Evolution of personal technique

In 1983, we started performing periareolar mastopexy with dermal cerclage of the areola via a purse-string suture in order to prevent postoperative enlargement of the areola and the scar. In view of this procedure’s effectiveness, we extended its application, calling it the “round block” because of the solidity of the dermodermal circular scar block reinforced by the cerclage, with a non-resorbable suture passed in a purse-string manner through the edge of the periareolar dermis. By using the round block, our efforts initially enabled reduction of the length of the horizontal scar, and subsequently, to totally eliminate the horizontal scar, going from a T-inverted technique to a vertical technique.^7,8 Finally, it was possible to eliminate the vertical scar with the periareolar technique.

This procedure has enabled us to treat more serious cases of ptosis and thereby extend the indications of periareolar mastopexy that in the past had been reserved only for moderate ptosis or hypertrophy, essentially because of the postoperative risk of enlargement of the areola and periareolar scar.

Our use of the round block technique has progressed with prudence. In the beginning, we obtained the best results in the correction of hypotrophic ptosis by using periareolar mastopexy with round block and simultaneous placing of a breast implant, ensuring the shape and the anterior projection of the breast.

To obtain breast coning in the treatment of simple ptosis and hypertrophy, simple plication and invagination of the base of the breast has yielded satisfactory results for small breasts, but unsatisfactory results for larger breasts, with some leading to long-term shape flattening and recurrence of ptosis.

Therefore, we applied the techniques classically used for reduction mammaplasty in an inverted-T, but practiced them only on the mammary gland without cutting the skin. This was then redraped around the areola without tension, using a round block on the skin aperture. The breast was then reduced and reshaped in the manner of an internal inverted-T to the glandular parenchyma alone.

The inverted-T techniques that give maximum coning and the best long-term hold are those that are characterized by crossing and overlapping of two flaps (lateral and medial), which ensure a maximum of anterior projection to the areola.^9,10

Concerning work on the gland itself, our goal has been to limit its detachment as much as possible in order to maximize the vitality of the glandular flaps and to ensure the conical shape. Concerning the skin, the trend has been to limit the amount of resection of the ellipse of the periareolar depithelialization, to prevent complications such as bad scarring and flattening of the breast owing to excess tension in the periareolar area.

Materials and methods

From 1983 to December 2007, we performed this surgical procedure on over 528 patients in aesthetic, tumoral, and reconstructive surgeries (Table 51.1). We have been progressive in our advancement of this procedure for cases of serious ptosis or hypertrophy. Breast reductions have entailed an average resection of 180 g (maximum 1200 g) on each breast.

Table 51.1 Clinical series (January 1983 to December 2007)

The principle of the operation is to perform an internal inverted-T mastopexy, with a large superiorly based vertical dermoglandular pedicle supporting the areola, and to redrape the skin without tension around the areola on the glandular cone by “round block”, just like a glove covers a hand. The skin will naturally retract itself on the new breast cone once the postoperative edema has disappeared, a few weeks after the operation. The breast skin has a remarkable capacity to retract, programmed by nature to adapt itself to the considerable changes of volume occurring during pregnancy and lactation, during which the areola easily adapts itself to various changes in diameter.

Indications of periareolar mastopexy and preoperative warning

Consultation before surgery is essential to understand the patient’s expectations: these expectations often extend beyond the possibilities of the surgery. The patient should be informed that the result of the operation depends on the anatomic quality of tissue. Thus, patient selection and surgery preparation must be performed with care.

In planning the operation, we must consider three factors: the psychological context, the anatomic conditions, and our own experience with the technique.

Psychological context

This is an important element. Patients must be willing to accept a less than perfect shape in favor of a reduced scar. One should paint a realistic picture of such possible postoperative difficulties in order to test their motivation to limit the scar.

Patients should be made aware of the potential postoperative inconveniences of mastopexy in general, and periareolar mastopexy in particular, such as the wrinkling of the periareolar skin, which may last for weeks or even months, the need to wear a bra night and day for 2 months, the possible need to revise the scar in case of poor scarring, persistence of cutaneous irregularities, and, in case of complete failure, the possible need to undergo an inverted-T mastopexy after all.

The patient’s reaction to this warning allows identification of those who probably could not emotionally tolerate the postoperative difficulties. “Impatient patients” generally are excluded, as are those with unrealistic expectations or exaggerated narcissistic suffering. The patients demanding a short scar technique usually wish to obtain a natural appearance and are generally satisfied with the result of the operation, appreciating the shape as well as the discrete nature of the scar.

Anatomic conditions

The best indications are moderate ptosis or hypertrophy in a young patient. For these patients, the skin has a good retracting potential, and the breast tissue is firmer. This is important, because the scar of a young woman’s skin is more likely to become hypertrophic, so we would like to limit the extent of the scar.

On the other hand, contraindications include breasts that are essentially fat or have a lot of additional skin. Surgeons should exercise caution when considering patients who are overweight, aged, or smokers.

The morphology of the thorax and the breast shape are also important: tubular breasts are a good indication, but very wide breasts are more difficult to treat.

Experience with the technique

It is preferable for surgeons unfamiliar with this technique to start by operating on patients with moderate ptosis where the vertical axis of the planned periareolar ellipse does not exceed 10 cm. After gaining some experience, the surgeon may choose to extend the indications to more severe cases of ptosis or hypertrophy. The degree of difficulty mostly depends on the degree of ptosis. The resection is performed on the distal part of the glandular flaps, cut out like a reduction mammaplasty in inverted-T fashion, but without cutting the skin.

We would thus be more likely to perform this procedure in a young patient, even in severe cases of hypertrophy, if the psychological and anatomic conditions are favorable.

Step 1: Planning and marking

We have no standard pattern. Each one is specific to the individual patient. The marking begins with the patient standing, then lying supine, and finally back in the standing position.

Marking in the standing position

The midline is marked to maintain symmetry. The breast meridian is marked at the beginning on the clavicle, 6 cm from the midline. The meridian is not the meridian of the ptotic breast, but the meridian of the manually reshaped breast. This new meridian will not necessarily cross the ptotic nipple, because the mammary ptosis is generally a lateralization of the breast due to chest wall convexity (Fig. 51.3).

Fig. 51.3 Skin marking. Select your four cardinal points in order to reduce the ellipse size at its minimum. You will need a large amount of skin to cover the glandular cone, and the skin will retract after surgery. Any skin over-resection can create serious complications. S, the breast meridian crosses the submammary crease.

The new meridian is often more medial than the one in the ptotic breast. The lower part of the breast meridian is not marked while the patient is standing, but while she is lying supine.

The new areola vertical position

The superior border of the areola (point A) is marked as in a Pitanguy technique on the breast meridian, 2 cm higher than the anterior projection of the submammary crease. Reshaping the breast manually, the surgeon verifies that point A is marked in the correct position. Contralateral point A is marked by measuring the distance to the sternal notch.

Symmetry

For a more precise evaluation, the surgeon observes the patient standing in the anatomic position. The best position for the observer is facing the patient at a minimum of 3 to 6 feet. During this inspection the surgeon also checks for other breast asymmetries.

In case of volume asymmetry, this preoperative evaluation in the standing position is useful for estimating the possible variation in reduction specimen weight from one side to the other.

Step 2: Preparation

With the patient sitting partly upright, the arms are affixed to the body using adhesive bands around the thighs. The region is infiltrated with a dilution of physiologic saline (1000 mL), epinephrine (0.50 mg), and xylocaine 2% (40 mL). All the area that will be detached is subcutaneously infiltrated, except for the ellipse and surrounding 3 cm, in order to preserve the vascularity of the skin edges. The prepectoral space is also infiltrated in the area of glandular resection.

Step 3: Incision and dissection

De-epithelialization of the periareolar ellipse is performed by pulling on a concentric epidermal flap (Fig. 51.4). The areola is marked with a tube on the tensed skin at 1.5 cm diameter more than the desired final diameter to compensate for a stretching and retracting afterwards. It is usually cut at 5.5 cm to close at 4 cm.

Fig. 51.4 De-epithelialization. The periareolar epidermis can be removed quickly by simple traction of a concentric epidermal flap.

An incision on the de-epithelialized dermis is made from 2 to 10 o’clock, at 1 cm inside the skin edge, to improve the subdermal vascular support of the epidermal edge.

Subcutaneous dissection is performed with consideration for the blood supply to the skin. Dissection extends from the ellipse to the submammary fold limits (Fig. 51.5).

Fig. 51.5 The cutaneoglandular detachment is extended at the minimum to facilitate even skin distribution over the new glandular cone.

At this stage, the surgeon incises the gland in order to constitute the dermoglandular flap that will be supporting the areola. This incision does not extend to the edge of the dermis, because it is often too near the areola, especially on the lateral side.

The glandular incision is semi-circular at 3 cm from the inferior areola’s edge in order to preserve innervation and blood supply to the areola. This incision facilitates opening the prepectoral space, which we dissect only in the avascular central space, preserving the peripheral blood supply, where the breast is more adherent to the fascia and where the perforators are located. The inferior glandular flap is then elevated between two clamps and cut vertically beyond the breast meridian up to the fascia.

As a result of this dissection, four flaps will have been created (Fig. 51.6):

Fig. 51.6 The cut of the glandular flaps and, if necessary, their reduction, are similar to those used in a T-inverted technique: a vertical dermoglandular superiorly based flap supporting the nipple–areola complex, a lateral and medial glandular pillar, and a skin flap.

Work on the glandular flaps will facilitate a reduction in volume, if necessary, and will reshape the breast by fixation of the flaps in a new position, forming a glandular cone on which the skin will be redraped with the round block closing.

Step 4: Resection of gland following the Wise pattern

Depending on the case, resection can be executed on the different glandular flaps. To reduce the upper pole, a Pitanguy keel-like resection can be performed (Fig. 51.6). To reduce the lateral lower pole, the resection on the lateral flap is performed as for a T-inverted reduction following the Wise pattern (Fig. 51.6). If the lateral flap remains too thick, the reduction can be extended to the posterior side of the flap in the prepectoral space to obtain the desired thickness.

To reduce the medial lower pole, the resection can be extended to the posterior side of the flap in the prepectoral space to obtain the desired thickness.

To reduce the medial lower pole, the resection can be performed on the distal part of the medial flap. If the volume to resect is large, the resection can be performed as in a T-inverted technique. In other cases, the medial flap reduction is not extended medially in order to leave the necessary volume to refill the inner pole of the breast.

Step 5: Glandular modeling

Depending on the anatomy of each patient, the glandular flaps are situated to achieve an attractive shape with minimal detachment, to prevent fat necrosis.

The glandular flaps are assembled in order to reduce the base of the breast, providing a conical shape and the best long-term support. The criss-cross mastopexy often works well to accomplish these goals.

We begin reducing the upper base of the breast using a plication, closing the keel-like reduction with a stitch.

The lower base of the breast is reduced by crossing the two lower glandular flaps (lateral and medial). The flap that is crossed over the other has the biggest amplitude of translation. Because ptosis involves a sagging of the breast, but also generally a lateralization of it, we generally prefer crossing the lateral flap over the medial one to medialize the breast shape. In the rare cases in which we desire to lateralize the breast, we cross the medial flap over the lateral one.

In most cases, we begin the criss-cross mastopexy by rotating and folding the medial flap behind the areola, fixing its distal part to the pectoralis muscle using a U-point (Fig. 51.7). The lateral flap is crossed over and fixed to the medial flap by additional U-points (Fig. 51.8). These glandular stitches do not squeeze the glandular tissue, thus avoiding glandular cyto-steatonecrosis. Moving the flaps reduces the base of the breast and creates a glandular cone on which we place the areola.

Fig. 51.7 Medial flap rotation, folding and fixation using a U point on the pectoral. The position of the fixation on the pectoral must be evaluated according to the anatomy of each patient. Most of the time, the medial flap is sutured behind the areola in order to ensure a better support of the areola anterior projection.

Fig. 51.8 The lateral flap is crossed over the medial flap, and the crossing line is sutured using some superficial U points, grasping the Cooper’s ligaments to prevent any constriction of the flap vascularization. Strong support of the new conic shape will be achieved after full breast lacing (Step 7).

Step 6: The dermal window for areola fixation

The fixation of the areola to the superior border of the ellipse is facilitated by a dermal window which we open with a 1 cm incision of the dermis (Fig. 51.9), 5 mm from the edge. Through this window we create a little intraglandular pocket in which we will lift and suture the supra-areolar dermis to the deep dermis of the pocket. This fixation supports the areola without tension on the skin edge.

Fig. 51.9 The dermal window prevents enlargement of the scar by strong fixation of the areola’s superior border through the window, and allows the surgeon to bury the round block cerclage knot.

Step 7: The full breast lacing

Optimally, the glandular cone will be well-shaped, with the areola at the top of the cone. The quality of the tissue determines whether this result can be maintained long term. To provide the best support of the shape, we prefer to use full breast lacing of braided polyester Mersilene 2-0, applied with a long straight needle (Fig. 51.10). This type of lacing is useful in case of poor-quality glandular tissue, especially in patients with adipose involution.

Fig. 51.10 Using a long, slightly curved needle, full breast lacing strongly supports the conic shape by using large inverted stitches of Mersilene 2-0. The first stitch is transareolar and allows control of the nipple-areola complex anterior projection. The other stitches traverse the entire thickness of the breast diameter. All of these stitches are tied without any tension.

The lacing is created by some large inverted stitches, with moderate tension traversing the entire thickness of the breast diameter to maintain the crossing of the glandular flaps. The lacing, at its superior part, also passes through the areola dermoglandular flap. This passage allows control of the anterior projection of the nipple–areola complex and prevents any protrusion of it. It is important that these full breast lacing stitches be applied without tension to avoid strangulating the gland and creating fat necrosis. The role of the full breast lacing is to provide passive support of the conical shape obtained by the superficial stitches of the glandular modeling (see Step 5).

Step 8: Round block cerclage stitch

The detached skin is redraped on the glandular cone, and complementary detachment may be necessary to free some skin in order to obtain an easy elevation and even distribution of the skin all around the areola.

Round block cerclage stitch can be placed in two ways: outside the ellipse or inside the ellipse.

Round block outside the ellipse

The round block cerclage stitch is passed like a purse-string in the deep dermis 5 mm beyond the edge of the ellipse (Fig. 51.11). The suture begins through the dermal window over the suture fixing the areola, follows a regular plane in the deep dermis, and finishes as its starting point (Fig. 51.11). We use Mersilene 2-0 applied with a 7 cm long straight needle, allowing a regular plane in the dermis.

Fig. 51.11 View of the long straight needle passing in a regular plane in the deep dermis 5 mm beyond the ellipse edge. The round block cerclage stitch is buried behind the entire thickness of the skin and is not superficially exposed below the scar.

Round block inside of the ellipse

The round block cerclage stitch, again a Mersilene 2-0, is passed with a curved needle like a purse-string going alternatively in and out of the dermis at 2 mm from the edge of the de-epidermized area inside of the ellipse (Fig. 51.12).

Fig. 51.12 The round block inside of the ellipse with a Mersilene 2-0 is passed with a curved needle like a purse-string going alternatively in and out of the dermis at 2 mm from the edge of the de-epidermized area inside of the ellipse.

Pulling on the suture elevates all the detached skin around the areola; a sliding of the skin on the stitch allows an even distribution of the pleats. To close with symmetry of the areola diameters, we measure the diameter with a rule, or we can also use a tube of the desired diameter which is inserted and the suture tied onto it (Fig. 51.13). The knot is buried behind the skin through the dermal window. We prefer a braided polyester suture like the Mersilene 2-0 because the scar penetrates the fiber of the stitch, avoiding a sliding of the skin on the suture when moving the breast. Before the skin closure, we improve the distribution of the pleats around the areola. We avoid accumulation of some deep pleats in one area; instead, we try to have more numerous superficial pleats distributed on all the circumference of the areola. This is more a compression than a plication of the skin excess. The round block allows the elevation and the even distribution of the skin flap over the new glandular cone (Fig. 51.14).

Fig. 51.13 The round block cerclage stitch is pulled and tied onto a tube, facilitating exact measurement and symmetry of the diameter of the two areolas.

Fig. 51.14 The round block allows the surgeon to lift and drape the detached skin regularly over the reshaped glandular cone, with an even distribution of the skin excess.

Step 9: A second dermoareolar round block taking the retroareolar tissue

This second dermoareolar round block (Fig. 51.15) will help to achieve an even distribution of the periareolar skin excess which is adapted and fixed to the areola on eight points that are the four cardinal points, with four points between each of them.

Fig. 51.15 The second dermoareolar round block is put in place after the first round block and will help to achieve an even distribution of the periareolar skin excess to be adapted and fixed to the areola on eight points that are the four cardinal points and four points between each of them.

The second round block is carried out with a clear nylon 4-0 monofilament on a curved needle. It starts at six o’clock in the retroareolar tissue, and continues by taking the crest of the dermic pleats inside the closed ellipse 3 mm inside the skin edge, and taking again the retroareolar tissue when arriving at the level of the next of the eight areolar points.

The second round block has the following goals:

Step 10: Regulation of areola projection

The coning of the gland gives a strong anterior projection to the nipple–areola complex, sometimes generating its protrusion.

We propose some specific sutures to control the anterior projection of the nipple–areola complex:

Fig. 51.16 Inverted dermoareolar stitches facilitate control of the areola’s protrusion through the round block cerclage and prepare the even distribution of the pleats around the areola like cardinal stitches.

Fig. 51.17 Diametrical transareolar U points constitute a barrier, preventing the areola’s protrusion and giving a circular shape to the areola when it has a tendency to be ovoid.

The second internal dermoareolar round block suture described in Step 9 is also very useful to control the nipple–areola complex projection.

All these types of stitches and sutures allow control of the size, shape, and projection of the nipple–areola complex.

Step 11: The skin closure

Accommodation of the big ellipse to the small areola requires a compensation suture (Fig. 51.18):

Fig. 51.18 Compensation suture using a Monocryl 4/0 intradermal sutures starting at the top of the areola taking a large horizontal bite on the edge of the ellipse and a vertical bite on the edge of the areola.

Step 12: The dressing and postoperative care

The first dressing is a wet compress on the areola and dry compresses on the detached skin. These are maintained with an adhesive bandage of moderate compression to prevent hematoma formation. Vacuum drainage exits below the axilla.

The day after or the second day after surgery following the volume of drainage, the vacuum drainage is removed and the patient leaves the clinic. One week after, at the office, we remove all the dressing and clean the skin with antiseptic solution and later with ether to facilitate the adhesion of an adhesive pad. This is a sterile, ultra-thin, highly conformable, semiocclusive polyurethane foam adhesive pad. This dressing covers the areola and scar and maintains the detached skin. The patient leaves the clinic wearing a simple brassiere that maintains the breast and the adhesive pad.

The adhesive polyurethane foam pad has many advantages:

The patient must wear a brassiere night and day for 2 months.

Fig. 51.C1 Patient no. 1: A, Hypertrophy and ptosis in a 20-year-old patient. B, One year after surgery, reduction of 120 g. C and D, Pre- and postop, 1 year. E and F, Profile pre- and postop, 1 week. Hyper-projection obtained by the criss-cross mastopexy. G, Profile at 1 year, after accommodation; good position of the glandular cone maintained by the breast lacing, and anchored to the pectoralis by permanent Mersilene suture. H, Areola before surgery. I, Areola at 1 month; even distribution of excess skin by the round block stitch, avoiding deep pleats. J, Areola at 1 year; the round block stitch avoids enlargement of the areola and scarring. K, Areola in the supine position at 1 year, disappearance of the pleats, and the natural aspect of the original submammary crease preserved by the dissection.

Fig. 51.C2 Patient no. 2: A, Breast empty and ptotic in a 45-year-old patient. B, One year after, mastopexy by round block and anatomic implant retropectoral 180 mL. C and D, Profile pre- and postop 1 year.

For good cutaneous vascularization

For a good glandular vascularization

The first assembling stitches of the criss-cross mastopexy should be superficial to avoid strangulation of the flaps. The full breast lacing stitches extend through the thickness of the reshaped glandular cone and are set without any tension. Their only role is one of passive contention of the mammary cone.

One case of infection involved a 16-year-old girl with thoracic acne. She had taken hot baths with her dressings and had kept them wet, not changing them for the whole week after surgery. The result was a sudden worsening of the acne underneath the wet dressings, in addition to staphylococcal cellulitis of each breast. The infected tissues then needed to be surgically cleaned. After spontaneous healing, she again underwent surgery, but this time with the T-inverted technique, which yielded a satisfactory result.

Two other cases of infection involved a severe polycystic mastosis and cytosteatonecrosis of the glandular flaps owing to tight, strangulating glandular stitches on a fatty breast and adipose involution, respectively. In these two cases, the healing was delayed but was finally satisfactory. Scar revision was undertaken using local anesthesia, but the scar remained periareolar.

Long-term problems

Use of the round block for mastopexy and breast augmentation

In the association of breast augmentation and periareolar mastopexy, the breast shape will be provided by the implant support and will help to maintain a long-term good anterior projection. We mainly use a retropectoral position. The release of the inferior attachment of the pectoral muscle allows a superior retraction of the muscle raising the breast parenchyma attached to it.¹¹

The choice of the location of the incision in the de-epithelialized ellipse depends on many factors: the ellipse gives space for a wide incision superior, inferior or lateral to the areola. That allows good vision and large access for the pocket dissection.

The shape given by the implant generally allows minimal glandular shaping, avoiding weak cover of the breast implant in the lower pole in which the pectoral muscle is not present.

After closing the round block on the reshaped breast by the breast implant, the areola is frequently strongly protruding due to the internal pressure through the round block. To control this protrusion, the sutures described in Step 10 are very helpful used separately or in association.