Better ability to detect abnormalities on mammograms versus in front of the muscle (submammary)
Lower risk for capsular contracture (hardness of the breast caused by the formation of scar tissue around the implants)
More soft tissue coverage overlying the implant resulting in a lower risk and extent of visible rippling
Provides a better and more natural interface of the implant with the chest wall
Serves to provide better support of the implant long term as compared to above the muscle where the weight of the implant will cause greater stretching and thinning out of the skin over time as well as its descent on the chest wall
Implants above the muscle. Note the rippling, harsher contours, stretched areolas and unnaturalness of the result. (not my patient)
Implants behind the muscle. Note the more natural shape and smoother curves. This approach is recommended for most of my patients.
Except for some rare exceptions, most women are best served with the submuscular placement of their implants. As a result, this is my recommendation for virtually all of my patients.
A periareolar mastopexy, also known as a purse string, doughnut or circumareolar mastopexy, is a breast lift that accomplishes the result with just one incision: around the areola. Many women find the idea attractive because of the idea that there may be fewer scars on the breast. Unfortunately, unless there is minimal drooping to begin with, the trade-off is a poorly shaped flattened breast.
The goal of a breast lift or mastopexy is to recreate a more somewhat conical shaped breast with the nipple-areola situated at the summit of the most projecting part. A “standard” inverted-T or anchor shaped incision allows for precise reshaping of the skin envelope in addition to the underlying breast tissue by utilizing a three dimensional approach. The nipple-areola complex can then be more accurately placed and sized so as to result in an aesthetically pleasing contoured breast.
Inverted "T" Shaped Incision
The periareolar mastopexy approach eliminates the vertical scar as well as the horizontal scar in the fold at the bottom of the breast. Through a two dimensional approach involving just the incision around the areola, it has to both lift and reshape the breast. It accomplishes both by removing excess skin asymmetrically around the areola, taking a larger circle and purse stringing it to make a smaller circle, thereby tightening the skin.
With this approach, the area of maximum tension is centered around the areola. Some of the untoward consequences of this can include but are not limited to:
1.) a flattening of the breast shape creating more of a pancake configuration than a cone
2.) stretching and flattening of the areola causing distortions and irregularities of shape
3.) unsightly pleating of bunched up skin around the areola resulting from the purse string closure
4.) widened and thickened scars around the areola
5.) limitations in the precise positioning of the areola on the breast
6.) difficulty in obtaining closer symmetry is breasts that are significantly different prior to surgery
Periareolar Mastopexy (A). Though mild in this case, flatness and some pleating of the skin of the left breast can be seen centered at the areola (not my patient)
Periareolar mastopexy (B). Greater flattening can be seen including at the lower part of the breast
I strongly feel that a periareolar mastopexy is very rarely indicated except for certain limited situations involving very minor drooping. The trade-offs as noted above are too high a price to pay for most women versus the far superior results that can be obtained with a few more incisions.
In a recent posting, I discussed the need to obtain mammograms for women beyond a certain age prior to undergoing a breast reduction. The reason for is to screen for any abnormalities that may need to be explored further prior to the reduction mammoplasty surgery. It was also noted that even with a “negative” mammogram, there is an incidence of occult breast cancer identified in the removed breast tissue of between 0.16% and 0.40%.
A retrospective study just published in the October 2009 issue of the Plastic and Reconstructive Surgery Journal evaluated the incidence of precancerous lesions present in the tissue removed in breast reductions. What they discovered was very interesting and clinically helpful in potentially identifying women who are at increased risks of developing invasive breast cancer. Atypical ductal or lobular hyperplasia (abnormal but not cancerous) was diagnosed in the specimens in 4.4% of the women and a non-invasive state of breast cancer (ductal and lobular carcinoma in-situ) was seen in an additional 1.8%.
Why is this important? Based on the pathological diagnosis, a woman’s risk for developing breast cancer in the future can be quantified and appropriate preemptive actions taken as warranted. Atypical ductal and lobular hyperplasia have a 4 – 5 time increased risk of developing invasive breast cancer whereas ductal and lobular carcinoma in situ have and 8 – 10 fold greater risk than the average woman. Ordinary fibrocystic disease has no elevated risk for the later development of breast cancer.
Those women with an elevated risk of developing breast cancer can then be referred to either an oncologist or breast cancer surgeon for further evaluation and possible treatment. This could include prophylactic mastectomies, radiation or even estrogen receptor modulator therapy such as taking tamoxifen.
Therefore, women who undergo breast reductions may now receive an additional benefit from a procedure that already has overwhelmingly positive satisfaction – reducing their risk of developing invasive breast cancer.
If you would like to obtain additional information on breast reduction, breast reconstruction or any cosmetic surgery procedure that I perform or to schedule a consultation, you can contact my office at 480-451-3000.
Steven H. Turkeltaub, M.D. P.C.
Scottsdale and Phoenix, Arizona
We are in the midst of an unparalleled epidemic of obesity in this country. This is related to a combination of a general overindulgence in food, excessive consumption of foods high in fat and calories, and a more sedentary life style. Many of these people have realized that, for a variety of reasons, this excess weight needed to be shed. Through arduous dieting, exercise often in conjunction with bariatric surgery such as lap banding or gastric bypass they have lost tremendous amounts of weight, often far exceeding 100 pounds.
Success, finally! Celebration? Maybe not quite yet. Despite the massive weight loss that was so difficult to achieve, what many people didn’t anticipate was the permanent consequences on their bodies of first gaining then losing this sizable poundage. The figure that they envisioned following all this effort is not what they are seeing in the mirror. Instead of being slimmed down, contoured and generally smaller, most are left with unsightly deformities consisting of an excess of lax, irregularly contoured stretched skin that frequently cascades in rolls creating hygienic issues and an aesthetic nightmare.
Which areas are affected? From the face on down, the sequelae from massive weight loss may be seen. There is considerable variability among individuals as to the severity and areas that are most affected. Common areas include the abdomen, buttocks, circumferential trunk, inner and outer thighs, breasts, arms and even face and neck.
If you would like to obtain additional information on body contouring surgery such as for a tummy tuck, belt lipectomy, breast lift (mastopexy), breast augmentation, arm lift and face lift, you can contact my office at 480-451-3000.
Steven H. Turkeltaub, M.D. P.C.
Scottsdale and Phoenix, Arizona
Dr. Steven H. Turkeltaub is the medical director of the Arizona Center for Aesthetic Plastic Surgery, a cosmetic surgery practice offering a variety of plastic surgery procedures that address aesthetic concerns of the breast, body, skin, and face. Dr. Turkeltaub offers several options for those considering plastic surgery in Phoenix and surrounding areas. In this article, Dr. Turkeltaub discusses how the economy has impacted his Plastic Surgery practice through Phoenix, Scottsdale and the surrounding areas in Arizona.
