Periareolar Benelli mastopexy and reduction: The “Round Block”

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CHAPTER 51 Periareolar Benelli mastopexy and reduction: The “Round Block”

Louis C. Benelli

History

The periareolar approach enables us to perform many breast operations, from mastopexy to reduction or augmentation, and also the excision of breast lesions.

The “round block” enables use of the periareolar approach to be extended to numerous types of breast surgery, giving easy access to all the glandular areas by extending the incision in an ellipse of depithelialized periareolar skin.

By performing a mastopexy, the main goal is to obtain an attractive breast shape with a lasting result, leaving the most inconspicuous scar. The shortest scar is confined to the periareolar circle, avoiding a vertical infra-areolar scar and a horizontal submammary scar.

However, the indications for the various periareolar plasty techniques have been limited.¹^–⁶ Only moderate cases of small breast ptosis have been treated using periareolar mastopexy, owing to the risk of enlargement and distortion caused by tension on the areola. The round block technique helps to eliminate this complication, and makes it possible to treat many cases of breast ptosis and hypertrophy by periareolar mastopexy.^7,⁸

One of the principal elements of our technique is to treat ptosis and hypertrophy by using a blocked circular dermal suture passed in a purse-string fashion. The round block constitutes a cerclage, fixing a solid circular dermodermal scar block around the areola (Figs 51.1 and 51.2).

Fig. 51.1 Round block cerclage stitch of 2-0 Mersilene made with a long straight needle passed in a purse-string method. This stitch is passed in a regular plane in the deep dermis 5 mm beyond the edge of de-epidermization. This round block cerclage facilitates good control of the areola and scar and can be used in many aesthetic tumoral and reconstructive periareolar operations.

Fig. 51.2 Cross-section view showing that the round block cerclage stitch does not produce tension on the areola and scar.

The concept of the periareolar round block technique is totally different from the concept of the traditional T-inverted or vertical technique, in which the skin tension on the scars gives conical shape to the breast.

On the other hand, in the periareolar round block technique, it is necessary to avoid tension on the periareolar skin, because the breast shape is not provided by cutaneous tension but by the internal shaping of the gland separated from the skin, or by an implant if volume augmentation is necessary.

To obtain an attractive breast shape, it is necessary to separate the work on the gland (creating the conical shape) from the work on the skin (removing the excess skin around the areola). The skin must cover the new conical shape without any tension. Excess tension on the skin will flatten the shape and cause healing problems.

The aim of the round block is not to create periareolar skin tension, but to drape an even distribution of the breast skin around the periareolar circle covering the glandular breast cone without tension.

To achieve the greatest anterior projection of the breast, we perform a criss-cross T-inverted technique on the gland, which provides good coning and support without cutting the skin.

The scars are less important for a mature woman, but might have negative consequences for a young woman in whom scars are sometimes hypertrophic.

When mammaplasties are performed, the efforts to limit the scar to the periareolar circle are motivated by the fact that periareolar healing generally produces an inconspicuous scar, even though the skin near the inframammary crease has much more potential to develop hypertrophic scarring, especially in the parasternal area.

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)

Breast reductions	43%	227
Mastopexies	22%	116
Mastopexies and augmentations	23%	122
Tumoral and reconstructive surgeries	12%	63
Total number of cases	100%	528

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.

Anatomy

On the breast we distinguish between the thin, elastic periareolar skin whose function is to adapt itself to the breast volume changes and which generally produces fine scars and is easily stretched by the weight of the gland, and the skin of the base of the breast and of the submammary fold. This thick skin’s function is to support the breast, and the scars it produces are potentially much larger.

For support of the breast, the periareolar technique is used to remove the thin, elastic stretched skin around the areola, which does not have any supportive value, and to conserve the thick skin at the base of the breast and submammary fold.

Vascularization and innervation of the areola and mammary gland are addressed in the same manner as for an inverted-T technique, with a vertical dermoglandular flap supporting the areola with a superior pedicle. This pedicle will be larger because it occupies the whole width of the ellipse, whereas in the design of an inverted-T mammaplasty the pedicle will be narrower, passing through the edge of the areola, where a straight liberation of the adjacent tissue is required to allow the lift. For this reason, the vitality, breast-feeding ability, and innervation of the areola seems to be better preserved by the round block technique.

Subdermal vascularization is preserved with skin excision done with scissors close to the gland. At the time of the dermal incision within the de-epithelialized ellipse, we conserve a 1 cm strip of dermis in order to protect the vascularity of the ellipse’s skin edge, especially in its lower part (see Fig. 51.5).

The entire operation thus preserves the blood supply and innervation of the breast. This advantage is essential for the improved control of the scar and vitality of the tissues constituting the remodeled breast.

Physical evaluation

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.

Technical steps

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.

Marking the patient who is lying supine

The lower part of the marking is done with the patient lying supine, with the arms lying symmetrically at the patient’s sides.

Marking of the submammary crease and of the gland limits

Point S is the point where the breast meridian crosses the submammary crease. It usually crosses the crease roughly 10 cm from the midline.

Point B is the inferior border of the new areola. It is marked on the breast meridian, and its position is determined by the estimated final breast volume to be covered, and by the potential for the breast skin to retract. The distance between point B and point S (BS) may vary from 5 to 12 cm.

Leaving an ample distance BS has two advantages

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