Periareolar Techniques

Alexandre Mendonca Munhoz

13

13.1

Introduction

13.2

Indications and Patient Selection

The nippleareola complex (NAC) is an important component of the breast and its aesthetic outcome is crucial in most patients who have been diagnosed with breast cancer. The technical objectives of breast surgery are resection of the breast tissue with adequate margins while restoring the breast volume. To achieve these goals, numerous approaches have been proposed involving a variety of designs incorporating a periareolar incision, or other variations in the shape around the NAC [18]. In our experience, with the periareolar approaches, the aesthetic results can be improved further [911]. In breast-conserving surgery (BCS), the nal scarring can be kept at the natural border of the NAC with the breast skin. In skin-sparing mastectomy (SSM), the patchlike effect of skin aps can be avoided, which may be less favorable than the other incisions [9, 10]. Thus, scar reduction and even total camouage by the future NAC reconstruction are the main positive aspects of the periareolar techniques [9]. Despite its advantages, it is our impression that the periareolar approach is not appropriate for all patients. In our experience, it is more suitable in patients with small/ medium-sized breasts with an adequate areola diameter. Restricted surgical exposure and difculty in skin ap dissection are commonly observed for patients with a small areola and inexperienced breast surgeons. The importance of obtaining a good aesthetic result, while avoiding visible scars, has led breast and plastic surgeons to shift the location of the incision to an areolar region in selected cases. We believe that the hemicircumareolar or total circumareolar technique with appropriate planning achieves favorable aesthetic results with fewer complications.

Appropriate patient selection is critical. Thus, patients are usually rst seen in the preoperative period by a multidisciplinary team to evaluate the breast volume, ptosis, and tumor size/location. For patients with a large-diameter areola (more than 4 cm) without breast ptosis (Regnault grade I), a hemicircumareolar incision is indicated (Fig. 13.1). Other important indications are the presence of a marked color transition between the NAC and the breast skin, small and medium-volume breasts (cup size A or B), and tumors located near the central quadrant (45 cm from the NAC). For patients with a small/medium-diameter areola (less than 4 cm), with some degree of breast ptosis (Regnault grade II), and with small and medium-volume breasts (cup size A or B), a complete circumareolar incision is better indicated (Fig. 13.2). Relative contraindications include more signicant breast ptosis (Regnault grade III or grade III [12] Table 13.1), very large breasts, and especially a very small NAC (less than 2.0 cm). As the degree of ptosis increases, it is more likely that an L-shaped or inverted-T skin excision will be helpful in consistently achieving the desired result. If the nipple sits well below the inframammary fold or must be elevated more than 4 cm, a periareolar mastopexy becomes riskier. A very small NAC with a well-dened border is more likely to result in an enlarged areola and an unsatisfactory scar, with irreparable loss of the original shape and size of the areola.

13.3

Skin Markings

A. M. Munhoz (&) Plastic Surgery Department, Hospital Srio-Libans, So Paulo, Brazil e-mail: munhozalex@uol.com.br

Usually, the skin markings (the sternum midline, the inframammary folds, and the areola diameters on the vertical lines from the midclavicle) are drawn with the patient in an upright position. If there is a large-diameter areola and no breast ptosis, a semicircular periareolar incision (hemicircumareolar) is usually indicated in BCS or nippleareola
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C. Urban and M. Rietjens (eds.), Oncoplastic and Reconstructive Breast Surgery, DOI: 10.1007/978-88-470-2652-0_13, Springer-Verlag Italia 2013

128 Fig. 13.1 A hemicircumareolar incision approach for patients with a large-diameter areola without breast ptosis

A. M. Munhoz

Fig. 13.2 A complete circumareolar incision associated with transdermic access along its inferior border for patients with a small/medium-diameter areola with some degree of breast ptosis

sparing mastectomy (NSM). In these cases no additional skin markings are necessary. To prevent conspicuous scarring within or outside the areola, the incision is performed exactly at the junction of the areola and surrounding skin. If there is a small/medium-diameter areola and breast ptosis, an epidermic decortication of the complete circumareolar marked cutaneous ring and transdermic access along its inferior border are indicated (Figs. 13.2, 13.3). In these cases it is important to make the following marks: Point A, 1921 cm from the midclavicular line and 1012 cm from the external line. The ideal diameter of the NAC (25 30 mm) is outlined as a complete circumareolar epidermic ring (maximum width of 2025 mm) which will be resected to reduce the cutaneous excess. The medial limit of resection coincides with the 1012 cm of the external line and the same distance is maintained for the lateral limit. These limits of skin resection are conrmed by the mediallateral

and superiorinferior pinch test, ensuring there was no tension after removal of the skin.

13.4

Surgical Technique

The surgical procedure is performed with the patient under general anesthesia and with the patients the arms supported symmetrically 30 away from the chest. It is important to begin the sharp dissection with a no. 10 blade and the NAC is elevated off the underlying breast parenchyma Care is taken to leave a thickness of the retroareolar glandular tissue of approximately 12 cm to avoid nipple retraction. The incision is closed in layers with interrupted subcutaneous Vicryl 4-0 sutures and a continuous intracutaneous Prolene 4-0 suture (Ethicon, Johnson & Johnson, Hamburg, Germany).

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Table 13.1 Regnaults classication of ptosis Degree Minor (grade I) Moderate (grade II) Severe (grade III) Glandular ptosis Pseudoptosis Characteristics Nipple at the level of the inframammary fold Nipple below the inframammary fold, but above the lower breast contour Nipple below the inframammary fold, at the lower breast contour Nipple above the level of the inframammary fold but the breast hangs below the fold Nipple above the level of the inframammary fold but the breast is hypoplastic and hangs below the fold

Fig. 13.4 A partial submuscular pocket under the pectoralis major muscle is elevated from the inferior to the superior positions and the pectoralis muscle is partially detached. Closure of the periareolar incision is performed by the triple-layer technique. This technique is achieved by the advancement of the remaining areolar edge over this deepithelialized area. The advanced areolar edge is xed over the deepithelialized area using a deeper layer of sutures anchoring the deepithelialized edge under the advanced areola and a supercial layer of sutures anchoring the edge of the advanced skin to the edge of the skin of the deepithelialized ap Fig. 13.3 The diameter of the nippleareola complex (NAC) is outlined, as is the complete circumareolar epidermic ring, which will be resected. After the decortication, full access (transdermic) along its inferior border is performed. The transdermic access along the inferior border of the decorticated ring and glandular resection

In patients with a small/medium-diameter areola with breast ptosis, an epidermic decortication of the complete circumareolar marked cutaneous ring and transdermic access along its inferior border are performed. Thus, the subdermal plexus coming from the medial, lateral, and cephalic side of the areola is spared to ensure vascular supply to the NAC. Glandular excision is completed, leaving an adequate thickness of the subcutaneous tissue and a proper subareolar amount of gland. Skin aps are handled carefully with the use of delicate hooks in order to maintain the integrity of the subdermal plexus and to avoid excessive skin ap traction. The skin is closed by the triple-layer technique. This technique is achieved by deepithelialization of the periareolar circle and advancement of the remaining areolar edge over this deepithelialized area. The advanced areolar edge is xed over the deepithelialized area using a deeper layer of sutures anchoring the deepithelialized edge under the advanced areola and a supercial layer of sutures anchoring the edge of the advanced skin to the edge of the skin of the deepithelialized ap. This way, the terminal skin suture only overlies intact dermal and subcutaneous tissues, and all other sutures are not present in only one layer

(Figs. 13.3, 13.4). A 2-0 nylon intradermal circumareolar purse-string suture is then used to limit the periareolar centrifugal tension and to improve areolar symmetry; a continuous 4-0 nylon suture (Ethicon, Johnson & Johnson, Hamburg, Germany) is used on the areolar skin surface to enhance the quality of the skinareola transition zone.

13.5

Periareolar Technique in Skin-Sparing Mastectomy

SSM has been demonstrated to be an oncologically safe procedure for the treatment of early-stage breast cancer [1 3, 13, 14]. Compared with traditional mastectomy, SSM provides an ideal color and texture of breast skin and enhances the contour of the inframammary crease. To allow for adequate breast skin preservation, the oncoplastic surgeon should preoperatively discuss the periareolar incision and the width of the remaining skin aps. A critical survey of the literature shows that SSM is normally performed through numerous techniques, but most involve central breast incisions [13, 13, 14]. Habitually, the technique differs from surgeon to surgeon and is dependent on factors such as the type of reconstruction and the size of the breast. Although the type of incision differs, it is our impression that the best aesthetic outcome is related to the total periareolar approach [9]. With this technique,

130 Fig. 13.5 The total periareolar approach for skin-sparing mastectomy (SSM) and immediate reconstruction. With this technique, the nal scar can be kept at the transition of the natural border of the future NAC

A. M. Munhoz

the nal scar can be kept at the transition of the natural border of the future NAC (Fig. 13.5). In therapeutic SSM, specic areas of skin may in some instances require excision including prior incisions. Our approach to this issue is better performed through a central incision where the previous biopsy scar is excised in continuity with the NAC. Thus, previous communication of the team performing the biopsy/lumpectomy with the oncoplastic surgery team is critical in order to plan the incision as close as possible to the NAC. Usually, a total periareolar incision is performed, and with use of delicate hooks and ber-optic retractors, the breast tissue dissection is performed in the same subcutaneous layer, reaching the nal margins of the breast parenchyma. Skin aps are handled carefully in order to maintain the integrity of the subdermal plexus and avoid excessive skin ap traction and even dermal exposure. A minimum ap thickness of 35 mm is maintained (Fig. 13.6). The immediate reconstruction can be performed with an implant only, an expander and an implant, an implant associated with a pedicled latissimus dorsi muscle ap (LDMF), a transverse rectus abdominis musculocutaneous ap, or a deep inferior epigastric adipocutaneous free tissue transfer ap. In our experience, the reconstruction technique is frequently performed with a biodimensional implantexpander system associated with an LDMF as described elsewhere [9] (Figs. 13.7, 13.8). This option is usually chosen on the basis of individual aesthetic considerations but taking into account patient choice. This aspect is important since we have noted that some groups of patients prefer less evident breast scars.

Fig. 13.6 The total periareolar incision is performed, and with use of delicate hooks and ber-optic retractors, the breast tissue dissection is performed in the same subcutaneous layer, reaching the nal margins of the breast parenchyma. Skin aps are handled carefully in order to maintain the integrity of the subdermal plexus and to avoid excessive skin ap traction. A minimum ap thickness of 35 mm is maintained

Thus, patients who are candidates for SSM and who do not want a large horizontal breast scar are the best candidates for SSM through a total periareolar incision. In fact, with the total periareolar incision and reconstruction, the nal scar can be kept at the transition of the future NAC border, which may even be camouaged by the NAC reconstruction. In addition, the latissimus dorsi muscle can be incorporated into the submuscular pocket. The implantexpander is placed in a

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Fig. 13.7 The reconstruction technique is performed with a biodimensional implant expander system associated with a latissimus dorsi myocutaneous ap. The ap provides adequate skin cover for the resected NAC and the nal scar can be kept at the transition of the future NAC border. The latissimus dorsi muscle can be incorporated into the submuscular pocket and the implantexpander is placed in a total submuscular position where a cover is made in its superior two-thirds by the pectoralis muscle and the inferior third by the latissimus dorsi muscle ap

total submuscular position, where a cover is made in its superior two-thirds by the pectoralis muscle and the inferior third by the LDMF. This allows creation of a tension-free muscular pocket while providing adequate tissue coverage for the implantexpander [9]. In cases in which vascularity of the mastectomy ap is unpredictable, the expansion can be initiated with limited uid, which allows these aps time to recover vascularity [9, 15, 16]. If there are small areas of skin necrosis, the patient can be treated on an outpatient basis with implant deation and dressing changes since the implant is located under a healthy muscular pocket [9, 17]. In our experience, native breast skin complications were observed in almost 10 % of patients and represented one-third of all complications. Most cases consisted of partial skin loss and wound dehiscence between the LDMF and the breast skin [9]. In spite of the main advantages, the total periareolar technique has some limitations. The surgical exposure is restricted and dissection can be troublesome if the oncological surgeon is inexperienced [1, 9, 13]. In this situation, more breast skin tension and ap irregularities can be noted and a poor exposure may result in an inadequate oncological resection (Fig. 13.8).

13.6

Periareolar Techniques in Nipple Areola Sparing Mastectomy

Recently, a debate has developed about the possibility of extending preservation of the skin in SSM to include the NAC [48]. Thus, NSM is an alternative to mastectomy

which aims at avoiding the removal of the NAC and the positive consequences for immediate reconstruction. The objectives of NSM reconstruction are resection of the breast tissue while restoring the breast volume, shape, and symmetry. To achieve these goals, numerous incisions have been proposed (Fig. 13.9). However, the decision of the access incision with no complications has attracted attention in the literature [4, 5, 7, 8]. Besides the restricted access, the conventional periareolar approach can potentially result in vascular impairment to collateral ow, which can induce partial or total NAC necrosis. In fact, Regolo et al. [5], in a series of 32 consecutive NSM using the conventional periareolar approach observed a high rate of necrotic complications of the NAC (60 %). Consequently, we have developed an approach to improve surgical access for patients who are candidates for NSM based on a total circumareolar incision similar to that previously described for gynecomastia treatment [10, 18, 19]. Usually, the diameter of the NAC (34 cm) is outlined, as is the complete circumareolar epidermic ring (maximum of 45 cm width), which will be resected to improve surgical access. An epidermic decortication of the complete circumareolar marked cutaneous ring and full access along its inferior border are performed. The skin closure is performed by the triple-layer technique described previously [10]. This last aspect is crucial in some circumstances, since the pectoralis major muscle is usually not long enough to cover the implant totally. Thus, extending the deepithelialization around the areolar

132 Fig. 13.8 A 54-year-old patient with a 4.8-cm invasive ductal carcinoma located in the right breast (a, b). The reconstruction markings showing the planned periareolar SSM (c). The patient underwent SSM with axillary dissection (d). The patient underwent immediate reconstruction with a biodimensional implant expander (McGhan 150 volume 385405 cm3) associated with a latissimus dorsi myocutaneous ap (e, f). Postoperative appearance at 11 months with a very good outcome after radiation therapy (g, h)

A. M. Munhoz

incision allows complete and secure triple-layer closure of the entire wound. In this fashion, no part of the suture lines are present in only one layer, thus lessening the risk of implant contamination or exposure. In some situations, small potential areas of delayed healing of the incision can be treated conservatively as a consequence of the complete underlying soft-tissue cover over the implant (Fig. 13.10).

There are some limitations of present technique related to breast anatomy and experience. The surgical eld is limited and dissection can be difcult. Thus, the procedure is not applicable for all types of breast volume, position, and tumor location. Partial and full-thickness NAC necrosis has been described following NSM [47]. It is our impression that our acceptable incidence of NAC necrosis is probably due

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Fig. 13.9 A 51-year-old patient with a strong familial history of breast cancer and a previous biopsy with atypical hyperplasia located in the right breast (a, b).The reconstruction markings showing the planned hemiperiareolar nippleareola sparing mastectomy (NSM) (c). The patient underwent bilateral NSM (d). The patient underwent immediate bilateral reconstruction with a transverse rectus abdominis musculocutaneous ap (e, f). The postoperative appearance at 10 months with a very good outcome (g, h)

to several factors. These factors include full access along the inferior border of NAC which seems to allow adequate blood supply to the NAC. In addition, another important aspect is related to the preparation of the skin aps and the retroareolar tissue. For this reason, it is important to leave an adequate thickness of the subcutaneous tissue and a adequate subareolar amount of gland to avoid postoperative areolar retraction and necrosis [10].

13.7

Periareolar Techniques in BreastConserving Surgery

BCS is an important component of early breast cancer treatment, with a survival outcome comparable to that of radical procedures [20]. On the other hand, for BCS to be successful, breast surgeons must resect tumors with

134 Fig. 13.10 A 40-year-old patient with 2.8-cm ductal carcinoma in situ located in the left breast (a, b). The reconstruction markings showing the planned total periareolar NSM (c). The patient underwent left-sided NSM (d). The patient underwent immediate reconstruction with a biodimensional implant expander (McGhan 150 volume 295315 cm3) (e, f). Postoperative appearance at 1 year with a very good outcome (g, h)

A. M. Munhoz

adequate surgical margins and yet preserve the breasts form and shape [2127]. In BCS for T1 and T2 tumors, we have increasingly adopted the periareolar approach for lumpectomy. In these cases, incisions can be made semicircularly or total circularly concentric to the NAC similar to the incisions used for NSM. These approaches make it possible to remove lesions that are close to the NAC, up to

45 cm away. In most cases, we prefer to use separate incisions for sentinel lymph node biopsy or axillary clearance. Because of rich breast tissue vascularization, it is possible to plan the incision and the pedicle for the NAC according to the tumor location. Thus, the location of the NAC pedicle may be medial, superior, inferior, and lateral and usually results in a total periareolar scar pattern [25].

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Fig. 13.11 A 55-year-old patient with 2.0-cm invasive ductal carcinoma located in the left breast (a, b). The reconstruction markings showing the planned total periareolar breast-conserving surgery (c). The patient underwent upper-left quadrantectomy (d). The patient underwent immediate reconstruction with local glandular aps similar to Benellis round-block procedure (e, f). Postoperative appearance at 1.5 years with a very good outcome after radiotherapy (g, h)

In patients with a small/medium-diameter areola and deeply located tumors, the total periareolar incision can be advantageous as an alternative to radial-segmental BCS. Described elsewhere as donut mastopexy lumpectomy, this technique has the benet of a unique breast resection in which a tissue segment is removed through a periareolar incision [28]. Another similar option is the Benelli

mastopexy technique as a variation of donut mastopexy [29]. In Benellis round-block procedure, the periareolar outer circle is extended superiorly, rst to excise the skin over the lesions and second to lift up the breast. The inner circle is at the circumareolar margin. The skin between the circles is deepithelialized, and a wedge resection of the superior segment of the breast is performed. The remaining

136 Fig. 13.12 A 64-year-old patient with 2.0-cm invasive ductal carcinoma located in the left breast (a, b). The reconstruction markings showing the planned total periareolar breast-conserving surgery (c). The patient underwent central quadrantectomy (d). The patient underwent immediate reconstruction with an inferior pedicle dermoglandular ap (e, f). Postoperative appearance at 1 year with a very good outcome after radiotherapy (g, h)

A. M. Munhoz

breast is detached from the pectoral fascia, and the skin ap of the upper half of the breast is undermined and detached from the gland. The posterior aspect of the breast at the level of the areola is sutured to the pectoralis fascia at the level of the third intercostal space to lift up the breast and ll part of the defect. The superior breast pillars are wrapped around each other and sutured to the pectoral fascia to

further ll the defect and reshape the gland and the lumpectomy defect [29]. In spite of the benets previously described, total periareolar incision is more technically challenging and time-consuming than the radial approach, with a wide skin undermining in which only a segment of the breast is removed. As we emphasized for the NSM techniques,

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resection of the skin ring (double circle incision) is necessary to allow both adequate access to the breast tissue and closure of the skin envelope around the remaining breast tissue. This tissue is returned to the skin envelope and sutured at deep and supercial margins to close the resulting defect as a breast-ap advancement. In the case of breast ptosis, a purse-string closure around the NAC completes the procedure, leaving only a periareolar incision (Fig. 13.11). Another important point is related to centrally located breast cancer. Traditionally, these tumors have been treated with radical surgery (SSM). However, recent studies have demonstrated that BCS is an adequate treatment for selected patients with central or retroareolar breast cancers when compared with SSM [3032]. In this group, a primary association of oncological and reconstructive techniques can improve the nal scar outcome and breast symmetry, especially for women who may need contralateral breast reduction [33]. In this eld, an increasing number of studies have reported different approaches and various techniques for achieving satisfactory results, ranging from local advancement glandular aps and reduction mammaplasty/ mastopexy procedures to LDMF reconstruction [24, 30, 31, 33]. In our experience, for tumors located in the central breast region, the superior NAC pedicle is frequently injured by the tumor resection. Thus, the remaining lower breast tissue may be moved into the defect as a dermoglandular ap and an inferior pedicle mammaplasty technique can be used [33] (Fig. 13.12). In fact, Courtiss and Goldwyn [34] demonstrated by cadaver dissections that the principal sources of blood ow to the inferior pedicle are the perforating and intercostal branches of the internal mammary artery and the external mammary branches of the lateral thoracic artery. This anatomical characteristic permits a suitable pedicle vascularization and minimizes vascular pedicle complications when the procedure is planned and performed effectively.

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13.8

Conclusions

The main objectives of oncological breast surgery are to control the tumor locally and achieve a satisfactory aesthetic outcome with acceptable scars. It is our experience that with the periareolar techniques the aesthetic results can be improved further. Scar reduction and even total camouage by the future NAC reconstruction are the main positive aspects of these techniques. For this purpose careful preoperative planning and intraoperative care is crucial, as consideration must be given not only to tumor location, prior biopsy incisions, and the reconstruction technique, but also to NAC vascularization.

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