Periareolar Benelli mastopexy and reduction: The “Round Block”

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

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.16 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).

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.

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

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).

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.