All procedures were bilateral. In all cases, breast implants were placed submuscularly, using predominantly the inframammary approach (95.0 percent) and saline-filled implants (94.6 percent). Resections of 300 g or more from at least one breast were categorized as breast reductions. Eleven reduction patients were simultaneously treated with implants (Fig. 2). All mammaplasties were performed by the author using the vertical technique and medially based pedicle as described by Hall-Findlay,⁹ but without a mosque-dome pattern; the nipple position was determined intraoperatively (Figs. 3 and 4). Sequential compression devices were used. No patient received enoxaparin.

Statistical analyses were performed using IBM SPSS for Windows version 20.0 (IBM Corp., Armonk, N.Y.). An independent t test was used to compare means of continuous variables for two groups of patients. A one-way analysis of variance was used for more than two groups. Scheffé post hoc tests were used. The Pearson chi-square test of independence was used to compare categorical variables. The “reduction plus implants” group was not included in group comparisons because of its small sample size (n = 11). Correlations were tested using Pearson correlations. A value of p < 0.01 was considered significant. An a priori power analysis was performed for the one-way analysis of variance. To achieve 80 percent power, with an alpha level of 0.01, sufficient to detect a medium-sized treatment effect (f = 0.25)¹⁰ comparing across four groups, 256 total subjects would be needed.¹¹

Although breast augmentation and reduction have traditionally been considered individually, interprocedural comparisons can be useful.¹² Today, we recognize an overlap in indications for these procedures and even in physical benefits.² When a vertical technique is used, the mammaplasties are essentially the same, differentiated only by the resection weight.⁷

There are no published prospective clinical or outcome studies of mastopexy or augmentation/mastopexy. This deficiency is remarkable considering the popularity
of breast-lift surgery, which witnessed a 72 percent surge from 2000 to 2011,⁶ and by the increasing popularity of augmentation/mastopexy, an operation that is now performed more commonly than mastopexy alone in many practices.⁷,¹³ Existing studies of mastopexy¹⁴ and augmentation/mastopexy¹³,¹⁵–²² are all retrospective and often include multiple techniques¹³,¹⁵,¹⁷,¹⁸,²² and multiple surgeons.¹⁸,²² Prospective studies of consecutive patients are preferred, to avoid selection bias and confounding factors.²³ A power analysis is recommended to determine the adequacy of sample sizes, to avoid type II statistical errors.²⁴ A rigorous 0.01 alpha value reduces the risk of type I errors.

A growing number of plastic surgeons have adopted the vertical technique as their procedure of choice for mastopexy and reduction.²⁵ At a recent meeting of the American Society of Plastic Surgeons, 47 percent of audience members responding to a poll reported using the vertical technique for their augmentation/mastopexies, versus 38 percent who still favored the inverted-T design, and 10 percent who preferred a periareolar resection.²⁶ Persistent ptosis is a frequent problem after a periareolar mastopexy.⁵,¹⁶,²⁷ The shape deficiencies of the inverted-T, inferior pedicle technique have been recognized for decades.²⁷ Although the idea of an “all-seasons” mammaplasty has been dismissed in the past,²⁸ an increasing number of plastic surgeons use the vertical technique exclusively,⁷,²⁹–³⁴ including the author. Its versatility is demonstrated in Figures 5 through 8, which depict not typical cases but more challenging ones (i.e., very large breasts, tuberous breasts, asymmetrical breasts, and secondary surgery).

Commonly, a periareolar mastopexy is recommended for patients with minimal degrees of ptosis, a vertical technique for more moderate cases, and the inverted-T technique for cases of moderate or severe ptosis.³⁵,³⁶
However, a vertical technique is particularly advantageous in large resections because a long pedicle is unnecessary,⁷ improving safety for the nipple and areola,³¹–³⁴ and avoiding the need for nipple grafting. The anatomical and geometrical advantages of the vertical technique²⁷ do not change with breast size (Fig. 5). Elegant in its simplicity, this technique may be used for all cosmetic mammaplasties, with the only variables being implant size (if used) and the resection weight, making it truly an all-seasons mastopexy. Even small, ptotic breasts and
tuberous breasts, traditionally considered the domain of the periareolar technique,¹⁵ respond well to vertical mastopexy (Fig. 6).