Key Points

Summary

Periareolar techniques have been very criticized, some of them rightly so. This technique avoids a foreign body and risk of gland necrosis because there is no incision inside the gland, no glandular flap, preserving glandular integrity and blood supply. It is called V-T parachute because of the way the gland is resected: resembling a V then shaped in a T and the dermis around the areola is spread over the gland, reminding one of a parachute. A periareolar technique cannot be a four-season technique and the indications must be precisely selected: as every periareolar technique decreases the anterior projection the best results are obtained when the breast has a pendular or conic shape, with a normal or straight base.

Introduction

Periareolar mammaplasty techniques aim to meet the justifiable concern that the surgical scar be as unobtrusive as possible.

Nevertheless, the result of a mammaplasty must achieve a suitable compromise between the final shape and the resultant scar. In this process, it is necessary to strike a reasonable balance between, on one hand, the aesthetic benefit of altering breast shape and size; and on the other, the aesthetic ‘harm,’ such as the presence of scars, resulting from sacrificing skin in order to reduce and adapt the cutaneous envelope to residual breast volume, which is of course reduced in the case of reduction, identical in the case of ptosis, and augmented if associated with an implant.

Hence the surgeon must make every effort to reduce scar length, and render scars as unobtrusive as possible by virtue of their site and quality. This goal is difficult to achieve for a periareolar scar, which is noticeable no matter which technique is employed since the areola is always lifted for both size reduction and ptosis correction purposes. The paradox of this scar – which is the only scar in periareolar techniques – is that it must resolve the entire surface problem and absorb the entirety of the cutaneous excess, which is easier to distribute in the presence of an associated vertical or inverted T scar. At the same time this scar must also be inconspicuous, although it is in fact always the most visible segment of any mammaplasty scar. If too much is demanded of this scar by virtue of its being the sole scar, a low quality, extensive and ultimately more palpable scar may be obtained than with a scar that is associated with a vertical or T scar.

Scar length can only be reduced via a cutaneous resection of limited scope, but this is not always a suitable method in the presence of excessive skin. The surgical ‘trickery’ constituted by techniques that restrict the scar to the areolar region is not very satisfactory since cutaneous resection is subject to limitations in any case (as is the volume reduction achieved). Moreover, little or no reduction can be achieved in the cutaneous breast base (which is left intact), and the skin leaves little room for such manipulation.

Periareolar techniques are not indicated in all volume reduction and ptosis correction situations where it is necessary to remove a large amount of skin and substantially reduce breast volume. Form should never be given short shrift in the interest of obtaining a less obtrusive scar. Indeed, in some cases it is preferable to dispense with surgery altogether or use a different technique rather than end up with suboptimal results and little or no shape improvement. Any surgical procedure aimed at altering breast shape and volume will inevitably be associated with a scar, and a far from negligible one at that. A shorter scar, or avoidance of a scar segment, should not and cannot be used as an excuse for a morphologically unsatisfactory result, since such a scar will in any case never be completely invisible. Instead the focus should be on proper adaptation of the cutaneous envelope to breast size, irrespective of whether it is modified during the procedure.

The indication for periareolar techniques is extremely limited, much more so than the inverted T method, which allows for practically any breast size reduction and cutaneous envelope modification desired, regardless of the amount of excess baseline skin (extent of ptosis) and the quality thereof (dermal characteristics). Thus in addition to the surgical technique used, the success of a periareolar mammaplasty depends upon rigorous selection of the indications, since by no means is this procedure suitable in all settings.

Historical Background

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 Gillet¹ 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. Bustos⁶ partially encircles the breast with silicone mesh, but only partially, so as to allow for expansion during pregnancy. However, Sampaio Goes^7–9 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 technique¹⁰).

Operative Technique