A mathematical design in creating the new nipple-areolar complex in vertical mammaplasty.

SUMMARY: Vertical mammaplasty for breast reduction has been widely popularized by Lejour. In her planning for the new nipple-areolar complex, she did not specify a method of drawing the periareolar curve, leaving it to the surgeon's creativity. We have designed a simple method using mathematics to draw the new periareolar curve consistently and reliably, not requiring any additional or complex devices. This method is easy for those who are accustomed to the Wise pattern to adopt and targets those who prefer formulated preplanned operative markings.

Vertical mammaplasty for mastopexy or breast reduction was first introduced by Dartigues[1] in 1925 and subsequently modified by many[2-8] in an attempt to improve cosmesis. In the early 1990s, the technique was popularized by Lejour.[9] Before this, majority of breast reductions were performed using the Wise pattern.[10]

In Lejour’s planning for marking the new nipple-areolar complex (NAC), she described a free-hand drawing of a “dome”-shaped periareolar curve measuring 14–16 cm in length to suit the patient’s individual body habitus and desired postoperative result.[9] The method of drawing this curve was not specified and suggested to be chosen according to the preferred method of the surgeon.

It has been said that plastic surgeons can be divided into the artistic ones who operate freely and those who are more mathematically minded and operate according to a preplanned drawing. Methods that have been proposed to date include using a malleable dome-shaped areolar marker,[11] intraoperative positioning using discs cut from adhesive surgical tape,[12] a modified compass with adjustable limbs,[13] a flexible ruler,[14] and a wire coat hanger.[15] These methods are somewhat technically fiddly and require additional equipment. We hereby present our “mathematical” method of designing the areolar marking for the Lejour technique or vertical mastopexy/breast reduction. We have found this method to produce consistent results and is easy for those who are accustomed to the Wise pattern marking[10] to adopt.

DESIGN

The location of the new NAC is first marked preoperatively using the surgeon’s preferred method, usually 23–25 cm from the sternal notch in line with the existing nipple at the level of or 1–2 cm above the inframammary fold. Two lines are drawn extending downward on either side of the existing NAC at a 75-degree angle from the breast meridian (Fig. 1). A vertical line is then drawn 2 cm superior to the nipple position to mark the top end of the new areola (point A in Fig. 1). Next, 2 lines measuring 3 cm down the previously drawn 2 limbs are marked (points B and C). These 3 points are then joined with a curved line which forms the outline of the new areola (lines AB and AC). Intraoperatively, one can tag the points BC together with a suture to form the inferior curved border of the new areola and confirm it with a 42 mm diameter nipple marker (Figs. 2, 3).

Fig. 1.

Marking of the new nipple-areolar complex.

Fig. 2.

Comparing the new nipple-areolar complex size with a 42-mm diameter nipple marker.

Fig. 3.

Confirming the new nipple-areolar complex size with a 42-mm diameter nipple marker.

Mathematically, this design forms a somewhat asymmetric circle with a diameter of just <5 cm. The circumference of a circle with a diameter of 5 cm would be: Circumference = π × diameter, that is, 3.14 × 5 = 15.7 cm which is within Lejour’s recommended 14–16 cm.[8,9] Using this new nipple marking as the top of the new nipple location, and assuming an average nipple of approximately 1-cm round, the resultant areola will be 2 cm all round with this design. A simple diagram summarizing the steps described above is shown in Figure 4.

Fig. 4.

Diagram illustrating marking of the new nipple-areolar complex.

CONCLUSIONS

We present a simple mathematical method of marking a new NAC for Lejour’s technique or vertical mammaplasty which is easily adapted by one who is more accustomed to the Wise pattern marking or who prefers more mathematically or formulated markings.