Mastopexy

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Chapter 5 Mastopexy

One of the primary goals of any aesthetic procedure is to restore aged or otherwise injured structures to a rejuvenated and youthful appearance. In fact, it is the youthful ideal that serves as a template for nearly every aesthetic procedure commonly performed in plastic surgery today. To that end then with regards to the breast, in order better to understand the surgical principles involved in mastopexy, it is helpful to review the attributes of the youthful breast that help identify it as an object of beauty and femininity. Then, understanding how these attributes are altered in the ptotic patient allows an organized and complete surgical plan for the operative correction of ptosis to be developed.

Breast Ptosis – Definitions

From an anatomical standpoint, the youthful breast is positioned in the middle of the chest, with the inframammary fold variably located at the level of the 4th to 6th intercostal space. In fact, when considering the proportions that define the aesthetics of the body, the breast is clearly a chest wall structure that is distinctly separate from the abdomen. In this position, a breast with a full rounded lower pole contour and a nipple–areola complex (NAC) that is positioned directly at the point of maximal projection can accentuate and provide a pleasing contrast to the decidedly female contours of an aesthetic abdomen. By keeping these relationships in mind, four elements of breast ptosis can be described.

Positional Breast Ptosis

Many patients who present for ptosis surgery in fact have developed descent of the entire breast complex on the chest wall such that the normal aesthetic ideals are altered. These patients present with a low inframammary fold and an often underfilled and lax breast skin envelope that overhangs the fold and rests on the lower rib cage, masking the contour of the upper abdomen (Figure 5.1). This anatomic relationship is referred to as positional breast ptosis and it represents an under-recognized component of the overall presentation of the ptosis patient. It is most commonly seen in the massive weight loss patient where, after weight loss, the overall soft tissue expansion of the skin envelope of the breast caused by the obesity results in physical descent of the entire breast complex including the inframammary fold inferiorly on the chest wall. In some patients, the breast can actually be seen to fall as low as halfway down the length of the torso (Figure 5.2). Positional breast ptosis is very difficult to correct surgically and can actually be made worse very easily if the attachments of the inframammary fold are disrupted in any way. For this reason, recognizing positional ptosis is critical in allowing appropriate management of the breast to optimize the final result.

Figure 5.1 The location of the breast is ideally in the upper third of the torso. When the inframammary fold falls below the upper third, the entire breast appears malpositioned inferiorly in relation to the torso. This is referred to as positional breast ptosis.

Figure 5.2 (A,B) This patient underwent a 150 pound (68 kg) weight loss after gastric bypass surgery. While she was obese, the volume effect of the underlying fat expanded the skin envelope of the entire chest wall. Then, with the deflation of the skin envelope that occurred as a result of the weight loss, the entire breast complex shifted inferiorly, creating a positional breast ptosis characterized by inferior malposition of the inframammary fold and ptosis of the redundant skin envelope. As a result, when the entire length of the torso is considered from the shoulders to the pubis, the most inferior portion of the breast can be seen to fall approximately halfway down the length of the torso. Another indicator of the inferior positioning of the breast can be identified by noting that the location of the inframammary fold is significantly below the midpoint of the humerus, which serves as an additional commonly used marker for the ideal location of the inframammary fold.

Volume Ptosis

Assuming that the inframammary fold and overall position of the breast is properly located, it is then very common for the existing breast volume to become ptotic. In the aesthetic youthful breast, the support structures in the breast as well as the skin are strong, uninjured and are able to contain the developing breast volume without inordinately stretching. As a result, the volume of the breast is symmetrically distributed over the chest wall. When the patient stands upright, a mild descent in the volume distribution occurs that creates a pleasing, full and rounded lower pole along with an upper pole contour that has a smooth takeoff from its attachments to the upper chest and results in a straight line contour extending down to the point of maximal projection, where, ideally, the NAC is located (Figure 5.3). Alteration in these relationships contributes significantly to the appearance of the ptotic patient. Over time, and under the influence of other factors such as pregnancy, weight fluctuations or simply aging, the support structure of the breast can change. As the internal ligamentous support of the breast stretches, particularly with the changes in breast volume that occur with pregnancy and subsequent breast-feeding, stress is placed on the skin. Gradually, the skin gives way and the inherent elastic character becomes diminished. The result is tissue stretching with descent of the majority of the volume of the breast into the inferior portion of the skin envelope. This volume ptosis can result in a concavity in the contour of the upper pole of the breast and a breast that appears elongated (Figure 5.4). Occasionally, ptosis of the volume of the breast disproportionately involves only the skin envelope of the lower pole and as the breast gradually descends, a new point of maximal projection is created by the newly configured breast contour. In these patients, the existing NAC actually assumes a position in the upper pole of the breast above the point of maximal projection and the distance from the nipple down to the inframammary fold becomes disproportionately lengthened. This form of volume ptosis is known as pseudoptosis (Figure 5.5).

Figure 5.3 (A,B) In the ideal breast, a full rounded lower pole contour is present with the NAC positioned at the apex of the breast mound. When viewed from the side, a straight line contour from the take off point from the chest wall down to the nipple is created that is the hallmark of the aesthetically mature, unaugmented breast.

Figure 5.4 In patients with an exaggerated elastic character to the skin and connective tissue framework of the breast, the support provided by these structures can be overcome over time by the mass effect of the parenchyma, creating a condition called volume ptosis. When this occurs, the overall breast contour appears inferiorly malpositioned on the chest wall as the entire breast is drawn inferiorly. Often there is an associated upper pole concavity.

Figure 5.5 (A,B) In selected cases, the lower pole of the breast can expand preferentially, creating an anatomical configuration called pseudoptosis, which is characterized by marked expansion of the lower pole skin envelope along with a superiorly malpositioned NAC. In this patient, the inferiorly directed pull on the fixed position of the nipple is so severe that the nipple is actually inverted as the underlying breast parenchyma falls away under the influence of gravity.

Breast Skin Ptosis

With aging, weight loss or after pregnancy, the breast fat and parenchyma can variably involute, resulting in a decrease in breast volume. Typically, however, the skin surface area does not appreciably change and the breast becomes underfilled and redundant with the result being ptosis of the breast skin envelope. In these patients, the breast often demonstrates a wide and flattened contour that drapes over the inframammary fold, creating a very unaesthetic appearance to the breast. Also, it is very common in these types of patients for the NAC to be positioned very low on the breast mound (Figure 5.6).

Figure 5.6 Patients with mild to moderate degrees of breast hypertrophy who then undergo involution of the breast with loss of breast volume will present with a redundant skin envelope that hangs over the inframammary fold, creating what is termed breast skin ptosis. In these patients, the breast has a very wide and flat appearance that is often associated with severe ptosis of the NAC.

NAC Ptosis

Finally, the position of the NAC can further accentuate these changes. In the aesthetic breast, the nipple is located just at the point of maximal projection of the breast mound. For some, even just a hint of an upturn in the nipple location adds a visual element of softness to the breast that some find aesthetic (Figure 5.7). However, any shift in the position of the nipple below the point of maximal projection is most decidedly unaesthetic and detracts from what might otherwise be an acceptable breast contour in selected patients. For this reason, any nipple position that is noted to be below the point of maximal projection is termed NAC ptosis. Traditionally, this type of ptosis has been graded as:

Grade 1 – Nipple at the most projecting point of the breast

Grade 2 – Nipple between the most projecting point and the lower breast contour

Grade 3 – Nipple at the lower breast contour (Figure 5.8).

Figure 5.7 A slightly upturned nipple position can be viewed as aesthetically pleasing when it is associated with a full rounded breast contour.

Figure 5.8 (A) An example of grade 1 ptosis where the nipple is directly at the point of maximal projection on the breast mound. (B) An example of grade 2 ptosis with the nipple being located at a point between the point of maximal projection and the lower breast contour. (C) An example of grade 3 ptosis where the nipple is located at the level of the lower breast contour.

It must be recognized, however, that this classification system is incomplete and misses a very important relationship that directly affects the surgical management of the position of the NAC. In many patients, the nipple is located directly at the point of maximal projection; however, because the skin envelope is ptotic as well, the overall position of the NAC is low and therefore requires lifting to optimally restore an aesthetic relationship between the breast mound and the position of the NAC (Figure 5.9). The structure that defines this position is the inframammary fold and where the NAC lies in relation to the fold must also be described. This is performed by noting where the nipple lies in relation to the inframammary fold when looking at the patient from the front. By drawing a line that connects the inframammary fold on each side across the midline, the position of the nipple in relation to this line can be assessed by simply standing back and observing the relationship with the aid of a straight edge. The following classification is utilized:

Grade A – Nipple above the inframammary fold line

Grade B – Nipple at the inframammary fold line

Grade C – Nipple below the fold line.

Figure 5.9 (A–C) The preoperative appearance of a patient with a mild tubular breast deformity in association with macromastia and asymmetry. Despite the presence of the nipple at the most projecting point of the breast mound on each breast, as seen particularly on each lateral view (grade 1 ptosis), the overall appearance of each breast is one of ptosis due to the fact that both nipples lie below the inframammary fold. (D) When the level of the fold is drawn across the midline, it becomes apparent that both nipples are below the fold with the left being lower than the right. Nipple ptosis in relation to the fold is an important relationship to note and must be considered in conjunction with nipple position on the breast mound to optimally design a sound surgical plan for operative correction.

By combining the two classifications, a useful indicator of nipple position can be developed that can guide surgical management of NAC ptosis. For example, a patient with a nipple that is at or slightly above the point of maximal projection and lies above the inframammary fold (1A) does not require lifting of the NAC. Such a relationship is seen with pseudoptosis, where operative correction would be aimed at lifting the volume of the breast to position it properly under the NAC (Figure 5.10). However, a patient with a nipple at the point of maximal projection that lies below the inframammary fold (1C) will require not only lifting of the NAC but also reduction of the redundant skin envelope to restore an aesthetic relationship between the NAC position and the breast mound (Figure 5.11). For patients who have a nipple at the point of maximal projection that lies directly at the inframammary fold (1B), several surgical options may be appropriate including mild lowering of the fold, augmentation particularly with shaped cohesive gel breast implants, periareolar mastopexy or some combination of these techniques (Figures 5.12, 5.13).

Figure 5.10 (A,B) Preoperative appearance of a patient with asymmetry and pseudoptosis of the left breast. The NAC is located at the apex of the breast and is above the level of the inframammary fold, therefore, according to the described classification, she demonstrates a 1A NAC position. As a result, despite the fact that she requires a left-sided tightening of the lower pole skin envelope to restore an aesthetic appearance to the breast, no lifting of the NAC position is required.

Figure 5.11 (A–D) Preoperative appearance of a patient with ptosis of the skin envelope and the gland. Here the NAC is at the most projecting point of the breast mound but falls well below the inframammary fold. Therefore, she demonstrates a 1C NAC position. This combination represents the most complex of ptosis conditions, therefore, she will require a full circumvertical skin pattern along with internal reshaping to restore an aesthetic shape to the breast.

Figure 5.12 (A,B) Preoperative appearance of a patient with asymmetry and ptosis of the left NAC. Here the left NAC is at the most projecting point of the breast and is located directly at the level of the inframammary fold, therefore, she demonstrates a 1B NAC position. Because of the relationship between the NAC and the fold, she will require a periareolar procedure to restore an aesthetic relationship between location of the NAC and the breast mound.

Figure 5.13 General summary algorithm combining fold relationship with breast contour as it related to treatment of ptosis. A1 describes a normal NAC breast contour relationship and requires no repositioning of the NAC. B1, A2 and B2 describe mild disproportion between the position of the fold and the location of the NAC in relation to the breast contour. Typically, periareolar lifting, augmentation, lowering of the fold or some combination of these maneuvers will restore an overall aesthetic breast appearance. C1, C2 and C3 represent significant ptosis not only of the NAC but also the skin envelope. Here, more aggressive skin envelope management is typically required in the form of a circumvertical lift. The B3 relationship is seen in severe cases of tuberous breast deformity. The A3 relationship does not apply.

When patients present with asymmetry in the level of the inframammary fold, treatment decisions must then be made based on the proposed final fold position. For instance, in augmentation mastopexy, it is far easier to lower the high fold to create symmetry with the opposite side than it is to raise the lower fold. Basing treatment decisions on NAC placement is therefore best done relying on the new lower fold position. Alternatively, in mastopexy alone, utilization of the vertical technique in particular can elevate the lower fold relatively easily, therefore, in this circumstance, treatment decisions regarding placement of the NAC would best be made based on the new higher fold position.

Whatever technique is used, in most instances it is best to set the position of the fold and then reposition the NAC based on this chosen fold position.

Evaluation of the Ptotic Patient

When designing a surgical strategy for the correction of ptosis, it must be recognized that each of the four elements of ptosis can be variably present and these elements will combine to determine the overall appearance of the breast. Therefore, the goal of the preoperative evaluation is to determine the presence and extent of each of these elements to allow for an appropriate surgical strategy for correction to be devised. This must be done in conjunction with an overall evaluation of the patient’s health, with particular attention placed on conditions that can affect the size and shape of the breast. Any history of previous breast problems must be obtained and the presence of breast scars from previous biopsies is noted as this can alter the surgical approach with regard to skin incisions or pedicle choice. Inquiry is made into any family history of breast cancer that might be present and the date of the last mammogram and the result is documented. A reproductive history is obtained, including the number of pregnancies, deliveries and any plans for future children. Particular note is made with regard to breast-feeding. How many children were breast-fed and how long this process continued can provide insight into the forces applied to the breast that may have significantly influenced the patient’s present condition. If further pregnancies are planned, it is best to inform the patient that this may have an adverse effect on the ultimate result, necessitating a revision in the future.

Examination of the breast and chest wall is performed to document the presence of any suspicious masses as well as make note of any asymmetries in the shape, size or position of the breasts. Asymmetries in the level of the inframammary fold as well as the nipple are noted. Measurements that document the distance from the clavicle to the nipple, the sternal notch to the nipple and the inframammary fold to the nipple as a static measurement and with the lower pole breast skin under stretch, as well as the intermammary distance are made. The rationale for these measurements is the same as for breast augmentation as this information documents asymmetries and triggers appropriate discussion with the patient about what can be achieved with mastopexy.

Once the basic appearance of the breasts has been documented, the goals of the patient must be assessed. One of the first decisions to be made centers around whether or not a breast implant will be required to achieve the desired result. In the most straightforward circumstance, the patient has decided ahead of time that she does not want a breast implant. In this instance, the decision-making process is simplified and centers on lifting and reshaping the existing breast as needed to achieve the optimal result. Alternatively, some patients are open to the possibility of using a breast implant if it will improve the postoperative aesthetics of the breast. In these patients, the benefits of providing additional volume to the breast with the addition of an implant must be weighed against the potential complications that come into play when an implant is used. If there is enough volume in the breast preoperatively to achieve a proportional result and all that is required is lifting and reshaping of the existing breast volume, it is best to avoid the use of an implant. The procedure is more predictable, simpler and if all goes as planned, avoids any of the potential complications that can occur over the long term if an implant is placed. The need for an implant is assessed by simply cupping the lower pole of the breast and lifting it up to a youthful position. This maneuver lifts the entire breast including the skin, parenchyma and NAC to try to provide for the patient some rough idea of how big the breast will be with a lift alone. If it appears that this size will be satisfactory to the patient, a mastopexy without an implant is planned. If the patient seems to want a bigger breast than that seen with this breast transposition maneuver, discussion over the merits and potential complications of adding an implant must be entertained.

When discussing breast size after mastopexy, it is helpful to stress to the patient that the size of the breast very frequently appears smaller after the procedure (Figure 5.14). The simple act of removing skin to tighten the skin envelope can create the illusion of a smaller breast despite the fact that no parenchyma was removed. This is due to the fact that a breast with variable ptosis of the skin envelope and volume looks bigger than it actually is. Once the volume is lifted and the redundant skin envelope is reduced, the true volume of the breast becomes evident. As a result, for some patients the newly shaped and proportioned breast can appear smaller than expected. It is important to discuss this ahead of time with the patient, particularly when the use of an implant is being considered, to avoid the potential for postoperative patient dissatisfaction.

Figure 5.14 Intraoperative appearance of a patient after undergoing a left mastopexy using the SPAIR technique. Although no fat or parenchyma was removed from the breast, the overall size of the breast appears smaller than the untreated side. This case demonstrates that simple tightening of the skin envelope with repositioning of the ptotic breast parenchyma superiorly can create a breast that appears smaller than what otherwise might be expected.

Beyond the questions about whether or not to use an implant, other common patient requests include lifting the entire breast higher on the chest wall, increasing the fullness in the upper pole, lifting the position of the NAC, reducing the diameter of an enlarged and out of proportion areola and creating a firmer consistency to the breast. Each of these goals can be achieved using the techniques described in this chapter, either alone or in combination.

Surgical Techniques in Mastopexy

There are three surgical goals that must be variably accomplished to correct breast ptosis and provide a firm, uplifted and aesthetic result. These include, lifting the NAC position in relation to the breast mound, managing the excess skin envelope and reshaping the breast.

Lifting the NAC

When the nipple is located at or below the point of maximal projection of the breast, it must be lifted to adequately restore an aesthetic breast contour. It is important to remember, however, that the point of maximal projection is assessed in relation to the new surgically altered and uplifted contour of the breast. As such, a preoperative nipple location that appears to be non-ptotic can appear to be low on the breast mound after the ptosis of the breast volume has been corrected. For this reason, nearly every patient who presents for mastopexy will require some degree of lifting of the NAC, even in those cases where the NAC did not appear to be inferiorly displaced preoperatively.

Repositioning the NAC superiorly requires an asymmetrical periareolar skin excision with the amount of skin removed above the NAC being greater than the amount removed below. When the outer periareolar skin incision is sutured to the incision made in the areola, the result is an overall lifting of the position of the NAC as well as a reduction in the diameter of the areola. Although the periareolar lift is a well-described and accepted technique in aesthetic surgery of the breast, there are several well-recognized complications that can compromise the aesthetic result. Critically examining these complications as well as their cause can lead to surgical maneuvers that can prevent or at least limit their effect and improve the results and consistency of periareolar techniques.

Asymmetrical areolar shape

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.

Widened areolar diameter

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.

Suture material

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.

Suture placement

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.