Reduction mammaplasty is one of the most commonly performed breast operations in the United States. In 2007, over 106,000 breast reductions were reported by the American Society of Plastic Surgeons (a 167% increase since 1992) ranking it among the top five reconstructive procedures performed in the United States (1). Reduction mammaplasty is consistently associated with high patient satisfaction and improved quality of life (2,3).

The primary goal of all methods of breast reduction is to remove and reshape excess and redundant parenchyma and skin while preserving nipple-areola complex vascularity (4). The ideal breast reduction technique would produce the “perfect” breast size and shape with minimal scarring, intact nipple vascularity and sensation, good projection, a stable inframammary fold, preservation of the ability to lactate, and structural stability over time (5). In addition, an ideal method should be easy to perform, reproducible by other surgeons, easy to teach, expeditious, and free from complications. However, as evidenced by the number of operations available, no one procedure is ideal “for all seasons,” and good patient selection is key to obtaining the optimal result for any individual. Breast reduction without a vertical scar is no exception.

A wide variety of breast reduction techniques exist, resulting in combinations of vertical, horizontal, and periareolar scars. In addition, nipple-areolar blood supply may be based on inferior, lateral, superomedial, central, vertical, and horizontal pedicles or bipedicles. While countless variations and combinations of incisions, scars, and pedicles have been developed, the most popular technique currently remains one of the various forms of inverted-T scar methods (4,6). In a subset of patients with significant ptosis requiring large-volume reductions, a technique using only periareolar and inferior horizontal incisions can produce excellent results, with good shape, less scarring, a well-vascularized and innervated nipple-areola complex, the ability to lactate, and stability of the inframammary fold. The technique detailed here is relatively fast and simple, reliable, reproducible, expeditious, easy to teach, and relatively free from complications.

Several arguments can be made for methods without a vertical scar in breast reduction surgery. First, extensive scarring due to inverted-T pattern reductions can be unaesthetic, wound complications may occur, especially at the “T-intersection” of the incisions, and this region is prone to hypertrophic scarring (5,7). In addition, while surgeon evaluations suggest similar hypertrophy and color matching for periareolar, vertical, and inframammary scars, vertical scars do have a tendency to widen in time (3). Second, methods that significantly interfere with the inframammary fold may results in loss of shape through pseudoptosis or “bottoming out,” resulting in an unfavorable change in breast shape in the long term. Third, in cases of very large breast reductions, the length of a typical narrow, inverted-T-style inferior pedicle may be too long to reliably support the nipple-areola complex, with some authors advocating free nipple grafting when transpositions of greater than 10 cm are required (8). Many methods of breast reduction are well suited to small reductions, and their translation to larger reductions may compromise nipple vascularity and sensation (7). Fourth, wound healing and contraction of the vertical scar may distort the periareolar scar, causing an ovoid and unnatural shape to the areola (6). With these points in mind, periareolar scars have been shown to be most popular with patients, and a well-placed scar located at the lower aspect of the breast and hidden by the breast mound when viewed from in front is very acceptable (3,6,9). Thus, avoiding a vertical scar may have significant benefits in some patients.

Breast reduction surgery dates to 1669, with a procedure performed by William Durston from England (10). After studies of subdermal plexus blood supply to the nipple in the 1930s many newer techniques involving deepithelialized pedicles were developed (11). It was from this basis that Wise published a paper in 1956 on the geometry of the breast, giving rise to the now popular “Wise-pattern” breast reduction, based on an inferior deepithelialized pedicle and inverted-T scar with excisions of “wedges of gland from one or more quadrants” (12). Since the 1960s, surgeons such as Arié, Pitanguy, Strömbeck, McKissock, and Skoog have used a variety of deepithelialized pedicles beneath an inverted-T scar to expand the array of breast reduction techniques and options (13,14,15).

A further evolution in breast reduction has been the minimization of scarring. Despite high patient satisfaction with breast reduction surgery, scarring remains a significant concern for many patients (3). Surgeons such as Benelli (4,16) (periareolar reduction), Lassus (13) (vertical reduction), Lejour (17,18) (modification of the vertical reduction), and Hall-Findlay (19) (simplified vertical reduction) have developed techniques based on periareolar scars, vertical scars, or reduction of the horizontal/inframammary fold scars (20).

Passot (6,21) is frequently credited with developing the first breast reduction technique in the 1920s that avoided a vertical scar. Excess tissue was removed as a wedge from only the inferior pole of the breast. This technique was used in cases with minimal hypertrophy and moderate ptosis (22).

The original Robertson technique of breast reduction, published in 1967, removes a central wedge of breast tissue through the horizontal mid-axis of the breast (23). Central breast tissue underlying the nipple is resected, an inferior, bell-shaped flap is advanced superiorly, and the nipple-areola complex is resited by free grafting. The steep, bell-shaped inferior incision and straight superior incision eliminate the discrepancy between incision lengths but result in a bell-shaped,
curved scar through the mid-axis of the breast and new nipple-areola complex.

Ribeiro (22,24) repopularized Passot’s technique in 1975 with modifications based on techniques used by Thorek, Maliniac (25), and Conway (26), all of whom frequently used free nipple grafts. Ribeiro’s technique is marked by sutures producing a conical breast mound and no free nipple grafting with a postoperative plaster dressing to support breast shape while healing. Notably, Ribeiro places the inferior incision 2 cm below in the inframammary fold and, in contrast to other authors, refers to this dropping to the “proper position” after healing. Ribeiro’s later publications discuss dissatisfaction with breast flattening and long horizontal scars, encouraging reversion to an inferior glandular dermolipo pedicle in modified inverted-T, vertical scar, and periareolar techniques (27).

In a paper by Hurst et al. (28) from 1983, the first modification of the Robertson technique uses a broad, bell-shaped inferior pedicle 10 cm in height, with a deepithelialized flap above this containing the nipple-areola complex. There is adequate vascularity to the nipple-areola complex, so that a free nipple graft is not required, but the end result is still with a bell-shaped scar crossing the mid-axis of the breast, as in the original Robertson technique (28).

In the early 1990s, Yousif et al. (9) published a paper explaining their use of a no-vertical-scar technique for cases of very large and/or ptotic breasts. Their “apron technique” was developed to reduce unsightly scars in cases in which the nipple-areola complex is greater than 7.1 cm from the center of the planned new nipple location (29). This allows draping of a superiorly based flap over the pedicle, which forms the lower pole after the remaining breast tissue is tacked together in an axial plane. Emphasis is placed on “internal mound contouring” into a conical shape to produce a stable form rather than relying on a shaped skin envelope. In addition, excess inferior skin is gathered to the center of the incision, creating several small cones to help maintain projection.

Our no-vertical-scar breast reduction (also called the Boston modification of the Robertson technique) has evolved from the modified Robertson technique and includes further modification and several refinements. It is fundamentally different from Passot’s technique, which removed a wedge of breast tissue inferiorly and was used only for small reductions. It is also different from the original Robertson (23) and Hurst (28) (modified Robertson) techniques, which have a scar visible from the front and through the horizontal mid-axis of the breast. There are additional shaping maneuvers to narrow the transverse diameter of the breast and improve projection. Incision placement and the siting of the nipple-areola complex differentiate it from a technique described by Keskin et al. (30). The no-vertical-scar breast reduction places the flat, bell-shaped inframammary scar 1.5 to 2 cm above the inframammary fold so that it is still hidden in the shadow of the breast and is not irritated by the bra, thus making it far less visible while maintaining the advantage of a large and broad pyramidal nipple-areola complex pedicle (5). This broad pedicle allows avoidance of a free nipple graft even in very large reductions.

The no-vertical-scar breast reduction has provided us with an effective and reliable reduction mammaplasty operation for large, ptotic breasts. It requires 6 to 7 cm (but a minimum of 5 cm) of nonpigmented skin between the position of the inferior edge of the new areola and the superior edge of the existing pigmented areolar skin (5,6). This allows adequate coverage of the lower pole without a visible scar through the center of the breast. A lack of ptosis or a very large areola can preclude this. This technique is not effective for mastopexy alone.

Several key points underscore the benefits of this technique for these large reductions. First, it eliminates a vertical scar, and hides a transverse scar in inferior breast shadow. Second, it removes the need for free nipple grafting due to the wide inferior and central pyramidal pedicle. Third, pseudoptosis is minimized by an undisturbed inferior and central pyramidal pedicle and intact inframammary fold. Fourth, the superiorly based “apron” flap overlying the pedicle acts to support the breast tissue like an intrinsic brassiere, thus eliminating stretch typically seen in inverted-T scar breast reductions and avoiding problems with dehiscence of the T-incision. Fifth, this technique is reliable, is easy to learn and teach, and can be performed safely in obese patients.

This reliability of this technique in extreme ptosis is underscored by considering the pathophysiology of breast changes with progressive hypertrophy. Typically, as the breast enlarges and becomes ptotic, the nipple-areola complex descends; the distance from the sternal notch to nipple progressively increases and may get to 50+ cm. However, the distance from the nipple-areola complex to the inframammary fold increases to a much lesser degree, rarely to more than 20 cm (31). The result is that the nipple-areola complex may descend so that it is not visible from frontal view. Why this happens is not entirely clear. It may be related to Cooper ligaments. Thus, resection of skin and breast parenchyma, which contributes to the upper pole lengthening, makes sense in cases with very large mammary hypertrophy and ptosis. In addition, an inferior and central pyramidal pedicle is optimal at maintaining nipple vascularity and sensibility.