We've now placed some interrupted 4-0 dermal sutures here, 4-0 monocryls, to obtain preliminary closure and now we're ready to deal with our peri-reeler defect. And again, as a result of the combination of the vertical closure with our peri-reeler component, we've been able to diminish the dimensions of the peri-reeler opening so that it is now approximately 4 by 4 1⁄2 centimeters. So this will be very easily cinched down with our interlocking technique. We routinely close much larger defects than this. And so here's the suture we'll use. This is a Teflon suture, polytetrafluoroethylene, and it's been swedged onto a Keith needle. And this is just the most successful, unique material to accomplish this maneuver with because it's strong, it's permanent, it's supple, and it slides through this defect that we're going to bring together very easily. Now the other comment that I'd make on this is that this is already very circular. It's very common for this defect to have an oval shape at this point, at which time we don't hesitate to de-epithelialize a little extra skin to turn it into a perfect circle. But for today's purposes, we don't need to do that. And so now the idea is going to be to divide this into eight equal segments, what we call the eight cardinal points, like this. And now we do the same thing to our areola. We divide the areola into eight equal segments, like this. So the idea is to bring each cardinal point together with our interlocking technique. And so to start the suture, we go immediately, and we go from deep to superficial, right within the substance of the dermal shelf that was created at the beginning of the case. And then we come over to the areola, and we incorporate a small bit of the dermis, like this. Now, coming back over to the dermal shelf, we go right next to where the suture exited, and we come to our next cardinal point, like so, passing that directly within that dermal shelf, and then back over again to the areola, again incorporating a small dermal bite. And just working this now all the way around the incision, we'll be able to successfully pass our interlocking suture. Now one point relates to the technical placement of the suture. If the width of this bite here in the periareolar portion is the same as the width in the areolar portion, that tends to create a more contoured closure without any bunching. Just a technical challenge that can ease the placement of the suture and improve the quality of the subsequent periareolar scar. And so now we'll just work this all the way around the opening, placing this directly in the dermal shelf. One point that we'd make is that there's no need to go way back into the dermis like this. That just creates unnecessary bunching of your closure and doesn't really help at all. As long as this needle is passed directly within the dermal shelf, it tends to hold and secure really quite well. Now, as we come to the vertical segment, there's one small adjustment that is made, and that relates to this. Sometimes a potential complication is to create a little teardrop deformity to your areola where the vertical segment joins the periareolar. So to keep that from happening, the needle is passed down within the substance of the vertical incision. And then on the opposite side, a similar bite is passed back up across the other side, like this. And so now when that's pulled, it tends to support that critical juncture right there. And so now we go just to the side of the 6 o'clock mark right here to match up to the fact that we're just to the side of the 6 o'clock mark there. We should be able to cinch this together without too much trouble. And we come to our last cardinal point. And now as that pulls up, that'll prevent that teardrop deformity from developing. And so now we incorporate just a small bit of dermis, and then our last pass. And now we started this suture from deep to superficial. And again, there's that dermal shelf right there. You can see how strong that is. It solidly holds that suture. And now we end from superficial to deep. And so there's the interlocking pattern, eight evenly spaced segments of passage of the needle So that now, as we pull this down, you'll be able to see how that controls the position and the shape of the areola. So now we can just tease that back open, and that will nicely control the diameter and the shape of our areola. So now we can finish this off with closure. Now we cut this at about 40 millimeters to start with. Typically this cinches down to a diameter of about three and a half with that level of incision. This is about three by three and a half. So that'll work just fine. Now we typically try to get two passes with the same Keith needle. So what we can do is we can just simply pull that through like that. And there's really no other suture that you can do this with that passes through that amount of soft tissue as readily as the Teflon. So once we've got that in place, we'll simply tie this down. Now one caveat to using the suture is that you need to place several knots as you cinch this down. Because it's really quite smooth and the knots will slip. So typically eight properly placed square knots are required to be certain that this knot doesn't slip. And this is a very secure closure. Today there's not a lot of tension on this. So knot slippage is likely to not be a problem. Now just one last caveat. We'll place just a little bit of Betadine on this knot because it is a foreign body. And then as it's just pinched underneath that medial flap since we started deep and ended deep it just falls below that medial flap never really to be seen again. And this completes now the management of the periurelar opening. And now we'll proceed with closure. And this closure will involve the use of a barbed suture just in the subcuticular area here. There's no dermals placed at this point because we don't want to injure the Teflon suture. We've got our subdermal interrupted inverted sutures placed here. So now we'll just run a subcuticular here for closure, a subcuticular here for closure and that will complete this side. Subtotal placation of the breast flaps has become a fairly controversial subject in the world of breast surgery. And there is a thought that the tissue doesn't stay where you put it. I would disagree. Certainly there's a relapse over time and so you need to over correct the superior repositioning of the tissue in the upper pole of the breast. But it will prevent that postoperative scooped out ski slope type appearance that you can see in patients that have a large amount of elasticity to their breast. So by repositioning that tissue superiorly, you'll at least create a straight line contour in the upper pole of the breast and avoid that ski slope under filled contour that the patients find objectionable. Now one of the unique features of suture that we utilize when we're closing here is use of this barb suture. This is a suture that has small barbs in it and it really facilitates the closure of these wounds particularly when there's a suture or an incision like the inequality. So now as we've pulled this up, you can see the barbs engaging in that soft tissue. And so now we can simply run this all the way around the defect and it cinches as it goes. And it's a beautiful adjunct to use with the interlocking Teflon suture to manage this periareolar defect. And so you can just basically run this around as a subcuticular and it's been a nice feature to add to our technique as far as trying to control the quality of this periareolar scar Because of the locking nature of this barb suture, micro motion at the incision line is diminished and this has resulted in very nice periareolar scars in the patients that we've used this material on. So the barb suture has been a nice adjunct to our overall technique. Now in the upright position, I think we've been able to create just the perfect result for what we're looking for. It does appear to be just mildly tight along the inferior pole, which means that as it stretches just a little bit, it will fall into a very beautiful shape. But by fall, I don't mean bottom out. The inframammary fold is exactly where we put it at the marking sequence earlier this morning. It's not been changed. And so that breast will not fall below that point, but it will round out just a bit and create just a very nice shape. And compared to the opposite side, I think it's a nice reduction and lift and cosmetic improvement in the overall shape of the breast. And so a nice demonstration of how the strategy of the operation works. This is a specimen. And you can see how this was removed from around the pedicle a little bit longer laterally than it is medially. And so that as that is removed and the breast is debrided, the inferior pedicle fits into that space and the flaps wrap around it to complete the strategy, almost a jigsaw puzzle putting together of the breast. And so it's a nice strategy to accomplish reduction of the breast and still create a very nice aesthetic shape. And so now this completes this side. We'll go ahead and match to the other side to complete the procedure. We've now completed the case, and we've been able to accomplish the exact same procedure on the opposite side. To ensure symmetry, we gauged the thickness of the flaps, the volume in the pedicle, and the way that the skin was tailored to try to make the sides match up from side to side. That ended up removing 407 and 366. And with the patient upright, I think you can see that we've got a very nice symmetry volume-wise from side to side in the position of the nipple and the areola, in the shape of the areola, and then in the position of the fold. And as we look at her preoperative appearance, I think it's evident we've been able to accomplish a lift of the nipple and areola, a narrowing of the base diameter, and an overall tightening of the breast. The spare mammoplasty can provide outstanding results for all forms of macromastia and breast ptosis. I'm sure you'll find this procedure a useful adjunct in your own practice.

peri-areolar defect

Teflon suture

breast aesthetics

scar quality

surgical procedure