In a previous blog I discussed the issue of areolar balance in breast surgery.  Simply put, if the areola is too large or too low, the result with a simple breast augmentation operation will not be pleasing to the eye.  The long term result will be particularly disappointing if the surgeon chooses to place an oversized implant in the subglandular plane, a strategy that is unfortunately all too common.

Fortunately there is an operation which will restore a pleasing size and balance to the areola and allow for a proportionate augmentation with an implant.  The operation is known as a periareolar mastopexy or a periareolar breast lift.  In this operation the areola is reduced in size and repositioned to a higher location on the breast.  I make a circular incision within the enlarged areola that corresponds to the optimum size of the areola.  Further out I make a second oval-shaped incision that includes the enlarged portion of the areola and as much of the surrounding breast skin as is necessary.  I then remove the outer layer of the skin and areola that exists between the two incisions, a technique known as deepithelialization.  I can now tighten the outer oval down to the scale of the inner circle.  The result is both a reduction in the size of the areola and a lifting of the areola to a better position on the breast.
 
 The scar from this operation runs around the border of the areola.  The visual transition between the different colors of the areola and the rest of the breast skin makes this an ideal place to put a scar.

In the past this technique suffered one important limitation: because of the tension that results from bringing the larger oval down to the smaller circle, there was a tendency for the scar to spread out over time.  We have Doctor Louis Benelli of Paris to thank for the introduction of what he refers to as a blocking suture.  This is essentially a circular thread that runs beneath the skin at the border of the outer oval.  When this suture is tightened and the two ends are tied to each other it brings the oval down to the size of the areola, so that the incision can be closed without tension.  This leads to a much less conspicuous scar.

In the next Blog in this series I will describe how I combine the periareolar mastopexy technique with the placement of a breast implant.