Aesth Plast Surg (2009) 33:228–234
DOI 10.1007/s00266-008-9296-6
ORIGINAL ARTICLE
Periareolar Breast Reduction
Antonio Roberto Bozola
Received: 23 January 2008 / Accepted: 11 November 2008 / Published online: 3 January 2009
Ó Springer Science+Business Media, LLC and International Society of Aesthetic Plastic Surgery 2008
Abstract A personal approach to periareolar breast
reduction is presented. The circular demarcation of peri-
areolar skin must be limited to twice the demarcated
areolar diameter (2 9 4 = 8 cm). A cylindrical resection
of volume is removed, as in Strömbeck’s technique, from
below the areola to the aponeurosis of the pectoral muscle.
Through this space, two to four ‘‘keel-like’’ parenchymal
pieces are removed to reduce the breast at the cardinal
points. The breast cone is assembled by suturing the raw
areas from bottom to top, hyperprojecting it. A ‘‘round-
block’’ suture around the areola is made, and the procedure
is concluded with skin suture. Indications, limitations, and
possibilities for use of the technique are analyzed, and the
equation is summarized as follows: residual ptosis versus
long scars inside the limits and indications of more or less
300 g of removed volume and small or medium breast
ptosis. Only after the first 10 cases was the limit of the
technique determined. Therefore, these results were not
homogeneous. The results were satisfactory and regular for
68 of the 78 patients subjected to surgery and follow-up
evaluation.
Keywords Breast
Periareolar
Reduction
The first report on breast periareolar aesthetic surgery was
published by Andrews et al. [1] in 1975. Afterward, several
authors [2–8] reported their personal approaches.
The main advantage of breast periareolar aesthetic sur-
gery is the small residual scar around the areola that
A. R. Bozola (&)
Division of Plastic Surgery, School of Medicine in São José
do Rio Preto, Sao Jose do Rio Preto, Brazil
e-mail: ceplastica@hotmail.com
123
generally is less conspicuous than scars from conventional
techniques. The main disadvantage is that this technique
cannot be used to correct ptosis or flabbiness of the breast.
To avoid this inconvenience, some authors are using
alloplastic materials such as a silicone sheet to mold the
mammary cone [2]. Others are using the deepithelialized
tissue as a support to make the mammary cone [3].
The embryologic origin of the breast is ectodermic, with
its innervation and vascularization running centripetally in
the subdermal and subcutaneous plane toward the areola.
Breast tissue grows from surface to bottom, attached to the
skin, with nerves and perforating vessels in the center of its
base. Undermining of glandular tissue from its attachments
on the fascia pectoralis does not jeopardize breast integrity
and function if the subdermic plexus and subcutaneous
tissue are preserved. On the other hand, extensive subder-
mic undermining may injure nerves and blood vessels.
Based on these details, some surgeons [5–7] resect skin
excesses at the periareolar region, then use the remaining
skin to assemble the breast cone, with good aesthetic results.
They also use this procedure for patients with tuberous
breasts [7]. Secondary ptosis, wide scars, flat breasts, and
progressive spreading of the areolar diameter are the most
common long-term inconveniences for indications of this
procedure [8, 9]. Its use should be limited to patients with
thick elastic skin, small and mild breast ptosis, resections less
than 300 g, and glandular breasts.
Surgical Technique
With the patient in a standing position, the inframammary
sulcus and the meridian line of the breast are demarcated.
Point I is considered the intersection of the meridian line
with the inframammary sulcus, and point A is the
Aesth Plast Surg (2009) 33:228–234
projection of I on the breast. When ptosis is present, the
superior point of the diameter for skin resection is 2 cm
(new areolar radius) above point A (Fig. 1a). In breasts
without ptosis, point A does not exist, and the superior
point of the diameter for skin resection should be 19 to
21 cm from the sternal furculae (Fig. 1b). The inferior
point of the diameter for skin resection is 6 to 7 cm above
point I (Fig. 1b and c).
The patient, under general anesthesia, is positioned in a
prone horizontal position with both arms abducted 908.
With the hand flattened, the breast is moved medially until
it leaves the meridian in a straight line. A circular line is
demarcated around the areola. Its diameter should not be
twice the diameter of the new areola. Its medial line must
be 8 to 10 cm from the midsternal line (Fig. 1b and c).
A saline solution with 1:200.000 of epinephrine is
infiltrated into the subglandular space, the periareolar tis-
sue, and the subcutaneous tissue of the four breast
quadrants before deepithelialization of the skin between the
new areola and the external demarcated limits (Fig. 2a).
The dermis of two lower quadrants in the infra-areolar
segment is incised transversally (Fig. 2b).
With the blade, a breast tissue cylinder type of resection
similar to that described by Strömbeck [10] is removed to
the muscle fascia level (Fig. 2c and d). From this space,
using trident retractors, two to four ‘‘keel ship’’ type of
breast resections are performed in cardinal lines according
to the breast volume reduction necessary to provide a good
shape (Fig. 3a–c). The trident retractors (Fig. 4a) keep the
breast stretched during the ‘‘keel ship’’ resection and dur-
ing the placement of nonabsorbable stitches applied to
close the resected keel areas.
Fig. 1 a In case of ptosis, point A is placed in the projection of point
I placed at the inframammary sulcus, both in the same breast meridian
line. Another point placed 2 cm above A represents the superior point
of a circular deepithelialized area around the future and definitive
areolar position. b In case of no ptosis, this point remains 19 to 21 cm
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In a similar process, from the base at the fascia level up
to the top, the breast tissue is sutured and the dead space
eliminated (Fig. 4b–d). The breast shape remains projected
as a cone in an overcorrection effect (Fig. 5a and b). The
periareolar access view (Fig. 5c) is closed by a ‘‘round-
block’’ [4] method with a 5-0 nylon monofilament running
suture (Fig. 5d), and the skin suture is placed (Fig. 6a).
With a hook fixed at the nipple, the whole breast is stret-
ched to maintain its cone shape and wrapped as a bra with
elastic bandages for 1 week (Fig. 6b).
Results
The described surgery was performed for 78 patients.
Figure 7a–d illustrates the limits of quality. No early com-
plications were registered in any patients subjected to the
operation. Neither the areola–nipple sensibility nor the skin
quality was altered in the first 6 months of the postoperative
period. For the cases with previous ptosis only, a residual
ptosis was noticed (Figs. 8a, b and 9a, b). No periareolar scar
broadness was evident after the principle of a maximum skin
resection twice that of the prior areola diameter was used.
Also, no flatness of the breast cone occurred based on the
hyperprojection of the breast during its assembly.
For the first 10 cases, the results were not homogeneous
or satisfactory. With adequate indications and limits, as
described earlier, the results became better, and the patients
were more satisfied in their expectations. They were
advised about the presence of residual ptosis with less
extensive scars. Within the limitations of the technique,
both patients and surgeon were pleased.
from the sternal furculae. The inferior point of a circular deepithel-
ialized area is 6 to 7 cm above point I placed at the inframammary
sulcus. The circle is 8 to 10 cm from the midsternal line. c The
circular deepithelialized area should not be more than twice the new
areola diameter
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Fig. 2 a The areola–nipple

complex isolated with all the
surrounding exposed dermis.
b Transverse parallel dermal
incision from the areola exposes
the glandular tissue, and the
breast is stretched from the
chest wall. c A cylinder-like
breast tissue resection 2 to 3 cm
below the areola is limited down
to the muscular pectoralis
fascia, similar to that in the
Strömbeck procedure.
d Superior view of the breast
showing the open space left
after tissue removal

Fig. 3 a Schematic superior breast view illustrating the four keel-like involves the four keels and the cylinder breast tissue. c Comparative
glandular resections painted in bold, converged to the center where aspect applied to an orange with four slices diametrically placed
the cylinder of breast tissue also is resected. b Surgical resection that

Discussion
In the past decade, breast reductions and breast pexies have
been requested more frequently by patients in Brazil. Grad-
ually, these procedures have changed to breast augmentations.
Another important factor was less tolerance for breast ptosis.
Our proposed technique has specific limitations because
it does not remove a significant amount of skin excess.
Residual ptosis will remain if this problem existed before
the surgery. The options for these cases will be other
techniques that leave longer scars. For situations in which
patients accept mild ptosis, a higher number of patients
may undergo surgery using this technique.
In our first cases, the results included scar broadness,
augmentation of the areola diameter, flatness of the breast
cone, and evident ptosis. These undesirable results were
eliminated after the current method was applied in com-
bination with more strict indications.

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Aesth Plast Surg (2009) 33:228–234 231

Fig. 4 a Trident hooks

specifically designed to expose
the central area of the breast to
offer a better access and view
during the ‘‘keel-ship’’
resection. b and c Schematic
and profile views of the process
to close the dead spaces after
the cylinder and keel tissue
resections. d Close-up superior
view of the breast stretched by
two trident hooks and
completion of the suture

Fig. 5 a and b Schematic

profile view showing the final
suture of the space left after the
cylinder breast tissue resection,
with care taken to hypercorrect
to obtain better breast cone
projection. c and d Aspects of
the areola–nipple complex
placed inside the dermal pad to
be sutured with a ‘‘round block’’

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Fig. 6 a Final aspect of the

‘‘round-block’’ and skin suture
with nonabsorbable material. A
suction drain is left, if
necessary. b Final adhesive
micropore material wrapping
the whole breast as a bra

Fig. 7 a–d Front and three-

fourth views of the pre- and
postoperative aspect in a patient
without previous ptosis
submitted to breast reduction
and new areola–nipple complex
repositioning

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Aesth Plast Surg (2009) 33:228–234 233

Fig. 8 a and b Front view of

the pre- and postoperative
aspect in a patient with limited
to moderate breast hypertrophy
combined with ptosis of the
lower quadrants including the
areola–nipple complex. The
reduction of the breast volume
was effective, but a mild ptosis
still remains

Fig. 9 a and b Patient with

shape and volume asymmetry
combined with limited
hypertrophy and significant
areola–nipple and breast ptosis.
Postoperative aspect showing a
new breast with bilateral
symmetry, volume reduction,
and improved ptosis

Fig. 10 a–c Pre-, intra-, and

postoperative aspects of
tuberous breasts in which only
half of all glandular tissue in a
cone-shaped aspect was
resected and the skin sutured
without any special
hypercorrection to avoid areola–
nipple complex projection

The use of epinephrine in the local infiltration could
provide conditions for performing the surgery, making it
faster. Breast reduction with the Strömbeck cylinder type
of breast resection below the line of the areola has specific
indications for cases of breast base reduction. If minimal
volume reduction is the goal instead of a cylinder resection,
only a small trunk cone resection is performed, and the
suture is applied from the base to the infra-areolar space. A
similar procedure is used for tuberous breasts. The tuberous
projection of the areola–nipple complex disappears by a
pulling-down position (Fig. 10a–c).
The ‘‘keel-like’’ resection also depends on the necessity
for base and breast volume reduction. They are selectively
resected from two to four keel-like and position according
to the diameter of the breast reduction in its cardinal
quadrants. The shape and volume of the cone breast are
important [11] (Fig. 11a–c).
In summary, these maneuvers reduce the breast height
through its central segment by removal of the cylinder and
the external excesses via the cardinal selective keel
resection. The maximum skin resection should be twice
that of the primary areolar diameter to avoid flatness of the

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Fig. 11 a Schematic aspect of the ideal breast aesthetic profile in
which all the cone shape should be placed at plan A above the
inframammary sulcus. Plan M should cross the breast at the areola–
nipple line to divide the cone breast into upper and lower poles in the
proportion of 1:1.5 to 1:1.6 compared with the divine proportion of
breast pole projection and to adjust the skin suture better,
leaving no tension and wrinkling. The ‘‘round-block’’
suture does not avoid possible late ptosis. It offers better
periareolar skin distribution.
In an attempt to facilitate the ‘‘keel’’ tissue resection and
suture from the base up to the infra-areolar sector, a pair of
trident type of hooks is used to stretch the whole skin cone
breast so that an 8-cm opening diameter twice the areola
natural diameter is left for the access view. This also
exposes the mammary cone center after the Strömbeck
tissue cylinder resection.
Very frequently, the areola–nipple complex is not circular
and not positioned in the meridian line. The meridian posi-
tion should not be considered during the skin demarcations.
In both situations, the correction should be included in the
program to obtain the ideal symmetry. The technique also
can be indicated in cases of small and limited tumor resec-
tion, with modification of the keel and cylinder resections
according to specific situations and adenomastectomies with
inclusion of a prosthesis. The technique has limitations
according to the preexisting volume and ptosis. Its ideal
indication is for cases without ptosis and small volume
resection.
Conclusion
The described method has limited indications, as detailed
in this report, but it is simple to execute. The results can be
worse in cases of more severe ptosis and larger volume
resections. The residual ptosis is as severe as the initial
ptosis or slightly less severe and must always be discussed
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Aesth Plast Surg (2009) 33:228–234
1:1.618. b The breast base on the chest wall has the transverse
diameter related to the vertical diameter in a proportion of 1:1.3. c
The areola–nipple complex should be placed at the vertex of the cone
breast. Nevertheless, many times this complex is in the wrong
position and should be replaced in the right position during surgery
with the patient preoperatively in terms of the following
binomial: more ptosis-less scarring, and vice versa.
References
1. Andrews JM, Jshizuki MMA, Martins DMSF, Ramos RR (1975)
An areolar approach to reduction mammaplasty. Br J Plast Surg
28:166
2. Bustos RA (1992) Periareolar mammaplasty with silicone sup-
porting lamina. In: Toledo LS (ed) Anais de Simpósio
Internacional: Avanços Recentes em Cirurgia Plástica. Brazilian
Society of Plastic Surgery, São Paulo, Brazil, pp 108–110
3. Góes JCS (1996) Periareolar mammaplasty: double skin tech-
nique with application of polyglactine or mixed mesh. Plast
Reconstr Surg 97:959–968
4. Benelli L (1990) A new periareolar mammaplasty: the ‘‘round
block’’ technique. Aesth Plast Surg 14:93–100
5. Martins PDE (1986) Mamaplastia periareolar com transposição
de retalhos. Rev Soc Bras Cir Plast 6:1–10
6. Aboudib JH, Castro CC (1998) Mammaplasty utilizing the peri-
areolar approach. Aesth Plast Surg 22:51–57
7. Ribeiro L, Canzi W, Buss A, Accorsi A (1998) Tuberous breast: a
new approach. Plast Reconstr Surg 101:42–50; discussion 51–52
(Comment in Plast Reconstr Surg 102:920–921, 1998)
8. Fayman MS, Potgieter E, Becker PJ (2003) Outcome study:
periareolar mammaplasty patients’ perspective. Plast Reconstr
Surg 111:676–684 (discussion 685–687)
9. Baran CN, Peker F, Sensöz O, Baran NK (2001) Unsatisfactory
results of periareolar mastopesy with or without augmentation
and reduction mammaplasty enlarged areola with flattened nip-
ple. Aesth Plast Surg 25:286–289
10. Strömbeck JO (1960–1961) Mammaplasty: report of a new tech-
nique based on the two pedicle procedure. Br J Plast Surg 13:79
11. Bozola AR, Ferreira LM, Sabino Neto M (2005) Reconstrução
Mamária com expansão prévia da area da mastectomia e preen-
chimento com retalho TRAM desepidermizado. Rev Bras Cir
Plást 5:95–101