Skin Marking

The final position of the nipple–areola complex (NAC) marking is critical in both mastopexy and breast reduction. Too medial placement causes the impression of “squinting nipples” which is almost impossible to correct satisfactorily. Too lateral a position causes unattractive divergence of the nipple position. Pitanguy’s point can be used to determine this position fairly well but may result in inadequate elevation over time. Slight overcorrection can be helpful when mastopexy alone is being performed, as these patients have already demonstrated a significant tendency to stretch out in the past. When marking patient, many surgeons drop a perpendicular from the midclavicular point to the nipple. They then use a line from the suprasternal notch to the intersection with the midclavicular line to determine the level of the new NAC position. While this can be fairly accurate, there is a tendency for the nipple to be placed slightly too lateral when using this technique, particularly in very ptotic women requiring significant cephalad movement of the NAC or in women with broad breasts (▶Fig. 23.1 ).

The nipple is marked 1 to 2 cm above the existing inframammary crease (i.e., slightly above Pitanguy’s point), along the median of the breast. The upper point of the new areolar location (point A in ▶Fig. 23.2) is typically marked at 18 to 20 cm from the nipple to the notch, depending on the patient’s height and chest wall length. This places the nipple itself at 20 to 21 cm from the sternal notch. An inverted C-shaped dome incision is marked, with the lower limbs of the inverted C ending at or just below the lower border of the preexisting areolar position (points B and B’ in ▶Fig. 23.2). The medial and lateral portions of the dome should not be too wide as this places excessive lateral tension across the freshly sutured NAC. The breast is displaced medially, and a perpendicular line is dropped along the median of the breast to within 2 cm of the inframammary crease. The breast is displaced laterally, and the medial vertical incision is marked in a similar fashion. The two vertical incisions are joined by a gentle U-shaped incision with its base 1 to 2 cm above the inframammary crease (point D in ▶Fig. 23.2).

Nipple–Areola Incision and Breast Deepithelialization

The nipple–areolar diameter is marked with an imprint from a “cookie cutter” marker, typically at 42 mm. This imprint is incised into, but not through the deep dermis (▶Fig. 23.3).

The outermost skin incision is made into dermis, and intervening skin to be resected is deepithelialized (▶Fig. 23.4).

Dermal Cuff Creation

The dermis of the periareolar inset is incised full thickness down to the parenchyma, 3 to 5 mm within the outermost circumference of the areolar skin inset. This provides a 3- to 5-mm dermal cuff in preparation for the periareolar Gore-Tex suture insertion (▶Fig. 23.5).

Preparation of the Inferior Dermal Triangle for Imbrication

The dermal triangle below the inferior border of the areola is incised into the parenchyma transversely, allowing the areola to ride upward more easily and to facilitate easier vertical plication of the lower pole for autoaugmentation of the central breast (▶Fig. 23.6).

Vertical Lower Pole Imbrication for Autoaugmentation

The deepithelialized lower pole is imbricated using a running 3–0 Vicryl suture on a taper pointed needle. This maneuver infolds the lower central breast parenchyma into the center of the breast mound to some degree, creating autoaugmentation. Leaving a layer of deepithelialized dermis on the lower glandular triangle is critical to allow the sutures to hold well enough without tearing through breast fat (▶Fig. 23.7).

Elevating Lateral and Medial Skin Flaps

Thick skin flaps are raised for 2 to 3 cm laterally and medially along the vertical limbs of the mastopexy after imbrication of the central gland has been performed to achieve projection. The flaps are approximately 1-cm thick leaving a robust blood supply to the overlying skin (▶Fig. 23.8). This maneuver allows for easy approximation of the medial and lateral skin pillars over the central imbricated glandular tissue. Inferiorly, the gland can be elevated off the underlying pectoralis major muscle and sutured down again 1 to 2 cm higher if the inframammary fold (IMF) needs adjustment. This can also improve lower pole shape at the IMF for a more rounded profile if there is any tendency for dog-ear formation to occur (▶Fig. 23.9).

Vertical Pillar Closure and Dog-Ear Management

At this juncture, the medial and lateral skin pillars can be tailor-tacked with staples prior to subcuticular closure. Any gross dog-ear formation or adjustment to excess vertical scar length can be made at this time with excision of the dog-ear or removal of a horizontal wedge resection of skin at the IMF (▶Fig. 23.10).

Insertion of the Gore-Tex Periareolar Cartwheel Suture

The insertion of the Gore-Tex periareolar suture is a key step toward achieving a stable nipple–areolar diameter in the long term. The use of absorbable sutures tends to permit late stretching of both the areola diameter and the periareolar scar. The areolar inset is first divided into four major and then an additional four minor quadrants with a marking pen. Reciprocal markings are performed on the NAC itself to match the inset markings.

These orientation marks are important for maintaining even tension and placement along the suture line before final tightening takes place. A 2–0 Gore-Tex equivalent polytetrafluoroethylene suture on a Keith needle is used (Surgiform, Lugoff, SC). The suture is started within the edge of the 3- to 5-mm dermal cuff; I usually begin at the 7 o’clock position. Larger bites are taken on the outermost area of the periareolar inset, and smaller bites taken on the areola (▶Fig. 23.11). Once a 360-degree inset has been placed, traction is applied to both ends of the Gore-Tex suture, and the purse-string is closed down to a diameter of 42 mm on average. The knot is tied with 8 to 10 throws on the suture. The knots should be pulled down into the breast parenchyma, inserting the suture deep into the subcutaneous tissues and bringing it out laterally through the skin. It is cut flush with the skin surface. A running 4–0 Monocryl suture is used to close. The vertical closure is completed with interrupted sutures, followed by running 3–0 or 4–0 Monocryl sutures. Steri-Strips are applied (▶Fig. 23.12).