Lin Zhu, Ang Zeng, Xiao-jun Wang, Yi-hong Jia, and Zhi-fei Liu*

Department of Plastic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China

ORIGINAL ARTICLE

Perinipple Broken Line Incision: a Novel Approach for Breast Augmentation

Lin Zhu, Ang Zeng, Xiao-jun Wang, Yi-hong Jia, and Zhi-fei Liu*

Department of Plastic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China

breast augmentation; incision; intra-areolar incision; scars

Objective To investigate reliability of the infra-nipple broken line incision for breast augmentation.

Methods From January 2012 to January 2013, 15 patients underwent primary bilateral retromuscular breast augmentation with round textured silicone-gel implants and a novel infra-nipple broken line incision. Preoperatively, a semicircular incision was marked along the inferior base of the nipple. It was then extended bilaterally using two transverse right-angled geometric broken lines within the pigmented areolar skin. Follow-up was performed to evaluate the sensation of nipple-areolar complex, the scar, and the shape and texture of the breasts.

Results The average follow-up was 6.7 months. Most of the patients complained of paresthesia of the nipple or breast skin, but transient decreased sensation improved within 3 months. No patients showed permanent sensory changes of the nipple areolar complex at a minimum follow-up of 4 months. The scars were imperceptible in all patients.

Conclusion We believe that for selected patients, the infra-nipple broken line incision is a practical and reliable method to achieve aesthetic result.

Chin Med Sci J 2015; 30(2)：76-79

VISIBLE scars remain a considerable concern for patients seeking augmentation mammaplasty. The most popular incisions for breast augmentation are the inframammary, axillary, and periareolar approaches. The transareolar incision has not gained widespread popularity although it was used nearly three decades ago by Pitanguy et al.1, 2 This research is to describe a novel design of infra-nipple broken line incision and to evaluate the sensation of the nipple-areolar complex (NAC), the scar of the incision and the aesthetic results of the breasts.

PATIENTS AND METHODS

Patient

From January 2012 to January 2013, 15 patients underwent primary bilateral retromuscular breast augmentation with round textured silicone-gel implants. The patients’ age ranged from 20 to 45 years, with an average age of 35.4 years. The areolar diameter ranged from 2.8 to 4.5 cm, with an average diameter of 3.75 cm. The implant volume ranged from 225 to 275 cc, with an average volume of 248 cc.Patients who had areolar scars were excluded from this study.

Surgery technique

Preoperatively, a semicircular incision was marked along the inferior base of the nipple. It was then extended using two transverse right-angled geometric broken lines within the pigmented areolar skin bilaterally (Fig. 1).

During the operation, 0.06% lidocaine with 1:600 000 epinephrine was injected at the perinipple incision and the inferior portion above the breast parenchyma until tissue swelling was noted. The incision was cut completely through the epidermis to the parenchymal surface. Using tissue scissors and bipolar electrocautery, the areolar skin was carefully undermined with adequate thickness to prevent skin slough. The dissection was performed 4 cm below the nipple base and the parenchyma was dissected longitudinally. The pectoralis major was split at this point and open dissection with electrotome was then performed to create a proper pocket. After the insertion of the implant and the placement of the drain, the muscle and gland were both closed with 3-0 absorbable sutures (Vicryl, Ethicon Inc., Somerville, NJ, USA). The incision itself was closed in two layers. The dermis was sewed up with 5-0 absorbable sutures (Vicryl) and then epidermis was closed with 6-0 nylon sutures. The epidermis stitches were removed 10 days postoperatively. Drainage was placed thorough the inframammary fold and was removed when daily drainage was less than 10 ml.

Follow-up

Follow-up was performed at least 3 months after surgery. All the patients were called back to have a clinic visit. The sensation of NAC, the scar, and the shape and texture of the breasts was evaluated.

RESULTS

Patients were followed up from 4 to 8months, with an average time of 6.7 months. During follow-up, no infections occurred. Most of the patients complained of paresthesia of the nipple or breast skin, but transient decreased sensation improved within 3 months. No patient showed permanent sensory change of the NAC at a minimum follow-up of 4 months. During the early convalescent period, most of the patients complained of a firm band on the inferior aspect of the breast, corresponding to the path of the implant, but these disappeared with scar maturation. During the follow-up period, 2 patients experienced a mild capsular contracture, which did not need any surgical revisions. The scars were imperceptible in all patients (Fig. 2).

Figure 1. The incision is designed with one infra-nipple semicircle and two transareolar V-shaped broken lines.

Figure 2. A 46-year-old female patient underwent bilateral breast augmentation with 225 cc textured silicone implant for both sides (areolar diameter: left: 3.8 cm, right: 3.8 cm).A-C: Preoperative view.D-F: Six months after surgery, the breasts were symmetric and soft. The peri-areolar scars were imperceptible. No change of the sensation has been found. The patient was very satisfied with the result.

DISCUSSION

Most of the time, breast augmentation is purely a cosmetic surgery and so incision is often one of the key parameters that influence the final result. The possible incision sites include inframmamary, axilla, areola, and umbilicus. The scars of inframammary approach are usually more conspicuous than periareolar or axillary incisions, especially for Asians who have thick and more pigmented skin. Thus, the inframammary approach has not gained popularity in Asia. The axillary incision, which is the most popular incision in China, avoids a scar on the breast. However, a major handicap of this approach is that it is inconvenient for implant positioning, although malpositioning of the implant is less frequent with the use of an endoscope.3If revision surgery is necessary to correct the malpositioning, another incision will also be necessary. The periareolar scar is rather inconspicuous to the patients who have a well-demarcated skin–areolar junction. However, in many patients, the boundary between the nonpigmented skin and the pigmented areolar is usually not sharply demarcated and is rarely a perfect circle.4In addition, the periareolar scar tends to widen or become hypertrophic with age. In addition, there are many other factors that may influence the periareolar scar including internal expansion by the implant, external massage, skin quality, and gravity.5

The transareolar incision for breast augmentation was first reported by Pitanguy et al1,2in 1970s, but has not gained widespread popularity. Some authors argued that this incision would increase the possibility of impaired lactation and NAC sensation. However, there are no direct estimates from large clinic series that have confirmed this claim. In fact, research has shown that the transareolar incision has no influence in the lactation function of the breasts.

The possibility of NAC sensation impairment is an important reason to avoid using the transareolar incision. Anatomical studies using magnification, microsurgical techniques have histologically confirmed that the NAC receives innervation from lateral and anterior cutaneous branches of the second to fifth intercostals nerves.5,6These nerves join the plexus in the subdermal region, which explains why the NAC retains sensation in a majority of cases even when the core of breast tissue is excised.7,8Therefore, the transareolar incision, with a strictly vertical course toward the pectoralis major muscle, would theoretically be of great benefit in sparing many of the smaller nerve branches.9A study using Pressure-Specified Sensory Device showed no significant differences in the sensitivity of the NAC between the inframammary or the periareolar incision. Moreover, patients receiving the inframammary incision suffered a significant loss in sensation in the inferior region of the breast, whereas patients receiving the periareolar incision showed no statistically significant sensory differences in any of the test sites of the breast.10In another study, an inverse relationship between implant size and the degree of sensitivity within the NAC was found, and sensibility outcomes were most variable with implant sizes greater than 475 cc.11A study containing 18 patients undergoing transareolar breast augmentation revealed that 2 years after surgery, 89% of patients judged their breast sensation to be normal.9In our series, the tumescence technique was used to enlarge the tissue space between the breast parenchyma and the skin. Sharp dissection with scissors was used to avoid the thermal injury of the electrotome. These techniques help to decrease the nerve damage of the NAC and none of our patients complained of permanent sensory change of NAC at a minimum follow-up of 4 months.

There are a few articles that discuss improvement in the appearance of transareolar incisions in the literature. Some authors prefer a circumnipple incision10,11as the scar is perfectly concealed, but a circumnipple incision is not suitable for patients with small nipples and areolas.

The transareolar incision was designed in order to avoid scarring due to the periareolar incision. In Atiyeh et al’s report, two transverse lines are drawn on each side of the nipple, not reaching the cutaneous areola junction. The two lines are then joined medially by a V-shaped infra-nipple extension.12Tenius et al13reported a transverse transareolar geometric zigzag incision for breast augmentation, which is located on the inferior part of the areola but not at the nipple-areola junction.

The nipple-areola junction is an area where scarring can be concealed and become virtually inconspicuous. For this reason, we prefer to make an incision along the infra nipple-areola junction. We have all been taught the value of breaking up a linear scar with a Z-plasty. This technique is similar in principle to a W-plasty used in facial linear scar revisions.14,15Thus, the two wings of the incision were designed as V-shaped to offer a greater camouflage. In addition, this V-shaped design can increase the length of the incision, which facilitates the pocket dissection and the implant insertion.

The transareolar incision is limited to the breasts without ptosis because nearly every incisional pattern in mastopexy techniques requires a periareolar approach.This technique cannot be applied to cases with small nipple-areola or where the implant required is very large.

Scars were barely visible in most of the cases. Areas of hypopigmentation were rare, and were often caused by skin slough. If the hypopigmentation does happen, it can be camouflaged using a medical tattooing procedure. No scar hypertrophy has been observed in this series.

If patients are appropriately selected with respect to the limitations of the technique (i.e., limited implant size in relation to the diameter of the areola and augmentation of only breasts without ptosis), the transareolar access has its definite place among the different incisions used in breast augmentation.2

In conclusion, the infra-nipple broken line incision is considered to be practical and reliable for breast augmentation in selected patients. The major advantages of this incision are a well concealed incision scar, ease of dissection and manipulation.

REFERENCES

1. Pitanguy I, Carreirao SE, Garcia LC. Transareolar incision for augmentation mammaplasty. Plast Reconstr Surg 1974; 54:501.

2. Pitanguy I. Transareolar incision for breast augmentation. Aesth Plast Surg 1978; 2:363-72.

3. Hidalgo DA. Breast augmentation: Choosing the optimal incision, implant, and pocket plane. Plast Reconstr Surg 2000; 105:2022-16.

4. Atiyeh BS, Hashim HA, Kayle DI, et al. Perinipple round-block technique for correction of tuberous/tubular breast deformity. Aesth Plast Surg 1998; 22:284-8.

5. Lee EJ, Jung SG, Cho BC, et al. Submuscular augmentation mammaplasty using a perinipple incision. Ann Plast Surg 2004; 52:297-302.

6. Banbury J, Yetmand R, Lucas A, et al. Prospective analysis of the outcome of subpectoral breast augmentation: Sensory changes, muscle function, and body image. Plast Reconstr Surg 2004; 113:701-7.

7. Sarhadi NS, Shaw Dunn J, Lee FD, et al. An anatomical study for the nerve supply of the breast, including the nipple and areola. Br J Plast Surg 1996; 49:156-64.

8. Sarhadi NS, Shaw-Dunn J, Soutar DS. Nerve supply of the breast with special reference to the nipple and areola: Sir Astley Cooper revisited. Clin Anat 1997; 10:283-8.

9. Kompatscher P, Schuler C, Beer GM. The transareolar incision for breast augmentation revisited. Aesth Plast Surg 2004; 28:70-4.

10. Okwueze MI, Spear ME, Zwyghuizen AM, et al. Effect of augmentation mammaplasty on breast sensation. Plast Reconstr Surg 2006; 117:73-83.

11. Mofid MM, Klatsky SA, Singh NK, et al. Nipple-areolar complex sensitivity after primary breast augmentation: A comparison of periareolar and inframammary incision approaches. Plast Reconstr Surg 2006; 117:1694-8.

12. Atiyeh BS, Al-Amm CA, El-Musa KA. The transverse intra-areolar infra-nipple incision for augmentation mammaplasty. Aesthetic Plast Surg 2002; 26:151-5.

13. Tenius FP, da Silva Freitas R, et al. Transareolar incision with geometric broken line for breast augmentation: A novel approach. Aesth Plast Surg 2008; 32:546-8.

14. Place MJ, Herber SC, Hardesty RA. Basic techniques and principles in plastic surgery. In: Aston SJ, Beasley RW, Thorne CHM, editors. Grabb and Smith's Plastic Surgery. 5th ed. Philadelphia: Lippincott-Raven; 1997. p. 13-26.

15. Ehlert TK, Thomas JR, Becker FF Jr. Submental W-plasty for correction of 'turkey gobbler' deformities. Arch Otolaryngol Head Neck Surg 1990; 116:714-7.

for publication January 20, 2015.

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