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LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. Describe surgical techniques associated with mastopexy and mastopexy augmentation. 2. Understand the evolution of mastopexy and augmentation mastopexy. 3. Address patient goals. 4. Achieve a favorable cosmetic outcome. SUMMARY The surgical techniques associated with mastopexy and mastopexy augmentation have continued to evolve. Traditional mastopexy techniques have included periareolar, circumvertical, and inverted-T patterns; however, adjuncts to these have included the use of various surgical mesh materials, implants, and fat grafting. This evidence-based article reviews how the techniques of mastopexy and augmentation mastopexy have evolved to best address patient goals and provide a favorable cosmetic outcome.

Single-stage mastopexy with augmentation is a commonly performed procedure. The single-stage procedure can be performed in primary cases or a secondary procedure in patients with previous history of augmentation, mastopexy or mastopexy with augmentation. The procedure is challenging and not without its risks. A retrospective chart review of all consecutive cases of layered mastopexy with augmentation mammoplasties, carried out from September 2015 to August 2019, was performed. All patients had their implants placed in muscle splitting pocket first and access for the pocket was closed prior to the commencement of mastopexy. During the period of 4 years, 102 consecutive layered mastopexy with augmentations were performed in muscle splitting plane. Of these 102 patients, 74 (72.5%) patients had it as a primary and 28 (27.5%) as a secondary procedure. Of these 102 patients, 53 (52.0%) had textured, 37 (36.3%) had smooth and 12 (11.8%) had microtextured implants and 72 (70.6%) patients had high profile and 30 (29.4%) had medium profile implants. Same size implant was used in 89 patients with a mean of 298 cc, and 13 patients had different size implants with a mean of 362 cc on the right and 395 cc on the left. In current study, bilateral periareolar, vertical scar cat’s tail and Wise pattern mastopexies were performed in 11, 51 and 27 patients, respectively. Of the 102 patients, 5 had unilateral right periareolar, 5 unilateral right vertical scar cat’s tail, 2 unilateral left periareolar and 1 patient had a combination of periareolar and vertical scar combination. There was no nipple loss or periprosthetic infection. There was a minor wound breakdown seen in 4 (3.9%), haematoma in 2 (2.1%), nipple sensation loss in 2 (2.1%) and 12 (11.8%) had layered mastopexy as a part of a combined procedure. Revision was performed in 6 (6.5%), drains were used in 14 (13.7%), and 92 (90.2%) had the procedure performed as a day case. Layered mastopexy with augmentation is a safe procedure with added stability and safety to lower pole of the breast as well as nipple-areolar complex. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Background For the correction of small breasts with grade I ptosis, it is very challenging for plastic surgeons to obtain excellent aesthetic results by performing simultaneous breast augmentation and nipple-areolar complex (NAC) lifting. Previous research has introduced one-stage augmentation mastopexy, but most studies described using the periareolar approach. The current study proposes a technique for augmentation mastopexy using the inframammary fold approach for augmentation and the periareolar approach for mastopexy.Methods Twenty patients were enrolled, and surgery was performed on 40 breasts. A pocket was made with the inframammary fold approach and the dual-plane method; subsequently, a tear-drop shape implant was inserted using a funnel. We performed NAC lifting using the de-epithelialization and interlocking purse-string suture method through the periareolar approach.Results The mean distance from the mid-clavicular line to the nipple was 23.4 cm preoperatively, 19.6 cm at 7 days of follow-up, and 20.3 cm at 12 months of follow-up. Complications such as hematoma, infection, NAC necrosis, capsular contracture, and wound dehiscence were not reported.Conclusions We performed successful breast augmentation and mild ptosis correction. No specific complications were observed during 1 year of postoperative follow-up. Our method is a simple and fast method that enables surgeons to perform augmentation and mastopexy in one stage for breasts with grade I ptosis.

BACKGROUND Male tuberous breast is an exceedingly rare condition that not fit properly into the majority of existing classifications of gynecomastia. This deformity has been categorized by Cordova and Moschella as gynecomastia grade III; however, they do not make any reference to the isolated tuberous deformity of the nipple-areola complex (NAC). Considering that the areolar area is the main ''esthetic unit'' in the male chest, surgical correction of the isolated tuberous NAC deformity can be challenging. There is a belief that this deformity is unsuccessfully corrected when approached through a limited periareolar incision at the lower pole. A complete periareolar incision, with a concentric excision of excess areolar skin, is usually required leaving an unnatural-looking round periareolar scar on the male thorax. METHODS We describe a variation of a surgical technique for the correction of a male tuberous NAC deformity in a teenager who rejected a conspicuous round periareolar scar after surgery. This modification combines a conventional lower hemiareolar approach with a percutaneous intradermal purse-string suture in the superior areolar margin to reduce the areolar diameter, avoiding an evident circumareolar scar. RESULT At the six-month follow-up, areolar widening or tuberous deformity relapse was not observed. The patient felt satisfied with the outcome. CONCLUSION The use of percutaneous intradermal purse-string periareolar suture for correction of this rare deformity is a simple and reproducible surgical technique that could help to obtain a better cosmetic result by restoring the contour of the male chest while minimizing the visibility of the residual scar. LEVEL OF EVIDENCE V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Breast ptosis is a deformity commonly found in patients seeking breast augmentation. Current mastopexy techniques rely on incisions on the breast to correct ptosis; nonetheless, they leave extensive scars. Having to opt for a visibly scarred breast over a ptotic breast can be a difficult choice. We sought an innovative internal suture mastopexy for hypomastia of mild breast ptosis. A procedure that left a tiny scar on the nipple-areolar complex was introduced. This method was safe and efficient when combining mastopexy with augmentation. Overall, 53 patients underwent this operation in the Plastic and Cosmetic Department of Guangdong Second Provincial General Hospital from January 1, 2013, to June 30, 2017, with a mean follow-up of 38 ± 16 months. The pre-operation and post-operation SN-N lines (the distance from the sternal notch to the nipple) were 21.8 ± 1.2 cm and 20.7 ± 1.0 cm, respectively; the difference was statistically significant (P

Breast ptosis is one of the most common complaints in the clinical setting. Simultaneous mastopexy via areola excision involves a reliable modified aesthetic technique with distinctive features to correct mild and moderate pendulous breasts. The aim of this study is to determine whether the novel surgical approach is a safe and long-lasting technique for patients with breast ptosis. We performed a retrospective study of 48 patients who received simultaneous mastopexy through circumareolar excision and followed up for 12 months. Breast size, shape, fullness, symmetry, scar appearance, and sensitivity of nipple-areolar complex were evaluated. Patients were satisfied with upper pole fullness, symmetry and scar less appearance. There were no cases of NAC deformity or sensation loss, neither sever capsular contracture was observed. The new surgical technique, one-stage periareolar augmentation mastopexy, is a reliable and long-lasting operation for patients with mild and moderate breast ptosis. This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Purpose We performed breast-conserving surgery (BCS) using periareolar incisions for cancers located far from the nipple–areolar complex (NAC) and examined if BCS via a periareolar incision maximized cosmesis and maintained oncologic safety. One of the most important goals of BCS is to improve cosmesis after surgery and quality of life, but the skin incision can affect cosmesis based on the tumor location. Methods Fifty-five patients with breast cancers located far from the NAC underwent BCS via periareolar incisions between January 2017 and April 2018. If a sentinel lymph node biopsy was required, another skin incision was created in the axilla using the conventional technique. Medical records of patients were reviewed retrospectively. Results The mean patient age was 48.1 ± 10.6 years. The mean tumor size was 1.8 ± 1.0 cm (range 0.2–4.5 cm) on preoperative magnetic resonance imaging (MRI); the mean distance from the NAC to the tumor was 5.9 ± 1.9 cm (range 4.0–12.3 cm). Patients with cancers in the subareolar area were excluded even though the distance from the nipple was > 4 cm on MRI. Negative microscopic margins were obtained in all patients. There was no surgical complication such as seroma, bleeding, or infection. Re-operation was not needed. All patients received whole breast radiation therapy. After surgery and radiation therapy, periareolar incision scars were nearly invisible. Conclusion For cancers located far from the NAC, BCS via periareolar incisions is feasible and leads to superior cosmesis in selective patients. Moreover, BCS seems oncologically safe, although long-term outcomes need to be evaluated.

Summary Background The funnel has been used in esthetic breast surgery that requires a small incision. Recent advances in minimally invasive surgical techniques have led to more cases of nipple-sparing mastectomy (NSM) through periareolar incision. However, prepectoral implant placement and complete coverage with acellular dermal matrix (ADM) is almost impossible with the periareolar approach. Funnels can also be useful for direct-to-implant breast reconstruction. Methods NSM with periareolar incision and direct-to-implant breast reconstruction were performed with prepectoral implant placement between January 2017 and July 2019. The ADM full-wrapped anatomic textured implant was inserted using a funnel without additional incisions during surgery. Results A total of 21 patients were enrolled, including 2 who received bilateral breast reconstruction. All operations were successfully performed using funnels with minimal periareolar incisions. Anatomic textured implants (mean: 251.7 cc, range: 90–450 cc) wrapped in ADM can be effectively inserted in the prepectoral plane using a funnel. Two patients experienced delayed wound healing of the areola that was treated by conservative wound management. Patients also experienced less pain overall, and the cosmetic result was very good. Patient satisfaction scores were also very high. Conclusions While the periareolar incision is esthetically pleasing, additional resection is often necessary. However, the use of funnels ensured that no additional incision was needed even in large implants. This subsequently led to better results in terms of pain and scarring. Prepectoral breast reconstruction involving complete implant coverage with ADM using a funnel through the periareolar approach represents a good alternative to the traditional dual plane subpectoral method. This method provides good patient satisfaction without adverse outcomes.

Objectives: For management of mild degree breast ptosisperiareolar mastopexy had been commonly used. Since Benelli1990 had confined the scar to the areola in his round-blocktechnique, several authors has adopted this technique. Whethermastopexy had been done with or without augmentation, theproblems of breast shape, areolar irregularities,and stretch ofthe areola had been annoying to both patients and surgeons.These problems also represent a major challenge to thistechnique. In this paper purse string closure was used in twoconsecutive different layers one in dermal de-epithelized layerand another in the deep dermis of the skin. The aim is tominimize widening of scars of peri-areolar incision andimprove its long term appearance.Patients and Methods: 50 cases underwent mastopexywith breast augmentation. Cases were divided into two groups:Group A: Underwent closure by single purse string layer andGroup B: Two consecutive purse string closure. The secondconcentric row was applied to the deep dermal plane of thenormal non de-epthelialized skin similar to the classical pursestring closure described previously. Both subjective andobjective evaluation were done. Surgery was done by singlesurgeon and two surgeons not involved in research evaluatedthe post-operative photos. Follow-up was done at 3, 6 monthand at 1 year post-operative.Results: Group B patients showed superior results asregarding breast shape, contour, projection, superior fullness,periareolar scar shape, regularity, areola width and position.These results were followed-up for one year.Conclusion: Decreasing the tension of the periareolar sutureby applying double purse string technique in two differentplanes improved long term results of periareolar scar in orderto avoid widening, irregularities and hypertrophic scarring.

After a partial mastectomy, large or ptotic breasts can be reconstructed using breast reduction techniques. Wise-pattern reduction is typically used to remove masses in any quadrant of the breast, but this technique leaves a large inverted T-shaped scar. Instead, the short scar periareolar inferior pedicle reduction (SPAIR) technique involves a periareolar line and does not result in a scar along the inframammary fold (IMF). A 49-year-old patient with macromastia and severely ptotic breasts was diagnosed with invasive cancer of the left breast. Her large breasts caused pain in her back, shoulders, and neck. She also expressed concern about postsurgical scarring along the IMF. In light of this concern, we chose the SPAIR technique, and we designed and performed the procedure as described by Hammond. During surgery, we removed 36 g of breast tumor and 380 g of breast parenchyma from the left breast. To establish symmetry, we also removed 410 g of tissue from the right breast. Postoperatively, the patient reported satisfaction regarding the reduction mammaplasty and, in particular, noted decreased back, shoulder, and neck pain. In summary, we used the SPAIR technique to achieve oncologic and aesthetic success in a patient with macromastia and a tumor located lateral to the nipple-areolar complex.

Background Nipple-sparing mastectomy (NSM), followed by immediate reconstruction (IR) of the breast, has become a preferred surgical procedure with good cosmesis results and patient satisfaction. However, nipple-areolar complex (NAC) ischemia and necrosis remain major problems after NSM and IR. Methods We retrospectively analyzed patients who underwent NSM and IR at Gangnam Severance Hospital from January 2009 to June 2018. We compared the patient characteristics and complication rate among three different incisions (inframammary fold [IMF], radial, periareolar). Additionally, we identified the risk factors of NAC necrosis. Results Data from 290 eligible breasts in 275 patients were analyzed. Patients with IMF incision had relatively lower breast weights. The overall complication rate was the highest with periareolar incision and the lowest with IMF incision (42.6% vs. 18.8%, p, Highlights • Periareolar incision shows higher complication rate in nipple-sparing mastectomy. • Periareolar incision is a risk factor for nipple-areolar complex necrosis. • Other risk factors include tumor-nipple distance and breast weight.

In the surgical treatment of breast ptosis, the plastic surgeon's main challenge is to mobilize the nipple–areola complex (NAC) over long distances, preserving its sensitivity. Herein, we aimed to evaluate the NAC sensitivity following a periareolar dermis release in patients undergoing surgical correction of breast ptosis. This is a prospective, double-blinded, randomized study in which 39 patients (78 breasts) were operated on for the treatment of breast ptosis. Patients’ breasts were divided into two groups, each breast in a group. In breasts of the experiment group, the periareolar dermis release was used after decortication. This maneuver was not used in the control group's breasts. To analyze the sensitivity in relation with the distance that the NAC should be mobilized to correct breast ptosis, the value of 6 cm was used as boundary. Sensitivity of the NAC was assessed with monofilaments preoperatively and postoperatively—at three and six weeks and one year. Regarding the sensitivity of the areola, a significant difference was observed in the comparison between the control and experiment groups at the NAC mobility ≤ 6.0 cm in the preoperative. Regarding the nipple, a significant difference was observed in the comparison between the control and experiment groups at three weeks postoperatively for a NAC mobility ≤ 6.0 cm. After one year, there was no difference in the comparison between the groups in either areola or nipple. The periareolar dermis release does not compromise NAC vascularization and pressure sensitivity in patients undergoing breast ptosis correction. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Scar placement has always been a bit of a concern for patients as well as surgeons; therefore, various periareolar oncoplastic techniques were introduced in an attempt to eliminate scars visibility, by limiting them to the periareolar region. Among these oncoplastic techniques, round block mammaplasty has recently been gaining more popularity. Round block mammaplasty is a level II volume displacement oncoplastic breast surgery technique involving adequate resection of the tumour while maintaining a good cosmetic outcome. Eighty-six patients who had round block mammaplasty over a period of 3 years were included in this retrospective study. The participants’ demography, breast cancer characteristics, postoperative complications and patients’ satisfaction were collected from their clinical records and their standard patient’s questionnaires. The standard patient’s questionnaire was completed by most patients as a mean of assessing patients’ outcome and satisfaction after a round block mammaplasty. Out of all 86 patients who underwent a round block mammaplasty, the average tumour size was 26 mm, and the average weight of the specimen was 52 g. Four patients (4.6%) had involved/close margins, two of which (2.3%) had re-excision in order to achieve clear margins and the other two patients (2.3%) required mastectomy. Twenty-six patients (41%) thought they had excellent results, 21 patients (33%) good results and 16 patients (26%) fair results. The round block mammaplasty technique can be used safely for management of all quadrants breast lesions with favourable cosmetic results and high degree of patient satisfaction.

Round block technique (RBT) is an oncoplastic technique used in periareolar lesions, particularly in breasts with moderate ptosis or hypertrophy. However, it has some drawbacks including the possibility of late-onset scar widening, change in areolar shape, and asymmetry of the breasts. Moreover, it is hard to be performed with tumors located in periphery of breast. Modified round block technique (MRBT) is a new technique described to overcome these problems. A circumferential periareolar incision was made around the areola followed by subcutaneous dissection to the entire breast. Wide local excision (WLE) could then easily be performed with a good field of view, the breast tumor was excised with an acceptable macroscopic safety margin, and specimens were marked with orienting sutures for intraoperative frozen section. Remodeling of the breast was done, a close suction drain was placed, and the wound was narrowed with a nonabsorbable purse-string suture and attached to the NAC with continuous subcuticular absorbable suture. This study was conducted on 144 female patients diagnosed with breast cancer. The median size of the tumor was 2 cm, the majority of the patients (66.7%) had moderate breast size (cup B) and the median distance of the tumor from NAC was 7 cm. Patients' satisfaction was assessed according to Harvard scale and good to excellent results were found in 88.8% of the patients. There were no postoperative changes in areolar shape or position. Complications in the form of hematoma, wound dehiscence, and infection were encountered in 25% of the patients. Modified round block technique is an oncoplastic technique that permits excision of peripherally located breast cancer without excision of periareolar skin and it is suitable for all quadrant tumors. It also avoids the scar which occurs after ordinary breast-conserving surgery.

BackgroundMany techniques for the surgical treatment of gynaecomastia have been reported to be effective with reasonable limited scar formation. The aim of this study was to develop a grade adopted algorithm for effective and scar sparing techniques in reconstruction of the male breast dependent on aetiology and grading.MethodsOperative techniques, results, rates of revisions and complications were recorded between 2006 and 2018 and results of 164 male patients were analysed, retrospectively. Skin resecting methods have been used in the earlier stage but were later replaced by minimal periareolar incisions and subcutaneous mastectomy. Resections were combined with ultrasound-assisted liposuction up to grade 2b and inferior pedicled breast reduction in 3rd degree gynaecomastias resulting in reduction of scars and effective removal of breast tissue.ResultsRetrospective analysis showed that a periareolar mastopexy was used in 24% of patients with gynaecomastia grade I, IIa and IIb to reshape the breast after subcutaneous mastectomy in the early stage of this study from 2006 to 2010. With the established standardised use of ultrasound-assisted liposuction, only 2% of patients required a mastopexy in the following years. In grade 3 gynaecomastia, the classical approach resulting in an inverted t-scar was later abandoned for an approach with a periareolar and submammary scar and inferior dermoglandular flap. The rate of secondary surgery with the used techniques did not increase.ConclusionsWhen using standardised techniques in reshaping the male breast, an aesthetically pleasing and safe result can be achieved by scar sparing techniques in a safe single-stage procedure.Level of evidenceLevel IV, therapeutic study.

Background: The difficulty of treating severe grades ofgynecomastia lies in the resection of excess skin. This resectioncan result in extensive scars located in conspicuous sites. Toreach the optimum results, excess skin should be excised andthe excess fat and gland should be managed too. Managingthe excess fat, enlarged mammary gland, together with excisionof excess periareolar skin with nipple-areola transposition insingle-stage is associated with higher risk of injuring thevascular pedicle of nipple-areola, and also associated withexcessive pleating of periareolar skin due to the suddenreduction in the size of areola which don't allow for skinretraction to occur. Staged-reconstruction will allow for gradualreduction in the size of areola allowing for skin adaptationleading to minimal pleating of periareolar skin, and alsopreserve the nipple-areola vascularity.Aim of Work: Is to compare between reconstruction ofgrade III gynecomastia in single-stage versus two-stage, asregard the complications rate.Patients and Methods: Twelve patients with severe (gradeIII) gynecomastia with enlarged ptotic nipple-areola, underwentsurgery over a 2-year period. All patients were marked preoperatively.Under general-anesthesia, traditional liposuctionof the pei-glandular area was performed, followed by deepithelializationof excess peri-areolar skin to elevate thenipple-areola. The glandular tissue was delivered by “pullthrough”technique, through a lateral trans-dermal peri-areolarincision. Study performed on two groups, group I, surgerywas performed in single-stage, while in group II, surgery wasperformed in two-stages, with liposuction of excess fat andresection of excess peri-areolar skin with elevation of nippleareolain the first stage then, three months later, patientsunderwent minimal liposuction just to facilitate delivery ofthe gland, with its delivery using the “pull-through” technique.Results: Fellow-up period was 6 months. No hematoma,seroma, breast skin necrosis, breast asymmetry, or nippleareolamalposition were detected post-operative in both groups.Results were reported as “uniformly good to excellent” on apatient satisfaction scale, as all patients were satisfied withtheir breasts contour and nipple-areola position postoperative.Transient hyposthesia of nipple-areola occurred and improvedspontaneously at 6 months post-operative. By comparing thecomplications rate between both groups, results showed thatsingle-stage reconstruction in group I was associated withhigher complications rate as regard the nipple-areola vascularity,and as regard the presence of excessive pleating of69periareolar skin than in group II. One case in group I showcomplete loss of nipple-areola. Another case of nipple-areolavascular compromise and partial necrosis were also detectedin group I. While, no cases showed compromised vascularityof nipple-areola in group II patients with two-stage reconstruction.Conclusions: Two-stage reconstruction is considered assafe procedure for correction of severe (grade III) gynecomastia,which preserve nipple-areola vascularity, and permitsbroad resection of excess skin and mammary tissue, whileavoiding unattractive scars on the patient's chest, with minimalpleating of periareolar skin.

Purpose Nipple-sparing mastectomy (NSM) has become increasingly popular due to improved cosmesis without compromising oncologic safety. Radial and inframammary incisions are usually used to achieve NSM, with periareolar incisions usually being avoided because of the risk to nipple-areola complex viability. In an attempt to maximize esthetic effects, we performed NSM through periareolar incision with immediate reconstruction. We report our initial experience. Methods This case series consisted of all consecutive patients (n = 34) who underwent NSM through a periareolar incision in our institution between August 2017 and December 2018. All patients underwent NSM through periareolar incision followed by immediate reconstruction with an implant or deep inferior epigastric perforator flap. Patient demographics, tumor and treatment characteristics, and short-term postoperative outcomes were reviewed. Results The mean patient age was 46.74 ± 6.69 years (range, 38-62 years), and the mean operation time was 96.68 ± 28.00 minutes. Indications included in situ cancer in 12 cases and invasive cancer in 22 cases. There was 1 major complication (postoperative hematoma) requiring operative reintervention. No other complications including fistula, implant exposure, or reconstruction failure was observed. At the time of writing, no case of local recurrence has been observed. Conclusion Our initial report shows that NSM with immediate reconstruction may successfully be performed through periareolar incision. This method maximizes esthetic effects and may be an appropriate surgical option for NSM.

The inferior pedicle is still the most commonpedicle used for breast reduction using both inverted T andvertical closure, however many unfavorable results may followas bottoming out and decreased upper pole fullness. Manytechniques were done to overcome the drawbacks of theinferior pedicle technique.Patients and Methods: 10 patients complain of huge ptoticbreast had inferior pedicle technique with full release ofpedicle from skin with glandular brassiere support in form oflower pillars on both sides with vertical skin closure.Results: Satisfactory long term results both objectivelyand subjectively, with good upper pole fullness and withoutbottoming out and only with vertical scar.Conclusion: This technique combined both the merits ofthe inferior pedicle reliability and better aesthetic results.

Background: Polyacrylamide hydrogel (PAAG) was used as an injectable implant for augmentation mammoplasty for over 30 years, but its use was ceased due to various related complications. The only way to treat these complications is PAAG removal, but this causes breast ptosis, nipple retraction, breast asymmetry, and skin laxity. Objectives: This article reports a new technique for breast reshaping after PAAG removal without prosthesis implantation. Method: From January 2015 to June 2018, twenty-three patients underwent periareolar mammoplasty with the tissue folding technique (PMTFT) for breast reshaping after PAAG removal. Postoperative breast shape and the degree of satisfaction of the patients were evaluated during follow-up. Results: All patients recovered well without severe complications. All patients were satisfied with their postoperative breast shape and their symptoms were relieved after surgery. Conclusions: PMTFT provides satisfactory postoperative breast shape results. Economical, practical, and technical advantages were found over traditional prosthesis-mediated breast reconstruction. PMTFT can be an ideal surgical choice in appropriate cases.

A standard method of performing breast lymphoscintigraphy is anterior and lateral views after periareolar intradermal injection of a radiotracer. However, a sentinel lymph node may be obscured by the activity at injection site, especially on anterior view. Also, breast tissue may cause attenuation to prevent sentinel node visualization. Repeat images during medial traction of breast by patient is an effective technique to improve visualization of sentinel lymph nodes in axillary region.

Background: Gynecomastia is the most common breast disorder in men. The usual treatment of grade III is surgical excision of the excess skin which may cause embarrassment and dissatisfying results Objective: To evaluate skin redraping after traditional liposuction in management of grade III gynecomastia Simon`s classification. Patients and methods: 20 patients with grade III gynecomastia with age group between 18 and 40 years old with mean 28.25 ± 4.18. It was a prospective observational cohort study. 11 cases underwent surgical gland excision through a semicircular infraareolar incision while 9 cases didn’t need to. The study was conducted at Alazhar university hospitals Results: The subjective results for all patients at 3 months assessment point. Four patients were very satisfied, eight satisfied, four neither satisfied nor dissatisfied while three patients dissatisfied. only one was very dissatisfied. The average sternal notch to nipple length pre and 3 months postoperative were respectively 27cm, 22cm. Our overall success rate is easily explained by several factors. The selection of young nonsmoker patient with no comorbid diseases or defective elasticity (varicosities or hernias), and the proper choice of the corset size and fiber as well as wearing it for the whole time of the study (3 months). The semicircular periareolar incision scars are not well defined as it become camouflaged by the color change between normal skin areola Conclusion: Conventional liposuction alone could be a reliable method to treat grade III gynecomastia in young patient with a good skin quality and helps in avoidance of undesirable scars.

Background:. Mastectomy and chest-wall contouring is the most common gender confirmation surgery. With increasing prevalence of transgender individuals, there is a demand for better surgical outcomes and aesthetic results. Our aim was to evaluate surgical techniques used and assess modifications in gender confirmation mastectomies at Karolinska University hospital in Stockholm, Sweden. Methods:. A retrospective cohort study was performed on 464 patients undergoing gender confirmation mastectomies in our department between 2009 and 2018. Patient demographics, psychiatric comorbidity, surgical method, and outcome were analyzed. Follow-up was at least one year. Results:. The most frequently used surgical technique for gender confirmation mastectomies was double incision with free nipple graft (243 patients, 52.4%), followed by periareolar incision (113 patients, 24.4%) and semicircular incision (67 patients, 14.4%). The double incision technique and periareolar technique were associated with 18.9% and 28.3% complications, 3.3% and 12.4% acute reoperations, 28.4% and 65.5% secondary revisions, respectively. The double incision technique increased from being used in 17.8% of all mastectomies during 2009–2013 to 62.9% during 2014–2018, while periareolar incision decreased from 43.0% to 18.5%. Conclusions:. The current study describes a successful transition of surgical technique from periareolar incision to double incision with free nipple graft in gender confirmation mastectomy, leading to significant improvements in the overall outcome with fewer complications, less acute reoperations and less secondary corrections. Hence, we consider the double incision with free nipple graft technique to be the favored technique in the vast majority of cases in female-to-male chest wall contouring.

Background: Bodybuilder gynecomastia represent special entity, being secondary to use/abuse of anabolic steroids leading to glandular enlargement as the sole or the main underlying pathology with occasional fatty element. Typical management entails complete gland excision through the least visible scar, (typically periareolar) with preservation of pectoral muscle and fascia integrity. Adjuvant small volume liposuction is needed in some cases with fatty element.Patients and Methods: The study enrolled a series of 13 bodybuilder with gynecomastia and history of anabolic steroids use/abuse. All cases presented with glandular tissue enlargement, with fatty element noted in 4 cases. Operations were done under general anesthesia with tumescent fluid infiltration. Through inferior periareolar incision almost the whole enlarged gland was excised, with adjuvant liposuction as indicated. Meticulous hemostasis and preservation of pectoral fascia integrity aimed to minimize excessive scaring beneath a thin overlying areolar skin flap and possible subsequent adhesions and contour irregularities.Results: All cases achieved final satisfactory results with high patients satisfaction. Early complications included minor hematoma in one case. Probably this was the cause of later dynamic depression seen with pectoral muscle contraction noted at 6 months follow up and resolved spontaneously during the next year.Conclusion: Bodybuilder gynecomastia managements entailed almost complete glandular tissue excision with limited liposuction in some cases. Meticulous technique including proper hemostasis is important to avoid even the minor contour irregularities and other complications in such demanding cases seeking perfect shape.

Background To date, studies on periareolar dermis release have recorded the areola sensitivity as a mean. Despite being clinically reported by patients, specific points of the areola may present sensitivities not detected when researchers only consider mean values. Objectives The aim of this study was to determine the pressure sensitivity at specific points of the nipple-areola complex and compare these values with the mean value measured in the areolas of patients undergoing reduction mammaplasty with periareolar dermis release. Methods This is a prospective, randomized controlled trial of 39 consecutive patients (78 breasts) who underwent surgery for treatment of breast hypertrophy; the same surgical technique was used for all patients. In each patient, 1 breast was assigned to a control group and the other to an experimental group. The periareolar dermis release was performed in the experimental group (39 breasts). Pressure sensitivity was tested with Semmes-Weinstein monofilaments on the papilla and at 4 specific points of the areola. The evaluations were conducted preoperatively and at 3 weeks, 6 weeks, and 1 year postoperatively. Results The group comparisons show a statistically significant difference in sensitivity at the medial point of the areola and in the papilla at 3 weeks postoperation. This difference disappeared in the 1-year evaluation. This recovery profile also occurs when areola sensitivity corresponds to a mean value. The sensitivity significantly decreased at the lower point of the areola up to 1 year postoperation in the control and experimental groups. Conclusions The periareolar dermis release did not compromise the pressure sensitivity at the points evaluated in the nipple-areola complex. The mean areola sensitivity differed from the sensitivity at the lower point of the areola. Level of Evidence: 4

Women seeking improvement of breast ptosis will often accept less of a lift for a reduced scar pattern. Periareolar incisions are at higher risk of scar widening related to excessive tension or suture failure along the areolar edge. The subareolar mastopexy technique can offer a means to reduce tension through dermal plication and provide satisfactory results in the right patient.

The treatment of the ptotic breast can be complex with the technique and the result dependent on a variety of factors. When a mastopexy is necessary, if performed alone, it is often inadequate to achieve the aesthetic goals of the patients, both in terms of volume and fullness in the upper pole. The addition of an implant can ameliorate these aesthetic issues. The success of augmentation mastopexy is multifactorial, but implementing the optimal surgical technique based on patient factors can significantly contribute to the long-term success of the procedure. Much attention is often given to the mastopexy approach, whether it be periareolar, vertical, or inverted-T. However, potentially even more impactful in the results is consideration for the type of implant to be placed and the pocket selected to optimize long-term success.

BACKGROUND: This study evaluated the feasibility of direct-to-implant breast reconstruction after nipple-sparing mastectomy using pure hemi-periareolar incision without extension and with the aid of indocyanine green angiographic evaluation on the mastectomy skin flap. METHODS: Patients who underwent immediate direct-to-implant breast reconstruction from December 2018 to February 2020 were included. After nipple-sparing mastectomy, indocyanine green angiographic evaluation of perfusion to nipple-areola complex was performed by video recording with a near infrared camera, and nipple perfusion time and perfusion pattern were analyzed. Patients were divided into a pure hemi-periareolar incision group and conventional lateral radial incision groups to compare nipple perfusion and surgical outcomes. RESULTS: A total of 61 breasts in 56 patients were included. Pure hemi-periareolar incision was used in 41 breasts, and conventional lateral radial incisions were used in 20 breasts. Nipple perfusion time was significantly increased in the pure hemi-periareolar incision group (79.6±65.8 vs. 43.2±49.8 seconds, P=0.031). While minor nipple-areola complex necrosis was significantly increased in the pure hemi-periareolar incision group (19.5% versus 0%; P=0.044), major nipple-areola complex necrosis (2.4% versus 5.0%; P>0.999) was not significantly different between the two groups. The rates of nipple-areola complex necrosis were 0%, 16.7%, and 63.6% in rapid, delayed, and no perfusion groups, respectively (P

Primary cutaneous follicle center lymphoma (PCFCL) is defined as a low-grade B-cell non- Hodgkins lymphoma, which primarily occurs and remains confined to the skin, without evidence of extracutaneous or systemic involvement at the time of diagnosis. PCFCL affecting the breast skin is an exceedingly rare entity with only two cases reported in the English literature. We present a case of PCFCL affecting the periareolar breast skin and review the relevant literature. Our patient was a 64-year-old female who presented with an erythematous plaque in the periareolar region of the left breast. The diagnosis of PCFCL was confirmed by a biopsy performed with a seven-month delay, as the tumor had been initially misdiagnosed as a benign lesion. The patient was successfully treated with local radiation therapy. PCFCL is an indolent lymphoma associated with an excellent prognosis. For localized lesions, skin-directed therapies mainly consisting of radiation therapy or complete surgical excision are curative therapeutic approaches, while systemic chemotherapy should be reserved for patients with extensive disease. This case highlights the need to consider PCFCL as an important differential diagnosis in patients presenting with non-resolving erythematous breast skin lesions. A timely biopsy should be obtained to avoid delays in the initiation of appropriate treatment.

Introduction While the long-term oncologic safety of robot-assisted nipple sparing mastectomy (RNSM) remains to be elucidated, histologically detected residual breast tissue (RBT) can be a surrogate for oncologically sound mastectomy. The objective of this study is to determine the presence of RBT after RNSM. Methods Between August 2019–January 2020, we completed 5 cadaveric RNSMs. Full thickness biopsies from the mastectomy skin flap were obtained from predefined locations radially around the mastectomy skin envelop and nipple areolar complex to histologically evaluate for RBT. Results The first case was not technically feasible due to inability to obtain adequate insufflation. Five mastectomy flaps were analyzable. The average mastectomy flap thickness was 2.3 mm (range 2–3 mm) and the average specimen weight was 382.72 g (range 146.9–558.3 g). Of 70 total biopsies, RBT was detected in 11 (15.7%) biopsies. Most common location for RBT was in the nipple-areolar complex, with no RBT detected from the peripheral skin flaps. Conclusions In this cadaveric study, RNSM is feasible leaving minimal RBT on the mastectomy flap. The most common location for RBT is in the periareolar location consistent with previous published findings after open NSM. Clinical studies are underway to evaluate the safety of RNSM., Highlights • Robot-assisted nipple sparing mastectomy (RNSM) is technically feasible. • Residual breast tissue after RNSM is histologically detected only from the periareolar location. • Further clinical trials are underway to determine oncologic safety of RNSM.

Chest masculinization is the most common gender-affirming operation performed. With increased access to care and improved insurance coverage, there has been a marked increase in the number of procedures performed. A video is presented with narration focused on the surgical technique of a "double-incision" mastectomy for gender-affirming chest masculinization. The Fisher grading scale used in technique selection of double-incision versus periareolar mastectomy, based on patient-specific anatomical parameters, is reviewed. Technical pearls for refinement of the double-incision top surgery technique for gender affirmation are then demonstrated.

Background Breast-conserving surgery (BCS) has been performed as a standard procedure because the addition of radiation therapy after breast-conserving surgery in early breast cancer patients is similar to that of mastectomy.The surgical methods for breast cancer have been developed in recent years, and the cosmetic aspect has become important.Several incisions are used to reduce the scar to the incision site during BCS. The periareolar incision is often used when the small tumor relatively close to the nipple. However, periareolar incision does not have sufficient field of sight, which can result in difficult or impossible operations if the tumor is large or far from the nipple. In plastic surgery, various methods such as zigzag incisions have been recommended to achieve satisfactory esthetic results. The periareolar zigzag incision has the advantage of a not only good surgical field but also contributed to better surgical scars. The purpose of this study was to evaluate the oncological safety of procedures by studying the status of the surgical margins of the excised tumor specimen and reduces the need for further surgery Methods From January 2016 to November 2017, we conducted a survey of female patients who underwent BCS using zigzag incision. Patients with exclusion criteria were excluded from this study if they had a Patients with bilateral breast cancer or neoadjuvant chemotherapy was included in the study. Intraoperative frozen section margin was evaluated in all patients and additional resection was performed when the positive margin was present. Final margin status was determined by examination of the permanent paraffin-embedded sections. In patients with invasive breast cancer or relatively large carcinoma in situ, axillary surgery was performed according to the presence of axillary metastasis. Patients characteristics, tumor characteristics, operative time, size of the specimen and the distance from the tumor to nipple were evaluated Results 393 patients were enrolled in the study, including 9 patients with bilateral breast cancer, and a total of 402 cases of BCS surgery were analyzed. Thirty-five patients received neoadjuvant chemotherapy. The median age of the patients was 51 (range: 25-84 years), the median time of operation was 72 minutes in patients who did not undergo axillary surgery or sentinel node biopsy only, and 83 minutes in patients who underwent axillary node dissection or supraclavicular node dissection. The median tumor size was 1.6 cm (range: 0-8.8 cm), median tumor distance from the nipple was 3.0 cm (range: 0.4-8.1 cm), mean excised specimen sized was 5.0 cm (range: 0.9-15.0 cm). Frozen biopsy of the resection margin during surgery revealed tumor-positive in 69 (17.2%) cases and re-excision was performed. All patients were discharged with no sign of infection or skin necrosis. Conclusions The periareolar zigzag incision technique has good cosmetic results and provides a sufficient surgical field, which can be useful for removing relatively large tumors or tumors far from the nipple. Citation Format: Ko B, Kim H, Chung I, Lee S, Kim J, Lee J, Son B, Ahn SH. Usefulness of periareolar zigzag incision in oncoplastic breast-conserving surgery [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-13-08.

Background Periareolar mammoplasty is a volume displacement oncoplastic technique for patients with small to medium sized breasts. This approach provides good access for a safe excision for both central and peripheral lesions, especially for those in the upper half of the breast. Cosmetically it allows good reshaping of the breast, and contralateral symmetrisation is rarely required. This technique has the potential to replace the standard wide local excision for breast cancer. There is scarcity of data about the results of this procedure in the literature. We present a single surgeon experience with this technique in terms of surgical and oncological outcomes. Methods Retrospective review of patients' records from October 2013 to December 2017 was performed. The patients' demographics, tumour characteristics and the early oncological outcomes were studied. The postoperative complications and rate of symmetrisation were also studied. Results -There were 110 patients in this study period. The median age was 60 years (range 36 – 82 years) and screen detected tumours accounted for 66% (72 patients) of cases. -Neoadjuvant therapy was given in 14 patients (endocrine therapy – 12, chemotherapy – 1, dual targeted therapy – 1). -Most patients had the lesion in the upper half of the breast (upper outer-71, upper inner-33). -The average size of the tumour was 18.9mm (range 1.8 – 70mm) and the average weight of the excised specimen was 47.2gm (range 11-190gms). Invasive carcinoma was seen in 94 patients (85%) of which 86 patients had invasive ductal carcinoma, 4 had invasive lobular carcinoma and 4 had special type. Pure DCIS was present in 16 patients (15%). Most patients had grade 2 cancers (45%). DCIS was present with invasive carcinoma in 55% of cases. -Thirteen patients had positive margins ( -Of the 13 patients with positive margins: 5 required margin re-excision, 6 had completion mastectomy and 2 received only radiotherapy. -The median follow-up was 25 months (range 3 – 53 months). Seven patients developed complications which included 3 hematomas (2 requiring evacuation) and 4 wound infection which were treated with antibiotics. Only two patients required contralateral symmetrisation and no local recurrences were encountered in this study period. Conclusion Periareolar mammoplasty is a robust, easily adaptable and reproducible oncoplastic technique allowing for safe wide local excision of breast cancer. The margin re-excision, postoperative complication and recurrence rates in this study are acceptable and low compared to standard wide local excision. This technique gives excellent access, and allows better breast reshaping resulting in pleasing aesthetic outcome. Contralateral symmetrisation is rarely required with this technique. Citation Format: Burrah R, Vinayagam R, James K. Breast conserving surgery by periareolar mammoplasty – Surgical and oncological outcomes [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-13-06.

Paget’s disease of the breast is a rare intraepithelial malignancy involving the nipple–areola complex, often associated with an underlying in-situ or invasive carcinoma in the breast parenchyma. Most of the cases disease is usually limited to nipple–areola or surrounding periareolar skin. We are reporting a case of extensive Paget’s disease, involving entire breast skin and even part of abdominal wall skin without any underlining breast pathology, which is a rare presentation.

BACKGROUND Nipple-sparing mastectomy allows for preservation of the entire nipple-areola complex using various incision patterns. Reconstructive trends and overall risk associated with these diverse nipple-sparing mastectomy incisions have yet to be fully elucidated. METHODS All nipple-sparing mastectomies from 2006 to 2017 were identified; outcomes were stratified by type of mastectomy incision: lateral or vertical radial, inframammary fold, Wise pattern, previous, and periareolar. RESULTS A total of 1207 nipple-sparing mastectomies were included for final analysis. Of these, 638 (52.9 percent) used an inframammary fold incision, 294 (24.4 percent) used a lateral radial incision, 161 (13.3 percent) used a vertical radial incision, 60 (5.0) used a Wise pattern incision, 35 (2.9 percent) used a previous incision, and 19 (1.6 percent) used a periareolar incision. The groups were heterogeneous and differed significantly with regard to various factors, including age (p < 0.001), body mass index (p < 0.001), reconstruction modality (p < 0.001), and others. In crude multivariate logistic regression analysis, vertical radial (16.1 percent) and inframammary fold incisions (21.0 percent) were associated with lower overall complication rates. In a reduced multivariate logistic regression model, inframammary fold incisions (p = 0.001) emerged as significantly protective of overall complications after controlling all variables. CONCLUSIONS Nipple-sparing mastectomy may be safely performed using various mastectomy incisions, each with unique advantages and limitations. Overall, inframammary fold incisions appear to be associated with the lowest risk, whereas Wise pattern incisions may increase risk. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.

Background: The recognized procedures that have been used to treat gynecomastia are said to have relatively a long operative time, less patient satisfaction rate, they are merely used, in mild to moderate gynecomastia, leaves a mild bulging over the nipple areola complex, resulting in aesthetically unsatisfactory results. The more the grade of gynecomastia, the more complicated the used surgical techniques. This study evaluates the success rate of these simplest surgical technique in higher grades of gynecomastia. Objectives: to present the experiences with use of Modification of Combined Vibrated Power Assisted Liposuction with Periareolar Gland Excision in management of in different type Gynecomastia Type of the study: This is a retrospective study Methods: The study includes the use of a modification of combine vibrated power-assisted liposuction with periareolar gland excision applied for managing different types of gynecomastia. In 23 consecutive patients (46 breasts) treated between February of 2011 and March of 2016. Results: 23 patients (46 breasts) were successfully treated using this technique. Volume aspirated in both breast was 792 ml (range, 450 to 1600 ml). Using the periareolar excision technique, the mean operative time was 55 minutes (range, 45 to 90 minute). Complications were minimal (1.5 % per breasts), and no revisions were required. Conclusions: The modified Combined vibrated power assisted liposuction and the periareolartechnique have demonstrated to be a less time consuming versatileapproach, for the treatment of gynecomastia and consistently produces a smoothcontoured male breast, it is promising method to achieve good aesthetic results in gynecomastia surgerywhile resulting in an inconspicuous scar.

Surgical treatment of breast cancer has changed considerably over the past four decades, culminating in the substitution of conservative approaches for Halsted's paradigm from 1894. In parallel, many breast reconstruction techniques have been proposed for patients requiring mastectomy with loss of the nipple-areola complex (NAC). Myocutaneous flaps were once the most common form of reconstruction, but recently the use of implants and nipple-sparing mastectomy (NSM) in one or two stages has gained popularity. In this descriptive and cross-sectional study, we evaluated a sample of 31 NSM procedures with periareolar incision and two-stage reconstruction (tissue expander followed by implant) conducted between 2013 and 2017, with emphasis on the rate of complications after at least 3 months of follow-up, local disease control and cosmesis measured on the Harvard scale. Five complications (16%) were observed, all of which related to the first stage: seroma (n = 1; 3.2%), treated with needle aspiration, NAC necrosis (n = 3; 9.6%), one case of which required debridement, and dehiscence (n = 1; 3.2%), treated with resuture. Cosmesis was classified as excellent by the surgeon in 96.8% (n = 27). At the time of writing, no local recurrence had been observed. In conclusion, NSM with periareolar incision and two-stage reconstruction was found to be technically feasible and associated with few complications and satisfactory esthetic outcomes.

Background: Patients with tuberous breasts suffer ofpsychosocial problems which may be aggravated with presenceof asymmetry. Plastic surgeons should fully understand thedevelopmental and anatomical basis of such deformity. Thesurgical plan is individualized according to the severity ofdeformity, presence of ptosis and degree of asymmetry. Inthis study we aim to correct the whole pathology and improvebreast aesthetics in patients with bilateral asymmetric tuberousbreasts.Methods: 8 female patients with bilateral asymmetrictuberous breasts presented to outpatient clinic. Breast examinationand measurements were done. Surgical correction withperiareolar mastopexy and differential augmentation mammoplastywere done in all cases.Results: Patients' mean age was (28.7) years. All patientshad asymmetric breasts as regards; tuberous type, breastvolume, projection, areola diameter, nipple and areolar complexposition and degree of ptosis. Postoperatively, tuberous deformitywas corrected in all cases. Good symmetry, andenhancement of breast volume and projection with naturallylookingbreasts are achieved. Intermammary distance wastremendously decreased. Seven patients were highly satisfied,(87.5%) one patient (12.5%) as only satisfied.Conclusion: Periareolar mastopexy approach, efficientrelease of constricting ring, repositioning of inframammarycrease and differential breast augmentation are keys to achievethe best possible aesthetic outcome in managing tuberousbreast asymmetry.“Level of Evidence: Level IV”.

Background Women with large and/or ptotic breasts are often not considered candidates for nipple-sparing mastectomy (NSM) and/or immediate breast reconstruction given difficulties avoiding ischemic complications and achieving a favorable aesthetic result. We report a novel technique involving deepithelialized skin reduction to simultaneously reduce the skin envelope and preserve perfusion to the skin and nipple in immediate breast reconstruction for women that fit this high-risk anatomic profile. Methods We reviewed cases of NSM and skin-sparing mastectomy (SSM) with immediate implant-based and free autologous reconstruction by a single plastic surgeon from 2013 to 2017. All patients had at least size C cup breasts (>500 g) and/or grade 3 ptosis. Select patients undergoing NSM had devascularization of the nipple-areolar complex (NAC) 1 to 2 months before surgery to promote adaptive circulatory change. After mastectomy, skin reductions were performed via Wise, periareolar, or circumareolar reduction patterns, with infolding of a deepithelialized inferior and periareolar skin flap over a tissue expander or free flap. In NSM, the nipple was advanced superiorly and redirected through a keyhole of deepithelialized skin flap. Results Patients had an average age of 43.6 years and body mass index of 27.7. A total of 33 breasts in 19 patients (14 bilateral, 5 unilateral) underwent deepithelialized skin reduction. There were 14 NSM and 19 SSM. Reconstructions consisted of 13 tissue expanders exchanged to implants and 20 abdominally-based free flaps. Four patients underwent devascularization of the NAC before NSM. Six (18%) breasts had partial thickness flap loss that healed by delayed primary (n = 1) or secondary (n = 5) intention. Four nipples, all in patients without prior NAC devascularization, had ischemic complications (2 epidermolysis, 12.5%; 2 partial necrosis, 12.5%), which all healed by secondary intention with the exception of 1 case of NAC removal. Conclusions Skin reduction with deepithelialization and tissue infolding preserves dermal plexus perfusion and promotes nipple and skin flap survival in immediate implant-based and autologous breast reconstruction after SSM and NSM. This technique can be combined with NAC devascularization to further promote nipple perfusion. Overall, this method offers an acceptable complication rate and the potential to expand the reconstructive options available to women with large and/or ptotic breasts.

There is an increased demand for gender affirmation surgery. Chest contouring, or “top” surgery, is especially important in the female-to-male (FtM) transgender population. This Continuing Medical Education (CME) article critically appraises the available literature on top surgery to allow plastic surgeons to understand current practices and determine the best surgical technique using a decision algorithm and the patient’s preoperative anatomy and characteristics. Because a single best surgical approach does not exist due to significant variance in preoperative patient anatomy, and in order to provide a useful framework for decision making, surgical approaches described are categorized as: approach 1—remote incision procedures without skin excision; approach 2—procedures with periareolar skin excision; and approach 3—mastectomy procedures with skin excision other than periareolar skin excision. Decision algorithms that help determine the most suitable surgical technique for individual patients are reviewed. Data on complication rates and patient satisfaction will improve informed consent discussions and create realistic patient expectations.

BACKGROUND Chest wall masculinization by means of mastectomy is an important gender affirming surgery for transmasculine and non-binary patients. Limited data exist comparing commonly used techniques in masculinizing top surgery, and most are single institution studies. METHODS A systematic review was performed on primary literature dedicated specifically to the technical aspects and outcomes of mastectomy for masculinizing top surgery. For each study, patient demographics and surgical outcomes were compared. RESULTS Eight studies met inclusion criteria. There were 2138 breasts with an average patient age of 28.6 years and the average breast weight was 353 g. The most commonly reported techniques are those without skin resection (8.0%), those with periareolar skin resection (34.1%), inferior pedicle mammoplasty (15.7%), and inframammary fold skin excision with free nipple grafting (FNG, 42.2%). In total, 6.0% of all breasts required acute reoperation for hematoma and 26.5% required secondary operations. Acute reoperation occurred significantly less often in the FNG cohort (4.8%) compared with both the inferior pedicle mammaplasty cohort (8.9%, P < 0.05) and techniques without skin resection cohort (10.3%, P < 0.05). Secondary operations occurred significantly more often in the periareolar skin resection cohort (37.5%) than techniques without skin resection cohort (19.0%, P < 0.01), inferior pedicle mammaplasty cohort (27.9%, P < 0.01), and FNG cohort (20.3%, P < 0.05). In addition, secondary operations occurred significantly more often in inferior pedicle mammaplasty cohort (27.9%) compared with FNG cohort (20.3%, P < 0.01). CONCLUSIONS This analysis notes several significant differences with regard to percentage requiring acute reoperation and percentage requiring secondary revision based on technique. Candidates for masculinizing top surgery should be educated on these differences.

At our department, the authors performed a periareolar mastopexy and harvested costal cartilage for use in a rhinoplasty through the same periareolar incision. This technique has several advantages compared to the traditional method, including less invasion, minimal chance of a hypertrophic scar and easier postoperative care. However, the location of the incision determines that the fifth costal cartilage is the lowest one accessible. Thus, calcification of the implant material poses a challenge to surgeons.In this case report, the authors present a 25-year-old female with a low-profile nose and mild breast ptosis who received a periareolar mastopexy and a dorsal and nasal tip augmentation simultaneously. The operation method, outcomes, advantages and potential risks are included.

Skin-sparing mastectomy (SSM) enables a radical cure of breast cancer while overcoming the cosmetic issues related to surgery. We review our experience of performing SSMs and assess whether preservation of the nipple–areola complex (NAC) could have been an option for some patients who underwent SSM. The subjects of this retrospective study were women who underwent SSM that utilized four incision types; namely, the so-called tennis racket incision, a periareolar and midaxillary incision, an areola-sparing and midaxillary incision, and a small transverse elliptical incision. We assessed whether preservation of the NAC would have been an option in SSM, based on histologic examination of three serial cut surfaces of the specimen around the nipple, ruling out the option when evidence of the malignant lesion/s was found in at least one of the following locations: in the nipple, within a 1-cm radius from the base of the nipple, or within 1 cm from the surface of the NAC. We performed 193 SSMs. The cumulative 10-year local disease-free survival rate was 98%, with 89% of patients reporting levels of satisfaction with the reconstructed breast, of excellent, very good, or good. We evaluated that 70 of the 193 procedures could have been performed as nipple-sparing mastectomy (NSM). The outcomes of SSM in this series were excellent and NSM might have been an option for about one-third of the patients.

The periareolar access has been the preferred technique used at our institution for minimally invasive cardiac surgery since 2006. The surgical approach consists of video-assisted minithoracotomy in the 4th right intercostal space, through a periareolar incision. Initially, the technique was restricted to minimally invasive mitral valve surgeries but, due to its feasibility and safety, was soon incorporated as an ideal access for other cardiac pathologies such as tricuspid valve disease, atrial septal defect, atrial fibrillation, and pacemaker leads endocarditis. The technique was performed in 214 patients, and it is associated with excellent aesthetic and functional results, with low morbimortality and no reoperations at long-term follow-up. Here, we describe and support the use of periareolar access as a routine surgical technique for correction of several cardiac pathologies, especially in women.

Gynaecomastia is excessive or abnormal enlargement of male breast tissue. It is one of a common problem among young men. The term gynaecomastia means female like enlargement of male breast due to increase ductal tissue, stroma or fat. Most common cause of gynaecomastia is idiopathic. Surgical treatment of gynaecomastia involves liposuction and glandular excision and in few cases skin excision. Here author presents a case of 24 years old young healthy male with Simon’s grade 2B bilateral gynaecomastia. He had stubborn fat over bilateral chest which was resistant to exercise. Gynaecomastia was mixed type in characteristic having adipose tissue as well as glandular tissue enlargement. Bilateral liposuction and glandular excision by limited periareolar incision under general anesthesia as a day care procedure was done. In our procedure we used Cross chest liposuction. Patient was discharged at the same evening without any complications. After four months of follow up patient has male pattern chest with almost invisible scar and intact Nipple areolar complex (NAC) sensation.