Evolution of the technique

The areolar surgical approach has always been of great interest to the authors, as it enables surgical access to the whole breast; the glandular mound can be treated separately from the skin coverage, and the surgery results in minimal scars, avoiding the unpleasant ‘surgical’ appearance. In 1976, the authors described the areolar mammary quadrant resection, with plastic repair using two internally rotated glandular flaps detached from the skin.¹

This technique, which is currently used in oncological quadrantectomies, was the basis for the development of Góes’ periareolar technique, first published in 1989.^2–9 Periareolar mammoplasty was initially intended to reposition the glandular mound and provide a new positioning in relation to the thorax and a new aesthetic format.^10–16 The skin cover, initially detached from the gland, only covers the repositioned gland, leaving one scar in the periareolar region. Excessive periareolar skin is de-epithelialized and used as an internal flap, working as an internal bra to support the new breast.

In early postoperative follow-up, it was observed that this tissue structure was insufficient to maintain ideal conic format of the remodeled breast for a prolonged period, and therefore a permanent internal support system is required to provide stability and avoid distension of tissues in a centrifugal direction, thus avoiding expansion of the breast base and the diameter of the areola. In order to create stability, Góes started using a support mesh sandwiched between the two skin layers, the external layer and the de-epithelialized internal layer.

This system provides a long-lasting aesthetic result based on a more resistant support system. It helps maintain the ideal position of the gland after surgery and enables adequate fixation of the tissues into place, counterbalancing the forces of gravity.

Different kinds of materials have been used for the support system. A polyglactin 910 mesh was initially used in 55 cases. Because it is an absorbable material, there was a partial loss of the aesthetic result after 2 years of follow-up.^4,5

To obtain a long-lasting result, a mixed-mesh of polyglactin 910 and polyester was used in 172 cases, providing excellent results which were maintained in the late follow-up for several years. Other partially absorbable materials were also used and with delicate permanent components, which we consider important to maintain the ideal format of the breast, such as Vypro made of polypropylene and polyglactin and presently, we are using ULTRAPRO made of polypropylene and monocryl.^6,7

It is important to emphasize that the nonabsorbable material used is the same as that of suture threads usually used in surgeries in general. There were no complications resulting from their use after hundreds of surgeries.

Patient selection

Patient selection is a fundamental principle because the technique is not ideal for all patients. Resection limits, breast dimensions, tissue quality, and the presence of thoracic wall deformities are important factors that must be taken into consideration. Tissue quality is important because eventual scars produced by the mesh and skin retraction are responsible for the end result. Therefore, patients with thicker and more elastic skin have better retraction, less postoperative periareolar wrinkles, and longer-lasting maintenance of the newly shaped breast.

Breasts with greater proportions of glandular tissue (i.e., younger patients) are ideal for this operation because the newly shaped gland is more consistent and more firmly supported. Obese patients with fatty breasts have a worse result because there might be greater tissue displacement in relation to the thoracic wall, resulting in variable loss of anterior projection.

In terms of resection limits, satisfactory results can be obtained when resections of up to one-third of the breast volume are used. In addition, when ample periareolar skin resections are required, there is a higher rate of postoperative periareolar wrinkles. Finally, glandular reassembly may be technically difficult in patients with exaggerated breast ptosis and a narrow breast base.

Technique

The technique consists of separately treating the skin coverage of the breast gland, involving the construction of an internal support system (internal-bra) using the following anatomical elements:

Marking

Preoperative planning and marking must be carefully performed so that the correct amount of skin is present to cover the reassembled gland without tension (Fig. 8.6.1). Insufficient skin at any point tends to pull the areola, leading to loss of anterior projection and compromising the final result.

Fig. 8.6.1 Preoperative marking of the patient.

An important observation is that the position of the NAC in relation to the breast and thorax is not taken into consideration during marking. Because the markings are based on fixed points on the thorax (sternal notch, midline, inframammary fold (IMF), and lateral breast border) and not on the breast’s anatomic structure, gland asymmetries lead to asymmetric markings. Also, the resulting teardrop is larger in larger breasts, reflecting the increased amount of tissue to be resected.

Marking is carried out by defining the four cardinal points that will automatically bring the nipple-areola complex (NAC) to its new position.

Point A (superior cardinal point) defines the upper border of the future NAC and is located 2 cm above the projection of IMF on the breast surface. Its precise location depends on individual thoracic shape and lies anywhere between 16 and 18 cm from the sternal notch.

Point B corresponds to the inferior border of the future NAC and is normally placed 7 cm from the IMF. In patients with <7 cm of skin available in the lower hemisphere (e.g., in tuberous breasts), more skin may be harvested by advancing the dissection inferiorly to the IMF.

Point C represents the medial border of the future NAC and should be at least 9 cm from the midline to ensure that the new NAC maintains its slightly lateralized normal positions. This distance may reach 10.5 cm in patients with large breasts.

Point D corresponds to the lateral border of the future NAC and should be placed at least 12–13 cm from the breast’s lateral border.

Due to the force of gravity, the final shape of the marking should resemble a teardrop with the patient standing and a circle when the patent lies down.

Surgical technique

The procedure begins by defining the diameter of the future areola, which is normally 4.5–5 cm and should be 0.5 cm larger than the purse-string suture placed at the end of the operation. This produces a slightly projected and convex areola in relation to the new breast. If these dimensions are made equal, there is a slight tension on the suture during the early postoperative period with a tendency to flatten the NAC.

The region between the areola and the teardrop markings is de-epithelialized. Dissection of the upper skin flap is beveled, so that the thickness of adipose tissue attached to the skin increases progressively. This maneuver enhances the upper pole fullness since the thickened flap overlaps the newly assembled gland at the end of the operation. The first 4–5 cm are dissected, leaving a 0.5 cm layer of subcutaneous adipose tissue attached to the dermis, which preserves the subdermal vascular plexus responsible for flap viability. From then on, flap thickness increases until the anterior pectoral fascia appears. Dissection continues superiorly for approximately 4 cm or until the ideal position of the future upper breast pole is reached (Fig. 8.6.2).

Fig. 8.6.2 Subcutaneous dissection to the pectoralis major fascia.

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