Periareolar Benelli Mastopexy and Reduction: the “Round Block”

Louis C. Benelli

Whatever type of mammaplasty is performed, the main concerns are to limit scars and create a nice breast shape. Ideally, scarring is confined to the periareolar circle.

The indications for various periareolar plasty techniques have been limited (1,2,3,4,5,6). Only moderate cases of small breast ptosis should be treated using periareolar mastopexy, owing to the risk of enlargement and distortion caused by tension on the areola. The “round block” technique helps eliminate this complication, making feasible the treatment of many cases of breast ptosis and hypertrophy by periareolar mastopexy (7,8).

One of the principal elements of our technique is to treat ptosis and hypertrophy by using a blocked circular dermal suture passed in a purse-string fashion. The round block constitutes a cerclage, fixing a solid circular dermodermal scar block around the areola (Figs. 83.1 and 83.2).

To obtain a nice breast shape, it is necessary to separate the work on the gland (creating the conic shape) from the work on the skin (removing the excess skin around the areola). The skin must cover the cone shape obtained by the work on the gland without any tension. Excess tension on the skin will flatten the shape.

To achieve the greatest anterior projection of the breast, we perform a criss-cross T-inverted technique on the gland, which provides good coning and support without cutting the skin. The skin is simply detached to cover the glandular cone without irregularity.

This control of the periareolar scar gives us a number of new possibilities in breast surgery because the periareolar approach provides easy access to the whole gland, minimizing the required incision. The periareolar approach thus allows us to perform diverse operations, such as mastopexy, mastopexy with reduction or augmentation, tumorectomy, subcutaneous mastectomy, and total mastectomy with reconstruction.

The image of the breast as a symbol of femininity plays an essential role in the way a woman looks at herself. It also contributes to her personal and social development. This image is shaped by the ethnocultural context or sometimes just by the fashion of the moment—the same patient may find herself simultaneously offered a breast augmentation by a North American surgeon and a breast reduction by a Brazilian surgeon. The surgeon must set aside his or her personal taste and listen carefully to the patient’s demands, keeping in mind that these demands must be considered with regard to anatomic harmony because certain patients want to pass from one extreme to the other regarding the size of their breasts.

The progress made in endoscopic surgery and other areas has permitted the reduction of scars in many operations. By the use of an axillary or periareolar approach, breast augmentation patients can obtain a satisfying result, with very discreet or invisible scars. Because fashion uncovers rather than covers a woman’s body, the long scars resulting from mammaplasty are less accepted now than they were in the past—more so because the scar quality is unforeseeable. Even if the scars are generally discreet when the patient is sitting upright, they may be more visible when the patient is lying supine.

The scars may be less important for a mature woman but might have negative consequences for a young woman in whom scars are sometimes hypertrophic. The scar can be minimized simply by making the incision only around the circumference of the areola.

Mammaplasty via periareolar incisions has the aesthetic advantage of a short scar, but the surgeon should be alert to other potential obstacles inherent to this procedure. It is important to prevent reduction of the scar, which can detrimentally affect the shape of the breast and the quality of the periareolar scar itself.

In this chapter, I analyze the technical elements that make it possible to avoid these potential obstacles to a successful result and to judiciously select the periareolar technique that is suitable for the particular patient. Each technique can yield outstanding results when it is executed in the appropriate case.

Evolution of Personal Technique

In 1983, we started performing periareolar mastopexy with dermal cerclage of the areola via a purse-string suture to prevent postoperative enlargement of the areola and the scar. In view of this procedure’s effectiveness, we extended its application, calling it the round block. This name was used because of the solidity of the dermodermal circular scar block reinforced by the cerclage, with a nonresorbable suture passed in a purse-string manner through the edge of the periareolar dermis. This procedure has enabled us to treat more serious cases of ptosis and thereby extend the indications of periareolar mastopexy that in the past had been reserved only for moderate ptosis or hypertrophy, essentially because of the postoperative risk of enlargement of the areola and periareolar scar.

Our use of the round block technique has progressed with prudence. In the beginning, we obtained the best results in the correction of hypotrophic ptosis by using periareolar mastopexy with round block and simultaneous placing of a breast implant, ensuring the shape and the anterior projection of the breast.

To obtain breast conization in the treatment of simple ptosis and hypertrophy, simple plication and invagination of the base of the breast has yielded satisfactory results for small breasts but unsatisfactory results for larger breasts, with some leading to long-term shape flattening and recurrence of ptosis.

Therefore, we applied the techniques classically used for reduction mammaplasty in an inverted T. Yet, we practiced them only on the mammary gland without cutting the skin, which
was redraped around the areola without tension using a round block on the skin aperture. We then reduced and reshaped the breast in the manner of an internal inverted T to the breast alone.

Figure 83.1. Round block cerclage stitch of 2/0 Mersilene made with a long, straight needle passed in a purse-string method. This stitch is passed in a regular plane in the deep dermis 5 mm beyond the edge of deepidermization. This round block cerclage facilitates good control of the areola and scar and can be used in many aesthetic tumoral and reconstructive periareolar operations.

The inverted-T techniques that give maximum coning and the best long-term hold are those that are characterized by a crossing and overlapping of two flaps (lateral and medial), which ensures a maximum of anterior projection to the areola (9).

To ensure the breast keeps its shape, we found it equally useful to perform a fixation, at least temporarily, of the glandular cone to the pectoralis major muscle (10).

Concerning work on the breast itself, our goal has been to limit its detachment as much as possible to maximize the vitality of the glandular flaps and to ensure the conical shape. Concerning the skin, the trend has been to limit the amount of resection of the ellipse of the periareolar deepithelialization. This helps prevent complications such as bad scarring and flattening of the breast owing to excess tension in the periareolar area.

Patients and Methods

Since 1983, we have performed this surgical procedure on more than 386 patients in aesthetic, tumoral, and reconstructive surgeries (Table 83.1). We have been progressive in our advancement of this procedure for cases of serious ptosis or hypertrophy. Breast reductions have entailed an average resection of 220 g (maximum 1,200 g) on each breast.

Figure 83.2. Cross-section view showing that the round block cerclage stitch does not produce tension on the areola and scar.

Table 83.1 Clinical Series (January 1983 to January 1997)

Breast reductions	51%	198
Mastopexies	19%	73
Mastopexies and augmentations	18%	69
Tumoral and reconstructive surgeries	12%	46
Total number of cases	100%	386

The principle of the operation is to perform an internal inverted-T mastopexy, with a large, superiorly based dermoglandular pedicle supporting the areola, and to redrape the skin without tension around the areola on the glandular cone by “round block,” just like a glove covers a hand. The skin will naturally retract itself on the new breast cone once the postoperative edema has disappeared, a few weeks after the operation. The breast skin has a remarkable capacity to retract, programmed by nature to adapt itself to the considerable changes of volume occurring during pregnancy and lactation, during which the areola easily adapts itself to various changes in diameter.

On the breast, we distinguish between (a) the thin and elastic periareolar skin, whose function is to adapt itself to the breast volume changes and which generally produces fine scars and is easily stretched by the weight of the gland, and (b) the skin of the base of the breast and of the submammary fold. This thick skin’s function is to support the breast, and the scars it produces are potentially much larger.

For support of the breast, the periareolar technique is used to remove the thin and elastic stretched skin around the areola, which does not have any supportive value, and to conserve the thick skin at the base of the breast and submammary fold. However, other techniques producing an inverted-T scar involve skin removal at the base of the breast, whereby the vertical skin suture, underneath the areola, is the former thin and elastic periareolar skin that was transposed to reshape the breast. This fact explains the good scars generally seen with this vertical scar, as well as its tendency to stretch and elongate in the postoperative period. This segment is usually fixed at 5 cm during the operation because it is known to stretch out afterward.

Vascularization and innervation of the areola and mammary gland are addressed in the same manner as for an inverted-T technique, with a vertical dermoglandular flap supporting the areola with a superior pedicle. This pedicle will be larger because it occupies the whole length of the ellipse, whereas in the design of an inverted-T mammaplasty the pedicle will be narrower, passing through the edge of the areola, where a straight liberation of the adjacent tissue is required to allow the lift. For this reason, the vitality, breast-feeding ability, and innervation of the areola seems to be better preserved by the round block technique.

Subdermal vascularization is preserved with skin excision done with scissors close to the gland. At the time of the dermal incision within the wide deepithelialized ellipse, we conserve a 1-cm strip of dermis to protect the vascularity of the ellipse’s skin edge, especially in its lower part.

The entire operation thus preserves the blood supply and innervation of the breast. This advantage is essential to the improved control of the scar and vitality of the tissues constituting the remodeled breast.

Patient Selection and Preparation

Consultation before surgery is essential to understand the patient’s expectations; these expectations often extend beyond the possibilities of surgery. The patient should be informed that the result of the operation depends on the anatomic quality of tissue. Thus, patient selection and surgery preparation must be performed with care.

In planning the operation, we must consider three factors: the psychological context, the anatomy, and our experience with the technique.

Psychological Context

This is the most important element. Patients must be willing to accept a less-than-perfect shape in favor of a reduced scar. Therefore, one should paint a realistic picture of such possible postoperative difficulties to test the patient’s motivation to limit the scar.

Patients should be made aware of the potential postoperative inconveniences of mastopexy, in general, and periareolar mastopexy, in particular, such as the wrinkling and scalloping of the periareolar skin, which may last for weeks or even months, the need to wear a bra night and day for 2 months, the possible need to revise the scar in case of poor scarring, persistence of cutaneous irregularities, and, in case of complete failure, the possible need to undergo an inverted-T mastopexy after all.

The patient’s reaction to this warning allows identification of those who probably could not emotionally tolerate the postoperative difficulties. “Impatient patients” are generally excluded, as are those with unrealistic expectations or exaggerated narcissistic suffering. Patients who demand a short-scar technique usually want to obtain a natural appearance and are generally satisfied with the result of the operation, appreciating the shape as well as the discreet nature of the scar.

Anatomy

The best indications are moderate ptosis or hypertrophy in a young patient. In these patients, the skin has a good retracting potential and the breast tissue is firmer, which is important because the scar of a young woman’s skin is more likely to become hypertrophic, so we want to limit the extent of the scar.

However, contraindications include breasts that are essentially fat or have a lot of additional skin. Surgeons should exercise caution when considering patients who are overweight, elderly, or smokers.

The morphology of the thorax and the breast shape are also important: Tubular breasts are a good indication, but very large breasts are more difficult to treat.

Experience with the Technique

It is preferable for surgeons unfamiliar with this technique to start by operating on patients with moderate ptosis, where the vertical axis of the planned periareolar ellipse does not exceed 10 cm. After gaining some experience, the surgeon may choose to extend the indications to more severe cases of ptosis or hypertrophy. The degree of difficulty mostly depends on the degree of ptosis. The resection is performed on the distal part of the glandular flaps, cut out like a reduction mammaplasty in inverted-T fashion but without cutting the skin.

We would thus be more likely to perform this procedure in a young patient, even in severe cases of hypertrophy, if the psychological and anatomic conditions are favorable.

Surgical Technique

Step 1: Planning and Marking

We have no standard pattern. Each surgery is specific to the individual patient. The marking begins with the patient standing, then lying supine, and finally back in the standing position.

Marking in the Standing Position

The midline is marked to maintain symmetry (Fig. 83.3). The breast meridian is marked at the beginning on the clavicle, 6 cm from the midline. The meridian is not the meridian of the ptotic breast, but the meridian of the manually reshaped breast. This new meridian will not necessarily cross the ptotic nipple because the mammary ptosis is generally a lateralization of the breast due to chest wall convexity.

The new meridian is often more medial than that of the ptotic breast. The lower part of the breast meridian is not marked while the patient is standing but while she is lying supine.

The New Areola Vertical Position.

The superior border of the areola (point A) is marked on the breast meridian, 2 cm higher than the anterior projection of the submammary crease. Reshaping the breast manually, the surgeon verifies that point A is marked in the correct position. Contralateral point A is marked by measuring the distance to the sternal notch.

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