Recently, Ahmad and Lista evaluated the clinical results of 49 patients who underwent vertical scar reduction mammaplasty, analyzing the fate of the nipple-areola complex position. Compared with preoperative markings, they observed that the nipple-areola complex was located on average 1 cm higher at 4-year follow-up, and the average distance from the inframammary crease to the inferior border of the nipple-areola complex had decreased 0.4 cm.1 We would like to report our clinical experience with more than 100 cases of customized lift and reduction mammaplasty by using a inferior dermal flap and either vertical scar2 or round block3 technique.
We obtained reduction measurements of nipple-areola complex displacement. We used a simple method: we consider the anatomical variability, achieving tissue removal calibrated on a single patient. Preoperative marking starts with the patient in the upright position; considering standard lines from the clavicle to the nipple, the new nipple position is marked at 18 to 22 cm, according to the patient’s degree of ptosis. Then, with the patient lying down, we consider 10 to 11 cm of distance from the medial sternal to the projection of the new nipple on the mammary crease; also, the new fold is considered after marking of the future vertical scar (≤6 cm). Skin periareolar excess is evaluated by means of the pinch test in order of appropriate resection, drawing a rhomboidal area.
The operation starts with deepithelialization of this area and dermal flap harvesting from the inferior pole. Glandular resection is performed according to the traditional inverted V shape, saving the dermal flap that was previously deepithelialized. The medial and lateral edges of the inverted V are put back together, and the dermal flap is fixed with three interrupted resorbable stitches to the new mammary crease to hold the inferior pole of the new breast. This is to prevent the herniation of the lower pole that often occurs with vertical scar techniques. Thus, the dermal flap is anchored to a new crease, with a distance never more than 6 cm to the inferior border of the nipple-areola complex. It then makes a breast cone again. A round block is performed around the areola, followed by vertical scar closure.
This procedure offers many advantages and few complications.4 Fifty-two women underwent our vertical scar reduction mammaplasty, which resulted in good reshaping of the mammary cone and ptosis resolution. A major advantage is that the cone projection is exceptional and long lasting. The patients had the following measurements taken of their right breast preoperatively and at postoperative follow-up at 4 years: the distance from the clavicle to the nipple, and the distance from the inframammary crease to the inferior border of the nipple-areola complex. We observed that the nipple-areola complex was located on average 0.6 cm higher at 4-year follow-up and that the average distance from the inframammary crease to the inferior border of the nipple-areola complex had decreased 0.2 cm. Therefore, we believe that a technique that combines the advantages of a supporting dermal flap and vertical scar and round block techniques appears to produce superior results. This technique offers the safety of the pedicle, affords immediate control over breast shape, limits the scar to the areola with a vertical to the inframammary fold (combining the advantages of the round block and vertical scar techniques), and is long lasting because of its supporting inferior dermal flap. This dermal flap further improves the projection and avoids herniation and flattening.
In addition, we analyzed skin and glandular resection during the preoperative evaluation. We attempted to remove most of the extra skin with the round block and to avoid breast flattening using the vertical scar, to give projection to the breast, and the dermal flap was very helpful in maintaining the glandular tissue in the new position and the new mammary crease. Moreover, the dermal flap anchored to the inframammary crease works against the weight of residual tissue, maintaining the crease at the desired position, with a natural result. We found this very useful in cases with weight loss after breast reduction, which is often followed by ptosis.
This custom-made technique is safe and versatile for both breast reduction and mastopexy, can be modulated on each patient, and results in a successful aesthetic outcome with minimal scar (vertical of just 5 to 6 cm) and suitable mammary cone projection. This very good projection, without lower pole flattening, is stable and long lasting at both early and long-term follow-up. Thus, it achieves the four successful specific elements described by Hammond: parenchyma and fat must be removed to reduce the volume of the breast; tissue must be removed in a way that preserves blood supply to the nipple and areola; an aesthetic shape must be created that is stable and long lasting; and scars must be acceptable, both in location and in appearance.5 The drawbacks are an unaesthetic aspect early postoperatively because of edema of the upper pole, and intractability of gigantomastia.
Cristiano Monarca, M.D.
Mauro Tarallo, M.D.
Maria Ida Rizzo, M.D.
Nicolò Scuderi, M.D., A.M.
Plastic Surgery Department
La Sapienza University of Rome
1. Ahmad J, Lista F. Vertical scar reduction mammaplasty: The fate of nipple-areola complex position and inferior pole length. Plast Reconstr Surg.
2. Lejour M. Vertical mammaplasty. Plast Reconstr Surg.
3. Benelli L. A new periareolar mammaplasty: The “round block” technique. Aesthetic Plast Surg.
4. Tarallo M, Cigna E, Monarca C, Scuderi N. Mastoplastica riduttiva: Una tecnica “custom made.” Paper presented at the 56th Congress of the Italian Society of Plastic, Reconstructive and Aesthetic Surgery; Pozzo Faceto di Fasano (BR), Italy; September 26–29, 2007.
5. Hammond DC. Short scar periareolar inferior pedicle reduction (SPAIR) mammaplasty. Plast Reconstr Surg.
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