Every breast reduction technique has three main parts: parenchyma removal, the choice of the pedicle for the areola, and the incision and final scar. Short-scar techniques are modern trends in surgery, to the point that in plastic surgery, Nahai (25) popularized the term “scar wars.”

Twenty years ago, Benelli (3) introduced the periareolar technique, but in my hands and those of many others, the scars and final results were not always optimal. Almost at the same time, Lejour (14,15) popularized a vertical technique that was an adaptation of the original Lassus (11,12,13) vertical technique. Since then, in spite of the many different papers published, as well as the many hours of lectures, these two techniques and their modifications have not had universal acceptance (26). The reasons are manifold: The techniques are not easy to learn, it is not easy to obtain nice results, the indications are limited by the skin quality and large-volume breast removal, the results are not always observed at the end of the surgery, and the long vertical scars usually cross the inframammary fold (IMF) with a significant number of touch-ups (2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17).

Thirty years ago, when the idea of the purse-string suture did not exist, I started using a primitive vertical technique called at that time the Arié (1,2,3,4,5,6,7,8) technique for minor breast hypertrophies and ptosis. Fifteen years ago, in an attempt to find a way to have a shorter vertical scar, I began using a combination of the periareolar technique and a prolongation at the inferior quadrant like a vertical technique, thus developing the circumvertical reduction mastoplasty (CVRM). I found that after the inferior lateral and medial skin was undermined, a W-Wise pattern was the best means of parenchyma removal (as in the inverted-T technique) (Fig. 93.1); in most cases, no pedicle was needed for areola transposition. Initially, the areola was sutured with the purse-string suture, which was then changed for the cinching running suture. As I observed that the skin retracted during surgery, I resected less skin and obtained an acceptable result at the end of the surgery. As happens with every new technique, with time and experience, refinements improved the initial technique (18,19,20,21,22,23,24).

In general, for small-volume breast removals (200 to 300 g) I use the periareolar or the vertical Lassus technique (11,12,13); when the areola is too low, I plan a medial or lateral pedicle (7); and for huge breasts (gigantomastia) I use the inverted-T technique or the Yousif–Lalonde (9,10,28) techniques. CVRM is selected when the breast removal is between 300 and 1,000 g.

In order to select CVRM, the skin has to have a good tone and the areola should not be located more than 10 cm away from its ideal anatomic placement. I move the areola with my fingers, and if I foresee that it will be difficult to move, I consider a pedicle. In cases of more than 10 cm of areola ascension, I also select a pedicle for its transposition.

Before surgery, with the patient standing, I mark the IMF on both sides and the ideal future location of the areola (i.e., the whole areola over the IMF). If the areolas are going to be moved upward, I follow a vertical line coming from the middle part of the clavicle. In case the areolas are place laterally and need to be moved medially, I follow a line that unites the sternal notch to the areola (Figs. 93.2 and 93.3). Then, at 4 to 6 cm lateral and medial of the nipple, I mark the lateral limit of the periareolar. The superior future areola border mark is continued with curved lines, with the lateral marks forming the superior part of the CVRM. From these points two curvilinear lines are drawn downward converging at a point located 2 to 4 cm above the IMF (Fig. 93.4).