Application and modification of the circular skin excision and pursestring procedures

Getting the Most Out of Augmentation-Mastopexy

LEARNING OBJECTIVES

After reviewing the article, the participant should be able to: 1. Understand the tenets of proper patient selection. 2. Be familiar with the assessment of patients for augmentation-mastopexy. 3. Be able to plan an operative approach and execute the critical steps. 4. Be able to recognize common complications and have a basic understanding of their management. 5. Be aware of emerging adjunctive techniques and technologies with respect to augmentation-mastopexy.

SUMMARY

Despite being a multivariable and complex procedure, augmentation-mastopexy remains a central and pivotal component of the treatment algorithm for ptotic and deflated breasts among plastic surgeons. Careful preoperative planning, combined with proper selection of approach and implant, can lead to success. Physicians need to understand that there is a high frequency of reoperation cited in the literature with regard to this procedure, and discussions before the initial operation can help alleviate common misunderstandings and challenges inherent in this operation.

Scar Area and Cosmetic Outcome after Circular and Elliptical Excision of Small Skin Lesions

Background:

Cutaneous surgery for removal of small skin tumors is usually performed as elliptical excision. There is some indication that circular excisions could result in cosmetically more favorable scars and should therefore be considered as an alternative method.

Objective:

The aim of this study was to compare circular and elliptical excisions with respect to scar area and cosmetic result.

Methods:

Fifty-six operations were performed, 27 elliptical and 29 circular. The cosmetic results were determined as patient's opinion by questionnaire and assessment of photo slides by three independent observers. Also, scar areas were measured by computer program.

Results:

The scar area was significantly smaller after circular excisions compared with elliptical excisions after 6 and 12 months of observation ( p = 0.005 and p = 0.001, respectively). The assessment of cosmetic results by the patients did not differ between the two groups ( p = 0.44), while the independent observers slightly favored the cosmetic outcome of elliptical scars ( p = 0.03). When analyzing only excisions without complications, there was no difference in cosmetic results between the two groups.

Conclusion:

Circular excisions seemed to cause smaller scars and equal cosmetic results compared with traditional elliptical excisions and could therefore be an alternative method for small skin excisions on the trunk and extremities.

Reconstruction of Areolar Projection Using a Purse-String Suture Technique

Background:

Nipple–areolar complex creation is the last step in the breast reconstruction process and plays a significant role in patients’ overall satisfaction. Although numerous surgical techniques have been described to create the nipple, very few procedures address the natural contour of the areola.

Methods:

We describe a surgical technique using a purse-string suture for improved areolar projection. After creation of nipple–areolar complex using a CV flap, evenly spaced stab incisions are made in a circular pattern, approximately 5 mm outside of the boundary of the proposed areola. Using these incisions, a nonabsorbable purse-string suture is placed in the deep dermis. The diameter is cinched down to the desired measurement, providing areolar projection.

Results:

Our experience using this technique has provided a satisfactory and stable projection of the areola in 10 patients with at least 1 year follow-up for each patient. There was no spitting of purse-string sutures in any of these patients, and there was no late areolar widening after at least 1 year follow-up. This provides a means for symmetry with an unreconstructed contralateral side.

Conclusions:

Improving aesthetic outcomes for areola reconstruction may further refine our goals of an ideal breast reconstruction.

Periareolar augmentation mastopexy with interlocking gore-tex suture, retrospective review of 50 consecutive patients

Background

Periareolar Augmentation Mastopexy is one of the most challenging operations in plastic surgery. Problems with scar quality, areolar widening, and distortion are frequent problems that interfere with a predictable result.

Methods

A retrospective review was performed on fifty consecutive patients who underwent a periareolar augmentation mastopexy with the interlocking approach. Of the 50 patients, 30 had both preoperative and postoperative photographs and were the basis of the study.

Results

The age of the patients ranged from 19 to 56 years with the average age being 39 years. The postoperative follow-up averaged 9.5 months and the implants averaged 316 mL. There were no deaths, pulmonary embolism, deep vein thrombosis, or infected implants. Four patients had complications following surgery for an overall complication rate of 13%. Two patients developed an infected Gore-Tex suture. Two of these complications were treated with revision surgery. Five patients required reoperation for an overall reoperative rate of 16% (one patient was converted to a full mastopexy).

Conclusions

As a result of this retrospective study, we have found the interlocking approach to periareolar augmentation/mastopexy to be a safe and reliable operation.

Extended crescent mastopexy with augmentation

Problems with periareola or circumareolar mastopexy procedures include areola spreading, hypertrophic scar, and recurrence of the ptosis largely because of tension on the closure. To minimize this tension associated with a conventional crescent mastopexy procedure, the authors modified the operation by excising parenchyma with the crescent of skin as well as two small triangles of parenchyma on either side of the areola. Implant augmentation was performed at the same time. The described operation is indicated for patients who have a small to moderate amount of ptosis. The best candidate is the patient whose areola-inframammary distance is not excessive. Nine such patients received this "extended crescent mastopexy with augmentation" and were followed for up to 3 years. Areola spreading and hypertrophic scar were kept to a minimum. Although not the final answer for ptosis patients, the extended crescent mastopexy with augmentation has been a step in the right direction.

Periareolar reduction mammaplasty utilizing the inferior dermal pedicle

The critical points which should not be overlooked when performing reduction mammaplasty are to minimize scar on the breast and to ensure a sufficient blood supply for the viability of the nipple-areolar complex. Periareolar reduction mammaplasty has been widely used because it left only one scar around the areola. However, with the typical periareolar reduction mammaplasty technique, it is difficult to remove a large amount of breast tissue and mobilize the remaining breast tissue. It may result in necrosis of the nipple-areolar complex in some cases. To overcome these limitations we combined the periareolar incision with the inferior dermal pedicle, which has a relatively good blood supply. This new technique was employed in 22 consecutive women (44 breasts) with hypertrophy and a varying degree of ptosis. Infiltration of a tumescent solution and liposuction were performed in all cases. After periareolar incision, dissection of the skin was performed, and the breast was elevated from the fascia of the pectoralis major muscle, leaving the inferior dermal pyramidal pedicle. An adequate amount of tissue was resected in the superior, medial, and lateral areas. After mastopexy, closure was done with a purse-string suture. The amount of tissue resected ranged from 180 to 1510 g per breast, and the mean was 466.1 g. The mean length of elevation of the nipple was 10.6 cm along the meridian of the breast. There were a few complications which needed revision operation: hematoma collection in one breast (2.3%), wound dehiscence in one breast (2.3%), and fat necrosis in one breast (2.3%). There was no necrosis of the nipple-areolar complex. With this new technique of periareolar reduction mammaplasty utilizing the inferior dermal pedicle, we were able to minimize the scar, preserve the nipple-areolar complex, and improve the motility of the breast tissue. But we also observed a flat or square appearance in the case of a large amount of resection in the patients with poor skin elasticity. This technique is safe and versatile and produces aesthetically acceptable results in selected patients.