The Owl Technique Combined With The Inferior Pedicle In .

Aesth Plast Surg (2008) 32:11–15DOI 10.1007/s00266-007-9032-7ORIGINAL ARTICLEThe Owl Technique Combined with the Inferior Pedicle inMastopexyHugo D. Loustau Æ Horacio F. Mayer ÆManuel SarrabayrouseReceived: 2 June 2007 / Accepted: 26 June 2007 / Published online: 13 September 2007Ó Springer Science Business Media, LLC 2007Abstract Mastopexy patients usually are concerned withaesthetic outcomes, making the procedure a challengingone. Besides recreating a youthful, firm breast, a majorconcern is reducing the extent of scarring. Over recentdecades, a number of short-scar techniques have emergedas alternatives. In 2002, Ramirez reported the owl technique, which combines the features of the periareolar andthe vertical techniques. Nevertheless, the ideal techniquealso should improve shape and breast contour to withstandthe test of time. The authors aim to show the results fromcombining the owl technique with the inferior pedicle forthe treatment of patients who have mammary ptosis with orwithout hypertrophy.Keywordsvertical component eliminates the pleating effect of theperiareolar incision. Thus, the horizontal inframammaryscar is either made very short or completely eliminated.Nevertheless, the ideal technique also should improveshape and breast contour to withstand the test of time.In 1971, Ribeiro described the inferior pedicle, whichprovides a conical shape for the breasts and gives goodlong-term results [6–8]. Because the flap is attached to thepectoral fascia, the weight of the remaining breast isreduced, and the bascule movement is decreased. Theauthors aim to show the results from the combination ofboth techniques for the treatment of patients who havemammary ptosis with or without hypertrophia.Inferior pedicle Owl technique MastopexyMaterials and MethodsMastopexy patients usually are concerned with aestheticoutcomes, making the procedure a challenging one.Besides recreating a youthful, firm breast, a major concernis reducing the extent of scarring. Over recent decades, anumber of short-scar techniques have emerged as alternatives [1].In 2002, Ramirez [2] reported the owl technique, whichcombines the features of the large periareolar reduction inthe ‘‘round block’’ periareolar technique of Benelli [3] andthe vertical reduction of Lassus [4] and Lejour [5].Enlargement of the periareolar skin resection diminishesthe length and pleating of the vertical scar while theH. D. Loustau (&) H. F. Mayer M. SarrabayrousePlastic Surgery Department, Hospital Italiano de Buenos Aires,University of Buenos Aires, School of Medicine, Gascon 450Buenos Aires, Argentinae-mail: hugo.loustau@hospitalitaliano.org.arThis retrospective study included 36 patients who underwent the aforementioned combination of techniquesbetween May of 2002 and November of 2006. All theprocedures were performed at the Hospital Italiano deBuenos Aires with the patient under general anesthesia. Inall cases, the owl technique modified to preserve the centralpart of the breast’s lower pole for creation of a dermolipoglandular flap was used.When the modified owl technique is used, skin markingsare made preoperatively according to the originaldescription by Ramirez [2] (Fig. 1). The periareolar area ofdeepithelialization and the vertical component of the owlincision are infiltrated with a solution of xylocaine andepinephrine to minimize blood loss. Then deepithelialization of the periareolar area and full-thickness skin resectionon the vertical component are performed. The inferior flapis drawn 4 to 5 cm in width, with a length 2 cm below thenipple–areola complex (NAC) and a thickness of 2 to 3 cm123

12Aesth Plast Surg (2008) 32:11–15(Fig. 2). If necessary, the undermining proceeds beneaththe parenchyma, toward the upper pole, but without anyresection behind the NAC.The excess breast gland, if any, is trimmed from each ofthe borders of the pillars. Then the inferior pedicle is fixedover the pectoralis major fascia, and the vertical pillars aresutured together over the flap, giving excellent projection(Fig. 3). There is no skin undermining. The periareolarincision is closed by means of a 3-0 Prolene purse-stringsuture placed with a straight needle, 5-0 nylon invertedknot Halstead-type stitches, and a 4-0 nylon intradermalsuture. The remainder of the vertical closure also is performed with inverted sutures and intradermal suture(Fig. 4). Suction drains are seldom necessary.ResultsMastopexy patients who underwent this combination oftechniques were followed for 6 to 60 months. The averagefollow-up period was 26 months. The average age of thepatients was 31 years (range, 18–59 years).Mastopexy was performed as an outpatient procedure in80% of the cases (29 patients), whereas 20% stayed overnight. In 10 cases of mammary ptosis associated withhyperplasia, it was necessary to perform breast reduction.Fig. 2 Deepithelialization of the periareolar area and full-thicknessskin resection of the vertical component. The inferior flap is drawnThe average amount of breast tissue resected was 150 g perbreast (range, 95–260 g). Complications were rare and of aminor nature. Hypertrophic scarring was detected in threepatients. Suture complications related to nylon suturesoccurred in five cases. These included suture reaction orgranuloma, delayed healing with suture exposure, andpalpable knots requiring removal. No partial or totalnecrosis of the NAC was detected. The aesthetic resultswere considered good to excellent in all cases, and contourresults were stable in long-term follow-up evaluation(Figs. 5–8).DiscussionFig. 1 Preoperative skin markings123The goals of mastopexy are to reconstruct a ptotic breast byrepositioning a neurovascularly intact nipple and to createan aesthetically pleasing breast mound with minimal scarsand long-lasting results. The abundance of mastopexytechniques for breast ptosis reported in the literature atteststo the absence of one ideal mastopexy technique [1]. Manytechniques that incorporate parenchymal reshaping andsupport have evolved to improve breast projection and theduration of ptosis correction.In 1969, Lassus [4] described the vertical mastopexytechnique. In recent years, variations of the vertical mastopexy techniques by Lejour [5], Hammond [9] and HallFindlay [10] have increased in popularity.The short-scar techniques are effective because theyapply different methods of parenchymal rearrangement andsupport, without reliance on the skin envelope for

Aesth Plast Surg (2008) 32:11–1513Fig. 3 The inferior pedicle israised and fixed over thepectoralis major fasciaFig. 4 Closure of the periareolar incision by means of a purse-stringsuturecorrection of ptosis. One disadvantage of these techniquesis the perception that the procedures are technically difficult and frequently require revision. The owl techniquecombines the features of the vertical reduction by Lassus[4] and Lejour [5] and the large periareolar reduction byBennelli [3]. This allows important skin envelope reductionwithout pleats and uses the superocentral pedicle of thebreast for repositioning of the NAC without traction orrotation. Because no glandular resection behind the NAC isperformed, and because retroglandular undermining isperformed only in the central area, the perforating vesselsto the gland are preserved, so no necrosis of the NACshould occur. Sensation also is well preserved because thelateral portions of the gland are not undermined.Fig. 5 A 43-year-old patientwith mammary hyperplasia andptosis. (A) Preoperative frontalview. (B) Preoperative obliqueview. (C) Postoperative frontalview after 1 year. (D)Postoperative oblique view after1 year123

14Aesth Plast Surg (2008) 32:11–15Fig. 6 A 19-year-old patientwith mammary hyperplasia andptosis. (A) Preoperative frontalview. (B) Preoperative obliqueview. (C) Postoperative frontalview after 4 months. (D)Postoperative oblique view after4 monthsFig. 7 A 27-year-old patientwith mammary ptosis. (A)Preoperative frontal view. (B)Preoperative oblique view. (C)Postoperative frontal view after5 months. (D) Postoperativeoblique view after 5 monthsAlthough not described for the original technique, closure of the periareolar incision by means of a purse-stringsuture, in the authors’ hands, ensures good-quality scarsand avoids areolar enlargement. Another technique withsome characteristics similar to the owl technique is the onedescribed by Mottura [11]. The main differences are theskin marking around the areola continued in an invertedcone and the need for some undermining as with Lejour’stechnique.Originally described for reduction mammaplasty, Ramirez’s [2] technique also involves a heart-shapedparenchymal resection, which is not performed in this123technical variation. The lower pole of the breast is insteadpreserved to create a dermolipo glandular flap as describedby Ribeiro [6]. This flap works as a ‘‘natural prosthesis’’and maintains the conical shape of breasts for a long time,lessening the chances of ‘‘bascule’’ movement. In somecases, when the flap is long enough, it can be folded onitself to increase the breast mound projection even more.On the other hand, the technique also allows the desiredadjustment of breast width via the approximation of breastpillars. The possibility of adding these resources to theoriginal technique is of great value when it is being used tomimic a prosthetic contralateral reconstructed breast. In the