Modifications in Vertical Scar Breast Reduction

Modifications in vertical scar breast reduction

G. M. Beer, W. Morgenthaler, I. Spicher and V. E. Meyer Institute of Hand, Plastic and Reconstructive Surgery, University Hospital Zürich, Zürich, Switzerland

SUMMARY. The use of vertical-scar breast reduction techniques is only slowly increasing, even though they have been advocated by Lassus and Lejour and are requested by patients. Possible reasons why surgeons are reluctant to use these techniques are that they are said to be more difficult to learn, they require considerable experience and intuition, and their applicability is confined to small breasts. Several surgeons have developed modifications, combining vertical-scar breast reduction techniques with details of the familiar inverted-T-scar technique. We present a procedure involving two further modifications of the vertical-scar breast reduction technique: first, a standardised, geometrical preoperative drawing from our superior-pedicle T technique, with the aim of establishing a reproducible method of reduction requiring no particular intuitive touch, and, second, the addition of a periareolar skin resection, to give the breast the desired round shape. Between September 1998 and December 1999 we used this technique in a prospective series of 52 patients. The median resection weight was 450 g. The maximal postoperative follow-up was 15 months. There were no acute postoperative complications necessitating reoperation. The late complication rate was within the expected range for such procedures (seven patients, 13.5%) and included vertical-scar widening, areolar distortion, residual wrinkles due to incomplete shrinkage of the undermined skin in the inferior pole and asymmetry of the breast. This procedure enables us to offer patients with moderate to marked hypertrophy a reproducible versatile vertical breast reduction technique. The technique is easy to teach and easy to learn, especially for those who are familiar with the superior pedicle inverted-T-scar technique. © 2001 The British Association of Plastic Surgeons

Keywords: vertical-scar breast reduction, modifications, standardisation.

Breast reduction has been a controversial theme in plastic shape the breast by drawing together the skin of the surgery over the decades, as evidenced by the multitude amputated lateral and medial breast pillars with repeated of surgical techniques available. In the past, the surgeon rows of skin-framing stitches going upward and down- and the patient have had to choose either a beautiful ward, tightening the skin until the breast reaches the shape and long scars or short scars with a less beautiful desired form. When finally suturing the vertical incision shape. The inverted-T-scar breast reduction, still the most he did not try to gather the skin to shorten the scar. frequently used technique the world over, is a prime Lejour, in contrast, developed a procedure that shapes the example of a technique that gives a good shape but leaves breast with glandular sutures and then drapes the skin long scars.1,2 At the other end of the scale, the vertical over the underlying gland.9–13 She widely undermines the technique leaves short scars but is said to create less skin in the inferior pole, making it thin enough to shrink. beautifully shaped breasts. This dilemma for patients Whereas Lassus closes the skin with a considerable ended when Lassus and Lejour refined and popularised a amount of tension, Lejour does not, in order to minimise version of vertical-scar breast reduction that combined a the dangers of skin necrosis and stretching of the scar. beautiful shape with short scars. Despite the short scars, these vertical-scar breast reduc- Interestingly, this technique has a long history, starting tion techniques enjoy only a limited popularity. Reasons with Dartigues,3 who, in 1925, described a vertical-scar for this include the fact that the techniques are said to be procedure for mastopexy. The technique was revisited by more difficult to learn, that they require considerable Arie4 in 1957 but did not gain wide acceptance because experience and intuition, and that they are applicable the vertical scar crossed the inframammary line and only to small breasts.14,15 extended far into the upper abdomen. It was Lassus who The Lassus and Lejour techniques have been modified revived vertical-scar breast reduction by developing a several times to try to make them as easy to learn, plan procedure with an upper pedicle for the areola, a central and execute as the inverted-T-scar methods. The majority wedge resection, no parenchymal anchor stitches and no of authors have tried to adapt the vertical-scar technique undermining of the breast tissue.5–8 When, in very large to their familiar T-scar technique by modifying the design breasts, the inferior portion of the scar showed below the of the pedicle or the modes of resection or reshaping, inframammary fold, he added a short horizontal scar. thus making the change from the old method to the new Later on, Lassus modified his technique and returned to method less drastic. the use of a vertical scar that always ended above the The modification we present here is derived from the original inframammary fold. The main feature of his basic principles of the inverted-T-scar breast reduction operative technique is that it relies solely on the skin to procedure of Pitanguy1 and Höhler,2 a very reliable

341 342 British Journal of Plastic Surgery method in which all details of the preoperative marking and resection can be planned by measuring.

Patients and methods A prospective series of 52 patients aged between 17 and 57 years (mean: 33 years) were operated on between September 1998 and December 1999. Out of these, 45 patients had a bilateral breast reduction, five patients had a balancing unilateral breast reduction with contralateral breast reconstruction and two patients had a unilateral breast reduction with a contralateral mastopexy to correct breast asymmetry. The resection weight ranged from 10 g (the two unilateral mastopexies) to 1270 g (mean: 340<204 g; median: 450 g). All operations were performed by two surgeons. The postoperative follow-up included clinical examina- tion and photographic documentation of the patients after 1 week and after 1, 3, 6 and 12 months. The postoperative follow-up ranged from 3 to 15 months. All patients, irrespective of their age, were offered a Figure 1—Preoperative drawing. The usual three vertical marker lines: 16 base-line mammography 3 months after the operation. the mid-sternal and the two mid-clavicular lines. The postoperative results were analysed using a standardised protocol, measuring the sternal notch to nipple distance, the length of the vertical scar, the breast projection and the diameter and configuration of the areola. Additionally, our visual impression was recorded, since ‘perfect numbers’ in breast measurement do not necessarily correspond to beautiful breasts.

Preoperative markings The patient is marked preoperatively in an upright position. As in the conventional inverted-T-scar breast reduction, three vertical lines, the mid-sternal line and both the mid- clavicular lines, are determined (Fig. 1). The inframammary fold is located, marked and transposed to the anterior skin on the mid-clavicular line of the breast. The new position of the areola (A) is marked 2 cm below this point. Thus, the distance from the sternal notch to A varies between 20 and 23 cm, depending on the stature and height of the patient. Point A becomes the apex of the classical triangle (Fig. 2) with an angle of between 80Њ and 120Њ. The angle is estimated by gently pinching the breast between two fingers at the lower border of the areola until the fingers touch each other. The angle depends Figure 2—Preoperative drawing. Point A lies at least 2 cm below the on the size of the breast, the amount of superfluous skin representation of the inframammary fold on the mid-clavicular line. The and the desired shape of the reduced breast. The larger the lines AB and AC are each 9 cm long and meet at an angle of between angle, the more conical the breast will become and the 80Њ and 120Њ. more tension will result on the vertical scar. The sides AB and AC measure 9 cm each. At the ends measured with precision, thus ensuring the reproducibil- of these sides (B and C) lines are drawn horizontally to ity of the method. meet the marking of the inframammary fold, as in the inverted-T-scar technique (Fig. 3). Additionally, lines are continued downwards from B and C in a V-fashion to Operative technique meet at the mid-clavicular line 2–4 cm above the infra- The patient is placed in a semi-sitting position with her mammary fold (D) (Fig. 4). The bigger the breast, the arms at her sides. The superior pedicle is de-epithelialised larger the distance from point D to the inframammary and cut in the usual manner, beginning at point A and fold should be. Thus, in contrast to the ‘classical Lassus including the areola. The rest of the rhomboid ABCD is and Lejour’ vertical-scar breast reduction markings, all incised and the central tissue lying beneath this area is parts of the drawing follow precise geometrical anatomi- resected en bloc. The skin beyond B, C and D down to the cal criteria. The lines and markings may be calculated and inframammary fold and laterally to the medial and lateral Modifications in vertical scar breast reduction 343 extremities of the breast is undermined in such a way that shape of the parenchymal breast is perfect, the superior only a thin layer of subcutaneous tissue remains adherent pedicle is buried and the whole length of the overlying to the skin. This is necessary in order to allow these areas skin is temporarily closed vertically with staples or of skin to shrink (Fig. 5, shaded area). In contrast to the sutures. This tends to give the breast a rather conical inverted-T technique, the tissue from the medial and shape (Fig. 6). This shape is not just left, but is refined by lateral extremities need not necessarily be resected; it can an additional periareolar skin resection and a purse-string be reflected to enhance further the projection of the suture17 with Gore-Tex 3/0, which gives the breast a breast, or just left in place. After the central-wedge resec- rounder more pleasing shape. The insertion of the areola tion, medial and lateral breast pillars are left. If necessary, is always marked below the peak of the breast cone (Fig. mastopexy stitches are made with resorbable suture mater- 7) and the area de-epithelialised. To design the areola, the ial (Vicryl 2/0) to create an upper-pole fullness. When the skin is slightly gathered vertically with the areola marker

Figure 5 Figure 3—Preoperative drawing. Points A, B and C have been defined —The shaded area in the periphery of points B, C and D, from and the drawing is continued as for the inverted-T-scar breast reduction. the horizontal marks down to the inframammary fold, represents the area to be undermined.

Figure 4—Preoperative drawing. For the vertical-scar breast reduction, a semicircle is added to the inferior pole ending 2–4 cm above the inframammary fold (point D). The larger the breast, the higher point D Figure 6—The conical breast shape produced after temporarily closing should be. the vertical incision and burying the superior pedicle. 344 British Journal of Plastic Surgery

Figure 7—The insertion of the new areola. The areola is placed slightly beneath the cone of the breast in a vertical-oval manner to shorten the vertical scar. of the preferred diameter. The larger the diameter of the de-epithelialised area, the rounder the final breast shape but the larger the tension on the areola. The vertical-oval configuration of the areola further decreases the length of the vertical scar. The knots of the Gore-Tex thread are buried deeply in the breast parenchyma in order to prevent postoperative exposure.18 The areola is sutured into place with a continuous subcuticular 5/0 Monocryl suture. The vertical incision is closed in two layers. The deep dermis is sutured with interrupted non-resorbable sutures (Nylon 3/0). The skin is closed with a continuous subcuticular Monocryl 4/0 suture. Beyond point BC the thin undermined skin can be gathered easily to reduce the length of the vertical scar. It is best to start gathering the skin somewhat beneath the areola in order to prevent areolar distortion. At this stage, the vertical-scar breast reduction still could be converted to a conventional T technique (or to an L technique) by resecting horizontally, according to the T-technique drawing (Fig. 8), rather than gathering the superfluous skin vertically. After the central-wedge resection, the vertical incision tends to bulge horizontally and produce the well-known medial and lateral dog ears. At this point, should the surgeon choose, for any reason, not to proceed with the vertical-scar technique, the procedure Figure 8—The vertical incision always bulges horizontally in the can be conveniently converted to an inverted-T-scar pro- inferior part of the breast. If it is not possible or convenient to create a cedure. Thus, there is very little risk, even for the begin- vertical scar, a T-scar can be added. ner just starting with the vertical-scar technique. If superfluous bulging fat tissue remains in the medial and lateral extremities of the inferior pole, it may be suc- Results tioned cautiously at the end of the operation. Otherwise liposuction is not routinely performed.10 Liposuction is The results were assessed by the two attending sur- never performed at the beginning of the operation nor in geons. Acute postoperative complications included one the centre of the breast. haematoma, not requiring surgical evacuation, and four The skin is not taped postoperatively. Instead, suture cases of slight wound dehiscence along the vertical scar. strips are applied and a surgical brassiere worn for 3 The latter epithelialised spontaneously. Postoperative late months (day and night). complications were as follows: the periareolar Gore-Tex Modifications in vertical scar breast reduction 345

Table 1 Summary of early and late complications, technique, is the uncertainty which of the two popular including those necessitating reoperation; in total seven methods of vertical-scar breast reduction (Lassus or patients required reoperation Lejour) beginners should use. The Lassus technique involves no skin undermining and produces ungathered Complications Number of Reoperation patients vertical scars with considerable tension in the skin. The Lejour technique, in contrast, makes use of the well- haematoma 1 0 known principles of skin shrinkage to help achieve breast seroma 0 — reduction. The skin of the resected inferior pole shrinks, infection 0 — shortening the vertical scar. delayed healing of the 4 0 The medial and lateral extensions of the inferior pole vertical scar no longer contain visible areas of breast parenchyma but areolar necrosis 0 — are composed merely of fat tissue. This subcutaneous fat Gore-Tex stitch rupture 2 2 is either resected openly or suctioned at the end of the vertical-scar widening 3 3 breast reduction. Interestingly, Gasparotti19 and Planas residual wrinkling of skin 1 1 20 (mild) asymmetry 6 2 and Morais also use this principle of skin shrinkage in their ‘superficial’ liposuction, which permits surgeons to treat localised lipodystrophies without skin resection. thread ruptured and had to be resutured in two cases According to whether surgeons follow the Lassus or because of marked areolar asymmetry; in three cases a the Lejour ‘philosophy’, the recently published modifica- vertical-scar revision was carried out because of scar tions of the vertical-scar breast reduction can be grouped widening; and in one case residual wrinkling of the skin into those that use the principle of skin shrinkage and in the inferior pole made an inverted-T resection neces- those that do not. Among those that do not rely on skin sary. Altogether, seven patients (13.5%) had to be reoper- shrinkage, Hammond18 reported a short-scar periareolar ated during the first 15 months’ follow-up. The biggest inferior-pedicle reduction mammaplasty, in which he problem at the beginning of our series was a repeated combined the inferior-pedicle technique with a mainly slight breast asymmetry, which twice necessitated surgi- periareolar skin resection, adding a short inferior vertical- cal correction. Other complications, such as seroma, to-oblique skin excision. Most of the skin resection was infection, fat necrosis, partial or total areolar necrosis, periareolar, and the skin was gathered with a non- marked areolar widening or bottoming out, were not seen. resorbable purse-string suture to create an areolar diame- A summary of all complications is listed in Table 1. ter of 4 cm. Despite adding a small vertical resection, The longest preoperative distance from the areola to such a large periareolar resection inevitably left the breast the inframammary fold was 16.5 cm. This was reduced to with a flattened appearance. Hall-Findlay demonstrated 8.5 cm, but had elongated to 9.5 cm 9 months after the a vertical reduction mammaplasty in a series of 400 operation. A further detailed evaluation of the standard- patients,15 using a Wise21 pattern for the preoperative ised protocol for our patients, including a comparison of drawing, a medial pedicle and a tissue resection en bloc the preoperative and postoperative measurements, will be without skin undermining. This procedure is said to be reported elsewhere. particularly easy to master. Other authors, including ourselves, have published Discussion further modifications to the vertical-scar breast reduction that do rely on the principle of skin shrinkage.22,23 To accommodate the wishes of patients for short scars in Asplund and Davies preferred the vertical-scar breast breast reduction, we embarked upon a vertical-scar reduction with a medial pedicle or glandular transposition reduction technique. Our modification of this technique of the nipple–areola, and resected the gland and fat in a is particularly convenient for surgeons who are familiar similar manner to the lower resection of a Strömbeck with the inverted-T-scar technique using a single superior reduction.24 Hagerty and Nowicky integrated the central- dermoglandular pedicle.1,2 mound technique with an inferiorly based pedicle to The biggest benefits to patients of using this kind of develop the ‘vertical skin takeout reduction technique’ vertical-scar breast reduction are the significant reduction and used extensive liposuction.25 Palumbo et al further in scar length and the avoidance of a long inframammary modified the Lejour vertical mammaplasty and presented scar, which is often broad and sometimes shows signs of an analysis of 100 cases where they had used a template hypertrophy at the medial and lateral ends. for drawing (a mosque-shaped pattern) and applied lipo- Despite the wishes of patients and the advantages of suction at the end of the operation rather than at the the vertical-scar technique, the use of this technique is beginning.26 With this technique they had the option of still not very widespread. Hidalgo et al recently presented further reducing the breast volume or of further defatting the results of a questionnaire distributed to members of the skin flaps prior to skin closure. the American Society of Plastic and Reconstructive The advantages of our modification are: first, that the Surgeons, reviewing current trends.14 Out of 192 mem- geometrical design of the preoperative markings is com- bers, only 12% carried out a vertical (Lejour) breast pletely reproducible and therefore easy to teach and learn; reduction and only 22% carried out combined liposuction no difficult dome- or mosque-shaped configurations or with reduction. semicircles in the inferior-pole region need be drawn and One of the reasons for this reluctance to use vertical- no artistic skill or estimation is necessary;9 and, second, scar techniques, besides the challenge of learning the in cases in which the resulting breast shape is too conical, 346 British Journal of Plastic Surgery

Figure 9—Preoperative (A–C) and postoperative (D–G) views of a patient who underwent a vertical-scar breast reduction. The resection weight was 706 g on the right and 1272 g on the left. The vertical scar (D) is shown 3 weeks after the operation along with the result 3 months postoperatively (E–G). Modifications in vertical scar breast reduction 347 a periareolar skin resection can be added, which converts 7. Lassus C. A 30-year experience with vertical mammaplasty. Plast the breast mound to an aesthetically pleasing more Reconstr Surg 1996; 97: 373–80. 8. Lassus C. Update on vertical mammaplasty. Plast Reconstr Surg rounded shape. 1999; 104: 2289–304. Our late-complication rate of 13.5% is comparable to 9. Lejour M. Vertical mammaplasty and liposuction of the breast. Plast other series,8 and the rates of vertical-scar corrections and Reconstr Surg 1994; 94: 100–14. corrections due to residual wrinkling are low.11 Overall, 10. Lejour M. Maliniac Lecture. Plastic surgery of the breast: a these figures represent the complication rate from the woman’s decision, a surgeon’s challenge. Aesthetic Plast Surg 1995; 19: 345–51. learning period of a new unfamiliar technique. In our 11. Lejour M. Pedicle modification of the Lejour vertical scar reduction opinion it would be unwarranted to abandon this reward- mammaplasty. Plast Reconstr Surg 1998; 101: 1149–50. ing technique on the basis of this complication rate. 12. Lejour M. Vertical mammaplasty: early complications after 250 per- We should also mention that the vertical-scar breast sonal consecutive cases. Plast Reconstr Surg 1999; 104: 764–70. 13. Lejour M. Vertical mammaplasty: update and appraisal of late reduction has some limitations. Despite the facts that we results. Plast Reconstr Surg 1999; 104: 771–84. have applied it to ever larger breasts and that the median 14. Hidalgo DA, Elliot LF, Palumbo S, Casas L, Hammond D. Current resection weight in our series was 450 g, we do not think trends in breast reduction. Plast Reconstr Surg 1999; 104: that this technique is suitable for extremely large breasts. 806–15. Our largest resection was 1270 g (Fig. 9), but we are hesi- 15. Hall-Findlay EJ. A simplified vertical reduction mammaplasty: shortening the learning curve. Plast Reconstr Surg 1999; 104: tant to reduce breasts with resection weights higher than 748–63. 1000 g on a routine basis as the amount of skin shrinkage 16. Beer GM, Kompatscher P, Hergan K. Diagnosis of breast tumors is limited and the vertical scar remains too long. after breast reduction. Aesthetic Plast Surg 1996; 20: 391–7. However, for all other, ‘smaller’ breasts we now use 17. Benelli L. A new periareolar mammaplasty: the ‘round block’ technique. Aesthetic Plast Surg 1990; 14: 93–100. exclusively this technique. 18. Hammond DC. Short scar periareolar inferior pedicle reduction With this modification of the vertical-scar breast (SPAIR) mammaplasty. Plast Reconstr Surg 1999; 103: 890–902. reduction we have developed a reproducible technique for 19. Gasparotti M. Superficial liposuction: a new application of the tech- reducing medium- to large-sized breasts that is easy to nique for aged and flaccid skin. Aesthetic Plast Surg 1992; 16: teach and learn. The drawings are standardised and the 141–53. 20. Planas J, Morais BB. New indications in the approach to the pendu- method does not require a touch of ‘artistry’. We are able lous abdomen. Aesthetic Plast Surg 1999; 23: 267–70. to produce round breasts instead of the very pronounced 21. Wise RJ. A preliminary report on a method of planning the conical shape that often results from the classical vertical mammaplasty. Plast Reconstr Surg 1956; 17: 367–75. technique. These advantages have made the vertical-scar 22. Van der Lei B. Pedicle modification in the Lejour vertical scar reduction mammaplasty. Plast Reconstr Surg 1997; 99: 2118–20. breast reduction a reliable technique over a considerable 23. Pickford MA, Boorman JG. Early experience with the Lejour verti- range of breast sizes, even for beginners in breast plastic cal scar reduction mammaplasty technique. Br J Plast Surg 1993; surgery. At our clinic it has become the method of choice 46: 516–22. for trainees, achieving the same excellent results, with a 24. Asplund OA, Davies DM. Vertical scar breast reduction with medial similar rate of complications, as most surgeons executing flap or glandular transposition of the nipple–areola. Br J Plast Surg 1996; 49: 507–14. breast reductions, and fulfilling patients’ wishes for short 25. Hagerty RC, Nowicky DJ. Integration of the central mound tech- scars. nique with the vertical skin takeout reduction mammaplasty. Plast Reconstr Surg 1998; 102: 1182–7. 26. Palumbo SK, Shifren J, Rhee C. Modifications of the Lejour verti- Acknowledgements cal mammaplasty: analysis of results in 100 consecutive patients. Ann Plast Surg 1998; 40: 354–9. We thank Mr Peter Roth, scientific illustrator, University of Zürich, for his medical drawings. The Authors

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