The Transareolar-Periareolar Approach.

The periareolar approach is limited by areolar diameter. Asian women typically have smaller areolae than Western women. Voluminous and form-stable silicone implants demand larger incisions. Zigzag transareolar approaches closely approximate the nipple and improve exposure, but scar appearance remains problematic, and there is a risk of ductal injury and capsular contracture. We prefer a zigzag incision that straddles the areolar border. Between 2013 and 2015, 11 augmentation mammoplasties (20 incisions) were performed through a transareolar-periareolar (TAPA) incision. The TAPA incision resembles 3 inverted V's that traverse the inferior areolar border. Outcomes were evaluated on the basis of photographs, clinical charts, and surveys. Women were 36 years old (range, 25-50). Silicone implants were used in 10 patients and saline in 1 patient. Implants were 270 cm3, placed in subpectoral position in 6 patients and subglandular position in 5. Follow-up was 12.5 months (range, 5-20 mo); there were no hematomas or infections. There was 1 case each of seroma (9.1%) and unilateral capsular contracture (9.1%) after secondary mammoplasty. There was no implant malposition or contour deformity. There were no keloids or hypertrophic scars. Every patient was satisfied. Nipple sensation was maintained or heightened in 100% of patients surveyed. The incisions were 139% longer than 180-degree periareolar scars. TAPA scars were well tolerated in this series of Asian women. We did not observe malposition, infection, or sensory disturbances. Despite its peripheral position on the nipple-areola complex, there are not enough data to determine whether TAPA incisions reduce risks compared with traditional approaches.

The demand for breast augmentation is rising in Asia. Decision-making reflects cultural values, anatomic features, and wound healing tendencies of women who are classically prone to, and fear, unsightly scarring.[1,2] Asian women who seek augmentation are typically slim, with small breasts and areolae and large nipples. Transareolar (TA) and periareolar (PA) incisions have limitations. Because Asian areolae may be 10 to 15 mm smaller than whites’ areolae, traditional PA approaches may not enable adequate visualization and placement of large silicone implants. Zigzagged TA modifications extend the effective incision length and improve scarring but the ability to lactate may be impaired,[3] and poor scarring has been reported.[4-6] There may be increased risk of capsular contracture, malposition, and secondary procedures.

The perfect incision would be nearly imperceptible, maximize exposure, minimize ischemic sloughing,[6] and preserve nipple sensation. The transareolar–periareolar (TAPA) approach is a zigzag incision that resembles current TA incisions but is positioned inferiorly. The incision is designed to combine cosmetic benefits of zigzag incisions with the safety and visualization of the inframammary fold approach. The senior author has used this technique since 2013 with excellent results.

TECHNIQUE

The incision is marked as shown in Figure 1. The first mark is made 5 mm inside the areolar border (“−5”) at the 4-o’clock position of the areola. The second is 5 mm outside the border (“+5”) at 5-o’clock position, −5 at 6, +5 at 7, and −5 at 8. Dots are connected with a fine-tip absorbable marker to reveal a “W” that straddles the areolar border. At each end of the W, a curvilinear tail is drawn to veer away from the horizontal breast meridian and marked at the “+5” position. Care should be taken during dissection to preserve a thick flap and avoid breast parenchyma. Gentle tissue handling will eliminate the risk of iatrogenic injury and the need for intraoperative tissue trimming. After the implant is placed, dermal and subcuticular layers are placed, taking special care to reapproximate the smooth muscle foundation of the areola.[7] 5-0 Nylon suture is placed at the apex of each “V” and removed at 5 days.

Fig. 1.

Artist’s rendition of the TAPA incision.

OUTCOMES

Between November 2013 and November 2014, the senior author used this approach for 11 consenting women. Cosmetic outcome was based on clinical evaluation and telephone-based surveys. Scar appearance was evaluated for 9 of 11 patients (81.8%) with 6 or more months of follow-up using a modified Manchester Scar Scale (MSS) by 4 independent investigators who assigned a visual analog score (score range: 0–10) and evaluated color (1–4), texture (1–2), contour (1–4), and areolar distortion (1–4) for each patient. The best possible composite MSS score is 4; the worst is 24 points.

Scars were evaluated using photographs taken at the most recent follow-up for 10 women (90.9%) with 6 or more months of follow-up. Follow-up time was 13.2 months (range, 6–20 mo). There were no keloids, dyspigmented, or hypertrophic scars. Representative postoperative results are shown in Figure 2. The MSS for TAPA scars was 8.92 ± 1.9.

Fig. 2.

Appearance of healed TAPA scars with the best (4.75, left), median (9.25, middle), and poorest (11.5, right) MSS scores. The first patient was a 32-year-old woman who underwent bilateral revision mammoplasty for bilateral implant rupture. The middle and right were the images of 25- and 39-year-old women, respectively, and who underwent primary breast augmentation for micromastia.

PATIENT SATISFACTION

Seven women with more than 6 months of follow-up were interviewed by telephone. These women assigned a score of 3.7 ± 0.8 points to their scars using a 5-point scale to evaluate subjective appearance (5 represents an invisible scar). Four women (57.1%) were very satisfied with the result of surgery; 3 were neutral. Two women (28.6%) would strongly recommend the procedure to friends, and the rest were neutral. Six women (85.7%) agreed or strongly agreed that their sexual attractiveness improved as a result of surgery. Two women (28.6%) stated that one or both nipples were more sensitive after surgery; the remainder did not appreciate any change in sensation. No patients were treated with steroids or other methods for unsightly scarring, and no scar revision procedures or treatments were indicated.

DISCUSSION

It is unlikely that unfavorable scarring, tissue loss, sensory changes, the inability to lactate, infection, and malposition risks are sufficiently problematic that current TA and PA approaches should be sidelined in Asian women undergoing breast augmentation. However, scarring remains imperfect with these procedures, and TA perinipple approaches may increase risk of contamination, injury to lactiferous structures, and nerve injury. Proposed benefits of the TAPA approach include scar camouflage, enhanced access, and reduced risk of contamination and capsular contracture.

One of the greatest limitations of the PA approach is that the size of the areola dictates incision width. This poses a challenge for Asian women with small nipples seeking form-stable gel implants. Saline implants would solve this problem, but many patients are keen on using silicone. A zigzag incision is useful for extending the effective incision length. A model was created to predict effective incisional length as a function of areolar diameter, and a best-fit curve was obtained using Microsoft Excel 2011 (Microsoft Corp.; Redmond, Calif.). The model demonstrated that theoretical gains in incision length decreased with increasing areolar diameter. Beyond an areolar diameter of 50 mm, there is no predicted length benefit with the TAPA incision.

The path measurement feature of Adobe Illustrator CS6 (Adobe Systems; San Jose, Calif.) was used to determine actual increase in path (incision) length based on most current scar photographs compared with a 180-degree tracing along the superior areolar border of the same areola. For all incisions, there was a 139% ± 17% increase in incision length compared with the PA incision (range, 112%–179% increase).

Inferior placement of the incision directs dissection away from the lactiferous ductal system. This is expected to reduce risk of bacterial colonization and associated risk of capsular contracture. Nipple sensation is preserved when PA incisions are used because nerve afferents originate superiorly.[8,9] Sensory abnormalities were reported when perinipple approaches were used in 14%[5] to “most” patients,[6] but all patients reported return of sensation by 2 years.[4-6,10] We observed few complaints of nipple dysesthesia using the TAPA incision, but sensation was not formally assessed in this study.

ACKNOWLEDGMENTS

The authors would like to thank Dr. Sonia Wei-Ting Chen, MD and Chia-Yu Lin, MSc for assistance in data collection and Dr. Cheng-I Yen, MD for assistance in evaluating scar appearance. There is no other source of support to acknowledge.