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.     

Medial pedicle reduction mammaplasty for severe mammary hypertrophy

Current options in reduction mammaplasty for severe mammary hypertrophy include amputation with free-nipple graft as well as the inferior pedicle and bipedicle techniques. Complications of these procedures include nipple-areola necrosis, insensitivity, and hypopigmentation. The purpose of this study was to determine whether medial pedicle reduction mammaplasty can minimize these complications. Twenty-three patients with severe mammary hypertrophy were studied. The medial pedicle successfully transposed the nipple-areola complex in 44 of 45 breasts (98 percent). Mean change in nipple position was 17.1 cm, and mean weight of tissue removed was 1604 g per breast. Nipple-areola sensation was retained in 43 of 44 breasts (98 percent) using a medial pedicle. Hypopigmentation was not observed, and central breast projection was restored in all patients. This study has demonstrated that medial pedicle reduction mammaplasty is a safe and reliable technique and should be given primary consideration in cases of severe mammary hypertrophy.     

The role of vasoconstrictors in control of blood loss in reduction mammaplasty

Because blood loss has been a concern in reduction mammaplasty, a prospective double-blind study was undertaken to determine whether instillation of an epinephrine solution into the breast parenchyma would reduce blood loss during this procedure. the inferior glandular pedicle technique was used with each patient serving as her own control. A significant reduction in operative blood loss compared with the control solution was observed. We believe that instillation of an epinephrine solution should be a routine part of the reduction mammaplasty procedure.     

Quantitation of breast sensibility following reduction mammaplasty: a comparison of inferior and medial pedicle techniques

The preservation of sensitivity within the nipple-areola complex is of paramount importance to patients presenting for reconstructive and aesthetic breast procedures. Previous attempts to measure sensation in the breast before and after surgery have relied primarily on the Semmes-Weinstein monofilament test, which is an imprecise study that measures the logarithm of force necessary to bend a series of six to 20 filaments. Within the last 10 years, various authors have published normative pressure threshold data for the breast that have varied by a magnitude of greater than 10-fold. Recently, precise anatomic studies have been performed that have elucidated the innervation of the nipple-areola complex medially and laterally from cutaneous branches of the intercostal nerves. Despite this knowledge, no quantitative sensibility studies have yet been performed that compare postoperative sensation when medially versus laterally innervated pedicles have been used in reduction mammaplasty. The present study is the first to use computer-assisted neurosensory testing to generate normal breast sensation data and to compare sensory outcomes between the inferior and the medial pedicle techniques of reduction mammaplasty.A total of 34 patients were divided into four groups and underwent breast sensory testing (67 breasts total) using the Pressure-Specified Sensory Device, a computer-assisted force transducer that measures static and moving one and two-point discrimination. Sensation in the nipple and in the four quadrants of the areola was measured. Groups I and II were composed of 17 unoperated controls with breast sizes ranging from 34A to 36C (group I; 18 breasts) and 36DD to 46EE (group II; 16 breasts) who presented to a general plastic surgery clinic. Groups III and IV were composed of 17 patients who underwent either medial or inferior pedicle reduction mammaplasty between July of 1997 and March of 1999. Pressure thresholds in the most sensitive breasts were as low as 0.3 g/mm2, a marked contrast to data from previous studies using Semmes-Weinstein monofilaments documenting the lowest recordable pressure threshold as greater than 2 g/mm2. Several findings from previous studies using Semmes-Weinstein monofilament testing were confirmed in unoperated controls, including an inverse relationship between sensitivity and breast size, superior nipple sensitivity when compared with the areola, and significant interpatient variability with respect to static and moving two-point discrimination among women matched according to age and breast size. When comparing medial with inferior pedicle reduction mammaplasty patients, it was found that despite significantly greater reductions using the medial pedicle technique (mean of 1.7 kg versus 1.1 kg of breast tissue removed), there were no significant differences in postoperative sensory outcomes in the sample size of 17 patients. Furthermore, within each group of patients undergoing either the medial or inferior pedicle technique, the amount of breast tissue removed did not correlate with postoperative sensory outcomes.Computer-assisted quantitative neurosensory testing is a highly accurate technique for measuring sensibility. The use of this technology demonstrates a 10-fold difference in measurable sensory thresholds in normal patients from preexisting data using Semmes-Weinstein monofilaments. Advances in measurement methods have allowed the authors to compare postoperative sensory outcomes reliably using two popular techniques of reduction mammaplasty.     

Prevention of the teardrop areola following the inferior pedicle technique of breast reduction

Elevation of the inferior portion of the areola with placement of dermal traction sutures will reduce the risk of an inverted teardrop areola deformity following inferior pedicle reduction mammaplasty. The long-term results in creation of a circular areola have been uniformly successful.     

Importance of the pedicle length measurement in reduction mammaplasty

Various measurements are still considered to be important for making decisions regarding the approach in reduction mammaplasty, even though the vast majority of techniques used are based on an inferior pedicle. This study was performed to analyze the variability of the suprasternal notch-to-nipple and nipple-to-inframammary fold distance measurements when using the inferior pedicle technique. In 92 patients, 184 breasts having various volumes were measured preoperatively, and the variability of the measurements of the suprasternal notch-to-nipple and nipple-to-inframammary fold distance was analyzed. The values of the distance from the suprasternal notch to nipple were dispersed over a wide range with a trimodal distribution, with peaks at the intervals of 23 to 27 cm, 28 to 33 cm, and 34 to 45 cm. In contrast, the values of the nipple-to-inframammary fold distance showed a normal distribution pattern, with the peak at 14 cm. The distance from the suprasternal notch to nipple has a fair relationship to the inframammary fold-to-nipple distance, the latter being concentrated in a smaller range (r = 0.51). The former is often used to decide whether a free-nipple graft should be performed. However, the relative consistency of the latter measurement has led to the conclusion that the free-nipple graft technique need never be considered.     

The pure posterior pedicle procedure for breast reduction

The inferior pedicle technique, which has already become classic, employs a glandular areola-bearing pedicle whose source of vascularization is primarily posterior. In fact, the inferior pedicle is a posterior pedicle with an inferior border. After systematically and progressively reducing this inferior border, I have completely eliminated it. The pure posterior pedicle that results is independent of the inframammary fold. It is vascularized by means of the pectoral muscle and fascia, as has been demonstrated by injection studies of the thoracoacromial artery in fresh cadavers. The resulting mammary reduction technique retains the advantages of the inferior pedicle technique while avoiding its major inconveniences: dependence on the inframammary fold, bulging at the inferior base of the pedicle, and the necessity of low positioning for the breast.     

Superomedial pedicle technique of reduction mammaplasty

A series of 148 patients who underwent reduction mammaplasty utilizing the superomedial pedicle technique is presented. Resections as large as 4100 gm per breast with nipple-areola transpositions up to 30 cm were done with reliable nipple-areola survival, including preservation of sensation. The superior pedicle technique of breast reduction is recognized by many as technically easier and capable of producing a longer-lasting aesthetic effect. Classically, however, it has been limited to smaller resections. By incorporating the medial quadrant in the superior pedicle, more aggressive reductions can be safely undertaken with the same excellent results. Details of the procedure, the anatomic basis for its success, and complications are discussed.     

Secondary reduction mammaplasty: is using a different pedicle safe?

Reduction mammaplasty is a frequently performed procedure and one with consistent patient satisfaction. Few patients present for revisional procedures, and even fewer present for a secondary or repeated reduction mammaplasty. This study defines secondary reduction mammaplasty as performing an additional reduction using a pedicled nipple-areola complex. Few reports of secondary reduction are found in the literature. Operative guidelines for secondary reduction mammaplasty have been published recently. However, the experience of others has differed from these guidelines, and herein is presented another experience with secondary reduction mammaplasty. Ten cases of secondary reduction over a 37-year period were identified and reviewed. The initial reductions were performed using six different techniques. An average of 307 g of tissue per breast (range, 130 to 552 g) was removed at the initial operations. The secondary reductions were performed using four different techniques, and an average of 458 g of tissue per breast (range, 147 to 700 g) was removed at the secondary operations. Three of the 10 patients underwent initial and secondary reduction with the same technique. An average of 4 years (range, 1 to 10 years) separated these surgeries. Seven of the 10 patients underwent initial and secondary reductions with different technique. An average of 15 years (range, 5 to 19 years) separated these procedures. There was an average 5-year follow-up (range, 1 to 20 years) in this series. Four of the 10 patients experienced self-limiting complications after secondary reduction, including delay in wound healing, delay in the return of nipple sensitivity, and mild fat necrosis. Three of the four patients with complications had undergone secondary reduction with a different pedicle technique. No significant or long-lasting skin, pedicle, or nipple-areola complex compromise was found after secondary reduction mammaplasty. In contrast to the recently published guidelines, this study demonstrates that secondary reduction mammaplasty is a safe and viable option when performed with either similar or different technique. This finding allows secondary reduction mammaplasty to be tailored to the individual breast type and to the abilities of the specific surgeon.     

Tissue oxygenation and perfusion in inferior pedicle reduction mammaplasty by near-infrared reflection spectroscopy and color-coded duplex sonography

Near-infrared reflection spectroscopy has been used in various experimental and clinical settings to investigate tissue perfusion and oxygenation noninvasively. Its application in plastic surgery has only recently been reported. The current study used near-infrared reflection spectroscopy to monitor cutaneous microcirculation in breast skin flaps after inferior pedicle reduction mammaplasty. Thirty patients underwent bilateral reduction mammaplasty by a modified Robbins technique. Near-infrared reflection spectroscopy measurements were performed preoperatively and postoperatively at several defined positions of the breast. The reflection spectroscopy system was capable of detecting absolute values of total hemoglobin in milligrams per milliliter of tissue and tissue hemoglobin oxygen saturation in percent. Color-coded duplex sonography was used to visualize nutrient vessels of the inferior dermoglandular pedicle and to measure systolic peak flow in the arteries supplying the nipple-areola complex. Reflection spectroscopy values were examined for changes during the postoperative course. Reflection spectroscopy and duplex sonography values were analyzed for differences between patients with normal and compromised skin flap perfusion and wound healing, which was assessed clinically and by ultrasound. Preoperative reflection spectroscopy values demonstrated local, regional, and interindividual variations. Postoperatively, characteristic changes of tissue hemoglobin oxygen saturation and total hemoglobin were observed in all patients during the 2-week follow-up. Reflection spectroscopy values differed significantly between breast and nipple-areola skin. Tissue hemoglobin oxygen saturation was significantly lower, and total hemoglobin significantly higher, in patients with impaired wound healing compared with patients having normal wound healing. However, systolic peak flow in arteries of the inferior dermoglandular pedicle did not reveal differences between patients with impaired or normal wound healing of the nipple-areola complex. Near-infrared reflection spectroscopy allows the detection of hemoglobin content and oxygenation in skin flaps. Changes in tissue hemoglobin oxygen saturation and total hemoglobin reflect hemodynamic changes in skin flaps during normal and pathological wound healing. Because of considerable intraindividual and interindividual variations, trend values seem to be superior to single measurements. Although in this study, near-infrared reflection spectroscopy was capable of distinguishing between normal and impaired perfusion in skin flaps in a clinical model, its future implication may be the early detection of vascular compromise in free flaps.     

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.     

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.     

Evaluation and comparison of aesthetic results and patient satisfaction with bilateral breast reduction using the inferior pedicle and McKissock's vertical bipedicle dermal flap techniques

In the last two decades, McKissock's technique for reduction mammaplasty was largely replaced by Robbins's inferior pedicle technique. However, a substantial number of plastic surgeons still perform McKissock's technique in the belief that it is superior to the inferior pedicle technique in terms of aesthetic results and complication rate. In this study, the authors compared the aesthetic results, complication rates, and patient satisfaction with the two techniques. Numerous studies in the past few years have shown an improvement in physical symptoms in addition to excellent patient satisfaction after breast reduction. However, almost all of these studies have used questionnaires that were mailed to the patients for evaluation. In the present study, aesthetic evaluations by the surgeon and an objective observer were performed in addition to evaluations by the patients themselves, thereby increasing the objectivity and the significance of the patients' evaluations. Two groups of 24 and 27 patients were compared. The groups were almost identical in terms of demographic data and the amount of breast tissue removed. The aesthetic results were good to excellent in both groups, and the groups had similar complication rates. When the patients' evaluations were compared with those of the surgeon and the objective observer, no significant difference was found between the observer and the patients. In one of the groups, the surgeon's evaluations were significantly higher than those of the patients, although they were not significantly higher than the observer's. In terms of aesthetic results, complication rates, and patient satisfaction, no differences existed between the groups. In addition, the patients' evaluations were determined to be a reliable index of aesthetic results and, in these cases, they were often identical to objective evaluations.     

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.     

Current trends in breast reduction

Results of our study describe the long term effects of reduction mammaplasty. Many women with excessively small or large breasts have an altered personal self-image and often suffer from low self-esteem and other psychological stresses. This procedure is designed to reduce and reshape large breasts, and since the size, shape, and symmetry of a woman's breasts can have a profound effect on her mental and physical well-being it is important to observe the patient's long-term outcome. Currently, breast reduction surgery is safe, effective and beneficial to the patient. In Croatia, reduction mammoplasty is often excluded from the general health care plan. The distinction between "reconstructive" versus "cosmetic" breast surgery is very well defined by the American Society of Plastic Surgeons Board of Directors. Unfortunately, the Croatian Health Society has yet to standardize such a distinction. There is an imperative need for evidence-based selection criteria. We retrospectively analyzed data of 59 female patients suffering from symptomatic macromastia who underwent reduction mammaplasty over a 16 year period (1995 until 2011). Our aim was to compare and contrast the various techniques available for reduction mammaplasty and to determine, based on patient outcome and satisfaction, which technique is most suited for each patient. The results of our study generally reinforce the observation that reduction mammaplasty significantly provides improvements in health status, long-term quality of life, postsurgical breast appearance and significantly decrease physical symptoms of pain. A number of 59 consecutive cases were initially treated with the four different breast reduction techniques: inverted-T scat or Wisa pattern breast reduction, vertical reduction mammaplasty, simplified vertical reduction mammaplasty, inferior pedicle and free nipple graft techniques. The average clinical follow-up period was 6-months, and included 48 patients. The statistical analysis of the postoperative patient complications revealed a significant positive relationship in regards to smoking. The majority of these complications were wound related, with no significant relationship between patient complications and variables such as age, BMI, ASA score, resection weight of breast parenchyma, nipple elevation, duration of surgery, and type of pedicle. The higher number of complication correlated with a lower volume of parenchyma resection (rho=-0.321). Overall satisfaction with the new breast size (79%), appearance of the postoperative scars (87%), overall cosmetic outcome score (91%), overall outcome (100%), psychosocial outcome (46%), sexual outcome (85%), physical outcome (88%), satisfaction with preoperative information data (92%), and finally satisfaction with overall care process (96%) was calculated. As expected, the physical symptoms disappeared or were minimized in 88% of patients. Each method of breast reduction has its advantages and disadvantages. The surgeon should evaluate each patient's desires on the basis of her physical presentation. Breast reduction surgery increases the overall personal and social health; not only for the patient, but for their family and friends as well. It is an imperative that every surgeon is aware of this, in order to provide the highest level of care and quality to their patients.     

Repeat reduction mammaplasty

Repeat reduction mammaplasty is an uncommonly performed procedure. Currently, no clear operative guidelines of management exist. Sixteen patients (28 breasts) with a mean age of 29 years (range, 13 to 52 years) underwent repeat breast reduction over an 11-year period. Before the first reduction, the mean notch to nipple distance was 29.6 cm (range, 24 to 38 cm) and mean nipple to inframammary crease distance was 15.5 cm (range, 12 to 18 cm). The mean mass of tissue excised was 615 g per breast. A number of different pedicles were used (six inferior, five superior, four superomedial, one unknown). All patients subsequently developed pseudoptosis. The nipple to inframammary crease distance was a mean of 11.4 cm (having initially been set at 7 cm) before the second procedure. At the second operation, two patients (three breasts) had their initial pedicles transected and the nipple-areola complex moved, and both patients developed vascular compromise of the nipple-areola complex (two breasts). Where the same pedicle was used in the second operation (five patients, 10 breasts), one patient developed unilateral nipple-areola complex necrosis. In eight patients, because of the development of pseudoptosis, the nipple was in a satisfactory position, and therefore only an inferior wedge of tissue required excision. This was performed without nipple-areola complex compromise, irrespective of the initial pedicle. The mean mass of tissue excised in the second operation was 325 g per breast (range, 120 to 620 g). Fourteen patients were available for follow-up after a mean of 5.1 years (range, 3 months to 11.7 years) following the repeat reduction mammaplasty. In the repeat breast reduction, where nipple-areola complex transposition is planned, the initial pedicle should be reused to maintain nipple-areola complex perfusion. Where the initial pedicle is not known, a free nipple graft may be the safest option. In patients with pseudoptosis, in whom the nipple does not require transposition, an inferior wedge of tissue can be safely excised, irrespective of the initial pedicle.     

Breast-feeding after inferior pedicle reduction mammaplasty

The breast-feeding practices of a series of postpartum women, who had undergone prior reduction mammaplasty by means of an inferior pedicle approach, are reported in this retrospective study. Also identified are the factors that influenced the decision to breast-feed postoperatively. From a patient pool of 544 individuals who elected to have reduction mammaplasty between 1984 and 1994 (age range, 15 to 35 years), 334 could be contacted and interviewed by means of telephone by using a standardized questionnaire. Successful breast-feeding was defined as the ability to feed for a duration equal to or greater than 2 weeks. Seventy-eight patients had children after their breast reduction surgery. Fifteen of the 78 patients (19.2 percent) breast-fed exclusively, 8 (10.3 percent) breast-fed with formula supplementation, 14 (17.9 percent) had an unsuccessful breast-feeding attempt, and 41 (52.6 percent) did not attempt breast-feeding. Of the 41 patients not attempting to breast-feed, 9 patients did so as a direct consequence of discouragement by a health care professional. Further reasons for feeding with supplementation, having an unsuccessful attempt, and not attempting to breast-feed are presented. Of the 78 women who had children postoperatively, a total of 27 were discouraged from breast-feeding by medical professionals with only 8 of the 27 (29.6 percent) subsequently attempting, despite this recommendation. In comparison, 26 patients were encouraged to breast-feed; nineteen (73.1 percent) of them did subsequently attempt breast-feeding. This rate is statistically significant by using a chi2 test with 1 df(p = 0.0016). Postpartum breast engorgement and lactation was experienced by 31 of the 41 patients not attempting to breast-feed. Of these 31 patients, 19 believed that they would have been able to breast-feed due to the extent of breast engorgement and lactation experienced. Given the use of an inferior flap mammaplasty technique and patient encouragement, the possibility for breast-feeding after reduction mammaplasty exists. This prevalence falls near the breast-feeding rate found in the population not having undergone breast surgery, according to an article in the Canadian Journal of Public Health.     

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.     

Outcome analysis of reduction mammaplasty using the modified Robertson technique

The benefits of reduction mammaplasty have been well documented in previous literature. Anticipating and correcting for pseudoptosis (bottoming-out), however, can impair the cosmetic outcome as the inferior skin envelope stretches and lengthens over time. We present long-term results on patients using the modified Robertson technique for reduction mammaplasty, which appears to have significant benefit in helping to prevent bottoming-out. Surveys were sent to patients undergoing reduction mammaplasty surgery with this technique from 1987 to 1997. Patients were queried regarding preoperative and postoperative symptoms, satisfaction, and outcome related to their surgery and were also offered free follow-up examinations. The patients who returned for follow-up were then evaluated by the attending surgeons for evaluation of scarring, nipple position, ptosis, pseudoptosis, shape, and overall appearance. Reduced breasts were also compared with cosmetically optimal breasts to compare for measured levels of pseudoptosis using our defined visual inferior pole ratio measurements. Average reduction size was 910 g and follow-up was 4.7 years from the time of surgery. There was significant improvement demonstrated in all areas questioned, with the greatest relief shown in back and shoulder pain, shoulder grooving, and difficulty fitting clothing. There was also demonstrated to be significantly less use of medical modalities postoperatively and significant increases in activity levels. Satisfaction for size, shape, symmetry, and overall results was 85, 94, 98, and 94 percent, respectively. Evaluations for pseudoptosis by the attending surgeons were rated good or excellent in 95 percent of patients. Measurements of the visual inferior pole ratio for pseudoptosis also demonstrated no significant differences when compared with aesthetically optimal breasts. The modified Robertson reduction mammaplasty is a reliable technique that can be used for both small and large reductions, giving both reliable and consistent results. This technique significantly improves symptoms, as do other reduction techniques, but has the added advantage of helping to avoid pseudoptosis postoperatively.     

The vertical mammaplasty: a reappraisal of the technique and its complications

Since 1989, superior pedicle vertical scar mammaplasty as described by Lejour has been used in the authors' department as the only technique for breast reduction. From 1991 through 1994, a series of 170 consecutive patients (330 breasts) underwent an operation. In these patients, minor complications were observed in 30 percent of the patients and major complications in 15 percent. Surgical revision for scar or volume corrections was necessary in 28 percent of the breasts, which seemed unacceptable. Therefore, the original technique was modified by decreasing the skin undermining and avoiding liposuction in the breast. Primary skin excision was performed in the submammary fold at the end of the operation if the skin could not be puckered adequately. This modified technique was used from 1996 through 1999 in 138 consecutive patients (227 breasts). In the second series, minor complications were observed in 15 percent of the patients and major complications in 5 percent. However, the technical modifications did not significantly change the rate of secondary scar and volume corrections, which were still necessary in 22 percent of the breasts. In large breasts, the addition of a horizontal scar at the end of the operation did not change the rate of secondary revision, which however compares favorably with the figures obtained with the inverted T, superior pedicle mammaplasty.