Breast reduction with vertical scar
One of the problems with the techniques of breast reduction is the placement of the nipples to ensure that they are symmetrical. The breast reduction protocol was set in motion by R J Wise, who designed a pattern for placing the nipple areola complex in the correct site. In large and ptotic breasts the nipple areola complex falls downwards and outwards, following the mid-clavicular line. The correct anatomical site is at the level of the fifth rib. The inframammary fold is located at the sixth rib and in profile, and the nipple-areola complex must be slightly higher than the fold.
If we use Wise’s pattern, after performing the reduction the breasts are in the correct position, but they present very large inverted T shape scars. The skin supports the weight of the entire gland and this causes the scars to hypertrophy, especially at the vertices of the T shape.
Dr. Lasso and Dr. Lejour described a breast reduction technique with a vertical scar, suturing the glandular tissue to the muscular plane; in this way, the skin does not have to support the glandular tissue. Then, the skin is sutured and a single vertical scar remains. To resolve the problem of the excess skin a puckering is performed; as it does not have to bear weight, it merely retracts and smoothens out. The problem with the Lejour technique is that the puckering may cause the nipples to be asymmetrical. With our technique, published in the Journal of the American Society of Aesthetic Surgery, we first perform the entire breast reduction. We then suture the breast to the muscle to keep it in place. Next, we suture the whole of the vertical scar and perform puckering. When the skin is closed and the entire breast is covered, we seat the patient and, using a compass, we mark the exact place where we will situate the two nipple-areola complexes. We then remove these two circles of skin and suture the nipple-areola complex. This ensures that they are at the same height and are symmetrical.
In very marked gigantomasties, we use an inverted "T" technique but make an autoprosthesis from the breast tissue from the inferior pedicle in order to fill the upper quadrants and give projection to the new breast. The pedicle is held in place by a band of the pectoralis major muscle.