts can cause other problems for patients besides aesthetic ones; they can also be responsible for other symptoms that can diminish quality of life. Women with large breasts often suffer from back pain due to too much weight and deep marks caused by the bra straps on their shoulders, and lethargy. Breast reduction surgery can relieve these symptoms.

Large breasts

The breasts are located on the front of the chest and the ability to breastfeed is what differentiates mammals from other animals. Some women and some men may, however, have more breast volume, called breast hypertrophy. Large breasts in men are called gynaecomastia. When the breasts reach an extremely exaggerated volume, we call it Gigantomastia. While gynecomastia usually causes an aesthetic discomfort in men, women with breast hypertrophy or Gigantomastia may have the symptoms mentioned above, such as back pain, deep marks on the shoulders caused by bra straps, fatigue, difficulty walking and even diaper rash under the breasts caused by sweating, especially under large sagging breasts.

Breast asymmetry

Most women have breasts with different sizes, and some have not even noticed it. Most of the time, the left breast is larger than right one, but some women have the right breast larger. It is unknown why the left breast is usually larger.

Regardless of which breast is larger, breast reduction performed by Dr. Zamarian reduces significantly this difference. He removes more tissue from the larger breast and, before closing the surgery, he compares the two breasts with the patient in the seated position in order to make them as similar as possible. Pitanguy's breast reduction technique makes different breasts look the same, bringing back the patient's confidence and self-esteem.

When marking the patient's skin before the surgery in the operating room, Dr. Zamarian use wires recommended by Professor Pitanguy, a compass and the preoperative photos in order to evaluate and compare the breasts and plan the surgery. Some small differences may remain after the breast reduction surgery, especially when breasts have very different bases, but in the end, the differences between the breasts are greatly reduced, improving their appearance significantly.

Examples of asymmetry that can be improved:

Breasts with different volumes;
One breast is lower than the other;
Lateral displacement of breasts;
Areolas of different sizes;
Nipples of different sizes;
Breasts with different shapes;
Ultimately, several aspects can be improved with breast reduction surgery.

Pitanguy technique

Dr. Zamarian Jr. performs breast reduction surgery according to Pitanguy's classic technique, which consists in making an incision around the areola, another vertical incision and, finally, a horizontal incision, in an inverted "T" shape. This surgery is recommended for large breasts which need to be lifted and to have their volume greatly reduced, resulting in an attractive and comfortable aspect. Plastic surgery of the breasts gives back to women quality of life. For smaller breasts, which need more lifting than reduction, Dr. Zamarian uses the Pitanguy's rhomboid technique (formerly known as Arié-Pitanguy) for mastopexy (breast lift), which can be performed with or without silicone prosthesis.

For some years, in the beginning of his career, Professor Ivo Pitanguy studied and compiled several breast reduction techniques, which were used in various parts of the world. With the knowledge we had of physiology and anatomy, combined with an accurate surgical technique, professor Pitanguy developed the Pitanguy's classic technique for breast reduction. It consists of an inverted "T" shape scar and some other characteristics such as:

The surgery is performed with the patient in a semi-seated position;
Two sutures are made on the middle line, one at the wishbone level, and another at the inframammary fold level, to help the surgeon find the symmetry. These lines allow the marking made on one breast to be transferred to the other quite accurately;
A midclavicular line is made through the nipple-areola complex (NAC) down to the inframammary fold. Point A is marked on this line, in the projection of the inframammary fold. This point A will correspond to new position of the NAC;
Points B and C are marked by pinching the excess of skin with the fingers;
Two points D and E mark the medial and the lateral extension of the horizontal scat and it normally does not extend beyond the medial and the anterior axillary lines. When there is significant excess of skin, these lines are curved in order to remove more skin;
The area between points A-B-C are denuded (Schwarzmann's manoeuvre), which ensures the maintenance of the dermal capsule of the upper pole, helping maintain PAC innervation and vascularisation;
Some tissue is removed from the lower pole of the breast tissue and another from the central region of the breast, in a vessel keel shape, to facilitate closure and allow the rise of the NAC;
The marking of the areolas is free and made at the end the breasts' positioning. They are positioned according to the surgeon's experience and the desired result;
The surgery is closed internally with absorbable thread and Dermabond cyanocrylate glue on the surface, so that patients do not need to have stitches removed in the postoperative period, and have an aesthetically superior result.

Gigantomastia

Gigantomastia is the name given to breast hypertrophy of major proportions. Patients with gigantomastia usually have great difficulty to perform physical exercises due to overly large breasts, looking obese due to the volume of the breasts. By using Professor Pitanguy's classic technique it is possible to treat cases of gigantomastia by reducing large volumes by half a kilo to two kilos from each breast. The biggest concern during a gigantomastia, however, is the position of the areola. Many patients may have their areolas lower than their elbows, requiring more NAC lifting procedures. When areolas need to be placed more than ten centimetres higher, a free nipple graft might be needed.

Patients with gigantomastia usually have shoulders projected forward and downward, with grooves on the shoulders caused by the bra straps due to the weight of the breasts, and they often have pain. As time goes by, these problems get worse, so, as soon as the gigantomastia is diagnosed, a breast reduction is recommended to prevent serious problems.

Preoperative evaluation

Consultation

During the medical consultation, Dr. Zamarian asks each patient some questions about her past such as age of first menstruation, grooves on her shoulders, and back pain, which is very common among patients with large breasts, before they become candidates for a reduction mamoplasty in Londrina.

During the physical examination, the doctor evaluates the asymmetry of the breasts, the positions of the areola, the volume of the breasts, the type and thickness of the skin, the sagging, if there is filling in the upper pole of the breast, the breast base width, the presence or absence of nodules, milk leakage, diaper rash in the inframammary fold, and the breasts lateral position. In addition, he makes an overall evaluation of the patients, taking into account their weight and height in order to check the possibility of performing the surgery and also to predict the breasts final size.

Reduction mammoplasty can be performed on patients aged 15, 16 and over, provided they did not have a late first menstruation.

Required tests

Before the reduction mammoplasty, some exams are required by Dr. Zamarian to check the patient’s health condition. They are fundamental for the safety of the surgery:

Complete blood count + platelets;
Coagulation tests (PT-INR + APTT);
Urea;
Creatinine;
Fasting blood glucose;
Total serum protein;
Urinalysis (UA);
Electrocardiogramme and
Cardiac evaluation.
Breast ultrasound for women under 35 and mammography for women over 35.

Anaesthesia

Dr. Zamarian performs reduction mammoplasty in the operating room with the patient under general anaesthesia. The anesthesia team is very careful and uses the most modern anaesthetics, so the patient recovers consciousness about three minutes after the end of the surgery.

Surgical procedure

Breast reduction is performed according to Professor Pitanguy's classic technique, with patient in the semi-seated position. The marking of the breasts is done following the procedure described above, to minimise any asymmetries. The surgery begins with the Schwarzmann's manoeuvre (periareolar incision), with scarification of the A-B-C area. Then, the lateral incisions are made, and finally the incision in the fold, removing the excess gland in the lower pole. The keel resection completes the removal of the gland. Hemostasis is careful to avoid bruising and bleeding. The pillars are put closer with a mononylon 2-0 and the breasts are positioned with a mononylon 3-0. Then, the position of the areolas is marked, and the surgery is closed internally with 4-0 vicryl subdermal suture stitches and externally with cyanoacrylate glue.

Although reduction mammoplasty ends up with a bigger scar than liposuction, for example, it is not a painful procedure; on the contrary, more than 90 % of the patients report no pain.

Length of scars

The only factor that determines the size of the scar is the breast volume to be reduced. The larger the breast the longer the final scar, especially on patients whose breasts lateral positions are below the armpits. However, no matter how lengthy the scar is, it will have a good aspect since Dr, Zamarian started to use cyanocrylate glue for the final skin closure.

Will large and low areolas be corrected?

Yes. Dr. Walter Zamarian performs some procedures to raise the areola and give them a proportional size in relation to the new breasts size. These areolas lifting procedures can vary from a simple keel, as recommended by Professor Ivo Pitanguy's technique, to a more complex procedure involving a higher position as recommended by Letterman's (vertical rise) or Silveira Neto's (90 degree rotation of the areola to allow a maximum lifting of about 10cm). For areolas needing more than a 10-cm lift, an immediate free areola graft is recommended to prevent postoperative necrosis.

Breast implants

Many women worry about the results of a breast reduction surgery because they believe that, afterwards, the upper breast pole (part above the areola) will be empty and droopy soon. To minimise this condition, Dr. Zamarian has two alternatives: either he leaves a bit more volume in their reduced breasts so that they do not get a little "empty" after surgery, or he implants a silicone prosthesis during the same surgery. The silicone prosthesis can be implanted during breasts reduction surgery to project the upper pole and delay drooping.

However, patients who need a great reduction of the breast volume breast should avoid implanting silicone prosthesis to prevent scar healing problems. In cases where patients really want to reduce breasts volume, a prosthesis implant is not recommended since they may keep the same volume the patient had before the surgery, or even make them bigger, depending on the volume chosen.

A detail about the choice of the prosthesis volume to be implanted during a reduction surgery is that, as the vertical scar left by this technique is smaller than that left by a mastopexy, the prosthesis volume chosen should not be very large. Dr, Zamarian recommends one of the following volumes: 240, 255, 280 or 335 ml.

So, normally, smaller volumes are chosen for breast reduction surgeries compared to those chose for a mastopexy (sagging breasts surgery).

Postoperative care

Dr. Zamarian informs the patients about breast reduction surgery postoperative care:

Regular diet: no food restrictions;
Avoid smoking fifteen days before and after the surgery (very important for the healing);
Avoid sunbathing for six months after the reduction mammoplasty, nevertheless, from the third to the sixth month after the surgery, the patient can catch sun wearing sun block lotion factor 30 or 40;
Sleep on the back in the first month after the surgery;
Avoid going to the gym and lifting weight or doing physical exercises thirty days after the surgery;
Avoid hot places and cooking, to prevent breasts from swelling;
Avoid lifting the arms (the elbow can be lifted at the shoulders level) for thirty days;
Avoid driving for three months;
Avoid wetting the dressings before the return consultation, which is usually in the second or third day after the surgery, in order to prevent the glue from getting wet;
Avoid long baths in a bathtub after the surgery so that there is no early detachment of the Dermabond glue.

FAQ

Does breast reduction reduce the risk of breast cancer?

It is known that large breasts have more mammary glands and, therefore, the risk of breast cancer increases. Similarly, a breast reduction procedure reduces the excess of mammary tissue thus reducing the risk of developing breast cancer.

Can you breastfeed normally after a breast reduction plastic surgery?

Most of the times, yes, except for breasts with very low areolas, which have to be moved higher, about 10 cm, using Silveira Neto's technique, which rotates the areolas 90 degrees to allow this repositioning. In these cases, just over 50 % of the ducts are cut, which might reduce patients' breastfeeding capacity as well as in cases of free areolas graft, where 100 % of ducts are cut.

Do the areolas lose their sensitivity?

Usually they don’t. As mentioned above, only in cases of very low areolas there might be a reduction in sensitivity.

How long does it take for me to see the final result?

Soon after the surgery the breasts become swollen and wrinkled, restoring normal anatomy with time. In two months’ time, you can see about 85 % of the final result, when we take postoperative pictures. The other 15 % will appear in the next four to six months.

What happens to the scars after the surgery?

In general, the scars are very thin in the first month, becoming red, a little thick and very evident 60 days after surgery. After that, the scars get thinner, lower and clearer over the next 18 months. During this process, Dr. Zamarian monitors each patient's healing development closely and, if necessary, he prescribes some alternatives to improve the scars that might eventually be different from the standard by prescribing an individualised treatment for each case.

Do you want to reduce breast size and look like you have lost weight?

Find out how good it is to reduce the breasts that prevent you from wearing tight blouse, and weigh on your shoulders and back. Conquer new smaller breasts, that can be firmer with silicone implants if you want to. Take the weight off your back, get a new silhouette and be happier and sensual because you deserve it!