All vertical mammaplasties, including augmentation/mastopexies, reduced (elevated) the lower pole level on both sides (P < 0.008) (Table 6 and Fig. 7). The inverted-T procedure did not raise the lower pole significantly for augmentation/mastopexy but raised the lower pole level significantly for breast reduction and mastopexy (P ≤ 0.008).
The lower pole distance3 (the length along the lateral curve from the plane of maximum postoperative breast projection to the posterior breast margin), a measure of breast constriction, was reduced in both vertical and inverted-T breast reductions, but to a greater degree for inverted-T reductions (right, not significant; left, P < 0.017) (Table 6 and Fig. 4).
Vertical mastopexy, augmentation/mastopexy, and reduction significantly (P < 0.008) increased the breast parenchymal ratio (upper pole area/lower pole area). The inverted-T procedure increased the breast parenchymal ratio significantly on both sides for breast reduction (P < 0.008) and on the left side for mastopexy (P < 0.008), but on neither side for augmentation/mastopexy (Table 6).
The importance of evaluating the aesthetic result after reduction mammaplasty is well recognized.20 Remarkably, no existing publication compares the quality of the aesthetic result using defined, objective measurements in consecutive patients. This investigation was undertaken to remedy this deficiency.
The history of mastopexy and breast reduction is important because many old concepts continue to influence our thinking today. Aubert,21 in 1923, is credited as the first surgeon to transpose the nipple, bringing it out through a new buttonhole located higher on the breast. Nipple transposition has been a cornerstone of breast reduction and mastopexy surgery ever since. The inverted-T technique was introduced by Kraske22 and Lexer23 in the 1920s. This skin closure technique was also used by Biesenberger24 and was widely adopted.25–27 Aufricht26 removed breast tissue from the upper pole, transposed the nipple, and used an inverted-T skin closure, relying on the “skin brassiere” to provide form. Biesenberger24 and Maliniac25 believed that the parenchymal dissection was most important for shape, not the skin covering. Penn28 took Aufricht’s position that it was the skin envelope that mattered. The skin/parenchyma controversy continues to this day. Any surgeon performing a skin-only mastopexy relies on the skin envelope for shape. The inverted-T, inferior pedicle reduction, described by Ribeiro,29 Courtiss and Goldwyn,30 and Robbins14 in the 1970s, remains the most common breast reduction technique used in the United States, although the vertical technique is gaining popularity.31
Nipple/areola transposition is based on an assumption that the nipple position falls on the breast and needs to be elevated with respect to the breast tissue. In an inverted-T mammaplasty, the nipple is separated from the rest of the breast tissue and moved superiorly while the surrounding breast tissue is paradoxically displaced inferiorly.13 This maneuver causes nipple overelevation.12,13
Even today, no procedure has been shown to truly accomplish upward movement of the breast on the chest wall. The illusion of a breast lift can only be reliably achieved by resecting lower pole excess tissue and filling the upper pole with an implant.32–35
Measurements reveal that in 60% of mammaplasty candidates, the nipple falls with the breast, not on it, and when it does slide on the breast, the distance is typically under 6.5 cm.13 Using the vertical technique, the nipple is raised with the breast mound and requires minimal relocation. Notably, Dartigues’36 original description of a vertical resection did not include nipple transposition, an approach that may still be suitable in secondary mammaplasties. In these patients, the nipple position is rarely too low.32
The inferior pedicle dissection removes breast tissue from the superior, medial, and lateral portions of the breast and preserves breast tissue centrally and inferiorly. Parenchymal removal from the upper pole rather than the lower pole puzzled Maliniac,25 in 1950. This skin resection pattern makes use of a horizontal ellipse that reduces breast projection and constricts the lower pole,12 a geometric effect that is confirmed by measurements of lower pole distance (Table 6 and Fig. 4). This parenchymal resection removes the medial and lateral breast tissue that might otherwise be used to elevate the nipple and increase projection, the length dividend that results from side-to-side closure of a vertical ellipse.13,32 In an inverted-T mammaplasty, the breast skin is pulled down rather than pushed up.12 Limiting the vertical limb to 5 cm does not prevent nipple overelevation (Figs. 2 and 4).12 Not surprisingly, in view of the upper pole parenchymal resection, the upper pole contour is consistently flat or concave (Figs. 2 and 4).
A midline resection cannot interfere with medially and laterally based blood supply and sensation. Ideally, the nipple/areola would remain attached both medially and laterally and even superiorly,37 but such a wide attachment allows minimal mobility and was the shortcoming of the Strombeck procedure.38 Fortunately, unilateral pedicles, based either laterally or medially, are sufficient.39,40 The medial circulation is dominant in about 70% of women and lateral circulation in 20% of women. Ten percent of women have equal contributions.41,42
Hall-Findlay2 found that a medially based pedicle provided better breast shape, by preserving tissue in the upper, medial quadrant, where it is desirable. Because of its geometry, a vertical ellipse improves projection and creates a tighter, more semicircular lower pole than the inverted-T, inferior pedicle technique [Tables 5 and 6, Figs. 1–4, and Supplemental Figs. 1–4 (Supplemental Digital Content 1, http://links.lww.com/PRSGO/A21)]. These anatomic considerations support the use of a vertical mammaplasty and medially based pedicle.
The techniques are compared in Table 7. As might be expected from anatomic considerations, the inverted-T, inferior pedicle mammaplasty can compromise nipple/areola perfusion. Lista and Ahmad7 report a series of 1501 vertical reductions without a single case of nipple loss. This experience is instructive to any surgeon wishing to avoid a complication that is devastating for patients and surgeons alike. Nipple/areola loss after the vertical technique may be related to compression and thinning of the pedicle when a superior pedicle is used2; a medial pedicle is safer.
Courtiss and Goldwyn,43 in their well-known investigation of breast sensation, reported a 35% incidence of persistent nipple numbness 2 years after an inverted-T, inferior pedicle breast reduction. This rate may be compared with a 21.5% incidence of persistent numbness 2.5 years after a vertical reduction.44 Medial nipple innervation is important and should be preserved; superior pedicles, used in the Lejour technique, are more likely to compromise sensation by sacrificing the deep innervation and by partially excluding superficial medial innervation.45
It has been long recognized that the inverted-T technique produces flattening of the upper poles, boxiness of the lower poles, and a tendency to bottom-out.2,7,46 These clinical observations are confirmed by measurements in the present study.
The inverted-T, inferior pedicle technique produces a long inframammary scar, with levels of patient dissatisfaction in the range of 11–71%.47–51 Scar dissatisfaction after vertical mammaplasty is 4.7%.44 Patients consistently prefer the aesthetic result and scars of the vertical technique.50,52–54
Vertical mammaplasty requires a shorter operating time and less blood loss than the inverted-T, inferior pedicle technique.2,7 Blood transfusions are avoided.7 There is less surgeon fatigue and therefore more opportunity to safely perform other cosmetic surgeries at the same time.32
Limitations of the Study
The author first performed the vertical technique in 2002, so that patients in the prospective study group include his learning curve experience. Accordingly, the level of proficiency in the retrospective, inverted-T group is likely to be higher. Despite this advantage for the inverted-T group, the measurement data favor the vertical technique. The retrospective group included fewer patients because only 57.4% of the retrospective study patients met the 3-month follow-up criterion compared with 85.7% of the prospective study patients. Patients in the retrospective group were often discharged from follow-up after their 1 month postoperative photographs. Longer follow-up times are desirable, but come at the price of a reduced inclusion rate. Other studies have shown that postmammaplasty shape changes after 3 months are minimal,13,55 indicating that at 3 months swelling has resolved sufficiently for the purpose of measurements.
This study compares a prospective cohort with a historical control group. Two prospective contemporaneous cohorts are preferred. However, it would be unethical for the author to conduct such a study because of known advantages of the vertical technique. Long-term changes in breast shape are not assessed; such an analysis would be an appropriate subject for future study.
Strengths of the Study
This study benefits from consistencies that reduce confounding factors—the same surgeon, the same measurement system, and consecutive patients meeting the same inclusion criteria. Treating all patients in each group with the same technique (the author abandoned the inverted-T mammaplasty in 2002) removes selection bias that can weaken a comparison of cohorts if the surgeon prefers one technique more than the other for certain patients. For example, a common practice is to use the vertical technique for moderate degrees of hypertrophy and the inverted-T reduction for very large ones.56
Photographic measurements of relevant breast parameters favor the vertical technique over the inverted-T technique and are consistent with anatomical considerations and clinical experience.
The author thanks Jane Zagorski, PhD, for statistical analyses; Lindsey Kroenke, BSN, for data collection; and Gwendolyn Godfrey for illustrations.
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