British Journal of Plastic Surgery (2001), 54, 341–347 © 2001 The British Association of Plastic Surgeons doi:10.1054/bjps.2001.3573 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 tech- nique. © 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 unilat- eral 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 stan- dardised protocol, measuring the sternal notch to nipple distance, the length of the vertical scar, the breast projec- tion 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 inframam- mary 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 are- ola 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.