Advantages of intraoperative marking of the new nipple/areola site in mammaplasty.

Sir:

Lai and Lam[1] present their method for creating the new nipple/areola recipient site in vertical mammaplasty. Any design of a new nipple/areola recipient site must be based on clear objectives. Fortunately, most of these objectives are widely accepted and are not subject to opinion. Ideally, the nipple sits at the apex of the breast, and the areola margin is circular.[2] How well does the authors’ technique meet these criteria? Unfortunately, there are no before-and-after photographs to support their method. In Figure 3 presented by Lai and Lam,[1] the pattern has evidently been redrawn so that the reader cannot assess how the mosque-dome shape would appear after cinching the bottom margin (probably narrower). Moreover, the pattern is drawn on the same preoperative breast, so that one cannot judge how the shape would change after resection of a vertical ellipse. The authors inform us[1] that the result is a “somewhat asymmetric circle with a diameter of just < 5 cm.” Of course, an asymmetric circle is no longer a circle, by definition. In Figure 4 presented by Lai and Lam,[1] the breast meridian is misrepresented as a line from the nipple to the sternal notch rather than to the midclavicle,[2] which is traditionally represented by a tape measure draped around the neck. The original nipple location is drawn too far laterally, and the new nipple location is (quite severely) superomedially malpositioned. Any reliance by the reader on this diagram would be unwise.

The authors[1] base the new nipple site on the superior border of the existing areola. The question is, will the nipple be appropriately positioned once the new breast mound is created? Even for experienced surgeons, it is difficult to accurately predict the exact location of the new breast apex preoperatively.[2] Patients differ considerably in their degree of ptosis[2] and skin elasticity. The use of an implant makes this prediction even more difficult. A vertical mammaplasty elevates the breast mound between 0 and 10 cm.[2] Commonly, the nipple position is placed too high when preoperative marking is used.[3] The Wise-pattern mammaplasty incorporates nipple transpositioning that overelevates the nipple, even when limiting the vertical limb to 5 cm.[4] A recent study recommends nipple grafting to change the nipple position if necessary.[5] However, nipple/areola grafting is extremely debilitating to the nipple and should be avoided. Intraoperative nipple positioning offers a safer alternative.[6] The surgeon need not commit to a nipple position before the dissection, allowing him or her to make this judgment once the breast mound is created in surgery. The nipple should be positioned at or just below the breast apex.[2] This method reduces the risk of nipple overelevation.[2] A nipple that sits slightly too low is natural and, if necessary, easy to correct surgically.[6] By contrast, an overelevated nipple appears unnatural and is difficult to correct.[6]

The second criterion for an ideal nipple/areola appearance is circularity.[2] An inverted teardrop shape compromises an otherwise excellent surgical result, giving the breast an operated-on look.[3] The mosque-dome or keyhole pattern commonly produces this unnatural shape, which is apparent on the operating table and will not spontaneously resolve.[3] When performing a vertical mammaplasty, a dog ear results as the vertical wound is closed.[2] The amount of skin to be removed exceeds what is typically outlined using a preoperative mosque-dome or keyhole pattern. The excess skin may be oversewn and then excised (Fig. 1).[2] This method ensures that the new nipple/areola position will be at the apex and that the tension around the areola will be evenly balanced, reducing the risk of postoperative areola distortion.[2,3] An arbitrary 75 degree wedge does not take into account the variable width of the vertical ellipse used in a vertical mammaplasty, which is influenced by the degree of ptosis. If intraoperative nipple positioning is used, there is no need for a mathematical formula. There is no downside to intraoperative marking, but a considerable upside in more reliably positioning the nipple and areola. There is no advantage in marking the site preoperatively, a process that always involves a degree of guesswork.

Fig. 1.

Vertical augmentation/mammaplasty. After insertion of the breast implant, the vertical ellipse is resected, preserving a deepithelialized medial pedicle (A). The nipple and areola are temporarily oversewn as the wound edges are approximated in the midline. This maneuver corrects the superior dog ear and provides balanced tension around the new nipple/areola site (B). A 39-mm areola marking ring is used to guide the incision for the circular resection at the new nipple/areola site. This position is determined intraoperatively, after creation of the new breast mound. The nipple is located at or slightly below the breast apex (C). The nipple and areola are brought through the new opening and the wound is sutured. The areola shape is circular with no evidence of an inverted teardrop deformity (D).

The third consideration is the diameter of the areola. An outcome study reveals that women prefer an areola diameter of not more than 5 cm.[7] The areola tends to stretch approximately 1 cm after mammaplasties.[2] A 39-mm areola marking ring helps keep the areola from stretching much over 5 cm and is therefore preferred over larger-diameter rings.[2] Intraoperative nipple positioning has been used by plastic surgeons for decades.[3] This technique offers the best opportunity for correct postoperative nipple positioning and improved circularity.[2] Correct nipple/areola position, shape, and size complement the result of any mammaplasty.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article. The Article Processing Charge was paid for by the authors.