The term ‘periareolar scar’ refers solely to the site of the scar, but omits any mention of the technique used on the neighboring tissue. This idea is not new, since already in 1952 Gillet ¹ described a ptosis correction technique involving implantation of nylon mesh around the nipple by suspending it from a narrow cloth band looped around the clavicle. But the author also states that it is difficult to perform a satisfactory cutaneous resection using this method and terminates with a Biesenberger T scar² in cases where extensive cutaneous resection is required. A number of authors have also used this circular approach, which involves solely an intra- or periareolar incision without insertion of a foreign body. For example Andrews³ advocates an L-shaped resection in the lower outer quadrant secondary to complete dissection of the dermis. This cleavage, which reduces the vascular network of both the skin and breast tissue, explains why the resection in such cases is inevitably of limited scope. For mastopexy, Andrews dissects and plicates the lower extremity of the breast. Following resection of a small strip of skin around the initial intra-areolar incision, the incision is closed in such a way that the cutaneous envelope wraps itself back around the reshaped breast. However, this method is indicated solely in the presence of minor hypertrophy or ptosis and good skin elasticity, and follow-up of the results shown in the illustrations has been unduly brief (1, 2, and 3 months). Benelli⁴ de-epithelializes a far larger periareolar area, remodeling the adjacent region using glandular flaps, thus incurring a risk of devascularization if resection and dissection are unduly extensive. However, in such settings it is essential to achieve breast projection since periareolar techniques tend to diminish it (assuming of course that shaping the gland alone has a lasting effect). If this (or any other) periareolar technique is performed inadequately or on fatty breasts, a flattened, donut-like appearance is obtained. What should be performed instead is a periareolar circle using robust, non-resorbable sutures, since this is the only type of material that can conserve the incongruence between the two areolar circles and thus avoid excessive areolar enlargement. Felicio⁵ shifts the site of the resection to the periphery of the breast, with a view to conserving a central pedicle, and likewise uses non-resorbable sutures to maintain the size of the areola. This technique yields the most satisfactory result in younger patients whose skin exhibits good elasticity, and for resections amounting to an average of 300 g per breast (although exceptions to this rule are altogether possible). However, such procedures may be associated with unsatisfactory breast projection, suboptimal scar quality, and areolar enlargement, as well as a risk of areolar necrosis in cases where extensive and multiple resections are performed in the various quadrants.

Other authors have attempted to remedy the main shortcoming (i.e. deficient breast projection) by inserting a net between the skin and breast tissue with a view to creating and maintaining a conical shape. Bustos ⁶ partially encircles the breast with silicone mesh, but only partially, so as to allow for expansion during pregnancy. However, Sampaio Goes⁷^–⁹ has achieved the most impressive cosmetic and reconstructive surgery results in remodeling the breast following lumpectomy, via the most promising technique of all. This involves the use of resorbable netting, then taking maximum advantage of dermal spreading, and finally the deployment of partially resorbable netting.

Insertion of a non-resorbable foreign body between the skin and breast is associated with the following risks: intolerance owing to unavoidably shallow placement; calcification, which may be misinterpreted; and long-term insert instability induced by substantial breast size variation secondary to body mass change, pregnancy or nursing.

The V-T Parachute Technique Principles

This technique aims to combine the advantages of the methods described above with a new approach to resection that is closely related to breast remodeling and avoids the use of a foreign body. Instead of interposing netting, I perform extensive de-epithelialization with a view to achieving the vascular efficiency afforded by the dermis and advocated by Lalardrie (this is also the most innovative feature of his dermal vault technique ¹⁰).

Operative Technique

Markings

• The axis of the breast is drawn from a point located 5 cm lateral to the suprasternal notch, down to the inframammary fold.

• After marking point A on the line, 17–19 cm from the suprasternal notch, place the patient in a supine position (Fig. 33.1A).

• Mark point B on the same line, 5 cm above the inframammary fold.

• Mark point C 9–10 cm from the midline, halfway between points A and B (Fig. 33.1B). While pressing the nipple into the breast, connect points A, B, and C to form a semicircle. Then draw an external semicircle symmetrical to the original semicircle. Define point D on the external semicircle (Fig. 33.1C) in such a way that its position is symmetrical to that of point C vis-à-vis the nipple. Then measure the distance from point D to the outer edge of the breast, which is usually easy to find with the patient in a supine position. Note: In order to prevent the areola from facing outward and being located too laterally, the distance from point D to the outer edge of the breast should not be less than the distance between point C and the median line. If necessary, move point D closer to the nipple.

• Mark points A, B, C and D symmetrically on the other breast (i.e., as for the original breast).

• Proceeding this way leaves the same residual skin envelope on each side, although there may be some asymmetry at the outset. In other words, the diameters of the two circles may differ, but their boundaries must be equidistant from the distal reference points (suprasternal notch, inframammary fold, median line, and anterior axillary line).

• When the patient stands back up, the circles become ellipses of varying sizes, depending on breast weight and ptosis gradient (Fig. 33.1D).

Fig. 33.1 A The point ‘A’ is marked on the breast meridian 17–19 cm from the suprasternal notch. B The patient is placed in the supine position. Point ‘B’ is marked on the breast meridian 5 cm above the inframammary fold. Point ‘C’ is marked halfway between points A and B. C While pressing the nipple into the breast, points A, B and C are connected to form a semicircle (see text). D With the patient back in the upright position, the circles become ellipses of varying sizes, depending on breast weight and amount of ptosis.

Surgical Procedure

The operation is performed under general anesthesia and with the patient in a sitting position with her arms hanging down at her sides (Fig. 33.2A). The final marking is realized by reducing the diameter of the areola to 4 cm. This line is marked using a 4 cm Dufourmentel ring while an assistant spreads the areolar region slightly. All skin between the two circles is de-epithelialized using a mammostat (Fig. 33.2B). The skin is then fully incised along the periphery of the de-epithelialized region and is dissected from the breast up to its periphery just under the subcutaneous plane at the level of the crests of Duret, as is done for a subcutaneous mastectomy (Fig. 33.2C). The breast mass should not be penetrated, nor should the dissection be more superficial than the fatty subcutaneous level. Pre-incision infiltration of cold saline containing a minute amount of adrenaline (no more than 1 mg per 500 ml of saline) will facilitate the skin dissection. Breast resection (when necessary) is performed in a V shape that straddles the upper quadrants, through the whole thickness of the breast tissue down to the perimysium of the pectoralis major (Fig. 33.2D). If the resection extends to slightly behind the de-epithelialized region, the breast dermis is dissected here as well in order to maintain the continuity of the dermal crown. The point of the V should not reach the lower edge of the pectoralis, or the nipple (taking account of the ptosis), so as to avoid injuring the pedicle (which arises at the fifth intercostal space together with the nipple nerve) and preserve nipple sensitivity. It is all the more important to proceed in this manner since the other option for preserving nipple–areola sensitivity arising in the dermal and subcutaneous network is interrupted by the peripheral cutaneous incision.

Fig. 33.2 A Surgery is performed with the patient in a sitting position with her arms hanging down at her side. B The skin between the two marked circles is de-epithelialized using a mammostat. C The skin is then fully incised along the periphery of the de-epithelialized region and is dissected from the breast up to its periphery just under the subcutaneous plane at the level of the creases of Duret, as is done for a subcutaneous mastectomy. D Breast resection, when necessary, is performed in a ‘V’ shape that straddles the upper quadrants, through the whole thickness of the breast tissue down to the perimysium of the pectoralis major.

The aforementioned resection site was selected on the grounds that this region of the breast is poorly vascularized and contains no main pedicle, thus ensuring that breast vascularization is preserved; and the gap created by the upper resection will be filled by shaping the breast, which constitutes the first step in the ptosis correction process.

The breast is shaped by converting the V into a T, as follows: The central gap is filled and the nipple is raised by taking two symmetrical sutures on the lateral margins of the breast resection and anchoring these sutures to the same site as the pectoralis major muscle (Fig. 33.3A). In doing this, the distance between the suprasternal notch and nipple should be noted down so that the procedure can be replicated for the other breast. Five or six additional sutures are realized to reinforce the fixation of the horizontal element of the T at the muscular level.

Fig. 33.3 A The central gap is filled and the nipple is raised by taking two symmetrical sutures on the lateral margins of the breast resection and anchoring these sutures to the same site as the pectoralis major muscle. The defect is closed from a ‘V’ to a ‘T’. B The dermis is then spread as far as possible across the surface of the breast and is fixed to the entire periphery of the breast via eight tacking sutures and one continuous suture using a long term resorbable suture. C As much of the dermis as possible should be sutured to the muscular wall and not to the breast itself. D This spreading can be completed by performing a dermal tuck in the lower segment of the breast which also enhances breast projection.

The dermis is then spread as far as possible across the surface of the breast and is fixed to the entire periphery of the breast via eight tacking sutures (Fig. 33.3B) and one continuous suture using a long-term resorbable suture (Fig. 33.3C). As much of the dermis as possible should be sutured to the muscular wall and not to the breast itself, although this of course depends on the size of the de-epithelialized region. If the entirety of the dermis can be sutured to the wall (as is the case with tuberous breasts) at the periphery of the breast, a parachute-like form is obtained – hence the name of the technique. This spreading can be completed by performing a dermal tuck in the lower segment of the breast (Fig. 33.3D), which also enhances breast projection.

If there is not enough skin to reach the periphery of the breast, the parachute is extended as far as possible across the breast tissue and is then attached to it using the technique described above. Nipple height is definitively fixed once this procedure has been completed. The breast may look very taut and projected at this point, but the dermis will relax within a few days. However, this technique using the dermis provides optimally robust breast support compared with breast tissue suture methods, which lack long term stability, particularly in the case of fatty breasts.

Hemostasis is then checked and a suction drain is inserted in the subcutaneous space.

In performing the skin closure, the difference in size between the two areolae is corrected. It is essential that non-resorbable sutures be used here so as to avoid undue postoperative areolar enlargement. I originally performed the suturing as follows: a continuous suture using Gore-Tex® 4-0 suture material and a straight needle was realized in the peripheral dermis 2 or 3 mm beyond the incision (Fig. 33.4A). After eight interrupted sutures are taken in order to distribute the excess skin evenly (Fig. 33.4B), the purse is gathered (Fig. 33.4C). However, I have since modified the technique in such a way that I perform a star-shaped suture by radiating the Gore-Tex suture out from one circle to the other and of course spreading the excess skin evenly across the breast with the aid of the eight markings on the areola and the peripheral dermis. I then gather and close the incision via a continuous superficial intradermal suture using resorbable suture material (Biosyn 4 or 5-0).

Indications

Breast Reduction

The V-T parachute technique only yields good breast reduction results in the presence of moderate hypertrophy (resection of 400 g or less), good skin quality, and a normal or straight breast base (see Fig. 33.4).

Fig. 33.4 The V-T parachute technique.

Fig. 33.5 Pendulous breasts constitute a good indication for this technique since the breast cone is too large for its base; 195 g was removed from the left breast and 135 g from the right breast. A, C preoperative. B, D 4 years postoperative.

Ptosis

The indication for ptosis is based on the same preoperative criteria as those indicated above, namely the presence of normal or straight breast bases and conical breasts with a low areola (Fig. 33.6).

Fig. 33.6 Application of V-T parachute technique in ptosis patient. A, C preoperative. B, D postoperative.

However, ptosis correction involves a compromise between the shape obtained and scar minimization. If the patient’s breasts are unduly small or lack projection, a small implant can be inserted in a submuscular and retropectoral position or even in a retromammary position. The dissection of the central element of the posterior side of the breast tissue should be as small as possible so as to achieve the all important goal of conserving the internal and external breast pedicles. This type of implant compensates for the absence of a suitable surgical technique since it recreates satisfactory central projection.

Asymmetry

In cases of asymmetry where one breast is regarded as normal or requires augmentation (Fig. 33.7), the V-T parachute technique is preferable to the inverted T since the scar is less obtrusive by virtue of its being unilateral. Often in such cases, the technique is performed only partially via a limited resection or without any resection at all; or the skin is not spread all the way across the breast.