Prevention of the inverted teardrop areola following mammaplasty

Abstract

Although the major objective of mammaplasty is to produce a breast mound of the desired size, position, and projection, oftentimes minor nuances can make the difference between just a good clinical result and a superior aesthetic outcome acceptable to the patient. Since the nipple-areola complex usually becomes the focal point when evaluating the operated breast, its location, size, sustained viability, scar visibility, and geometry become extremely important secondary characteristics when seeking the excellent result. In this regard, we have been asked to update our modification of just one such simple technique to minimize the risk of creating an iatrogenic inverted teardrop areolar deformity [1]. The inverted teardrop or comma-shaped areola is a documented sequela of breast reduction following horizontal or vertical bipedicled nipple-bearing flaps [2] or a single inferior pedicle technique, as we still most commonly utilize (Fig. 80.1) [3]. This can also occur aft er a vertical mastopexy, without reduction (Fig. 80.2) [4]. This deformity occurs at the junction of the vertical line of the breast closure with the areola. Many theories have been advanced to explain its pathogenesis. Some believe that it is inevitable with a circular areolar design to have such distortion, and so an oval shape with a larger horizontal axis is intentionally made from the outset [5]. Scalloping the edges of the areola and the corresponding recipient keyhole intentionally by distorting the entire perimeter of the areola so as to make it more subtly blend-in with the surrounding paler breast skin will hide any such malformation, yet the entire result can be so distorted [6]. A tight closure of the breast envelope below the nipple, whether due to excessive medial or lateral skin or breast tissue excision, will pull in the direction of that excessive resection, also pulling the areola with it [2]. A most plausible explanation is that the tightness of the vertical scar alone due to contraction pulls the areola down with it, which is simply prevented by minimizing tension by the usual subcuticular running closure at least in the superior portion of the vertical limb closure [4]. Whatever the actual cause of the inverted teardrop shape of the areola, we have found that our technique of insetting the nipple- areolar complex has permitted us to avoid this deformity in all the cases which we have performed over the past 20 years since our introduction of this idea [1]. © 2009 Springer-Verlag Berlin Heidelberg.