Phẫu Thuật Thẩm Mỹ Vòng 1: Các Khái Niệm Và Kỹ Thuật (Aesthetic Breast Surgery)

The markings on this woman’s right breast show the di erence between a pure
medial pedicle and a true superomedial pedicle. The crosshatching (black ar-
row) indicates how to convert the pedicle to a true superomedial pedicle by in-
cluding the descending artery rom the second interspace (purple arrow marked
on the skin). This artery enters the areolar opening usually just medial to the
breast meridian and approximately 1 cm deep to the skin sur ace, which means
it can be traced with a pencil Doppler.
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Part II • Technique
The arteries and veins travel separately in this superf cial vascular pattern. The
venous drainage, which can o ten be seen through the skin, drains superome-
dially. A medial or superomedial pedicle can be designed to include the veins,
which are o ten clearly visible. The upper breast border is marked at the junc-
tion o the chest wall and the breast. The new breast meridian is marked in its
desired position and not in its existing position. This patient is high breasted,
with only 11 cm between the clavicles and the upper breast border. The new
nipple position is placed on the new meridian 10 cm rom the upper breast bor-
der. This is determined be ore measuring the distance (23 cm) to the new nip-
ple rom the suprasternal notch. The areolar opening is marked 2 cm above the
new nipple position, and a 16 cm opening is marked reehand. This patient is
5 eet 2 inches tall, weighs 70 kg (155 pounds), and wears a 34 H brassiere.
1
6-1 Preoperative
markings

A true superomedial pedicle has a dual blood supply from
both the second and third interspaces. A long superomedial
pedicle is far easier to inset than a superior pedicle.
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Chapter 6 • Vertical Breast Reduction
The inframammary fold was intentionally elevated on this patient’s right breast.
It measured 1 cm lower than the left fold. Postoperatively the inframammary
fold is elevated, but a pucker is present, with a scar that extends down onto the
chest wall. The remnant of the original fold is just below the pucker, and the
new fold is about 2 cm higher.
This inframammary fold elevation is the reason that the skin resec-
tion design should remain well above the inframammary fold.
OPERATIVE TECH NIQU E
Positioning
The patient is placed supine on the operating table with arms extended out-
ward but angled less than 90 degrees. General anesthesia is used. Some sur-
geons place the patient upright at the end of the surgery to assess the shape. If
this is done, the arms need to be properly secured. I usually rely instead on my
preoperative markings and rarely place the patient upright.
Inframammary Fold Level
It is important to mark the inframammary fold level, because it is often quite
different from one side to the other. The surgeon may want to intentionally el-
evate the inframammary fold (this increases the revision rate, unless the conse-
quences are understood) or try to make the levels more even.
1
6-1 Preoperative
markings
1
6-2 Intraoperative
review of markings

282
Inf ltration
I used to inf ltrate lidocaine with epinephrine along the incision
lines until I understood the blood supply. The veins are very su-
perf cial and lie just under the dermis. (They can o ten be seen
through the skin.) Veins were o ten damaged, so I stopped inf l-
trating incisions in an e ort to preserve as many vessels as possible.
I do inf ltrate the areas where liposuction will be per ormed. These are the preax-
illary ullness, the lateral chest wall, and just above the in ramammary old. When
extensive liposuction is needed, I use up to a liter o tumescent-type solution
divided between the two sides (1 L o Ringer’s lactate, 20 ml o lidocaine 2%,
and 1 ml o epinephrine 1/ 1000). In thinner patients I inf ltrate about 40 ml
o a lidocaine/ epinephrine mixture on each side with a spinal needle (lidocaine
0.5% with 1/ 400,000 epinephrine).
Deepithelialization
I place a lap pad around the breast and hold it with a Kocher clamp to acilitate
the deepithelialization. The medial and superomedial pedicles are easy to deep-
ithelialize. I usually cut the skin initially into strips. The base o the true medial
pedicle is about 4 cm up into the areolar opening and about 4 cm down into
the vertical skin resection pattern. The base o a superomedial pedicle extends su-
periorly just lateral to the breast meridian to preserve the descending branch o
the artery rom the second interspace. In this patient, the pedicle can be incised
Part II • Technique
1
6-3 Infiltration

around its periphery as ar as needed to achieve good rotation and easy areolar
inset. The arrow on the lateral side indicates the limits o a true superomedial
pedicle, and the medial arrow indicates the extent o the incision to create a
true medial pedicle.
Pedicle Creation
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Chapter 6 • Vertical Breast Reduction
The pedicle is created ull thickness, not because o the blood supply, but to
preserve the deep branch o the lateral intercostal nerve. The superf cial branch
o the lateral ourth intercostal nerve curves up into the subcutaneous tissue; it
is inevitably transected during the resection. The deep branch, conversely, lies
just above the pectoralis ascia and then turns vertically toward the nipple at the
level o the breast meridian. A ull-thickness pedicle can preserve this deep
branch and provide an elegant curve to the lower pole o the breast. In addi-
tion, a ull-thickness pedicle is more likely to preserve ducts and potentially im-
prove the ability to breast- eed. The thinning required with a superior pedicle
can leave an empty area in the lower pole, and the shape o the breast at the end
o the procedure can be concave in eriorly.
To avoid inadvertent undermining, the assistant should not pull on the pedi-
cle. I usually use cutting cautery or this dissection, but scalpel dissection is
equally e ective.
1
6-4 Pedicle
creation

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Part II • Technique
Parenchymal Resection
Vertical Wedge Resection
The key to vertical breast reduction is the vertical wedge resection removed
rom the in erior and central portion o the breast. Removal o this vertical
wedge allows the breast base to be narrowed and the breast shape to be coned,
thereby producing good projection. The breast tissue is removed in eriorly,
whereas the superior, superomedial, and superolateral breast tissue is le t at-
tached to the skin f aps. Note that the pedicle has been incised superiorly, cre-
ating a true medial pedicle. This allows the pedicle to be adequately rotated so
that its in erior border becomes the medial pillar.
The principle o the vertical wedge resection is shown in this patient. H er lat-
eral pillar (arrows) has been le t about 2 cm thick. The lateral pillar corresponds
to the Wise pattern design and measures 5 to 7 cm in length.
Resected
breast tissue
1
6-5 Parenchymal
resection

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Chapter 6 • Vertical Breast Reduction
This photo shows a di erent patient (and the le t breast) to demonstrate that
there is usually a small strip o skin removed above and lateral to the medially
based pedicle. A small plat orm o breast tissue (arrows) is le t behind superi-
orly and laterally to act as a support or the pedicle.
The medially based pedicle is much like an inferior pedicle—it ap-
pears to have been thinned out when it has actually been created
full thickness. This superior platform is not tissue that can be
pushed up to create upper pole fullness (it will bottom out instead),
but it is just enough tissue to support the pedicle and prevent post-
operative retraction.
Lateral Resection
It is o ten di f cult to remove enough breast tissue with the vertical approach.
Extra tissue should be removed rom under the lateral ap. It is important to
leave the lateral skin ap with a 2 cm thick pillar be ore bevelling out the lat-
eral resection. Most o the thick glandular and f brous breast tissue is under the
lateral ap, and it needs to be directly excised. This is most evident in teenage pa-
tients where this tissue needs to be carved out as i it were made o soapstone.
The excess tissue and the resulting edges should be care ully carved into a good
shape. Relying on sutures under tension will not work to hold the shape. It is
almost as important to close the breast parenchyma without any tension as it is
to close the skin without any tension.
1
6-5 Parenchymal
resection

286
Part II • Technique
The lateral pillar is indicated with arrows. The extra breast tissue below the Wise
pattern is removed both laterally and medially. The extra tissue is held above
using a Kocher clamp, and the tissue is removed by either sharp or cautery dis-
section.
This young woman has very thick glandular breast tissue that must be carefully
carved out to achieve a good result. Much of the excess gland is lateral in
younger patients (the patient’s left breast is shown) and needs to be directly ex-
cised to prevent postoperative lateral fullness. The forceps shows where the ex-
1
6-5 Parenchymal
resection

cess gland retracts laterally a ter the initial in erior wedge resection. This must
be directly carved out. The f nal photograph shows residual lateral breast tissue
that is still too thick and needs to be resected on its deep sur ace.
Inferior Resection
As mentioned previously, the Wise pattern is used or determining what should
be removed—the central vertical wedge as well as the tissue beyond the bor-
ders o the pattern itsel . A good guideline is to leave the parenchymal pillars
about 7 cm long and to remove all tissue in eriorly.
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Chapter 6 • Vertical Breast Reduction
This area (indicated with crosshatching in the photo on the right) is o ten called
the “ghost” area by Dr. Carolyn Kerrigan. The tissue can be removed with a
combination o direct excision and liposuction. The pectoralis ascia is not ex-
posed, because it not only bleeds more but can also damage some o the nerves.
Sometimes the in ramammary old f bers are intentionally excised so that the
in ramammary old can rise. It is important not to violate the in ramammary
old f bers i any weight (such as an implant) will add downward orce.
I will o ten directly excise the in erior tissue using a Kocher clamp to hold the
tissue and ensure that the skin is not button-holed. It is important to leave at
least 1 cm o at on the dermis so that scar contracture does not occur.
1
6-5 Parenchymal
resection

288
Part II • Technique
The ghost areas are cleared out, but, as shown in the photo on the right, it is
important to leave tissue attached to the skin f ap so that postoperative scar con-
tracture does not occur.
Closure of the Areolar Opening Into a Circle
Medial and lateral pillars
sutured together
Resected breast tissue
The areola is closed in eriorly to make the pillar closure easier. The surgeon can
also better assess the extent o the resection and decide whether more needs to
be removed. I use 3-0 Monocryl. The dermis at the base o the pedicle does
not need to be undermined to suture the areolar opening. It is important to
avoid the veins under the dermis when placing the suture.

Pillar Closure
289
Chapter 6 • Vertical Breast Reduction
need art
Medial pedicle
rotated superiorly
The pillars are closed with interrupted 3-0 Monocryl. It is important to suture
“white stu ” to “white stu .” Even in very atty breasts, some solid f brous tis-
sue can be ound to approximate the medial and lateral pillars. Deep constrict-
ing sutures are not necessary and are more likely to cause at necrosis. I usually
only use about three sutures to get good approximation. I start in eriorly where
the base o the medial pedicle ends in eriorly (arrow), and I rotate the pedicle up
into the areola. This makes the in erior border o the medial pedicle become
the medial pillar. It can be closed to the lower end o the lateral pillar. The su-
tures do not need to be deep.
1
6-6 Pillar closure

The blue forceps shows where the inferior border of the medial pedicle joins
the base of the pedicle. This is now the inferior limit of the medial pillar. It is
then sutured to the lower end of the lateral pillar.
The nipple rotates easily into position. The arrows show the inferior extent of
both medial and lateral pillars. Pillar closure does not start at the skin opening
or at the inframammary fold, but about 5 to 7 cm below the areola, where the
lower extent of the Wise pattern would come together. The space below the
Wise pattern (ghost area) is left empty.
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Part II • Technique

291
Chapter 6 • Vertical Breast Reduction
The nipple and areola can be elevated to help orient the pillars for closure.
In this patient the residual lateral fullness can be further managed with lipo-
suction. In a young woman with thick glandular breast tissue, the sutures need
to be removed and this lateral area directly excised before reclosure.
Tension is to be avoided on both the parenchymal closure and the
skin closure. The f nal result o the closure depends on the nature
and design o the parenchymal resection.
This photo shows how the vertical wedge excision allows the breast to be coned,
producing more breast projection while narrowing the base diameter.
These sutures do not need to be deep, and they should not be used to try to pull
lateral breast tissue around for shaping. Any tension on the parenchymal closure
will just result in the tissue tending to revert back to its original position.

Pushing the breast down inferiorly against
the inframammary fold (and not folded
over it) will give the surgeon a good ap-
preciation for the adequacy of the resec-
tion. The breast tissue should be above the
solid line, and all tissue (except for enough
fat to prevent scar contracture of the der-
mis to the deep tissues) should be removed
in the crosshatched areas.
292
Part II • Technique
Dermal Closure
The dermis is closed before liposuction is performed. This provides some form
to better assess the areas to be suctioned. The dermis is closed with just enough
deep dermal 3-0 Monocryl sutures to achieve dermis-to-dermis apposition. Too
many sutures constrict the blood supply.
Liposuction Tailoring
Liposuction is performed through the vertical skin opening. I usually use a stan-
dard 3 mm cannula. It is important to remove the subcutaneous tissue that can
create an inferior pucker or dog-ear (without removing the fat needed to pad
the dermis and prevent scar contracture postoperatively). It is best to carry the
liposuction inferior to the inframammary fold to provide a smooth transition.
The areas beyond the Wise pattern are suctioned (crosshatching). These include
the lateral chest wall, the preaxillary areas, and the area above the inframam-
mary fold. Liposuctioning in the preaxillary area should be conservative to avoid
irregularities.
1
6-7 Closure
of dermis
1
6-8 Liposuction
for contouring

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Chapter 6 • Vertical Breast Reduction
The skin is closed with subcuticular 3-0 Monocryl. It is important
not to cinch up or gather the vertical incision. The vertical length
is needed to accommodate the increased projection that results.
The subcuticular suture can cause constriction o the wound edges and inter-
ere with blood supply and subsequent healing. My studies have shown that the
vertical incision will stretch i gathered (see Appendix A) and, i it does not
stretch, it will o ten leave a pleated appearance that may need to be corrected.
It can be tempting to add a T to excise the in erior pucker, but it o ten tucks
in and disappears. Creation o a T can be di f cult; it needs to be curved up-
ward, or the f nal scar will curve downward. Curving the incision leaves a long
in erior incision, which needs to be closed to a much shorter length. It can be
di f cult to avoid adding an additional lateral and medial pucker.
I skin quality is good with a C to D f nal size, I will accept a 12 to 15 cm ver-
tical length. In patients with poor quality skin, I will add a J, L, or T with an
11 to 12 cm vertical length.
Subcuticular suture
gathered
Final Skin Closure
1
6-9 Skin closure

A larger postoperative breast can tolerate (and need) a longer vertical distance
to accommodate the increased projection that results rom a medial pedicle ver-
tical reduction. A vertical distance o 7 cm is normal with many B cup breasts,
9 cm with many C cup breasts, and 11 cm with many D cup breasts. The 5 cm
rule was ollowed with inverted-T approaches, because it was well known that
skin used as a brassiere to support the weight o the in erior pedicle would
stretch in eriorly over time.
294
Part II • Technique
1 month postoperatively

7 months postoperatively
It can also be tempting to suture the in erior pucker down to the chest wall to
help it tuck in, but this maneuver will cause a hole or indentation and delay res-
olution o the shape. The pucker was sutured down in this patient. She is shown
1 month and 7 months a ter surgery. It was very slow to resolve.
This drawing depicts how the longer vertical length rom the bottom o the
areola to the in ramammary old is actually desirable. A 5 cm vertical length re-
sults in a f attened breast with little projection.
Good projection
Little projection

More projection

295
The f nal closure is shown, with the suctioned area indicated by crosshatching on
the right breast. This patient had only 219 g removed rom the right breast and
353 g removed rom the le t breast. Liposuction was used to remove an addi-
tional 550 cc. The vertical incisions were not cinched or gathered.
Drains
I only use drains in very large breast reductions and in patients who have an un-
usual amount o oozing. I stopped using drains when I had a patient return
2 weeks postoperatively with a hematoma that must have occurred when the
drain was removed.
I do not believe that drains prevent hematomas. It is important instead to care-
ully secure hemostasis, especially o the known arteries. Be ore closure I check
the areas where I expect to f nd the deep per orator (just above the f th rib),
the superf cial branch o the lateral thoracic artery (in the lateral pillar), and the
descending branch o the artery rom the second interspace (just medial to breast
meridian in the areolar opening about 1 cm deep to the skin sur ace).
It is better to allow the pucker to settle into its own position. It will ini-
tially swell and protrude; eventually it will tuck in and settle quite nicely in
most patients. I encourage patients to wait or a ull year. I have def nitely
pushed the limits to see how long I can leave the incision. Correction can
easily be per ormed under local anesthesia in the o f ce through either a
vertical or a horizontal incision. (See pp. 309 through 318 or a discus-
sion o puckers.)
The areola is sutured into place with our interrupted 3-0 Monocryl sutures in
the deep dermis and subcuticular 3-0 Monocryl in the skin. Any irregularities
in the areolar opening are corrected be ore f nal closure.
Chapter 6 • Vertical Breast Reduction

Tape
296
Part II • Technique
I cover the patient’s incisions with Micropore paper tape (3M, St. Paul, MN).
It initially does not look as i it will stick well, but, once it warms up to the pa-
tient’s temperature, it provides a good cover. The tape is le t in place or 3 to
4 weeks. The patient is encouraged to shower the day ollowing surgery. Pa-
tients like the tape, because it covers the incisions nicely. I tried generic paper
tape, but the adhesive coalesced and did not per orm as well. I do not believe
that taping the skin itsel in an attempt to shape the breasts has any benef t.
Garments
Patients are placed in a surgical brassiere. Compression on the nipple-areola
complex is avoided. It would be ideal to provide some compression on the ar-
eas where liposuction was per ormed, but I believe it is better not to compress
the nipple circulation.
POSTOPERATIVE CARE
Activities are not generally restricted. Patients are allowed to raise their arms.
They may wear their own brassiere or the one that we provide, but they are not
required to wear either one. I suggest that they do what is most com ortable.
Most patients elect to wear some orm o support or about 2 weeks, day and
night.
Patients can shower daily starting the f rst day postoperatively. The Micropore
tape stays in place quite well or 3 to 4 weeks. It can actually be di f cult to re-
move the tape earlier. Patients are encouraged to trim the edges o the tape i
needed.
1
6-10 Wrap-up

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Chapter 6 • Vertical Breast Reduction
PROBLEMS AND COMPLICATIONS
Necrosis of Nipple Areola and Fat
I was ortunate that I did not have a complete nipple necrosis until I had been
in practice or 12 years. But I knew it had happened to the patients o good
surgeons. I believe now that the problem is one o blood supply, because some-
times only three o the our main vascular supplies are dominant (see Chapter
11). I have per ormed over 2000 vertical reductions, and my (complete) necro-
sis rate is about 0.5%, which is about the same as the published rate. I had prob-
lems with the superior pedicle initially, but I think that was my ault, because I
tried to keep it ull thickness. This probably caused compression and subsequent
necrosis.
My patients with necrosis have not been smokers. Fat necrosis tends to occur
at the distal end o the pedicle and can be elt as a hardened area just above the
areola. It may be important to trim some o what might be parasitic at o the
pedicle. I have not had to take a patient back to surgery or at necrosis, but it
does occur occasionally. The surgeon must palpate the breasts postoperatively
to be aware o this problem. (See Chapter 11 or a more comprehensive dis-
cussion o necrosis.)
Infection/ Wound-H ealing Problems
I initially accepted wound-healing problems as a normal part o breast reduc-
tion surgery, especially at the T junction in an in erior pedicle inverted-T breast
reduction. It has been quite enlightening reviewing the photos o all my pa-
tients since I began practice.
The problem continued when I started using the vertical technique, and, again,
I accepted it as a usual complication. I did not use perioperative antibiotics un-
til a couple o my patients developed in ections and underwent surgery by gen-
eral surgeons in the patients’ home town about 3 hours away.
I f nally conceded and gave all patients antibiotics. The nurses in my o f ce were
amazed that patients no longer called with suture-spitting problems. The change
was so dramatic that I realized wound-healing problems were primarily a low-
grade in ection.
This improvement happened even be ore I understood that the vertical incision
did not need to be gathered. I had noticed that the vertical incision did not heal
well when my assistant did “too good a job” and constricted the wound edges
with backtracking on the subcuticular suture. It also became clear that avoid-
ing tension on the skin closure was very important to prevent wound-healing
problems.

When the in ectious disease specialists warned against postoperative prophy-
lactic treatment, I changed my regimen and gave patients only a 24-hour course
o antibiotics. Un ortunately, my patients developed wound-healing problems
again, but to a lesser extent (both in severity and occurrence) than when I gave
no antibiotics at all.
Then I tried combining a 24-hour course o antibiotics with antibacterial su-
tures. (Monocryl Plus sutures are coated with triclosan, an antibacterial, not an
antibiotic agent.) There were occasional wound-healing problems and mild in-
ections, but these were all easily treated with antibiotics. Although I pre er to
give all patients antibiotics or a ull week a ter surgery, I understand that this
is discouraged by in ectious disease specialists. I assume that it is better to oc-
casionally have to administer antibiotics to a patient who develops an in ection
postoperatively than to treat every patient prophylactically and risk the devel-
opment o adverse e ects. I have also noted that in ections are more likely in
obese patients and large breast reductions, and I now give these patients post-
operative antibiotics.
I now use IV cephazolin 1 gm at induction o anesthesia only. I also insist on
the antibacterial suture. Patients with a BMI over 30 and/or patients with a breast
reduction over 800 g are also given a week o postoperative cephalexin orally.
298
Part II • Technique
Both o these women developed postoperative in ections a ter bilateral medial
pedicle vertical breast reduction. The patient on the le t developed the in ection
1 month a ter surgery, and the patient on the right developed the in ection at
2 weeks a ter surgery. Both patients responded well to antibiotics (ciprof oxacin
or the patient on the le t and cephalexin or the patient on the right).

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Chapter 6 • Vertical Breast Reduction
Before I gave my patients antibiotics, the type of wound-healing problem shown
above was common. I rarely see it now. The only change I made at the time
was to give intraoperative cephazolin and a postoperative 5-day course of
cephalexin. The last photo provides an example of why I now perform liposuc-
tion on all patients for shaping, especially along the inframammary fold and the
lateral chest wall.
I believe there are two reasons for having problems with wound healing: (1)
the skin is under too much tension and (2) there is too much gathering of the
skin, which constricts the blood supply to the wound margins. I keep the skin
loose, and I do not use it to try to maintain the shape. I was careful to keep the
gathering sutures loose as well, but I now no longer gather or pleat the verti-
cal incision (see Appendix A).

300
Part II • Technique
Occasionally, sutures come free, and a wound-healing problem such as this oc-
curs. It is best left to heal secondarily.
H ematoma
I have had to take four breast reduction patients back to the operating room to
evacuate postoperative hematomas.
I stopped using drains after this patient came to see me 2 weeks postoperatively.
I had placed drains and left them in overnight. I suspect that bleeding was
caused by irritation as the drain was removed. This eventually healed without
intervention.

This patient developed a hematoma a ter I used tumescent-type inf ltration
throughout the breast. I took her back to the operating room and ound that
the bleeding was rom a per orator that normally supplies an in erior pedicle. I
do not give patients antiin ammatories postoperatively, so it was tempting to
blame this hematoma on the anesthetist or giving her ketorolac intravenously
at the end o the case. The reality was that I did not check and properly secure
hemostasis be ore closure. The constriction caused by inf ltration can be par-
ticularly misleading.
Seroma
Seromas do occur, but I rarely eel the need to treat them. We would need to
leave drains in or several days to prevent the development o a seroma. Most
o them resolve without treatment. My nurses call all patients a ter surgery, and
patients are com ortable calling with any issues. Rarely do they ever complain
about any uid draining. I have aspirated only one patient or a seroma. I be-
lieve that seromas settle quite well on their own, because the uid can easily
spread out and be absorbed (as opposed to abdominoplasty where the uid is
blocked by the long transverse incision).
301
Chapter 6 • Vertical Breast Reduction

This woman had a bilateral medial pedicle vertical breast reduction with 505 g
removed from the right breast and 240 g removed from the left breast. Another
100 cc of fat was removed with liposuction. She returned 2 weeks postopera-
tively, upset that there was still persistent asymmetry. Aspiration of a seroma
(100 cc) corrected the problem.
302
Part II • Technique

This woman had a breast reduction with 660 g removed rom the right breast
and 670 g removed rom the le t breast. Liposuction was used to remove an-
other 450 cc. At the time o revision or urther reduction, 15 months later, she
had a seroma with a bursalike cavity. She is shown 6 months a ter the revision in
which 65 g was removed rom the right breast and 45 g was removed rom the
le t breast. The seroma cavity was a surprise f nding and only on the right side.
I have only seen one other small seroma in a revision procedure.
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Chapter 6 • Vertical Breast Reduction
Preoperative
Immediately after original reduction
Seroma cavity found 15 months after original reduction
Immediate result after revision
6 months after revision

Scarring
I have no better answer than anyone else for patients with hypertrophic
scarring.
304
Part II • Technique
When this 16-year-old patient developed hypertrophic scarring, I felt better
that I had used a vertical approach and avoided what could have been a very
unsightly scar along the inframammary fold. I removed 425 g from the right
breast and 440 g from the left breast. No liposuction was performed.

This woman knew that she was likely to form hypertrophic scars from her pre-
vious experience with liver surgery. She had a medial pedicle vertical breast re-
duction with 600 g removed from the right breast and 575 g removed from
the left breast. Another 200 cc of fat was removed with liposuction. She is shown
3 months, 1 year, and 5 years after surgery.
305
Chapter 6 • Vertical Breast Reduction
Preoperative

3 months preoperatively
1 year postoperatively

5 years postoperatively

306
Part II • Technique
This woman is o East Indian origin, and thick scars were expected. She had a
medial pedicle vertical breast reduction with 370 g removed rom the right
breast and 400 g removed rom the le t breast. She is shown 1 year and 61⁄2 years
a ter surgery. This type o pigmentation that develops on both sides o the scars
is common in darker-skinned patients.
Asymmetry
Asymmetry is di f cult to prevent. I have learned to place the new nipple position
lower on the larger breast to help avoid this problem. Such asymmetry did not
occur with the inverted T, because the resection involved a horizontal ellipse.
But when a vertical ellipse is larger on one side, closure raises the nipple more
on that side. I usually try to lower the new nipple position by at least 1 cm. Nip-
ples also appear to be higher i not enough tissue has been removed in eriorly.
The extra weight on the skin o the larger breast can artif cially pull the skin
down. The new nipple position should be marked with the breast weight sup-
ported.
Preoperative
1 year postoperatively
61⁄2 years postoperatively

This patient’s nipple positions were both marked 26 cm rom the suprasternal
notch, but, postoperatively, the larger breast has a much higher nipple position.
I believe that this resulted rom three actors: the weight o the larger breast
during marking, the e ect o closing a vertical ellipse, and underresection on
the right breast.
Sometimes it is di f cult to be sure which breast is larger preoperatively because
o di erences in shape. Many patients are unaware o their own size di erences
preoperatively, but they complain about asymmetry postoperatively.
307
Chapter 6 • Vertical Breast Reduction
Even i one breast is obviously larger, the actual di erence becomes clearer when
the arms are raised. It is also important to determine i one old is higher than
the other.

308
Part II • Technique
It is essential to mark the new nipple position lower on the larger breast. This
woman developed a pucker on the right breast, but more important is the higher
location o the right nipple postoperatively. (See p. 316 or a discussion o how
this patient’s puckers were treated.) She had a medial pedicle vertical breast re-
duction with 460 g removed rom the right breast and 300 g removed rom
the le t breast.
This woman shows how dramatic the di erence in nipple position can be with
breast asymmetry. She had a large f broadenoma in her le t breast. The nipples
were placed preoperatively at the same level. Note how much higher the nip-
ple is on the larger breast (with only a small amount o residual glandular pto-
sis), compared with the right side. I believe the problem occurs or three rea-
sons. First, the breast skin is dragged down by the weight, and the surgeon
should support the breast weight when per orming the markings. Second, clo-
sure o a larger ellipse (parenchyma as well as skin) pushes the ends o the el-
lipse urther (both up and down). This is not an e ect that occurs with the in-
erior pedicle inverted-T type o breast reductions, because the elliptical excision
is horizontal rather than vertical. Third, any residual glandular ptosis makes the
nipple look a bit higher.

Puckers
Puckers at the bottom o the vertical incision may require revision. This is a
problem with the vertical approach to breast reduction. Surgeons can excise the
pucker at the time o the original surgery, but this is usually not necessary. I
have pushed the limits o the procedure. The ollowing cases show how the
problem can present, how it can be treated, and how treatment can create ur-
ther problems. Puckers can occur with inverted-T procedures, but these lateral
and medial dog-ears are sometimes harder to prevent and correct than the in-
erior dog-ear that can occur in a vertical procedure. Medial puckers that occur
with inverted-T procedures are particularly di f cult to correct without carrying
the scar across the midline o the chest. This is not recommended because o
the resultant scar contracture.
309
Chapter 6 • Vertical Breast Reduction
This woman had an inverted-T breast reduction and requested correction o
the lateral pucker. Direct excision was used.
There are two other problems that develop at the lower end o the vertical inci-
sion. The f rst is pleating that occurs when this end o the incision is cinched or
gathered. I have measured the vertical incision length on the preoperative de-
sign, intraoperatively, and at each visit postoperatively (see Appendix A). I ound
that the vertical incision invariably stretched back nearly to its original length
be ore closure. I the vertical incision did not stretch, it sometimes le t pleats that
needed to be corrected. The second problem is delayed wound-healing that re-
sults when this gathering maneuver constricts the circulation to the skin edges.
Cinching the closure and closure under tension can result in wound breakdown.

310
Part II • Technique
Prevention of Puckers
This woman developed pleating a ter a medial pedicle vertical breast reduction.
The lower end o the vertical incision was shortened by gathering. Un ortu-
nately, pleats remained and required revision and release.
Converting a vertical incision to a J, L, or T can easily be done; however, many
o the puckers will disappear on their own. I rarely add a horizontal excision.
My revision rate now is about 5% (but a revision “rate” depends on the sur-
geon’s threshold or revision). Puckers are usually easily excised in the o f ce
under local anesthesia.
Two years a ter a medial pedicle vertical breast reduction, this patient returned
to inquire about pucker correction.
Preoperative

2 years postoperatively, before pucker correction

She had 800 g o tissue removed rom her right breast and 890 g removed rom
her le t breast. The vertical incisions were each gathered only 1 cm, which le t
unsightly protrusions (above, left). The small puckers in the photo on the right,
shown 2 years postoperatively, are easily excised in the o f ce through a small
vertical incision. It is sometimes hard or surgeons to believe that these photos
are o the same patient. It is unnecessary to gather the vertical incision, and it
can lead to scar contracture and an increased revision rate.
When per orming pucker excision or, conversely, when leaving the puckers (and
not per orming a horizontal excision, which may be tempting), the surgeon
needs to remember that the breast does not drop, as shown in the photo on the
le t. Rather, it slides downward, as shown in the photo on the right.
311
Chapter 6 • Vertical Breast Reduction
In this case, the vertical length was 15 cm, and the decision was made to add a
small J to the lower end o the incision. A J or L is o ten easier and less prob-
lematic than a T shape. I try to curve the J upward while excising the excess
skin. It is not the size o the reduction (in this case only 560 g) that is used to
determine when to add this skin extension, but rather the length o the verti-
cal incision. I will (as a general rule) add a horizontal scar i the vertical length
is more than 15 cm with good quality skin and more than 12 cm with poor
quality skin.

Pucker Correction With Vertical Excision
312
Part II • Technique
The pucker in this case was best corrected through a vertical incision with this
f nal result. When the pucker is above the in ramammary old, a vertical cor-
rection can be used. When the pucker is below the in ramammary old, a hori-
zontal excision (curved upward) may be necessary to tuck the scar up and o
the chest wall.
Preoperative
Immediate postoperative result
This woman had a medial pedicle vertical breast reduction with 652 g removed
rom her right breast and 629 g removed rom her le t breast.

She is shown 3 years postoperatively, when she had a pucker correction through
a vertical skin incision with horizontal fat removal. She is also shown 15 months
after the pucker revision.
313
Chapter 6 • Vertical Breast Reduction
3 years postoperatively at pucker correction
15 months after pucker revision

314
Part II • Technique
This woman had a medial pedicle vertical breast reduction with 285 g removed
from the right breast and 230 g removed from the left breast. Another 350 cc
of fat was removed with liposuction. The pucker was corrected with a small ver-
tical skin incision (with horizontal fat removal) on both sides.

This woman had a medial pedicle vertical breast reduction. She had 435 g re-
moved from the right breast and 435 g from the left breast. Another 200 cc
was removed with liposuction. She is shown 2 months and 4 years after surgery.
Four years after her original surgery she had a vertical pucker revision. She is
shown 2 months after the revision.
315
Chapter 6 • Vertical Breast Reduction
Preoperative
Immediate postoperative result
2 months postoperatively

4 years postoperatively
4 years postoperatively at pucker revision

2 months after pucker revision

316
Part II • Technique
Pucker Correction With H orizontal Excision
When the puckers extend below the new inframammary fold, a horizon-
tal excision is needed.
This woman had a medial pedicle vertical breast reduction with 460 g removed
from her right breast and 300 g removed from her left breast. (See p. 308 for
a discussion of nipple placement in this patient.) The right inframammary fold
was lower than the left fold preoperatively, and both folds were elevated at sur-
gery. The pucker extends below the inframammary fold on the right breast. A
horizontal excision was necessary for correction. If a pucker is above the infra-
mammary fold, the skin can be excised vertically, and the excess fat is excised
horizontally. If the pucker is below the fold, a horizontal excision of both skin
and fat will be necessary.

This woman had a medial pedicle vertical breast reduction with 280 g removed
rom her right breast and 320 g rom her le t breast. Another 125 cc o at was
removed with liposuction. She had visible puckers under both breasts, which
were corrected 16 months a ter surgery under local anaesthesia in the o f ce.
317
Chapter 6 • Vertical Breast Reduction
Postoperative pleating and pucker formation
Preoperative
Immediate postoperative result
After pucker correction

318
Part II • Technique
This woman had a horizontal correction of her puckers. In this case, a poorly
designed horizontal excision on my part resulted in a downward-curving scar.
Note, however, that adding a horizontal scar can also add two more puckers
that may need to be chased laterally and medially.

U nderresection/ Bottoming Out
319
Chapter 6 • Vertical Breast Reduction
Even though I removed over 1200 g per side on this patient, her breasts are
still too large. The breasts have too much excess in the lower pole, with bot-
toming out and a nipple position that looks too high on the lateral view.
This result, on a different patient, shows why
I now perform tailored liposuction on the ex-
cess lateral fat in all patients. Both the location
of the old inframammary fold and where the
new one wants to be are shown. This is not a
pucker, but excess subcutaneous tissue between
the old and new inframammary folds.

320
Part II • Technique
It would be tempting to excise the excess in this patient through a long hori-
zontal incision. H owever, only a small horizontal incision was used. Most of
the excess was actually subcutaneous fat and not excess skin. The correction in-
volved fat excision—not skin excision. The correction was good on the patient’s
left breast (with a 1 cm skin incision) but not complete on the right breast (with
a 4 cm skin incision).
This patient did not have liposuction performed on the lateral chest wall, but a
good correction was achieved with secondary lateral liposuction.

I used the lateral pedicle or vertical breast reductions a ter I had problems in-
setting the superior pedicle. I thought that the lateral pedicle would have bet-
ter sensation (see Appendix B), but I soon realized that the medial pedicle had
excellent sensation and could produce a better shape. The problem with the
lateral pedicle was that the base o the pedicle consisted o the tissue that needed
to be removed, and the f nal result had too much lateral ullness. The patient
shown above had a lateral pedicle vertical breast reduction with 370 g removed
rom the right breast and 425 g removed rom the le t breast.
321
Chapter 6 • Vertical Breast Reduction
This woman had a lateral pedicle used on the
right breast and a medial pedicle on the le t
breast. The medial pedicle gave a better shape
than the lateral pedicle, because the lateral
pedicle prevented adequate lateral resection o
parenchyma.

322
Part II • Technique
This woman developed bottoming out
rom inadequate in erior pole resection.
Part o the problem was the f nal size o the
medial pedicle, which prevented adequate
resection. She had 1220 g removed rom
the right breast and 1335 g removed rom
the le t breast. She is shown 2 weeks a ter
surgery and again 14 months a ter surgery.
Preoperative

2 weeks postoperatively
14 months postoperatively
Any attempt to push lower pole volume up into the upper pole will result in bot-
toming out with time. Later removal o lower pole volume in the le t breast
would help correct both the glandular ptosis and high nipple position.
Depigmentation of the Areola
For some unknown reason, the areola may develop some areas o depigmenta-
tion, even with no blistering or any sign o circulatory compromise.

Persistent Indentations
Although there is still a controversy about how well sutures work in the
breast, I believe that they can cause delayed resolution if indentations left
while the patient is on the operating table are allowed to persist. I do not
believe that permanent sutures hold in the long term. The tissue will adapt
to tension, and the new cells will settle around the sutures to reduce that
tension. Excess tension on the breast tissue will take time to settle.
323
Chapter 6 • Vertical Breast Reduction
I used to think indentations such as these would disappear with time. They did
settle with time, but not completely. I now will reach in and cut a pillar suture
if it is causing an indentation.

324
Part II • Technique
Six weeks postoperatively this patient had an indentation in the lateral aspect
of her left breast. The indentation settled on its own without further treatment.
She is shown 8 months postoperatively.
Preoperative
Immediate postoperative result
6 weeks postoperatively

8 months postoperatively
Another form of indentation that may occur postoperatively is nipple inversion.
This seems to occur without any particular reason. It does not seem to be re-
lated to problems with fat necrosis or other circulatory problems. This patient
had a slightly inverted nipple preoperatively, and this persisted postoperatively.
I will not attempt to correct nipple inversion at the same time as a breast re-
duction, because I do not want to add any further risk of nipple necrosis with
loss of blood supply.

325
Chapter 6 • Vertical Breast Reduction
Overresection of Skin
I too much skin is removed, the closure will be tight and wound-healing prob-
lems can occur. These photos show how the skin stretches over time when too
much is removed. They also provide a good example to show that skin is not
good as a handle or as a brassiere.
Breast reduction patients with over a ull year ollow-up were analyzed or re-
vision rates (see table below). Revisions were divided into correction o puck-
ers, re-reduction, and other corrections. My revision rate or puckers is now 5%.
The numbers were high, because I was pushing the limits o the vertical ap-
proach to try to determine when to add a J, an L, or a T. I also have a very low
threshold or revision, because I do not need to charge the patient when I per-
orm a revision under general anesthesia. I can also per orm most pucker revi-
sions in my o f ce under local anesthesia.
Breast Reduction Revision Rates
Patients

Puckers

Re-reduction

Other Revisions
1544

161 (10.4%)

53 (3.4%)

60 (3.8%)

326
Part II • Technique
RESU LTS
A superomedial vertical breast reduction was performed on this 38-year-old
woman. She had 500 g of tissue removed from each breast. Another 200 cc of
fat was removed with liposuction. She is shown 2 years postoperatively.
She is shown 4 years and 6 years postoperatively. H er suprasternal notch-to-
nipple distance preoperatively was 27 cm on the right and 29 cm on the left.
H er new nipple position was marked at 24 cm. Postoperatively this distance re-
mains unchanged at 23 cm on both sides. She has complete return of sensation.
H er vertical incision design measured 11.5 cm (left breast) and 12 cm (right
breast) preoperatively while she was upright, and 9 cm and 10 cm on the op-
erating table before subcuticular closure. The vertical incision was gathered to
5 cm and 6 cm. One month postoperatively the vertical measurement was al-
ready 7 cm and 8 cm; at 9 months it measured 8 cm and 10 cm. Six years post-
operatively, the vertical scar measured 9 cm and 10 cm. The areolar opening
was marked with a 17 cm circumference preoperatively, and the areolar diame-
ter remains unchanged postoperatively at 5 cm.
Preoperative

2 years postoperatively

Analysis
This patient shows how e ective a vertical breast reduction is in nar-
rowing a wide breast base. Note how her breasts were touching at the cleavage
and overf owing laterally preoperatively. The long-term ollow-up shows how
the shape is long-lasting and does not tend to descend with time. Gathering or
cinching up the vertical incision did not help in shortening the vertical scar. It
stretched quite quickly, and the long distance is actually needed to accommo-
date the increased projection. The idea that a vertical length o 5 cm is needed
or a good result is misleading. This patient has a nice shape, with the distance
between the lower border o the areola and the in ramammary old measuring
9 cm and 10 cm. H er breasts are still slightly asymmetrical; more parenchyma
could have been removed rom the le t breast. A patient with asymmetrical
breasts preoperatively will usually tolerate some (minor) asymmetry postoper-
atively as long as it is not reversed rom one side to the other.
327
Chapter 6 • Vertical Breast Reduction
4 years postoperatively
6 years postoperatively

This 29-year-old woman had a medial pedicle vertical breast reduction; 195 g
was removed rom the right breast, and 330 g was removed rom the le t breast.
She was 5 eet 11 inches tall and weighed 82 kg (180 pounds). Small medial
pedicle extension aps were used to try to f ll the upper pole. An additional
125 cc o at was removed rom the lateral chest wall and preaxillary olds. She
is shown 3 weeks postoperatively.
The patient is shown 4 months, 11 months, and 2 years postoperatively. H er
suprasternal notch-to-nipple distance was 26 cm on the right breast and 28.5 cm
on the le t. Her new nipple position was marked at 24 cm on the right and 25 cm
on the le t to accommodate or the asymmetry. Postoperatively this distance
measures 23.5 cm on the right and 24 cm on the le t. She lost about 25% o her
nipple sensation on both sides. Her vertical incision length was 9 cm on the right
breast and 8.5 cm on the le t breast, as marked when standing preoperatively,
and both were shortened by gathering to 7 cm and 6 cm, respectively. These
stretched back to 8 cm and 7 cm. Her suprasternal notch-to-in ramammary old
distance remains unchanged rom the preoperative distance o 23 cm.
328
Part II • Technique
Preoperative

3 weeks postoperatively