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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_591_Библиотеки_им_академика_М_И_Перельмана
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Fig. 20.6 Intraoperative
view after expansion of the
right lower breast pole
using the sting technique
from the areola to the new
inframammary fold,
augmentation with smooth
round subpectoral implants
(350cc on the left and 375
on the right), and bilateral
periareolar mastopexy
G. Campiglio
Fig. 20.7 (a) Postoperative frontal view. (b) Postoperative three-quarter right view. (c)
Postoperative three-quarter left view
a
abc
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Fig. 20.8 Bilateral severe hypoplasia with tight inframammary fold and stiff inferolateral quadrant of the left breast. (a) Preoperative frontal view. (b) Preoperative three-quarter right view. (c)
Preoperative three-quarter left view
Fig. 20.9 Intraoperative
view. Subpectoral dual
plane round and smooth
implant (350cc). (a) Sting
technique has been applied
to a wide strip between the
old and new inframammary
fold in order to prevent a
double bubble deformity.
(b) The inferolateral
quadrant of the left breast
has been treated as well in
order to expand it
adequately after the
placement of the implant
b
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Fig. 20.10 (a) Postoperative frontal view. (b) Postoperative three-quarter right view. (c)
Postoperative three-quarter left view
G. Campiglio
Results
Aesthetic results evaluated by the surgeons’ group reported a mean aesthetical outcome of 7.7, whereas the ones of the patients reported a mean value of 8.5.
Complications
In two cases, the aesthetic result needed a revision consisting in a fat graft in order
to improve the roundness of the lower pole. In seven cases, a subcutaneous blood
effusion, due to the punctures of the skin, was observed. This complication never
presented as a true hematoma and therefore did not require an additional drainage.
After 7–10days, it disappeared spontaneously and never led to other serious consequence such as skin retraction.
In two patients with darker skin (Fitzpatrick III), the small holes produced by the
needle left pigmented spots that required the use of hydroquinone cream 4% for
2months and then completely disappeared.
Any serious complication such as permanent scarring or infection was observed
in this series of patients.
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339
Conclusion
Hypoplastic lower pole with a high inframammary fold and short distance from the
areola can complicate an augmentation mammoplasty. This condition belongs to the
great family of the tuberous breasts. A key point for a successful result is the lowering of the inframammary fold so that an adequate volume of the prosthesis is located
below the nipple, thus avoiding a high-riding implant deformity. Many surgical
techniques have been described in the past to treat these features such as the use of
inferior rotation of glandular aps (Puckett and Concannon 1990) and the releasing
of the supercial fascia alone or followed by fat grafting of the lower part of the
breast (Servaes etal. 2010) (Oroz-Torres etal. 2014). Positioning of the new fold is
determined by the position of the contralateral non-pathological side. If there is
bilateral deformity, the fold is placed at a location that 55% of the breast volume is
below the areola and the remaining 45% above it. Nevertheless, subcutaneous dissection in the inferior quadrants can be difcult due to the resistance of the skin and
of the underlying fascia supercialis. Regardless of the severity of the deformity
and the technique adopted, placement of either breast tissue or an implant in the new
fold is necessary to maintain its new location. According to Pardo, if an implant is
used, the inframammary fold should be placed 2cm more inferiorly to allow for
subsequent contraction (Pardo etal. 1999). In the case that the inframammary fold
is adequately lowered but the constricted lower pole is not expanded, the tight crease
of the original fold can indent the implant transversely, dividing it into two and
creating a second “bubble” beneath the breast (double bubble deformity). Moreover,
if the poorly treated constricted lower pole is combined with large breast implants,
the risk of this iatrogenic deformity may increase further.
The use of big needles instead of blunt cannulas to inject fat has been rstly
reported by Klinger etal. in 2008 (Klinger etal. 2008). They adopted sharp needle
(18G angiographic needles) to overcome the great resistance of the brotic tissue
of severe post-burn hypertrophic scars and keloids. Sharp angiographic cannulas
allow performing a highly precise technique making possible to lay a constant
amount of fat at the dermal-hypodermal junction. Postoperative histologic examination of scar tissue showed new collagen deposition, neovascularization, and dermal
hyperplasia. Clinically, the 6months follow-up demonstrated a signicant improvement of the skin texture, softness, and thickness. This positive effect was due to the
regenerative properties of the adipose-derived stem cells (ADSC) but also to the
mechanical breakage of the contracted collagen bers by the sharp tip of the big
needles. In another paper, the same group proved the safety of the procedure treating a large series of post-burn scars with fat delivered in this way (Maione etal.
2015). Complication rate was very low and mostly related to the use of needle such
as bruising, swelling or transient numbness, hematoma, seroma, and infections. The
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G. Campiglio
most feared complication was intravascular fat injection, but it was easily avoided
adopting a retrograde injection method. Caviggioli etal. subsequently demonstrated
the versatility of the technique extending the application of the procedure to other
types of scar and brotic tissue (Caviggioli etal. 2012). Other advantages of using
sharp needles are that a skin incision with a scalpel for cannula access is not needed,
thus minimizing the patient discomfort and avoiding a new scars. Angiographic
sharp needles are also easily available, disposable, and low-cost devices.
A similar technique to treat contracted tissue or scar in the breast has been subsequently described by Khouri and named “Rigottomy” after its inventor Dr. Rigotti
(Khouri etal. 2014). In this article, an innovative application of the sharp needles to
prepare the optimal bed for fat micrograft during autologous breast enhancement is
described. Indeed, if scarred or contracted tissue is present, the use of blunt cannulas is not able to deposit thin multiple fat layers and can lead to the formation of
larger cavities that would not be a good graft to recipient interface. Exactly as in the
post-burn scars, adopting sharp 18-gauge needles can break the hard brous architecture of the recipient sites and allows the creation of multiple tiny nicks. These
microcavities are subsequently lled by fat particles that can survive by diffusion
until neovascularization occurs. Being the purpose of Rigottomy to create the optimal bed for the subcutaneous fat grafting, the skin does not need to be punctured
several times as in the sting technique but ideally only a couple just enough to introduce the needle under the skin and create the many subcutaneous microcavities
(subcision).
The sting technique differs from Klinger and Rigotti procedures as sharp needles
are not used to create spaces for fat particles. Indeed, multiple full-thickness prickings are performed to break and release the cutaneous and subcutaneous (glandular
and fascial) restrictions along the hypoplastic breast poles. Insertion of the implant,
immediately after the pricking, maintains this tridimensional expansion until reepithelialization completes the healing. As fat is not used, there are not the problems
associated both with the difculty of harvesting enough adipose tissue in patients
who often are very slim and the uncertainty and unpredictability of taking the graft
(Gutierrez-Ontalvilla etal. 2020).
Complications of sting technique are rare and self-resolving as the subcutaneous
blood collection or requiring a simple treatment as the long-lasting markings in
darker skin. Any case of hematoma, scarring, or infection has been observed.
Hypoplastic lower breast poles can complicate the outcome of a breast augmentation procedure. The results obtained using the “sting technique” in this group of
patients are satisfying showing the creation of a nice, round, and regular contour of
the constricted inferior quadrants. Nevertheless, longer follow-up and larger series
are necessary in the future to understand better the real potentialities of the sting
technique in these kinds of breast malformations and the eventual applications in
other populations such as male to female transgender along with its limits and risks.
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References
Rees TD, Aston S (1976) The tuberous breast Clin Plast Surg; 3:339–47
Brown MH, Somogyi (2015) Surgical strategy in the correction of tuberous breast Clin Plast Surg;
42:53–549
Dos Santos B, Ruiz-Castilla M (2021) Inferior pole expansion with lipolling for tuberous breast
surgery Clin Surg; 6:3287
DeLuca-Pytell D, Piazza R, Holding J (2005) The incidence of tuberous breast deformity in asym-
metric and symmetric mammaplasty patients Plast Reconstr Surg; 116:1894–1899
Klinger M, Klinger F, Giannasi S, Veronesi A et al (2017): Stenotic Breast Malformation and
Its Reconstructive Surgical Correction: A New Concept From Minor Deformity to Tuberous
Breast Aesth Plast Surg; 41:1068
Orentreich DS, Orentreich N. (1995) Subcutaneous incisionless (subcision) surgery for the correc-
tion of depressed scars and wrinkles. Dermatol Surg; 21:543–9.
Klinger M, Marazzi M, Vigo D, Torre M. (2008) Fat injection for cases of severe burn outcomes:
a new perspective of scar remodeling and reduction; Aesthetic Plast Surg. May; 32(3):465–9.
Khouri R, Rigotti G, Cardoso E, Biggs T (2014): Megavolume Autologous Fat Transfer: Part
II.Practice and Techniques; Plast reconstr Surg, 133: 1369
Puckett C and Concannon M (1990): Augmenting the Narrow-Based Breast. The Unfurling
Technique to Prevent the Double-Bubble Deformity Aesth. Plast. Surg. 14:15
Servaes M, Mahaudens P, Sinna R, Vanwijck R, Denoel C (2010) Advantages of the superior areolar
approach for tuberous breast II and III correction with implants. Ann Chir Plast Esthet, 56:342
Oroz-Torres J, Pelay-Ruata MJ, Escolán-Gonzalvo N, Jordán-Palomar E. (2014) Correction of
tuberous breasts using the unfolded subareolar gland ap Aesthetic Plast Surg 38:692.
Pardo A, Watier E, Georgieu N (1999) Tuberous breast syndrome: report on a series of 22 operated
patients Ann Chir Plast Esth; 44:583:592
Maione L, Vinci V, Klinger M, Klinger FM, Caviggioli (2015) F.Autologous fat graft by needle:
analysis of complications after 1000 patients. Ann Plast Surg; Mar;74(3):277–80
Caviggioli F, Forcellini D, Vinci V, Cornegliani G, Klinger F, Klinger (2012) M.Employment of
needles: a different technique for fat placement. Plast Reconstr Surg; Aug;130(2):373e-374e.
Gutierrez-Ontalvilla P, Naidu N, Lopez Blanco E , Condiño Brito B , Ruiz-Valls A (2020)
Autologous Fat Grafting with Percutaneous Fasciotomy and Reduction of the Nipple-
Areolar Complex for the Correction of Tuberous Breast Deformity in Teenagers Aesth Plast
Surg; 44:264
Chapter 21
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Importance ofEvaluation oftheBreasts
byPhotos andPhotometry Related
withBody Contouring
PauloRogérioQuieregattodo EspiritoSanto, ThalesWalteniorTrigo Jr,
MiguelSabinoNeto, andLydiaMasakoFerreira
Abstract Photography is the method most frequently adopted by plastic surgeons
for recording and planning surgeries. The way photographs are obtained directly
affects such surgical programming, as well as the evaluation of surgical procedures
(Quieregatto etal. 2014a, b, 2020a, b).
Introduction
Photography is the method most frequently adopted by plastic surgeons for recording and planning surgeries. The way photographs are obtained directly affects such
surgical programming, as well as the evaluation of surgical procedures (Quieregatto
etal. 2014a, b, 2020a, b).
Standardization is essential for comparing pre- and postoperative photos and
allows correct surgical programming (Hochman et al. 2005; Quieregatto et al.
2014a, b).
Photographic equipment has evolved from machines with a negative that produced printed photographs to digital machines with image les playing the role of a
negative, which has required our familiarization with this new type of device.
P. R. Q. do EspiritoSanto (*)
UNIFESP/EPM e Membro titular da SBCP, São Paulo, SP, Brazil
e-mail: contato@pauloquieregatto.com.br
T. W. TrigoJr
Universidade Presbiteriana Mackenzie, São Paulo, SP, Brazil
M. S. Neto · L. M. Ferreira
DCP da EPM e Membro Titular da SBCP, São Paulo, SP, Brazil
Switzerland AG 2023
J. M. Avelar, R. Cavalcanti Ribeiro (eds.), Body Contouring,
https://doi.org/10.1007/978-3-031-42802-9_21
343© The Author(s), under exclusive license to Springer Nature
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In addition, some factors directly interfere in photography standardization,
including the patient positioning, especially stance of the arms, angulation relative
to the camera, illumination, type of image le, distance between the patient and the
camera, type of lens, reference sites on the patient, ruler for software calibration,
and type of software used to evaluate the digital images (Quieregatto etal. 2020a, b,
2014a, b, 2015).
According to Jakowenko (2009), image capturing using a digital camera is frequently carelessly performed, which may lead to inaccurate results.
Hochman etal. (2005) stated that image recording for scientic research can
fulll its purpose of scientic documentation, especially considering reproducibility, if conducted in a systematized and standardized form.
Using photography instead of obtaining linear measures directly on the individual has been considered an efcient breast evaluation method (Sacchini etal. 1991).
According to Nechala etal. (1999), indirect anthropometry (evaluation of images)
has advantages over direct anthropometry (measurement directly on the patient)
such as minimized measurement errors, millimetric precision, possible measurements over time, comparison between pre- and postoperative periods, reduced discomfort to the patient, and shorter exposure for measurements.
The photographic records routinely used in our clinic differ from those for scientic documentation, considering that a detailed scientic analysis requires absolute
numbers for millimetric comparison. A comparative analysis using pre- and postoperative photos not always needs to be millimetric. Such a difference must be understood since, in case a comparison of measures is necessary, adhesive labels at
specic sites and a ruler for software calibration must be employed during measurements (Quieregatto etal. 2020a, b, 2014a, b).
In the current study, considering the differences between segments, a standardization technique was developed for breast photographs, which allows subsequent
analysis of the obtained images in a scientic and objective manner. Such standardization will be exemplied here.
P. R. Q. do Espirito Santo et al.
Photographic Standardization
Standardization ofPatient Positioning
A template made of ethylene-vinyl acetate (EVA) was employed to standardize at
30cm the distance between the medial edges of the feet and at 70cm the distance
between the volunteer and the background. The distance between the volunteer and
the lens is 2.5m (Fig.21.1).
The patients were instructed to remain in anatomical position with eyes looking
straight ahead (Frankfurt plane) while photographs were taken.
ba
ab c
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Framing andDelimiting Anthropometric andAnatomical Points
The mammary region was delimited by the gnathion transversal line on the top and
by the navel inferior edge on the bottom (Fig.21.2). The frontal plane was chosen
for allowing evaluation of different types of breasts, regardless of their base width
and lateral extension. Photos in oblique and lateral planes show some limitations, as
described by Quieregatto etal. (2014a, b) (Fig.21.3).
Fig. 21.1 (a) EVA template for positioning the feet. (b) Positioning and illumination of the pho-
tographic studio
Fig. 21.2 (a) Photographic framing of the mammary region. (b) Marking of anthropometric and
anatomical points with adhesive labels. (c) Segments that can be evaluated. Counterclockwise:
IJ= center of the jugular notch; xCl=half the distance between IJ and acromion; Ac=lateral
prominence of the acromion; Ax= proximal point of the anterior axillary line; 1/2 Um=mean
distance between Ac and EpL; EpL=anterior projection of the lateral epicondyle; PAP =center
of the mammary papilla; Xi=basis of the xiphoid process; Gn=gnathion; Umb=inferior edge
of the navel. Schematic representation of 17 segments formed by joining the adopted points, 8 line
segments, and an angular measure for each hemibody
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P. R. Q. do Espirito Santo et al.
Adhesive labels of 0.6cm diameter were used to evidence the central point.
Eight points per hemibody were labeled, of which ve are anthropometric: center of
the jugular notch (IJ) and bottom of the xiphoid process (Xi), unilaterally, and center of the mammary papilla (PAP), acromion (Ac), and anterior projection of the
lateral epicondyle (EpL), bilaterally. Other three anatomical points were adopted
bilaterally: the point corresponding to half the distance between the center of the
jugular notch and the acromion, named “x” point of the clavicle (xCl), the proximal
point of the anterior axillary line (Ax), and the point corresponding to half the distance between the acromion and the lateral epicondyle, named mean point of the
humerus (1/2Um) (Fig.21.2).
Joining one point to the other results in 15 line segments (Table21.1).
Fig. 21.3 (a) Impaired visualization of the median inferior point of the mammary groove. (b)
Mammary groove of difcult denition. (c) Extension of the lateral point of the mammary groove
Table 21.1
Segment Description
IJ-Xi Center of the jugular notch to the bottom of the xiphoid process
IJ-PAP Center of the jugular notch to the center of the mammary papilla
xCl-PAP Half the distance between the center of the jugular notch and acromion to the center
Ac-PAP Lateral prominence of the acromion to the center of the mammary papilla
Ax-PAP Proximal point of the anterior axillary line to the center of the mammary papilla
LM-PAP Anterior median line to the center of the mammary papilla
Ac-EpL Lateral prominence of the acromion to the anterior projection of the lateral
Ac-1/2 UmHalf the distance between the lateral prominence of the acromion to the anterior
Projection Projection point on the breast, resultant of the mean distance between acromion and
 Angle formed by segments IJ-xi (center of the jugular notch to the bottom of the
Description of segments
of the mammary papilla
epicondyle
projection of the lateral epicondyle
projection of the lateral epicondyle (1/2 um)
xiphoid process) and IJ-PAP (center of the jugular notch to the center of the
mammary papilla)
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