This chapter explains the principles and the practical realization of our technique of vertical mammaplasty with a short horizontal scar.

I devised this technique after using many different methods during my training and early experience: the lateral approach of Dufourmentel and Mouly, the Biesenberger conical remodeling with complete separation of the skin and the gland, and the Pitanguy approach with very little skin undermining and central resection. I borrowed some principles from each of these techniques, my aim being to attain natural, good-looking breasts with short scars and a stable result.

The main idea was a vertical resection of skin and glandular tissue. This created two “dog ears.” The upper one corresponds to the areola and is easily adjusted by resecting periareolar skin. The lower one is the main problem. A vertical resection as proposed by Arié and Dartigues is going to show below the inframammary fold, so our idea was to limit all of our incisions to well above the inframammary fold and to make a horizontal incision at this higher level. We started doing it in this way in 1977 and published the technique in 1982. We did not know at that time that Claude Lassus had published his vertical mammaplasty approach in 1981, proposing the limitation of incisions to above the inframammary fold as well.

We also introduced the concept of upper plication and suspension to the pectoralis fascia, conical gland reconstruction, and lower support by the glandular lateral pillar sutured together.

All of these ideas have been used and modified by Madeleine Lejour in her vertical mammaplasty with skin undermining and use of skin retraction to address the lower dog ear. This is an interesting development; in principle, it is better to avoid a horizontal scar. However, we still think that a horizontal scar is a good solution in many cases to avoid the skin undermining, the extensive postoperative wrinkling, and the frequently necessary revision of a remaining dog ear by a horizontal excision. It has been said that the scar from the horizontal incision performed initially was sometimes found later higher on the breast, the inframammary fold recreating itself below. We do not think that this is a problem: The scar is not visible when the patient is standing, and the inframammary fold is completely free of scars, which is a distinct advantage when the patients are wearing a beach bra. In any event, regarding long-term results, the only really visible scar is the periareolar one.

A breast technique should meet the following requirements:

The important goal is the final result. Scars evolve differently on the breast.

When the skin is sutured under limited tension, the vertical scar becomes hardly visible with time. The horizontal scar also becomes practically invisible, as long as it remains short. When it continues medially, it often becomes hypertrophic and, later, white. When it is prolonged laterally, spreading is common. That is why it is so important to keep the scar hidden under the breast, so that it does not show laterally or medially when the patient is standing.

The quality of the areolar scar is related to the tension applied to it. We always try to design the deepithelialized area in a way that avoids tension. A discrepancy between the edges is not a problem, but tension is. A circular nonabsorbable stitch passed around the deepidermized area can help diminish the tension.

To attain these goals, our technique relies on three main principles:

I now explain the technique step by step.

The operation is performed with the patient in the semisitting position. The head must be fixed in a central position, the arms must rest on the side of the table, with good padding, and the legs must be bent, the feet on a foot rest. Excessive pressure points must be avoided. An elastic strap is placed across the thighs to stabilize them.

We usually make our final markings while the patient is on the table, the semisitting position allowing a good evaluation of the ptosis. We nevertheless like to mark the upper limit A beforehand in the patient’s room, in the standing position, to try to avoid asymmetry. For this we pinch the breast with the index
in the inframammary fold and the thumb above the areola. We mark these points A and then carefully check their symmetry on the patient standing straight. We then mark the axis of each breast. The axis of the breast is the line on which we want to have our future vertical scar and, even more important, the areola and nipple. One has to lift the breast and see in what location the areola is satisfactory. A vertical line is drawn on the thorax, usually 8 to 10 cm from the midline. Symmetry is again carefully checked.

The next step is to draw the planned vertical wedge excision. The breast is pushed gently medially and laterally, not too much, to keep some fullness, and a line is drawn on the breast in continuity with the thoracic axis. The pull on the breast should be horizontal, to end up with two vertical lines (Fig. 89.1A, B).

The horizontal lower line D–E is located by pinching the lower part of the vertical lines. One sees what level produces a nice new inframammary line, without too much tension. It is usually 3 to 4 cm above the inframammary line, according to the size of the breast and its implantation.

From points D and E one measures 4, 5, up to 6 cm, according to breast size. We thus obtain our future vertical suture. At the level of the upper markings, B and C, one marks a 0.8-cm indent to diminish the tension below the areola (Fig. 89.2A).

The periareolar line is then drawn by joining points C and B, passing through point A. A gentle, semicircular curve must be made.

The last marking is the upper limit of the pectoral undermining. The breast is lifted and pushed up, and the superior limit becomes apparent and is marked (Fig. 89.2B).

We then carefully check the symmetry of our markings. If the breasts are asymmetric, we consider the residual skin flaps on each side, which should be equal, and not the width of the resection. When in doubt, it is always better to diminish the width of the vertical resection, which can easily be adjusted at the end of the operation, because exaggerated skin tension should be avoided.