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

330
Part II • Technique
This 41-year-old woman had a medial pedicle vertical breast reduction with re-
moval of 410 g on each side. She had another 500 cc of fat removed with li-
posuction in the preaxillary and lateral chest wall areas and along the infra-
mammary fold. She was 5 feet 4 inches tall.
Preoperative
After induction
She is shown after induction of anesthesia, with Doppler markings indicating
the artery (red arrows) that would supply a superior pedicle. The medial pedi-
cle artery cannot be easily found with Doppler assistance. (Using a Doppler de-
vice is not necessary for surgery, but was performed for study purposes). The
markings were made to show a medially based pedicle. The Wise-type pattern
was drawn to show where the liposuction was to be performed (crosshatching).

The Wise pattern placed on the breast shows how removal o the in erior wedge
allows the remaining parenchyma to be closed. The heavy in erior breast tissue
was removed, and the superior, superomedial, and superolateral tissue was le t in
place. The pillars were brought together, and the breast was narrowed and coned,
achieving improved projection.
331
Chapter 6 • Vertical Breast Reduction
Wise pattern
Immediate postoperative result
Most surgeons would not like to leave this much puckering at the end o the
procedure. But the breast settles, as shown in the photo on the right, and the
pucker tucks in. This maneuver in which the breast is pushed downward rom
above (note the f nger position), rather than olded down simulates what hap-
pens a ter surgery and can help the surgeon decide when to add a J or a T. Sit-
ting the patient up at the end o the surgery is not as e ective as this (pushing
down rom above) maneuver.

332
Part II • Technique
The patient is shown 1 month, 4 months, and 1 year after surgery. H er supra-
sternal notch-to-nipple distance measured 27.5 cm on the right and 28 cm on
the left before surgery. The new nipple position was marked at 22 cm and mea-
sures 23 cm postoperatively. Her vertical incision was not gathered, and the dis-
tance from the lower border of her areola to her inframammary fold measures
10 cm on both sides postoperatively. She has complete return of sensation.
1 month postoperatively

4 months postoperatively

1 year postoperatively

She is shown with raised arms 4 months and 1 year after surgery.
Analysis
This patient example demonstrates how much the puckers will set-
tle. A short T may have been a good idea, but it also shows how much of the
pucker will settle with time. The early result is not abnormal; patient satisfac-
tion is good early in the postoperative phase. A preoperatively informed patient
is the surgeon’s best ally.
333
Chapter 6 • Vertical Breast Reduction
4 months postoperatively

1 year postoperatively

334
Part II • Technique
This 36-year-old woman had a medial pedicle vertical breast reduction; 910 g
was removed from each breast. Liposuction was used to remove 450 cc of fat
from the right breast and 375 cc from the left breast. She was 5 feet 5 inches
tall and weighed 102 kg (225 pounds). Note the extra roll of fat beneath the
right inframammary fold. This was a lipoma that weighed 235 g. (I no longer
gather the vertical scar as I did in this patient.)
Three weeks after surgery she has good shape and good correction and eleva-
tion of the right inframammary fold. She is shown 3 years after surgery. H er
suprasternal notch-to-nipple distance measures 37 cm on the right and 36 cm
on the left before surgery. The new nipple position was marked at 26 cm. The
vertical incision length was 17 cm bilaterally in the standing position. On the
operating table the vertical incision measured 14 cm on both sides; it was gath-
Preoperative
Preoperative
Immediate postoperative result

335
Chapter 6 • Vertical Breast Reduction
3 years postoperatively
ered and shortened to 8 cm on the right breast and 7.5 cm on the left breast.
Postoperatively the suprasternal notch-to-nipple distance is 26 cm on the right
and 27 cm on the left. The vertical scar is 15 cm on the right breast and 12 cm
on the left breast. The areolar skin circumference was 19 cm preoperatively; the
areolar diameter measures 6 cm postoperatively. (A 19 cm areolar circumfer-
ence corresponds to a 6.2 cm areolar diameter.) She has only minimal return
of sensation.
Analysis
This patient demonstrates that a large breast reduction can still be
performed using the medial pedicle vertical approach. The left nipple was ele-
vated 10 cm, and the pedicle itself measured 10 cm from the base to the nip-
ple. The excision of the lipoma at the right inframammary fold shows how the
removal of tissue around the fold can be effective in raising it. The nipple po-
sition on the right breast (the larger breast) should have been marked lower to
prevent it from being higher postoperatively.
3 weeks postoperatively

336
Part II • Technique
Preoperative
Immediate postoperative result

2 months postoperatively
This 46-year-old woman had a medial pedicle vertical breast reduction with
555 g removed from the right breast and 770 g removed from the left breast.
Another 950 cc of fat was removed with liposuction. She was 5 feet 6 inches
tall and weighed 82 kg (180 pounds). A hockey stick–shaped extension was
added to the incision to prevent a postoperative pucker.
She is shown 2 months after surgery, with good healing of the L extension.

She is shown again 8 months a ter surgery. Her new nipple position was marked
24.5 cm rom the suprasternal notch on the right breast and 25.5 cm on the
le t breast. This distance is 24.5 cm on the right and 25 cm on the le t postoper-
atively. Her suprasternal notch-to-in ramammary old distance measured 24.5 cm
preoperatively and 23 cm postoperatively. The distance rom the lower border
o her areola to the in ramammary old is 10 cm on each side postoperatively.
She has complete return o sensation.
Analysis
This patient shows the benef t o adding a J or L to the vertical in-
cision. It is important to make sure that enough at is removed laterally or the
result shown in the ollowing patient may occur.
337
Chapter 6 • Vertical Breast Reduction
Preoperative

4 months postoperatively
8 months postoperatively
This patient had a medial pedicle vertical breast reduction with 730 g removed
rom the right breast and 745 g removed rom the le t breast. An additional
740 cc o at was removed with liposuction. She is shown 4 months a ter sur-
gery. More at should have been removed lateral to the hockey stick incision.

338
Part II • Technique
This patient had a hockey stick extension added to the vertical incision. The ex-
tension is best curved upward, with the subcutaneous tissue adequately excised.
She is shown 3 months and 9 months after surgery. Pucker prevention maneu-
vers can take just as long to settle as the puckers themselves.
Preoperative
Immediate postoperative result
3 months postoperatively

9 months postoperatively
Immediate postoperative result

7 months after surgery
This patient had a similar hockey stick extension. Care should be taken to keep
the extension high so that it does not extend below the inframammary fold,
which usually rises. She is shown 7 months postoperatively.

339
Chapter 6 • Vertical Breast Reduction
This 49-year-old woman had a medial pedicle vertical breast reduction with
435 g removed rom the right breast and 470 g removed rom the le t breast.
She had another 400 cc o at removed with liposuction. She was 5 eet 2 inches
tall and weighed 70 kg (155 pounds). She is shown on the f rst day postopera-
tively. The right pucker is swollen and protrudes, whereas the le t pucker has
tucked in.
Preoperative
Immediate postoperative result

Unfortunately, both puckers persisted, because there was not enough fat re-
moved on either side of the lower end of the vertical incision. A vertical exci-
sion of skin and a horizontal excision of fat was performed 1 year after surgery.
340
Part II • Technique
She is shown at 3 weeks postoperatively.
1 year postoperatively
Immediately after pucker removal

341
Chapter 6 • Vertical Breast Reduction
She is shown 61⁄2 years a ter the original surgery.
Analysis
Puckers can be di f cult to prevent and treat, either at the time o
surgery or postoperatively. The initial puckers will settle as swelling settles, but
eventually a pucker revision may be needed. O ten the puckers are best cor-
rected with a vertical skin excision and a horizontal at excision.
The results o the pucker corrections are shown 4 months a ter the revision.

342
Part II • Technique
This 17-year-old woman had a medial pedicle vertical breast reduction with
335 g removed from the right breast and 320 g from the left breast. She had
another 200 cc of fat removed using liposuction. She was 5 feet 7 inches tall
and weighed 66 kg (145 pounds).
She is shown 1 month and 13 months after surgery. H er new nipple position
was marked 21 cm from the suprasternal notch. It measures 22 cm on both
sides after surgery. Her suprasternal notch-to-inframammary fold distance mea-
sured 23 cm before surgery and 24 cm after surgery. She has complete return
of sensation.
Preoperative
Immediate postoperative result

Analysis
This patient had a long vertical breast footprint with a low infra-
mammary fold. The new nipple position was marked well above the inframam-
mary fold but about 10 cm below the upper breast border. This patient exam-
ple shows that the new nipple position should be marked in relation to the upper
breast border rather than the inframammary fold.
343
Chapter 6 • Vertical Breast Reduction
1 month postoperatively
13 months postoperatively

This 31-year-old woman had a medial pedicle vertical breast reduction with
600 g removed from the right breast and 550 g removed from the left breast.
She had another 475 cc of fat removed with liposuction. She was 5 feet 9 inches
tall and weighed 73 kg (160 pounds).
She is shown 2 months and 31⁄2 years after surgery. Preoperatively her supraster-
nal notch-to-nipple distance measured 31 cm on the right and 30.5 cm on the
left. H er new nipple position was marked 25.5 cm from the suprasternal notch
before surgery. It measures 24.5 cm on both sides at 2 months and 31⁄2 years
postoperatively. H er suprasternal notch-to-inframammary fold distance was
25.5 cm preoperatively and 23 cm postoperatively. The distance from the lower
border of her areola to the inframammary fold measures 9 cm on both sides
postoperatively. She has complete return of sensation.
344
Part II • Technique
Preoperative

345
Chapter 6 • Vertical Breast Reduction
2 months postoperatively

31⁄2 years postoperatively
Analysis
The medial pedicle vertical breast reduction can be used in many
different types of patients with good results.

This 40-year-old woman had a medial pedicle vertical breast reduction with
560 g removed from the right breast and 940 g removed from the left breast.
She had another 600 cc of fat removed with liposuction. She was 5 feet 6 inches
tall and weighed 72 kg (158 pounds). A hockey stick extension was added to
the vertical incision on the left breast. She is shown 1 week after surgery, with
typical bruising from the liposuction.
346
Part II • Technique
Preoperative
Immediate postoperative result

1 week postoperatively

347
Chapter 6 • Vertical Breast Reduction
She is shown 1 year, 2 years, and 4 years postoperatively. Preoperatively her new
nipple position was marked at 25 cm from the suprasternal notch on the right
and 26 cm on the left. Postoperatively this distance is 25 cm on both sides. The
distance from the lower border of the areola to the inframammary fold mea-
sures 13 cm on both sides. H er suprasternal notch-to-inframammary fold dis-
tance measured 24 cm preoperatively and 23 cm postoperatively. She has com-
plete return of sensation.
Analysis
This series shows that the results of the medial pedicle vertical ap-
proach hold up well with time. Many surgeons worry that the medial pedicle
will not have good postoperative sensation, but my experience has shown that
sensation with this pedicle is actually better than with other pedicles.
1 year postoperatively

2 years postoperatively

4 years postoperatively

TWENTY-FIVE CONSECU TIVE BREAST REDU CTIONS
Robert Goldwyn requently admonished plastic surgeons or only presenting
their best cases and not presenting reality. H e repeatedly asked or a series o
15 consecutive cases. I decided to accept his challenge. I sent him my list o
400 vertical breast reductions, and asked him to choose a beginning date. H e
chose July 1, 1998. I compiled the data on 25 patients a ter spending consid-
erable time ying to Vancouver and Ontario to get adequate ollow-up photo-
graphs. I presented these cases at the American Society o Plastic Surgeons meet-
ing in San Antonio in November 2002. I have been able to ollow several o
these patients or longer times, but it is di f cult to get some patients to return.
I started per orming vertical breast reductions in 1993 using a superior pedi-
cle. I had some trouble insetting the pedicle and switched to a lateral pedicle.
It was di f cult to resect the excess lateral breast tissue, because that tissue ormed
the base o the pedicle. I was surprised by how good the sensation could be
with the medial pedicle; there was no question that I could achieve better shape.
I did not per orm liposuction on all these patients, because some o them chose
not to pay or the extra procedure.
I am sorry that I never submitted this or publication and that Robert Goldwyn
is no longer alive to f nally see it in print. I would like to dedicate this work to
his memory.
348
Part II • Technique

349
Chapter 6 • Vertical Breast Reduction
Patient Pro le
Date
July 15, 1998
Age
40
Weight
Preoperative
68 kg (150 pounds)
Postoperative
66 kg (145 pounds)
Height
5 feet 3 inches
Bras s iere
36 DD
Es timated blood los s
300 ml
OR time
90 min
Pedicle—right
Medial
Pedicle—left
Medial
Removed—right
475 g
Removed—left
400 g
Lipos uction
No
Pos toperative Follow-up
Length of follow-up
16 months
Sens ation
Right—preoperative
Excellent
Right—postoperative Good/excellent
Left—preoperative
Excellent
Left—postoperative
Good/excellent
Vertical s car
Right

9 cm
Left

9 cm
Complications
No
Revis ions
No
Comment
Good result with
slight pucker on right
Case 1

350
Part II • Technique
Patient Pro le
Date
July 15, 1998
Age
39
Weight
Preoperative
66 kg (145 pounds)
Postoperative
64 kg (141 pounds)
Height
5 feet 2 inches
Bras s iere
34 DD
Es timated blood los s
500 ml
OR time
120 min
Pedicle—right
Medial
Pedicle—left
Medial
Removed—right
600 g
Removed—left
725 g
Lipos uction
No
Pos toperative Follow-up
Length of follow-up
17 months
Sens ation
Right—preoperative
Excellent
Right—postoperative
Fair
Left—preoperative
Excellent
Left—postoperative
Fair
Vertical s car
Right

9 cm
Left

10 cm
Complications
No
Revis ions
No
Comments
Good result
Case 2

351
Chapter 6 • Vertical Breast Reduction
Patient Pro le
Date
July 21, 1998
Age
34
Weight
Preoperative

75 kg (165 pounds)
Postoperative

80 kg (176 pounds)
Height
5 feet 6 inches
Bras s iere
36 DD
Es timated blood los s
300 ml
OR time
120 min
Pedicle—right
Superior
Pedicle—left
Superior
Removed—right
400 g
Removed—left
340 g
Lipos uction
No
Case 3
Pos toperative Follow-up
Length of follow-up
29 months
Sens ation
Right—preoperative
Poor
Right—postoperative Poor
Left—preoperative

Poor
Left—postoperative
Poor
Vertical s car
Right

10 cm
Left

10 cm
Complications
No
Revis ions
Liposuction right
inferior breast at
same time as general
trunk liposuction
Comments
Good result—some
asymmetry in nipple
position; right still a
bit larger

352
Part II • Technique
Patient Pro le
Date
July 22, 1998
Age
45
Weight
Preoperative

70 kg (154 pounds)
Postoperative

80 kg (176 pounds)
Height
5 feet 4 inches
Bras s iere
Unknown
Es timated blood los s
400 ml
OR time
110 min
Pedicle—right
Medial
Pedicle—left
Medial
Removed—right
235 g
Removed—left
315 g
Lipos uction
No
Pos toperative Follow-up
Length of follow-up
17 months
Sens ation
Right—preoperative
Fair
Right—postoperative
Excellent
Left—preoperative
Fair
Left—postoperative
Excellent
Vertical s car
Right

8 cm
Left

7 cm
Complications
No
Revis ions
Liposuction
Comments
Good result initially,
but weight gain has
added lateral fullness
Case 4

353
Chapter 6 • Vertical Breast Reduction
Patient Pro le
Date
July 22, 1998
Age
34
Weight
Preoperative

70 kg (154 pounds)
Postoperative

81 kg (178 pounds)
Height
5 feet 4 inches
Bras s iere
38 D
Es timated blood los s
300 ml
OR time
120 min
Pedicle—right
Medial
Pedicle—left
Medial
Removed—right
170 g
Removed—left
240 g
Lipos uction
Yes
Pos toperative Follow-up
Length of follow-up
23 months
Sens ation
Right—preoperative
Good
Right—postoperative Good
Left—preoperative

Good/excellent
Left—postoperative
Fair
Vertical s car
Right

8 cm
Left

7 cm
Complications
No
Revis ions
No
Comments
Scars a bit wide
Case 5

354
Part II • Technique
Patient Pro le
Date
Aug 11, 1998
Age
51
Weight
Preoperative

81 kg (178 pounds)
Postoperative

81 kg (178 pounds)
Height
5 feet 5 inches
Bras s iere
40 DD
Es timated blood los s
200 ml
OR time
105 min
Pedicle—right
Medial
Pedicle—left
Medial
Removed—right
550 g
Removed—left
510 g
Lipos uction
No
Pos toperative Follow-up
Length of follow-up
15 months
Sens ation
Right—preoperative
Good
Right—postoperative
Fair
Left—preoperative

Very good
Left—postoperative
Fair
Vertical s car
Right

11 cm
Left

12 cm
Complications
Fat necrosis right;
settled spontaneously
Revis ions
No
Comments
Good result
Case 6

355
Chapter 6 • Vertical Breast Reduction
Patient Pro le
Date
Aug 11, 1998
Age
51
Weight
Preoperative

81 kg (178 pounds)
Postoperative

81 kg (178 pounds)
Height
5 feet 5 inches
Bras s iere
40 DD
Es timated blood los s
200 ml
OR time
105 min
Pedicle—right
Medial
Pedicle—left
Medial
Removed—right
550 g
Removed—left
510 g
Lipos uction
No
Pos toperative Follow-up
Length of follow-up
15 months
Sens ation
Right—preoperative
Good
Right—postoperative
Fair
Left—preoperative

Very good
Left—postoperative
Fair
Vertical s car
Right

11 cm
Left

12 cm
Complications
Fat necrosis right;
settled spontaneously
Revis ions
No
Comments
Good result
Case 7

356
Part II • Technique
Patient Pro le
Date
Aug 19, 1998
Age
44
Weight
Preoperative

73 kg (161 pounds)
Postoperative

77 kg (169 pounds)
Height
5 feet 5 inches
Bras s iere
38 DD
Es timated blood los s
300 ml
OR time
105 min
Pedicle—right
Medial
Pedicle—left
Medial
Removed—right
450 g
Removed—left
380 g
Lipos uction
Yes
Pos toperative Follow-up
Length of follow-up
25 months
Sens ation
Right—preoperative
Good
Right—postoperative Poor
Left—preoperative

Good
Left—postoperative
Poor
Vertical s car
Right

10 cm
Left

10 cm
Complications
No
Revis ions
Revision of puckers
on both breasts
2 years post-
operatively
Comments
Good result except for
lateral fullness
Case 8

357
Chapter 6 • Vertical Breast Reduction
Patient Pro le
Date
Aug 26, 1998
Age
17
Weight
Preoperative
64 kg (141 pounds)
Postoperative
66 kg (145 pounds)
Height
5 feet 5 inches
Bras s iere
34 DD
Es timated blood los s
200 ml
OR time
95 min
Pedicle—right
Medial
Pedicle—left
Medial
Removed—right
420 g
Removed—left
435 g
Lipos uction
No
Pos toperative Follow-up
Length of follow-up
20 months
Sens ation
Right—preoperative
Good
Right—postoperative
Fair
Left—preoperative

Good
Left—postoperative
Fair
Vertical s car
Right

9 cm
Left

9 cm
Complications
No
Revis ions
No
Comments
Left still larger
Case 9

358
Part II • Technique
Patient Pro le
Date
Aug 26, 1998
Age
40
Weight
Preoperative

57 kg (125 pounds)
Postoperative
65 kg (143 pounds)
Height
5 feet 6 inches
Bras s iere
34 D
Es timated blood los s
200 ml
OR time
70 min
Pedicle—right
Medial
Pedicle—left
Medial
Removed—right
170 g
Removed—left
200 g
Lipos uction
No
Pos toperative Follow-up
Length of follow-up
30 months
Sens ation
Right—preoperative
Good
Right—postoperative
Fair
Left—preoperative

Good
Left—postoperative
Fair
Vertical s car
Right

7 cm
Left

7 cm
Complications
No
Revis ions
Minor scar revision
Comments
Good result
Case 10

359
Chapter 6 • Vertical Breast Reduction
Patient Pro le
Date
Aug 26, 1998
Age
49
Weight
Preoperative
69 kg (152 pounds)
Postoperative

75 kg (165 pounds)
Height
5 feet 7 inches
Bras s iere
40 DD
Es timated blood los s
400 cc
OR time
105 min
Pedicle—right
Medial
Pedicle—left
Medial
Removed—right
510 g
Removed—left
540 g
Lipos uction
Yes
Pos toperative Follow-up
Length of follow-up
16 months
Sens ation
Right—preoperative
Fair
Right—postoperative
Fair
Left—preoperative
Fair
Left—postoperative
Fair
Vertical s car
Right

9 cm
Left

9 cm
Complications
No
Revis ions
No
Comments
Asymmetry—left too
large
Case 11

360
Part II • Technique
Patient Pro le
Date
Sept 1, 1998
Age
65
Weight
Preoperative
60 kg (132 pounds)
Postoperative

70 kg (154 pounds)
Height
5 feet 2 inches
Bras s iere
36 D
Es timated blood los s
200 ml
OR time
115 min
Pedicle—right
Medial
Pedicle—left
Medial
Removed—right
300 g
Removed—left
290 g
Lipos uction
Yes
Pos toperative Follow-up
Length of follow-up
20 months
Sens ation
Right—preoperative
Excellent
Right—postoperative Very good
Left—preoperative
Excellent
Left—postoperative
Very good
Vertical s car
Right
6 cm
Left
6 cm
Complications
No
Revis ions
No
Comments
Good result
Case 12

361
Chapter 6 • Vertical Breast Reduction
Patient Pro le
Date
Sept 2, 1998
Age
35
Weight
Preoperative

70 kg (154 pounds)
Postoperative

70 kg (154 pounds)
Height
5 feet 3 inches
Bras s iere
36 DD
Es timated blood los s
400 ml
OR time
105 min
Pedicle—right
Medial
Pedicle—left
Medial
Removed—right
340 g
Removed—left
380 g
Lipos uction
No
Pos toperative Follow-up
Length of follow-up
16 months
Sens ation
Right—preoperative
Poor
Right—postoperative Good
Left—preoperative

Poor
Left—postoperative
Good
Vertical s car
Right

9 cm
Left

8 cm
Complications
No
Revis ions
No
Comments
Good result
Case 13

362
Part II • Technique
Patient Pro le
Date
Sept 2, 1998
Age
42
Weight
Preoperative

57 kg (125 pounds)
Postoperative

59 kg (130 pounds)
Height
5 feet 6 inches
Bras s iere
34 D
Es timated blood los s
200 ml
OR time
90 min
Pedicle—right
Medial
Pedicle—left
Medial
Removed—right
370 g
Removed—left
340 g
Lipos uction
No
Pos toperative Follow-up
Length of follow-up
14 months
Sens ation
Right—preoperative
Poor
Right—postoperative
Excellent
Left—preoperative

Poor
Left—postoperative
Excellent
Vertical s car
Right

8 cm
Left

8 cm
Complications
No
Revis ions
No
Comments
Good result
Case 14

363
Chapter 6 • Vertical Breast Reduction
Patient Pro le
Date
Sept 2, 1998
Age
29
Weight
Preoperative

82 kg (180 pounds)
Postoperative

73 kg (161 pounds)
Height
5 feet 3 inches
Bras s iere
38 G
Es timated blood los s
200 ml
OR time
120 min
Pedicle—right
Medial
Pedicle—left
Medial
Removed—right
1110 g
Removed—left
800 g
Lipos uction
No
Pos toperative Follow-up
Length of follow-up
14 months
Sens ation
Right—preoperative
Excellent
Right—postoperative Poor
Left—preoperative
Excellent
Left—postoperative
Poor
Vertical s car
Right

12 cm
Left

12 cm
Complications
No
Revis ions
No
Comments
Left still too large;
nipple asymmetry
Case 15

364
Part II • Technique
Patient Pro le
Date
Sept 9, 1998
Age
34
Weight
Preoperative
66 kg (145 pounds)
Postoperative
66 kg (145 pounds)
Height
5 feet 5 inches
Bras s iere
36 D
Es timated blood los s
200 ml
OR time
95 min
Pedicle—right
Medial
Pedicle—left
Medial
Removed—right
420 g
Removed—left
450 g
Lipos uction
Preaxillary
Pos toperative Follow-up
Length of follow-up
29 months
Sens ation
Right—preoperative
Good
Right—postoperative
Fair
Left—preoperative

Good
Left—postoperative
Fair
Vertical s car
Right

7 cm
Left

7 cm
Complications
No
Revis ions
111⁄2 years
postoperatively
Comments
Asymmetry and wide
scars corrected with
revision
Case 16

365
Chapter 6 • Vertical Breast Reduction
Pos toperative Follow-up
Length of follow-up
15 months
Sens ation
Right—preoperative
Good
Right—postoperative
Fair
Left—preoperative

Good
Left—postoperative
Good
Vertical s car
Right

10 cm
Left

8 cm
Complications
Mild right areolar
dehiscence
Revis ions
No
Comments
Right still too large
Case 17
Patient Pro le
Date
Sept 9, 1998
Age
23
Weight
Preoperative
64 kg (141 pounds)
Postoperative
60 kg (132 pounds)
Height
5 feet 8 inches
Bras s iere
36 D
Es timated blood los s
300 ml
OR time
100 min
Pedicle—right
Medial
Pedicle—left
Medial
Removed—right
425 g
Removed—left
400 g
Lipos uction
Preaxillary

366
Part II • Technique
Patient Pro le
Date
Sept 10, 1998
Age
35
Weight
Preoperative

70 kg (154 pounds)
Postoperative
68 kg (150 pounds)
Height
5 feet 8 inches
Bras s iere
36 DD
Es timated blood los s
500 ml
OR time
160 min
Pedicle—right
Medial
Pedicle—left
Medial
Removed—right
370 g
Removed—left
450 g
Lipos uction
Preaxillary
Pos toperative Follow-up
Length of follow-up
15 months
Sens ation
Right—preoperative
Excellent
Right—postoperative
Fair
Left—preoperative
Excellent
Left—postoperative
Fair
Vertical s car
Right

11 cm
Left

10 cm
Complications
No
Revis ions
No
Comments
Good result
Case 18

367
Chapter 6 • Vertical Breast Reduction
Patient Pro le
Date
Sept 16, 1998
Age
32
Weight
Preoperative

84 kg (185 pounds)
Postoperative

102 kg (224 pounds)
Height
5 feet 5 inches
Bras s iere
36 DD
Es timated blood los s
200 ml
OR time
95 min
Pedicle—right
Medial
Pedicle—left
Medial
Removed—right
475 g
Removed—left
490 g
Lipos uction
Preaxillary
Pos toperative Follow-up
Length of follow-up
15 months
Sens ation
Right—preoperative
Poor
Right—postoperative
Excellent
Left—preoperative

Poor
Left—postoperative
Excellent
Vertical s car
Right

10 cm
Left

10 cm
Complications
Infection right areola
Revis ions
No
Comments
Scar right areola,
too full laterally (but
excessive weight
gain)
Case 19

368
Part II • Technique
Patient Pro le
Date
Sept 16, 1998
Age
33
Weight
Preoperative
67 kg (147 pounds)
Postoperative
67 kg (147 pounds)
Height
5 feet 7 inches
Bras s iere
38 D
Es timated blood los s
200 ml
OR time
75 min
Pedicle—right
Medial
Pedicle—left
Medial
Removed—right
415 g
Removed—left
425 g
Lipos uction
No
Pos toperative Follow-up
Length of follow-up
15 months
Sens ation
Right—preoperative
Excellent
Right—postoperative
Fair
Left—preoperative
Excellent
Left—postoperative
Fair
Vertical s car
Right

9 cm
Left

9 cm
Complications
No
Revis ions
No
Comments
Good result
Case 20

369
Chapter 6 • Vertical Breast Reduction
Patient Pro le
Date
Sept 23, 1998
Age
60
Weight
Preoperative
63 kg (139 pounds)
Postoperative
62 kg (136 pounds)
Height
5 feet 5 inches
Bras s iere
38 D
Es timated blood los s
200 ml
OR time
120 min
Pedicle—right
Medial
Pedicle—left
Medial
Removed—right
385 g
Removed—left
355 g
Lipos uction
Yes
Pos toperative Follow-up
Length of follow-up
14 months
Sens ation
Right—preoperative
Good
Right—postoperative
Fair
Left—preoperative
Excellent
Left—postoperative
Fair
Vertical s car
Right

8 cm
Left

8 cm
Complications
No
Revis ions
No
Comments
Good result; a bit of
lateral fullness
Case 21

370
Part II • Technique
Patient Pro le
Date
Sept 30, 1998
Age
35
Weight
Preoperative
68 kg (150 pounds)
Postoperative
65 kg (143 pounds)
Height
5 feet 8 inches
Bras s iere
36 D
Es timated blood los s
300 ml
OR time
100 min
Pedicle—right
Lateral
Pedicle—left
Lateral
Removed—right
300 g
Removed—left
325 g
Lipos uction
No
Pos toperative Follow-up
Length of follow-up
20 months
Sens ation
Right—preoperative
Good
Right—postoperative Good
Left—preoperative

Good
Left—postoperative
Good
Vertical s car
Right

8 cm
Left

8 cm
Complications
No
Revis ions
No
Comments
Good result
Case 22

371
Chapter 6 • Vertical Breast Reduction
Patient Pro le
Date
Sept 30, 1998
Age
26
Weight
Preoperative

91 kg (200 pounds)
Postoperative

90 kg (198 pounds)
Height
5 feet 3 inches
Bras s iere
42 DDD
Es timated blood los s
300 ml
OR Time
105 min
Pedicle—right
Medial
Pedicle—left
Medial
Removed—right
980 g
Removed—left
1080 g
Lipos uction
No
Pos toperative Follow-up
Length of follow-up
31 months
Sens ation
Right—preoperative
Good
Right—postoperative
Excellent
Left—preoperative

Good
Left—postoperative
Excellent
Vertical s car
Right

14 cm
Left

14 cm
Complications
Slight dehiscence
right
Revis ions
No
Comments
Good result
Case 23

372
Part II • Technique
Patient Pro le
Date
Sept 30, 1998
Age
24
Weight
Preoperative

107 kg (235 pounds)
Postoperative

77 kg (169 pounds)
Height
5 feet 4 inches
Bras s iere
42 DD
Es timated blood los s
300 ml
OR time
85 min
Pedicle—right
Medial
Pedicle—left
Medial
Removed—right
995 g
Removed—left
970 g
Lipos uction
No
Pos toperative Follow-up
Length of follow-up
30 months
Sens ation
Right—preoperative
Fair
Right—postoperative Good
Left—preoperative
Fair
Left—postoperative
Good
Vertical s car
Right

14 cm
Left

15 cm
Complications
Slight dehiscence
right vertical
Revis ions
No
Comments
Good result; a bit full
laterally, especially
right
Case 24

373
Chapter 6 • Vertical Breast Reduction
Patient Pro le
Date
Oct 21, 1998
Age
21
Weight
Preoperative

77 kg (169 pounds)
Postoperative

84 kg (185 pounds)
Height
5 feet 9 inches
Bras s iere
36 DD
Es timated blood los s
200 ml
OR time
85 min
Pedicle—right
Medial
Pedicle—left
Medial
Removed—right
260 g
Removed—left
245 g
Lipos uction
No
Pos toperative Follow-up
Length of follow-up
25 months
Sens ation
Right—preoperative
Excellent
Right—postoperative
Fair
Left—preoperative
Excellent
Left—postoperative
Fair
Vertical s car
Right

8 cm
Left

8 cm
Complications
Dehiscence right
vertical
Revis ions
No
Comments
Good result
Case 25

374
Part II • Technique
REFLECTIONS
Breast reduction can be accomplished with multiple choices in pedicle design,
parenchymal resection approaches, and skin resection patterns. I prefer the in-
ferior wedge resection approach, which enables heavy inferior breast tissue to
be removed while leaving behind the (desired) superior breast tissue. This pro-
vides the best shape both initially and over the long term.
I prefer the medial or superomedial pedicle, because it has excellent blood sup-
ply, recovers excellent sensation, is easy to rotate into position, and it gives an el-
egant curve to the lower pole of the breast. I evaluate my result in relation to
the Wise pattern so that I leave a good parenchymal shape, with tissue beyond
the pattern removed directly and complemented by peripheral liposuction. It
is important to close both the pillars and the skin without tension and remove
all tissue beyond the Wise pattern.
I remove any excess skin that I think will not redrape properly, but much of the
excess skin is needed to drape around the new breast shape, which now has in-
creased projection. A long vertical scar is not a detriment to the procedure; it
is actually needed to accommodate the increased projection.
Complications occur with all surgery. The discussion in this chapter is com-
prehensive and provides detailed information on preventing and treating prob-
lems. A separate chapter is included on nipple necrosis, because it is one of the
more feared (and eventually inevitable) complications in breast surgery (see
Chapter 11).

375
Chapter 6 • Vertical Breast Reduction
Concepts to Recall
• The breast ootprint varies rom patient to patient and rom side to side.
• The upper breast border is the most important landmark or determin-
ing the new nipple position.
• There are three separate components to breast reduction:
– Pedicle design and creation
– Parenchymal resection
– Skin resection pattern
• The medial or superomedial pedicle is the best choice to combine both
blood supply and shape.
• The Wise pattern is help ul or visualizing what should be le t behind.
• Good results can be obtained by leaving parenchyma behind in the up-
per pole and removing excess in the dependent lower pole.
• The breast base is narrowed and breast projection is improved.
• Upper pole ullness—or lack thereo —remains the same postoperatively as
it was preoperatively.
• The key to preventing complications is to avoid tension on both the pil-
lar closure and the skin closure.
• Wound-healing problems are o ten a low-grade in ection.
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