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.

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).

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:

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:

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).

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.

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.

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.

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.

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.

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).

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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).

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Interlocking Gore-Tex suture technique

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 5.235.25).