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278
a
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J. D’silva and A. Deshpande
b
c
Fig. 17.32 (a) Closure of the rectus sheath using nonabsorbable sutures. (b) Closure of the abdomen incision over a drain. (c) Umbilical reposi-
tioning and closure completed
ab
cd
17 Breast Reconstruction
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279
Fig. 17.33 (a, b) Preoperative photographs of a 36-year-old lady who has Grade II cancer of the right breast. She underwent DIEP ap surgery
and her 4week postoperative result is attached (c, d)
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J. D’silva and A. Deshpande
References
Brown M, Namnoum JD. Indications and controversies for implant-
only based breast reconstruction. Clin Plast Surg. 2018;45(1):47–
54. https://doi.org/10.1016/j.cps.2017.08.003.
Connon FV, Taylor GI, Gascoigne AC, Corlett RJ, Ashton
MW. Understanding the vascular anatomy of zone IV in DIEA
perforator aps: a review of the literature and anatomical studies.
Aust J Plast Surg. 2018;1(1):71–80. https://doi.org/10.34239/ajops.
v1i1.38.
Flaherty F, Vizcay M, Chang EI.Implant-based breast reconstruction
cutting edge and controversies. Curr Surg Rep. 2020;8(12). https://
doi.org/10.1007/s40137- 020- 00274- 2.
ISAPS.ISAPS International Survey on Aesthetic/Cosmetic Procedures.
ISAPS; 2018. p.49.
Studinger R.Getting out of a tight spot in breast reconstruction— sal-
vage and saving techniques for DIEP, SIEA, and lymphatic aps.
In: Spiegel AJ, editor. Breast reconstruction - current perspectives and state of the art techniques. IntechOpen; 2013. https://doi.
org/10.5772/56642.
JavierPalacios
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The large areola may be occurring naturally in some people,
although the size of the areola is often genetic, it may
increase with age as the skin loses elasticity and sags due to
breast implants, weight change, pregnancy, and also in the
tuberous sinuses that affect the size of the areola.
The skin of the areola has an exaggerated elasticity compared to the skin of the surrounding breast and has a tremendous ability to stretch when placed under tension. The size
and shape of the areolas are affected by muscle contraction
and relaxation.
Large areolas can also occur as a result of peri-areolar
cosmetic surgery in cases where too much skin has been
removed from around the areola, resulting in widening of
the areolar diameter post-operatively and therefore, a side
effect. When a plastic surgeon performs an areola reduction during a breast lift, he should be aware of this fact,
taking steps to avoid ending up with incorrectly sized areolas (Fig.18.1) (Berger and Bostwick III 1994; Morehead
1982).
Women seek reduction of the areola for a number of reasons,
but primarily to meet the desired beauty standard or to return
to the time before weight gain, pregnancy, or aging took its
toll. Areola reduction is often combined with other procedures, such as breast reduction, breast lift, or breast augmentation surgery.
There are no medical reasons to opt for an areola reduction, but some of the indications include
J. Palacios (*)
Veracruz, Mexico
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023
M. Thomas, J. D‘silva (eds.), Manual of Cosmetic Medicine and Surgery, https://doi.org/10.1007/978-981-99-3726-4_18
1. when the areolas look large and out of proportion to the
breasts, especially after a breast lift or breast reduction
surgery,
2. if the areolas have been enlarged or stretched after delivery or after signicant weight gain, or
3. if for some other reason the patient does not like the
appearance of areolae, areola reduction surgery is the
way to go.
One must understand the limitations and realities of are-
ola reduction surgery.
Just as a woman’s breasts can be asymmetric in shape or
size, so can be the areolas. In case where there are differ-
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J. Palacios
ences in the diameter or shape of the areolas, surgical correction can improve the symmetry between them (Fig.18.2).
The most common mistake while reducing an areola during a breast lift is to create a circular incision around it
(Fig.18.3), followed by a smaller one within the rst circle,
the breasts will stretch and relax after surgery and the centrifugal forces will cause an unwanted long-term appear-
sion in the areolar closure
ance. The same happens with the “Round Block” technique,
where a deep peri-areolar support suture is placed to control
the diameter of the areola over a period of time to allow the
skin around the areola to adapt. As a result, when there is
tension in the wound closure around the areola after a periareolar procedure, the areola can stretch over time, creating
a larger areolar diameter than initially created at the time of
surgery.
The etiology of postoperative radial spread is related to
tension in the areolar closure. Just 1cm of peripheral areolar
margin expansion can convert an initial areolar incision of
4cm diameter into a 6cm widened areola (Fig.18.4). Tight,
ring-shaped bands of tissue around the areolas and nipples
can create the appearance of bulging or swollen areolas
(Fig.18.5).
18 Technique forAreolar Reduction
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stretched over time by the
centrifugal forces caused by
gravity and the weight of the
breast itself
Areola reduction surgery is undertaken to reduce the diameter of the skin and to correct asymmetries.
283
For the areola reduction procedure, the patient will be placed
supine under local anesthesia, with a sedative, or under general
anesthesia. The width and length of the areolar diameter are
measured when it is tension-free and preferably before manipulating the areola so that contracture of the areolar smooth
muscle bers does not articially constrain the areola.
The technique was adapted by the amalgamation of the
following procedures: peri-areolar scar resection with the
addition of a triangular segment resection to an intra-areolar
skin pattern. This technique makes it possible to reduce the
dimensions of the external peri-areolar skin incision, limiting
the amount of skin removed in the horizontal dimension
(Figs.18.6, 18.7, and 18.8).
The area of a circle is equal to that of the right triangle whose
legs are the radius and length, the circumference of the circle
itself.
The area between the triangle and the edges of the scar
represents the tissue to be excised. Incisions will be made
according to preoperative markings and excess tissue will be
undermined and removed, tension in the areola is thus greatly
minimized, reducing the incidence of postoperative areolar
spread (Figs.18.9, 18.10, 18.11, and 18.12).
pattern
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J. Palacios
inverted knot to uniformly distribute the tension around the peri-areolar
opening is then performed with a 4/0 absorbable suture and the aps are
joined (Fig.18.10)
angle and the edges of the areola of the scar to be resected will be traced
on to the external base
18 Technique forAreolar Reduction
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the triangle will be closed
with simple non-absorbable
stitches, and for closure at the
peri-areolar incision the
length of the two pedicles has
to be equal to the length of
the incision, the wound
closure tension should be
minimized as much as may be
possible (Figs.18.11 and
18.12)
285
post procedure suture line
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18.14a, b, 18.15)
This technique is denitely recommended in revisions cases
and should be undertaken after allowing the skin around the
areola to adapt, also in cases of secondary surgery.
a b
J. Palacios
This procedure can be performed on both women and
men alike (Figs.18.15).
c
change of the implants and the results with breast size but not with the peri-areolar scars. (c) Result after areola reduction procedure
a
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b
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