Evolution of technique

The sculpted pillar technique evolved from a constellation of maneuvers all aimed at creating a stable breast cone built from two pyramids of carefully shaped breast tissue. It has been said about other techniques that what is important is the tissue that is left behind rather than what is resected, and that axiom certainly applies to the sculpted pillar technique as well. In general, the superior pedicle popularized by Lassus with a vertical approach is the same as the sculpted pillar. Only when the nipple areolar complex cannot be physically manipulated to its new position on a gliding plane do we convert to the superomedial pedicle of Hall-Findlay. The “A point” is selected from the anterior reflection of the inframammary fold, the humeral midpoint, and the visual most projecting point of the new simulated breast shape. The position selected is the top of the areola rather than the actual new nipple position.

The shaping sutures used in the sculpted pillar have been described previously by Marchac, but the lateral shaping sutures were introduced by Alex de Souza, a Brazilian plastic surgeon, in an unpublished communication. The shaping of the pillars themselves is done using concepts described by Armando Chiari, but the gland is not rotated as in the Chiari technique, fully outlined later in this chapter. We have gradually improved the sculpted pillar method since 1999 and have used it on hundreds of patients up to the present time.

Patient selection

Ideal patients for the sculpted pillar technique are those with moderate breast hypertrophy or smaller. Individual breast weights of approximately ≤1000 g lend themselves well to this method. Young patients with more fibrous parenchyma and normal skin without striae are ideal, although if the breast is too large, the superior pedicle may have difficulty folding on itself and will require more thinning. Therefore, in this group of patients, a superomedial pedicle may be a better choice. Even with larger breasted patients, we prefer to approach the reduction using this technique. Because the gland and the skin are handled separately, the larger patients will most often benefit by an inverted T skin resection, so the scar will be longer. The smaller reduction or moderate ones in patients with normal skin can always be handled with a vertical scar only in addition to the periareolar closure.

Patients who have true gigantomastia, the elderly, or active smokers must be approached cautiously. Some are better treated with either an inferior pedicle or free nipple graft technique. Smokers should be encouraged to quit at least four weeks prior to the procedure to reduce the risk of wound healing problems.

Planning and markings

Video 1

The markings are performed with the patient in the standing position (Fig. 8.7.1). The future nipple position is determined right at the reflection of the inframammary fold on the anterior surface of the breast (the A-point or Pitanguy point). This is checked against the visual midpoint of the acromion to humerus distance, as well as other visual landmarks. Typically, this point is about 2 cm lower than the point chosen for inverted T techniques. It is preferable to use the standard superior pedicle for the nipple-areolar complex, but if the density of the gland or distance of elevation appears restrictive, the superomedial pedicle recommended by Hall-Findlay is used.^1,² The medial and lateral pillar lines are drawn by manually distracting the breast tissue medially and laterally. The volume to be left behind is approximated, and the resulting shape is visualized (Fig. 8.7.2). These lines should anticipate the parenchyma to be removed and should be adjusted in or out on the basis of the planned volume of resection. These lines mark the anterior-most projections of what will be, after resection of the intervening parenchyma, the vertical pillars of this technique. Inferiorly, the bottom of the V should be at least 2–3 cm above the native inframammary fold (Fig. 8.7.3). It is also preferable to mark on the skin surface the glandular tissue that will be resected at the caudal extent of the planned medial and lateral pillars, much the same way as one would mark this in a Wise pattern reduction. This will indicate the level of base resection for the medial and lateral vertical pillars, which, when approximated later in the procedure, will stabilize the construct of the new breast on the chest wall via these adjoined medial and lateral solid pyramids.