13Periareolar Techniques

Alexandre Mendonca Munhoz

13.1 Introduction

The nipple–areola complex (NAC) is an important compo-nent of the breast and its aesthetic outcome is crucial in mostpatients who have been diagnosed with breast cancer. Thetechnical objectives of breast surgery are resection of thebreast tissue with adequate margins while restoring the breastvolume. To achieve these goals, numerous approaches havebeen proposed involving a variety of designs incorporating aperiareolar incision, or other variations in the shape aroundthe NAC [1–8]. In our experience, with the periareolarapproaches, the aesthetic results can be improved further[9–11]. In breast-conserving surgery (BCS), the final scarringcan be kept at the natural border of the NAC with the breastskin. In skin-sparing mastectomy (SSM), the patchlike effectof skin flaps can be avoided, which may be less favorablethan the other incisions [9, 10]. Thus, scar reduction and eventotal camouflage by the future NAC reconstruction are themain positive aspects of the periareolar techniques [9].

Despite its advantages, it is our impression that theperiareolar approach is not appropriate for all patients. Inour experience, it is more suitable in patients with small/medium-sized breasts with an adequate areola diameter.Restricted surgical exposure and difficulty in skin flapdissection are commonly observed for patients with a smallareola and inexperienced breast surgeons.

The importance of obtaining a good aesthetic result,while avoiding visible scars, has led breast and plasticsurgeons to shift the location of the incision to an areolarregion in selected cases. We believe that the hemicircu-mareolar or total circumareolar technique with appropriateplanning achieves favorable aesthetic results with fewercomplications.

13.2 Indications and Patient Selection

Appropriate patient selection is critical. Thus, patients areusually first seen in the preoperative period by a multidis-ciplinary team to evaluate the breast volume, ptosis, andtumor size/location. For patients with a large-diameterareola (more than 4 cm) without breast ptosis (Regnaultgrade I), a hemicircumareolar incision is indicated(Fig. 13.1). Other important indications are the presence ofa marked color transition between the NAC and the breastskin, small and medium-volume breasts (cup size A or B),and tumors located near the central quadrant (4–5 cm fromthe NAC). For patients with a small/medium-diameterareola (less than 4 cm), with some degree of breast ptosis(Regnault grade II), and with small and medium-volumebreasts (cup size A or B), a complete circumareolar incisionis better indicated (Fig. 13.2).

Relative contraindications include more significantbreast ptosis (Regnault grade III or grade III [12]—Table 13.1), very large breasts, and especially a very smallNAC (less than 2.0 cm). As the degree of ptosis increases, itis more likely that an L-shaped or inverted-T skin excisionwill be helpful in consistently achieving the desired result.If the nipple sits well below the inframammary fold or mustbe elevated more than 4 cm, a periareolar mastopexybecomes riskier. A very small NAC with a well-definedborder is more likely to result in an enlarged areola and anunsatisfactory scar, with irreparable loss of the originalshape and size of the areola.

13.3 Skin Markings

Usually, the skin markings (the sternum midline, theinframammary folds, and the areola diameters on the ver-tical lines from the midclavicle) are drawn with the patientin an upright position. If there is a large-diameter areola andno breast ptosis, a semicircular periareolar incision (hemi-circumareolar) is usually indicated in BCS or nipple–areola

A. M. Munhoz (&)Plastic Surgery Department, Hospital Sírio-Libanês,São Paulo, Brazile-mail: munhozalex@uol.com.br

C. Urban and M. Rietjens (eds.), Oncoplastic and Reconstructive Breast Surgery,DOI: 10.1007/978-88-470-2652-0_13, � Springer-Verlag Italia 2013

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sparing mastectomy (NSM). In these cases no additionalskin markings are necessary. To prevent conspicuous scar-ring within or outside the areola, the incision is performedexactly at the junction of the areola and surrounding skin. Ifthere is a small/medium-diameter areola and breast ptosis,an epidermic decortication of the complete circumareolarmarked cutaneous ring and transdermic access along itsinferior border are indicated (Figs. 13.2, 13.3). In thesecases it is important to make the following marks: Point A,19–21 cm from the midclavicular line and 10–12 cm fromthe external line. The ideal diameter of the NAC (25–30 mm) is outlined as a complete circumareolar epidermicring (maximum width of 20–25 mm) which will be resectedto reduce the cutaneous excess. The medial limit of resec-tion coincides with the 10–12 cm of the external line andthe same distance is maintained for the lateral limit. Theselimits of skin resection are confirmed by the medial–lateral

and superior–inferior pinch test, ensuring there was notension after removal of the skin.

13.4 Surgical Technique

The surgical procedure is performed with the patient undergeneral anesthesia and with the patient’s the arms sup-ported symmetrically 30� away from the chest. It isimportant to begin the sharp dissection with a no. 10 bladeand the NAC is elevated off the underlying breast paren-chyma Care is taken to leave a thickness of the retroare-olar glandular tissue of approximately 1–2 cm to avoidnipple retraction. The incision is closed in layers withinterrupted subcutaneous Vicryl 4-0 sutures and a contin-uous intracutaneous Prolene 4-0 suture (Ethicon, Johnson& Johnson, Hamburg, Germany).

Fig. 13.1 A hemicircumareolarincision approach for patientswith a large-diameter areolawithout breast ptosis

Fig. 13.2 A completecircumareolar incision associatedwith transdermic access along itsinferior border for patients with asmall/medium-diameter areolawith some degree of breast ptosis

128 A. M. Munhoz

In patients with a small/medium-diameter areola withbreast ptosis, an epidermic decortication of the completecircumareolar marked cutaneous ring and transdermicaccess along its inferior border are performed. Thus, thesubdermal plexus coming from the medial, lateral, andcephalic side of the areola is spared to ensure vascularsupply to the NAC. Glandular excision is completed, leavingan adequate thickness of the subcutaneous tissue and aproper subareolar amount of gland. Skin flaps are handledcarefully with the use of delicate hooks in order to maintainthe integrity of the subdermal plexus and to avoid excessiveskin flap traction. The skin is closed by the triple-layertechnique. This technique is achieved by deepithelializationof the periareolar circle and advancement of the remainingareolar edge over this deepithelialized area. The advancedareolar edge is fixed over the deepithelialized area using adeeper layer of sutures anchoring the deepithelialized edgeunder the advanced areola and a superficial layer of suturesanchoring the edge of the advanced skin to the edge of theskin of the deepithelialized flap. This way, the terminal skinsuture only overlies intact dermal and subcutaneous tissues,and all other sutures are not present in only one layer

(Figs. 13.3, 13.4). A 2-0 nylon intradermal circumareolarpurse-string suture is then used to limit the periareolarcentrifugal tension and to improve areolar symmetry; acontinuous 4-0 nylon suture (Ethicon, Johnson & Johnson,Hamburg, Germany) is used on the areolar skin surface toenhance the quality of the skin–areola transition zone.

13.5 Periareolar Technique in Skin-SparingMastectomy

SSM has been demonstrated to be an oncologically safeprocedure for the treatment of early-stage breast cancer [1–3, 13, 14]. Compared with traditional mastectomy, SSMprovides an ideal color and texture of breast skin andenhances the contour of the inframammary crease. To allowfor adequate breast skin preservation, the oncoplastic sur-geon should preoperatively discuss the periareolar incisionand the width of the remaining skin flaps.

A critical survey of the literature shows that SSM isnormally performed through numerous techniques, but mostinvolve central breast incisions [1–3, 13, 14]. Habitually,the technique differs from surgeon to surgeon and isdependent on factors such as the type of reconstruction andthe size of the breast. Although the type of incision differs,it is our impression that the best aesthetic outcome is relatedto the total periareolar approach [9]. With this technique,

Fig. 13.3 The diameter of the nipple–areola complex (NAC) isoutlined, as is the complete circumareolar epidermic ring, which willbe resected. After the decortication, full access (transdermic) along itsinferior border is performed. The transdermic access along the inferiorborder of the decorticated ring and glandular resection

Fig. 13.4 A partial submuscular pocket under the pectoralis majormuscle is elevated from the inferior to the superior positions and thepectoralis muscle is partially detached. Closure of the periareolarincision is performed by the triple-layer technique. This technique isachieved by the advancement of the remaining areolar edge over thisdeepithelialized area. The advanced areolar edge is fixed over thedeepithelialized area using a deeper layer of sutures anchoring thedeepithelialized edge under the advanced areola and a superficial layerof sutures anchoring the edge of the advanced skin to the edge of theskin of the deepithelialized flap

Table 13.1 Regnault’s classification of ptosis

Degree Characteristics

Minor (grade I) Nipple at the level of the inframammary fold

Moderate (grade II) Nipple below the inframammary fold, but above the lower breast contour

Severe (grade III) Nipple below the inframammary fold, at the lower breast contour

Glandular ptosis Nipple above the level of the inframammary fold but the breast hangs below the fold

Pseudoptosis Nipple above the level of the inframammary fold but the breast is hypoplastic and hangs below the fold

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the final scar can be kept at the transition of the naturalborder of the future NAC (Fig. 13.5).

In therapeutic SSM, specific areas of skin may in someinstances require excision including prior incisions. Ourapproach to this issue is better performed through a centralincision where the previous biopsy scar is excised in con-tinuity with the NAC. Thus, previous communication of theteam performing the biopsy/lumpectomy with the onco-plastic surgery team is critical in order to plan the incisionas close as possible to the NAC. Usually, a total periareolarincision is performed, and with use of delicate hooks andfiber-optic retractors, the breast tissue dissection is per-formed in the same subcutaneous layer, reaching the finalmargins of the breast parenchyma. Skin flaps are handledcarefully in order to maintain the integrity of the subdermalplexus and avoid excessive skin flap traction and evendermal exposure. A minimum flap thickness of 3–5 mm ismaintained (Fig. 13.6).

The immediate reconstruction can be performed with animplant only, an expander and an implant, an implant asso-ciated with a pedicled latissimus dorsi muscle flap (LDMF), atransverse rectus abdominis musculocutaneous flap, or a deepinferior epigastric adipocutaneous free tissue transfer flap. Inour experience, the reconstruction technique is frequentlyperformed with a biodimensional implant–expander systemassociated with an LDMF as described elsewhere [9](Figs. 13.7, 13.8). This option is usually chosen on the basisof individual aesthetic considerations but taking into accountpatient choice. This aspect is important since we have notedthat some groups of patients prefer less evident breast scars.

Thus, patients who are candidates for SSM and who do notwant a large horizontal breast scar are the best candidates forSSM through a total periareolar incision. In fact, with the totalperiareolar incision and reconstruction, the final scar can bekept at the transition of the future NAC border, which mayeven be camouflaged by the NAC reconstruction. In addition,the latissimus dorsi muscle can be incorporated into thesubmuscular pocket. The implant–expander is placed in a

Fig. 13.5 The total periareolarapproach for skin-sparingmastectomy (SSM) andimmediate reconstruction. Withthis technique, the final scar canbe kept at the transition of thenatural border of the future NAC

Fig. 13.6 The total periareolar incision is performed, and with use ofdelicate hooks and fiber-optic retractors, the breast tissue dissection isperformed in the same subcutaneous layer, reaching the final marginsof the breast parenchyma. Skin flaps are handled carefully in order tomaintain the integrity of the subdermal plexus and to avoid excessiveskin flap traction. A minimum flap thickness of 3–5 mm is maintained

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total submuscular position, where a cover is made in itssuperior two-thirds by the pectoralis muscle and the inferiorthird by the LDMF. This allows creation of a tension-freemuscular pocket while providing adequate tissue coveragefor the implant–expander [9]. In cases in which vascularity ofthe mastectomy flap is unpredictable, the expansion can beinitiated with limited fluid, which allows these flaps time torecover vascularity [9, 15, 16]. If there are small areas of skinnecrosis, the patient can be treated on an outpatient basis withimplant deflation and dressing changes since the implant islocated under a healthy muscular pocket [9, 17]. In ourexperience, native breast skin complications were observedin almost 10 % of patients and represented one-third of allcomplications. Most cases consisted of partial skin loss andwound dehiscence between the LDMF and the breast skin [9].

In spite of the main advantages, the total periareolartechnique has some limitations. The surgical exposure isrestricted and dissection can be troublesome if the onco-logical surgeon is inexperienced [1, 9, 13]. In this situation,more breast skin tension and flap irregularities can be notedand a poor exposure may result in an inadequate oncolog-ical resection (Fig. 13.8).

13.6 Periareolar Techniques in Nipple–Areola Sparing Mastectomy

Recently, a debate has developed about the possibility ofextending preservation of the skin in SSM to include theNAC [4–8]. Thus, NSM is an alternative to mastectomy

which aims at avoiding the removal of the NAC and thepositive consequences for immediate reconstruction.

The objectives of NSM reconstruction are resection ofthe breast tissue while restoring the breast volume, shape,and symmetry. To achieve these goals, numerous inci-sions have been proposed (Fig. 13.9). However, thedecision of the access incision with no complications hasattracted attention in the literature [4, 5, 7, 8]. Besidesthe restricted access, the conventional periareolarapproach can potentially result in vascular impairment tocollateral flow, which can induce partial or total NACnecrosis. In fact, Regolo et al. [5], in a series of 32consecutive NSM using the conventional periareolarapproach observed a high rate of necrotic complicationsof the NAC (60 %). Consequently, we have developed anapproach to improve surgical access for patients who arecandidates for NSM based on a total circumareolarincision similar to that previously described for gyneco-mastia treatment [10, 18, 19].

Usually, the diameter of the NAC (3–4 cm) is outlined,as is the complete circumareolar epidermic ring (maxi-mum of 4–5 cm width), which will be resected toimprove surgical access. An epidermic decortication ofthe complete circumareolar marked cutaneous ring andfull access along its inferior border are performed. Theskin closure is performed by the triple-layer techniquedescribed previously [10]. This last aspect is crucial insome circumstances, since the pectoralis major muscle isusually not long enough to cover the implant totally.Thus, extending the deepithelialization around the areolar

Fig. 13.7 The reconstructiontechnique is performed with abiodimensional implant–expander system associated witha latissimus dorsi myocutaneousflap. The flap provides adequateskin cover for the resected NACand the final scar can be kept atthe transition of the future NACborder. The latissimus dorsimuscle can be incorporated intothe submuscular pocket and theimplant–expander is placed in atotal submuscular position wherea cover is made in its superiortwo-thirds by the pectoralismuscle and the inferior third bythe latissimus dorsi muscle flap

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incision allows complete and secure triple-layer closure ofthe entire wound. In this fashion, no part of the suturelines are present in only one layer, thus lessening the riskof implant contamination or exposure. In some situations,small potential areas of delayed healing of the incisioncan be treated conservatively as a consequence of thecomplete underlying soft-tissue cover over the implant(Fig. 13.10).

There are some limitations of present technique relatedto breast anatomy and experience. The surgical field islimited and dissection can be difficult. Thus, the procedureis not applicable for all types of breast volume, position, andtumor location.

Partial and full-thickness NAC necrosis has beendescribed following NSM [4–7]. It is our impression thatour acceptable incidence of NAC necrosis is probably due

Fig. 13.8 A 54-year-old patientwith a 4.8-cm invasive ductalcarcinoma located in the rightbreast (a, b). The reconstructionmarkings showing the plannedperiareolar SSM (c). The patientunderwent SSM with axillarydissection (d). The patientunderwent immediatereconstruction with abiodimensional implant–expander (McGhan 150 volume385–405 cm3) associated with alatissimus dorsi myocutaneousflap (e, f). Postoperativeappearance at 11 months with avery good outcome afterradiation therapy (g, h)

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to several factors. These factors include full access alongthe inferior border of NAC which seems to allow adequateblood supply to the NAC. In addition, another importantaspect is related to the preparation of the skin flaps and theretroareolar tissue. For this reason, it is important to leavean adequate thickness of the subcutaneous tissue and aadequate subareolar amount of gland to avoid postoperativeareolar retraction and necrosis [10].

13.7 Periareolar Techniques in Breast-Conserving Surgery

BCS is an important component of early breast cancertreatment, with a survival outcome comparable to that ofradical procedures [20]. On the other hand, for BCS to besuccessful, breast surgeons must resect tumors with

Fig. 13.9 A 51-year-old patientwith a strong familial history ofbreast cancer and a previousbiopsy with atypical hyperplasialocated in the right breast (a,b).The reconstruction markingsshowing the plannedhemiperiareolar nipple–areolasparing mastectomy (NSM) (c).The patient underwent bilateralNSM (d). The patient underwentimmediate bilateralreconstruction with a transverserectus abdominismusculocutaneous flap (e, f).The postoperative appearance at10 months with a very goodoutcome (g, h)

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adequate surgical margins and yet preserve the breast’sform and shape [21–27]. In BCS for T1 and T2 tumors, wehave increasingly adopted the periareolar approach forlumpectomy. In these cases, incisions can be made semi-circularly or total circularly concentric to the NAC similarto the incisions used for NSM. These approaches make itpossible to remove lesions that are close to the NAC, up to

4–5 cm away. In most cases, we prefer to use separateincisions for sentinel lymph node biopsy or axillary clear-ance. Because of rich breast tissue vascularization, it ispossible to plan the incision and the pedicle for the NACaccording to the tumor location. Thus, the location of theNAC pedicle may be medial, superior, inferior, and lateraland usually results in a total periareolar scar pattern [25].

Fig. 13.10 A 40-year-oldpatient with 2.8-cm ductalcarcinoma in situ located in theleft breast (a, b). Thereconstruction markings showingthe planned total periareolarNSM (c). The patient underwentleft-sided NSM (d). The patientunderwent immediatereconstruction with abiodimensional implant–expander (McGhan 150 volume295–315 cm3) (e, f).Postoperative appearance at1 year with a very good outcome(g, h)

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In patients with a small/medium-diameter areola anddeeply located tumors, the total periareolar incision can beadvantageous as an alternative to radial-segmental BCS.Described elsewhere as donut mastopexy lumpectomy, thistechnique has the benefit of a unique breast resection inwhich a tissue segment is removed through a periareolarincision [28]. Another similar option is the Benelli

mastopexy technique as a variation of donut mastopexy[29]. In Benelli’s ‘‘round-block’’ procedure, the periareolarouter circle is extended superiorly, first to excise the skinover the lesions and second to lift up the breast. The innercircle is at the circumareolar margin. The skin between thecircles is deepithelialized, and a wedge resection of thesuperior segment of the breast is performed. The remaining

Fig. 13.11 A 55-year-oldpatient with 2.0-cm invasiveductal carcinoma located in theleft breast (a, b). Thereconstruction markings showingthe planned total periareolarbreast-conserving surgery (c).The patient underwent upper-leftquadrantectomy (d). The patientunderwent immediatereconstruction with localglandular flaps similar toBenelli’s ‘‘round-block’’procedure (e, f). Postoperativeappearance at 1.5 years with avery good outcome afterradiotherapy (g, h)

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breast is detached from the pectoral fascia, and the skin flapof the upper half of the breast is undermined and detachedfrom the gland. The posterior aspect of the breast at thelevel of the areola is sutured to the pectoralis fascia at thelevel of the third intercostal space to lift up the breast andfill part of the defect. The superior breast pillars are wrap-ped around each other and sutured to the pectoral fascia to

further fill the defect and reshape the gland and the lump-ectomy defect [29].

In spite of the benefits previously described, totalperiareolar incision is more technically challenging andtime-consuming than the radial approach, with a wide skinundermining in which only a segment of the breast isremoved. As we emphasized for the NSM techniques,

Fig. 13.12 A 64-year-oldpatient with 2.0-cm invasiveductal carcinoma located in theleft breast (a, b). Thereconstruction markings showingthe planned total periareolarbreast-conserving surgery (c).The patient underwent centralquadrantectomy (d). The patientunderwent immediatereconstruction with an inferiorpedicle dermoglandular flap (e,f). Postoperative appearance at1 year with a very good outcomeafter radiotherapy (g, h)

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resection of the skin ring (double circle incision) is nec-essary to allow both adequate access to the breast tissueand closure of the skin envelope around the remainingbreast tissue. This tissue is returned to the skin envelopeand sutured at deep and superficial margins to close theresulting defect as a breast-flap advancement. In the caseof breast ptosis, a purse-string closure around the NACcompletes the procedure, leaving only a periareolar inci-sion (Fig. 13.11).

Another important point is related to centrally locatedbreast cancer. Traditionally, these tumors have been treatedwith radical surgery (SSM). However, recent studies havedemonstrated that BCS is an adequate treatment for selectedpatients with central or retroareolar breast cancers whencompared with SSM [30–32]. In this group, a primaryassociation of oncological and reconstructive techniquescan improve the final scar outcome and breast symmetry,especially for women who may need contralateral breastreduction [33]. In this field, an increasing number of studieshave reported different approaches and various techniquesfor achieving satisfactory results, ranging from localadvancement glandular flaps and reduction mammaplasty/mastopexy procedures to LDMF reconstruction [24, 30, 31,33]. In our experience, for tumors located in the centralbreast region, the superior NAC pedicle is frequentlyinjured by the tumor resection. Thus, the remaining lowerbreast tissue may be moved into the defect as a dermo-glandular flap and an inferior pedicle mammaplasty tech-nique can be used [33] (Fig. 13.12). In fact, Courtiss andGoldwyn [34] demonstrated by cadaver dissections that theprincipal sources of blood flow to the inferior pedicle arethe perforating and intercostal branches of the internalmammary artery and the external mammary branches of thelateral thoracic artery. This anatomical characteristicpermits a suitable pedicle vascularization and minimizesvascular pedicle complications when the procedure isplanned and performed effectively.

13.8 Conclusions

The main objectives of oncological breast surgery are tocontrol the tumor locally and achieve a satisfactory aes-thetic outcome with acceptable scars. It is our experiencethat with the periareolar techniques the aesthetic results canbe improved further. Scar reduction and even total cam-ouflage by the future NAC reconstruction are the mainpositive aspects of these techniques. For this purposecareful preoperative planning and intraoperative care iscrucial, as consideration must be given not only to tumorlocation, prior biopsy incisions, and the reconstructiontechnique, but also to NAC vascularization.

References

1. Carlson GW (1996) Skin sparing mastectomy: anatomic andtechnical considerations. Am Surg 62:151–158

2. Singletary SE (1996) Skin sparing mastectomy with immediatebreast reconstruction: the M. D. Anderson Cancer Instituteexperience. Ann Surg Oncol 3:411–416

3. Simmons RM, Adamovich TL (2003) Skin-sparing mastectomy.Surg Clin North Am 83:885–894

4. Cense HA, Rutgers EJTh, Lopes Cardozo M et al (2001) Nipple-sparing mastectomy in breast cancer: a viable option? Eur J SurgOncol 27:521–526

5. Regolo L, Ballardini B, Gallarotti E et al (2008) Nipple sparingmastectomy: an innovative skin incision for an alternativeapproach. Breast 17:8–11

6. Crowe JP Jr, Kim JA, Yetman R et al (2004) Nipple-sparingmastectomy: technique and results of 54 procedures. Arch Surg139:148–150

7. Garcia-Etienne CA, Borgen PI (2006) Update on the indicationsfor nipple-sparing mastectomy. J Support Oncol 4:225–230

8. Caruso F, Ferrara M, Castiglione G et al (2006) Nipple sparingsubcutaneous mastectomy: sixty-six months follow-up. Eur J SurgOncol 32:937–940

9. Munhoz AM, Aldrighi C, Montag E et al (2007) Periareolar skin-sparing mastectomy and latissimus dorsi flap with biodimensionalexpander implant reconstruction: surgical planning, outcome, andcomplications. Plast Reconstr Surg 119:1637–1645

10. Munhoz AM, Aldrighi C, Montag E et al (2009) Optimizing thenipple-areola sparing mastectomy with double concentricperiareolar incision and biodimensional expander-implantreconstruction: aesthetic and technical refinements. Breast18:356–367

11. Munhoz AM, Arruda E, Montag E et al (2007) Immediate skin-sparing mastectomy reconstruction with deep inferior epigastricperforator (DIEP) flap. Technical aspects and outcome. Breast J13:470–478

12. Spear SL, Giese SY, Ducic Y (2001) Concentric mastopexyrevisited. Plast Reconstr Surg 107:1296–1302

13. Slavin SA, Schnitt SJ, Duda RB et al (1998) Skin-sparingmastectomy and immediate reconstruction: oncologic risks andaesthetic results in patients with early-stage breast cancer. PlastReconstr Surg 102:49–54

14. Simmons RM, Fish SK, Gayle L et al (1999) Local and distantrecurrence rates in skin-sparing mastectomies compared with non-skin-sparing mastectomies. Ann Surg Oncol 6:676–681

15. Maxwell GP (2003) Immediate breast reconstruction usingbiodimensional anatomical permanent expander implants: aprospective analysis of outcome and patient satisfaction. PlastReconstr Surg 111:139–145

16. Gui GP, Tan SM, Faliakou EC et al (2003) Immediate breastreconstruction using biodimensional anatomical permanentexpander implants: a prospective analysis of outcome andpatient satisfaction. Plast Reconstr Surg 111:125–132

17. Cicchetti S, Leone MS, Franchelli S, Santi PL (2006) One-stagebreast reconstruction using McGhan Style 150 biodimensionalexpanders: a review of 107 implants with six years experience.J Plast Reconstr Aesthet Surg 59:1037–1044

18. Huang TT, Hidalgo JE, Lewis SR (1982) A circumareolarapproach in surgical management of gynecomastia. PlastReconstr Surg 69:35–42

19. Persichetti P, Berloco M, Casadei RM et al (2001) Gynecomastiaand the complete circumareolar approach in the surgicalmanagement of skin redundancy. Plast Reconstr Surg 107:948–954

20. Fisher B, Anderson S, Bryant J et al (2002) Twenty-year follow-upof a randomized trial comparing total mastectomy, lumpectomy,

13 Periareolar Techniques 137

and lumpectomy plus irradiation for the treatment of invasivebreast cancer. N Engl J Med 347:1233–1240

21. Clough KB, Cuminet J, Fitoussi A, Nos C, Mosseri V (1998)Cosmetic sequel after conservative treatment for breast cancer:classification and results of surgical correction. Ann Plast Surg41:471–480

22. Kroll S, Singletary SE (1998) Repair of partial mastectomydefects. Clin Plast Surg 25:303–310

23. Kronowitz SJ, Feledy JA, Hunt KK et al (2006) Determining theoptimal approach to breast reconstruction after partialmastectomy. Plast Reconstr Surg 117:1–10

24. Munhoz AM, Montag E, Arruda EG et al (2005) Outcome analysisof breast-conservation surgery and immediate latissimus dorsi flapreconstruction in patients with T1 to T2 breast cancer. PlastReconstr Surg 116:741–752

25. Munhoz AM, Montag E, Fels KW et al (2006) Critical analysis ofreduction mammaplasty techniques in combination withconservative breast surgery for early breast cancer treatment.Plast Reconstr Surg 117:1091–1103

26. Munhoz AM, Montag E, Arruda EG et al (2006) Superior-medialdermoglandular pedicle reduction mammaplasty for immediateconservative breast surgery reconstruction. Ann Plast Surg 57:502–513

27. Losken A, Elwood ET, Styblo TM, Bostwick J 3rd (2002) The roleof reduction mammaplasty in reconstructing partial mastectomydefects. Plast Reconstr Surg 109:968–977

28. Amanti C, Regolo L, Moscaroli A et al (2003) Total periareolarapproach in breast-conserving surgery. Tumori 89:169–172

29. Benelli L (1990) A new periareolar mammaplasty: the ‘‘roundblock’’ technique. Aesthet Plast Surg 14:93–100

30. McCulley SJ, Durani P, Macmillan RD (2006) Therapeuticmammaplasty for centrally located breast tumors. Plast ReconstrSurg 117:366–375

31. Huemer GM, Schrenk P, Moser F et al (2007) Oncoplastictechniques allow breast-conserving treatment in centrally locatedbreast cancers. Plast Reconstr Surg 120:390–398

32. Simmons RM, Brennan MB, Christos P et al (2001) Recurrencerates in patients with central or retroareolar breast cancers treatedwith mastectomy or lumpectomy. Am J Surg 182:325–330

33. Munhoz AM, Montag E, Arruda E et al (2007) Reliability ofinferior dermoglandular pedicle reduction mammaplasty inreconstruction of partial mastectomy defects: surgical planningand outcome. Breast 16:577–589

34. Courtiss EH, Goldwyn RM (1977) Reduction mammaplastyby the inferior pedicle technique. Plast Reconstr Surg 59:500–511

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