A 16-year-old woman visited our outpatient clinic and reported rapid enlargement of a large mass in her left breast over 12 months. The physical examination revealed a huge mass that occupied the lower quadrants of her left breast causing expansion of both the overlying skin and the nipple areolar complex (Fig. 1a, b). Ultrasonography revealed lobulated and well-circumscribed solid mass. A fine-needle aspiration biopsy and a Tru-Cut needle biopsy were consistent with a benign phyllodes tumor.
After careful discussion about the best approach to provide an adequate access to the tumor excision as well as addressing the excess skin envelope after tumor excision, the periareolar mastopexy approach was planned. It provides exposure through incision at the lower half of the outer periarolar circular incision for tumor excision. Furthermore, we are able to reduce the expanded skin envelope and mobilize the nipple–areola complex to restore breast symmetry.
Surgical technique
The technique begins by marking a pair of concentric circumareolar skin incisions. The inner circle diameter represented the areolar diameter and would be reduced in size to be symmetrical with the contralateral breast. The outer circle diameter is determined by standard four key points that are connected to form an outer circular incision pattern. The superior (point A) and inferior points (point B) represent the nipple-to-sternal notch and the nipple-to-infra-mammary fold distance respectively on the breast meridian. The medial and lateral points (point C&D) are determined by the intended skin resection. All these point was measured in comparison with normal contralateral breast dimensions (Fig. 1c). At first, deepithelialization of the entire skin between the inner and outer periareolar incisions was done. Through the preplanned full-thickness incision at the lower half of the outer periareolar circular incision, the phyllodes tumor was easily reached with an adequate and perfect view for resection with sufficient safety margin (Fig. 1d). After a wide local excision of the tumor, no dermoglandular tissue was discarded, and the breast parenchyma was approximated and fixed to the pectoralis fascia. For skin closure, a round block suture technique was placed at the outer skin margin to reduce its diameter to that of the normal areola result in a periareolar scar only (Fig. 1e, f).
The macroscopic appearance of the removed tumor was a well-encapsulated lobulated fibrous mass, measured 12 cm in its maximum dimension. The tumor was histopathologically diagnosed as benign phyllodes tumor consisted of benign epithelial and stromal cells with no obvious mitosis or cellular atypia.
Three months postoperatively, the symmetry of the bilateral breast has been nearly identical in terms of the nipple– areola complex’s position, skin quality, and breast shape (Fig. 1g, h).