One of the recognized techniques for lifting the areola involves an incision around the upper half of the areola that is then combined with an excision of a wedge of skin above the areola. This technique, called a crescent mastopexy, is intended to provide a distracting force that lifts the top of the areola but limits the scar to the upper border of the areola where it joins with the breast skin. While limiting the scar is an attractive goal, in actuality, the net effect of the asymmetrical force that is applied to the areola is to stretch it along the vertical axis with the result being an oval-shaped and widened areolar diameter. The resulting distorted areolar size and shape compromises the appearance of the areola and creates a less than optimal aesthetic result (Figure 5.15). From this experience is derived one of the technical concepts that governs successful periareolar surgery, namely that, to achieve a round and properly positioned areola, the periareolar incision must be carried around the entire peripheral margin of the intended areolar diameter in order to redistribute evenly and adequately the forces around the subsequent closure. In this fashion, a controlled and consistently round areolar shape can be created.

Figure 5.15 (A) Preoperative appearance of a patient in preparation for augmentation mastopexy. (B) On the left, an incision along the superior margin of the areola was utilized to gain access to the breast for placement of the implant. On the right, a superior crescent of skin has been tailor-tacked together to lift the areola to provide symmetry with the opposite side. (C) After removal of the staples, the degree of ptosis on the left can be seen and the margins of the skin crescent to be removed are determined. (D) Appearance of the breast after de-epithelialization of the superior crescent of skin. (E) After skin closure, a mild elongation of the areola in the vertical dimension is already noted. (F,G) The 4-month postoperative appearance demonstrates vertical elongation of the areola due to the asymmetric forces created by the crescentic skin excision.

Another and perhaps more widely recognized complication of periareolar surgery is widening of the areolar diameter postoperatively. The skin of the areola has an exaggerated elasticity compared to the surrounding breast skin and possesses a tremendous ability to stretch when placed under tension. As result, when there is tension placed on the wound closure around the areola after a periareolar procedure, the areola can spread over time, creating a larger areolar diameter than was initially created at the time of surgery. At times, this postoperative spreading can be dramatic and the distorted proportion that the wide areola creates can significantly detract from the overall aesthetic appearance of the breast (Figures 5.16, 5.17). Clearly, the etiology of postoperative spreading of the areola is related to tension on the areolar closure. From this experience is derived the second of the technical concepts that governs periareolar surgery, namely that the tension on the wound closure must be minimized as much as possible. Minimizing tension can be accomplished using a number of different technical modifications, including adding a vertical segment to a periareolar skin pattern whenever possible to reduce the dimensions of the outer periareolar skin incision, limiting the amount of skin removed in the horizontal dimension and using smaller implants in cases of augmentation mastopexy. But perhaps the most effective technique involves stabilizing the dimensions of the periareolar opening with the use of a periareolar purse string suture. By evenly cinching down the outer skin incision to the desired dimension, tension on the areola can be greatly minimized, leading to a reduced incidence of postoperative areolar spreading.

Figure 5.16 Schematic diagram demonstrating the peripherally directed forces that are placed on an unsupported periareolar closure. Due to the pronounced elasticity of the areola, any pressure from within the breast, whether it comes from repositioned breast parenchyma, a tightened skin envelope or the addition of an underlying implant, can result in undesirable and often excessive areola spreading. As little as 1 cm of peripheral expansion of the areolar margin can turn a 4 cm areolar initial incision into a 6 cm widened areola.

Figure 5.17 Widened areola after periareolar augmentation mastopexy.

The technique of applying a purse string suture involves strategically utilizing the appropriate suture material, along with optimizing the technique of suture placement to evenly distribute the tension around the periareolar opening.

The optimal suture material is a permanent monofilament, which slides much more easily through the dermis than a braided suture which tends to catch and become resistant to movement as it is passed through a dermal length of more than 3 or 4 cm. When the suture material passes easily through the dermis, it facilitates an even cinching down of the periareolar opening without any asymmetrically positioned crimping or bunching of the skin edges. The use of a permanent suture also provides long-term support to the periareolar closure. When absorbable materials are used, reabsorption of the suture can occur before scar stabilization of the tissues has occurred. By using a permanent suture, the chances for postoperative areolar spreading are minimized. Although materials such as nylon and prolene can be used for smaller diameter openings, the ideal suture for this purpose is Gore-Tex (Gore Tex Corporation, Flagstaff, Arizona). This material, which comes from the disciplines of vascular and cardiovascular surgery, where it has been used in conjunction with vascular grafts for years, is a very strong, smooth and permanent material that slides through tissues with ease. The optimal suture size to use is CV-3, which has a soft and manageable pliability and great strength, all with the size of about a 2–0 prolene suture. By cutting off the curved needles on either end and threading the suture onto a straight needle, long passes with the needle through the dermal layer of the outer periareolar incision can be made, which speeds suture placement. Alternatively, a slightly larger but stronger CV-2 suture may be used. This particular suture comes already swedged onto a straight needle, which obviates the need to thread the suture separately (Figure 5.18). Once the suture is placed, it then becomes very easy to cinch the periareolar defect down to the desired dimension as the Gore-Tex easily slides through the soft tissues without catching or bunching. Using this suture material provides for a precise and controlled management of the periareolar opening over and above that which is possible with any other suture material.

Figure 5.18 Gore-Tex non-absorbable monofilament CV-2 suture on a CS 65 straight needle. This material is smooth, flexible, strong and permanent. It has excellent handling characteristics and passes easily within the dermal framework of a periareolar incision. As a result, excellent control of the dimensions and shape of the periareolar opening can be achieved.

When performing a periareolar lift, there are several technical maneuvers that can improve the chances for success and can minimize the potential for areolar spreading, wound dehiscence and irregular, widened or prominent scars. Initially, the limits of the outer periareolar incision are outlined. Vertically, the top of the pattern is located at the point where the top of the areola will be positioned. Inferiorly, the pattern skirts the lower border of the areola. Medially and laterally, the pattern again skirts the areola to avoid unnecessary removal of skin in the horizontal plane that can create a tight closure. This pattern variably assumes the shape of an elongated oval. The width of the planned areolar incision varies from 40 to 44 mm. Using a wider areolar incision can predispose to areolar spreading with an excessive areolar diameter developing postoperatively (Figure 5.19). The initial incisions are made just into the dermis and the intervening skin between the outer periareolar incision and the inner areolar incision is de-epithelialized. To place the purse string suture effectively and securely, it is helpful to create a small dermal shelf around the periphery of the periareolar defect. This is as opposed to cutting through the dermis directly at the margin of the periareolar incision. By dividing the dermis approximately 5–6 mm away from the de-epithelialized skin edge, a dermal cuff is created that provides a firm scaffold to hold the Gore-Tex suture. By then passing the straight needle directly within the substance of the dermal shelf and minimizing any gaps that are present as the various passes with the straight needle are made, the tension on the purse string suture is evenly distributed in the strong and stable architectural framework of the dermis. This helps prevent the suture from rupturing through the dermal cuff and pulling out. Also, because the tension is evenly distributed, the surrounding breast skin is evenly pulled down to the areolar diameter, which prevents uneven gathering of the pleats which inevitably form when the purse string is cinched down. Avoiding intermittent skip areas in the dermal shelf when placing the suture also prevents the development of stress points in the suture strand once it is pulled down that could potentially lead to the suture breaking. It is important to note that the width of the dermal cuff should not be any wider than 5–6 mm. If a dermal shelf wider than this is used, then the periareolar opening that results after the purse string suture is cinched down can become quite small and can crowd the areola as it is pulled through the opening, possibly resulting in swelling, NAC ischemia and areolar necrosis.

Figure 5.19 When diagramming a periareolar incision, there is a tendency to use a circular pattern designed to match the circular incision made in the areola (pink line). However, this incision pattern unnecessarily removes skin medially and laterally on either side of the areola and results in increased tension on the subsequent closure that can predispose to areolar widening postoperatively. A better option is to limit the amount of skin removed by drawing the pattern so that it just skirts the medial and lateral border of the areola (black line). In this fashion, there will be less tension on the periareolar closure and the shape of the areola will still be circular once the purse string suture is applied and cinched down.

Once the dermal shelf is developed, the underside margin of the periareolar incision is undermined for a distance of 1–2 cm directly at the level of the dermis in all directions. Undermining at this level for a limited distance is well tolerated and does not result in necrosis of the breast skin edges. Nor does it interrupt the parenchymal blood supply to the NAC as long as skin elevation is done under the dermis only with no extension of the dissection into the breast parenchyma. This release of the dermis prevents the fat and parenchyma of the breast from being pulled inward once the purse string is cinched down. If this occurs, a tissue crowding effect can be created around the areola that exerts pressure around the periphery of the areola, creating a slightly depressed areolar contour in relation to the remainder of the breast mound. The resulting contour irregularity results in a flattened breast appearance that detracts from an otherwise smooth and shapely breast mound.

After development and undermining of the dermal shelf, the purse string suture is placed. Ultimately, the suture will be cinched down and secured with 8–10 square knots as the very smooth surface of the Gore-Tex material has a tendency to cause the knot to slip unless a sufficient number of ‘throws’ are used to secure the knot. This creates a knot complex that is quite bulky and, if it is not buried securely under a healthy layer of tissue, postoperative exposure of the knot can occur. Therefore, to begin suture placement, the needle is passed from deep under the dermal edge to superficial and then once the purse string has been placed, it ends by passing the needle from superficial to deep. This positions the knot securely under the dermal shelf and away from the skin closure. Once the knot is tied down, it is then very easy simply to tuck the knot under the dermal shelf so that it will be reliably buried under healthy tissue and will completely prevent subsequent erosion with exposure of the knot. It is my preference always to place the knot at the most medial aspect of the areola in the event that, for whatever reason, it becomes necessary to remove the Gore-Tex suture. For the right breast this would mean starting the purse string at the 3 o’clock position and for the left breast the 9 o’clock position. Then, if the Gore-Tex needs to be removed, it is very easy to simply spread with scissors to separate the incision at the location of the knot, gently pull the intact suture strand away from the skin edge and cut it to pull the suture out. If the location of the knot is not known, this process can be somewhat difficult as, when the suture is cut midstrand and an attempt is made to remove the suture, the knot catches in the scar around the areola, which prevents easy removal.

When placing the purse string suture with the straight needle, the ideal technique is to pass the needle directly through the substance of the dermal shelf for as long a pass as can easily be made, given the length of the needle. This is as opposed to taking intermittently spaced ‘bites’ around the periphery of the defect. Generally speaking, the fewer the passes, the better, as this means that most of the suture will be in contact with the dermal shelf and skip areas are minimized. In this fashion, any pleats or redundancies that form due to a mismatch in the circumference of the periareolar incision as compared to the areolar incision can be more evenly distributed over the entire periareolar opening, which enhances the likelihood that postoperative scar contraction along the scar line will cause these pleats to settle. If an uneven distribution of the pleating is left uncorrected, an exaggerated bunching in one portion of the periareolar closure could lead to persistent wrinkling in the skin of the breast. It is not necessary to pass the needle back away from the skin edge and incorporate large ‘bites’ of dermis from the surrounding breast skin in the purse string closure. This technique simply creates unnecessary bunching of the skin edge once the purse, string suture is cinched down, which can create permanent contour irregularities along the suture line. One added benefit of this technique is that the purse string suture is actually buried in the most inner portion of the dermal ledge under the areola as the areola is advanced to meet the skin incision around the periareolar opening. This suture/flap relationship protects the Gore-Tex and helps prevent postoperative exposure.

Once the purse string suture has been placed, the outer periareolar incision is cinched down to the desired diameter. The Gore-Tex suture is secured with 8–10 ‘throws’ and the knot complex is buried under the dermal ledge. It should be noted that, if redundancy with pleating of the periareolar skin becomes evident, this pleating tends to become particularly prominent along the superomedial margin of the periareolar opening and the inferolateral margin tends to form more of a one-to-one length relationship with the areolar skin. By redistributing these pleats more evenly around the periphery of the closure, the likelihood that scar contracture will effectively minimize or even eliminate these pleats is enhanced. It is advisable to cinch the opening down to a smaller size than what ultimately is desired for two reasons. First, despite the positive effects of the purse string suture on maintaining the areolar diameter, a modest amount of areolar stretching almost always occurs postoperatively. By adding an element of overcorrection to the operative strategy, the effects of this postoperative spreading on the quality of the final result can be minimized. Second, if the shape of the areola is not round, a small additional amount of very superficial de-epithelialization can be performed as needed to make the periareolar defect round and this maneuver can enlarge the areolar diameter slightly. Care must be taken during this maneuver not to inadvertently cut the Gore-Tex suture. If the suture is cut, it is a simple matter to simply reinsert a new purse string suture; however, the stress dynamics of the new suture are invariably different from the first and the opening must frequently be modified with additional de-epithelialization to create a round areola. Once the purse string is in place and the defect has the proper shape, the areola is inset with 4–0 absorbable monofilament dermal sutures placed in a buried inverted, interrupted, fashion followed by a running subcuticular suture to complete the procedure (Figure 5.20).

Figure 5.20 (A,B) Preoperative markings in preparation for periareolar mastopexy. The limits of the periareolar pattern are outlined (A) and the initial incision is carried only through the superficial dermis. The skin is then de-epithelialized to expose the deeper dermis of the peripheral margins of the periareolar pattern (B). (C,D) An incision line is marked in the de-epithelialized dermis 5–6 mm inside the outer periareolar incision (C) and the dermis is divided at that point, creating a shelf of dermis around the periphery of the periareolar defect (D). This shelf will eventually hold the purse string suture. (E,F) The dermal shelf is slightly undermined around the periphery of the periareolar defect just at the level of the dermis to allow the purse string suture to cinch down the circular defect without creating excessive tissue bunching. (G) A straight needle swedged onto the purse string suture material facilitates passage of the suture directly in the dermal shelf with a minimum of passes and a maximum of efficiency. (H,I) The placement of the purse string suture begins by passing the needle from deep to superficial through the dermal shelf (H) and ends by passing the needle from superficial to deep (I). In this fashion, the fairly bulky knot complex that forms after the suture strands are tied together will pass easily under the dermal shelf, which effectively covers the knot and prevents subsequent exposure. (J) The straight needle is passed directly in the substance of the dermal shelf to position the suture within the firm support structure of the dermal edge. (K,L) The most efficient utilization of the purse string technique involves minimizing as much as possible any skip areas between ‘bites’ of the straight needle. By beginning each pass of the straight needle directly at the point where the previous pass ended (K), exposure of the suture strand is minimized (L) and the tension created when the purse string suture is cinched down will be evenly distributed around the entire circumference of the periareolar defect. (M,N) After the purse string suture has been securely placed in the architectural scaffold of the dermal shelf (M), the defect is cinched down by pulling on the free ends of the suture (N). It is at this point that Gore-Tex provides maximal benefit as the smooth and yet strong nature of the suture material allows it to slide easily through the dermal shelf without catching or bunching. The closing down of the periareolar opening is intentionally overdone slightly to allow for subsequent revision in an attempt to create a perfectly round areolar shape. (O,P) The suture ends are tied with 8–10 throws to prevent knot slippage (O). The knot complex is dabbed with betadine and then buried under the dermal edge to prevent subsequent erosion with exposure of the knot (P). (Q,R) At this point, it is very common for the periareolar defect to be irregularly oval shaped. Therefore, the patient is placed upright to allow gravity to exert whatever effect it might have on the shape of the periareolar opening and a nipple marker is used to re-shape the defect into a perfect circle. (S,T,U) The additional skin areas are de-epithelialized with care taken to avoid cutting the Gore-Tex suture (S) and the areola is inset first with eight evenly spaced 4-0 absorbable monofilament inverted interrupted sutures (T) followed by a running subcuticular suture to complete the procedure (U).

Even with the described technical modifications, it is not at all unusual for some degree of postoperative spreading of the areola to occur. This can also be associated with distortion and asymmetry in the shape of the areola. The reason for this relates back to the marked ability of the areola to stretch under tension. Despite the placement of the supporting Gore-Tex purse string suture located deep within the dermis of the periareolar breast skin, it is possible for the areolar dermis to be pulled over the top of this supporting suture framework if the tension on the surrounding skin is great enough. When this happens, the more superficial elastic dermis of the areola is pulled over the top the stable purse string support and a widened areola results (Figures 5.21, 5.22). In order better to secure the areola into the fixed periareolar opening, the interlocking Gore-Tex suture technique was developed. In this technique, all of the modifications described earlier are utilized, including the creation of a dermal shelf, undermining of the skin edges to ease the periareolar closure and use of the Gore-Tex suture on a straight needle to manage the periareolar defect. What differs is the manner in which the suture is placed. Before suture placement, eight evenly spaced orientation marks are placed on the outer diameter of the periareolar opening as well as the areola itself. By starting at the most medial point, the Gore-Tex is passed from deep to superficial through the dermal shelf. The suture is then directed over to the corresponding point on the areola and a small bite of areolar dermis is incorporated in the stitch. The suture is directed back over to the dermal shelf and the needle is passed directly in the dermis until the next orientation mark is reached. Here, the needle goes back over to the corresponding point on the areolar dermis, again to incorporate a small bite of tissue. This process repeats until the suture has passed all the way around the defect, where the needle ends by passing from superficial to deep under the dermal shelf. The appearance of the pattern created by placing the suture in this fashion is one of a wagon wheel. Ideally, all the bites of dermis through the areola are equal and the spacing between the ‘spokes’ is even. By then pulling on the free suture ends, the Gore-Tex strand can be seen to slide smoothly through the fairly complex weave created by the pattern and the purse string is clinched down until the two unequal diameters are brought together. While a small amount of widening of the contracted areola contributes to the closure of the gap between the two diameters, it is mainly the outer periareolar incision that is cinched down to close the wound. Because of the friction encountered by the Gore-Tex as it is passed through the extensive dermal framework of the periareolar dermal shelf and the areola, it holds without even the need to place a knot. Typically, the diameter of the periareolar opening is made smaller than intended and by using gentle manipulation, the size of the overcorrected areolar defect can be slowly massaged open to whatever diameter is desired. As before, 8–10 throws are placed to keep the knot from slipping and the knot complex is buried under the dermal shelf. The shape of the areola is then checked with the patient in the upright position and if it is not round, additional superficial de-epithelialization is performed at the appropriate margins of the breast skin flaps to create a round shape and the incision is then closed with a running subcuticular 4–0 absorbable monofilament to complete the closure. By interlocking the dermis of the areola into the periareolar closure using the same purse string suture as described, the tendency for the areolar dermis to be pulled over the purse string is held in check. As a result, a more stable distribution of forces is created that tends to resist areolar spreading postoperatively (Figures 5.23–5.25).

Figure 5.21 Schematic cross-section through the NAC after placement of a periareolar purse string suture. Because the purse string stabilizes the diameter of the periareolar opening, there is less tension placed on the periareolar incision. However, it is important to realize that, if there is enough tension, a certain degree of areolar spreading can still occur as the dermis of the areola is pulled over the top of the purse string suture. Typically, the degree of areolar spreading seen with the use of a purse string suture is much less than when no purse string support is present and, depending on other variables, approximately 5 mm of spreading can be expected, enough to turn an initial 4 cm areolar diameter into a 5 cm areola postoperatively.

Figure 5.22 One-year postoperative result after placement of a periareolar Gore-Tex purse string suture. The suture can be palpated as an inner ring within the substance of the areola (black line) as a result of tension pulling the areola over the top of the purse string suture, creating a mild widening of the areola diameter.

Figure 5.23 (A) Preoperative markings in preparation for application of the interlocking Gore-Tex suture technique in a 20-year-old patient who presents for revision of a widened areolar diameter after previous periareolar surgery. A 44 mm areolar incision is marked with the areola under stretch while the outer incision is diagrammed to be just outside the existing widened areola. Eight evenly spaced cardinal points are marked on both the inner areolar diameter and the outer periareolar incision. These marks will guide subsequent suture placement to ensure even cinching up of the disparate periareolar diameters. (B) The incisions are made extending just into the superficial dermis and the area between the two circular incisions is de-epithelialized. (C,D) The dermis is divided approximately 5 mm inside the outer periareolar incision such that a small dermal shelf is constructed that will eventually hold the interlocking purse string suture. (E) The surrounding breast flaps are undermined at a level just under the dermis for a distance of 1–2 cm away from the incision edge to allow the outer periareolar incision to be cinched down without creating tissue crowding and distortion of the periareolar closure. (F) When applying the interlocking technique, the optimal suture material to use is Gore-Tex. The suture is strong, permanent and slides through the complex interlocking weave without difficulty, a fact that facilitates precise control of the shape and dimension of the periareolar closure. In this case, a CV-3 size suture was used swedged onto a CS 65 straight needle. (G) Appearance of the interlocking weave after placement of the Gore-Tex suture. (H) The suture is cinched down by pulling the two free ends until the desired areolar diameter is created. (I,J) After securing the suture ends with 8 to10 square knots, the fairly substantial knot complex is buried under the skin edge to eliminate the risk for subsequent exposure. (K) Final appearance of the areola after closure of the wound with a running subcuticular 4–0 absorbable monofilament suture.

Figure 5.24 Schematic diagram depicting a cross-section through the NAC after placement of an interlocking Gore-Tex suture. Because the dermis of the areola is locked together with the dermis of the outer periareolar incision, the ability of the areola to spread is significantly diminished. All that can take place is a mild expansion of the most superficial portion of the thickness of the areolar skin. Typically, this expansion is limited to 2 mm or less. Thus an areola that initially demonstrates a 4 cm diameter can eventually expand to 4.4 mm. For this reason, even when using the interlocking technique, it is best just slightly to overcorrect the initial areolar diameter to anticipate for this mild degree of spreading.

Figure 5.25 Summary diagram depicting the differences between the different types of periareolar closures. With simple skin closure, there is essentially no stabilization of the areola and the likelihood of postoperative areolar spreading is high. With placement of a purse string suture, the diameter of the periareolar opening is stabilized; however, since the dermis of the areola is free to expand over the top of the purse string, mild spreading of the areolar diameter can still occur. With placement of an interlocking Gore-Tex suture, the areolar dermis is locked into the periareolar closure and only minimal postoperative stretch of the areolar diameter is possible.

While this technique has been used successfully in primary periareolar cases, where the results have been particularly dramatic is in secondary revisions where patients have presented with widened areolar diameters after an initial periareolar procedure. Despite the presence of, at times, dramatically enlarged areolar diameters, a small, circular and stable areolar size and shape have been restored using this technique.

The skin of the areola has a greater elasticity than the surrounding breast skin. Also, the fascial support structure of the breast is greatly attenuated to absent in the area under the areola. As a result, pressure from the underlying breast volume can stretch the skin of the areola to a greater degree than the skin of the breast (Figure 5.26). This difference in skin elasticity leads to the third technical concept of periareolar surgery, namely that when performing skin envelope reducing procedures that increase the pressure being placed on the breast parenchyma, the differing elasticities between the breast skin and areola can result in an exaggerated bulging or ‘herniation’ of the areola. This tendency for the areola to herniate can be overcome by making the initial areolar incision small enough to create a trampoline effect on the areola when it is inset into the periareolar defect. By slightly increasing the pressure on the areola, the tendency to bulge or herniate is reduced. Because the periareolar diameter is stabilized by the purse string suture, the effect of the tension created by insetting the areola into the periareolar defect is confined to the areola alone and is more or less separate from the surrounding breast skin. In this fashion, the tension on the more elastic areola can be adjusted separate from the tension on the surrounding breast skin such that there is no elasticity differential between the two. The result is that pressure from below cannot be differentially expressed through the areola and the tendency to herniate is reduced. Occasionally, areolar herniation is noted early in the postoperative recovery period when none was noted at the time of surgery. This is because temporary swelling in the breast has caused the more elastic areola to stretch in relation to the surrounding breast skin. When the swelling subsides, the areolar herniation will recede. Also, if areolar herniation is persistent after the swelling resolves, it does tend to improve over time as the entire skin envelope of the breast as well as the areolar skin accommodates to its new size and shape. When areolar herniation is noted at the time of surgery, simply reducing the diameter of the areola and re-insetting it into the periareolar defect will usually correct the problem. It must be remembered, however, that, in each circumstance, management of areolar herniation depends upon a strong and stable purse string support of the periareolar closure.

Figure 5.26 (A) Lateral close-up view of the NAC after breast augmentation. As a result of the lack of fascial support to the underside of the areola coupled with the pronounced elasticity of the areolar skin, there is herniation of the breast parenchyma through the area of the areola due to the pressure created by the mass effect of the implant and the native breast volume. (B) Lateral close up view of the NAC after augmentation mastopexy. Here as well, pressure created by the mass effect of the implant combined with the native breast parenchyma is manifested as herniation through the area of the areola.

Using these technical modifications, it is possible to reliably control the shape, diameter and position of the areola in periareolar surgery. Of course, it is important to realize that, even with these modifications, the positive effect of the purse string suture technique can be overcome. There is a limit to the size of the periareolar opening beyond which the quality of the overall result becomes compromised. When the diameter of the outer periareolar incision exceeds 10 cm, depending on the elasticity of the tissues, complications such as persistent pleating around the areolar closure, widened areolar scars, postoperative areolar spreading with shape distortion and purse string suture failure become increasingly more likely. Also, breakage of the purse string closure can result in sudden spreading of the areolar diameter. If scar stabilization of the periareolar closure is strong enough, the tendency for subsequent areolar spreading can be minimized. In most instances, however, the described technical modifications can enhance the reliability and dependability of periareolar surgery in mastopexy.

As discussed previously, periareolar approaches can be utilized with great success to lift the position of the NAC. However, periareolar techniques are much more effective in lifting the NAC than they are at reducing the skin envelope. This is because, when increasing amounts of periareolar skin are removed, not from just above the NAC, but from around the periphery of the areola, the shape of the breast becomes adversely affected as the projection decreases and breast begins to demonstrate a flattened appearance with rounding out of the lower pole of the breast. Generally, when the NAC is lifted more than 3 cm, flattening of the breast projection will begin to develop. The point at which periareolar skin reduction begins to compromise breast aesthetics varies depending on other factors including the size of the breast, the degree of ptosis, the amount of skin laxity, the body habitus of the patient and the nature of any underlying reshaping techniques that are used. Generally speaking, however, as more skin is removed, the degree of deformity becomes more noticeable. For this reason, it is best to utilize a periareolar approach for patients who primarily require a lift of the position of the NAC with only a minimal amount of skin resection.

The technique is simply an extension of the other periareolar techniques described previously. The top of the periareolar pattern is estimated by grasping the superior aspect of the inferiorly malpositioned areola and manually lifting it to a new position higher on the breast mound until it appears to be located at the proposed point of maximal projection of the breast. This point is marked as is the inferior aspect of the areola skin junction with the breast skin. A curved line is then drawn communicating these two points both medially and laterally. In shorter patients with just a modest amount of NAC ptosis, the resulting pattern tends to be more circular. This is an advantage as the circular periareolar pattern matches well with the perfectly circular areolar incision to create a round areola after the intervening skin has been removed and the purse string suture is cinched down. In taller patients, patients with a more ptotic NAC, or in patients with an excessive degree of skin laxity, the resulting pattern becomes more of an oval shape. In these patients, it is generally necessary to adjust the de-epithelialized skin margins after placement of the purse string suture to obtain a round areola.

All of the technical steps described previously apply to periareolar mastopexy. However, one additional technical point merits emphasis when dealing with larger periareolar openings. As the dimensions of the periareolar opening begin to exceed 10 cm in diameter, the pleating that forms as the outer periareolar incision is cinched down to the diameter of the inner areola can be significant, making subsequent placement of the subcuticular suture difficult. To help evenly distribute the discrepancy between the circumferences of the two incisions, a modified subcuticular closure technique is used. Here, instead of taking evenly spaced ‘bites’ of dermis on either side of the incision as would be done with a wound where the two incision lengths are even, the length of dermis incorporated in a single pass of the needle through the dermal shelf of the outer periareolar incision is greater than in the inner areolar incision. One fairly straightforward way to accomplish this is by placing a horizontal mattress bite in the outer incision and a vertical mattress bite in the inner incision. By gradually working this inequality in the amount of tissue incorporated in each pass of the needle around the entire perimeter of the defect, even large differences in areolar diameter can be effectively taken up (Figure 5.27). As the powerful forces of wound contracture subsequently come into play, these pleats then settle significantly over time. In modest size defects, all that is left after full healing occurs is often just a minor skin irregularity noted at the margin of the periareolar skin with the incision. However, for larger defects, the pleating in the skin edge, even after full healing has occurred, can create a noticeable and persistent wrinkle, particularly in the superomedial margin of the incision (Figure 5.28). For these reasons, periareolar management of the redundant skin envelope in mastopexy can be effectively used up to a variable but identifiable limit. When problems regarding the shape of the breast, the shape or size of the areola or the quality of the periareolar scar begin to become noticeable, alternative techniques must be used to obtain the optimal result.

Figure 5.27 Schematic diagram demonstrating the suture technique used for closure after periareolar mastopexy. As a result of the differing dimensions of the larger diameter outer periareolar incision versus the smaller diameter of the inner areolar incision, a redundancy in the outer skin edge is present after placement of the purse string suture. This inequality in incision length is gradually and evenly equalized during final wound closure with the placement of a running subcuticular suture using a horizontal mattress technique in the outer skin edge and a corresponding vertical technique in the inner areolar edge. In this fashion, the pleating that results after final wound closure is distributed as evenly as possible thus creating the best chance for a smooth and well-healed periareolar scar.

Figure 5.28 After periareolar lifting procedures, persistent pleating particularly at the superomedial aspect of the areola can be seen after purse string closure of larger periareolar defects.

The circumvertical skin pattern is the most powerful and versatile skin reduction technique available for use not only in mastopexy, but in augmentation mastopexy and breast reduction as well. The technique can be thought of as simply adding a vertical component to a periareolar skin pattern. For smaller skin redundancies, the vertical component is truly vertical and simply extends straight down to the inframammary fold. For larger cases, the lower portion of the vertical plication turns laterally along the inframammary fold as the redundant skin is taken up. In every instance, however, the pattern is considered to be circumvertical. The tremendous advantage afforded by adding the vertical component is twofold. First, by removing a segment of skin from the underside of the breast that communicates with the periareolar incision, the dimensions of the periareolar defect are reduced, which creates a much more manageable periareolar opening (Figure 5.29). Therefore, in patients who were perhaps at risk for compromised periareolar aesthetics due to the large size of the periareolar incision, the postoperative finding of a widened or distorted areola with an unattractive periareolar scar is significantly reduced. Second, the plicating maneuver of removing skin from the inferior pole of the breast is a powerful shaping technique. Tightening the skin in this fashion not only reduces the skin envelope but also slightly lifts the NAC and increases the projection of the breast, while at the same time narrowing the breast base diameter. Also, any tendency for the periareolar component to flatten the breast contour is generally more than offset by the addition of a vertical segment to the pattern. The only drawback to the addition of a vertical segment relates to the presence of the additional scar that runs down the front of the breast from the inferior portion of the areola down to the inframammary fold. However, this unavoidable disadvantage must be viewed in the context of what is achieved by adding the vertical component. Typically, the vertical scar heals in an imperceptible fashion and is the most inconspicuous of all the standard scar locations used in breast surgery today. Therefore, when assessing the positive effects adding a vertical component can have on the shape of the breast and the overall quality of the aesthetic result, the vertical scar is nearly always a reasonable tradeoff in achieving the optimal result. For this reason, if the addition of a vertical component is deemed to improve the aesthetic result even slightly, it is highly advisable to add it to the overall pattern. For the vast majority of patients, optimizing shape at the expense of the additional vertical scar is well accepted as a necessary strategy to provide the optimal result (Figure 5.30).

Figure 5.29 By adding the vertical segment to the periareolar pattern, the dimensions of the periareolar opening are reduced thus placing less stress on the periareolar closure.

Figure 5.30 (A) Preoperative appearance of a patient who presents with left-sided recurrent ptosis and widening of the areola after primary augmentation mastopexy. (B,C) Preoperative markings in preparation for combined periareolar revision along with vertical plication of the lower pole of the breast. (D) After periareolar revision alone, the lower pole of the breast appears excessively rounded and the apex of the breast is flattened due to the forces created by the periareolar closure. (E) With addition of the vertical segment, the base diameter of the breast is narrowed and the overly ptotic lower pole is lifted to provide better symmetry with the opposite side. (F–I) After the redundant lower pole skin is plicated to good effect, the area is marked, the staples removed and the intervening skin is de-epithelialized. (J–L) After final closure, the breast is lifted, the areola is smaller and the vertical plication line extends down to the inframammary fold but not beyond. (M) One-year postoperative appearance demonstrating better symmetry and long-term correction of the lower pole ptosis on the left along with lifting of the left NAC and a better symmetry in the size and shape of the areolas. By adding the vertical component to the periareolar skin pattern, the size of the periareolar defect is reduced, thus reducing the tension that is placed on the purse string suture and enhancing the aesthetics of the eventual periareolar scar. (N,O) Comparison of the preoperative and postoperative lateral views demonstrates a more contoured lower pole with correction of the mild pseudoptosis. (P) Appearance of the vertical scar at one year.

Historically, the most commonly used technique for managing the redundant skin envelope in mastopexy was the Wise pattern inverted T approach. As a result, it is this technique against which all other ‘short scar’ techniques are measured in terms of results and complications. Here, the apex of the inverted T is located by transposing the inframammary fold anteriorly onto the breast by placing the fingers of the left hand under the breast and palpating with the right hand where the tips of the fingers could be felt. An angled inverted V pattern is then drawn from this point downward, skirting the medial and lateral margins of the areola with the lengths of these two limbs being 5–7 cm long. A medial and lateral extension is then drawn as needed to meet a similar line drawn directly in the inframammary fold. The strategy of this marking pattern is to keep the inframammary component of the incision as short as possible to appropriately take up any redundancy in the skin pattern and yet not leave behind a ‘dog ear’ at either the medial or lateral end of the incision. After the breast is re-shaped, the areola is then inset into a matching defect created by removing a circular segment of skin at the apex of the vertical incision (Figure 5.31). The advantage afforded by this technique relates to the ease with which the skin envelope can be reduced as even large skin redundancies can be managed without difficulty. Because of the manner in which the pattern is designed, there is a more or less 1:1 relationship in the lengths of the corresponding skin incisions, which eases closure and prevents any of the pleating or skin redundancy that can be noted with periareolar or circumvertical techniques. Because of the familiarity many surgeons have with the inverted T technique along with the directness of the skin closure, this pattern remains a popular choice for mastopexy.

Figure 5.31 (A) The markings for an inverted T Wise pattern mastopexy. The apex of the pattern is positioned at the level of the inframammary fold. From this point two limbs extend inferiorly skirting the areola on either side. The length of the limbs varies from 5 to 7 cm depending on the size of the breast. Medial and lateral extensions are then angled away toward the fold as needed to take up the redundant skin envelope. The inferior pedicle is diagrammed skirting the margins of the areola. (B) After elevation of the flaps and removal of the redundant skin, the inframammary and vertical incisions are closed and the location for the areola is sited in. (C) The areola is then inset completing the procedure.

In breast ptosis, the internal connective tissue scaffold of the breast is generally very lax. Therefore, even when the skin envelope is tightened, there is little internal support of the breast parenchyma. As a result, when the breast skin inevitably relaxes postoperatively, there is no restraining force to help maintain breast shape and the breast sags. In an attempt to reconstruct the stretched-out supporting framework of the breast such that it complements the tightened skin envelope and therefore helps create a more aesthetic and long-lasting breast shape, various types of parenchymal plication strategies have been developed. All of these strategies have as their goal a tightened and firmer breast mound that will withstand the test of time as the soft tissues relax postoperatively. When using this technique, any skin pattern can be used to address the redundant skin envelope. Once the initial skin incisions are made, the skin envelope is elevated away from the underlying breast parenchyma at a level that would normally be considered mastectomy flap thickness. This will be more easily done when using an inverted T or circumvertical pattern; however, it is possible to use a periareolar pattern as well, although exposure will be somewhat limited using this approach. It is important to elevate the skin flaps all the way to the periphery of the breast to release the tethered skin completely away from the breast parenchyma. If this is not done, distortions created by the plication of the breast parenchyma may become visible through the skin envelope postoperatively. Once the flaps have been developed, the breast parenchyma can be suture plicated to restore a more youthful, full and firmer appearance. Plication begins in the upper half of the breast first by imbricating the superior pole parenchyma upon itself. This serves to lift the position of the NAC and corrects any concavity present preoperatively in the upper pole of the breast. Once this contour is reset, a vertical plication line is run from the bottom of the areola down to the inframammary fold (IMF). This serves to narrow the width of the breast and increases the projection of the breast mound (Figure 5.33). Together, these two plication strategies will serve to reduce the effective surface area of the breast mound. As a result, the existing breast volume is redistributed in a more confined space, which results in a firmer and more uplifted appearance to the breast. It may be advisable to use 3–0 non-absorbable monofilament (Prolene) suture for this plication to avoid any possibility that early hydrolysis of an absorbable suture could lead to loss of parenchymal support before scar tissue has sufficiently developed to hold the shape. Once the breast is reshaped, the skin envelope is tailored to wrap around the newly formed breast in a way which complements the reduced breast surface area. When using this parenchymal plication strategy, it is important to note that the end result must be overcorrected as a certain amount of postoperative settling will occur. Also, because the effective surface area of the breast is being reduced, the breast will likely appear smaller to the patient, even though no tissue other than skin is removed. Given the wide area of dissection, it is advisable to use a drain postoperatively to prevent a seroma from leading to complications such as infection, scarring and shape distortion. This parenchymal plication technique is a very straightforward method of breast reshaping and additional plication can be added as needed to accomplish specific corrections. No matter how the plication is performed, the concept is the same, namely separate the skin envelope from the gland, reshape the gland and then wrap the reduced skin envelope around the gland using any one of the several skin patterns described previously (Figure 5.34).

Figure 5.33 (A,B) Schematic diagram depicting the strategy for breast reshaping using internal suture fixation of the parenchyma. After degloving of the breast skin envelope, the upper pole is plicated in a superior direction at two levels, the first being at the parenchymal level above the NAC and the second incorporating the de-epithelialized dermis in the superiorly directed suture plication. Once the breast has been lifted, the inferior pole is plicated vertically to narrow the breast base diameter and increase the projection.

Figure 5.34 (A) Preoperative markings of a patient in preparation for left-sided periareolar mastopexy with internal parenchymal plication and right mastectomy with latissimus dorsi flap with tissue expander breast reconstruction. The periareolar pattern is drawn to not only lift the position of the NAC but also to reduce the areolar diameter. (B,C,D) A 44 mm areolar diameter is incised along with the outer periareolar incision (B) and the intervening skin is de-epithelialized (C). The dermis is then divided around the periphery of the periareolar defect, leaving a small dermal cuff eventually to hold the purse string suture (D). (E,F) A medial breast flap is developed by separating the parenchyma from the overlying skin envelope at the level of the breast fascia (E). Dissection proceeds to the medial border of the breast but does not divide the internal mammary perforators (F). (G–L) The same dissection strategy used superiorly (G,H), laterally (I,J) and inferiorly (K,L) to separate completely the breast from the overlying skin envelope. (M,N) Once the parenchyma is freed from the overlying skin envelope, the parenchyma is plicated superiorly upon itself to lift the breast and correct the glandular ptosis.(O,P) After the breast has been lifted, the inferior pole is plicated with a row of sutures placed along the vertical axis, extending from the inframammary fold to the areola to shape the breast further and increase the projection. (Q,R) With patient upright, the effect of the strategy can be seen as the pre-existing ptosis of the NAC (Q) is corrected by the parenchymal plication and the NAC is lifted to a higher position (R). (S,T) In the oblique view, the effect of the vertical plication in particular can be seen as the post-plication view (T) demonstrates increased breast projection with a more contoured lower pole. (U,V) After the breast has been reshaped with internal suture plication, the redundant skin envelope is re-draped using a purse string suture. (W) Immediate appearance of the lifted breast in the upright position. (X,Y) Appearance after 6 weeks, demonstrating an early correction of the breast ptosis and effective reduction in the diameter of the areola. The patient has been well prepared for her subsequent second-stage reconstructive procedure.

The glandular separation and plication approach is a fairly aggressive and technically demanding technique for breast reshaping that does carry a certain risk for potential vascular compromise to the skin flaps. Therefore, as an alternative, suture fixation of internally designed flaps has been described as another very versatile technique for breast reshaping. This approach has the advantage of providing a more direct control of the shape of the breast without the need to separate completely the breast skin envelope from the gland.

Pedicle flaps

Perhaps the most well-known type of internal flap is the inferiorly based parenchymal flap used in conjunction with the vertical mammaplasty procedure. In this technique, the blood supply to the NAC is based on a superior pedicle and the skin envelope is managed using a circumvertical approach. Inferiorly, a parenchymal flap is designed extending up from the inframammary fold to the inferior border of the areola. The width of the flap will vary depending on the size of the breast but it generally ranges anywhere from 6 to 8 cm. As the medial and lateral skin flaps are dissected free from around the lower pole of the breast, the inferior pedicle flap is developed. Inferiorly, the flap is dissected free from its dermal attachments along the inframammary fold. Medially and laterally, the flap is divided by extending the dissection deeply within the breast parenchyma through to the septum. The deep superior border of the flap is then the septum itself with the contained blood vessels that define the blood supply to the flap. The flap is then sutured superiorly under the breast, which is then folded around the pedicle flap as the vertical incision is closed and the NAC is inset. The flap easily reaches the superior pole of the breast and thus provides direct fill to this area, completely correcting any preoperative concavity which may be present. Also, by securing this flap superiorly, any tendency for the inframammary fold to drop is minimized as this flap slings the fold up and holds it in position. Initially, as with many procedures performed on the breast, the appearance of the upper pole of the breast will be excessively full; however, with time, the fullness settles into a persistent and long-lasting contour correction (Figures 5.35, 5.36).

Figure 5.35 Using a vertical technique based on a superior pedicle to provide neurovascular support to the NAC allows the creation of an inferiorly based flap that can be rotated superiorly to fill in a preoperative upper pole concavity. This flap can be constructed to include the breast septum with the associated neurovascular support to ensure viability of the flap.

Figure 5.36 (A,B) Preoperative appearance of a 34-year-old woman who has previously undergone removal of a benign tumor from the superior aspect of the left breast, resulting in a significant contour depression in the region above the NAC. (C) Preoperative marks in preparation for a right-sided circumvertical (SPAIR) mastopexy in conjunction with a left superior pedicle circumvertical mastopexy using an inferiorly based flap to fill in the upper pole defect. (D,E) The previous incision in the left breast was made just below the areola, which necessitated a superior pedicle approach to ensure adequate vascularity to the NAC. The incision is plainly visible after the surrounding periareolar skin has been de-epithelialized. (F,G) Once the incision has been opened, the superior pole of the breast is undermined to prepare for flap advancement. (H) After plication of the vertical segment has confirmed the proper shape, the area that will be de-epithelialized is determined and marked with a purple surgical marker. The dimensions of the planned inferior pedicle flap lie well within the margins of the redundant skin pattern. (I–K) The flap is developed and inset by suturing it to the underlying pectoralis major muscle. (L) Immediate appearance of the left breast, demonstrating complete correction of the upper pole depression and lifting of the breast and NAC. (M,N) Four-year postoperative result, demonstrating a symmetric appearance with complete correction of the preoperative left upper pole contour deformity.

A modification of the inferior parenchymal flap technique for upper pole reshaping has been described that involves suturing the flap under a small strip of muscle elevated from the lower leading edge of the pectoralis major muscle. It is theorized that fixating the flap in this fashion more securely holds the flap in position and provides more reliable recontouring of the upper pole of the breast. Concerns over this technique have focused on placing breast tissue under muscle and thus compromising the ability of this tissue to be properly screened via mammography. While the oncologic issues are debatable, my personal feelings regarding the technique have more to do with possible constriction of the blood supply to the flap with potential ischemia and fat necrosis being the result of a tight muscle sling, either initially at the time of flap elevation, or subsequently as the muscle swells during the early phase of healing. This coupled with the fact that the flap can be reliably sutured up into position by simply directly affixing it superficially to the fascia of the pectoralis major muscle has led me to choose the direct approach in those patients who are candidates for use of the flap as opposed to the use of the muscle sling. Certainly, further research into this area will clarify the utility of the muscular sling in utilizing this flap.

Breast resuspension

One variation to the flap reshaping strategy involves the use of the entire underside of the breast to resuspend the breast superiorly. In this technique, the breast is approached from an inferior direction, using either an inframammary fold incision or the lower portion of a vertical incision. A subglandular pocket is created that extends up to and slightly beyond the superior pole of the breast. Once the breast is released from its attachments to the pectoralis major muscle, it is lifted superiorly and reattached by suturing the deep surface of the breast to the pectoralis major fascia in a location that is higher up on the chest wall. This serves to shift the entire breast position superiorly and thus functions as an operative correction for positional breast ptosis. Also, upper pole concavity can be addressed by using the superior translocation to effectively ‘autoaugment’ the upper pole of the breast. Although an element of overcorrection must be employed with this technique to take into account recurrent stretching of the tissues, this resuspension strategy can be used in conjunction with skin envelope retailoring to provide for a very simple and yet effective mastopexy technique (Figure 5.37).

Figure 5.37 Schematic diagram of resuspending the breast superiorly to restore an aesthetic upper pole. By undermining in a subglandular plane, the breast can be resuspended by advancing the breast superiorly and suturing it to the fascia of the pectoralis major muscle.

Dermal flaps

In an attempt to suture fixate the breast parenchyma into position, it is possible to use the redundant skin envelope left over after skin retailoring to act as an internal brassiere to help hold the breast parenchyma up into position. In periareolar approaches, the redundant dermis around the areola is de-epithelialized and undermined up to the NAC. The circular dermal flap can then be sutured to the surrounding breast parenchyma such that the redundant parenchyma is reinforced into a more compact and supported shape (Figure 5.38). Also, when using an inverted T skin pattern, rather than discarding the redundant wings of the lateral skin flaps, they can be de-epithelialized, released from the inframammary fold and wrapped around the inferior pedicle to help mold and shape the breast into a more projecting and aesthetic mound. Although only small flaps may be available after retailoring of the skin envelope, even partial coverage of the breast parenchyma can aid in molding the breast.

Figure 5.38 (A) Preoperative markings in preparation for breast reduction including a large periareolar component. (B) Appearance of the breast after de-epithelialization of the redundant periareolar skin. (C–F) The de-epithelialized dermal cuff is elevated away from the underlying parenchyma up to the margin of the areola circumferentially to create a dermal flap. (G,H) Appearance of the dermal flap after it has been wrapped around the central breast mound to help cone and shape the breast and increase projection.

Mesh

Although not a commonly used technique, various types of synthetic and mixed absorbable/non-absorbable meshes have been used to provide sturdy and long-lasting support to the shape of the breast. In that regard, the technical strategy is the same as when dermal flaps are used and as well when the breast is plicated. By applying a molding force to the redundant and ptotic breast parenchyma that has been separated away from the surrounding breast flaps, the redundancy is taken up and the shape of the breast is improved (Figure 5.39). The advantage provided by mesh as opposed to dermal flaps is that there is no limitation to the surface area of the mesh that can be applied to the breast, which allows the entire gland to be supported. Also, with the non-absorbable mesh materials, permanent support of the breast will be accomplished. The major concern related to the use of mesh in the breast relates to oncologic issues. Despite evidence to the contrary, possible interference with mammographic evaluation of the breast prevents many surgeons from adopting this approach. Also, the placement of a widely dispersed foreign body in an organ that has a well-recognized and significant malignant potential also causes concern. Despite these concerns, this technique is a very important conceptual concept when applied to breast shape. Once it is realized that the breast shape can be controlled by the application of an external force, all that remains is to determine the optimal external force, whether that be suture plication, dermal flaps or soft tissue rearrangement. Research into the possible development of mesh materials that are ‘physiologically inert’ may well allow this technique to become a valuable adjunct in shaping the breast in the future.

Figure 5.39 Intraoperative appearance of a meshed collagen matrix applied to the lower pole of the breast in a patient undergoing a circumvertical mastopexy. The mesh is designed to help shape the breast and provide long-term support to the parenchyma, thus resisting any tendency for the breast to ‘bottom out’ over time.

The patient is marked in the upright position with the arms resting comfortably at the sides. The inframammary fold is marked on each side by drawing the location of the fold directly in the crease that forms as the breast is gently lifted away from the chest wall (Figure 5.47 A–C). It is important to place this mark directly in the fold as the location of the fold will not change postoperatively, therefore, there is no need to artificially raise or lower the incision location in an attempt to compensate for the bottoming out phenomenon. Because the support structure of the inframammary fold is not violated in the SPAIR mastopexy, bottoming out in the classic sense does not occur. The position of the breast on the chest wall is noted and a meridian line is visualized such that it divides the breast into two equal halves. This line is drawn from the clavicle down to and beyond the inframammary fold (Figure 5.47 D,E). The top of the proposed incision in the areola is then lifted superiorly to a point where the apex of the breast is destined to be positioned. The exact location of this point is identified by estimating, based on the visual appearance of the breast as the areola is lifted, where the point of maximal projection of the breast will eventually be located. The areola is positioned here and the top of the periareolar pattern is drawn where it intersects the breast meridian line (Figure 5.47 F). The same location is identified on the opposite breast and a line running parallel to the inframammary fold line is drawn across the chest (Figure 5.47 G). The position of the top of the periareolar pattern can be checked by measuring the distance between the IMF line and the line denoting the top of the periareolar pattern. This distance can measure up to 6 cm in some patients. It should be emphasized, however, that the measured distance is meant to be only a confirmatory finding to support the estimation made by the surgeon as to the proper location for the top of the periareolar pattern. In smaller breasts, the remainder of the periareolar incision is diagrammed so as to skirt the medial, inferior and lateral borders of the existing areola. The resulting shape assumed by the proposed periareolar incision becomes that of an elongated oval. In larger breasts, a displacement maneuver is used to simulate what the desired contour will be. By gently transposing the breast medially and laterally with just enough pressure to create the desired shape and noting where the breast meridian would be located at a level even with the nipple, the proper amount of skin can be preserved to eventually wrap around the inferior pedicle in a contoured fashion (Figure 5.47 H,I). Finally, to complete the periareolar pattern, an 8 cm pedicle is diagrammed inferiorly centered on the breast meridian. On either side of this pedicle, a distance is measured up from the inframammary fold 8–10 cm and these two points are smoothly joined in a manner that parallels the shape of the inframammary fold (Figure 5.47 J). The 8 cm measurement is used in smaller breasts and the 10 cm measurement is used in more ptotic patients with a large skin envelope excess. Once these four cardinal points have been determined, they are smoothly joined together in what becomes an elongated oval (Figure 5.47 K). The landmarks for the interlocking Gore-Tex suture are applied and marks are checked for symmetry to complete the marking process (Figure 5.47 L,M). A useful maneuver to ensure symmetric application of the marks is to compress the breasts against each other in the midline to be sure that the marks are evenly and symmetrically applied and that the same amount of skin is left behind (Figure 5.47 N). This can be very helpful in patients who present with any degree of asymmetry. Although the amount of skin resected from each side may differ, leaving behind the same amount of skin on each side offers the best environment for obtaining symmetry. A useful adage to remember in this regard is, ‘it’s not what you take, it’s what you leave behind that is important’.

Figure 5.47 (A) Preoperative appearance of a 36-year-old woman with NAC and volume ptosis, skin redundancy and NAC asymmetry who presents for SPAIR mastopexy. (B) The marking procedure is begun by first identifying the midsternal line and the location of each inframammary fold. (C) By communicating the IMF location with a line that runs across the midline, the location of the fold can be determined from afar without the need to manipulate the breast and possibly distort the soft tissue relationships. (D,E) The breast meridian is drawn in a fashion that bisects the breast volume into two equal halves (D). If the NAC is asymmetrically positioned, it is ignored during the determination of this line. This line is then carried down onto the chest wall (E) ultimately to aid in properly locating the central portion of the pedicle. (F) The top of the periareolar pattern is identified by lifting the ptotic NAC up to the apex of the breast mound and transposing this point onto the superior pole of the breast. This point is symmetrically located from side to side with the aid of a line that parallels the location of the inframammary fold. It is not uncommon for this line to be located 5–6 cm above the previously drawn inframammary fold line. (H,I) The breast is gently pushed up and out (H) and then up and in (I) and the breast meridian is transposed onto the breast skin at the level of the nipple to identify the optimal amount of breast skin to preserve during the development of the periareolar pattern. (J) An 8 cm wide pedicle is drawn along the IMF centered on the breast meridian. A distance of 8–10 cm (in this instance 9 cm) measured from the IMF line is then diagrammed up on either side of the pedicle and these two points are communicated in a line that parallels the IMF. (K) The four cardinal points are joined to create a periareolar pattern that takes on the shape of an elongated oval. (L) The eight orientation marks to guide the eventual placement of the interlocking Gore-Tex suture are made in the outer periareolar skin and the areola. (M) The appearance of the final marking pattern. Note that the left NAC is medially malpositioned and therefore ignored as the left breast meridian is drawn. The proposed extent of superior pole plication is illustrated by the pink arrows. (N) A final check for symmetry can be performed by compressing the breast in the midline to be certain that the same amount of skin has been preserved on each side.

At surgery, the proposed areolar incision is made with the assistance of a multidiameter areolar marker. With the areola under stretch, an areolar diameter of 40–44 mm is diagrammed and incised (Figure 5.48 A,B). The outer periareolar incision is made and the intervening skin de-epithelialized (Figure 5.48 C). The dermis is divided around the periphery of the periareolar defect leaving a 5 mm dermal cuff that will ultimately hold the periareolar Gore-Tex purse string suture. The dermis in the inferior 25% of the periareolar pattern is left intact to preserve the dermal contribution of the blood supply to the NAC (Figure 5.48 D,E). The medial, superior and lateral breast flaps are then developed in preparation for breast reshaping. Initially, dissection of the superior and medial flaps proceeds directly under the dermal shelf and then progressively curves downward toward the chest wall, creating a flap that will be 4–6 cm in thickness. The end result is a flap that is quite thin initially but then becomes substantially thicker at the base of the breast (Figure 5.48 F–I). In contrast, however, the lateral flap is dissected at the level of the investing breast fascia down to the chest wall (Figure 5.48 J). If the lateral flap is left too thick, experience has shown that a pronounced lateral fullness to the breast will often result. An effort is made to make a smooth transition between the base of the thicker superior flap and the thinner lateral flap to avoid the possibility of a visible contour step off in the superolateral aspect of the breast. Once the flaps have been developed, the inferior pedicle with the attached NAC can be identified as it lies in the center of the breast mound. Every effort is made to avoid undermining the pedicle and to keep as wide a base of attachment as possible to ensure maximal neurovascular supply to the pedicle (Figure 5.48 K,L).

Figure 5.48 (A,B) A multidiameter areolar marker is used to create a 40 mm areolar diameter with the breast and areola under tension. (C) After the areolar and periareolar incisions are made, the intervening skin is de-epithelialized. (D,E) The dermal shelf is marked (D) and the dermis divided to define the periareolar opening as well as the inferior pedicle (E). (F–I) The medial flap is dissected to be quite thin initially (F) and then become thicker as dissection nears the chest wall (G). The same is true for the superior flap (H,I). (J) Laterally, the flap is dissected at the level of the breast fascia and is therefore somewhat thin. (K,L) Appearance of the inferior pedicle with the attached NAC after flap development.

Once the flaps have been developed, the superior flap is undermined up to a level that approaches the clavicle (Figure 5.49 A) and the medial flap is undermined over to but not beyond the internal mammary perforators (Figure 5.49 B). Superiorly, the leading deep edge of the flap is advanced up and under itself, where it is sutured to the pectoralis major fascia in three locations using an absorbable 3–0 monofilament suture (Figure 5.49 C–E). Ideally, these sutures are placed correspondingly at the 10, 12 and 2 o’clock positions to evenly advance the flap superiorly. Absorbable sutures can be used in this procedure as a result of the fact that the flaps are actually undermined and directly repositioned. Scar will eventually form, which then functions to hold the repositioned tissues into place. In this fashion, an autoaugmentation of the upper pole of the breast is performed using the soft tissue thickness of the superior flap as the basis for supplying tissue to fill in the upper breast contour. The deep leading edge of the medial flap is then imbricated to itself again with the 3–0 absorbable monofilament suture (Figure 5.49 F–H). This serves to gather the medial flap tissues together, which creates a more rounded and improved medial breast contour. The inferior pedicle that was created by default after dissection of the flaps is now translocated superiorly such that it meets the superior flap, at which point the deep margin of the pedicle is secured to the pectoralis major fascia with two to three sutures (Figure 5.49 I). If there is a sharp tissue edge around the apex of the pedicle, this edge is trimmed to provide a rounded smooth contour. Finally, if the surrounding flaps have enough bulk, the pedicle can be directly sutured to the medial and superior flaps to assist further in holding the pedicle in position to improve the shape of the breast (Figure 5.49 J,K).

Figure 5.49 (A) The upper flap is undermined up to the general region of the clavicle to prepare for flap resuspension. (B) The medial flap is elevated over the medial internal mammary perforators but not beyond in order to preserve this vigorous source of blood supply to the breast. (C–E) The leading edge of the superior flap is advanced superiorly and sutured to the pectoralis major fascia to provide an autoaugmentation to the upper pole of the breast. (F–H) The medial flap is plicated upon itself to create a medial fullness and more rounded contour. (I) The inferior pedicle is advanced superiorly and sutured to the pectoralis major fascia. (J,K) The pedicle is sutured to the surrounding breast flaps (J) to further shape the breast. At the conclusion of the shaping process, the favorable effect of the shaping maneuvers can be seen on the breast with the patient upright (K).

From a technical standpoint, the plication of the redundant skin in the lower pole of the breast is a very straightforward maneuver and yet, at the same time, it is this maneuver that requires the most artistry on the part of the surgeon. The procedure is begun by placing the patient upright at least 45 degrees to allow gravity to affect the breast in a way that allows the surgeon to accurately assess the effect of the vertical plication. By placing traction on the most superior aspect of the inferior pedicle, the skin envelope will buckle medial and lateral to the pedicle (Figure 5.50 A). These two buckle points are grasped with a forceps and the edges are brought together and temporarily secured with what is called the ‘key’ staple (Figure 5.50 B–D). This is the fixation point that sets the remainder of the pattern as all other judgments regarding the extent of plication are based on the key staple as a starting point. The de-epithelialized dermal shelf on either side of the key staple is grasped with a hemostat and, by providing upward traction, the lower pole skin envelope is placed under tension (Figure 5.50 E). In this position, when inward pressure is applied against the center of the lower pole of the breast, the edges can be seen to imbricate in a vertical to slightly oblique orientation that identifies the plication line needed to optimally create the desired breast shape (Figure 5.50 F). It is then a simple matter to apply staples sequentially to secure the plication line in the desired location (Figure 5.50 G,H). As the plication line nears the inframammary fold, it is angled laterally to prevent the vertical incision from extending down onto the upper abdomen (Figure 5.50 I). Once the vertical segment is fully plicated, the dimensions of the periareolar defect will be markedly reduced and the areola can be inset into the defect to allow final assessment of the breast shape (Figure 5.50 J,K). At this point, further tightening of the plication line can be performed as needed to create the best shape possible. Conversely, some staples can be loosened slightly to correct excessive lower pole flattening. Essentially, whatever maneuver is required to create the best shape possible is what is required at this point. This aspect of the shaping strategy represents one of the major advantages of the technique, namely, that the shape immediately on the table is designed to be the shape that is ultimately created after full healing has occurred. In patients with poor skin tone, it may be advisable to over-tighten the plication line slightly in anticipation of some postoperative skin envelope relaxation. Once the vertical segment has been set, the margins of the plication line are marked and the staples are removed (Figure 5.50 L,M). The vertical segment is de-epithelialized and the lateral flap is fully released to allow it to cross over on top of the de-epithelialized pedicle to meet the medial incision line (Figure 5.50 M–P). This maneuver creates a more contoured lower pole and obviates any potential for flattening along the incision line that can occur when the lower pole tissues are simply imbricated without any tissue release. The vertical incision is then closed in layers to prepare for placement of the purse string suture.

Figure 5.50 (A) The pedicle is grasped along the superior margin and upward traction is applied. (B–D) As a result, two buckled skin folds develop medial and lateral to the pedicle (B). The points are grasped with forceps and stapled together to position the key staple (B–D). (E) The dermal shelf on either side of the key staple is grasped with a hemostat and upward traction is placed on the lower pole skin envelope. (F) By pushing inward on the central portion of the lower pole of the breast, the flaps imbricate upon themselves to reveal the location of the optimal line of plication. (G,H) The plication line is tailor tacked closed with staples until the desired shape has been created. (I) Inferiorly, the plication line is curved laterally to prevent the vertical incision from extending down onto the upper portion of the abdomen below the breast. (J,K) After the inferior pole of the breast has been plicated (J) and the areola has been inset (K), the breast should have a pleasing shape immediately. (L,M) The edges of the vertical plication line are marked with a surgical marker (L) and the staples are removed to reveal the segment of skin that will require de-epithelialization (M). (N–P) After the skin is de-epithelialized (N), the lateral flap is fully released (O) and passed on top of the pedicle to meet the medial incision (P).

The patient is once again placed upright and the shape of the periareolar defect is assessed. If it is not round, additional skin and underlying parenchyma is removed to create a round opening, being sure to maintain a dermal shelf in the course of revising the defect (Figure 5.51 A,B). The markings for an interlocking Gore-Tex purse string suture are applied and the suture is placed as described previously (Figure 5.51 C–H). Final inset is performed in a layered fashion (Figure 5.51 I,J) and an occlusive dressing consisting of tissue glue (Dermabond-Ethicon Corporation) and Opsite is applied (Figure 5.51 K–N). A support garment is placed to provide support to the newly repositioned breasts (Figure 5.51 O).

Figure 5.51 (A,B) In the upright position, if the periareolar defect is not round after closure of the vertical segment (A), additional debridement is performed to create a rounded opening (B). (C–H) The marks to guide the placement of the interlocking Gore-Tex suture are made (C) and the suture is placed incorporating eight separate fixation points in the areola (D,E). After the purse string suture is conched down (F), the knot complex is dabbed with betadine (G,H) and buried under the medial skin flap. (I,J) A layered closure using a 4-0 absorbable monofilament suture is performed (I) to complete the procedure on the right (J). (K–N) After skin closure, tissue glue is applied to the incision line (K) followed by an occlusive dressing (L,M) to complete the procedure (N). (O) A support garment is applied for comfort.

Using this operative strategy, each of the elements that describe the ptotic patient is addressed. The positional ptosis and concavity in the upper pole are directly corrected by strategically developing the flaps and the pedicle, advancing them superiorly and suture fixating them into position. The redundant skin envelope is reduced using the circumvertical skin pattern along with the interlocking Gore-Tex suture technique to manage the periareolar opening. The SPAIR mastopexy technique is reserved for patients who present with more severe cases of breast ptosis where the degree of breast descent on the chest wall is pronounced or the amount of internal reshaping required to provide the optimal result is considered extensive. While it is the most complex and involved of all the mastopexy procedures described in this chapter, it is also a very consistent and reliable technique for management of the ptotic breast (Figures 5.52–5.54).

Figure 5.52 (A,B) Preoperative appearance of a 38-year-old woman in preparation for bilateral SPAIR mastopexy. (C,D) Preoperative marks. (E–H) One-year postoperative result.

Figure 5.53 (A,B) Preoperative appearance of a 39-year-old woman in preparation for bilateral SPAIR mastopexy. (C–G) Four-year postoperative result. Note that when the patient raises her hands over her head, there is no notching noted along the inferior pole of the breast (G).

Figure 5.54 (A,B) Preoperative appearance of a 44-year-old woman in preparation for bilateral SPAIR mastopexy after undergoing a 150 pound (68 kg) weight loss after gastric bypass surgery. Due to the severe shape distortion, the full SPAIR procedure will be required to reshape the breast adequately and take up the redundant skin envelope. (C,D) Preoperative marks. (E–G) Frontal view demonstrating the result at 1 week (E), 6 weeks (F) and 7 years (G). Although the patient has experienced a moderate weight gain, the shape of the breast has been remarkably maintained even after many years. (H–J) Lateral view at 1 week (H), 6 weeks (I) and 7 years (J). As a result of the direct control afforded by the SPAIR technique to the upper pole, an overcorrection was created initially that eventually settled into a neutral contour that has been maintained over time. (K–M) View of the vertical scar at 1 week (K), 6 weeks (L) and 7 years (M). (N–P) Close up view of the NAC at 1 week (N), 6 weeks (O) and 7 years (P). Despite the aggressive periareolar pattern, there has been little if any spreading of the areola postoperatively.