"I" becomes "L": modification of vertical mammaplasty

The problems of the vertical mammaplasty by Lejour (i.e., gathering the skin envelope in one vertical suture, frequent secondary healing problems, and later sagging of the inferior glandular part in the case of large and very large breasts) are well known. A simple modification of the Lejour technique, that is, adding a lateral inframammary scar to shorten the vertical scar length, is presented. The modified L technique was used in 45 patients (90 breasts) between October of 1999 and August of 2001. With an average follow-up of 13 months, the jugular notch-to-nipple distance was 21 cm, the vertical scar length was 8.4 cm, the lateral inframammary scar length was 11 cm, and the average resection weight was 625 g per breast (range, 200 g to 2080 g). Even among patients who had very large glandular bases and resection weights it was possible to achieve a breast base reduction, modeling the glandular corpus to a harmonic, well-projecting, and youthful shape. Slight wound-healing problems with spontaneous cicatrization within 2 weeks occurred in six patients. In two patients who exhibited gigantomastia up to 2080 g per breast, partial mamilla necrosis occurred on one side. Ninety-one percent of the patients reported being "very satisfied" with the outcome, and 9 percent reporting being "satisfied." The authors' modification of the vertical mammaplasty to an L-shaped scar technique enables the surgeon to apply the principles of the Lejour technique for higher resection weights and diminishes wound-healing problems, and it is still a scar-minimizing technique that results in a scar-free cleavage. It is easy to learn and an ideal standard technique for a teaching hospital.     

Alteration of nipple and areola sensitivity by reduction mammaplasty: a prospective comparison of five techniques

The preservation of the sensitivity of the nipple-areola complex after reduction mammaplasty is an important goal. The authors performed this prospective study to accurately assess whether sensitivity changes are influenced by the weight of resection or the surgical technique. Eighty patients who underwent bilateral breast reduction (Lassus, 10 patients; Lejour, 13 patients; McKissock, 18 patients; Wuringer, 20 patients; and Georgiade, 19 patients) were tested for sensitivity changes of the nipple and cardinal points of the areola with Semmes-Weinstein monofilaments before surgery, at 3 weeks, and at 3, 6, and 12 months after surgery. Patient characteristics (age, body mass index, and preoperative sensitivity) were statistically similar in all groups. The mean resection weight was significantly smaller in the Lassus (540 g) and the Lejour groups (390 g) than in the Georgiade group (935 g). The sensitivity of the nipple and the inferior and lateral part of the areola was significantly lower after a superior pedicle technique (Lassus and Lejour) than after any other technique at 3 weeks and at 3, 6, and 12 months postoperatively. Insensate nipples and areolas were found only after breast reductions with the Lassus and the Lejour techniques (47.8 percent). Nipple sensitivity after breast reduction by the other techniques was unchanged (Wuringer, McKissock, and Georgiade) or sometimes even improved (Georgiade) as early as 3 weeks postoperatively. Changes in nipple and areola sensitivity after reduction mammaplasty depend on the surgical technique rather than the weight of resection. Superior glandular pedicle techniques that require tissue resections at the base of the breast are associated with a higher risk of injury to the nerve branches innervating the nipple-areola complex.     

"Zigzag" wavy-line periareolar incision

There is almost no mention of improvement in the aesthetics of areolar incisions in the plastic and reconstructive surgery literature. The most visible area of the breast is the central mound; therefore, it behooves surgeons to make an areolar incision as inconspicuous as possible. Minimal incision breast operations and short-scar operations, such as mastopexy and vertical reduction mammaplasty, use a circumareolar incision. This circumareolar technique, which specifically avoids a purse-string support suture, is useful in all periareolar incisions. This method creates a scar that mimics the elusive, natural irregularity between the areola and periareolar skin. The goal is to have an irregular, random, wavy line that appears more natural. Between August of 1998 and August of 1999, 104 "zigzag" wavy-line procedures were performed. The complications seen in this series included delayed healing in four patients and hypertrophic scar in two patients. No scars were surgically revised. The results demonstrated a definite difference compared to a circular scar. The zigzag wavy-line technique complements the innovative methods that shorten scars while they create a more natural, lasting breast mound. For areolar incisions, good results are deceptively subtle, but unnatural results can be painfully obvious. The zigzag wavy-line incision subtly eludes the eye in diminishing the signs the patient has undergone an operation.     

Outcome study: periareolar mammaplasty patients' perspective

Residual scars on occasion compromise patient satisfaction with breast reduction procedures. Periareolar breast reduction was proposed to minimize the scarring produced by the operation. This technique was criticized predominantly for producing a breast with low projection, for recurrence of ptosis after surgery, and for widening of the periareolar scar. The purpose of this study was to evaluate patient satisfaction from this technique. In the first branch of the study, 11 patients who had periareolar or circumareolar breast reduction were compared with 13 patients who had vertical scar reduction mammaplasty. The groups were matched for patient's age, size of reduction, and follow-up period. The patients were contacted by phone and requested to comment on four aspects of their operation: breast size, symmetry, quality of scars, and appearance and position of the nipple-areola complex. The replies were converted to numerical values and analyzed statistically. A panel of three women, prospective patients for breast reduction, were presented with standardized five-view before-and-after photographs and requested to score the results using the same criteria. Their responses were analyzed in the same manner. Both phases of the study produced similar results. Breast reduction done through a periareolar scar scored higher than a vertical scar technique. The operation did not differ with respect to shape, symmetry, or nipple-areola shape but did with respect to dissatisfaction with scars, which affected the overall result. This experimental model of assessing results of cosmetic operations is proposed as a tool to assess the patient's rather than the surgeon's perspective of a surgical technique, and it could find application in assessing other cosmetic operations.     

Maximizing breast projection after free-nipple-graft reduction mammaplasty

In 1922, Thorek described standard free-nipple reduction mammaplasty for gigantomastia. This technique provided a simple and effective way to perform reduction mammaplasty. However, the technique is frequently criticized for producing a breast and nipple with poor projection. Even with the standard modification of the original technique, the resultant breast and nipple may be wide and flat, with unpredictable nipple-areola pigmentation. To create a breast mound and nipple with projection and even pigmentation, the free-nipple-graft breast reduction technique is presented. The Wise pattern skin reduction markings and the superiorly based parenchymal reduction technique are used. After the nipple-areola complex is removed, as a free graft, the inferior pole of the breast is then amputated along the Wise pattern skin markings, leaving lateral and medial pillars of breast tissue, with the apex of the resection corresponding to the new nipple location. The lateral and medial pillars of the superiorly based breast mound are then sutured together. Key interrupted sutures are placed, beginning at the most inferior and posterior point of the pillars, while recruiting tissue centrally to increase the projection. The intersecting point of the inverted T, at 7 cm from the new nipple position, is then sutured to the fasciae of the pectoralis major muscle. If more central projection is desired, the vertical limb design can be lengthened. The tissue inferior to the 7-cm mark is de-epithelialized and tucked under the central breast, if needed, contributing further to the final breast parenchyma projection. The skin of the vertical limb of the Wise pattern is then closed with a dog-ear at the apex to further contribute to nipple projection. The nipple is replaced as a free, thick, split-thickness skin graft. The breast is temporarily closed, and the medial and lateral breast tissue excess is liposuctioned to create a more conical breast. Excessive medial and lateral skin is then resected, keeping the inframammary crease incision under the breast mound. Twenty-five patients underwent free-nipple-graft reduction mammaplasty using this technique between 1992 and 2000. An average of 1600 g of breast tissue per breast was removed. The average follow-up period was 36 months. Patient satisfaction has been very high.     

Dermal suspension flap in vertical-scar reduction mammaplasty

Reduction mammaplasty has the following goals: appropriate reduction of breast size, symmetric and youthful breast shape, minimal and inconspicuous scars, and stable, long-term results. Although the first two parameters can be obtained by various reduction techniques, vertical-scar mammaplasty eliminates the horizontal inframammary scar, thereby reducing total scar length. Dermal flaps have been described in various types of reduction mammaplasty. The refinement of the authors' method is the incorporation of a superiorly pedicled dermal flap for better and longer-lasting support in vertical-scar reduction mammaplasty. A total of 73 vertical breast reductions in 38 patients were performed with this technique from May of 1996 to November of 1999. Vertical-scar reduction mammaplasty with a dermal suspension flap combines minimal scars with an internal support for long-term stability of the breast shape.     

Mammaplasty combining vertical and transverse approaches through a vertical incision

An adjustable vertical marking is described for vertical mammaplasty in mild and moderate hypertrophy or ptosis of the breast. A vertical rectangular flap with the pedicle supported at the inframammary fold provides fullness for the upper or the lower pole of the breast. It is fixed over the pectoralis aponeurosis along the upper pole to the base of the pedicle. Length, width, and thickness of the vertical rectangular flap change regarding the extent of breast ptosis and hypertrophy. Two transverse triangular flaps, dissected in the lower pole of the breast, are supported on the inferior half of the vertical pillars at the incision margins. The criss-crossing of the triangular flaps creates a transverse support sling, avoiding the downward displacement of the breast. The vertical flap is applied in conjunction with the triangular flap to attempt to achieve projection and support for the breast with long-term stabilization of the mammary cone. Resection of mammary tissue is performed transversely just above the pedicle of the vertical flap.     

Arch reduction mammaplasty

Arch mammaplasty is a breast reduction technique based on the inferior pedicle. It uses all the specific advantages of the inferior pedicle while avoiding the inframammary scars and dead space that occur with the inverted T technique. Arch mammaplasty has proven versatile and extremely safe, and it has a surprisingly good rate of acceptance by the patients. The scarring is aesthetically superior to that obtained with the well-accepted, inverted-T scar technique of the past.     

Preservation of projection after reduction mammaplasty: long-term follow-up of the inferior pedicle technique

In reduction mammaplasty by the inferior pedicle technique, the dermal-breast pedicle can be manipulated to form a central breast mound and enhance breast projection. When this technique is applied both to macromastia and breast asymmetry, excellent early results are reported. To study the effects of time on breast reduction, 22 patients were followed for an average of 4.7 years. Contour of the breast mound and projection are well preserved. However, evaluation of long-term results reveals a gradual increase in the inframammary fold to inferior areola distance. Since no increase in the midclavicle to nipple distance is observed, inferior migration of the breast parenchyma and superior displacement of the nipple-areola with respect to the breast mound occur after reduction mammaplasty with the inferior pedicle technique.     

Unilateral reduction mammaplasty: sculpturing the breast from the undersurface

Various traditional mammaplasty techniques have been suggested for unilateral breast reduction, and an inverted-T incision is still the most popular approach. However, unilaterally performed traditional techniques can rarely provide long-lasting symmetry because the operated and the unoperated breasts react differently to aging, weight changes, and pregnancy. Considerable residual scarring, interference with clinical and mammographic evaluation, and limited versatility are all major drawbacks of traditional procedures. We have performed unilateral mammaplasties on 47 patients with various types of congenital and acquired asymmetries, reducing and sculpturing the breast from the undersurface by means of minimal incisions, always avoiding horizontal scarring in the inframammary crease. Through a vertical infra-areolar incision, the breast is completely detached from the underlying pectoralis fascia and hooked up, thus completely exposing the undersurface of the mammary cone. The breast can thereafter be reshaped according to the size and shape of the contralateral breast by means of a discoid resection and/or selective sectoral removal of excessive subcutaneous tissues; modifications of the basic discoid resection can increase anterior projection of the new breast mound and can change the inclination of the anteroposterior breast axis on the anterior chest wall both on the horizontal and vertical planes. The results show that if criteria for patient selection are carefully respected, the procedure can provide long-lasting symmetry with minimal residual scarring and fully preserve the breast anatomy, function, and vascularization.     

Mammaplasty: large reduction with short inframammary scars

We present a technique for reduction mammaplasty that produces small inframammary scars measuring a maximum of 8 cm in large reductions and practically eliminates the difficulty in the mobility of the nipple-areola complex. We believe that the greatest contribution of the technique presented here is that good aesthetic results were obtained together with small inframammary scars.     

Vertical mammaplasty

Current criticisms regarding vertical mammaplasty include problems with poor immediate postoperative appearance, nipple-areola complex malposition, and excessive lower pole length. These problems can be avoided by proper patient selection, by utilizing correct concepts of skin design, and by observing correct glandular resection and closure concepts. Vertical mammaplasty also can result in other problems, such as hypertrophic circumareolar scars and lower pole deformities, including notching, boxy shape, infra-areolar depression, and flatness. These problems are also largely avoidable by using correct technique. Several basic concepts described previously have not proven necessary to achieve good results. Abandoning some of these principles has contributed to the ability to establish an aesthetically ideal breast shape intraoperatively as well as to a decrease in morbidity. This includes eliminating liposuction as a major integral component of the procedure, eliminating suturing the gland to the pectoralis muscle, not undermining the lower pole skin, and avoiding overly wide skin resection and tight wound closure that produces significant lower pole distortion in the early postoperative period. An important concept that has proven reliable is to use a "closed" design that does not predetermine the areolar opening whenever circumstances permit. When this is not possible, a modification that utilizes the smallest possible circumference as an open design is better than a large "mosque." These alternatives allow greater flexibility in determining final nipple position and also reduce the risk of hypertrophic circumareolar scars. Important glandular resection concepts include creating pillars that are attached to both the skin and the chest wall; making them of adequate dimension to avoid postoperative lower pole shape problems, such as flattening; resecting closer to the skin lateral to the pillars to avoid a boxy breast shape; and using a drain both to assist in accurately determining the endpoint of resection and to avoid postoperative seromas. Key closure concepts include approximation of the superior surfaces of the pillars at their base to maintain vertical height and thereby prevent lower pole flattening; approximation of the inferior surfaces of the pillars to the base of the breast to prevent notching; and proper management of the vertical incision by restricting the purse-string suture effect to only the inferior portion of the incision, where there may be skin excess present. Inclusion of these concepts leads to predictable and improved aesthetic results in vertical mammaplasty. This allows full realization of the purported advantages of vertical mammaplasty and allows this method to be utilized with a level of confidence similar to that seen with inverted-T techniques.     

A Z-mammaplasty with minimal scarring

An improved technique for reduction mammaplasty is described that has the advantage of giving a satisfactory final shape to the breast while producing a minimal scar. The method involves periareolar deepithelialization with displacement of the nipple-areola complex, partial subcutaneous mastectomy at the base of the mammary cone, and a Z-plasty to interlock two triangles of skin left after the removal of a little excess skin in the region above the inframammary fold. The Z-plasty adds skin vertically to the inferior pole, resulting in a better final shape and reducing tension around the areola. Any further excess skin is left to retract spontaneously. The best indications for this operation are in young women with elastic skin free of striae "gravidarum." Our experience now covers 53 patients aged 14 to 30 years with reductions of up to 900 gm per breast, and we have encountered no major complications over a 3-year follow-up period.     

Integrated breast mound reduction and nipple reconstruction with the wraparound flap.

A new method for nipple reconstruction is described that combines revision of an autologous tissue breast mound with creation of a projecting nipple. The method is applicable only to reconstructed breast mounds that must be reduced or lifted to achieve symmetry with the opposite breast. In this technique, the mound is reduced as if it were a normal breast, using an inverted-T or vertical mammaplasty pattern. In this way, breast projection can be increased and, if necessary, the inframammary fold can be elevated. A rectangular flap is created from skin and subcutaneous tissue that would normally be discarded during the breast reduction, and this flap is wrapped around on itself to form a projecting nipple. This new technique avoids the flattening of the breast mound usually seen after nipple reconstruction because it does not take tissue away from the completed breast mound to make the nipple. In appropriate patients who require reduction in size of their reconstructed breast mound, the wraparound flap nipple reconstruction is worth considering.     

Subglandular breast reduction: the evolution of a minimal scar approach to breast reduction

The authors describe a new modification of the breast reduction procedure. By means of an inframammary incision, the breast is mobilized from the chest wall, and a "doughnut" annulus of breast tissue is removed from the undersurface of the gland. No skin is excised. The nipple-areola complex is left attached to a central core of breast tissue that receives its blood supply from the subdermal plexus of vessels. When the resulting defect is closed within the breast by strategically placed sutures, the base of the gland is narrowed, the breast is projected forward, and the circumareolar and vertical scars of other techniques are eliminated. The authors report their results in a series of 37 patients.     

The medial periareolar approach to submuscular augmentation mammaplasty under local anesthesia

The medial approach to submuscular augmentation mammaplasty under local anesthesia begins with a medial periareolar incision around one-half or more of the areola. A subcutaneous tunnel is made toward the medial breast border, avoiding mammary ducts and sensory nerves to the nipple. The breast is reflected laterally, exposing a patch of pectoralis major muscle. A submuscular pocket is then created beneath portions of the pectoralis major, rectus abdominis, external oblique abdominis, and serratus anterior muscles, after which the implant is inserted and the muscle, dermis, and skin are closed sequentially. The periareolar incision allows for favorable scars without compromising the access or exposure necessary for accurate implant placement. Complete muscle coverage of the implant should contribute to a lower rate of capsular contracture. With a medial submuscular approach, nipple sensation is rarely altered, and revisions, if necessary, can be done through the same incision, still under local anesthesia, for increased safety, economy, and convenience. The medial approach to breast augmentation is a highly versatile, safe, and consistent method of achieving excellent results in breast augmentation in terms of scar, symmetry, and softness.     

Dual-pedicle dermoparenchymal mastopexy

Mastopexy for treatment of breast ptosis, with or without augmentation or reduction, is often followed by recurrent ptosis. A new mastopexy technique is described which appears to offer long-term correction. After conservative resection of excess skin, the breast parenchyma is elevated from the chest wall, and redundant caudal deepithelialized breast tissue is divided into two equal (or unequal) superiorly based pedicles. These are criss-crossed (as in folding of arms), overlapped, and secured to the pectoral fascia in a position cephalad to the nipple-areolar complex. This technique, dual-pedicle dermoparenchymal mastopexy (DPM), forms a cone of the breast tissue and provides a "cradle" of support. It permits insertion of a prosthesis if needed. Based, in part, on concepts of traditional and more recently described pedicled breast reductions, it enjoys the advantage of preserving skin attachment to underlying unresected breast parenchyma. In addition, it repositions ptotically displaced breast parenchyma into a cephalad position and fixes it (the "pexy") to the chest wall. A 10-year experience is presented with representative cases to illustrate the basic mastopexy and its use with augmentation or reduction.     

Simplifying the vertical reduction mammaplasty

The vertical reduction mammaplasty is an evolving technique. Its proponents report significantly decreased scarring, better breast shape, and more stable results compared with the standard inverted-T method, but the learning curve is long and cosmetic outcomes can be inconsistent. Many surgeons have experimented with the vertical closure before returning to methods more familiar to them. The authors present their modifications to the vertical reduction mammaplasty. Their changes simplify the preoperative markings and the intraoperative technique to shorten the learning curve while maintaining reliable aesthetic results. With the patient standing, only four preoperative marks are made: (1) the inframammary fold; (2) the breast axis; (3) the apex of the new nipple-areola complex; and (4) the medial and lateral limbs of the vertical incision. In the operating room, a medial or a superomedial pedicle is developed. Excess breast skin is resected with the inferior and lateral parenchyma as a C-shaped wedge. The lateral skin-adipose flap is redraped inferomedially and sutured to the chest wall. The inferior aspect of the breast is aggressively debulked and a gathering subcuticular stitch is started 2 cm below the nadir of the nipple-areola complex. Finally, a 38-mm to 42-mm nipple-areola complex marker is used to create a circular defect that is offset 0.5 cm medial to the vertical axis of the breast. In their series, 56 patients were treated and no major complications were noted. The median follow-up period was 17 months. The average reduction was 554.5 g per breast; however, the reduction was greater than 1000 g per breast in eight patients. The authors found that (1) chest wall anchoring improves lateral contour and minimizes axillary fullness; (2) aggressive debulking inferiorly avoids the persistent inferior bulge; and (3) starting the subcuticular gathering suture 2 cm below the nipple-areola complex followed by placement of a nipple-areola complex marker at the conclusion of the case prevents lateral deviation and corrects the nipple-areola complex teardrop deformity. These innovations accelerate the learning curve by simplifying the preoperative markings and lead to more consistent postoperative results and an improved cosmetic outcome. In conclusion, these modifications yield a simple, easily learned vertical reduction mammaplasty with aesthetically reliable results.     

Periareolar mammaplasty with silicone supporting lamina.

A mammaplasty technique through a periareolar incision and inferior pedicle trilobar flap with inclusion of a silicone supporting sheet was used in 485 patients between July of 1985 and December of 1989. The indications for the surgical treatment were ptosis, moderate to severe hypertrophy, or the association of both. The results were satisfactory in 458 patients (94.4 percent). The mean follow-up period was 22 months (range 6 to 50 months) in 427 patients without recurrences or functional alterations. No pathologic processes were observed as a result of use of the prosthesis. The silicone sheet did not interfere with manual, mammographic, or xeromammographic periodic examinations of the gland performed during the follow-up period. This technique has made it possible to mold the breast properly and to preserve its anatomic and functional unity, and in addition, it minimizes the scar and avoids recurrences.     

Method for intraoperative positioning of the nipple-areola complex in vertical scar reduction mammaplasty

The desired shape and position of the nipple-areola complex may be difficult to achieve in vertical scar reduction mammaplasty when using the standard technique of preoperative marking of the so-called mosque-shaped areolar pattern of excision. We describe our modified approach of intraoperative final positioning of the nipple-areola complex by hiding the nipple-areola complex behind the closed vertical incision. Individual positioning at the final part of the operation allows for more predictable results and also for a calculated lower positioning, which enables balance of the potential bottoming-out of the breast, particularly in previously large ptotic breasts. We believe that this modification helps to further improve the results of vertical scar reduction mammaplasty by adding more possibilities for shaping and "last-minute" modifications intraoperatively.