With decreased scarring and shortened operative time, the vertical breast
reduction increases patient satisfaction
Successful breast reduction addresses both the functional and aesthetic aspect
of the procedure. The plastic surgery community has been working along these
lines for many decades. The typical breast reduction technique commonly
utilizes the "Wise" pattern, which results in an upside-down T with
scars around the areola vertical and transverse components in the inframammary
fold.
The vertical breast reduction technique, however, leaves only circumareola and
vertical scars, which run from the areola to the inframammary fold. This
technique is gaining acceptance in the United States and can be performed in
less time than the standard breast reduction. It also requires less anesthesia
time, results in fewer scars, and allows for a shorter recovery period. In
addition, the vertical breast reduction also produces shapely breasts with more
projection. The late sequela of flattened and bottomed-out breasts seem to be
significantly less.
Practicing Principles
The basic landmark for vertical breast reduction is the same as in the more
conventional technique. Mainly, the inframammary fold, the level of nipple
areola complex as it is transposed onto the anterior breast and midline of each
breast, as well as the native inframammary fold are marked and compared for
symmetry.
Other components of this technique are radically different from the more
conventional reduction methods. In this technique, the new inframammary fold is
created 2 cm to 5 cm higher than the native inframammary fold. This technique
requires the creation of the medial and lateral pillars of the breast. These
two pillars create the basis of the new breast shape and position on the chest
wall. The entire procedure is dependent on glandular breast tissue for shaping
as opposed to on the skin. The skin is simply redraped over the new breast
mound.
The markings for this procedure are also quite different from the conventional
breast reduction technique. The two cardinal landmarks in this technique are
the vertical markings that demarcate the medial and the lateral pillars, as
well as the so-called "mosque" pattern for the areola. Additionally,
the new inframammary fold level is marked, approximately 2 cm to 5 cm higher
than the native inframammary fold. The technical maneuvers do not lend
themselves easily to a pattern type of reduction. They require a more intuitive
approach, making it difficult to teach and learn this technique.
I became intrigued with vertical breast reduction techniques more than a decade
ago when initial reports appeared in English language literature. While
discussing this technique with my colleagues at the time, I could not locate
anyone in the United States performing the vertical breast reduction technique
who would welcome an observer. I was pleased when Madelaine Lejour, MD, PhD, of
Belgium published her book with an accompanying video describing her technique
of vertical mammoplasty.1 This was the first English language
reference source that was adjusted to various breast shapes and sizes.
Vertical breast reduction surgery has the same risk and complication profile as
a conventional breast reduction. There does not seem to be any increase in
incidents of nipple areola complex, vascular compromise, or wound healing
difficulties. The main drawback to this procedure is that immediate
postoperative appearance of the breast may have too much superior projection
and takes longer for the breast to achieve its final shape. In my experience,
this has not been a significant issue in regards to patient acceptance.
Patients are uniformly pleased with the results, despite an occasional need for
revision surgery. The lack of the inframammary fold scar, as well as a pleasant
breast shape that tends not to bottom out, contributes greatly to patient's
satisfaction. Since breast contouring relies on shaping breast tissue and not
on skin tension, scars tend to heal nicely. •
Boris M. Ackerman, MD, a board certified plastic surgeon, is a graduate of
Massachusetts Institute of Technology, Cambridge, and Dartmouth Medical School,
Hanover, NH. He is in private practice in Newport Beach, Calif, and can be
reached at 949759-3284.
Reference
1. Lejour M. Vertical Mammoplasty and Liposuction. St Louis: Quality Medical
Publishing Inc; 1994.
helpful with various technical aspects of this procedure. After reading the
book, as well as viewing the video multiple times, I identified a patient in my
practice who I felt would be an ideal candidate to perform my first case. This
patient did not have a significant degree of ptosis, nor did she require a
significant amount of tissue removal.
After an extensive consultation with the patient, I performed my first vertical
reduction mammoplasty. Both the patient and I were pleased with the results. I
rapidly expanded indications for vertical breast reduction technique in my
patients. In a short period of time, I was comfortable performing vertical
breast reduction techniques in patients with larger breasts with greater
ptosis. Over the past 5 to 6 years, I have been performing vertical breast
reduction techniques exclusively, even with patients with large ptotic breasts.
In my early experience with this technique, I diligently followed Lejour's
recommendation on the markings. The mosque pattern was more challenging, even
with the vertical markings demarcating the medial and lateral pillars. I
experimented with various areola patterns, including x-ray film and wire.
Ultimately, I developed a wire pattern that could be easily
History Lessons
The history of breast reduction techniques evolved extensively from the late
19th century through today. Initially, breast reduction only reduced breast
size, relieving patients of the physical disability with no consideration for
nipple position or capacity for function. As techniques improved with time,
progress was achieved with regard to contour and viability of the breast.
However, the improvements came with extensive scarring with an inverted T
closure, or the "Wise" incision.
In North America, various techniques were introduced in an effort to maintain
good blood supply, areola sensation, and potential for lactation. Still, the
trade-off ot considerable scarring remained an undesirable result, particularly
along the inframammary fold, below the areola, and in the lateral breast area.
Some European and South American physicians were getting promising results with
a number of vertical skin closure techniques.
The vertical breast reduction procedure was first introduced in 1964, but only
received minimal attention until the late 1980s when Madelaine Lejour, MD, PhD.
of Belgium, began utilizing and perfecting the technique. North American
physicians have been resistant to the newer vertical breast reduction
procedures.
One reason for this reluctance can be attributed to the fact that this technique
relies less on pattern design and more on the freehand approach. This basic
conceptual paradigm change makes it more difficult to teach and to learn.
Nevertheless, it is worth the physician's time and effort to master this
technique. There are now more courses available at national meetings teaching
vertical breast reduction.