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Breast augmentation with periareolar mastopexy
Breast Augmentation With Periareolar Mastopexy Scott L. Spear, MD, and Steven P. Davison, DDS, MD
Augmentation alone can successfully enlarge many women's breasts without the need to reduce the skin envelope or alter the position of the nipple. In women with excessive breast skin laxity, or in many cases of mild to moderate ptosis, a periareolar pursestring mastopexy is a useful adjunct to prosthetic breast augmentation. This allows tailoring of the skin envelope and repositioning of the nipple, leaving only a circumareolar scar. Copyright @ 2000 by W.B. Saunders Company
ome women who present for a breast augmentation are
S seeking an improvement in ptosis as much as they are seeking an increase in breast size. Augmenting the volume of the breast alone may help camouflage mild ptosis in some patients. However, in many patients including those with a very lax skin envelope, with pseudo- or glandular ptosis or in patients with first-degree or mild second-degree ptosis, augmentation alone may prove inadequate. 1,2 In these patients, simultaneous periareolar mastopexy can help decrease the skin envelope or improve nipple position. Because the goals of volume augmentation and skin envelope reduction may be opposed, careful balance of the two operations is required. Combined augmentation/periareolar mastopexy is generally limited to patients with no more than moderate second-degree ptosis in which the nipple sits 2 to 4 cm below the inframammary fold (IMF) or higher. In borderline cases in which one is hoping to avoid a mastopexy, simultaneous mastopexy can be added intraoperatively or at a later time if the nipple position is deemed inadequate after the augmentation. To make the decision intraoperatively, the patient is sat upright and the need for skin excision is reassessed. The nipple should sit on the anterior face of the breast at or near the augmented breast's equator. If a periareolar mastopexy is being considered, it is best combined with either subglandular or partial submuscular implant placement. Subglandular or partly subpectoral placement is more effective than totally submuscular placement at filling out the ptotic breast envelope and reducing the need for a mastopexy. On the basis of the Food and Drug Administration's rules for the use of silicone implants in the U.S. adjunct studies, simultaneous mastopexy/augmentation does currently allow the use of silicone-filled implants, unlike simple primary augmentation in which silicone is prohibited. The periareolar scar is generally well accepted and certainly From the Division of Plastic Surgery, Georgetown University Medical Center, Washington, DC. Address reprint requests to Scott L. Spear, MD, Professor and Chief, Division of Plastic Surgery, Georgetown University Medical Center, 3800 Reservoir Rd NW, Washington, DC 20007-2197. Copyright 9 2000 by W.B. Saunders Company 1071-0949/00/0703-0006535.00/0 doi:10.1053/otpr.2000.22798
is better accepted and less visible when supine than the inverted "T" scar of the conventional mastopexy. However, one must remember that the potential of a periareolar mastopexy is limited to some extent because progressively more skin excision does not necessarily improve the overall results but may lead to problems such as flattening of the breast, distortion of the areola, spreading of the scar, or an overall poor cosmetic result. 3 A fundamental step for achieving success with the periareolar mastopexy is the circumferential cerclage stitch of permanent suture as advocated by Benelli and others, known as the "blocking" suture. The use of this suture, a 3.0 Mersiline (Ethicon, Sumerville, NJ) or a 2.0 Goretex (W.L. Gore, Phoenix, AZ) on a long straight needle, decreases the risk of enlargement of the areola by using permanent suture, while it decreases the likelihood and degree of periareolar puckering by using a straight needle along the dermal edge.< 5
Planning and Marking The patient is positioned upright with arms at the sides. The midline of the chest is marked from the jugular notch to the xyphoid. The position of the IMF is important and is carefully marked bilaterally with an indelible marker. The meridian of each breast is also marked as a line dropped from the midclavicle to the IMF. This is commonly midnipple; however, the nipple position may be asymmetric with the nipples occasionally situated medially or laterally from the ideal meridian. The marked meridian is used to help define the ideal new position of the nipple, as opposed to the nipple being used to define the correct position of the meridian. Setting the nipple height is extremely important. This position is determined by multiple factors. The distance from the jugular notch to the nipple should be in a range of 19 to 23 cm. It is affected by height, breast, and body habitus. The nipple height should be at or up to a few centimeters above the IMF and at the peak or equator of the anticipated breast mound. The nipple should not be placed too high during simultaneous augmentation mastopexy because it will look unnatural, and such unnatural positioning will exaggerate glandular ptosis, particularly if the new implants eventually drop. The new nipple position is marked by an "X" (Fig 1). After the nipple position is marked, the planned upper margin of the areola, "A", is marked. This is drawn 2 cm higher than point "X'. The amount of skin to leave from the inferior edge of the areolar to the IMF is determined by the anticipated size of the augmented breast. A large breast may require up to 7 cm and a small breast 5 cm of inferior skin. Point "B" marks the junction on the breast meridian between the skin that will be left inferiorly and the skin to be removed beneath the areola. The amount of skin to leave medially (point "C"), and laterally (point "D"), is assessed and marked. The shape of the skin to be excised is typically not perfectly round and concentric,
Operative Techniques in Plastic and Reconstructive Surgery, Vol 7, No 3 (August), 2000: pp 131-136
131
\J Breast meridian
//
Inframammary fold
] i
....
//I
~~
Fig 1. Marking of the patient. The IMF and breast meridian are marked first (top). Point "X" represents the new nipple position. It is located at or slightly above the IMF. Points "A, B, C, and D" mark the extent of skin excision. Point "A" is 2 cm superior to point "X" (bottom).
Breast meridian
Infrarnammary fold
j
,,y
but more oval and eccenmc so as to lift the nipple and not overly narrow the width of the breast. More often than not, points C and D lie just outside the current areola margins. The
132
dimension of the horizontal axis of the pattern is thus often significantly less than the vertical dimension. The size of the concurrent augmentation affects the size of the final design of
AUGMENTATION WITH PERIAREOLAR MASTOPEXY
/
/
/
/ J
/
l
J
~J
incision Fig 4. The subglandular implant pocket is outlined.
Fig 2. The periareolar incision for the augmentation is made from 4 to 8 o'clock on the inferior margin of the areola. This hides the incision for the augmentation while maximizing surgical access if the mastopexy is not completed.
the skin envelope, but typically point "C" is 8 to 12 cm from the chest midline. If no horizontal nipple repositioning is needed, point "D" is often more or less equidistant to the meridian as the meridian is from point "C". If medial or lateral movement is needed, point ~'D" is moved appropriately, giving an asymmetric skin resection relative to the meridian.
Operative Technique
Fig 3. Oblique dissection through the breast parenchyma to the lateral pectoral border, An adequate inferior flap thickness is essential to cover the implant.
SPEAR AND DAVISON
A tidy circle of 38- to 50-mm diameter is first marked with a sterile marking pen within the boundary of the existing areola. A periareolar incision is then made precisely along the inferior edge of the existing areola (Fig 2). Using electroca'utery, an oblique dissection is carried through the breast parenchyma to the pectoralis muscle fascia. Great care is taken to ensure that the inferior flap is at least I cm thick. This ensures adequate soft tissue coverage after much of the inferior pole of the implant (Fig 3). The surgical technique is dependent on whether the implant will be subglandular or partial subpectoral. Successful subglandular placement requires that adequate breast tissue be available to camouflage implant contour, particularly if using saline-filled implants. Although patients being considered for mastopexy will typically have some laxity, the better the skin quality, the more likely subglandular saline implants will prove satisfactory. For a subglandular implant, a pocket is precisely dissected under direct visualization with a lighted retractor and electrocautery. The pocket is created between the pectoralis major fascia and the gland, limiting the lateral extension over the serratus and the inferior dissection to the IMF. The medial dissection should match the desired medial breast border, and the superior dissection should be high enough to allow suffi-
133
A
I
B
ii
Fig 5. The subpectoral dissection commences at the lateral pectoral border and extends from 7 to 4 o'clock.
cient redraping of the glandular tissue without encouraging excessive superior migration of the implant (Fig 4). For a subpectoral implant, the procedure begins with the subglandular dissection, which is kept minimal and is limited to only a small area between the IMF and the nipple across the entire width of the breast. The pectoralis muscle is then grasped with an Allis clamp and the electrocautery is used to lift the pectoralis major muscle along its inferior border. An uretheral dilator may be used to quickly develop the upper-half to two-
thirds of the subpectoral pocket (Fig 5), staying on top of the pectoralis minor muscle. Blunt dissection is particularly helpful laterally to avoid errant dissection beneath the pectoralis minor. The subpectoral pocket superiorly and the small subglandular pocket inferiorly must be made confluent by finishing the blunt dissection laterally and careful limited sharp release medially off the sternal origin of the pectoralis major muscle (Fig 6). This medial muscle release should be kept minimal and nearly always stays inferior to the nipple to avoid the risk of creating symmastia. After the implant has been inserted and its accurate positioning confirmed, the breast parenchyma is closed over the implant with resorbable suture to cover the implant pocket. If saline implants are used, they are filled just
Fig 6. Partial subpectoral and subglandular position of the implant.
Fig 7. The periareolar skin is deepithelialized and the breast skin is undermined for redraping.
1;34
AUGMENTATION WITH PERIAREOLAR MASTOPEXY
F
B
Fig 8. The periareolar mastopexy is closed with a pursestring closure using Goretex or Mersiline on a straight needle. The suture is cinched down around a cookie cutter. Use of the straight needle allows the suture to stay along the cut dermal edge, minimizing the scalloping of the breast skin edge.
degree of ptosis, a simultaneous periareolar mastopexy should now be performed. For the periareolar mastopexy, the areola should have been marked previously to a reduced size somewhere between a 38and 50-mm diameter. The markings are now confirmed and the appropriate areolar and periareolar skin to be excised is deepithelialized. The dermis is incised between areolar and breast skin, preserving dermis on each side for secure closure later. The breast skin is undermined circumferentially outward for at least 1 cm to allow tissue redraping (Fig 7). Benelli and others advocated first suspending the nipple by a dermal anchor suture at the 12 o'clock position, 5 and then several key dermal to dermal vertical mattress sutures are placed to orient the areola to the breast skin. A "round block" suture is then placed to cerclage the skin. In our experience, the suture of choice is a 3.0 Mersiline or a Goretex stitch. Regardless of the suture, a straight needle serves best to allow the suture to carefully follow the dermal edge of the cut breast skin. This minimizes the perlareolar scalloping often observed when a half-curved needle is used. A 42-mm cookie cutter is used as a guide to the shape and size of the areola as the suture is tied (Fig 8). Final closure is achieved with subcuticular PDS or Monocryl or cuticular running nylon suture.
Conclusions before closing the breast parenchyma. The initial periareolar skin incision is tacked with one or two sutures or staples and the patient is sat upright. The nipple position and degree of ptosis is now critically reassessed. If the additional volume of the implant proves inadequate to correct the skin laxity or
Simultaneous augmentation and periareolar mastopexy are effective in changing nipple position. 6 It is useful for a lax skin envelope with pseudo- or glandular ptosis or first- or mild second-degree breast ptosis. Simultaneous augmentation and periareolar mastopexy are effective because the
Fig 9. A 57-year-old patient with Benelli mastopexy and partly subpectoral augmentation with McGhan style 110, 240-mL textured round silicone gel-filled implant. Preoperative views: (A) anteroposterior view, (El} right three-quarter view, (C) left three-quarter view. One-year postoperative follow-up views: (D) anteroposterior view, (E) right three-quarter view, and (F) left three-quarter view.
SPEAR AND DAVISON
135
o
Fig 10. A 35-year-old patient after Benelli mastopexy and partly subpectoral augmentation with 300-mL smooth round saline-filled implant. Preoperative views: (A) anteroposterior view, (B) right three-quarter view, (C) left three-quarter view. Postoperative views: (D) at 6 months, anteroposterior view, (E) right three-quarter view, (F) left three-quarter view, and at 1 year follow-up, (G) anteroposterior view, (H) right three-quarter view, and (I) left three-quarter view.
enlargement of the breast with an implant fills out m u c h of the excess breast skin while the periareolar mastopexy removes the remaining excess and repositions the nipple. Because the quantity of skin removal is less with an implant, the skin can be closed with just a periareolar scar. The addition of a permanent soft suture placed uniformally along the dermal edge with a straight needle reduces irregularities, scalloping, and the risk of areola or scar disappointments. However, for the procedure to be successful, careful intraoperative assessment is necessary and the skin resection should be conservative. Two patients' results are shown in Figs 9 and 10.
136
References 1. Regnault P: Breast ptosis: Definition and treatment. Clin Plast Surg 3:193, 1976 2. Pucket CL, Meyer VH, Reinisch JF: Crescent mastopexy and augmentation. Plast Reconstr Surg 75:533-539, 1985 3. Spear SL, Kassan M, Little JW: Guidelines in concentric mastopexy. Plast Reconstr Surg 85:961, 1990 4. Benelli LC: A new periareolar mammoplasty: The "round block" technique. Aesthetic Plast Surg 14:93, 1990 5. Benelli LC: Periareolar mastopexy and reduction, in Spear SL (ed): Surgery of the Breast: Principles and Art. Philadelphia, PA, LippincottRaven, 1998, pp 685-696 6. Spear SL, Giese SY: Simultaneous breast augmentation and mastopexy. Aesthetic Plast Surg 20:155-165, 2000
AUGMENTATION WITH PERIAREOLAR MASTOPEXY
Augmentation alone can successfully enlarge many women's breasts without the need to reduce the skin envelope or alter the position of the nipple. In women with excessive breast skin laxity, or in many cases of mild to moderate ptosis, a periareolar pursestring mastopexy is a useful adjunct to prosthetic breast augmentation. This allows tailoring of the skin envelope and repositioning of the nipple, leaving only a circumareolar scar. Copyright @ 2000 by W.B. Saunders Company
ome women who present for a breast augmentation are
S seeking an improvement in ptosis as much as they are seeking an increase in breast size. Augmenting the volume of the breast alone may help camouflage mild ptosis in some patients. However, in many patients including those with a very lax skin envelope, with pseudo- or glandular ptosis or in patients with first-degree or mild second-degree ptosis, augmentation alone may prove inadequate. 1,2 In these patients, simultaneous periareolar mastopexy can help decrease the skin envelope or improve nipple position. Because the goals of volume augmentation and skin envelope reduction may be opposed, careful balance of the two operations is required. Combined augmentation/periareolar mastopexy is generally limited to patients with no more than moderate second-degree ptosis in which the nipple sits 2 to 4 cm below the inframammary fold (IMF) or higher. In borderline cases in which one is hoping to avoid a mastopexy, simultaneous mastopexy can be added intraoperatively or at a later time if the nipple position is deemed inadequate after the augmentation. To make the decision intraoperatively, the patient is sat upright and the need for skin excision is reassessed. The nipple should sit on the anterior face of the breast at or near the augmented breast's equator. If a periareolar mastopexy is being considered, it is best combined with either subglandular or partial submuscular implant placement. Subglandular or partly subpectoral placement is more effective than totally submuscular placement at filling out the ptotic breast envelope and reducing the need for a mastopexy. On the basis of the Food and Drug Administration's rules for the use of silicone implants in the U.S. adjunct studies, simultaneous mastopexy/augmentation does currently allow the use of silicone-filled implants, unlike simple primary augmentation in which silicone is prohibited. The periareolar scar is generally well accepted and certainly From the Division of Plastic Surgery, Georgetown University Medical Center, Washington, DC. Address reprint requests to Scott L. Spear, MD, Professor and Chief, Division of Plastic Surgery, Georgetown University Medical Center, 3800 Reservoir Rd NW, Washington, DC 20007-2197. Copyright 9 2000 by W.B. Saunders Company 1071-0949/00/0703-0006535.00/0 doi:10.1053/otpr.2000.22798
is better accepted and less visible when supine than the inverted "T" scar of the conventional mastopexy. However, one must remember that the potential of a periareolar mastopexy is limited to some extent because progressively more skin excision does not necessarily improve the overall results but may lead to problems such as flattening of the breast, distortion of the areola, spreading of the scar, or an overall poor cosmetic result. 3 A fundamental step for achieving success with the periareolar mastopexy is the circumferential cerclage stitch of permanent suture as advocated by Benelli and others, known as the "blocking" suture. The use of this suture, a 3.0 Mersiline (Ethicon, Sumerville, NJ) or a 2.0 Goretex (W.L. Gore, Phoenix, AZ) on a long straight needle, decreases the risk of enlargement of the areola by using permanent suture, while it decreases the likelihood and degree of periareolar puckering by using a straight needle along the dermal edge.< 5
Planning and Marking The patient is positioned upright with arms at the sides. The midline of the chest is marked from the jugular notch to the xyphoid. The position of the IMF is important and is carefully marked bilaterally with an indelible marker. The meridian of each breast is also marked as a line dropped from the midclavicle to the IMF. This is commonly midnipple; however, the nipple position may be asymmetric with the nipples occasionally situated medially or laterally from the ideal meridian. The marked meridian is used to help define the ideal new position of the nipple, as opposed to the nipple being used to define the correct position of the meridian. Setting the nipple height is extremely important. This position is determined by multiple factors. The distance from the jugular notch to the nipple should be in a range of 19 to 23 cm. It is affected by height, breast, and body habitus. The nipple height should be at or up to a few centimeters above the IMF and at the peak or equator of the anticipated breast mound. The nipple should not be placed too high during simultaneous augmentation mastopexy because it will look unnatural, and such unnatural positioning will exaggerate glandular ptosis, particularly if the new implants eventually drop. The new nipple position is marked by an "X" (Fig 1). After the nipple position is marked, the planned upper margin of the areola, "A", is marked. This is drawn 2 cm higher than point "X'. The amount of skin to leave from the inferior edge of the areolar to the IMF is determined by the anticipated size of the augmented breast. A large breast may require up to 7 cm and a small breast 5 cm of inferior skin. Point "B" marks the junction on the breast meridian between the skin that will be left inferiorly and the skin to be removed beneath the areola. The amount of skin to leave medially (point "C"), and laterally (point "D"), is assessed and marked. The shape of the skin to be excised is typically not perfectly round and concentric,
Operative Techniques in Plastic and Reconstructive Surgery, Vol 7, No 3 (August), 2000: pp 131-136
131
\J Breast meridian
//
Inframammary fold
] i
....
//I
~~
Fig 1. Marking of the patient. The IMF and breast meridian are marked first (top). Point "X" represents the new nipple position. It is located at or slightly above the IMF. Points "A, B, C, and D" mark the extent of skin excision. Point "A" is 2 cm superior to point "X" (bottom).
Breast meridian
Infrarnammary fold
j
,,y
but more oval and eccenmc so as to lift the nipple and not overly narrow the width of the breast. More often than not, points C and D lie just outside the current areola margins. The
132
dimension of the horizontal axis of the pattern is thus often significantly less than the vertical dimension. The size of the concurrent augmentation affects the size of the final design of
AUGMENTATION WITH PERIAREOLAR MASTOPEXY
/
/
/
/ J
/
l
J
~J
incision Fig 4. The subglandular implant pocket is outlined.
Fig 2. The periareolar incision for the augmentation is made from 4 to 8 o'clock on the inferior margin of the areola. This hides the incision for the augmentation while maximizing surgical access if the mastopexy is not completed.
the skin envelope, but typically point "C" is 8 to 12 cm from the chest midline. If no horizontal nipple repositioning is needed, point "D" is often more or less equidistant to the meridian as the meridian is from point "C". If medial or lateral movement is needed, point ~'D" is moved appropriately, giving an asymmetric skin resection relative to the meridian.
Operative Technique
Fig 3. Oblique dissection through the breast parenchyma to the lateral pectoral border, An adequate inferior flap thickness is essential to cover the implant.
SPEAR AND DAVISON
A tidy circle of 38- to 50-mm diameter is first marked with a sterile marking pen within the boundary of the existing areola. A periareolar incision is then made precisely along the inferior edge of the existing areola (Fig 2). Using electroca'utery, an oblique dissection is carried through the breast parenchyma to the pectoralis muscle fascia. Great care is taken to ensure that the inferior flap is at least I cm thick. This ensures adequate soft tissue coverage after much of the inferior pole of the implant (Fig 3). The surgical technique is dependent on whether the implant will be subglandular or partial subpectoral. Successful subglandular placement requires that adequate breast tissue be available to camouflage implant contour, particularly if using saline-filled implants. Although patients being considered for mastopexy will typically have some laxity, the better the skin quality, the more likely subglandular saline implants will prove satisfactory. For a subglandular implant, a pocket is precisely dissected under direct visualization with a lighted retractor and electrocautery. The pocket is created between the pectoralis major fascia and the gland, limiting the lateral extension over the serratus and the inferior dissection to the IMF. The medial dissection should match the desired medial breast border, and the superior dissection should be high enough to allow suffi-
133
A
I
B
ii
Fig 5. The subpectoral dissection commences at the lateral pectoral border and extends from 7 to 4 o'clock.
cient redraping of the glandular tissue without encouraging excessive superior migration of the implant (Fig 4). For a subpectoral implant, the procedure begins with the subglandular dissection, which is kept minimal and is limited to only a small area between the IMF and the nipple across the entire width of the breast. The pectoralis muscle is then grasped with an Allis clamp and the electrocautery is used to lift the pectoralis major muscle along its inferior border. An uretheral dilator may be used to quickly develop the upper-half to two-
thirds of the subpectoral pocket (Fig 5), staying on top of the pectoralis minor muscle. Blunt dissection is particularly helpful laterally to avoid errant dissection beneath the pectoralis minor. The subpectoral pocket superiorly and the small subglandular pocket inferiorly must be made confluent by finishing the blunt dissection laterally and careful limited sharp release medially off the sternal origin of the pectoralis major muscle (Fig 6). This medial muscle release should be kept minimal and nearly always stays inferior to the nipple to avoid the risk of creating symmastia. After the implant has been inserted and its accurate positioning confirmed, the breast parenchyma is closed over the implant with resorbable suture to cover the implant pocket. If saline implants are used, they are filled just
Fig 6. Partial subpectoral and subglandular position of the implant.
Fig 7. The periareolar skin is deepithelialized and the breast skin is undermined for redraping.
1;34
AUGMENTATION WITH PERIAREOLAR MASTOPEXY
F
B
Fig 8. The periareolar mastopexy is closed with a pursestring closure using Goretex or Mersiline on a straight needle. The suture is cinched down around a cookie cutter. Use of the straight needle allows the suture to stay along the cut dermal edge, minimizing the scalloping of the breast skin edge.
degree of ptosis, a simultaneous periareolar mastopexy should now be performed. For the periareolar mastopexy, the areola should have been marked previously to a reduced size somewhere between a 38and 50-mm diameter. The markings are now confirmed and the appropriate areolar and periareolar skin to be excised is deepithelialized. The dermis is incised between areolar and breast skin, preserving dermis on each side for secure closure later. The breast skin is undermined circumferentially outward for at least 1 cm to allow tissue redraping (Fig 7). Benelli and others advocated first suspending the nipple by a dermal anchor suture at the 12 o'clock position, 5 and then several key dermal to dermal vertical mattress sutures are placed to orient the areola to the breast skin. A "round block" suture is then placed to cerclage the skin. In our experience, the suture of choice is a 3.0 Mersiline or a Goretex stitch. Regardless of the suture, a straight needle serves best to allow the suture to carefully follow the dermal edge of the cut breast skin. This minimizes the perlareolar scalloping often observed when a half-curved needle is used. A 42-mm cookie cutter is used as a guide to the shape and size of the areola as the suture is tied (Fig 8). Final closure is achieved with subcuticular PDS or Monocryl or cuticular running nylon suture.
Conclusions before closing the breast parenchyma. The initial periareolar skin incision is tacked with one or two sutures or staples and the patient is sat upright. The nipple position and degree of ptosis is now critically reassessed. If the additional volume of the implant proves inadequate to correct the skin laxity or
Simultaneous augmentation and periareolar mastopexy are effective in changing nipple position. 6 It is useful for a lax skin envelope with pseudo- or glandular ptosis or first- or mild second-degree breast ptosis. Simultaneous augmentation and periareolar mastopexy are effective because the
Fig 9. A 57-year-old patient with Benelli mastopexy and partly subpectoral augmentation with McGhan style 110, 240-mL textured round silicone gel-filled implant. Preoperative views: (A) anteroposterior view, (El} right three-quarter view, (C) left three-quarter view. One-year postoperative follow-up views: (D) anteroposterior view, (E) right three-quarter view, and (F) left three-quarter view.
SPEAR AND DAVISON
135
o
Fig 10. A 35-year-old patient after Benelli mastopexy and partly subpectoral augmentation with 300-mL smooth round saline-filled implant. Preoperative views: (A) anteroposterior view, (B) right three-quarter view, (C) left three-quarter view. Postoperative views: (D) at 6 months, anteroposterior view, (E) right three-quarter view, (F) left three-quarter view, and at 1 year follow-up, (G) anteroposterior view, (H) right three-quarter view, and (I) left three-quarter view.
enlargement of the breast with an implant fills out m u c h of the excess breast skin while the periareolar mastopexy removes the remaining excess and repositions the nipple. Because the quantity of skin removal is less with an implant, the skin can be closed with just a periareolar scar. The addition of a permanent soft suture placed uniformally along the dermal edge with a straight needle reduces irregularities, scalloping, and the risk of areola or scar disappointments. However, for the procedure to be successful, careful intraoperative assessment is necessary and the skin resection should be conservative. Two patients' results are shown in Figs 9 and 10.
136
References 1. Regnault P: Breast ptosis: Definition and treatment. Clin Plast Surg 3:193, 1976 2. Pucket CL, Meyer VH, Reinisch JF: Crescent mastopexy and augmentation. Plast Reconstr Surg 75:533-539, 1985 3. Spear SL, Kassan M, Little JW: Guidelines in concentric mastopexy. Plast Reconstr Surg 85:961, 1990 4. Benelli LC: A new periareolar mammoplasty: The "round block" technique. Aesthetic Plast Surg 14:93, 1990 5. Benelli LC: Periareolar mastopexy and reduction, in Spear SL (ed): Surgery of the Breast: Principles and Art. Philadelphia, PA, LippincottRaven, 1998, pp 685-696 6. Spear SL, Giese SY: Simultaneous breast augmentation and mastopexy. Aesthetic Plast Surg 20:155-165, 2000
AUGMENTATION WITH PERIAREOLAR MASTOPEXY