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Benefits and pitfalls of vertical scar breast reduction

      Abstract

      A quality assurance study was undertaken three years after beginning the vertical scar breast reduction technique. We examined the rate of early and late complications (major and minor) and compared these to the formerly used inverted-T scar and L scar breast reduction techniques. Inverted-T scar breast reductions have an early complication rate of up to 20% and a late complication rate of 20–30%.
      Our vertical scar breast reduction is a modified Lassus technique, incorporating a geometrically based and measurable preoperative marking of the breast, a superior pedicle, a central breast resection, an intraoperative positioning of the nipple-areola complex, and occasionally a periareolar skin resection.
      In the time span examined (September 1998–December 2001) 153 patients could be included in the study. The resection weight per breast ranged from 60 to 1262 g (mean 390±210 g, median 380 g).
      The early complication rate (hematoma, seroma, wound dehiscence, wound infection and necrosis) was 21.6%. Of these cases, 19.6% were minor complications. The late complication or imperfection rate was evaluated very strictly using the standardized, extended scheme of Ferreira (problems of volume, shape, symmetry, areola, scars and position of the breast on the thorax) and was 26%. Major late complications necessitating a reoperation occurred in 11.1% of cases.
      These complication rates compare well to those of other vertical breast reduction techniques and T scar reductions in our own clinic and in the literature. Given that the vertical scar breast reduction method also results in shorter scars and a significantly better, long-lasting breast projection, this technique is clearly justified to remain the standard method at our clinic.

      Keywords

      The use of vertical scar breast reduction techniques is only slowly gaining in popularity, even though Lassus introduced the method almost 40 years ago.
      • Lassus C
      A 30-year experience with vertical mammaplasty.
      In 1998, a questionnaire distributed to members of the American Society of Plastic and Reconstructive Surgeons revealed that out of 190 members, only 12% carried out a vertical (Lejour
      • Lejour M
      Vertical mammaplasty and liposuction.
      ) breast reduction.
      • Hidalgo D.A
      • Elliot L.F
      • Palumbo S
      • Casas L
      • Hammond D
      Current trends in breast reduction.
      Three years later, Menke
      • Menke H
      • Eisenmann-Klein M
      • Olbrisch R.R
      • Exner K
      Continuous quality management of breast hypertrophy by the German Association of Plastic Surgeons: a preliminary report.
      published a preliminary report on continuous quality management of breast hypertrophy as a tracer diagnosis by the German Association of Plastic surgeons. According to this report, the vertical scar breast reduction was carried out in 53% of 799 patients and had surpassed the rate of inverted-T scar breast reductions by 8%. At the moment, vertical scar techniques seem to be more popular in Europe than in the United States. However, if this method proves to have a similar rate of early complications (i.e. hematoma, seroma, wound dehiscence, infection and necrosis) and late complications (i.e. problems of volume, shape, symmetry, areola and scars
      • Ferreira M.C
      Evaluation of results in aesthetic plastic surgery: preliminary observations on mammaplasty.
      ) as that of the inverted-T scar techniques, and at the same time produces equal or better long-term results, it may well become the universal procedure of choice.
      • Schnur P.L
      Reduction mammaplasty—the Schnur sliding scale revisited.
      • Georgiade N.G
      • Serafin R
      • Riefkohl R
      • Georgiade G.S
      Is there a reduction mammaplasty for all seasons?.
      Information on the surgical outcome of T scar breast reductions was rare in the literature, but has recently been increasing.
      • Egmont D.B
      • Isselstein K.I
      • Ramselaar J.M
      A comparison between two methods of reduction mammaplasty.
      • Davis G.M
      • Ringler S.L
      • Short K
      • Sherrik D
      • Bengtson B.P
      Reduction mammaplasty: long term efficacy, morbidity, and patient satisfaction.
      • Dabbah A
      • Lehman J.A
      • Parker M.G
      • Tantri D
      • Wagner D
      Reduction mammaplasty: an outcome analysis.
      • Giovanoli P
      • Meuli-Simmen C
      • Meyer V.E
      • Frey M
      Which technique for which breast? A prospective study of different techniques of reduction mammaplasty.
      Dabbah
      • Dabbah A
      • Lehman J.A
      • Parker M.G
      • Tantri D
      • Wagner D
      Reduction mammaplasty: an outcome analysis.
      found a complication rate of 45% in various forms of T reduction in a retrospective study on 185 patients. The most common complications were fat necrosis or infection (22%) and wound dehiscence (10%). An even higher overall complication rate of 53%, was reported by Davis
      • Davis G.M
      • Ringler S.L
      • Short K
      • Sherrik D
      • Bengtson B.P
      Reduction mammaplasty: long term efficacy, morbidity, and patient satisfaction.
      in a study on 406 patients. Although most of these complications were minor, 5% required surgical correction. At our own clinic before we began using the vertical scar technique, the complication rate of three different T scar or L scar reduction techniques was also about 50%, including 4.9% major complications.
      • Giovanoli P
      • Meuli-Simmen C
      • Meyer V.E
      • Frey M
      Which technique for which breast? A prospective study of different techniques of reduction mammaplasty.
      In contrast, other authors
      • Schnur P.L
      Reduction mammaplasty—the Schnur sliding scale revisited.
      have reported a complication rate of about 20%. This discrepancy of more than two-fold in the indicated frequency of complication rates is due to a heterogenous and varyingly stringent definition of complication rate (i.e. early and/or late complications, minor and/or major complications). It is also due to the general difficulty of defining late complications systematically, a factor that impedes the comparison of various breast reduction studies with respect to complications (Table 1) . Despite this we obviously have to deal with a rate of up to 20% early and up to 20–30% late complications in T scar breast reductions.
      Table 1Comparison of early and late complication rates (in %) from two T scar breast reduction series
      • Davis G.M
      • Ringler S.L
      • Short K
      • Sherrik D
      • Bengtson B.P
      Reduction mammaplasty: long term efficacy, morbidity, and patient satisfaction.
      • Dabbah A
      • Lehman J.A
      • Parker M.G
      • Tantri D
      • Wagner D
      Reduction mammaplasty: an outcome analysis.
      and several vertical breast reduction series from the literature
      HematomaSeromaWound dehiscenceSurgical site infection (SSI)Necrosis (NAC, wound edges, fat tissue)VolumeShapeSymmetryAreolaScarsPosition on thorax
      AuthorYearn1234567891011
      Davis
      • Davis G.M
      • Ringler S.L
      • Short K
      • Sherrik D
      • Bengtson B.P
      Reduction mammaplasty: long term efficacy, morbidity, and patient satisfaction.
      199540619126189818
      Dabbah
      • Dabbah A
      • Lehman J.A
      • Parker M.G
      • Tantri D
      • Wagner D
      Reduction mammaplasty: an outcome analysis.
      1995185211022
      Surgical site infection and fast tissue necrosis together.
      44
      Berg
      • Berg A
      • Palmer B
      • Stark B
      Early experience with the Lejour vertical scar reduction mammaplasty technique.
      1995704.318.2
      Fast tissue necrosis.
      11.430
      Lassus
      • Lassus C
      A 30-year experience with vertical mammaplasty.
      19967100001.82.8
      Asplund
      • Asplund O.A
      • Davies D.M
      Vertical scar breast reduction with medial flap or glandular transposition of the nipple-areola.
      199657005.31.8015.81.81.8
      Lejour
      • Lejour M
      Vertical mammaplasty: early complications after 250 personal consecutive cases.
      19982501.353.40.40.4
      Hammond
      • Hammond D.C
      Short scar periareolar inferior pedicle reduction (SPAIR) mammaplasty.
      1998980213010151
      Menke
      • Menke H
      • Restl B
      • Olbrisch R.R
      Vertical scar reduction mammaplasty as a standard procedure—experiences in the introduction and validation of a modified reduction technique.
      19992285.27.810.48.4
      Fast tissue necrosis.
      15.613
      Menke
      • Menke H
      • Eisenmann-Klein M
      • Olbrisch R.R
      • Exner K
      Continuous quality management of breast hypertrophy by the German Association of Plastic Surgeons: a preliminary report.
      20014241.73.113.23.85
      Early complications are listed more regularly and more systematically than late complications, –, means missing indication.
      a Surgical site infection and fast tissue necrosis together.
      b Fast tissue necrosis.
      Concerning the vertical breast reduction techniques, there are already a considerable number of outcome reports, yet they mainly refer to the Lejour technique.
      • Lejour M
      Vertical mammaplasty: early complications after 250 personal consecutive cases.
      • Menke H
      • Restl B
      • Olbrisch R.R
      Vertical scar reduction mammaplasty as a standard procedure—experiences in the introduction and validation of a modified reduction technique.
      • Pickford M.A
      • Boorman J.G
      Early experience with the Lejour vertical scar reduction mammaplasty.
      • Berg A
      • Palmer B
      • Stark B
      Early experience with the Lejour vertical scar reduction mammaplasty technique.
      • Palumbo S.K
      • Shifren J
      • Rhee C
      Modifications of the Lejour vertical mammaplasty: analysis of results in 100 consecutive cases.
      Complication rates are strikingly similar to those obtained with the T technique, and range in general from 12 to 50%. Pickford
      • Pickford M.A
      • Boorman J.G
      Early experience with the Lejour vertical scar reduction mammaplasty.
      reports a minor complication rate (e.g. delayed wound healing, fat necrosis and wound infection) of 40% in his first 25 ‘Lejour patients’. Berg
      • Berg A
      • Palmer B
      • Stark B
      Early experience with the Lejour vertical scar reduction mammaplasty technique.
      even reports a rate of early complications of 37% using the Lejour technique in 70 patients. In contrast, Lejour's early complication rate
      • Lejour M
      Vertical mammaplasty: early complications after 250 personal consecutive cases.
      in 250 women (personal cases) lies as low as 12%.
      At our clinic, we evaluated the first group of 150 patients who underwent a vertical breast reduction using our modified vertical Lassus technique. This technique involves a geometrically-based and measurable preoperative marking of the breast, a superior pedicle, a central breast resection, an intraoperative positioning of the nipple-areola complex (NAC) and an occasional periareolar skin resection.
      • Beer G.M
      • Morgenthaler W
      • Spicher I
      • Meyer V.E
      Modifications in vertical scar breast reduction.
      For the sake of quality assurance we examined the overall rate of complications and compared it to that obtained with our formerly employed T scar or L scar breast reduction methods.
      • Giovanoli P
      • Meuli-Simmen C
      • Meyer V.E
      • Frey M
      Which technique for which breast? A prospective study of different techniques of reduction mammaplasty.

      Kompatscher P, Planta A, Spicher I, Vetter S, Minder J, Meyer VE, Beer GM. Antimicrobial prophylaxis for the prevention of early infections after breast reduction. Aesth Plast Surg, in press.

      1. Patients and methods

      All patients who had a primary bilateral vertical breast reduction in the time period from September 1998 to December 2001 were enrolled in the study. The examination consisted of a review of the medical charts from a prospective study protocol and a review of our digitally stored photographic records. Excluded from the study were patients with unilateral breast reduction or breast reconstruction or mastopexy, or a follow-up of less than half a year. Mastopexy was defined as a resection of skin alone, not involving underlying tissues.
      Patient characteristics such as age, weight, height, co-morbidity score (as classified by the American Society of Anesthesiologists (ASA)) and factors possibly associated with an increased risk of surgical site infection (SSI), such as diabetes, use of steroids or immunosuppressives, adiposity and operation time were noted. Adiposity was defined as a body mass index (BMI) >30 kg/m2.
      Within one hour before the beginning of the operation all women were given antimicrobacterials (cefuroxim 1.5 g, cephalosporine of the 2nd generation, half-life of 1–2 h) as a single-shot prophylactic dose.

      Kompatscher P, Planta A, Spicher I, Vetter S, Minder J, Meyer VE, Beer GM. Antimicrobial prophylaxis for the prevention of early infections after breast reduction. Aesth Plast Surg, in press.

      During the operation a drain was always used, i.e. a negative pressure drain inserted through a separate incision in the axillary region. The resection weight of both breasts was recorded, the number of surgeons carrying out the operations was also recorded.
      The wound dressing was changed once, usually 24 h after the operation. At this time the two drains were removed. The postoperative follow-up plan included direct examination of the patients' wounds after one week, two weeks and 1, 3, 6 and 12 months. A firmly supporting bra had to be worn day and night for the first three weeks post-operatively, and during the daytime for a further three months.
      All early complications, such as hematoma, seroma, wound dehiscence, wound infection and necrosis (classified according to whether they involved the skin edges, fat, part or all of the areola and nipple) were recorded. Hematomas were subclassified into clinical hematomas, i.e. necessitating surgical evacuation, and subclinical hematomas.
      • Asplund O
      • Gylbert L
      • Jurell G
      • Ward C
      Textured or smooth implants for submuscular breast augmentation: a controlled study.
      Only the clinical hematomas were included in the calculation of the complication rate. Infections were defined according to the guidelines for prevention of SSI,
      • Mangram A.J
      • Horan T.C
      • Pearson M.L
      • Silver L.C
      • Jarvis W.R
      Guideline for prevention of surgical site infection.
      i.e. as a purulent discharge from the superficial incision and painful spreading erythema indicative of cellulitis (∅>5 cm) within the first thirty days of operation. A stitch abscess alone was not reported as a wound infection. All late complications, i.e. imperfections of volume, shape, symmetry, problems of the NAC and scars, were similarly noted. In addition, the position of the reduced breast on the thorax was recorded. The breast volume was estimated based on the new bra-cup size and the symmetry of the breasts was judged visually. Symmetry of areola position was measured by the sternal notch to nipple, nipple to inframammary fold and internipple distances; symmetry of the areola configuration was also measured. Furthermore, special attention was paid to complications that have been attributed specifically to the vertical scar technique, such as teardrop deformity of the areola, residual wrinkling of the vertical scar, inframammary dog-ears or a vertical scar reaching beneath the new inframammary fold (i.e. a too high positioning of the breast on the thorax). Criteria such as breast function (breastfeeding), sensitivity changes, general complications such as thrombosis or emboli, relief of breast-related pain syndrome
      • Kerrigan C.L
      • Collins E.D
      • Striplin D
      • Kim H.M
      • Wilkins E
      • Cunningham B
      • Lowery J
      The health burden of breast hypertrophy.
      and patients' satisfaction were not included in this study.
      Results were analysed using SPSS 11.0 (SPSS, Chicago, IL) software. Continuous variables were summarised as mean±SD and were compared between the groups by using the Mann–Whitney test. Nominal variables were presented as n (%). A p-value of ≤0.05 was considered significant.

      2. Results

      The demographic and other basic data of the 153 patients included in the study are listed in Table 2. All patients had an ASA score of one or two. Six patients (3.9%) had the following comorbidities: hypertension (2), diabetes (1), HIV (1), multiple sclerosis (1), paraplegia (1). Adiposity was present in 5% of women. The resection weight per breast ranged from 60 to 1262 g (mean 390±210 g, median 380 g). One-third of the patients (52 cases, 34%) had a resection weight less than 300 g, 108 patients (71%) less than 500 g. Eighteen patients (12%) had over 700 g resection weight per breast. The mean operation time was 3 h and 10 min. There was a wide range, however, with some operations lasting up to more than 5 h. Only four operations were below two hours in length. The total number of surgeons was 15 (11 trainees). Of the early complications, wound dehiscence was encountered in 12.4% of women. Hematoma and wound infections were less frequent, at 4% each. The rate of seroma and necrosis was both below 1%. The one necrosis found was a partial areola necrosis, no fat tissue necrosis was encountered (Table 3) . The overall rate of early complications was 21.6%. Of these, only three cases (one patient with a wound infection and two patients with a hematoma) were classified as major complications (2%) and had to be readmitted and reoperated. The remaining 19.6% were classified as minor complications. The rates of late complications are listed in Table 3; often more than one complication occurred in a single patient. The overall rate of women with a late complication was 26%. The problems that arose were (i) a too large residual volume in 3.3%, (ii) shape problems in 5.2% (persisting cranial convexity), (iii) minor asymmetry of the breast and areola in a 1/4 of cases, (iv) distortion or malposition of the areola in 17% with two purse-string suture ruptures, (v) hypertrophied and broad vertical scars or small dog-ears at the end of the inframammary scar in 16%, and (vi) a too high positioning of the breast on the thorax (‘too long’ vertical scar) in 15% of cases. The following re-operations arose from major late complications: volume reduction (0.7%), areola correction in 3.9% with two ruptured periareolar purse-string sutures and scar revisions in 5.2%. Altogether the rate of re-operations was 11.1%. The results of our T- or L scar breast reductions are published elsewhere.
      • Giovanoli P
      • Meuli-Simmen C
      • Meyer V.E
      • Frey M
      Which technique for which breast? A prospective study of different techniques of reduction mammaplasty.

      Kompatscher P, Planta A, Spicher I, Vetter S, Minder J, Meyer VE, Beer GM. Antimicrobial prophylaxis for the prevention of early infections after breast reduction. Aesth Plast Surg, in press.

      Table 2Demographic data of the patients with a bilateral vertical breast reduction, n=153
      Mean±SDRange
      Age34±1317–67
      Weight in kg65±947–92
      Height in cm164±6150–181
      BMI (kg/m2)24.3±3.117.6–34.8
      Duration of OP (min)190±60100–320
      Resection (g)385±21460–1262
      Table 3Early (arising within the first 30 days postoperatively) major and minor complications (items 1–5) and late complications, i.e. imperfections (items 6–11, modified from the evaluation scheme of Ferreira
      • Ferreira M.C
      Evaluation of results in aesthetic plastic surgery: preliminary observations on mammaplasty.
      ) in vertical breast reduction
      Overall complicationsMajor complications
      Hematoma6 (3.9%)2 (1.36%)
      Seroma1 (0.7%)
      Wound dehiscence19 (12.6%)1 (0.7%)
      Surgical site infection (SSI)6 (3.9%)
      Necrosis (NAC, wound edges, fat tissue)1 (0.7%)
      Volume5 (3.3%)1 (0.7%)
      Shape8 (5.2%)
      Symmetry40 (26%)2 (1.3%)
      Areola26 (17%)6 (3.9%)
      Scars24 (15.6%)4 (2.6%)
      Position on thorax22 (15%)4 (2.6%)
      n=153. Complication rates are listed as % of patients.

      3. Discussion

      Our vertical scar breast reduction series had a 21.6% rate of early complications and a 26% rate of late complications or imperfections. These results were obtained in a teaching hospital, with a total of 15 different surgeons (among them 11 trainees) carrying out the operations.
      Whereas, the rates of hematoma, wound dehiscence and wound infection

      Kompatscher P, Planta A, Spicher I, Vetter S, Minder J, Meyer VE, Beer GM. Antimicrobial prophylaxis for the prevention of early infections after breast reduction. Aesth Plast Surg, in press.

      correspond closely to the frequencies found with other breast reduction techniques, two other parameters among the early complications deserve to be examined in more detail: the low rates of seroma and necrosis. We attribute the low rate of seroma to the fact that we did rarely liposuction and (with growing experience) did less and less undermining of the inferior pole of the breast. Seroma is probably a complication associated with those techniques of vertical reduction that use adjuvant liposuction and undermining of the breast. Lejour
      • Lejour M
      Vertical mammaplasty: early complications after 250 personal consecutive cases.
      herself reports a 5% rate of seromas; Menke
      • Menke H
      • Restl B
      • Olbrisch R.R
      Vertical scar reduction mammaplasty as a standard procedure—experiences in the introduction and validation of a modified reduction technique.
      found a rate of 7.8%. The low rates of necrosis, both of fat and of the wound edges, is also attributable to the central tissue resection en bloc with no undermining of the breast, even though the vertical scar is closed under a certain amount of tension. The tension on the rather delicate skin in the infra-areolar area made it rather prone to wound dehiscence (12.6% in our series), but this was probably aggravated by our usage of subdermal braided suture material (discontinued after the control study) that led to foreign body reactions.
      • Berg A
      • Palmer B
      • Stark B
      Early experience with the Lejour vertical scar reduction mammaplasty technique.
      • Lejour M
      Early experience with the Lejour vertical scar reduction mammaplasty technique-invited commentary.
      Whereas, early complications are relatively easy to classify, one major difficulty of this study was to define objectively late complication rates, as these tend to be difficult to measure. Ferreira proposed a reasonable scheme of standardisation to evaluate the appearance of the breast.
      • Ferreira M.C
      Evaluation of results in aesthetic plastic surgery: preliminary observations on mammaplasty.
      He proposed five visual characteristics to be evaluated on a score from 0 to 2 (0=poor, 1=fair (average), 2=good). We used his five characteristics, but rather than scoring between 0 and 2, we regarded all imperfections that would have resulted in a ‘fair’ or ‘poor’ result as ‘complications’. Additionally, we added a further feature to this score, namely the ‘position’ of the breast on the thorax.
      In the conventional T scar breast reductions, the position on the thorax is defined at the time of operation by the incision at the inframammary fold (later on, the inframammary scar tends to rise and becomes situated on the inferior pole of the breast). The situation is completely different in vertical reductions. Lassus
      • Lassus C
      A 30-year experience with vertical mammaplasty.
      observed that in large breasts the inferior portion of the vertical scar appeared below the inframammary fold. This was the reason why he recommended ending the vertical incision 2–4 cm above the inframammary fold for large breasts. Additionally, Lejour
      • Lejour M
      Vertical mammaplasty and liposuction.
      recommended the temporary creation of a new, higher inframammary fold at the end of the vertical incision point. With this technique the breast is raised in its position on the thorax. If the breast remains in its higher position and the vertical scar does not end at the new fold once the inferior pole has been tightened (a risk especially in small remaining breasts with good skin quality), the scar appears ‘too long’ and becomes visible. This is probably the biggest pitfall of the vertical scar technique and is both vexing to the surgeon and, more important, embarrassing to the women when they wear a small bra or a bikini. Fifteen percent of our scars appeared below the new, artificial higher submammary fold. On the basis of this experience, we now recommend—whenever there is no anatomical need to raise the submammary fold—leaving the submammary fold in its original position and terminating the vertical incision at that point.
      Further specific findings concerning late complications of the vertical scar breast reduction will be discussed according to Ferrera's evaluation Scheme.
      Volume (Size). The evaluative potential of this item is diminished by the technical difficulty of measuring the exact breast size.
      • Grossman A.J
      • Roudner L.A
      A simple means for accurate breast volume determination.
      • Tegtmeier R.E
      A quick, accurate mammometer.
      Various attempts have been made, using different forms of water displacement or imitating bra-cup sizes with calibrated, transparent plastic cups.
      • Berg A
      • Palmer B
      • Stark B
      Early experience with the Lejour vertical scar reduction mammaplasty technique.
      Other authors just use the woman's normal bra size.
      • Kerrigan C.L
      • Collins E.D
      • Striplin D
      • Kim H.M
      • Wilkins E
      • Cunningham B
      • Lowery J
      The health burden of breast hypertrophy.
      • Gonzalez F
      • Walton R.L
      • Shafer B
      • Matory W.E
      • Borah G.L
      Reduction mammaplasty improves symptoms of macromastia.
      However, irrespective of these technical difficulties, there does seem to be a tendency to under-resect breast tissue in vertical breast reductions, leaving the final volume larger than in a comparable T scar breast reduction.
      • Hall-Findlay E.J
      A simplified vertical reduction mammaplasty: shortening the learning curve.
      This is predominantly the case in the Lassus vertical reductions, since the tissue of the medial and lateral infraareolar extremities is left in place and no liposuction is carried out. At our clinic, a comparison between our modified, vertical breast reduction (the standard procedure for all patients since 1998) and previous T scar breast reductions performed by the first author,

      Kompatscher P, Planta A, Spicher I, Vetter S, Minder J, Meyer VE, Beer GM. Antimicrobial prophylaxis for the prevention of early infections after breast reduction. Aesth Plast Surg, in press.

      showed a significant difference in the mean resection weight per breast: 385 g in the vertical scar group and 450 g in the T scar group (p=0.0039 for the right and p=0.009 for the left breast). Whereas, in the vertical scar reduction group the majority of women postoperatively had a Cup C breast size, the majority of the T scar group had a bra size Cup B. No woman complained about over-resection in the vertical group, but 3.3% complained about under-resection. Hughes reports the opposite experience
      • Hughes L.A
      • Mahoney J.L
      Patient satisfaction with reduction mammaplasty: an early survey.
      in a series of 31 patients with T scar reductions, where 25.8% of patients thought, one month after the operation, that their breasts had been over-reduced (the rate dropped to 15% after two months). In most other reports, where the resection weight in the T scar group was substantially higher than in the I scar group, the latter group was composed of small to medium breast reductions only.
      • Menke H
      • Eisenmann-Klein M
      • Olbrisch R.R
      • Exner K
      Continuous quality management of breast hypertrophy by the German Association of Plastic Surgeons: a preliminary report.
      • Pickford M.A
      • Boorman J.G
      Early experience with the Lejour vertical scar reduction mammaplasty.
      Shape. One of the main benefits of all vertical forms of breast reductions is the enhanced, and long-lasting better projection of the breast as compared to the flatter appearance of the breast following a T scar breast reduction (Fig. 1) . However, the more tissue in the infraareolar region is excised, the smaller the foundation of the breast becomes, and the greater is the risk of producing ‘tube’ breasts with an overly raised projection. Similarly, exerting too much tension on the infraareolar scars can produce, in predisposed patients, a symmasty of variable degree. Such a deformity can only rarely be corrected. Another tricky shape problem in vertical breast reductions can be a persisting cranial convexity if the breast is positioned too high on the thorax, and the NAC is placed rather low. The cranial convexity results in a profile that differs significantly from the ideal shape of a smooth straight line in the upper pole of the breast to the NAC and a decent convexity on the lower pole. On the other hand, a low-set NAC will never give the impression of a bottomed out breast at a later date, as is sometimes the case in high-riding areolas.
      • Lejour M
      Vertical mammaplasty as secondary surgery after other techniques.
      Figure thumbnail gr1
      Figure 1Breast projection in the lateral view: apart from the short scars the enhanced breast projection is one of the most benefits in vertical breast reduction. (A and B) Lateral views of a vertical breast reduction 12 months after the operation and after a resection weight of between 450 and 500 g per breast with pronounced breast projection. (C) For comparison: lateral view 6 months after a conventional T-scar breast reduction (resection weight 500 g per breast) with the more flat breast mound and the long horizontal scar visible in the anterior axillary region.
      Symmetry. Although various attempts have been made,
      • Berg A
      • Palmer B
      • Stark B
      Early experience with the Lejour vertical scar reduction mammaplasty technique.
      it is extremely difficult to define breast symmetry.
      • Schnur P.L
      Reduction mammaplasty—the Schnur sliding scale revisited.
      Stark
      • Stark B
      • Olivari N
      Breast asymmetry: an objective analysis of postoperative results.
      defines excellent symmetry of the breast as a contralateral deviation of <1 cm in the distance between (i) the sternal notch and the cranial border of the areola, (ii) the midline of the sternum and the areola, and (iii) the inferior border of the areola and the submammary fold in postoperative patients. However, these measurements actually define the symmetry of areola position rather than true breast symmetry. Additionally, breast asymmetry only becomes noticeable when there is a certain proportional right-left weight difference; i.e. the bigger the breast, the bigger the difference must be to become noticeable. The goal of obtaining complete symmetry is a challenge irrespective of the method of breast reduction. It requires experience and can best be achieved by operating on the women in a semi-sitting position and using measurements rather than freehand drawing as the basis of the preoperative markings.
      Areola. The rate of 17% dissatisfaction with areola configuration in our study parallels the literature.
      • Hughes L.A
      • Mahoney J.L
      Patient satisfaction with reduction mammaplasty: an early survey.
      Besides horizontal and vertical malpositioning, irregular and asymmetric areolas and distortions due to the superior pedicle in most kinds of breast reductions, there are three possible complications specific to our modified vertical technique: (1) distension of the areola as a result of a periareolar skin resection, (2) rupture of the ‘Benelli’
      • Benelli L
      A new periareolar mammaplasty: the ‘round block‘ technique.
      purse-string suture, (3) a palpable circular purse-string suture and (4) a tear drop deformity of the areola
      • Wallach S.G
      Avoiding the teardrop shaped nipple areola complex in vertical mammaplasty.
      if the vertical infraareolar suture is pleated too strongly.
      The position of the areola is decisive for the appearance of recurrent ptosis, which happens nearly always after breast reduction (dependent on the residual volume and the quality of the skin). Besides preventing a bottomed out appearance of the breast, the placement of the NAC relatively low on the breast mound is certainly one of the main reasons why NAC necrosis has become very rare (below 1% in our group and in others
      • Pickford M.A
      • Boorman J.G
      Early experience with the Lejour vertical scar reduction mammaplasty.
      as well). Whereas, in many of the T scar breast reductions the nipples had a tendency to be placed too high,
      • Hughes L.A
      • Mahoney J.L
      Patient satisfaction with reduction mammaplasty: an early survey.
      we had a few complaints (during the first three months following the operation) that the nipples in our reductions had been placed rather low.
      Scars. One of the main pitfalls of the vertical Lassus reduction is the susceptibility to produce hypertrophied and spread scars (>2 cm)
      • Berg A
      • Palmer B
      • Stark B
      Early experience with the Lejour vertical scar reduction mammaplasty technique.
      as there is considerable tension on the vertical and periareolar scars (in the case of a periareolar resection), despite using a purse-string suture. Yet, in contrast to the T scar reductions, the scar is significantly shorter and in an area less prone to hypertrophy than in the medial and lateral extremity of an inframammary scar. The short scar is a real benefit and despite a rate of 15% unsatisfactory scars we would not change our operative design towards a wound closure involving less tension but producing a significantly worse shape. As there is no need to significantly shorten the vertical scar in the Lassus philosophy, the problem of wrinkling of the scar with inferior dog-ears is small.
      The standardised scheme of Ferreira
      • Ferreira M.C
      Evaluation of results in aesthetic plastic surgery: preliminary observations on mammaplasty.
      probably lead to the discovery of more (minor) long-term complications than would otherwise have been detected. We found this scheme to be a very versatile and powerful quality assurance tool, even for experienced surgeons, to systematise their postoperative long-term follow-up.
      Although using a stringent screening system, our complication rate is comparable to the complication rates of other types of vertical breast reductions and T scar reductions at our own clinic and in the literature. This is in contrast to Lassus,
      • Lassus C
      A 30-year experience with vertical mammaplasty.
      who stated that complications were rare in his experience in 710 personal cases. This statement gives us the certainty that with growing experience, the complication rates will diminish even at a teaching hospital with ever changing surgeons. Given that the drawbacks (complication rates) are comparable to other techniques, and the benefits significantly greater (shorter scars and a significantly better breast projection) in vertical breast reductions, the decision to adopt this method seems well justified. Vertical breast reduction will continue be the standard technique used at our clinic.

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