The Efficacy and Safety Assessment of Sequential Liposuction Modified Double Ring Areola Incision in Moderate and Severe Breast Ptosis Correction

Abstract

Background:

A total of 42 cases of moderate and severe breast ptosis were treated with sequential liposuction modified double ring areola incision surgery (experimental group), and 45 cases were treated with traditional double ring areola incision alone surgery (control group).

Methods:

They were followed up for 6 months after the operation. The scar formation and breast ptosis repair were observed, and postoperative complications and patient satisfaction were monitored.

Results:

Better results such as improved postoperative breast appearance were achieved in the sequential liposuction modified double ring areola incision group compared with the double ring areola incision alone group. After treatment, the distance between the midpoint of the inframammary fold and the nipple, the distance between the suprasternal fossa, and the nipple of the two groups were lower than those before treatment. The distance between the midpoint of the inframammary fold and the nipple showed no difference between the two experimental groups. The distance between the suprasternal fossa and the nipple of the experimental group were lower compared with the control group. Lower complication rates and higher satisfaction rates were observed in patients treated with sequential liposuction modified double ring areola incision. The patients in the experimental group were more satisfied with breast symmetry, breast shape, and breast size than those in the control group.

Conclusions:

The treatment with sequential liposuction modified double ring areola incision was effective and safe compared with double ring areola incision alone. It could improve the breast shape of patients, improve the satisfaction of patients, and reduce the occurrence of complications.

Takeaways

Question: Can sequential liposuction improve the operative outcome of modified double ring areola incision in moderate and severe breast ptosis correction surgery?

Findings: The treatment with sequential liposuction modified double ring areola incision is effective and safe compared with double ring areola incision alone.

Meaning: Sequential liposuction modified double ring areola incision can improve the breast shape of patients, improve the satisfaction of patients, and reduce the occurrence of complications.

INTRODUCTION

Breast ptosis is commonly observed in women due to factors such as breast enlargement or natural aging.¹ Breast ptosis is particularly prevalent among middle-aged and older women.^1–3 In a normal adult woman, the breasts form a semispherical shape supported by the skin and Cooper ligaments.^3–5 However, factors such as breastfeeding, aging, obesity, or fluctuations in body weight can lead to reduced elasticity of the skin and Cooper ligaments, resulting in breast ptosis.^5–7

Clinically, breast ptosis is often characterized by excessive breast development, resulting in increased breast volume or by the position of the nipples extending beyond the inframammary fold. In severe cases, they can cause lumbar disc herniation and spinal deformity, and significantly impair the patient’s daily life and work, often necessitating surgical correction.^1,5

Surgery can involve the removal of excess breast skin, glandular tissue, and fat to reduce breast volume and improve the shape.^8–10 Currently, breast lift procedures commonly use techniques such as the vertical incision or the double-ring areola incision.^11–14 Different techniques such as the periareolar, the vertical, the inverted-T, and the L-shaped scar have been previously evaluated with regard to scar length, patient selection, and complications.⁶ Plastic surgeons need to consider the advantages and limitations of each technique when performing the operations.

Although the double-ring areola incision method is suitable for mild to moderate breast enlargement, it has drawbacks such as the potential for early nipple inversion, deformity, and later enlargement of the scar around the areola.^10–15 The double-ring areola incision method offers advantages such as smaller scars and fewer complications.^1,5,16 In this study, we hypothesized that utilization of the sequential liposuction modified double-ring areola incision method was able to achieve more effective and safer therapeutic outcomes in breast ptosis correction compared with double-ring areola incision alone.

PATIENTS AND METHODS

Patients

From 2021 to 2022, a total of 42 patients with moderate or severe breast ptosis underwent correction surgery using sequential liposuction modified double ring areola incision (experimental group) in our hospital. A total of 45 patients underwent operation with double ring areola incision alone (control group). The clinical features of the patients were presented in Table 1. The experimental protocol was approved by the ethics committee of Southwest Hospital. The study was conducted according to the Declaration of Helsinki. The experimental data were presented as mean ± SD and analyzed using SPSS 20.0. The continuous data between the two groups were analyzed using either independent samples t test or Mann-Whitney U test. Shapiro-Wilk test was used to check the normality of the data before applying either the t test or the Mann-Whitney U test. The comparison before and after treatment was conducted using a paired t test. The categorical data between the two groups were analyzed using chi-square test or chi-square with Yates correction. A P value less than 0.05 was considered statistically significant.

Table 1.

Clinical Features of Patients ($\overline{x}\pm s$)

Features	Experimental Group (n = 42)	Control Group (n 45)	t/χ2	P
Age (y)	34.52 ± 5.73	33.97 ± 5.84	0.443	0.905
BMI	22.03 ± 2.81	21.80 ± 2.96	0.371	0.712
History of childbirth and lactation	31 (73.81%)	33 (73.33%)	0.003	0.960
History of breast augmentation	4 (9.52%)	6 (13.33%)	0.049	0.826
Lalardrie classification of breast hypertrophy16			0.001	0.974
Moderate	30 (71.43%)	32 (71.11%)
Severe	12 (28.57%)	13 (28.89%)
Breast asymmetry	5 (11.90%)	8 (17.78%)	0.590	0.443
Shoulder and back pain	13 (30.95%)	17 (37.78%)	0.448	0.503
Breast eczema	4 (9.52%)	8 (17.78%)	0.647	0.421

Grading of Breast Ptosis

There are various methods of grading and classifying breast ptosis, and one of the simpler and more understandable methods was first proposed by Regnault in 1976.¹ According to this classification, grade I or mild ptosis is when the nipple is within 1 cm of the inframammary fold, located above the lower pole of the breast; grade II or moderate ptosis is when the nipple is positioned 1–3 cm below the inframammary fold but still above the lower pole of the breast; grade III or severe ptosis is when the nipple is more than 3 cm below the inframammary fold and below the lower pole of the breast. Additionally, there is a special case known as pseudoptosis, where the nipple is above the inframammary fold, but a majority of the glandular tissue is located in the lower pole of the breast, creating the appearance of breast sagging.

Preoperative Design

1. Liposuction: Liposuction was performed before the double-ring areola incision. Incisions were made along the skin folds near both axillae and the anterior axillary lines, and slightly lateral to the midpoint of the lower crease of both breasts, with an approximate length of 5 mm each. Photographs were taken before liposuction (Fig. 1A and B). The total volume of liposuction was presented (Fig. 1C and D). Photographs of the patient were also taken immediately after liposuction (Fig. 1E), 4 days (Fig. 1F and 1G), 5 days (Fig. 1H), and 10 days postliposuction (Fig. 1I). For the experimental group, double-ring areola incision surgery was performed 1–2 months after liposuction.

2. Double-ring areola incision: The patient was positioned upright, and the midline of the sternum, the lower fold of the breast, and its midpoint were marked. The areolar skin was moderately tightened to form a circular design with a radius of 3 cm. The length of the inner incision line was 3.5-4.5 cm. Point “A” was marked as the highest point lifted along the lower fold of the breast along the nipple. Point “B” was marked 7–10 cm above the midpoint of the lower fold of the breast along the line connecting the sternal notch and the midpoint. By lifting and flattening the breast, points “C” and “D” were determined as the intersections of the line connecting the midpoint of the clavicle and the midpoint of the lower fold of the breast with the horizontal line of the fourth rib. Then, an arc was drawn to connect points A, B, C, and D, representing the outer incision line. (See figure, Supplemental Digital Content 1, which displays points A, B, C, and D were marked, representing the outer incision line. http://links.lww.com/PRSGO/D459.) The patient was then placed in a supine position, and the skin on both sides was gently lifted along the outer incision line to check for closer approximation. This represented the “safe design line” for the outer incision. The patient was positioned upright, and the midline of the sternum, inframammary fold, and their midpoint were marked (Fig. 2).

Fig. 1.

Liposuction was performed before breast lifting. A, The patient in an upright position. B, The patient was placed in a supine position. C, The liposuction volume of the left breast was presented. D, The liposuction volume of both breasts was presented. Photographs were taken immediately after the liposuction (E), 4 days (F–G), 5 days (H), and 10 days (I) postliposuction.

Fig. 2.

Double ring areola incision was carried out. A, The inner incision line was marked. B, The “safety design line” was marked for the outer incision. C, De-epithelialization between inner and outer circles. D–E, Surgical dissection between the skin and the gland. F, An intraoperative view of fixation and closure of incision.

Surgical Procedure

1. Liposuction: Tumescent fluid was injected within the planned liposuction area (tumescent fluid preparation: 1000 mL of Lactated Ringer’s solution, 20 mL of 2% lidocaine, 1 mL of epinephrine diluted in a 1:1000 ratio). During the procedure, liposuction should not be carried out too superficially to avoid damaging the skin and causing skin necrosis.

2. Double ring areola incision: Adrenaline saline solution was injected subcutaneously between the inner and outer circles. An incision along the inner and outer incision lines was made. The epidermis between the two incision lines was removed. The dermis and the subdermal vascular network should be retained to form a dermal cap (Fig. 2C).

Dissection between the skin and mammary gland was performed. An oblique incision was made along the outer incision line. An electric surgical knife was used to separate along the potential space between the deep and superficial fat layers until reaching the base of the breast, which completely freed the mammary tissue from the skin (Figs. 2D and 2E).

The dissection should extend upward to the second rib. The dissection was extended outward toward the anterior axillary line or axillary midline. During the dissection of the lower outer quadrant, a thin layer of mammary gland base tissue and chest muscle fascia should be preserved. The posterior gap of the mammary gland should be released to facilitate the overall elevation or rotation flap surgery. [See Video (online), which displays a brief illustration of the technique.]

Video 1. displays a brief illustration of the technique.

Download video file ^{(16.4MB, mp4)}

The decision to remove glandular tissue was based on the volume of mammary tissue in the patient. If the breast glandular tissue was minimal or relatively loose, only a folding and tucking procedure was performed. Below the breast (at the 5–6 o’clock position for the left breast/6–7 o’clock position for the right breast) and laterally (at the 3 o’clock position for the left breast/9 o’clock position for the right breast), intermittent tucking sutures were performed from the base toward the nipple-areolar complex. This technique tightened breast tissue, improved support in the lower and outer regions of the breast, and helped correct breast sagging and outward expansion. The remaining loose mammary tissue on the inner side could be suspended and fixed on one side of the sternum, whereas the upper part was fixed to the second rib.

If there was a significant amount of mammary tissue, a wedge-shaped excision method perpendicular to the chest wall could be used. The excision started from the outer side of the breast, with the preserved outer portion rotated inward and upward, and the inner portion rotated outward and upward, allowing for partial overlap between the two ends. If the excision was insufficient, the inner side of the breast could be further excised.

During the surgery, the horizontal diaphragm should be protected. If necessary, additional excision of internal and external surrounding tissues could be performed, but it was crucial to protect the outer gland tissue near the 4 o’clock position in the left breast and the 8 o’clock position in the right breast, preserving the thin layer of basal mammary tissue and the fascial layer of the chest muscle.

Fixation and shaping of the remaining breast tissue: According to the above plan, it was essential to increase support and stability in the lower and outer regions. Starting from the lowest point (left breast) or the 6–7 o’clock position (right breast) and the 3 o’clock position (left breast) or 9 o’clock position (right breast), a cone was formed by gradually folding layer by layer.

Additionally, a dermal cap was used to suspend and shape the glandular tissue. If the dermal cap was large enough, its upper edge could be fixed to the fascia of the second rib, ensuring secure and tight fixation on the upper inner side. The dermal cap should completely envelop the glandular tissue, preventing the glandular tissue from herniating through the needle spacing. If the dermal cap was insufficient, sutures could be placed at appropriate positions on the well-shaped surface of the glandular tissue.

Closure of the incision was carried out (Fig. 2F). The subcutaneous fat was trimmed from the distant end of the skin flap. A negative pressure drainage tube was inserted and secured from the upper outer edge of the breast to the axillary fold skin crease. The outer ring of the incision was sutured with 2-0 suture, gradually and evenly tightened to a diameter of ~3.5–4.5 cm. The incision was then layered with interrupted suture lines.

Postoperative Management

1. Postoperative management of liposuction: After the surgery, the breasts were appropriately lifted and repositioned, then secured with elastic bandages and compressed appropriately. Dressings were changed within 3–4 days, and sports underwear was worn after 5–7 days.

2. Postoperative management of double ring areola incision: Routine administration of antibiotics was performed. The negative pressure drainage tube could be removed within 3–5 days postoperatively. An elastic bandage compression dressing was applied for shaping purposes for 1 week, and the dressing was changed 2 days postoperative (Fig. 3A), followed by the use of a shaping bra. Sutures were removed in stages between 7 and 14 days. Photographs were taken 14 days postoperative (Fig. 3B–D).

3. Satisfaction survey questionnaire: A satisfaction survey questionnaire was administered to patients 6 months postoperatively for scoring (supplementary questionnaire). Patient scores were categorized into breast symmetry, breast size, breast ptosis, breast shape, and overall aesthetic appearance, with each item scored out of 100 points. All procedures were performed by a single doctor, who conducted satisfaction evaluations for all patients 6 months postoperatively. The doctor’s scores were based on surgical outcome and overall aesthetic appearance, with each item scored out of 100 points.

Fig. 3.

Postoperative management. A–B, The dressing was changed 2 days postoperative. C–D, Photographs were taken 14 days postoperative.

RESULTS AND DISCUSSION

After the treatment, patient satisfaction, postoperative evaluation, and postoperative complications were assessed. The treatment of sequential liposuction modified double ring areola incision resulted in better clinical outcomes and satisfactory results, with a lower incidence of complications compared with the double ring areola incision alone group.

Comparison of Surgical Procedure

As presented in Table 2, there was no statistically significant difference in breast morphology between the two groups before treatment. After treatment, there was an improvement in the appearance of the breast. For instance, the distance between the midpoint of the inframammary fold and the nipple was reduced, with no significant difference observed between the two experimental groups. The distance between the suprasternal fossa and the nipple was lower than before treatment, and this surgical indicator in the experimental group was significantly lower compared with the control group. Additionally, the volume of glandular tissue excision was significantly reduced in patients treated with sequential liposuction modified double ring areola incision compared with the control group.

Table 2.

Comparison of Surgical Procedure ($\overline{x}\pm s$)

Surgical Indicator	Experimental Group (n = 42)	Control Group (n = 45)	t	P
The distance between the suprasternal fossa and the nipple (cm)
Before treatment	35.49 ± 3.76	36.12 ± 3.83	0.773	0.441
After treatment	20.17 ± 1.54*	23.62 ± 1.79*	9.605	0.000
The distance between the midpoint of the inframammary fold and the nipple (cm)
Before treatment	9.53 ± 1.02	9.64 ± 1.11	0.480	0.632
After treatment	6.91 ± 0.62*	7.18 ± 0.75*	1.823	0.072
Volume of glandular tissue excision [median (IQR), g]	226.51 (154.20–272.10)	300.91 (202.39–348.94)	—	0.001

^*Compared with before treatment.

Comparison of Postoperative Complication

The treatment with sequential liposuction modified double ring areola incision resulted in a lower complication rate. The overall incidence rate of complications, including hematoma, flap necrosis, poor wound healing, and dull sensation in the nipple in the experimental group, was 14.29%, which was significantly lower than the control group with an overall incidence rate of 37.78% (P < 0.05; Table 3).

Table 3.

Comparison of Postoperative Complications

Complication	Experimental Group (n = 42)	Control Group (n = 45)	χ2	P
Flap necrosis	0 (0.00%)	1 (2.22%)
Poor wound healing	1 (2.38%)	4 (8.89%)
Hematoma	2 (4.76%)	4 (8.89%)
Dull sensation in the nipple	2 (4.76%)	5 (11.11%)
Overall incidence rate	5 (11.90%)	14 (31.11%)	4.695	0.030

Comparison of Postoperative Satisfaction

The treatment with sequential liposuction modified double ring areola incision resulted in a higher satisfaction rate. Photographs taken 6 months postoperative (Fig. 4) indicated that patients in the experimental group were more satisfied with breast symmetry, breast shape, breast size, laxity, and overall aesthetic appearance than those in the control group. Additionally, doctors expressed greater satisfaction with the surgical outcome and overall aesthetic appearance of patients treated with sequential liposuction modified double ring areola incision (Table 4).

Fig. 4.

Better clinical outcomes and satisfactory results were achieved by the treatment of sequential liposuction modified double ring areola incision 6 months postoperative.

Table 4.

Comparison of Postoperative Satisfaction

Criteria	Experimental Group (n = 42)	Control Group (n = 45)	t	P
Patients
Breast symmetry	87.32 ± 8.23	86.84 ± 8.01	0.276	0.784
Breast size	92.18 ± 8.97	91.83 ± 7.62	0.197	0.845
Breast ptosis	82.14 ± 9.42	78.17 ± 7.93	2.132	0.036
Breast shape	86.75 ± 7.46	80.22 ± 7.01	4.209	0.000
Overall aesthetic appearance	90.15 ± 8.25	85.31 ± 8.38	2.712	0.008
Doctors
Surgical outcome	92.94 ± 7.84	87.02 ± 7.15	3.684	0.000
Overall aesthetic appearance	95.29 ± 6.27	90.03 ± 6.83	3.734	0.000

DISCUSSION

The causes of breast ptosis include glandular atrophy due to hormonal changes after breastfeeding or menopause, significant degradation of the glandular tissue, fat, and supportive structures, and relative excess of skin, resulting in a sagging appearance of the breasts.^1–5 It can be classified into three degrees of severity: mild, moderate, and severe. In mild ptosis, the nipple is at the level of the inframammary fold; in moderate ptosis, the nipple is below the inframammary fold but above the lower margin of the breast; in severe ptosis, the nipple is below the lower margin of the breast.⁵

With improved living standards, an increasing number of patients are seeking improvement for breast ptosis. Currently, various surgical methods are available for breast ptosis correction. Severe breast ptosis, often associated with macromastia, typically involves breast reduction surgery. For mild to moderate breast ptosis, the traditional approach mainly focuses on adjusting the skin of the breast, relying on the constriction effect of the skin brassiere.^17–21 However, there has been insufficient emphasis on strengthening and reconstructing the supportive suspension structures inside the breast, which may lead to postoperative secondary ptosis or significant surgical scars. In recent years, with the increasing use of methods involving support and suspension structures for breast reconstruction, the correction results for mild to moderate breast ptosis have gradually improved.^22,23

Surgery for severe mastoptosis should typically be accompanied by a vertical incision on the lower pole of the breast or even a horizontal incision along the inframammary fold.^24–26 Asian women tend to have more noticeable scars after skin incisions compared to individuals with lighter skin tones, and Chinese women generally have a lower acceptance of vertical scars on the lower half of the breast. Consequently, some patients refuse to undergo surgery involving such incisions.

Liposuction can significantly reduce the intermammary distance of the breasts, allowing the upper half of the breast skin to retract remarkably. This reduction in skin laxity can noticeably decrease the amount of skin excision required during a breast lift procedure, making it possible to achieve satisfactory lifting results using only a double ring areola incision, thereby avoiding vertical and horizontal scars. This approach can cater to the needs of individuals concerned about visible scars.

Patients with severe breast ptosis often have relatively thin skin in the upper half of the breast, and in severe cases, enlarged pores can lead to recurrent folliculitis. Breast liposuction can significantly tighten the breast skin, and it may also lead to a reduction in the size of enlarged hair follicles. Severely sagging breasts typically have relatively thin skin in the upper half. When performing direct breast ptosis correction surgery, the thin skin may exhibit poor healing ability, thereby increasing the risk of incision-related complications. Postoperatively, the thin skin may present with a poor texture and weaker ability to resist future sagging.

More importantly, the timing for performing correction surgery for breast ptosis after liposuction differs from traditional cosmetic procedures. Traditionally, it was believed that there should be a minimum interval of 6 months between two procedures to avoid scar hypertrophy. However, the design principle of this procedure utilizes the scar hypertrophy and contraction that occurs after liposuction, allowing the skin to retract, thicken, and reduce the probability of incision-related complications. If the surgery is delayed, there is a risk of the breasts sagging again and the skin being thinned due to variations in patient compliance, thereby rendering the surgical design meaningless. Therefore, correction surgery after liposuction should be completed within 1–2 months.

Traditional breast lift surgery using a vertical incision often significantly raises the position of the inframammary fold. Moreover, the resulting shape of the fold is typically “I” or even “W” shaped, making it difficult to achieve a curved arc. On the other hand, the double ring areola incision technique does not require excessive elevation of the inframammary fold, which may better align with the aesthetic preferences of Chinese individuals.

After liposuction, the amount and extent of glandular tissue removal can be effectively reduced, significantly decreasing the occurrence of surgery-related complications. However, there are some limitations in this study. For instance, 6 months is a relatively short follow-up period to assess the patients for recurrent sagging of the breast and areolar enlargement; a study with longer follow-up is required in the future. Moreover, patient-reported outcomes (such as BREAST-Q) should be included in further study. Furthermore, the caseload in this study was limited; a future study with a larger sample size should be conducted. In summary, the treatment with sequential liposuction modified double ring areola incision is more effective and safe compared with traditional double ring areola incision alone. It can improve the appearance of the breasts, enhance postoperative satisfaction, and reduce the occurrence of surgery-related complications.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.

ACKNOWLEDGMENTS

The study was approved by the Ethic Committee of Southwest Hospital (Approval No. 20230366, Chongqing, China). Written informed consent was obtained from each patient. All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008. Written informed consent was obtained from all individual patients for whom photographs are included in the article.