Improving Safety and Aesthetic Results inInverted T Scar Breast ReductionDavid A. Hidalgo, M.D.Nm York, N.Y.

Breast reduction using an inverted T scar skin designand a variety of glandular pedicle qpes is widely practicedand is the standard by which more recent limited scartechniques are judged. The inverted T procedures areattractive because they are predictable and versatile andpermit great control over both the extent ofreduction andthe breast-shaping process. Despite these advantages,common criticisms of inverted T scar technicues includebreast shape abnormalities, areolar malposilion, hyper-trophic scars, and poor long-term projection.

Preoperative markings influence both safety and aes-thetics. A method of skin marking that is based on adisplacement method to determine vertical limb splayangle is described. This design concept must be modifiedto address certain variants, such as macromastia present-ingwith normal nipple position or large-diameter areolae,moderately severe macromastia, and macromastia involv-ing radiated breasts.

Safety in breast reduction is improved by paying atten-tion to patient positioning issues, using techniques thatminimize blood loss, raising flaps of appropriate thicknessin the correct plane, and performing resection by observ-ing the principles that reduce the risk of compromise ofnipple and areolar circulation. Aesthetic results are im-proved by analyzing vertical breast meridian lengths dur-ing final breast shaping, modifying areolar shape as nec-essary, and carefully tailoring the medial inframammarycrease. The latter is also important for minimizing thepotential for scar hypertrophy.

The principles presented have been refined during thecourse ofa 12-year experience with several hundred breastreduction procedures. They contribute to improved re-sults in inverted T scar breast reduction when practicedconsistently. (Plast. Rzconstr. Surg. 103: 874, 1999.)

Breast reduction has been performed tradi-tionally by using various methods that result inan inverted T scar pattern. Pedicle types in-clude superior, inferior, central, lateral, andbipedicle.l-7 Criticisms of these procedures in-clude long-term loss of projection with devel-opment of lower pole fullness, problems result-

From the Division of Plastic Sugery, Comell University Medical College.Presented at the Slmposium on Breast Surgery and Body Contouring

874

ing from hlpertrophic inframammary creasescars, and an excessive scar burden in general.However, inverted T scar melhods hive thegreatest versatility in terms of applicability toall types and degrees of macromastia, forwhichthey yield consistent and predictable results.Inverted T scar methods remain the standardagainst which newer methods must be judged.

The appeal of conventional T scar ap-proaches is that they allow for total control ofskin envelope shape; precision in glandularresection because of wide exposure of thegland (inferior and central pedicle methods);and complete control of areolar position, di-ameter, and shape (when using a closed skindesign). Tissue loss is rare with proper opera-tive design, and the method is the easiesr tomaster. However, flawed design concepts andlack of attention to detail result, at best, in anaverage result and, at worst, in either majortissue loss or a severely compromised aestheticresult. These patients often present as candi-dates for secondary surgery (Fig. 1).

The purpose of this article is to elucidate thekey concepts important for both safety andachieving optimal aesthetic results in breastreduction. Complete mastery of inverted T scarmethods is a prerequisite for successfullyadopting more intuitive, limited scar methodsof breast reduction and understanding the bestindications for them. A conventional invertedT scar approach with an inferior or centralpedicle will be used to illustrate importantpoints because it is probably the most widelyused technique at present. However, all of theskin design concepts and most of the otherprinciples discussed are applicable to superior

Received for publicationJanuary 23, 1998; revised November 20, 1998.in the 90s, in Santa Fe, New Mexico, Aueust 13, 1997.

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Frc. 1. Poor aesthetic results usually result frorn poor preoperative design. (lal) This resultis characterized by a skin envelope that is too large, poor areolar shape and areolar malposition,and poor tailoring of the medial inframammary crease incision. (Rlglzt) This result was most likelypredetermined by a skin envelope that'was designed too tight. Glandular over-resection was thennecessary because of a skin shortage. There is evidence that part of the design problem stems

from a nipple position that was planned too high.

and superomedial pedicle procedures. Theselatter alternatives are attractive because theycan be performed more efficiently and mayretain better long-term projection.s-13

N[A.rERrA,Ls AND METHoDS

The concepts presented and discussed inthis article are based on a lz-year experiencewith 251 reductions Derformed for both aes-thetic and reconstruitive purposes. The vastmajority of the reductions were inferior or cen-tral pedicle types, although superior pedicleand vertical scar mammaplasty were more com-monly used in the last year of the study period.A poor experience with the circumareolar ap-proach described by Benelli resulted in aban-donment of that particular technique. Freenipple graft breast reductions \\,-ere performedin only three patients.

Inuefied T Scar Skin Design

Inverted T skin design is usually drawn as a"closed" pattern, which means that the loca-tion and size of the areolar opening are deter-mined after the breasts are reduced and theincisions are approximated. A closed design is

875

possible because there is usually both sufficientptosis and a normal areolar diameter, so thevertical limbs can be drawn as desired, withoutthe prospect of intersecting the areolar skinedge. An "open" design is required when thenipple position is high or the areolar diameteris overly large. Macromastia variants that re-quire an open design will be discussed sepa-rately.

An inverted T skin pattern of the closed qpecan be designed reliably on the breast by afree-hand method based on breast displace-ment to accurately determine the splay angleof the vertical limbs. Previous descriptions thatrely on mechanical aids or rigid geometricanalysis are not as accurate.3'14-16 The first stepis to mark the middle breast meridian on theinframammary crease and then mark the posi-tion of the nipple in line with this and at thesame level as the inframammary crease.s'7'16 Incertain situations (described later), the newnipple position may be 1 cm above to 2 cmbelow the inframammary crease level, depend-ing on the relative amounts of skin and glan-dular volume that exist. Previous descriptionsthat advocate using arbitrary nipple-to-clavicle

876

measurements or other fixed points (such asthe midhumerus) to derermine the nipple 1o-cation are not reliable and may result in mal-position of the nipple and areola.l,i'17

Step two is to grasp the skin of the lowerbreast and displace the gland laterally enoughto simulate the desired shape of the medialhalf of the breast (Fig. 2). A ieference point isthen marked near the bottom of the breast thatlies on a line determined by the nipple markand the middle meridian mark. The breast isthen released and, beginning at the nipple, astraight line is drawn, 7 cn in length, thatpasses through the displacement-determinedreference point.

Step three is to draw a second vertical limbby displacing the breast medially enough tosimulate the desired lateral breast shape. Thesame steps just described for marking the me-dial vertical limb are then followed. The dis-

pLASTIC AND RECoNSTRUCTT\T, suRGERy, March 1999

placement method accurately determines theproper splay angle of the vertical limbs that willresult in the correct amount of skin resectionin the vertical dimension. In most cases, theendpoints of the vertical limbs are 10 to 11 cmapart when measured with the patient stand-irg.

The final step is to draw the horizontal limbsmedially and laterally. The upper limbs shouldbe drawn with a gentle upward culve in mostcases to equalize the lengths of the verticalbreast meridians. This is not done because ofconcerns that the upper limbs and the infra-mammary crease incision length need to "addup," a previously described concept that is ob-solete and not relevant.13,15 A slight curve willhelp avoid a boxy final shape. In very largebreasts, this principle is less important, and theupper limbs are drawn more as a straight line.The leneth of the limbs should not extend as

Frc. 2. Skin markings for the breast displacement method. (Aboue, left) -the breast is displaced laterally enough to simulateideal medial breast shape. A mark is made along a line connecting the new nipple position (top d.ot) u'ith the midbreast meridianpoint on the inframammary crease (lower dot) . The breast is released, and a 7-cm line is drawn along the line determined by thenew nipple position mark and the displacement-determined mark. (Aboue, right) The breast is then displaced medially br thedesired amount, and a mark is made for the second vertical limb. The breast is then released, and a second 7-cm line ls aiawn.(Below, left) The completed vertical limb design is shown. (Belout, right) Note that the horizontal limb desien does not extendas far as the end of the inframammarlr crease and lies above it at its endoornt.

Vot. 103, l{o. 3 / IMPRo\.ING IN\T,RTED T sc"cn BREAST

far medially and laterally as it is possible todraw them because the inframammary creaseendpoints cannot be accurately located preop-eratively. Final tailoring of excess skin at theend of the procedure with the patient in thesitting position finalizes the skin incision de-sign with the greatest degree of precision. It is

also important to raise the endpoint of thehorizontal limbs above the inframammarycrease medially and laterally.o Other^wise, thefinal scar could diverge downward from theline of the inframammary crease.

The amount of skin resected in the horizon-tal dimension is related in part to the height ofthe nipple mark. A nipple mark that is posi-tionedabove the inframammary crease will re-move more skin in the horizontal dimensionthan a nipple position that lies below the infra-mammary crease. A useful way to confirm thecorrect amount of horizontal skin excision is toexamine the breasts after marking with thepatient in the supine position' The horizontalii-b lines should lie inferior to the equator ofthe breast, as the breast is vertically centeredon the chest wall (Fig. 3). If the horizontallimbs are above the equator, they should belowered by adding approximately 1 cm to theend of the vertical limb and drawing new lines.It may be necessary to lower the previouslydetermined nipple position in cases in whichgreater horizontal limb correction is necessary.

Frc. 3. Note that the horizontal limbs of the skin design

in this patient correctly lie below the equator ofthe breast as

it is defined with the breast centered on the chest wali withthe patient in the supine position. When the horizontal limbs1ie above the equator, the amount of skin excised will be morethan 50 percent of the verticai circumference of the breast.

This is excessive and, if not adjusted, will dictate glandularover-resection to accommodate a tight skin envelope (lvithpossible development of hypertrophic scars, too). The skin

design must be revised by lou,-ering the horizontal limbs (and

possibly the new nipple position as well)

REDUCTT9N 877

Desi.gn Variants

Macromastia with large-diameter areolae. Somepatients present with large-diameter areolaeand insufficient ptosis to allow a conventionalclosed-pattern T-incision design. The T-incisionskin design in these cases is altered by planningan intra-areolar excision of excess skin in con-junctionwith the usual displacementmethod todetermine the vertical limb splay angle (Fig. ).A circumareolar incision and an interior areo-lar incision whose diameter is determined by atemplate (usually 42 or,less commonly, 38 mm)are marked. The vertical limbs are made 5 cmin length, given the open areolar design'

If there is some ptosis present, the circum-areolar incision must extend higher than theexisting areolar skin edge, from approximatelythe 10 o'clock to the 2 o'clock position, so thatpartial closure of the areolar opening with a

dermal pursestring suture will both decrease itscircumference and raise the opening slightiy'Otherwise, nipple position may be too low.Pursestring closure of the large areolar op-en-

ing does not guarantee a perfectly round cir-cle. After tightening it down to the desireddiameter, it is almost always helpful to trimportions of the circumference to restore anevenly round shape.

Macromastia with normal nipple position. Oc-casionally, macromastia may be present withoutany breast ptosis. Although this may representan excellent indication for a vertical scarmethod, conventional T-incision design is verycompatible with this situation' An open designis required, because existing areolar locationprecludes use of the usual closed design, whereihe areolar location is determined after incisionclosure. The markings skirt the top of the ex-isting areola to avoid raising the nipple posi-tion. The opening is drawn wider than the ex-isting areola, as if the round opening werehinged in the 12 o'clock position. The areolaropening will become a circle once the verticallimbs are approximated.

The splay angle of the vertical limbs is deter-mined by the same breast displacementmethod described previously. However, likethe large-areola variant described above, thevertical limbs are made 5, not 7, cm in lengthbecause an open areolar design is used.

A circumareolar pursestring suture is some-times useful in these cases. The final areolaropening may be "out of round" when the ver-tical limbs are approximated, simply because

878

FIc. 4. Large diameter areolae in breasts'rvith little or noptosis require a modification in skin marking design. Anintra-areolar excision is planned in these cases. Vertical limbsplay angle is determined by the breast displacement method,but 5-cm limb lengths are drawn. A pursestring surure isusually required to decrease the areolar diameter sufficientlyduring closure.

open areolar design is inherently less precise.Placement of a pursestring suture will improvethe shape of the opening in conjunction withminor skin trimming as required to form acircle.

Moderate\ seuere macromastia. Macromastiawith nipple-clavicular distances up to 40 cm andbreast volumes up to 2500 g per side can beperformed without using free nipple grafts.Breasts of this type have the same configurationin the supine position as more modest cases ofmacromastia, except that the overall scale isproportionately larger. This means that thesame approach to T-scar incision design andpedicled nipple transposition can be used withonly slight modification. The design parame-ters need to be relaxed somewhat to accomolishthis. The most important considerations are notto make the skin design too tight by using thestandard convention of 7-cm vertical limbs inthe initial skin design. Instead, increasing limblength to B (or even 9) cm prevents the need forexcessive glandular removal later to accommo-date an overly tight skin design.

Because the breast will be proportionatelylarger after reduction compared with an aver-age reduction case, the areolar diametershould be planned proportionately larger. This

PL{STIC AND RECONSTRUCTII'E SURGERY, MaTch ]999

will make the areola look more appropriate forthe final breast size. Equally important, it willmake nipple transposition on a longer pediclemore reliable because the blood supply to alarger diameter areola is, presumably, better.

_ The advantages of this method are that nip-

ple sensation may be preserved and the possi-bility of either incomplere free nipple grafttake or areolar depigmentation is avoided.lsThe disadvantages are that the procedure takessignificantly longer than the free nipple graftalternative, the pedicle must be folded on itselfto properly locate the areola, and the breastsoften have more residual volume comparedwith what is possible with a free nipple graftmethod. Relief of symptoms is reliably pro-vided with this variation on the standardmethod, however.

The free nipple graft method remains a use-ful one and is probably the procedure ofchoice when nipple-clavicular distances ap-proach 45 cn and breast volume exceeds3000 g.ts-zt

Radiated breasts. Occasionally, a patient withmacromastia and breast cancer previouslytreated by lumpectomy and radiation will seeka breast reduction.2? Lumpectomy scars locatedmore than 2 cm away from the areolar edge areusually compatible with a conventional T-inci-sion design for reduction. Like cases of mod-erately severe macromastia, it is important torelax the skin design parameters to ensuresafety. The design should not be planned astight as the usual breast displacement markingtechnique allows. The areolar diameter shouldbe planned slightlylarger to preserve maximumblood supply.

During dissection, the skin flaps should beraised thicker than normal and not elevated asextensively. Resection should be more conser-vative than in a comparable nonirradiatedCASC.

Cases in which the lumpectomy scar is peri-areolar in location are more problematic. Post-radiation scarring and fibrosis in close proxim-ity to the areola can adversely affect its bloodsupply when it is isolated on a pedicle. Partialareolar loss can occur, despite great care inplanning. Wound closure by secondary inten-tion is extremely protracted in these cases.

An alternative to the less-predictable situa-tion of postradiation reduction is to perform areduction at the time of lumpectomv. This isnot a widespread practice today, nor is it afoolproof concept. More extensive disease

Vol. 103, I,{o. 3 / rMpRo\4NG rN\,.ERTED T scen BREAST

found in the reduction specimen may require acomplete mastectomy, and there is the possi-bility of skin loss if the flaps are thinned andmore extensively undermined than usual.

Set-ult for Surgery

If breast volume is less than 2000 e per sideand the breasts are nol overly wide,'the pa-tient's hands can be positioned on her lapinstead of abducting the arms on armboards.This may decrease the possibility of neura-praxia injuries and increase the accuracy of thebreast shaping because there is no distortioncaused by arm position. After the glandularresection is complete and the incisions are par-tially closed, the remainder of the procedure(areolar positioning and breasr shaping) is per-formed with the patient in the sitting position.This will contribute to improved aesthetic re-sults, although there are also ventilatory bene-fits.zS It is best to pad the forehead and tape itto the table and later place the table in a flexedposition with the feer down before sitting thepatient up. Pneumatic calf compression bootsand a warming blanket are routinely used.

It is not necessary to transfuse patients whoundergo breast reduction if flap elevation andglandular excision are performed with a bovie.Use of this method usually requires high set-tings to be efficient. Either a smoke evacuatoror a no. 14 French anesthesia suction catheterslipped over the tip of the bovie and hooked towall suction is recommended to minimize ex-posure to noxious fumes. Injection of thebreast has been established as an alternativemethod for avoiding the need for transfu-sion.24-?6 FIowever. injection with solutionscontaining epinephrine may impair accuratebreast volume assessments and, possibly, in-crease the risk for postoperative hematoma.

Initial Dissection

The procedure is performed almost entirelyfrom one side of the table by rolling the tablefrom side to side to center each breast on thechest wall for skin flap elevation and glandularresection. After it has been confirmed that theskin design is not overly tight, the pedicle isdrawn for inferior pedicle reductions. It shouldnot be designed to lie closer than a radius of 2cm from the areolar edge. Although it is notnecessary to specify the width of the base of thepedicle by a specific measurement, it shouldrepresent roughly half of the total inframam-mary crease incision leneth.

REDUCTIoN 879

The areolar diameter is generally cut largerthan the diameter of the opening that will bemade in cases with a closed type of skin design.In most instances, a diameter of 42 mm is anappropriate initial template diameter for ei-ther an open or closed skin design. Largerinitial template diameters may be indicatedTorcases of more severe macromastia, as describedpreviouslv.-

The pedicle skin can be removed by eithercomplete excision or deepithelialization. Nei-ther method has been proven superior to theother by any criteria.zT It may be wise to leave asmall amount of deepithelialized skin at thebase of an inferior or central pedicle design tofacilitate healing in the event a small sloughshould develop at the confluence of the T scarincisions postoperatively. Others have recom-mended incorporating a dart of skin into theinframammary incision to reduce tension inthis area, but this is, for the most part, unnec-essary.z8,ze In superior pedicle designs, it ishelpful to leave a deepithelialized tab of tissueseveral centimeters inferior to the areola, pri-marily to avoid excessive flatness of the lowerbreast.

Skin Flap Ekuation

The skin is raised to expose the entire glandin inferior or central mound designs. Althoughtime-consuming, this facilitates and increasesthe precision of the glandular resection. Theflaps are best raised along the plane that liesbetween the breast tissue and the subcutane-ous fat. This plane can be well defined, al-though it is sometimes vague. In the youngpatient, it is generally more discernible. Elevat-ing the skin flap in the right plane will preservemaximum blood supply and also save time laterby avoiding the need to thin flaps to obtainmore resection volume.

The tips of the skin flaps are deliberatelymade thick (at least I cm) to ensure viability. Itis most efficient to first raise the flap mediallyand laterally, alternating skin hooks on the tipsof the flaps while another one is positioned atthe confluence of the vertical limbs.T Thehooks are then shifted ro the midpoint of eachvertical limb, and the central portion of theflap is raised (Fig. 5). The entiri extent of thegland is now exposed (Fig. 6).

It is important during skin flap elevation roavoid exposure of the pectoralis musclearound the base of the glandular pedicle. Thiswill preserwe blood supply ro the skin flap and

Ftc. 5. Skin flap elevation with inferior/central pedicledesign. Skin flaps can be efficiently and safely elevated byplacing skin hooks as shown. (A&oue) One side is elevated first

PLASTIC AND RI,(]ONSTRUCTI\,IE SURGERY, MaTch 1999

Ftc. 6. The entire gland is exposed after skin flap eleva-tion. This allorvs for ereat precision in slandular resection.

gland and protect sensation to the nipple.6It isalso best to preserye a soft-tissue connectionbetween the gland and skin in the upper innerquadrant of the breast. This will help avoidflattening in this area caused by over-resection.It also preserves blood flow to the gland fromthe large second intercostal space perforator,which is commonly present.

Skin flap elevation is far less problematicwith superior pedicle designs because far lessundermining is necessary. Usually, the tips ofthe flaps and a portion of the skin in the regionof the new nipple location still require eleva-tion (as described above).

Glandular Resection

Glandular resection with an inferior pedicletechnique consists of lateral, superior, and me-dial segments in descending order of amountsremoved. The operating table remains rolledto the opposite side, and resection of each areais performed with an assistant stabilizing thegland so that inward bevel of the pedicle isavoided as tissue is removed. As with skin flapelevation, resection does not extend deepenough to expose the pectoralis muscle in anyportion of the breast. Lateral resection must beadequate enough to eliminate breast fullnessin this area, a priority issue for most patients.Medial resection is generally minimal. A bridgeof tissue connecting the superomedial portionof the breast with the pedicle is often left in-tact. This will both contribute to a full shape in

( stipplerl, nrea) , alnd then the skin hook on that side is shiftedto the opposite flap tip. (Center) The opposite side is thenraised. and then both skin hooks are moved to the center ofthe vertical limbs. (Beloru) The central portion of the flap isthen raised over the gland.

\ "KW,V=W\'*9/

Vol. 103. l{o. 3 / rMpRo\.rNG TNvERTED T sc-A.n BREAST REDUCTToN

this area and presele the usually prominentinternal mammary branches from the secondintercostal space. Superior resection shouldnot encroach on the nipple or undercut thepedicle. Resection in superior pedicle designscan often be accomplished as a single excision,incorporating the lower pole of the breast witha lateral extension.

Manipulating the pedicle by folding it orsuturing it to the chest wall to enhance andmaintain projection has been advocated bysome.30,31 Flowever, this has not been conclu-sively shown to be of value as a general prac-tice.

Trial closure of the incisions is an empiricbut useful method to determine the endnointof glandular resection. The closure should notbe under great tension (under-resection), norshould the breast look flat, either superiorly ormedially (over-resection). Clandular volumeand skin design can be matched carefully sothat the breast shape is full within the down-sized skin envelope, but the fit is not so tight as

to result in a greater potential for hypertrophicscar formation.

Final Shaping and Closure

Temporary closure of the T incision is per-formed to assess the adeauacv of resection andto confirm volume s1,m-itry.'The incisions arethen reopened, hemostasis is confirmed, anddrains are placed, which will exit the lateralpart of the inframammary crease incision. Thevertical component of the T incision can thenbe definitively closed with interrupted dermalsutures, but the inframammary crease incisionis again temporarily closed with staples pend-ing final shaping of the skin envelope.

The patient is placed in the sitting position,and the areolar position is marked. The usual

Ftc. 7. (Left) Initial areolar closure often reveals oval orirregular shape. (rRlglzl) Closure r,vith a mnning suture facil-itates efficient revision ofshaoe. The suture is backed out andreplaced only along portions of the circumference wheresmall amounts of skin excision will contribute to imorovedshaoe.

Ftc. 8. Breast meridians. Analysis of the meridians thatdefine the vertical skin length in different sectors of the breastwill disclose lvhere excess tissue needs to be removed toestablish an ideal shape of the lower pole of the breast. A boxyshape requires that the meridians lateral to the nipple oneach side be shortened to create the preferred shape (illus-trated by th'e dotted line).

measurement is 4.5 cm above the inframam-mary crease, although it can be slightly more orless, depending on the overall breast propor-tions. The new areolar diameter should be in-dividualized and not always arbitrarily deter-mined by template measurements. It can bemore accurate to draw a circle than to usetemplates in some cases. The areolae are su-tured in two layers, and it is best to completethe closure with a continuous suture. This su-ture can be backed out over whichever portionof the circumference may prove to be dis-torted. Excess skin is trimmed as necessary tocreate an evenly round areolar shape. Thismaneuver does not take a great deal of time,and it contributes to an improved final result(Fig. 7).

Final shaping of the skin envelope isachieved by adjustments at the inframammarycrease, which bring into harmony all of thelongitudinal meridian lengths. The method ofskin marking previously described is relatively,but not absolutely, accurate, and adjustmentsare almost always required to achieve the bestpossible shape. It is often necessary to trim skinmedial and lateral to the middle breast merid-ian to avoid a boxy shape (Fig. B). It also oftenproves necessary to trim the inferior corners of

BB1

882

the underlying pedicle because a wide pediclemay also contribute to shape imperfections.

The lateral dog ears are usually minor anddo not require much skin excision. Axillaryfullness can be treated with liposuction. Accu-rate tailoring of the medial dog-ear is critical toestablish the best possible contour and to pre-

Frc;. g. An example of a moderatel,v large reduction is shown preoperativel,v (@) and 3 years

postoperarively (riCht). A total of 868 g r,as reinoved from the right breast and 886 g from the

ieft bieast. Particular attention to detail is impoltant r,hen contourine the medial portion oflarger breasts.

PLA.STIC AND RECONSTRUCTIVE SURGERY, MATCh 1999

vent hypertrophic scar formation in this area.The bigger the medial dog-ear (the more un-derdrar,vn the original medial markings), thesreater the opportunity for precise contouring.Ercess skin is first incised alons the inframam-mary crease, and then the upper flap is cut sothat there is absolutely no tension on the clo-

VoL 103. No. 3 / IMpRo\rING IN\T,RTED T scun BREAST REDUCTToN

Ftc. 10. An example of an average size reduction is shorvn preoperativelv (le.ft)and 7 yearpostoperatively (ri4hA. A total of 435 g n'as removed from the right breast and 456 g from theleft breast.

sure. It is almost always necessary to carefullydebulk the underlying parenchyma in this areato establish optimal contour. Slight longitudi-nal tension along the incision during sutureplacement often adds a small amount of addi-tional contour improvement and may also con-tribute to a decreased tendency for hypertro-

883

phic scar formation. Final skin closure isperformed using two layers of buried absorb-able sutures.

Patients are placed in a surgical bra at thecompletion of the procedure. Postoperativecare is minimal: drains are usually removed thenext day and areolar sutures after 5 days.

PLASTIC AND RECONSTRUCTNE SURGERY. MaTch ]999

Frc. 11. An example of a minimal reduction (mastopexy) is shown preoperatively (leffl and

18 months posroperatively (rilht). A total of 75 g r,vas remot'ed from the right breast and 142 g

from the left breast. The principles of skin design are the same for this tvpe of patient, except

rhat rhe degree of breast displacement (and therefbre the vertical limb splav angle) should be

less given that the planned volume reduction is minimal.

Rssur-rs

These techniques have been used in 251patients who were treated between 1986 and1998. Reduction volumes ranged from 47 to3465 g per breast, although the majority of

cases ranged from 300 to 600 g. Complicationshave been few and rarely required a return tothe operating room. The most common com-plication was minor dehiscence at the conflu-ence of the incisions. which invariably resolved

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within 1 month with conservative manage-ment. Other problems included partial areolarskin loss in two patients, complete areolar losson one side in a free nipple graft patient, under-reduction in five patients, over-reduction intwo patients, and hypertrophic scars in fourpatients. Breast sensibility, overall patient satis-faction, and other issues that were not thefocus of this study were not specifically re-viewed. Both aesthetic results and proceduresaf'ety continued to improve throughout theseries as the methods described became con-sistently employed. Representative examples ofresults are shown in Figures 9 through 11.

DrscussloN

Matching skin envelope design with the ex-tent of glandular resection is the most basicrequirement for success using inverted T scarmethods for breast reduction. Precise tailoringof the breast skin meridians at the inframam-mary crease is important beyond this to achieveoptimal shape and minimize the potential forscar hypertrophy. Nuances involved in areolarplacement and shaping further enhance thequality of the aesthetic results. There are alsonumerous small technical details that irrcrcasesaf'ety, improve efficiency, minimize blood loss,and contribute to improved results.

Limited scar techniques have become morepopular recently. The vertical scar techniquedescribed by Lassus3? and developed further byLejour3s is an appealing alternative. It has theoromise of a decreased scar burden and im-proved long-term projection. Experience todate suggests that it is a less versatile method,even in experienced hands. The nature of thescar-limiting skin design makes precision inmatching the skin envelope to the final breastvolume less precise and, therefore, a more in-tuitive process. Its use in large-volume reduc-tions is associated with incomplete control overthe skin envelope, which may require second-ary revisions for optimal results. Despite thesedrawbacks, this technique may prove to be uni-formly superior to inverted T scar methods insmall- to iverage-volume reductions (500 g orless per side) or for larger volume cases that donot have significant ptosis.

The periareolar method modified and advo-cated recently by Benelli3a and Felicio3s pro-duces the least amount of scar. Its chief indi-cation has been for mastopexy, although it hasbeen recommended for small-volume reduc-tions as well. It is not intended to be used for

REDUCTToN 885

large-volume reductions or cases of excessive(grade III) ptosis. Removal of excess skin by aperiareolar approach has two inherent limita-tions. First, it flattens the breast, despite elab-orate and invasive manipulation of the paren-chpna in an attempt to overcome this effect.Second, the tension on the periareolar scaroften results in poor scar quality and distortionof the areolar shape, widening of areolar diam-eter, and undesirable changes in areolar tex-ture. This latter problem is not remedied in aconsistent or predictable fashion by the place-ment of a pursestring suture, itself a foreignbody that has a small extrusion risk. Besidesselected mastopexy indications, this procedureis ideally suited to cases of tubular breast for-mation with hypertrophy. A periareolar resec-tion and pursestring closure have a beneficialeffect on the widened and herniated areolaecharacteristic of these cases. However, it hasnot achieved popularity as a general method ofbreast reduction.

Breast reduction using an inverted T scarmethod currently remains the best method forachieving optimal results for a wide variety ofmacromastia rypes. The methods described en-sure safety and accuracy in skin design andglandular resection. They minimize the poten-tial for poor scar location and quality andoptimize breast shape and areolar aesthetics.Increased experience with limited scar tech-niques may supplant inverted T scar methodsfor some $pes of reductions, but the latter arelikely to remain popular because of their pre-dictability and versatility.

Dauid A. Hidalgo, M.D.655 Parh AueruueI,{ew York, I{.Y. 10021

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