Transareolar-perinipple (areolar omega) zigzag incision for augmentation mammaplasty

Outcome Analysis Depending on the Different Types of Incision following Immediate Breast Reconstruction

Background

Immediate breast reconstruction following nipple-sparing mastectomy (NSM) is widely used for its cosmetic benefits. Due to the lack of guidelines, the types of incisions in NSM vary and which method is superior remains a debate. In this study, we hypothesized that the periareolar incision has a higher risk of complications, such as nipple-areolar complex (NAC) necrosis, than other incisions.

Methods

A retrospective chart review was conducted and divided into three groups: the periareolar, radial, and lateral incision groups. The reconstruction method and complications of NAC necrosis, wound dehiscence, seroma, hematoma, infection, and reconstruction failure were investigated.

Results

A total of 103 patients (periareolar incision (33%, n = 34), radial incision (39.8%, n = 41), and lateral incision (27.2%, n = 28)) who underwent NSM and immediate breast reconstruction from 2018 to 2020 were included. The reconstruction methods were direct-to-implant, DIEP flap, LD flap, and PAP flap, and there was all of which had no statistically significant difference between the groups regarding the reconstruction method (p=0.257). In terms of complications, there was no significant difference in NAC necrosis (29.4%, 19.5%, and 21.4%, in the periareolar, radial, and lateral groups, respectively; p=0.578), wound dehiscence, seroma or hematoma, infection, and reconstruction failure.

Conclusion

Breast reconstruction following NSM through periareolar incision does not increase the incidence of complications, including NAC necrosis. However, since only Asian patients with low BMI were included, if an appropriate patient group is selected for immediate reconstruction after NSM, reconstruction can be safely performed through the periareolar incision, and good cosmetic results can be obtained.

Comparison Of Endoscopic Transaxillary And Peri-areolar Approaches In Breast Augmentation With Smooth Implants

INTRODUCTION

The most common surgical approaches for breast augmentation in Asia have traditionally been peri-areolar and transaxillary. In recent years, transaxillary approach has become increasingly popular with the use of endoscopic methods, which result in safer and better outcomes. In the literature, there are no comparison studies of endoscopic transaxillary and peri-areolar approaches.

METHODS

This prospective study compared the outcomes of 275 women undergoing primary breast augmentation (endoscopic transaxillary n=205, peri-areolar n=70). All procedures were performed by a single surgeon using smooth round silicone implants and dual-plane pockets from April 2013 to March 2016. Every patient was monitored for a minimum of 4 years for minor and major complications.

RESULTS

Types and percentage of patients experiencing minor complications among transaxillary and peri-areolar patients were localized fluid collection in the wound (1% transaxillary, 7.1% peri-areolar), hypertrophic scarring or keloids (1% transaxillary, 8.6% peri-areolar), and areolar and nipple deformity (0% transaxillary, 8.6% peri-areolar). Major complications were postoperative bleeding (0% transaxillary, 2.9% peri-areolar) and capsular contracture, Baker Group III or IV (1% transaxillary, 5.7% peri-areolar).

CONCLUSIONS

Endoscopic transaxillary breast augmentation had better outcomes, with lower rates of complications than the peri-areolar approach. Reviewing the literature, our study is the first direct comparison of peri-areolar and endoscopic transaxillary incisions using smooth implants. With the risk of anaplastic large cell lymphoma associated with certain macrotexture implants, endoscopic transaxillary approach using smooth implants is the safer technique and very good alternative choice for Asian women who do not want any scarring on their breasts.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

The Use of a Retromammary Adipofascial Flap in Breast Augmentation for Patients with Thin Soft Tissue

BACKGROUND

In patients with a thin soft tissue breast envelope, lower pole implant palpability is a postoperative sequela that concerns patients. Anatomically, the lower aspect of the breast near the inframammary fold lacks sufficient soft tissue to cover the breast implant after augmentation.

METHODS

A transareolar incision was made, and subcutaneous dissection was performed. The dissection first proceeded caudally to the lower aspect to the breast parenchyma. The dissection then changed direction and moved cephalad to the mid breast or nipple region. The fatty tissue and pectoralis muscle fascia were cut transversely at this level, and the dissection was reversed caudally in a subfascial plane to the new inframammary fold region. This maneuver created a retromammary adipofascial flap.

RESULTS

A total of 368 breast augmentations were performed in 184 patients. Breast implants were inserted in the subfascial plane in 40 patients (21.7%) and in the subpectoral-subfascial plane in 144 patients (78.3%). A total of 368 breast implants were inserted, including 140 smooth cohesive silicone implants (38.0%), 2 textured round implants (0.5%), and 226 anatomic-type implants (61.5%). A cadaveric dissection revealed that a retromammary adipofascial flap measuring 3-4 mm in thickness can be acquired. Capsular contracture occurred in six breasts (1.7%).

CONCLUSIONS

During breast augmentation, an inferiorly based retromammary adipofascial flap can be created to help cover the lower pole of the breast from implant palpability. This is helpful especially in patients with thin skin, hypoplastic breasts, or constricted breasts.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The Transareolar-Periareolar Approach

The periareolar approach is limited by areolar diameter. Asian women typically have smaller areolae than Western women. Voluminous and form-stable silicone implants demand larger incisions. Zigzag transareolar approaches closely approximate the nipple and improve exposure, but scar appearance remains problematic, and there is a risk of ductal injury and capsular contracture. We prefer a zigzag incision that straddles the areolar border. Between 2013 and 2015, 11 augmentation mammoplasties (20 incisions) were performed through a transareolar–periareolar (TAPA) incision. The TAPA incision resembles 3 inverted V’s that traverse the inferior areolar border. Outcomes were evaluated on the basis of photographs, clinical charts, and surveys. Women were 36 years old (range, 25–50). Silicone implants were used in 10 patients and saline in 1 patient. Implants were 270 cm³, placed in subpectoral position in 6 patients and subglandular position in 5. Follow-up was 12.5 months (range, 5–20 mo); there were no hematomas or infections. There was 1 case each of seroma (9.1%) and unilateral capsular contracture (9.1%) after secondary mammoplasty. There was no implant malposition or contour deformity. There were no keloids or hypertrophic scars. Every patient was satisfied. Nipple sensation was maintained or heightened in 100% of patients surveyed. The incisions were 139% longer than 180-degree periareolar scars. TAPA scars were well tolerated in this series of Asian women. We did not observe malposition, infection, or sensory disturbances. Despite its peripheral position on the nipple–areola complex, there are not enough data to determine whether TAPA incisions reduce risks compared with traditional approaches.

Asian Breast Augmentation: A Systematic Review

BACKGROUND

Economic, cultural, and regulatory phenomena may explain recent popularization of implant-based augmentation in Asia; but the collective Eastern experience remains limited. Asian surgeons and their patients rely on evidence-based medicine that originates elsewhere and may not be entirely relevant. Distinct anatomic and cultural features of Asian women warrant a tailored approach to breast augmentation. We explore the Asian experience with a thorough exploration of the recent literature.

METHODS

A literature search was performed for articles written after 2000, of Asian women who underwent augmentation mammoplasty using MEDLINE, Embase, and Pubmed Databases. Technique and outcomes data were summarized.

RESULTS

Twelve articles reported outcomes of 2089 women. Korea contributed most series (English language, 7), followed by China (3), Taiwan (1), and Japan (1). Silicone implants were used in 82.1% of women studied, and almost exclusively after 2009. More round (68.9%) than anatomic implants (31.1%) were placed. Non-inframammary (axillary, areolar, and umbilical) incisions were used in 96.9% of cases. Nearly all implants were positioned below the muscle or fascia; subglandular placement accounted for 1.1% of cases. Implant/nipple malposition (1.3%), capsular contracture (1.9%), hematoma (0.6%), and infection (0.2%) rates were reported in most series. Undesirable scarring was the most frequent complication (7.3%), but was reported only in 4 of 12 series.

CONCLUSIONS

Studies of Asian women undergoing augmentation mammoplasty are limited, often with ill-defined outcomes and inadequate follow-up. As experience accumulates, an expanding literature relevant to Asian women will provide evidence-based guidelines that improve outcomes and patient satisfaction, and foster innovation.

Gynecomastia: Simultaneous Subcutaneous Mastectomy and Areolar Reduction with Minimal Inconspicuous Scarring

Acceptable scar positioning on the anterior male chest is very limited. In Gynecomastia surgery, an obvious areolar incision is the most sensitive indicator of a previous operation; a less apparent scar is indispensable for the patient's psychological satisfaction. Whenever only areolar diameter reduction is required, the circumareolar incision must be performed in a position leaving the least conspicuous scar. Standard excision of an outer doughnut of areolar skin results in a visible and unnatural peri-areolar scar. The peri-nipple excision of areolar skin leaves the skin-areola junction undisturbed. When combined with a transverse areolar infra-nipple incision, access for subcutaneous mastectomy is facilitated. With this approach, risk of nipple vascular compromise is thought to be reduced, and necrosis of areolar pigmented skin virtually impossible.

EBM LEVEL V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.