Dr. Alejandro Nogueira's Case #UFMFKBJI

This patient had been unfortunately been victim of the fraudulent periareolar lift, round block lift, donut lift, purse lift, Benelli lift or Goes lift among other given names; such technique is not a lift at all, the nipples never move towards any one direction, they stay the same location and never ever any lift is achieved.

It is easy understandable that cutting away skin around the areola does not apply any momentum or transposition effect on the areolas, they do not move; not only that, the breast reshaping cannot be accomplished, since just by pulling skin all over the breast towards the areola does not provide a breast gland restructuring which is a must do in all breast lifts; to the contrary, a deforming and grotesque effect of massive flattening is obtained, as it is obvious in this case.

Last but not least, the massive shortfall of skin around the areola creates a massive perimeter and circumferential tension and puckering, as an obvious consequence of stitching together one external ring which may be 3 or 4 times the length of the inner areolar edge ring; this massive tension creates the rippling or puckering lines irradiating from the areola, and sooner or later develops hypertrophic scars and scar widening; that is why among surgeons we know this pseudo technique leads to breasts like a fried egg this is flattened with massive central yolk areola and rippling around or Japan's flag-like.

It is absurd and reckless intending to suspend, sustain and reshape a whole ptotic or droopy breast which is out of shape just by means of a magical periareolar skin resection; needless to say this technique has been abandoned worldwide many decades ago by surgeons who practice in fields of realistic seriousness, honesty and results-oriented philosophy.

Once this periareolar skin resection is applied the sequels worsen over time, like in this patient's case which is bound to a full revision, only feasible by surgeons with solid experience in breast revisions of failed periareolar lifts.

In short, this patient's poor result is not due to poor planning or poor execution, hers is the typical, usual, regular and normal outcome of any well executed periareolar lift, since it is the typical result inherent to the procedure; unfortunately many women are victim of such procedure.

About the revision and repair of this mess it is not easy or accessible to any surgeon, needs deep understanding and knowledge, since it consists in converting the mess of periareolar missing skin into an inverted T or Wise pattern breast lift on a cut as you go intraoperative improvisation basis.

This means the surgeon can`t make many predictive preoperative markings and the final breast tailoring has to be made during the procedure on demand of the real skin shortfall and glandular reshaping requirements.

The fundamentals of the periareolar pattern conversion to an inverted T or Wise pattern is the recruitment of any spare skin and gland at the inner and outer parts of the breast and rotate it towards the areola so that the periareolar skin loss is restored and thus the areolar deformities corrected.

However, and after a thorough discussion with the patient about the pros and cons of performing a surgical conversion to eradicate the periareolar lift stigmata, she opted out and decided not to treat this part of her breast deformities; she requested and in fact it was performed so a full revision of the periareolar scars in order to improve their quality and a correction of the distorted shape of the areolas to make them rounder and nicely shaped; both goals were fully accomplished as can be seen in the postoperative images.

The animation deformity is due to the surgeon failing to release the pectoralis muscle from the skin when performing a partial submuscular or dual plane breast augmentation, leading to a dynamic deformity when contracting the muscle; this issue as very straightforward and simple treatment as well as prevention, which is separating the adhesions between the lower pole of the breast and the muscle.

The symmastia is a problem of breast implants pocket definition; the pocket was over expanded towards the inner cleavage of the breasts, creating a tenting effect which in some positions or with the brassiere on allowed rubbing of implants in symmastia.

As a direct and evident consequence of the former the implants did lose their centricity according to the nipple areola complex, becoming largely eccentric inwards and upwards; also the nipples were pointing down and laterally, which is exactly to the opposite direction of the migration of the implants, since inwards migration or symmastia entails outwards nipple orientation and the upwards eccentricity leads down gazing nipples.

Due to the aforementioned phenomena there is a problematic over dissection and over growth of skin at the medial pole of the breasts, which need to be reattached to the ribcage, being the perfect candidate for a multipoint capsulorrhaphy which allows both redefinition of the prosthetic pockets and eradication of the over expanded excess of skin; due to the particularities of the case and in order to prevent a new failure of adhesion, the patient opted for polyurethane coated implants which provide the highest grade of tissue adhesion from them all in the market thanks to their bio velcro effect, anatomical shaped and cohesive gel filled, significantly larger than the previous ones due to express patient request.

The capsulorrhaphy entailed a vertical row of anchors at the inner side of the pocket to redefine the cleavage from the 3rd to the 6th rib arcs; anchors are separated between them 10 to maximum 15 mm, otherwise they could fail or leave hammock effects between their gaps.

The lateral and lower breast pockets were expanded to achieve good prosthetic centricity beneath the nipples.

The combination of the multipoint capsulorrhaphy and the highly adhesive polyurethane coated implants lead to an impressive result, full correction of cleavage tenting and symmastia and perfect centricity of implants beneath the nipple areola complex, without any kind of nipple orientation distortion; no trace of breast dynamism persists, the areolas and their scars are significantly improved, the breasts look more natural and there is a comprehensive fullness of the breast mound.

On the other side the flattening and weird effect caused by the unacceptable periareolar mastopexy still persists; it is understandable some patients refuse its correction due to the high price of accepting visible scars on their breasts, nevertheless this correction could be applied at any future point should the patient wish to have fully round mammary mound at its periareolar end.