Vertical mammaplasty for breast reduction and mastopexy

Madeleine Lejour, MD Brussels, Belgium Vertical mammaplasty is a technique that involves adjustable markings, an upper pedicle for the nipple-areola complex, and a central breast reduction with lower skin undermining. The shape of the breast is created by suturing the gland and does not rely on the skin. No scar is produced in the submammary fold. Liposuction is added whenever feasible (in 55% of the cases). This technique, derived from the technique of Lassus,1 can be applied to small and large breasts. 2–4 It benefits from three innovative principles: Wide lower skin undermining to promote skin retraction and reduce scarring Overcorrection of the deformities to produce improved long-term results Liposuction to facilitate molding of the breast and remove unnecessary tissue, which is prone to absorb when the patient loses weight Results have been very gratifying with regard to not only the reduced scarring but also the durable improved shape obtained. Complications have been uncommon and only one case in a series of 220 patients required a revision with the patient under general anesthesia. The main drawback of this technique is that the result is not obtained immediately. This is often more difficult for the surgeon who is just starting to use the technique than for the patient. In many breast reductions, late results show breasts that are too broad, too flat, and too low. This means that, besides volume reduction, the other deformities of large breasts either have not been adequately corrected or have recurred. If the surgeon understands that the results obtained by the surgery will progressively deteriorate, the deformities can be overcorrected as part of the technique. Thus, contrary to traditional plastic surgery principles, a perfect result is not achieved on the operating table. This requires a mental effort and some courage by the surgeon, but the final result is rewarding. The high, prominent, and narrow breasts settle to the right position and shape in a few weeks. Scars left by breast reduction and mastopexy are always bothersome. The smaller the scars the better, as long as reducing them does not affect the quality of breast shape, which is often the case with pure periareolar techniques. A vertical extension from the periareolar scar to the submammary fold should thus be accepted to obtain an improved result. By chance, this vertical scar is also the one that fades best with time. Eliminating the horizontal submammary scar has been a major development in breast reduction techniques. However, this improvement should not be obtained by lengthening the vertical scar beyond the submammary fold because this would be unacceptable to the patients. This is why I have developed the idea of detaching the skin on the lower part of the breast and “gathering” it in temporary fine wrinkles along the vertical scar to reduce its length. These wrinkles disappear by skin retraction after a few weeks to a few months, depending on the size of the breast and the laxity of the skin. Skin retraction will, however, not be possible if the skin is subjected to inner pressure. A strong suture in the glandular tissue will prevent this, and an elastic brassiere worn day and night for 2 months postoperatively will help to keep the new shape of the breast. One advantage of this technique is its applicability to all cases. However, I have limited experience with extremely large breasts, with a distance more than 40 cm from the sternal notch to the nipple because these are uncommon in my country. In such cases the same technique combined with a horizontal lower skin excision would probably avoid long months of skin wrinkling and possible maceration. Markings (Figure 1) are done freehand with the patient in an upright position and are adjusted to suit the individual's habitus and desired postoperative result. Markings. A and B, Vertical markings in continuity with the lower vertical axis of the breast, drawn after pushing the breast medially, laterally, and upward. C, Lower curved marking, above the submammary fold. D, Upper marking around the future site of the areola, measuring 14 to 16 cm. The lateral vertical margins of skin resection are marked while the breast is pushed medially and then laterally. The two vertical lines are then joined by a curved line above the submammary fold and another curved line around the future site of the nipple, which is chosen according to the preferred method of the surgeon. When complete, the markings indicate the area to be deepithelialized in the upper part of the breast and the skin to be excised in the lower part of the breast. Liposuction is performed at the beginning of the reduction of all large breasts. A blunt cannula is pushed in all parts of the breast to remove as much fat as possible. This not only removes more of the unnecessary tissue but also facilitates the molding of the new shape of the breast. If the breast contains little fat, or fat mixed with fibroglandular tissue, liposuction cannot be performed, and more tissue is removed surgically. To begin the procedure (Figure 2), the lateral margin markings are incised, and the skin lateral to the markings is dissected free from the underlying gland laterally, medially, and inferiorly exactly to the submammary fold (Figure 2, C). No skin is undermined lateral to the periareolar marking; this facilitates skin healing around the areola. The medial and lateral dissections are done in an oblique fashion from the upper part of the vertical markings to the lower medial and lateral margins of the breast tissue. These dissections are performed as in a subcutaneous mastectomy, leaving about 0.5 cm of fat under the skin. This superficial level of dissection will facilitate the draping and retraction of the excess skin after the operation. If dissection is done at a deeper level, the skin will not retract and will later bulge on the lower breast. Operative technique. A, Incision on the marking and deepithelialization (hatched area). B, Lower incision in the marked area for liposuction. C, Skin undermining on the lower breast, up to the submammary fold. D, Glandular excision diverging laterally in the lower part. E, Removal of breast tissue behind the breast in large breasts. F, Elevation of the breast by posterior plication and fixation to the muscle. G, Suture of the anterior surface of the gland to create the breast cone. H and I, Vertical skin suture producing wrinkles. The breast is now too high, bulging above and flat below the areola. The lower central part of the breast is now elevated from the chest wall at the level of the submammary fold. Dissection proceeds upward to the upper margin of the gland, at the level of the third intercostal space, creating a central 6- to 8-cm vertical tunnel behind the breast. This central elevation of the parenchyma on the chest wall will allow upper displacement of the breast and overcorrection of ptosis. Lateral cuts are now made from the lower part of the future areola to the lower portion of the breast. This isolates the central portion, which will be partly excised, and creates medial and lateral pillars of breast tissue that will be sutured together (Figure 2, C and D). The pedicle supporting the nipple-areola complex may be thinned to about 2 to 3 cm, even in cases of major breast hypertrophy, in which the nipple must be elevated 10 to 12 cm. A strong, slowly resorbing suture is now used to attach the deep part of the gland at the level of the upper point of the nipple-areola complex to the pectoralis muscle at the highest level of dissection (Figure 2, F). This upper central stitch elevates the breast to an exaggerated level, creating a temporary upper bulge in the breast contour but also relieving tension on the lower half of the breast during healing. The areola is then sutured into place and the two breast pillars are approximated with three or four strong sutures (Figure 2, G). This suturing of the gland shapes the breast, creates its conical appearance, and reduces the size of its base. Once the breast is reshaped, the skin hangs loosely around it, and it is clear that, contrary to the concepts underlying most modern reduction techniques, the skin has no influence on shaping the breast. The skin will contract postoperatively to fit the new glandular size and location. Skin suturing is done in two planes, with a running subcutaneous 3-0 slowly resorbable stitch elevating the skin on the gland and a running subcutaneous suture wrinkling the skin on the whole vertical suture. At the end of the operation, the breasts should be bulging in the upper part and flat below the areola. Drains are placed in the wounds and are removed before the patient is discharged the next day. The lower breast is molded with Microporer® tape placed over gauze compresses, forming a tight dressing and supporting the breast superiorly. A sports brassiere should be worn day and night for the next 2 months. Depending on the magnitude of the reduction, the final result in terms of shape (Figures 3 and 4) may be expected by 2 to 8 weeks postoperatively. One week to 3 months postoperatively (rarely more in very large breasts), the wrinkles of the vertical scar have diminished. In heavy and ptotic breasts, however, some skin redundancy in the lower breast may persist and may require a minor correction with the patient under local anesthesia. This is performed at 6 months and is necessary in about 10% of the cases. Late results have been better and more stable than with the methods used previously. A 17-year-old patient. A and B, Preoperative. C and D, Postoperative result. A 30-year-old patient. A and B, Preoperative. C and D, Postoperative result. “Surgical Strategies” focuses on refinements in aesthetic surgical techniques. Contributors are Aesthetic Society members or other recognized experts.