The concept of the circumvertical technique on the skin is to prolong the periareolar technique and shorten the vertical component (Fig. 28.1). At the end of the procedure, the excess skin is distributed in two directions – around the areola and in the vertical component. The skin is adjusted to create an even distribution of wrinkles in both the areola and vertically. The vertical scar does not cross the inframammary fold.

Fig. 28.1 Circumvertical design.

In the past 10 years the vertical reduction mammaplasty has become the modern trend in breast reductions, although some surgeons are reluctant to adopt it because they think it is not easy to learn, not easy to obtain a nicely shaped projected breast and the result cannot be observed at the end of the surgery.

After the vertical reduction from Lassus ¹^,² and Lejour³^,⁴ other techniques have evolved^1,⁵^–⁷ such as the vertical with the medial pedicle, published by Hall-Findlay⁸ and the circumvertical one published in 1997, which will be described now.

In breast reductions, the differences between the circumvertical and the other vertical techniques lie not only regarding the way the skin is redistributed during the final suture, but also for more profound reasons. These are the W-pattern parenchyma removal (Fig. 28.2), the different ways to build a round-conic projected breast and the absence of a pedicle for the areola transposition. At the end of the surgery the following are observed: a well-shaped breast, with a harmonic distribution of the wrinkles around the areola and the vertical scar never crossing the inframammary fold (IMF).

Fig. 28.2 The W pattern of the parenchyma removal.

However, the same principles in marking and suturing the skin are also applied to some mastopexies and augmentation–mastopexies.

Operative Technique

Markings

Breast reductions

With the patient in a standing position the patient is studied to gauge her size, what the size preference is and if she wants a projected breast or small flat ones. Then the amount of skin to be removed can be assessed, and from what area of the breast; this is marked on the breast skin. The areola position and the natural asymmetry is also studied.

First, the IMF is marked. The vertical lines passing through the nipple go to the external notch if the areola is to be moved superomedially but they go to the midclavicular line if the areola is only to be moved superiorly. Then the areola is moved into position so that all of the final areolar projection will be above the future submammary fold. The superior border of the areola is then marked on the vertical meridian line. According to the amount of periareolar skin resection needed, 5–6 cm on each side of the nipple are marked, but this could be 4–7 cm if a lateralized areola is to move medially. Then, from the superior mark, a semicircumference is marked and from there two vertical lines are dropped downwards, which converge 2–4 cm above the IMF. The same markings are made on the contralateral side with appropriate adjustments if the breast is larger, smaller, or more ptotic (Fig. 28.3).

Fig. 28.3 The circumvertical preoperative markings.

Before beginning the surgery, each breast is thoroughly infiltrated with 250–300 ml of anesthetic solution into the submammary subglandular space, at the subcutaneous inferior half of the breast skin and under the areola. The anesthetic solution is prepared with 25 ml 2% lidocaine, 25 ml 0.5% bupivacaine, 1 ml 1 : 1000 epinephrine (adrenaline) diluted in 450–550 ml Ringer’s lactate solution.

Once the whole periareolar skin is de-epithelialized, the skin is undermined at the inferior half of the breast both medially and laterally leaving 1 cm thick subcutaneous tissue to preserve its blood supply (Fig. 28.4A). The inferior half of the breast is also detached from the pectoralis major muscle up to the fourth intercostal space, where the perforator of the fourth intercostal nerve usually emerges (Fig. 28.4B). This way, the dissected breast emerges and holding up the breast with a hook, a Wise pattern resection is marked, which is at the inferior quadrant and at the inferior part of the medial and lateral quadrants (Fig. 28.4C–E). After the resection, the lateral and medial glandular edges are sutured medially in two to three layers using a 3-0 Vicryl suture. If the breast is to project more centrally, both pillars can be imbricated (Fig. 28.4F, G). To have a more projected breast, two to three stitches are placed at the base of the cone in order to keep the pillars together (Fig. 28.4H, I). Once a conic-shaped breast has been obtained, the inferior edge of the parenchyma is fixed to the pectoralis fascia where it now sits using five to seven 3-0 Vicryl separate stitches placed all along what will be the future IMF. At this time, some defatting can be done to give a more even round breast shape. Then the areola is moved to the superior border of the skin and fixed with two to three subdermal 3-0 Vicryl sutures. To finish the surgery, a stitch is placed at 8–10 cm from the inferior part of the skin angle, thus dividing the wound into two parts: the superior round periareolar and the inferior vertical ellipse (Fig. 28.4J). The areola is moved upwards and sutured to the superior skin edge (Fig. 28.4K). The inferior wound is sutured in a vertical fashion with a 3-0 Vicryl subdermal running suture. The periareolar skin is sutured to the areolar border with another a subdermal cinching running suture. This running suture takes big 10–12 mm horizontal bites at the skin dermis and 2–3 mm vertical bites at the areola dermis. This way, after three passes the thread is pulled tight and the skin gathers toward the areola. The suturing is continued all around the areola to give an even distribution of wrinkles all along the areola border and to ensure no dead spaces are left. To finish the surgery, all the wounds are closed with intradermal 5-0 Vicryl suture. Aspiration drains are placed laterally and adhesive tape fixes the wounds. Figures 28.4L, M show the final result. Figure 28.5 shows a representative example.

Fig. 28.4 A The inferior half of the breast skin is undermined medially and laterally. B The inferior half of the breast parenchyma is separated from the pectoralis fascia. C The central wedge to be removed is also marked. D The lateral inferior parenchyma removal is marked. E The breast parenchyma removal is completed. F The criss-cross parenchyma is presented for suturing. G A round-shaped breast with the inferior wedge sutured to the pectoralis fascia. H If the base is sutured, the breast is projected. I If the base is not sutured the breast remains flat. J From the inferior wound angle, 10 cm upward, the mark shows the future first stitch and then with a stitch, the wound is divided in two parts: circumareolar and vertical. K The areola is moved upwards without any pedicle. L The final result, with a round shaped breast, with a harmonic distribution of the wrinkles and the vertical not crossing the new IMF. M The right breast treated and 350 g removed.

Fig. 28.5 A–C Breast ptosis and asymmetry. D–F Left circumvertical breast reduction of 200 g and circumvertical breast mastopexy on the right side. Two years follow up. G Circumvertical scars.

This technique is indicated when there is acceptably good skin quality, when the amount to be removed is less than 1000 g and when the areola elevation must be no more than 10 cm.

Mastopexy

The technique used in mastopexy consists of the same markings, while to raise the areola and to change the flat shape of the breast, different approaches can be used: such as simple plication of the dermis and parenchyma on the inferior quadrant in minor cases or using the inferior pedicle technique in moderate–severe ptosis.

Augmentation–mastopexy

In augmentation–mastopexies a very conservative skin removal is marked, the implant is placed subpectorally and plication of the inferior quadrant or inferior pedicle can be used to project a flat breast.

Results

I started using the circumvertical technique for breast reduction in 1992 so I have experience in over 300 breast reductions (Figs 28.6 and 28.7). Periareolar techniques are used, however, when prospective reductions are around 200 g. Between 200 and 1000 g, the circumvertical technique is used, but over 1000 g I prefer the inverted T. I have used the circumvertical technique removing more than 1200 g but even when the scars are vertical, the results are suboptimal. The ideal breast is a round firm breast, with minor ptosis and, the less ideal is a flat hanging breast with poor skin quality.

Fig. 28.6 A–C Ptosis and hypomastia. D–F Three years postoperative after 320 cc subpectoral textured silicone breast implants and the circumvertical technique with inferior pole plications. G–H Five years after surgery she became pregnant. I–K One year after the delivery (total 6 years postoperative) her breast kept almost the original postoperative shape.

Fig. 28.7 A–C Breast hypertrophy and ptosis. Circumvertical preoperative markings. D–F Two years postoperative after the removal of 400 and 470 g. G The final circumvertical scar.

The main complication is skin slough at the periareolar vertical junction, but now that a very limited amount of skin is removed and the flaps are not compressed, this problem is very rarely observed.

Hematomas occur in 4% of cases. All the wounds are washed out with cefuroxime before suturing and consequently, there have been no infections to date.

As no pedicle is used and the blood supply of the areola is preserved, no areolar necrosis is possible.

Thirty years ago when the idea of the purse-string suture did not even exist, I started using a primitive circumvertical technique described by Arie,⁹ in minor or moderate breast ptosis. I first began using the purse-string suture¹⁰ and then changed it for cinching sutures¹¹ and then changed to the cinching running suture. I have used the cinching suture in 60 mastopexy patients. The indication for this technique is for cases in which the breast volume is good and a flat breast shape needs to be corrected and the breast lifted. It is a good technique with only very few minor complications (Fig. 28.8).