Intra-Areolar Pexy: The “Compass Rose” Suture Technique for Small and Moderate Areola Herniation

Intra-Areolar Pexy: The “Compass Rose” Suture Technique for Small and Moderate Areola Herniation Abstract Background Common methods for addressing minor tuberous breast (type 0; normal mammary base breast with isolated areolar herniation) do not solve the underlying pathology and may leave an unsightly scar. Objectives To assess the efficacy and safety of a simple, scarless method based on a novel “compass rose” technique, which addresses the etiology of minor tuberous breast and other cases desiring small areolar diameter reductions. Methods The technique uses 3 layers of suturing, 1 in a compass pattern and 2 in round block. Retrospective data are provided for 77 consecutive women (141 breasts) undergoing cosmetic breast augmentation surgery and requiring unilateral or bilateral type 0 tuberous breast correction (n = 22) or areolar width reduction ≤ 15 mm (n = 55). Results Baseline mean age and body mass index were 29.7 ± 6.0 years and 19.4 ± 1.5 kg/m2, respectively. Patients were followed up for a mean of 27.2 ± 19.5 months. In tuberous breast, mean Northwood Index decreased from 0.55 ± 0.06 at baseline to 0.36 ± 0.02 at ≥ 6 months post surgery, indicating minimal residual deformity. In areolar width reductions without tuberosity, mean width decreases of 11.3 ± 1.8 mm (20.0%) were achieved. Patient satisfaction was high with regard to lack of scarring, stability of the result, and overall breast attractiveness. Eight complications were recorded (n = 2 superficial hematoma; n = 3 hypersensibility; n = 2 knot palpability; n = 1 recurrence); all were resolved. Conclusions The method is effective and safe, and may be applicable across patients with type 0 tuberous breast or desiring small areolar diameter reductions. Level of Evidence: 4 Tuberous breast is a congenital anomaly of the breast that may be unilateral or bilateral. It is associated with areolar pseudoherniation and constriction of the lower pole. This is most likely due to thickening of the superficial fascia, as well as laxity of sub-areolar muscles, in particular the muscle of Sappey (circular fibers) and the muscle of Mayerholtz (radial fibers).1 Classification of tuberous breast deformity is typically based on the criteria proposed by Grolleau and colleagues: type I, in which only the lower medial quadrant is deficient; type II, in which both lower quadrants are deficient; and type III, in which all four quadrants are deficient, giving rise to a substantially restricted breast footprint.2 More recently, a fourth type has been proposed, known as type 0, referring to a normal mammary base breast with isolated areolar herniation that is either permanent or intermittent.1 Implant-based augmentation of such a breast, with its apparently minor areolar deformity, may in fact accentuate the protrusion of the glandular tissue through the areolar ring. As a result, the final aesthetic result is often compromised. Commonly used methods for addressing this problem include the peri-areolar round-block technique published by Benelli,3 the peri-nipple method proposed by Atiyeh and co-workers,4 and the peri-areolar technique described by Mandrekas and Zambacos based on transection of the constricting ring and formation of 2 volume-providing breast pillars.5 However, these methods do not solve the pathological issue of areolar herniation, because they reduce and strengthen the areolar ring without reconstruction of areolar muscles. These techniques can also leave an unsightly scar that may not be justified for a relatively minor deformity. Meanwhile, for patients desiring small nipple reductions in the absence of tuberosity, published techniques have tended to focus more on decreasing projection in patients with nipple hypertrophy.6–10 These methods may often be too radical for patients desiring only a small change in nipple size. We therefore propose a simple and scarless technique to resolve type 0 tuberous breasts (and other cases desiring areolar diameter reduction) that addresses the etiology of the deformity. Our method is based on a novel “compass rose” technique, using 3 layers of suturing, 1 in a compass pattern and 2 in round block. Long-term outcome data are provided. METHODS Study Design This was a retrospective, observational study of 77 consecutive patients undergoing areolar width reduction during cosmetic breast augmentation. Patients were operated on by a single surgeon (RI) at one medical center between April 2009 and February 2016. The study was conducted in accordance with the Declaration of Helsinki. All provided written informed consent before surgery. Patients Eligible patients were females aged ≥ 18 years undergoing a cosmetic breast augmentation procedure. Prior to surgery, all had unilateral or bilateral tuberous breast type 0 (defined as normal mammary base breast with isolated areolar herniation1) and/or desired a reduction in areolar width of ≤ 15 mm. Those included in the present analysis had a minimum of 6 months of follow up. Patients undergoing any type of mastopexy or breast reconstruction were excluded. Video 1. Video 1. Watch now at https://academic.oup.com/asj/article-lookup/doi/10.1093/asj/sjy134 Video 1. Video 1. Watch now at https://academic.oup.com/asj/article-lookup/doi/10.1093/asj/sjy134 Close Surgical Techniques Patients were marked preoperatively while lying down, with pressure applied on the breast tissue to simulate the effect of the implant. Eight points were marked on the areola (Figure 1): 4 in the cardinal directions within the areola at 5 mm from the exterior edge, and 4 in between (the intercardinal points) at 5 mm from the nipple. Figure 1. View largeDownload slide The preoperative markings and suturing pattern are shown. Eight preoperative marks were made: 4 in the cardinal directions within the areola at 5 mm from the exterior edge (points 1, 3, 5, and 7) and 4 in between (intercardinal points) at 5 mm from the nipple (points 2, 4, 6, and 8). (A) The first layer of suturing was based on a compass pattern. (B) Additional layers of stitches were applied in round block, first at the level of the cardinal distal points (points 1, 3, 5, and 7) and then at the level of the intercardinal points (points 2, 4, 6, and 8). Figure 1. View largeDownload slide The preoperative markings and suturing pattern are shown. Eight preoperative marks were made: 4 in the cardinal directions within the areola at 5 mm from the exterior edge (points 1, 3, 5, and 7) and 4 in between (intercardinal points) at 5 mm from the nipple (points 2, 4, 6, and 8). (A) The first layer of suturing was based on a compass pattern. (B) Additional layers of stitches were applied in round block, first at the level of the cardinal distal points (points 1, 3, 5, and 7) and then at the level of the intercardinal points (points 2, 4, 6, and 8). All patients underwent breast augmentation surgery using a submuscular, dual-plane technique, with placement via an inframammary fold incision. The nipple markings were updated on the operating table post implantation. Nipple areola surgery commenced with local, subcutaneous infiltration of the areola with 5 mL of lidocaine and epinephrine 1:100,000. Small incisions (2 mm in length) were then made with a number 11 blade at each of the 8 preoperatively marked points, to help to bury the knot. Suturing was performed using a 21-gauge needle and Prolene 4-0 polypropylene sutures (Ethicon Inc., Somerville, NJ, USA). The first suture ran between the 8 points marked preoperatively (from point 1 to point 8 in Figure 1A), with the goal of replicating the effect of the radial fibers of the areola (muscle of Meyerholtz). The first point used was the lowest distal point, which was joined using a diagonal suture in the subdermic layer to a point next to the nipple. This continued in a compass-like design to cover all 8 points. Both Figure 2 and a short video (Video 1) show the key steps involved in this technique. Care was taken to avoid intersection of the lines in the middle of the areola under the nipple, to prevent infringement of the galactophorous ducts. Figure 2. View largeDownload slide View largeDownload slide Nipple surgery procedure in a 31-year-old woman undergoing bilateral breast augmentation and areolar width reduction. (A) Local, subcutaneous infiltration of the pre-marked areola with 5 mL of lidocaine and epinephrine 1:100,000; (B) creation of 2 mm incisions at each of the 8 points; (C-I) first suture in the subdermic layer in a compass pattern, (J) with moderate tightening to reduce the size of the areola; (K-N) 2 further stitches in a round block in a more superficial layer, the first around the distal, cardinal points (0-R) and the second around the intercardinal points; and (S) wound dressing using Omnistrip® 6 x 38 mm in a “compass” style around the nipple. Figure 2. View largeDownload slide View largeDownload slide Nipple surgery procedure in a 31-year-old woman undergoing bilateral breast augmentation and areolar width reduction. (A) Local, subcutaneous infiltration of the pre-marked areola with 5 mL of lidocaine and epinephrine 1:100,000; (B) creation of 2 mm incisions at each of the 8 points; (C-I) first suture in the subdermic layer in a compass pattern, (J) with moderate tightening to reduce the size of the areola; (K-N) 2 further stitches in a round block in a more superficial layer, the first around the distal, cardinal points (0-R) and the second around the intercardinal points; and (S) wound dressing using Omnistrip® 6 x 38 mm in a “compass” style around the nipple. The suture was pulled out via point 1 in the inferior part of the areola, and tightened moderately, with multiple knots, to reduce the size of the areola. The maximum reduction was around 15 mm of the total diameter. The knot was always buried in the subdermal layer. To minimize folding around the nipple, 2 other stitches were used in a round block, inserted into a more superficial layer than the compass suture: the first around the distal, cardinal points; the second around the intercardinal points (Figures 1B and 2). With these sutures, the goals were to minimize the iatrogenic wrinkles caused by the compass suture, and to replicate the effect of the sub-areolar smooth muscle layer of circular fibers (muscle of Sappey), which help in contraction of the nipple–areola complex (NAC). The wound was dressed using Omnistrip® 6 x 38 mm (Hartmann, Heidenheim an der Brenz, Germany), also in a compass pattern around the nipple (Figure 2S), to give stability to the area. Three absorbent gauzes (Hartmann) were then placed over the Omnistrips to prevent compression of the NAC by the patient’s bra. These gauzes had a hole in the middle to minimize compression of the nipple. Dressings were removed after 2 weeks. Assessments Prior to surgery, baseline characteristics were recorded for all patients, including age, weight, body mass index (BMI), and the type of surgery. Post-surgical outcomes, complications, and patient satisfaction (the latter assessed by oral questioning in the context of routine examination) were documented throughout followup. To give an objective assessment of long-term outcome in tuberous breast cases, the Northwood Index (NI) was measured pre-surgery (ie, before placement of the implant) and at ≥ 6 months post surgery. The NI is an objective instrument for defining the degree of tuberosity.11 It is calculated as the ratio between the amount of forward projection of the areola (measured in a posteroanterior direction from the edge of the areola to the tip of the nipple) and the areola diameter (Supplementary Figure 1). Statistical Analysis Descriptive statistics, including mean, standard deviation (SD), and range, are provided as appropriate. RESULTS Baseline Characteristics A total of 77 patients (141 breasts) who underwent areola reshaping during cosmetic breast augmentation surgery were included in this analysis (Table 1). Of these, 22 patients had type 0 tuberous breast (unilateral, n = 2; bilateral, n = 20), and 55 underwent areolar width reduction in the absence of tuberosity (unilateral, n = 11; bilateral, n = 44). Overall, the cohort had a mean age (± SD) of 29.7 ± 6.0 years (range, 19-48 years). Mean weight was 55.4 ± 5.1 kg (range, 44-67 kg), and mean BMI was 19.4 ± 1.5 kg/m2 (range, 14.7-24.2 kg/m2). Patients were followed up for a mean of 27.2 ± 19.5 months (range, 6-84 months). Table 1. Patient Characteristics Variable Baseline value (n = 77) Mean age (SD; range), years 29.7 (6.0; 19-48) Mean weight (SD; range), kg 55.4 (5.1; 44-67) Mean BMI (SD; range), kg/m2 19.4 (1.5; 14.7-24.2) Procedure, n (%)  Unilateral areolar width reduction 11 (14.3)  Bilateral areolar width reduction 44 (57.1)  Unilateral tuberous breast correction 2 (2.6)  Bilateral tuberous breast correction 20 (26.0) Variable Baseline value (n = 77) Mean age (SD; range), years 29.7 (6.0; 19-48) Mean weight (SD; range), kg 55.4 (5.1; 44-67) Mean BMI (SD; range), kg/m2 19.4 (1.5; 14.7-24.2) Procedure, n (%)  Unilateral areolar width reduction 11 (14.3)  Bilateral areolar width reduction 44 (57.1)  Unilateral tuberous breast correction 2 (2.6)  Bilateral tuberous breast correction 20 (26.0) BMI: body mass index; SD: standard deviation. View Large Table 1. Patient Characteristics Variable Baseline value (n = 77) Mean age (SD; range), years 29.7 (6.0; 19-48) Mean weight (SD; range), kg 55.4 (5.1; 44-67) Mean BMI (SD; range), kg/m2 19.4 (1.5; 14.7-24.2) Procedure, n (%)  Unilateral areolar width reduction 11 (14.3)  Bilateral areolar width reduction 44 (57.1)  Unilateral tuberous breast correction 2 (2.6)  Bilateral tuberous breast correction 20 (26.0) Variable Baseline value (n = 77) Mean age (SD; range), years 29.7 (6.0; 19-48) Mean weight (SD; range), kg 55.4 (5.1; 44-67) Mean BMI (SD; range), kg/m2 19.4 (1.5; 14.7-24.2) Procedure, n (%)  Unilateral areolar width reduction 11 (14.3)  Bilateral areolar width reduction 44 (57.1)  Unilateral tuberous breast correction 2 (2.6)  Bilateral tuberous breast correction 20 (26.0) BMI: body mass index; SD: standard deviation. View Large Outcomes Overall, the procedure was associated with reductions in areolar width of around 15 mm and increases in nipple projection of approximately 3 mm. The results were largely stable, although a relaxation in areolar width of around 5 mm was typically observed by 6 to 12 months post surgery. Representative preoperative and postoperative photographs are available as Figures 3 and 4 and Supplementary Figures 2 and 3. Figure 3. View largeDownload slide This 23-year-old woman underwent bilateral breast augmentation and unilateral (right) tuberous breast correction. (A, C) Prior to surgery and (B, D) at 12 months postoperatively. Figure 3. View largeDownload slide This 23-year-old woman underwent bilateral breast augmentation and unilateral (right) tuberous breast correction. (A, C) Prior to surgery and (B, D) at 12 months postoperatively. Figure 4. View largeDownload slide This 28-year-old woman underwent bilateral breast augmentation and tuberous breast correction. (A, C, E) Prior to surgery and (B, D, F) at 18 months postoperatively. Figure 4. View largeDownload slide This 28-year-old woman underwent bilateral breast augmentation and tuberous breast correction. (A, C, E) Prior to surgery and (B, D, F) at 18 months postoperatively. NI was measured in all patients with tuberous breast (n = 22). Mean NI decreased from 0.55 ± 0.06 (range, 0.44-0.66) pre-surgery to 0.36 ± 0.02 (range, 0.30-0.40) assessed at ≥ 6 months after the procedure. In patients undergoing areolar width reduction in the absence of tuberosity (n = 55), mean areolar width decreased from 56.1 ± 2.0 mm (range, 52.3-60.5) pre-surgery to 44.8 ± 0.4 mm (range, 43.9-45.6) at ≥ 6 months after the procedure. This equates to a mean reduction in areolar width from baseline of 11.3 ± 1.8 mm (range, 8.0-14.7) or 20.0%. Patient Satisfaction Patient satisfaction with the surgical outcome was assessed through oral questioning during routine followup. Satisfaction was high with regard to the lack of scarring and the stable form of the NAC. Most patients felt that the procedure had made their breasts more attractive. Only 2 patients expressed dissatisfaction, in both cases owing to increased nipple projection, which increased nipple visibility when wearing tight clothing. Neither required secondary surgery. Many other patients found the increased nipple projection to be a positive outcome from their procedure. Complications A total of 8 complications were recorded. Two patients experienced hematoma at a superficial level in the areola, with normal remission, and 3 patients experienced hyper-sensibility (a non-painful feeling that the nipple was always erect) for around 2 months post surgery. In 2 patients, 1 of the suture knots became superficial and hence palpable post surgery (after 1 and 6 months, respectively). These knots were eliminated, and the results remained stable owing to the remaining sutures. Finally, there was one case of recurrence, representing the only poor result obtained among the 77 patients included in this analysis. It came about due to the patient sleeping in a ventral position in the immediate aftermath of surgery (in contravention of the normal recommendation by the lead author not to sleep this way for 6 months post-breast augmentation), thereby placing excess pressure on the breast. The problem was successfully corrected with secondary surgery. There were no cases of nipple necrosis or vascular failure of the nipple, and no cases of hypertrophic or keloid scarring of the stabbed incisions in the areola. No patients complained about feeling the sutures. DISCUSSION Here, we have described our experience of areolar width reduction and type 0 tuberous breast correction in 77 women, using an areola reshaping technique based on a “compass rose” suture. This technique addresses the etiology of the tuberous breast deformity, which could be compared with an abdominal hernia through a herniation foramen, requiring reinforcement of the abdominal wall with mesh. Unlike many previously described techniques,3–5 the present approach does not leave unsightly scarring of the areola that may not be justified for a relatively minor defect. For patients desiring small nipple areola reduction in the absence of tuberosity, it may offer a simple and less invasive method of correction than other available techniques.6–10 Grotting and Chen have described a technique based on 2 diametral transareolar U sutures to prevent iatrogenic areolar protrusion after periareolar round-block mastopexy.12 However, these sutures would not correct a type 0 tuberous deformity and are not designed for reducing areolar diameter. This type of suturing is best used to adjust the shape of the areola from ovoid to circular. In practice, our method can be applied to most patients with moderate hyperplasia of the areola or type 0 tuberous breast, and can be used to reduce the diameter of the areola by up to 15 mm. It cannot be used as an alternative to periareolar mastopexy, owing to the limitation in areolar width reduction. All patients underwent the procedure within the context of breast augmentation. The procedure has never been used in a patient not desiring implants, although we believe it would be feasible. The mean BMI of patients included in this study was less than 20 kg/m2, which may be relatively low by international standards. However, it is typical of Romanian patients in this setting, and the techniques used are generally applicable across appropriate patient weights. Prolene 4-0 polypropylene suturing was used in all cases and has the key advantage of not being palpable between the natural folds of the revised areola. Although there was some permanent wrinkling at the level of the areola (similar to normal excitation of the NAC), no patients expressed any dissatisfaction with this aspect of the result. Indeed, only 2 patients conveyed any dissatisfaction overall—both as a result of increased projection of the nipple, resulting in greater visibility underneath tight clothing—but neither required secondary surgery. In general, this issue can be easily mitigated through the use of reusable nipple covers under the clothing, if required. Tuberous breast was defined according to the criteria developed previously by Costagliola and colleagues, in which type 0 refers to a normal mammary base breast with isolated areolar herniation.1 An objective assessment of tuberous breast can be made using the NI.11 According to this index, the tuberous defect may be defined as mild, moderate, or severe according to an index score of 0.4-0.5, 0.51-0.6, or > 0.61, respectively. In an analysis of 20 tuberous and 25 normal breasts, there was no overlap in NI between the 2 groups (the NI ranges were 0.41-0.66 and 0.07-0.35, respectively), indicating an objectively measurable difference.11 NI scores were available for all 22 patients with tuberous breast in the present study. Mean NI decreased from 0.55 pre-surgery, suggestive of a moderate defect, to 0.36 post surgery, indicative of a sub-mild level of residual deformity. The highest NI score measured post surgery in any patient was 0.40, only just within the lower end of the “mild” deformity range. The key strengths of this study were the substantial cohort of almost 80 patients all undergoing the same nipple procedure and the same type of underlying breast augmentation surgery, and the long follow-up time of up to 7 years. However, we must also acknowledge some important limitations. In particular, it was a retrospective analysis, and hence a prospective evaluation of this technique would be valuable. Furthermore, patient satisfaction was assessed only informally through oral questioning by the surgeon; the use of an objective and anonymized assessment tool would be valuable in future studies of this technique. CONCLUSIONS In conclusion, this method for areolar width reduction, based on a novel “compass rose” suturing technique, was effective and safe. Given the limitations of other currently available techniques for correcting minor tuberous breast and other cases desiring small areolar diameter reductions, it provides a valuable alternative method with potentially broad application. Supplementary Material This article contains supplementary material located online at www.aestheticsurgeryjournal.com. Disclosures Dr Ionescu is a consultant and has received honoraria from Allergan, Mentor, and Establishment Labs (Motiva). The other authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The authors received no financial support for the research, authorship, and publication of this article. Acknowledgments The authors would like to thank Dr Timothy Ryder from Biological Communications Limited for medical writing and editorial assistance in developing the manuscript. Presented at: The Allergan Master Course in Breast Surgery, Romanian Association of Plastic Surgeons in Bucharest, Romania, in March 2015 and also presented at the Mentor Central Eastern European Plastic Surgery Symposium in Dubrovnik, Croatia, in October 2016. REFERENCES 1. Costagliola M , Atiyeh B , Rampillon F . Tuberous breast: revised classification and a new hypothesis for its development . Aesthetic Plast Surg . 2013 ; 37 ( 5 ): 896 - 903 . Google Scholar CrossRef Search ADS PubMed 2. Grolleau JL , Lanfrey E , Lavigne B , Chavoin JP , Costagliola M . Breast base anomalies: treatment strategy for tuberous breasts, minor deformities, and asymmetry . Plast Reconstr Surg . 1999 ; 104 ( 7 ): 2040 - 2048 . Google Scholar CrossRef Search ADS PubMed 3. Benelli L . A new periareolar mammaplasty: the “round block” technique . Aesthetic Plast Surg . 1990 ; 14 ( 2 ): 93 - 100 . Google Scholar CrossRef Search ADS PubMed 4. Atiyeh BS , Hashim HA , El-Douaihy Y , Kayle DI . Perinipple round-block technique for correction of tuberous/tubular breast deformity . Aesthetic Plast Surg . 1998 ; 22 ( 4 ): 284 - 288 . Google Scholar CrossRef Search ADS PubMed 5. Mandrekas AD , Zambacos GJ . Aesthetic reconstruction of the tuberous breast deformity: a 10-year experience . Aesthet Surg J . 2010 ; 30 ( 5 ): 680 - 692 . Google Scholar CrossRef Search ADS PubMed 6. Fanous N , Tawile C , Fanous A . Nipple reduction - an adjunct to augmentation mammaplasty . Can J Plast Surg . 2009 ; 17 ( 3 ): 81 - 88 . Google Scholar CrossRef Search ADS PubMed 7. Jin US , Lee HK . Nipple reduction using circumcision and wedge excision technique . Ann Plast Surg . 2013 ; 70 ( 2 ): 154 - 157 . Google Scholar CrossRef Search ADS PubMed 8. Sim HB , Sun SH . Nipple reduction with the Chullo-Hat technique . Aesthet Surg J . 2015 ; 35 ( 6 ): NP154 - NP160 . Google Scholar CrossRef Search ADS PubMed 9. Yu Y , Wei L , Shen Y , Xiao W , Huang J , Xu J . Windmill flap nipple reduction: a new method of nipple plasty . Aesthetic Plast Surg . 2017 ; 41 ( 4 ): 788 - 792 . Google Scholar CrossRef Search ADS PubMed 10. Economides JM , Pittman TA . The 4-flap Jester’s hat technique for nipple reduction . Plast Reconstr Surg Glob Open . 2017 ; 5 ( 2 ): e1233 . Google Scholar CrossRef Search ADS PubMed 11. Pacifico MD , Kang NV . The tuberous breast revisited . J Plast Reconstr Aesthet Surg . 2007 ; 60 ( 5 ): 455 - 464 . Google Scholar CrossRef Search ADS PubMed 12. Grotting JC , Chen SM . Control and precision in mastopexy . In: Nahai F , ed. The Art of Aesthetic Surgery: Principles and Techniques . 2nd ed . St. Louis, MO : Thieme Medical Publishers Inc ; 2010 . © 2018 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Aesthetic Surgery Journal Oxford University Press

Intra-Areolar Pexy: The “Compass Rose” Suture Technique for Small and Moderate Areola Herniation

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Abstract

Abstract Background Common methods for addressing minor tuberous breast (type 0; normal mammary base breast with isolated areolar herniation) do not solve the underlying pathology and may leave an unsightly scar. Objectives To assess the efficacy and safety of a simple, scarless method based on a novel “compass rose” technique, which addresses the etiology of minor tuberous breast and other cases desiring small areolar diameter reductions. Methods The technique uses 3 layers of suturing, 1 in a compass pattern and 2 in round block. Retrospective data are provided for 77 consecutive women (141 breasts) undergoing cosmetic breast augmentation surgery and requiring unilateral or bilateral type 0 tuberous breast correction (n = 22) or areolar width reduction ≤ 15 mm (n = 55). Results Baseline mean age and body mass index were 29.7 ± 6.0 years and 19.4 ± 1.5 kg/m2, respectively. Patients were followed up for a mean of 27.2 ± 19.5 months. In tuberous breast, mean Northwood Index decreased from 0.55 ± 0.06 at baseline to 0.36 ± 0.02 at ≥ 6 months post surgery, indicating minimal residual deformity. In areolar width reductions without tuberosity, mean width decreases of 11.3 ± 1.8 mm (20.0%) were achieved. Patient satisfaction was high with regard to lack of scarring, stability of the result, and overall breast attractiveness. Eight complications were recorded (n = 2 superficial hematoma; n = 3 hypersensibility; n = 2 knot palpability; n = 1 recurrence); all were resolved. Conclusions The method is effective and safe, and may be applicable across patients with type 0 tuberous breast or desiring small areolar diameter reductions. Level of Evidence: 4 Tuberous breast is a congenital anomaly of the breast that may be unilateral or bilateral. It is associated with areolar pseudoherniation and constriction of the lower pole. This is most likely due to thickening of the superficial fascia, as well as laxity of sub-areolar muscles, in particular the muscle of Sappey (circular fibers) and the muscle of Mayerholtz (radial fibers).1 Classification of tuberous breast deformity is typically based on the criteria proposed by Grolleau and colleagues: type I, in which only the lower medial quadrant is deficient; type II, in which both lower quadrants are deficient; and type III, in which all four quadrants are deficient, giving rise to a substantially restricted breast footprint.2 More recently, a fourth type has been proposed, known as type 0, referring to a normal mammary base breast with isolated areolar herniation that is either permanent or intermittent.1 Implant-based augmentation of such a breast, with its apparently minor areolar deformity, may in fact accentuate the protrusion of the glandular tissue through the areolar ring. As a result, the final aesthetic result is often compromised. Commonly used methods for addressing this problem include the peri-areolar round-block technique published by Benelli,3 the peri-nipple method proposed by Atiyeh and co-workers,4 and the peri-areolar technique described by Mandrekas and Zambacos based on transection of the constricting ring and formation of 2 volume-providing breast pillars.5 However, these methods do not solve the pathological issue of areolar herniation, because they reduce and strengthen the areolar ring without reconstruction of areolar muscles. These techniques can also leave an unsightly scar that may not be justified for a relatively minor deformity. Meanwhile, for patients desiring small nipple reductions in the absence of tuberosity, published techniques have tended to focus more on decreasing projection in patients with nipple hypertrophy.6–10 These methods may often be too radical for patients desiring only a small change in nipple size. We therefore propose a simple and scarless technique to resolve type 0 tuberous breasts (and other cases desiring areolar diameter reduction) that addresses the etiology of the deformity. Our method is based on a novel “compass rose” technique, using 3 layers of suturing, 1 in a compass pattern and 2 in round block. Long-term outcome data are provided. METHODS Study Design This was a retrospective, observational study of 77 consecutive patients undergoing areolar width reduction during cosmetic breast augmentation. Patients were operated on by a single surgeon (RI) at one medical center between April 2009 and February 2016. The study was conducted in accordance with the Declaration of Helsinki. All provided written informed consent before surgery. Patients Eligible patients were females aged ≥ 18 years undergoing a cosmetic breast augmentation procedure. Prior to surgery, all had unilateral or bilateral tuberous breast type 0 (defined as normal mammary base breast with isolated areolar herniation1) and/or desired a reduction in areolar width of ≤ 15 mm. Those included in the present analysis had a minimum of 6 months of follow up. Patients undergoing any type of mastopexy or breast reconstruction were excluded. Video 1. Video 1. Watch now at https://academic.oup.com/asj/article-lookup/doi/10.1093/asj/sjy134 Video 1. Video 1. Watch now at https://academic.oup.com/asj/article-lookup/doi/10.1093/asj/sjy134 Close Surgical Techniques Patients were marked preoperatively while lying down, with pressure applied on the breast tissue to simulate the effect of the implant. Eight points were marked on the areola (Figure 1): 4 in the cardinal directions within the areola at 5 mm from the exterior edge, and 4 in between (the intercardinal points) at 5 mm from the nipple. Figure 1. View largeDownload slide The preoperative markings and suturing pattern are shown. Eight preoperative marks were made: 4 in the cardinal directions within the areola at 5 mm from the exterior edge (points 1, 3, 5, and 7) and 4 in between (intercardinal points) at 5 mm from the nipple (points 2, 4, 6, and 8). (A) The first layer of suturing was based on a compass pattern. (B) Additional layers of stitches were applied in round block, first at the level of the cardinal distal points (points 1, 3, 5, and 7) and then at the level of the intercardinal points (points 2, 4, 6, and 8). Figure 1. View largeDownload slide The preoperative markings and suturing pattern are shown. Eight preoperative marks were made: 4 in the cardinal directions within the areola at 5 mm from the exterior edge (points 1, 3, 5, and 7) and 4 in between (intercardinal points) at 5 mm from the nipple (points 2, 4, 6, and 8). (A) The first layer of suturing was based on a compass pattern. (B) Additional layers of stitches were applied in round block, first at the level of the cardinal distal points (points 1, 3, 5, and 7) and then at the level of the intercardinal points (points 2, 4, 6, and 8). All patients underwent breast augmentation surgery using a submuscular, dual-plane technique, with placement via an inframammary fold incision. The nipple markings were updated on the operating table post implantation. Nipple areola surgery commenced with local, subcutaneous infiltration of the areola with 5 mL of lidocaine and epinephrine 1:100,000. Small incisions (2 mm in length) were then made with a number 11 blade at each of the 8 preoperatively marked points, to help to bury the knot. Suturing was performed using a 21-gauge needle and Prolene 4-0 polypropylene sutures (Ethicon Inc., Somerville, NJ, USA). The first suture ran between the 8 points marked preoperatively (from point 1 to point 8 in Figure 1A), with the goal of replicating the effect of the radial fibers of the areola (muscle of Meyerholtz). The first point used was the lowest distal point, which was joined using a diagonal suture in the subdermic layer to a point next to the nipple. This continued in a compass-like design to cover all 8 points. Both Figure 2 and a short video (Video 1) show the key steps involved in this technique. Care was taken to avoid intersection of the lines in the middle of the areola under the nipple, to prevent infringement of the galactophorous ducts. Figure 2. View largeDownload slide View largeDownload slide Nipple surgery procedure in a 31-year-old woman undergoing bilateral breast augmentation and areolar width reduction. (A) Local, subcutaneous infiltration of the pre-marked areola with 5 mL of lidocaine and epinephrine 1:100,000; (B) creation of 2 mm incisions at each of the 8 points; (C-I) first suture in the subdermic layer in a compass pattern, (J) with moderate tightening to reduce the size of the areola; (K-N) 2 further stitches in a round block in a more superficial layer, the first around the distal, cardinal points (0-R) and the second around the intercardinal points; and (S) wound dressing using Omnistrip® 6 x 38 mm in a “compass” style around the nipple. Figure 2. View largeDownload slide View largeDownload slide Nipple surgery procedure in a 31-year-old woman undergoing bilateral breast augmentation and areolar width reduction. (A) Local, subcutaneous infiltration of the pre-marked areola with 5 mL of lidocaine and epinephrine 1:100,000; (B) creation of 2 mm incisions at each of the 8 points; (C-I) first suture in the subdermic layer in a compass pattern, (J) with moderate tightening to reduce the size of the areola; (K-N) 2 further stitches in a round block in a more superficial layer, the first around the distal, cardinal points (0-R) and the second around the intercardinal points; and (S) wound dressing using Omnistrip® 6 x 38 mm in a “compass” style around the nipple. The suture was pulled out via point 1 in the inferior part of the areola, and tightened moderately, with multiple knots, to reduce the size of the areola. The maximum reduction was around 15 mm of the total diameter. The knot was always buried in the subdermal layer. To minimize folding around the nipple, 2 other stitches were used in a round block, inserted into a more superficial layer than the compass suture: the first around the distal, cardinal points; the second around the intercardinal points (Figures 1B and 2). With these sutures, the goals were to minimize the iatrogenic wrinkles caused by the compass suture, and to replicate the effect of the sub-areolar smooth muscle layer of circular fibers (muscle of Sappey), which help in contraction of the nipple–areola complex (NAC). The wound was dressed using Omnistrip® 6 x 38 mm (Hartmann, Heidenheim an der Brenz, Germany), also in a compass pattern around the nipple (Figure 2S), to give stability to the area. Three absorbent gauzes (Hartmann) were then placed over the Omnistrips to prevent compression of the NAC by the patient’s bra. These gauzes had a hole in the middle to minimize compression of the nipple. Dressings were removed after 2 weeks. Assessments Prior to surgery, baseline characteristics were recorded for all patients, including age, weight, body mass index (BMI), and the type of surgery. Post-surgical outcomes, complications, and patient satisfaction (the latter assessed by oral questioning in the context of routine examination) were documented throughout followup. To give an objective assessment of long-term outcome in tuberous breast cases, the Northwood Index (NI) was measured pre-surgery (ie, before placement of the implant) and at ≥ 6 months post surgery. The NI is an objective instrument for defining the degree of tuberosity.11 It is calculated as the ratio between the amount of forward projection of the areola (measured in a posteroanterior direction from the edge of the areola to the tip of the nipple) and the areola diameter (Supplementary Figure 1). Statistical Analysis Descriptive statistics, including mean, standard deviation (SD), and range, are provided as appropriate. RESULTS Baseline Characteristics A total of 77 patients (141 breasts) who underwent areola reshaping during cosmetic breast augmentation surgery were included in this analysis (Table 1). Of these, 22 patients had type 0 tuberous breast (unilateral, n = 2; bilateral, n = 20), and 55 underwent areolar width reduction in the absence of tuberosity (unilateral, n = 11; bilateral, n = 44). Overall, the cohort had a mean age (± SD) of 29.7 ± 6.0 years (range, 19-48 years). Mean weight was 55.4 ± 5.1 kg (range, 44-67 kg), and mean BMI was 19.4 ± 1.5 kg/m2 (range, 14.7-24.2 kg/m2). Patients were followed up for a mean of 27.2 ± 19.5 months (range, 6-84 months). Table 1. Patient Characteristics Variable Baseline value (n = 77) Mean age (SD; range), years 29.7 (6.0; 19-48) Mean weight (SD; range), kg 55.4 (5.1; 44-67) Mean BMI (SD; range), kg/m2 19.4 (1.5; 14.7-24.2) Procedure, n (%)  Unilateral areolar width reduction 11 (14.3)  Bilateral areolar width reduction 44 (57.1)  Unilateral tuberous breast correction 2 (2.6)  Bilateral tuberous breast correction 20 (26.0) Variable Baseline value (n = 77) Mean age (SD; range), years 29.7 (6.0; 19-48) Mean weight (SD; range), kg 55.4 (5.1; 44-67) Mean BMI (SD; range), kg/m2 19.4 (1.5; 14.7-24.2) Procedure, n (%)  Unilateral areolar width reduction 11 (14.3)  Bilateral areolar width reduction 44 (57.1)  Unilateral tuberous breast correction 2 (2.6)  Bilateral tuberous breast correction 20 (26.0) BMI: body mass index; SD: standard deviation. View Large Table 1. Patient Characteristics Variable Baseline value (n = 77) Mean age (SD; range), years 29.7 (6.0; 19-48) Mean weight (SD; range), kg 55.4 (5.1; 44-67) Mean BMI (SD; range), kg/m2 19.4 (1.5; 14.7-24.2) Procedure, n (%)  Unilateral areolar width reduction 11 (14.3)  Bilateral areolar width reduction 44 (57.1)  Unilateral tuberous breast correction 2 (2.6)  Bilateral tuberous breast correction 20 (26.0) Variable Baseline value (n = 77) Mean age (SD; range), years 29.7 (6.0; 19-48) Mean weight (SD; range), kg 55.4 (5.1; 44-67) Mean BMI (SD; range), kg/m2 19.4 (1.5; 14.7-24.2) Procedure, n (%)  Unilateral areolar width reduction 11 (14.3)  Bilateral areolar width reduction 44 (57.1)  Unilateral tuberous breast correction 2 (2.6)  Bilateral tuberous breast correction 20 (26.0) BMI: body mass index; SD: standard deviation. View Large Outcomes Overall, the procedure was associated with reductions in areolar width of around 15 mm and increases in nipple projection of approximately 3 mm. The results were largely stable, although a relaxation in areolar width of around 5 mm was typically observed by 6 to 12 months post surgery. Representative preoperative and postoperative photographs are available as Figures 3 and 4 and Supplementary Figures 2 and 3. Figure 3. View largeDownload slide This 23-year-old woman underwent bilateral breast augmentation and unilateral (right) tuberous breast correction. (A, C) Prior to surgery and (B, D) at 12 months postoperatively. Figure 3. View largeDownload slide This 23-year-old woman underwent bilateral breast augmentation and unilateral (right) tuberous breast correction. (A, C) Prior to surgery and (B, D) at 12 months postoperatively. Figure 4. View largeDownload slide This 28-year-old woman underwent bilateral breast augmentation and tuberous breast correction. (A, C, E) Prior to surgery and (B, D, F) at 18 months postoperatively. Figure 4. View largeDownload slide This 28-year-old woman underwent bilateral breast augmentation and tuberous breast correction. (A, C, E) Prior to surgery and (B, D, F) at 18 months postoperatively. NI was measured in all patients with tuberous breast (n = 22). Mean NI decreased from 0.55 ± 0.06 (range, 0.44-0.66) pre-surgery to 0.36 ± 0.02 (range, 0.30-0.40) assessed at ≥ 6 months after the procedure. In patients undergoing areolar width reduction in the absence of tuberosity (n = 55), mean areolar width decreased from 56.1 ± 2.0 mm (range, 52.3-60.5) pre-surgery to 44.8 ± 0.4 mm (range, 43.9-45.6) at ≥ 6 months after the procedure. This equates to a mean reduction in areolar width from baseline of 11.3 ± 1.8 mm (range, 8.0-14.7) or 20.0%. Patient Satisfaction Patient satisfaction with the surgical outcome was assessed through oral questioning during routine followup. Satisfaction was high with regard to the lack of scarring and the stable form of the NAC. Most patients felt that the procedure had made their breasts more attractive. Only 2 patients expressed dissatisfaction, in both cases owing to increased nipple projection, which increased nipple visibility when wearing tight clothing. Neither required secondary surgery. Many other patients found the increased nipple projection to be a positive outcome from their procedure. Complications A total of 8 complications were recorded. Two patients experienced hematoma at a superficial level in the areola, with normal remission, and 3 patients experienced hyper-sensibility (a non-painful feeling that the nipple was always erect) for around 2 months post surgery. In 2 patients, 1 of the suture knots became superficial and hence palpable post surgery (after 1 and 6 months, respectively). These knots were eliminated, and the results remained stable owing to the remaining sutures. Finally, there was one case of recurrence, representing the only poor result obtained among the 77 patients included in this analysis. It came about due to the patient sleeping in a ventral position in the immediate aftermath of surgery (in contravention of the normal recommendation by the lead author not to sleep this way for 6 months post-breast augmentation), thereby placing excess pressure on the breast. The problem was successfully corrected with secondary surgery. There were no cases of nipple necrosis or vascular failure of the nipple, and no cases of hypertrophic or keloid scarring of the stabbed incisions in the areola. No patients complained about feeling the sutures. DISCUSSION Here, we have described our experience of areolar width reduction and type 0 tuberous breast correction in 77 women, using an areola reshaping technique based on a “compass rose” suture. This technique addresses the etiology of the tuberous breast deformity, which could be compared with an abdominal hernia through a herniation foramen, requiring reinforcement of the abdominal wall with mesh. Unlike many previously described techniques,3–5 the present approach does not leave unsightly scarring of the areola that may not be justified for a relatively minor defect. For patients desiring small nipple areola reduction in the absence of tuberosity, it may offer a simple and less invasive method of correction than other available techniques.6–10 Grotting and Chen have described a technique based on 2 diametral transareolar U sutures to prevent iatrogenic areolar protrusion after periareolar round-block mastopexy.12 However, these sutures would not correct a type 0 tuberous deformity and are not designed for reducing areolar diameter. This type of suturing is best used to adjust the shape of the areola from ovoid to circular. In practice, our method can be applied to most patients with moderate hyperplasia of the areola or type 0 tuberous breast, and can be used to reduce the diameter of the areola by up to 15 mm. It cannot be used as an alternative to periareolar mastopexy, owing to the limitation in areolar width reduction. All patients underwent the procedure within the context of breast augmentation. The procedure has never been used in a patient not desiring implants, although we believe it would be feasible. The mean BMI of patients included in this study was less than 20 kg/m2, which may be relatively low by international standards. However, it is typical of Romanian patients in this setting, and the techniques used are generally applicable across appropriate patient weights. Prolene 4-0 polypropylene suturing was used in all cases and has the key advantage of not being palpable between the natural folds of the revised areola. Although there was some permanent wrinkling at the level of the areola (similar to normal excitation of the NAC), no patients expressed any dissatisfaction with this aspect of the result. Indeed, only 2 patients conveyed any dissatisfaction overall—both as a result of increased projection of the nipple, resulting in greater visibility underneath tight clothing—but neither required secondary surgery. In general, this issue can be easily mitigated through the use of reusable nipple covers under the clothing, if required. Tuberous breast was defined according to the criteria developed previously by Costagliola and colleagues, in which type 0 refers to a normal mammary base breast with isolated areolar herniation.1 An objective assessment of tuberous breast can be made using the NI.11 According to this index, the tuberous defect may be defined as mild, moderate, or severe according to an index score of 0.4-0.5, 0.51-0.6, or > 0.61, respectively. In an analysis of 20 tuberous and 25 normal breasts, there was no overlap in NI between the 2 groups (the NI ranges were 0.41-0.66 and 0.07-0.35, respectively), indicating an objectively measurable difference.11 NI scores were available for all 22 patients with tuberous breast in the present study. Mean NI decreased from 0.55 pre-surgery, suggestive of a moderate defect, to 0.36 post surgery, indicative of a sub-mild level of residual deformity. The highest NI score measured post surgery in any patient was 0.40, only just within the lower end of the “mild” deformity range. The key strengths of this study were the substantial cohort of almost 80 patients all undergoing the same nipple procedure and the same type of underlying breast augmentation surgery, and the long follow-up time of up to 7 years. However, we must also acknowledge some important limitations. In particular, it was a retrospective analysis, and hence a prospective evaluation of this technique would be valuable. Furthermore, patient satisfaction was assessed only informally through oral questioning by the surgeon; the use of an objective and anonymized assessment tool would be valuable in future studies of this technique. CONCLUSIONS In conclusion, this method for areolar width reduction, based on a novel “compass rose” suturing technique, was effective and safe. Given the limitations of other currently available techniques for correcting minor tuberous breast and other cases desiring small areolar diameter reductions, it provides a valuable alternative method with potentially broad application. Supplementary Material This article contains supplementary material located online at www.aestheticsurgeryjournal.com. Disclosures Dr Ionescu is a consultant and has received honoraria from Allergan, Mentor, and Establishment Labs (Motiva). The other authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The authors received no financial support for the research, authorship, and publication of this article. Acknowledgments The authors would like to thank Dr Timothy Ryder from Biological Communications Limited for medical writing and editorial assistance in developing the manuscript. Presented at: The Allergan Master Course in Breast Surgery, Romanian Association of Plastic Surgeons in Bucharest, Romania, in March 2015 and also presented at the Mentor Central Eastern European Plastic Surgery Symposium in Dubrovnik, Croatia, in October 2016. REFERENCES 1. Costagliola M , Atiyeh B , Rampillon F . Tuberous breast: revised classification and a new hypothesis for its development . Aesthetic Plast Surg . 2013 ; 37 ( 5 ): 896 - 903 . Google Scholar CrossRef Search ADS PubMed 2. Grolleau JL , Lanfrey E , Lavigne B , Chavoin JP , Costagliola M . Breast base anomalies: treatment strategy for tuberous breasts, minor deformities, and asymmetry . Plast Reconstr Surg . 1999 ; 104 ( 7 ): 2040 - 2048 . Google Scholar CrossRef Search ADS PubMed 3. Benelli L . A new periareolar mammaplasty: the “round block” technique . Aesthetic Plast Surg . 1990 ; 14 ( 2 ): 93 - 100 . Google Scholar CrossRef Search ADS PubMed 4. Atiyeh BS , Hashim HA , El-Douaihy Y , Kayle DI . Perinipple round-block technique for correction of tuberous/tubular breast deformity . Aesthetic Plast Surg . 1998 ; 22 ( 4 ): 284 - 288 . Google Scholar CrossRef Search ADS PubMed 5. Mandrekas AD , Zambacos GJ . Aesthetic reconstruction of the tuberous breast deformity: a 10-year experience . Aesthet Surg J . 2010 ; 30 ( 5 ): 680 - 692 . Google Scholar CrossRef Search ADS PubMed 6. Fanous N , Tawile C , Fanous A . Nipple reduction - an adjunct to augmentation mammaplasty . Can J Plast Surg . 2009 ; 17 ( 3 ): 81 - 88 . Google Scholar CrossRef Search ADS PubMed 7. Jin US , Lee HK . Nipple reduction using circumcision and wedge excision technique . Ann Plast Surg . 2013 ; 70 ( 2 ): 154 - 157 . Google Scholar CrossRef Search ADS PubMed 8. Sim HB , Sun SH . Nipple reduction with the Chullo-Hat technique . Aesthet Surg J . 2015 ; 35 ( 6 ): NP154 - NP160 . Google Scholar CrossRef Search ADS PubMed 9. Yu Y , Wei L , Shen Y , Xiao W , Huang J , Xu J . Windmill flap nipple reduction: a new method of nipple plasty . Aesthetic Plast Surg . 2017 ; 41 ( 4 ): 788 - 792 . Google Scholar CrossRef Search ADS PubMed 10. Economides JM , Pittman TA . The 4-flap Jester’s hat technique for nipple reduction . Plast Reconstr Surg Glob Open . 2017 ; 5 ( 2 ): e1233 . Google Scholar CrossRef Search ADS PubMed 11. Pacifico MD , Kang NV . The tuberous breast revisited . J Plast Reconstr Aesthet Surg . 2007 ; 60 ( 5 ): 455 - 464 . Google Scholar CrossRef Search ADS PubMed 12. Grotting JC , Chen SM . Control and precision in mastopexy . In: Nahai F , ed. The Art of Aesthetic Surgery: Principles and Techniques . 2nd ed . St. Louis, MO : Thieme Medical Publishers Inc ; 2010 . © 2018 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)

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Aesthetic Surgery JournalOxford University Press

Published: May 28, 2018

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