(1) During breast reduction surgery, the nipple areola complex is relocated vertically, as shown. (2) The red lines represent incisions used in the vertical scar technique (left) and the inferior pedicle technique most often chosen for breast reduction su
Although breast reduction and breast lift surgery have been providing successful results for satisfied patients for more than half a century, it is only relatively recently that newer techniques are winning acceptance in the United States – techniques that offer a number of advantages over older methods, according to Ellis Tavin, MD, FACS, of the Plastic Surgery Group of Memphis.
Tavin has been performing 'short scar' breast reduction and breast lift surgery, also known as the vertical method, since 2000, but the surgery is still not commonly done in this country, he said.
Since 1955, standard breast surgery has employed the Wise Pattern, also known as the inverted T, or anchor scar technique. In 1987, vascularity to the nipple was improved with the description of the inferior glandular pedicle, allowing the nipple to routinely be left attached to underlying breast tissue. The blood supply to the nipple and areola complex was preserved by way of vessels passing through a central and inferiorly based attachment to the chest wall (an "inferior pedicle" or "central mound").
"There are downsides to this method, however," Tavin pointed out. "It leaves longer scars, and there is a tendency for the horizontal scar at the bottom of the breast to thicken, particularly along its medial aspect. The best-looking portion of the Wise pattern scar has always been the vertical component."
In contrast, the short-scar method, which utilizes only a vertically oriented closure, reduces the length of scars by at least half compared to the inverted T.
The vertical reduction or mastopexy method also provides a rounder shape to the breast, Tavin pointed out.
"When you do a reduction or lift in the vertical method, there is a narrowing of the breast width. Think of an ice cream cone; remove a pie-shaped wedge along the length of one side of the cone and bring the sides together, and the resulting cone shape is narrowed and elongated. In the short-scar methods, closure brings the medial and lateral pillars together in the lower pole of the breast where the wedge was removed, and causes the breast to become rounder and fuller in the upper pole. The short-scar method geometrically creates a perkier, more projecting breast."
The more commonly used inferior pedicle technique uses an anchor-shaped incision which encircles the nipple, then follows the natural curve of the breast downward, culminating in a horizontal incision along the bottom of the breast. After excess tissue, fat, and skin are removed, the nipple is relocated to a new position. Since excisions are performed at the medial, lateral, and cephalic aspects of the breast, this can potentially produce a less-desirable squared-off shape to the breast, Tavin notes.
An added advantage of the short-scar method is that it allows for longer persistence of the lifted effect of the altered breast. The vertical technique removes (in a reduction) or relocates (in a lift), the heavier tissue at the bottom of the breast while preserving and even supplementing tissue in the upper portion.
The standard Wise pattern inferior pedicle procedure may result in a breast that is more likely to "bottom out" over time. Tavin observed, "In an inferior pedicle technique, the heavier tissue at the bottom of the breast is held up by only the tighter skin envelope. The breast tissue may slip out from behind the nipple areola complex secondary to gravity and weakening of the inframammary fold fibers, leaving the nipples in an abnormally high position.
Does the short-scar method heal faster, because there is less scar to heal? Not necessarily, Tavin said, but patients do tend to experience fewer healing problems, he finds. "From ¼ to 1/3 of patients using the Wise method have a healing delay at the lower T junction of the incisions—the corners where the vertical and horizontal incisions meet. Since there is no such junction in the short-scar method, that potential healing delay is eliminated."
He recalled one of his vertical reduction patients who wore an underwire bra during the post-operative period. It created a problem by exerting pressure on the healing scar, so he advises against wearing underwire bras during this time. Otherwise, healing problems are rare during recovery from the short-scar method. Regardless of technique used, patients are back at work in one to two weeks following breast reduction or mastopexy surgery, he reports.
Tavin uses the short-scar method for nearly 100 percent of his lifts, and 70 percent of his reduction surgeries. Why not 100 percent of the reductions, as well?
"Some are just too big," he explained. "Gigantic breasts present a challenge; our ability to move the nipple up to the apex of the breast is limited by blood supply. There's a limit to how far the nipple can be moved without compromising the blood supply or innervation."
Although free nipple grafts can be done in very large reductions, Tavin has felt the need to perform only four such procedures in his 15 years of performing breast reduction surgeries. He finds the standard inferior pedicle method effective in most cases where the short-scar method is not practicable.
Although the short-scar method has been recently growing in popularity, it has taken a surprisingly long time to catch on, possibly because the technique was not developed in the United States. "Physicians tend to teach the methods they learned and have used successfully," Tavin claimed.
Vertical breast reduction and lift techniques were first introduced into the United States when Belgian plastic surgeon Madeleine Lejour published her book on the technique and began speaking at American plastic surgery meetings in the mid 1990's.
Others who pioneered the method were Claude Lassus in France who originally published his superior pedicle vertical technique in 1969, and Canadian Elizabeth Hall-Findlay, who developed her medial superior pedicle variation of the vertical technique in 1999.
Externally, all three vertical methods look the same; the patient can't tell the difference, according to Tavin. His decision on which method to use is made based on how far the nipple needs to be moved upward.
Is there a difference where surgeons are concerned? The inferior pedicle method is generally designed in advance, and the surgeon cuts along the pre-drawn lines, Tavin said. "The vertical techniques are a little more 'cut-as-you-go'; therefore, there is something of a learning curve if a surgeon makes the choice to switch techniques and adopt the short-scar method.
Additional information about the short scar techniques will be available on the Plastic Surgery Group's revised website within the next few months, at www.memphisplasticsurgery.com/surgeons.html.