Unsatisfactory results of periareolar mastopexy with or without augmentation and reduction mammoplasty: enlarged areola with flattened nipple

A method of repair is described for correction of abnormally enlarged nipple–areola complex following both periareolar mastopexy and pregnancy. Although during periolar mastopexy or reduction mammoplasty regular subcuticular dermal sutures may control the enlargement of nipple–areola complexes initially, the periareolar scar becomes hypertrophic and areolar spreading occurs to some extent. Periareolar mastopexy techniques are indeed advisable only for minimal hypertrophies or ptosis of the breast, especially for areolar asymmetry, if an acceptable, normal-size areola is expected. The authors believe that in periolar mastopexy or reduction mammoplasty cases resulting in enlarged nipple–areola complexes, the size of the areola can also be corrected by reduction mammoplasty or mastopexy using vertical bipedicle techniques. Although surgery results in an inverted T incision, the shape of the breast is more acceptable and the size of the areola does not enlarge with time.     

Auto-circler device (Tercan device) for marking a vertical scar mammaplasty

It is known that the desired shape and position of the nipple–areola complex may be difficult to achieve in vertical-scar reduction mammaplasty. The marking of a mosque-shaped areolar pattern varies from one surgeon to another, and therefore, periareolar trimming or resection may be inevitable with the use of such technique. We have developed a device to standardize the periareolar marking, and reduce the irregularity of the periareolar region. This device mimics the elasticity of normal breast tissue, and has the flexibility to be applicable to all breast types. We believe that this device improves the results of vertical-scar reduction mammaplasty and can eliminate the necessity of “last-minute” modifications intraoperatively.     

Periareolar reduction mammoplasty using an inferior dermal pedicle or a central pedicle.

The goals of reduction mammoplasty are to reduce the volume of a breast, to create an aesthetic shape that is stable over time, to maintain blood supply and innervation to the areolar complex, and to make fine limited scars. The present authors used periareolar reduction mammoplasty using an inferior dermal pedicle or a central pedicle. To minimise the scar, periareolar incision was performed. To reduce the volume of breast and to preserve blood supply and innervation to the nipple-areolar complex, a central or an inferior pedicle technique was used. To prevent areolar widening, a purse-string suture was used. A total of 82 breasts in 41 patients with very large breasts were operated on between July 1998 and June 2004. The mean age was 39, and the mean resection amount was 389 g per breast (right 413 g, left 364 g) with an average follow up of 28 months. Most of the patients were satisfied with the fine periareolar scar, the size of the breasts and the sensation of the nipple-areolar complex. The present authors have applied this procedure to all kinds of macromastia. Although the advantages of the periareolar reduction mammoplasty are an inconspicuous limited scar, a preservation of sensation to the nipple-areolar complex and a short operation time, 24 breasts (29%) showed areolar widening. There were persistent periareolar wrinkles in eight breasts (10%) and poor sensation to the nipple-areolar complex in 12 breasts (15%), in which more than 500 g of breast tissue was removed per breast. In conclusion, the periareolar reduction mammoplasty is optimal for patients who require a reduction of less than 500 g per breast. In severe macromastia with or without ptosis, the inverted T-incision is more preferable to periareolar incision, and periareolar incision can be modified by adding a wedge resection of the outer excess in skin flap inferiorly, which results in periareolar and vertical scars below the nipple-areolar complex.     

Vertical Scar with the Bipedicle Technique: A Modified Procedure for Breast Reduction and Mastopexy

Background Reduction mammaplasty and mastopexy are commonly performed aesthetic procedures. One such procedure, the vertical scar technique, has gained popularity in recent years, and various types of pedicles have been designed and associated with it. The vertical scar with the bipedicle technique is one such combination that ensures nipple safety and minimizes scarring, with a good aesthetic result. Method With the vertical scar marked on the outside and the bipedicle flap marked on the inside, the procedure was performed for 23 patients. Results Between 2004 and 2006, 17 reduction mammoplasties and 6 mastopexies were performed. The average tissue resection was 360 g, and the average blood loss was 70 g. The average preoperative nipple–areolar complex was 28 cm (range, 23–41 cm). Good results were achieved for the majority of the patients, with no nipple loss or loss of sensation. Conclusion The vertical scar bipedicle technique, a combination that meets the requirement of minimum scarring and a robust blood supply to the nipple–areolar complex, is a suitable option for selected reduction mammaplasty and mastopexy.     

Dermafascial Fixation Suture: A Technique for a More Durable Projection with Short-Scar (Vertical) Reduction Mammaplasty

Background Short-scar reduction mammaplasty has several advantages over the traditional technique, mainly reduced scarring and superior long-term breast shape. Multiple modifications of the short scar reduction mammaplasty technique have been made in an effort to decrease the learning curve while improving the results. The authors present another modification of the short-scar technique for a more durable projection without reliance on a skin envelope. Methods The perimeters of the medial pedicle and the nipple–areola complex are marked, and the medial pedicle is deepithelialized. A 2 × 5-cm skin area at the inferior border of the pedicle is further deepithelialized, then pexied to the pectoralis fascia in a superomedial direction using a nonabsorbable monofilamanet suture with a horizontal mattress suturing technique. Results Taking the suture bites from the dermis rather than the breast parenchyma for the pexy aims to spare the pedicle’s circulation. This durable internal rearrangement of the breast parenchyma with dermafascial pexy further decreases the tension at the nipple–areola complex because the final breast shape no longer relies on the skin closure. Suture spitting at the nipple–areola complex also is prevented with elimination of the purse-string suture because there is no need for a further decrease in the tension with the purse-string suture after the dermafascial pexy. Conclusions The authors believe that the dermafascial pexy is a concept more than a technique. It incorporates the two strongest structures, the dermis and the fascia, to achieve more durable results not only with reduction mammaplasty, but also with any aesthetic breast surgery that uses the pedicles.     

A New Personal Surgical Procedure for Breast Reduction and Lifting

A series of 40 patients operated from 1995 through 1997 is reviewed. The women ranged in age from 18 to 40 and were seen in either a university- or a private-hospital setting. Thirty-eight of the patients underwent reduction mammaplasty, which was performed using an inferior pedicle technique with a straight-line incision; two patients underwent mastopexy only. The reduction procedure depends on the formation of a cap from medial, lateral, and superior flaps. Following resection of breast tissue the cap is joined to a cone—the nipple–areola complex carried on a subcutaneous inferior pedicle. The cone is fixed to the chest wall with simple vertical stitches, minimizing the recurrence of ptosis. This technique is safe and versatile, avoids a submammary scar, and offers an aesthetic and long-lasting result.     

A Superior Vertical Dermal Pedicle for the Nipple–Areola: An Alternative for Severe Breast Hypertrophy and Ptosis

Background  

Nipple–areola nourishment and sensation have been the main concern in reduction mammaplasty for severe breast hypertrophy and ptosis. Free grafting for the nipple–areola can cause flatness and loss of sensation. These complications can be improved by pedicle techniques for the nipple–areola, no matter the pedicle orientation. The aesthetic outcomes and complications are similar for the inferior and superior pedicle techniques. The pedicle length has been crucial to nipple–areola viability and sensation.     

A prospective quantitative comparison of breast sensation after superior and inferior pedicle mammaplasty.

Reduction mammaplasty techniques using the inferior pedicle have been recommended to preserve the nipple and areolar sensation after surgery. The vertical scar mammaplasty with a superior pedicle has often been criticised because of the potential for damage to the sensory supply of the nipple-areola complex. The aim of this study was to assess the breast sensation in two prospective series of patients operated upon using superior pedicle and inferior pedicle mammaplasties. Between November 1996 and February 1997, 20 consecutive patients (39 breasts) underwent breast reduction using the inferior pedicle technique with inverted T scar (Robbin's technique). This series of patients was matched with another series of 18 patients (36 breasts) who had breast reduction using a vertical scar mammaplasty with superior pedicle (Lejour's technique) in another centre. Cutaneous pressure thresholds were recorded using Semmes-Weinstein monofilaments. The values were obtained on the quadrants of the skin of the breast, the areola and the nipple. The sensitivity test was performed preoperatively, then at 3 and 6 months postoperatively. Patients' characteristics (age, weight, breast ptosis, breast mass resected and risk factors) were statistically similar between the two groups. The preoperative values of pressure sensation on the different areas tested were statistically similar between the two groups. The sensitivity decreased on almost all the tested areas of the breast at 3 months postoperatively. No patient had an insensitive area on the breast at 6 months after surgery. Some areas of the breast showed a significant difference in pressure sensitivity after one technique compared to the other: better sensation on the skin of the superior and lateral quadrants after the superior pedicle technique at 3 months (P< 0.001), poorer areolar sensation on the inferior quadrant after the superior pedicle technique at 3 and 6 months (P< 0.05) and on the superior quadrant after the inferior pedicle technique at 3 months only (P< 0.05). However, the mean value of the areolar quadrants was statistically similar after both techniques. The nipple sensation was significantly decreased in both groups at 3 months but remained comparable between the two groups. Breast innervation was damaged by breast reduction using both the inferior and the superior pedicle techniques. The breast skin had better sensation after the superior pedicle technique while the areola had slightly better sensation after the inferior pedicle technique. At 6 months, the mean value of nipple-areola complex pressure sensation was comparable in the two series of patients.     

Short Scar Mastopexy with Flap Transposition

A personalized technique using a vertical scar mastopexy is described. The breast tissue is utilized as a transposition flap behind the nipple–areolar complex to increase its projection. The inferior pole of the breast can be developed either as a superiorly pedicled or inferiorly pedicled flap for that purpose and the indication for each version is described. The technique has been successfully utilized in 80 patients with pleasing results. Illustrative cases are presented.     

Breastfeeding After Reduction Mammaplasty Using Different Techniques

Background This study reviewed mammary glandular function and breastfeeding after reduction mammaplasty performed via four different surgical techniques. Patients who underwent this procedure were asked to answer questions concerning the birth of a child, natural breastfeeding, and the reasons why natural breastfeeding was not performed or was interrupted. Methods Between 1992 and 2001, 368 reduction mammaplasties were performed in the Department of Plastic Surgery at the “La Sapienza” University of Rome. After reduction mammaplasty, 105 patients had a child and were enrolled in the study. Breastfeeding data were compared with data from hospital records at the time of surgery in terms of patient age, reduction mammaplasty technique, sensitivity of the nipple–areola complex after the operation, and proportion of the gland removed. Results Maternal breastfeeding was considered to have occurred if it lasted more than 3 weeks and was not accompanied by any nutritional supplements. Babies were breastfed by 60.7% of the patients who underwent a superior pedicle reduction mammaplasty, by 43.5% of those who underwent an inferior pedicle reduction mammaplasty, by 48% of those who underwent a medial pedicle reduction mammaplasty, and by 55.1% of those who underwent a lateral pedicle reduction mammaplasty. Conclusions The findings demonstrate that conservative reduction mammaplasty techniques supported by medical and paramedical staff permit subsequent breastfeeding. In particular, the best outcomes resulted from superior pedicle reduction mammaplasty. Skilled execution of the surgical technique is mandatory to guarantee adequate vascularization and sensitivity of the nipple–areola complex and to spare as many of the glandular ducts and lobules as possible.     

Wineglass Pattern for Vertical Mammaplasty

The ideal reduction mammaplasty technique should create a pleasing breast shape with minimal scarring. The long and conspicuous scar associated with the classic inverted ``T' pattern mammaplasty techniques are not acceptable for many patients. Periareolar mammaplasty techniques cause less scarring, but they have major disadvantages such as scar widening, areolar distortion, and insufficient breast projection. We used a new pattern for vertical mammaplasty to overcome the insufficient breast projection caused by the round block technique and applied it to 51 patients during the last 3 years. This method results in a single vertical scar and a periareolar scar, allows sufficient volume reduction, and provides good breast shape and projection; the results are durable. This procedure is safe, causes few complications, and is easy to learn and perform.     

``Flip-Flap' Mastopexy

The ``flip-flap' mastopexy modifies the McKissock vertical bipedicle design by creating a wide superiorly based flap of breast tissue deep to the vertical bipedicle. Transposition of this flap up and beneath the upper breast, with suture anchoring to the pectoralis fascia at the level of the second rib, restores upper breast fullness, decreases mastopexy-wrecking lower breast bulk, and provides a pleasant forward thrust of the nipple–areolar complex. The ``flip-flap' is effective for improving the long-term aesthetic outcome for both reduction mammaplasty and mastopexies of moderate- to full-sized breasts.     

Central Pedicled Breast Reduction Technique in Male Patients After Massive Weight Loss

Male patients after massive weight loss often suffer from redundant skin and soft tissue in the anterior and lateral chest region, causing various deformities of pseudogynecomastia. Techniques with free or pedicled nipple–areola complex (NAC) transposition are widely accepted. The authors present their approach to male breast reduction with preservation of the NAC on a central dermoglandular pedicle and a wide elliptical tissue excision of breast and lateral thorax tissue in combination with liposuction. Male breast reduction was performed on patients after moderate to massive weight loss due to diet or bariatric procedures. Former procedures included free nipple–areola grafts or inferior pedicled techniques for NAC preservation. As a modification, we performed a central pedicled breast reduction on nine male patients with excessive liposuction of the pedicle and a horizontal elliptical skin removal, allowing for sufficient tissue removal at the lateral thorax. From October 2010 until June 2011, nine male patients had central pedicled breast reconstructions after massive weight loss. Mean age was 29.1 years, mean preoperative body mass index was 29.2, and mean preoperative weight loss was 63.9 kg. The chest wall improvement was rated “very good” by eight patients. No major complications occurred in all nine patients. Male chest deformities after massive weight loss can be dealt by several approaches. The optimal scar positioning and the preservation of NAC may be the most challenging aspects of these procedures. Therefore, the preservation of the NAC on a central dermoglandular pedicle with a horizontal submammary scar course may optimize the esthetic outcome.     

无垂直瘢痕的下蒂瓣法乳房缩小整形术

目的:介绍一种适用于中、重度乳房肥大的矫正术,探索乳房缩小手术的最佳术式。方法:回顾总结2001年以来对21例中、重度乳房肥大患者采用无垂直瘢痕的下蒂瓣法行乳房缩小整形术的情况,分析其效果。结果:21例患者术后双乳对称,下垂状况纠正,体积缩小,乳头乳晕感觉良好,术后瘢痕隐蔽。2例合并副乳,1例合并乳头内陷的患者同时手术切除矫正。2例乳晕表皮营养不良、部分坏死,经换药愈合。结论:无垂直瘢痕的下蒂瓣法乳房缩小整形术是治疗中、重度乳房肥大症的良好选择。     

Reconstruction of a burned breast with vertical mammaplasty: a case report

The right upper extremity, axilla, and right anterior hemithorax of a 25-year-old female had been burned with milk when she was 4. Breast tissue developed in a flattened form because of the burn to the entire anterior hemithorax; the nipple–areolar complex was far lower than it should have been; no inframammary fold had developed and the appearance was highly asymmetrical. A vertical mammaplasty was used to restore the nipple–areolar complex to its normal position, and a full-thickness skin graft taken from the groin was used to form an inframammary fold. In this way, the two asymmetrical breasts were given an acceptable symmetry.     

Circumareolar Mastectomy in Female-to-Male Transsexuals and Large Gynecomastias: A Personal Approach

Breast reduction or amputation in female-to-male surgery presents a specific surgical problem: obtaining a good breast shape of the masculine type. Over a 2-year period, 17 patients (12 female-to-male transsexuals and 5 extreme gynecomastias) were operated on using the circumareolar approach for subcutaneous mastectomy. The nipple-areola complex was left on a very wide deepithelialized dermal pedicle, and the final closure of the wound was performed using a round-block technique followed by numerous fine sutures to reduce wrinkling. This technique provides naturally flat masculine breasts, leaving sufficient dermal vascularization for the nipple-areola complex which is of the utmost importance. All the patients were very satisfied with the result because of the periareolar scar only. Two areolar necroses occurred due to perforation of the thin vascular dermal pedicle: one superficial which epithelialized spontaneously in a short period of time and one deeper which required skin grafting.     

Long-Lasting Evolution of Ptosis Control After Reduction Mammaplasty Using the Hammock Technique

Background The hammock technique combines inferior pedicle mammaplasty with retropectoral and inferior suspensions to prevent displacement of breast tissue toward the inferior mammarian pole. This study aimed to assess the long-lasting internal suspension with the author’s mammary reduction technique. Methods From 1987 to 2005, the hammock technique was performed for 623 breast reduction patients (1,201 breasts), including 318 women (636 breasts) who underwent the technique between 1994 and 2005. From the latter group, the author retrospectively reviewed the case histories of 281 patients who had come for long-term follow-up evaluation. All had significant ptosis associated with breast hypertrophy. Preoperative and postoperative examinations included evaluation of postoperative bottoming out by monitoring of three measurements: the sternal notch-to-nipple length, the inferior areolar border-to-inframammary fold length, and the distance between the inframmary fold and the projection of the lowest breast contour on the chest wall. Results The evaluation data on postoperative ptosis are derived from a control study at 30 months, 5 years, and 7 years or more for 281 women (562 breasts) of the 318 who underwent surgery using this technique over the 11-year period. Review after 2.5 to 7 years or more shows that inferior areolar border-inframammary fold distance increases no more than 10 mm. Conclusions The hammock technique suspension achieves true permanent breast lifting through dermis strips from the inferior pedicle itself. This procedure also gives predictable results, a low morbidity rate, and good breast shape.     

No-vertical-scar inferior pedicle breast reduction using the dermal suspension sling

Background

The authors previously presented favorable outcomes with the use of the horizontal dermal suspension sling and plication of the inferior pedicle in reduction mammaplasty surgical cases. We propose a modification to this technique tailored to patients with moderate to severe ptosis. The modification avoids the vertical scar inherent to the inverted T pattern.

Methods

The surgical technique utilizes portions of the dermal suspension and plication technique previously described by the authors. Minor modifications were made to take advantage of the vertical excess of skin found in patients with moderate to severe macromastia and ptotic breasts. The modification leads to a superior skin flap that drapes the inferior pedicle and newly constructed breast mound, resulting in a single inframammary scar.

Results

Thirty-eight women have undergone breast reduction using the vertical scarless inferior pedicle with horizontal dermal suspension and plication surgical technique. Breast projection and shape were sustained during follow-up with positive aesthetic results; the median follow–up time was 7 months.

Conclusions

The modifications to our surgical technique allowed for an improved appearance in the postoperative breast scar and in the overall cosmetic outcome in patients who underwent large-volume breast reductions. Level of Evidence: IV, therapeutic study     

Early experience with SPAIR mammaplasty: a useful alternative to vertical mammaplasty

The short-scar periareolar inferior pedicle reduction (SPAIR) mammaplasty is a recently developed "limited-scar" technique that attempts to combine favorable elements of several well-established mammaplasty operations. Parenchymal resection and nipple transposition are achieved in a manner similar to the standard inferior pedicle reduction. Skin closure is achieved through a combination of periareolar and vertical techniques. Indications, operative technique, and pitfalls of the operation are discussed. Early experience with this technique in 102 breasts in 61 patients has been very favorable.     

Vertical mammaplasty with a clamp technique

The vertical mammaplasty with a clamp technique is a personal adaptation of the clamp technique that leaves a single vertical scar in addition to the periareolar scar. This technique uses a superior pedicle from the dermal vault technique. There is no need for preoperative markings. The glandular tissue is removed with constant reference to the breast base. The skin is excised around a new clamp, which leaves only a vertical scar. This retrospective study includes 100 patients operated between 1996 and 2000. A total of 96% of the patients have been happy with the final cosmetic result. The best results were obtained when breast ptosis and moderate hypertrophy were present. The complication rate was 4%. This technique is as reliable as other procedures using the superior flap technique. A vertical scar is obtained by using a new clamp that allows a perfect match of the gland to its cutaneous cover. It is also a fast technique to perform (75 minutes).