Summary

The main purpose of a vertical mammaplasty is the principle of achieving as minimal scar as necessary to achieve an ideal breast shape. Based on this, and concerned about the possible drawbacks of the technique, we advocate some modifications of the previous techniques. These include specifically the use of a chest wall based flap under a sling of pectoralis muscle. The flap can be used with all types of incisions, including ‘L’ shape and inverted T mammaplasties, but must employ a superior, or superomedial (or lateral) flap for nipple–areola transposition. The uppermost advantage of the breast flap held by the pectoralis sling is to enhance and maintain long term upper pole fullness of the breasts.

Introduction

Breast hypertrophy and ptosis can cause considerable physical and emotional suffering including low self-esteem, fears of sexual embarrassment, difficulty with sports and exercise, and limited clothing or brassiere options.¹ Physical discomfort can include back and neck pain, as well as shoulder grooving and intertrigo. Many of these symptoms can be alleviated by different techniques of mammaplasty.²

Breast reduction and mastopexy techniques have changed dramatically during the last century. New knowledge of vascular anatomy led to the evolution of pedicle techniques, which provided reliable blood supply to the nipple–areola complex. Parenchyma and skin resection patterns have also changed over time. The great advances by Wise,³ Pitanguy,⁴ Lassus,⁵^–⁷ Lejour,⁸^–¹⁰ Hall-Findlay,¹¹^,¹² Benelli,¹³ Sampaio Góes¹⁴ and others have brought us significant advances to reach a better shape of the breast. These techniques have not only simplified the operative plan, but have contributed to a shorter scar and a more aesthetic breast. This chapter describes some maneuvers designed to give a better shape with the maintenance of upper pole fullness. The main technical detail involves the use of a chest wall based flap of breast tissue, which is transposed into the upper pole of the breast and held in place by a strip of pectoral muscle under which it is passed and supported further by sutures from dermis to the pectoralis fascia. The technique can be used with standard inverted-T incisions, vertical incisions with short transverse components, L-shaped, or pure vertical incisions.

Our choice, and the maneuver described in this chapter, is a vertical incision. Whatever redundant skin that remains after excising the vertical ellipse is removed from around the nipple and closed with a round block suture. This is best described as circumvertical skin excision. If reduction is necessary it can easily be carried out by removing the desired amount from under the breast and in the most appropriate location for resection. There is no limit to the amount of breast tissue that can be removed.

Vertical Mammaplasty: Advantages and Disadvantages

Although the history of vertical mastopexy dates back to Lotsch ¹⁵ and Dartigues,¹⁶ and later extended to breast reduction by Arié,¹⁷ it was otherwise lost to surgical history until Lassus⁵^–⁷ resumed interest in the 1960s. Using adjustable markings, an upper pedicle for the areola, and central breast reduction, Lassus has employed vertical reduction mammaplasty in a wide range of breast hypertrophies. It was then modified and popularized by Lejour⁸^–¹⁰ and other authors.¹⁸^,¹⁹

Lejour modified Lassus’s technique by including wider inferior skin undermining to promote skin retraction and to reduce scarring, sutures to the lower gland to remove tension and to create a stable shape that eliminated reliance on the skin envelope, and liposuction to mold the breast and remove tissue prone to absorption with weight loss.⁸^–¹⁰ Lejour’s technique was recognized widely to reduce scarring, improve breast contour, and produce more stable aesthetic results. Beside the excellent long-term outcomes, the long learning curve and the unattractive appearance during the immediate postoperative period caused most plastic surgeons, especially in the United States, to abandon the vertical reduction mammaplasty for procedures with which they were trained and comfortable, usually some variation of the inferior pedicle inverted T shaped techniques.¹⁸

More recently, based on some principles developed by Lassus and Lejour, Hall-Findlay described an original technique of vertical reduction mammaplasty. Innovations included a medial pedicle, no skin undermining, no pectoralis fascia sutures, and limited liposuction only to refine the operated breast.¹¹^,¹² The technique was a notable advance in shortening the learning curve, reducing total operating time, and simplifying the vertical reduction mammaplasty. After Hall-Findlay’s technique description, acceptance of vertical mammaplasty in United States increased. A 2001 survey among American surgeons showed that vertical scar breast reduction was performed in 53% of US patients and has surpassed the rate for inverted T-scar breast reductions.²⁰

Although the classic inverted T incision mammaplasties are easy learning techniques for young plastic surgeons and give more reproducible results on the operating table, they have several drawbacks that should be reassessed.²¹^,²² The short vertical limb dogma (near 5 cm), associated with the inferior horizontal pattern resection of the skin and parenchyma leads the breast to a broad and flat cone shape, with poor projection, and which tends to worsen with time.^19,^21,²³

Although most patients find the standard inverted T mammaplasties satisfying, have their general expectations fulfilled, exhibit physiologic improvements, and experience relief of psychological distress, one-third still find the resulting scars unacceptable.²⁴ These undesirable scars can be quite long, extending medially and laterally beyond the boundaries of the brassiere, becoming visible and unsightly.^5,^18,^21,²³ Even more, they are susceptible to hypertrophy, particularly in younger women who tend to scar more easily, or dark-pigmented women who may be prone to hypertrophic scar formation.²⁵ An additional problem with these techniques, especially if they utilize an inferior pedicle for nipple–areolar blood supply is the persistence of ptosis of the central third of the gland (the bulk of the pedicle) creating the ‘bottoming out’ look.

The psychological impact of these scars should not be underestimated. In 1987, a survey involving all members of the American Society of Plastic and Reconstructive Surgeons found that 11% of respondents had been sued by patients dissatisfied with the outcome of their breast reduction. The appearance of scars was the most commonly cited reason for litigation.²⁶ Therefore, if absence of scars in the visible part of the cleavage is the desire of the patient, the plastic surgeons must take this wish into account when deciding which of the currently available reduction mammaplasty techniques is more appropriate.

Since the inverted T approach relies primarily on skin tension to shape the breast, and because skin under tension stretches with time, the long-term result is often a widened, flattened and unattractive breast mound. An additional drawback is the frequency of delayed healing or dehiscence at the confluence of the vertical and transverse limbs of the closure.¹⁸^,²²

Vertical mammaplasty, however, also has its own drawbacks. Current criticisms of vertical techniques include immediate postoperative results that are often not pleasant, problems with nipple–areola complex malposition and irregularities, excessive lower pole and vertical scar length, wound healing problems due to vertical skin-gathering suture technique to reduce the scar length, and lower pole deformities including skin excess (’dog-ears’) in the distal part of the vertical incision. Revision of the vertical scar or a secondary, horizontally oriented excision of the excessive dog-ear tissue have been reported to be necessary in 16–28% of vertical scar breast reductions.^18,^19,^22,^27,²⁸