CHAPTER 17 No Vertical Scar Breast Reduction and Mastopexy

Summary

The ‘no vertical scar’ reduction/mastopexy is another tool which is useful to correct the large or sagging breast with a lot of ptosis. This technique can produce a pleasing breast shape and a nice areola without the areolar distortion or the visibility of a vertical scar.¹^–³

Key Points

1. Where does the ‘no vertical scar’ technique fit in the armamentarium of reduction/mastopexy techniques relative to the vertical scar and the T scar techniques?

2. The ideal patient for the ‘no vertical scar’ technique has a lot of ptosis with at least 5 cm between the areola and the new areolar site.

3. The main advantages of the ‘no vertical scar’ technique are a nice periareolar scar with the only other scar hidden in the inframammary fold. There is no vertical scar on the visible breast mound.

4. The main disadvantages of the ‘no vertical scar’ technique are the same as those of the T scar; medial and lateral dog ears as well as a possible boxy shape problem if attention is not given to detail.

5. Intraoperative breast sizers are useful to ensure that remaining breast tissue is of equal volume on both sides before the skin is closed.

Patient Selection

The ‘no vertical scar’ reduction/mastopexy is essentially the same reliable operation as the T scar inferior pedicle reduction except that it has one less scar: the vertical scar (see Figs 17.1–17.3). The most common cause of patient dissatisfaction after breast reduction is the scar.⁴ We believe that many patients can get the same nice breast shape achieved with the T scar without a vertical scar. If we can achieve good shape with one less scar than is achieved with a T scar reduction, then why not do it?

Fig. 17.1 The no vertical scar breast reduction has a periareolar scar and a hidden inframammary scar, with no vertical scar coming down the visible front of the breast.

Fig. 17.2 The T scar breast reduction has a visible vertical scar in the front of the breast which can distort the areola.

Fig. 17.3 The main difference between the T scar (right) and the no vertical scar (left) techniques is that the small quadrilateral piece of skin and fat below the areola is preserved with the no vertical scar technique.

This is a good technique for a patient that has a lot of ptosis and a lot of excess skin. The ideal patient is one who has 5 or more cm of skin between the areola and the new areolar site (see Fig. 17.4).

Fig. 17.4 A line is drawn down the center of the breast axis. The inframammary fold line is palpated though the breast and the new areolar position is marked at that point on the breast axis line.

Indications

Consider for a moment how much skin is removed with the skin excision patterns of the three reduction techniques of T scar, vertical scar reduction, and no vertical scar reduction.

The vertical scar reduction has the least amount of skin removal of the three techniques. We therefore prefer the medial pedicle vertical reduction/mastopexy ⁵ for the patient who does not have very much skin to excise, and who does not have a great deal of ptosis (less than 5 cm of skin between the areola and the new areolar site). This is about 25% of the patients in our practice.

If the patient has a lot of ptosis with a lot of skin requiring removal as well as breast, then we prefer the no vertical scar reduction (70% of our practice).

In the occasional patient where there is an excessively wide breast with a lot of horizontal skin needing excision, we still sometimes use the T scar reduction (=5% of our cases). However, even most of these patients would do well with the ‘no vertical scar’ technique because breast tissue can be made smaller with excision, projection can be obtained with breast shaping sutures, and excess lateral horizontal skin can redrape and become part of lateral chest wall skin no longer overlying the breast.

The ‘no vertical scar’ technique can be used for either reduction or mastopexy.¹^–³

The medial pedicle rotation advancement vertical scar operation (rotation of the medial pedicle superiorly and advancement of the lateral pillar beneath it) may give more projection than the T scar or ‘no vertical scar’ techniques. However breast shaping sutures do augment the projection obtained with the ‘no vertical scar’ and the T scar techniques.¹

Operative Technique

The Plastic Surgery Video Archive has an excellent film showing preoperative markings and intraoperative technique.⁶

A line is drawn down the center of the breast meridian line where the areola will look best (see Fig. 17.4). If a large part of the lateral breast is to be removed, the nipple–areola axis line can be moved medially as will be appropriate to the final anticipated breast width. The axis of the breast is drawn as a continued straight line below the inframammary fold by keeping it as a straight line seen through two fingers holding up the breast mound (see Fig. 17.5).

Fig. 17.5 The breast axis line is marked below the breast by lifting up on two fingers and seeing both the breast axis line on the breast and the skin below the breast through the fingers.

The new nipple site usually ends up between 19 and 22 cm from the sternal notch, and between 9 and 12 cm from the midline.

A finger on the breast is used to palpate another finger through the breast at the level of the inframammary fold, and this becomes the new nipple site (Fig. 17.4). The areolar recipient site skin excision is marked on the skin brassiere preoperatively with the patient sitting. It is drawn as a slightly horizontal oval (3.5 cm diameter horizontally, and 3.0 cm diameter vertically) as the oval will stretch to a circle when the skin brassiere flap is pulled down over the breast to the inframammary fold at the time of final closure. The areola is marked as a 4 cm diameter circle also with the patient sitting up. The area of the areolar recipient circle is deliberately marked to be a little smaller than the areola itself in order to achieve a tension free closure in the periareolar scar. The areolar recipient site is also marked smaller than the areola itself when the author uses the T scar or the vertical scar techniques.

A tension free areolar scar means a better appearing areolar scar. This scar is the most visible scar of the reduced breast (see Fig. 17.6). The areolar scar is the scar that the woman sees every day when she is naked. It is the showcase scar of the breast and should be treated as we treat the preauricular scar of the facelift; tension free and closed with care.