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19 Endoscopic Breast Reduction andLifting
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Fig. 19.10 (a1, 3) Preoperative 20-year-old patient with good skin elasticity, no striae, breast
hypertrophy, and ptosis. (b1–3) Two years after video-endoscopic breast reduction and lift (120g
each breast), showing a nice upper pole, good skin retraction, no function or sensation damage, and
no visible scars
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M. A. Faria-Correa
Fig. 19.10 (continued)
Conclusions
The results of 30years’ follow-up in 220 patients permit us to recommend its use in
rst-degree ptosis and breast reductions in younger patients. The technical procedure presented shows its utmost effectiveness and best aesthetic results in young
patients who present with a small amount of hypertrophy or asymmetry, but with
good skin elasticity, and who do not have signicant excess skin. The author believes
that the use of these endoscopic techniques is a new trend in plastic surgery when
properly applied.
References
Avelar M, Juarez-Illouz YG: Lipoaspiraco. Hipocrates 1986;3: 320
Faria-Correa MA: Videoendoscopy in Plastic surgery: Brief communication– A videocirurgia na
cururgia plastica: Rev Soc Bras de Cir Plastica Est Reconstr 1992; 7: 80-81
Faria-Correa MA: Endoscopic abdominoplasty, mastopexy and breast reduction. Clin Surg 1995a;
22 ( 4): 723-745
19 Endoscopic Breast Reduction andLifting
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Faria-Correa MA: Endoscopic mammoplasty. World J Plast Surg 1995c; 1: 118- 119
Faria-Correa MA: Videoendoscopic subcutaneous techniques for aesthetic and reconstructive plas-
tic surgery. Plast Reconstr Surg 1995d; 96 (2): 446-453
Faria-Correa MA: Mamoplastia por endoscopia. Rev Cirurg Plas Ibero Latino-Americana 1994a
; 20: 121-127
Faria-Correa MA: Mamoplastia Videodndoscopica Arquivos Catarinenses Med 1994b; 23: 116-118
Faria-Correa MA: Mamoplastia videoendoscopica e abdominoplastia videoendoscopica (subcu-
taneoscopica). In Tournieux AAB (ed), Atualizacao em Cirurgia Plastica Estetica. Sao Paulo,
SP, Robe 1993: 411-418
Faria-Correa MA: Mammoplastia por endoscopia. J Cirurg Plast Ibero-Latino-Americana
1994c;20 (2): 121-127
Faria-Correa MA: Mammoplastia videoendoscopica. Rev Soc Bras Med Estet 1994d; 4; 33-36
Faria-Correa MA: Endoscopic mammoplasty. In: Transactions of the 7th Asian Congress of Plastic
and Reconstructive Surgery, Bangkok, Holistic 1994e
Faria-Correa MA: Mamoplastia videoendoscopica. In: Tournieux AAB (ed), Atualizacao em
Circugia Plastica Estetica e Reconstructiiva. Sao Paulo, Robe, SP 1994f
Faria-Correa MA: Reducao e pexia mamaria por videoendoscopia. In: Saltz 9 (ed), Cirugia da
Mama-Esttica e Reconstructiva de Ricardo Ribeiro. Livaria e Editora Revinter 2000, pp319-327
Peixoto G: Reduction Mammoplasty. A personal technique. Plast Reconst Surg 1980;65(2):217-226
Ribeiro L: Circurgia Plastica da Mama. Rio de Janeiro, Medsi 1989
Verbicaro E: Historico. In: Cruz 0 (ed). Manual de Cirurgia Videoendoscopica. Rio De Janeiro,
Revinter 1993
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Chapter 20
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The Sting Technique: ANew Procedure
fortheCorrection oftheHypoplastic
Lower Breast Poles
GianlucaCampiglio
Abstract Correction of hypoplastic lower breast poles is a difcult challenge dur-
ing an augmentation mammoplasty. Many techniques have been described in the
past such as rotation of glandular aps and release of contracted supercial fascia
with or without sessions of fat injections. Starting from the experience in the treatment of post-burn keloids and hypertrophic scars using big angiographic sharp
needles (18G), a new surgical technique (“sting technique”) based on multiple percutaneous full-thickness puncturing of the hypoplastic interior quadrants of the
breast is presented. This maneuver acts by breaking the cutaneous and subcutaneous
restrictions that prevent a satisfying expansion of the lower pole and can lead to a
double bubble deformity when the original inframammary fold is particularly tight.
Preliminary results in patients with high inframammary fold (IMF) and short areola-IMF distance are encouraging even if longer follow-up and larger series can
help to understand better in the future the real potentialities and limits of the sting
technique. No major complications such as hematoma, infection, or permanent
scarring have been observed in the patient treated so far.
Keywords Breast augmentation · Breast implant · Tuberous breast · Breast
malformation · Surgical treatment
G. Campiglio (*)
Campiglio Plastic Surgery Center, Milan, Italy
Switzerland AG 2023
J. M. Avelar, R. Cavalcanti Ribeiro (eds.), Body Contouring,
https://doi.org/10.1007/978-3-031-42802-9_20
329© The Author(s), under exclusive license to Springer Nature
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G. Campiglio
Introduction
Breast augmentation is a very common procedure aimed to increase the volume and
improve the shape of the breast. Independently from the surgical technique adopted
and the type of prostheses implanted, results are usually very satisfying for both the
surgeons and the patients.
Nevertheless, mild malformations requiring additional surgical maneuvers in
order to obtain a nice shape and a natural appearance of the augmented breast can
complicate this procedure. This is the case, for example, of small breast with a
hypoplastic lower pole, a high inframammary fold, and a short distance from the
areola. This condition belongs to the large family of the tuberous breasts, initially
described by Rees and Aston for small breasts characterized by a reduction in both
vertical and horizontal diameters with glandular herniation behind a huge nippleareolar complex (Rees and Aston 1976) and then expanded to include also tubular
breast, nipple-areolar complex herniation, constricted breast, lower pole hypoplasia,
narrow base breast, and snoopy deformity.
The exact prevalence of tuberous breast is a contentious issue. Some authors
claim that it affects almost three fourths of the female population (Brown and
Somogyi 2015), while others suggest that it is under a tenth (Dos Santos and RuizCastilla 2021). This estimation is further complicated by the fact that less severe
forms might go unrecognized to both patients and surgeons. DeLuca-Pytell reported
an 88.8% incidence of these malformations in patients requiring a mammoplasty
due to breast asymmetry (DeLuca-Pytell et al. 2005). Recently, Klinger et al.
reviewed the incidence in aesthetic augmentation mammoplasty and also proposed
a new terminology for all these breast anomalies introducing the concept of stenotic
breast (Klinger etal. 2017). The authors distinguished vertical stenosis (upper position of the real inframammary fold with different grades of glandular development
and ptosis) and vertical-horizontal stenosis (upper position of the real inframammary fold and a constricted breast base with different grades of glandular development and ptosis). Eight different presentations, from minor deformities to real
tuberous breasts, can be the result of the combination of the type of stenosis, position of the inframammary fold, development of the gland, and grade of ptosis. In all
these combinations, the common feature is the hypoplastic lower pole that needs an
appropriate expansion in order to have a nice and round shape.
The use of needles to release retracted tissue is well known and quite popular in
plastic surgery. Subcision, also called as subcutaneous incisionless surgery, a term
coined by Orentreich and Orentreich in 1995 (Orentreich and Orentreich 1995),
describes a minor surgical procedure for treating depressed scars and wrinkles using
a tri-beveled hypodermic needle inserted through a puncture in the skin surface
(hence, “incisionless” surgery), and its sharp edges maneuvered under the defect to
make subcuticular cuts. The principle of this procedure is to break the brotic
strands that tether the skin to the underlying subcutaneous tissue with a gentle back
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and forth movement of the needle. The depression is lifted by the releasing action of
the procedure, and very often a thin layer of hyaluronic acid or of micro-fat is also
injected in the new dead space in order to prevent or delay a recurrence of the aesthetic defect. Although subcision is most often used to treat wrinkle and acne scars,
it may also help reduce scars caused by other conditions, like cellulitis, chicken pox,
or surgery as in the case of caesarean scars.
Klinger etal. in 2008 were the rst to describe the use of sharp needles in autologous fat grafting for the treatment of patients affected by burn scars, subsequently
demonstrating its safety and versatility in overcoming the resistance of brotic tissues (Klinger etal. 2008).
Later Dr. Rigotti described the “Rigottomy technique,” which is a subcutaneous
release (subcision) of the contracted breast tissue with big needles creating multiple
tiny 2mm cavities to be lled of autologous fat (Khouri etal. 2014).
In this chapter, the preliminary results obtained using a new surgical technique
named “sting technique” are presented. This technique is similar to the Rigottomy
but at the same time differs for two relevant aspects: (1) it is a percutaneous and not
subcutaneous release (subcision) of the stenotic tissue (in this way not only the
gland but also the skin envelope is expanded) and (2) fat is not injected at the end of
the needle treatment. The “sting technique” can be used in typical tuberous breasts
together with other fundamental maneuvers such as areola reduction and reshaping
of the glandular parenchyma or during an augmentation mammoplasty when the
inframammary fold is high and the inferior breast pole is contracted.
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Surgical Technique
A periareolar or inframammary approach is used to create a dual plane subpectoral
or subfascial pocket for a round implant. After checking the hemostasis, the pocket
is completely lled with gauzes soaked in antibiotic solution (clindamycin 600mg
diluted in 100cc saline) containing 500mg of tranexamic acid. This creates a soft
mound against which to perform the “sting maneuver” that is the expansion of the
constricted lower pole of the breast puncturing it many times with an 18 Gauge
needle (Fig.20.1). Each prick penetrates all the skin and the underlying tissue (fascia and gland) up to the gauzes inside the pocket. The distance between each hole
measures few millimeters. The punctures of the sting technique can extend along all
the inferior pole, from the nipple to the new inframammary fold when all the inferior pole has to be expanded (Fig.20.2). When the maneuver is aimed to weaken a
tight inframammary fold and prevent a double bubble deformity, puncturing is limited to a wide cutaneous strip between the old and the new inframammary fold
(Fig.20.3). The sting technique can also be performed asymmetrically if you need
a different reshaping on the two sides or can be used to expand only the lateral or
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Fig. 20.1 Percutaneous
full-thickness puncturing
(sting technique) of the
constricted lower breast
pole using a sharp 18G
needle once the implant
pocket is lled with gauzes
G. Campiglio
the medial quadrants of the breast if indicated. Puncturing creates a light bleeding
that does not require any coagulation and stops spontaneously very soon.
Subsequently, the gauzes inside the pocket are removed and substituted by the
denitive implant. If indicated, a periareolar mastopexy is performed, but in most of
the cases, the ptosis is only apparent. Once the inframammary fold is lowered and
the implant positioned, the hanging breast is corrected. The subcutaneous tissue and
skin are closed using re-absorbable sutures. The skin of the inferior breast pole is
dressed with greasy gauzes and sterile gauzes.
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Fig. 20.2 The sting
technique can be used to
expand the entire inferior
lower pole, from the areola
to the new
inframammary fold
333
Fig. 20.3 In the case of
high and tight
inframammary fold, the
double bubble deformity
can be prevented by
breaking the cutaneous and
subcutaneous restrictions
and puncturing a wide strip
between the old (superior
blue line) and the new
(inferior blue line)
inframammary fold
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G. Campiglio
Postoperative Dressing
Dressing is removed after 48h along with drains, when used. The patients are
instructed to wear a sport bra for 4weeks. The greasy gauzes on the treated area
are left attached to the skin till when they spontaneously detach themselves.
Healing of the punctured skin is usually completed in 7–10days after the procedure (Fig.20.4).
Fig. 20.4 Complete
re-epithelialization usually
occurs after 7–10days
without any scarring
ab c
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335
Clinical Cases
A total of 30 patients affected by a high inframammary fold with a hypoplastic
lower breast pole have been treated using the sting techniques. Age ranged from 21
to 35years. Evaluation of the results was performed by three surgeons using preoperative and postoperative digital photographs with frontal, lateral, and bilateral
oblique views for each patient. A questionnaire was used to evaluate each patient’s
satisfaction and graded from 0, extremely poor outcome, to 10, extremely satisfactory outcome. Categories used for the assessment by the surgeons and patients
included lower pole shape, height and symmetry of the inframammary fold, breast
volume, and breast symmetry (Figs.20.5, 20.6, 20.7, 20.8, 20.9 and 20.10).
Fig. 20.5 Breast asymmetry with a smaller right gland complicated by a constricted lower pole.
(a) Preoperative frontal view. (b) Preoperative three-quarter right view. (c) Preoperative threequarter left view
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