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EDITORIAL: BREAST: EDITORIALS

Scar Wars: Optimizing Outcomes with Reduction Mammaplasty

Nahabedian, Maurice Y. M.D.

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Plastic and Reconstructive Surgery: December 2005 - Volume 116 - Issue 7 - p 2026-2029
doi: 10.1097/01.prs.0000191197.21528.26
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Over the past 10 years, there has been significant debate and controversy generated over the various incisional techniques for reduction mammaplasty. The focus of these discussions has been to review the advantages and disadvantages of the Wise pattern versus the short-scar techniques. I am confident that it has been the intent of these discussions to educate the plastic surgeons about all of the available techniques to provide women with an optimal method of reduction mammaplasty. However, I am surprised by the dogma associated with these discussions because it does not seem to be in accord with the interests of the specialty but rather with the interests of the individual. This observation is based on my reading of published literature and attendance at national symposia. It is not my intention to criticize the proponents of short-scar or Wise pattern reduction mammaplasty, because I perform both of them and I feel that each is an excellent approach in certain situations. It is my intention, however, to examine all sides of this ongoing debate regarding incisions for reduction mammaplasty.

Perhaps it is a sign of the times, but it has been my observation that the introduction of a novelty is often predicated on severe criticism of its predecessor. This is true in any political situation and it also holds true in plastic surgery. Although change is usually perceived as positive, it does not necessarily imply that the prior method was inherently bad and needed to be fixed. With the repopularization of the short scar and, more specifically, the vertical mammaplasty, this is no exception. Although the inverted “T” incision has been used for 50 years, it is my sense that the current educational bias in breast surgery is that this incision pattern is beneath current standards. This is based on material that is being presented at national symposia in which the majority of the faculty are advocating vertical mammaplasty and condemning inverted “T” mammaplasty. Proponents of the vertical incision techniques will frequently begin a presentation with a worst-case scenario of a woman following an inverted “T” reduction mammaplasty in which the scars are hypertrophic, pigmented, or highly visible and the breast is abnormal in contour. Are these presentations intended to convey the notion that this scenario is common, not preventable, and that women who have inverted “T” incisions are all unhappy? This is then followed by numerous best-case scenarios illustrating the vertical scar reduction mammaplasty technique in which the scar demonstrates perfect healing and the breast has a contour that is claimed to be ideal. Are these presentations intended to convey the notion that this outcome is realistic for all women, 100 percent reproducible, and to impress upon the audience that if they are not doing this then they are doing a disservice to their patients? I am wholeheartedly in favor of advancing the art and science of plastic surgery to provide our patients with the highest quality of care. However, there are some who find it offensive when a procedure is touted as the “gold standard” and that it should be used for everyone when, in fact, it is merely an alternative form of reduction mammaplasty that is indicated for some patients and not for others.

Today, it is well known that there are numerous methods by which a reduction mammaplasty can be performed. These include the many pedicle designs that incorporate the inverted “T” pattern (inferior pedicle, McKissock, etc.), and the various types of short-scar methods (Lejour, SPAIR, etc). All of these methods have the potential for an excellent outcome based on appropriate patient selection and surgeon experience. However, over the past several years, the primary debate has been whether the resulting scar should be a vertical or inverted “T.” Having attended many symposia and having listened to numerous presentations on this topic at national and international meetings, I am still perplexed as to why the schools of thought are so rigid. It seems intuitive that the selected incisional pattern for reduction mammaplasty should be based on individual differences in breast volume and contour to deliver a predictable and successful outcome. It is concerning to many at our national and international symposia when a plastic surgeon approaches the podium and begins his or her presentation by stating that the inverted “T” or Wise pattern reduction mammaplasty is an outdated procedure and that they would never perform it again. This is a very nearsighted statement that I am certain does not reflect the position of the American Society of Plastic Surgeons. Dogmatic statements like this should not be tolerated because they are nothing more than conjecture on the part of the presenting individual. Rarely is there any scientific or aesthetic basis for these statements, because most would agree that there is no single technique of reduction mammaplasty that can or should be used for every breast.

These debates, or what I refer to as “scar wars,” are not new. Before the introduction of the Wise pattern in 1956, there was concern over the appearance and unpredictability of many of the limited incision techniques.1 The scar patterns before Wise were vertical, horizontal, and combined to varying degrees. After the introduction of the inverted “T,” many plastic surgeons in the United States converted to this technique; however, many European plastic surgeons continued to refine the short scar techniques due to patient demand. Most Western European and South American women favor these limited incisions because they are interested in a “cosmetic reduction mammaplasty,” whereas many women in the United States have moderate to severe mammary hypertrophy and are interested in a “functional reduction mammaplasty.” Many plastic surgeons in the Untied States will attest that their patients are more concerned about relieving the burden of supporting heavy breasts and less concerned about the horizontal scar. Interestingly, in most women, the horizontal incision following inverted “T” reduction mammaplasty is not visible on anterior view unless the breast is elevated.

The era of the modern vertical mammaplasty began in the mid 1960s and was introduced in France by Claude Lassus and later popularized by Madeleine Lejour in the late 1980s.2,3 However, most of the short-scar or vertical mammaplasty techniques in use today are essentially variations on previously described limited incision methods. Review of the literature reveals that limited incision reduction mammaplasty had its origins more than 100 years ago. Robert Goldwyn, in his textbook Plastic and Reconstructive Surgery of the Breast, thoroughly reviews this history.4 Reduction mammaplasty through an inframammary incision was described by Morestin,5 Guinard,6 and Passot7 in 1905, 1907, and 1921, respectively. Mammaplasty through a vertical incision with a short horizontal component was described by Lexer8 in 1923 and without a horizontal component by Lotsch9 and Dartigues10 in 1923 and 1925, respectively. At the 82nd Annual Meeting of the American Association of Plastic Surgeons in 2003, Dr. John McCraw delivered an outstanding presentation on reduction mammaplasty at the turn of the 20th century.11 It was interesting to note that 80 years ago most of the incisions and reduction techniques were through short scars that included vertical-only and horizontal-only incisions.

In his original manuscript from 1956, Robert Wise stated that one of the principal reasons for the inverted “T” pattern was to overcome some of the shortcomings in the shaping of the breast that were encountered with some of the other methods.1,12 Unfortunately, it is difficult, if not impossible, to appreciate the aesthetic outcomes following many of the short scar techniques because photography was not commonly used at that time. The inverted “T” incision allowed for three-dimensional control of the breast and improved the predictability of the final outcome. The operation described by Wise has undergone numerous modifications over the years, but the basic inverted “T” pattern has been retained and adopted by many plastic surgeons around the world because it provides a predictable, reliable, and attractive outcome in the vast majority of cases.

Like many practicing plastic surgeons, I have performed short- and long-scar techniques and have had outcomes that range from fair to excellent. Although the majority of women do well following these operations, are pleased with the outcome, and have few complications, a few women will have less-than-desirable outcomes. Complications following reduction mammaplasties using either an inverted “T” or vertical incision include delayed healing, hypertrophic or complex scar formation, loss of nipple sensation, poor breast contour, and nipple necrosis.13–15

There have been two studies that have compared long-term outcomes following these approaches. In a study of 208 women following reduction mammaplasty (105 inverted “T” and 103 vertical), the revision rate was 11 percent following the vertical pattern and zero following the inverted “T.”14 Using a visual analog scale, there was no difference in shape, symmetry, nipple sensation, symptom relief, or overall satisfaction between the two techniques. However, the appearance of the scar was ranked significantly better following the vertical technique (p < 0.05). In another study comparing surgeon versus patient assessment of outcomes following the inferior pedicle and the vertical technique, it was demonstrated that breast shape was considered good to excellent by 72 percent of women and 33 percent of physicians, nipple position was considered to be about right by 84 percent of women and by 55 percent of surgeons, and overall symmetry was found to be good to excellent by 82 percent of women and 39 percent of surgeons.15 This study demonstrates that women are generally pleased with the outcome regardless of the incisional pattern and despite what the surgeon feels.

Given the differences in the approach to reduction mammaplasty among plastic surgeons, a proposed instructional method would be to review all available techniques and to instruct surgeons on selecting the most appropriate technique based on individual characteristics of the breast. This may mean that for women with severe mammary hypertrophy (greater than 1200 grams), a Wise pattern rather than vertical pattern may be more appropriate. For women with moderate hypertrophy (600 to 1200 grams), a horizontal (Passot), vertical (Lejour, SPAIR), or inverted “T” technique may be appropriate. And for some women with mild hypertrophy (less than 600 grams), a vertical or inverted “T” technique may be appropriate.

Conclusions

I am of the opinion that these controversies are beneficial to our specialty because they force us to constantly think about what we are doing and how we can change or expand upon our techniques to improve outcomes. I am frequently reminded of two quotes from Stanley Klatsky, who continues to be one of my mentors in plastic surgery. “It’s not the tool, but the hand that controls the tool that determines the outcome,” and “When the only tool in one’s possession is a hammer, everything looks like a nail.” The point of these is that there is no substitute for good judgment and technical skill and that we should perform an operation that is best suited for an individual patient. To say that there is no longer an indication for an operation that has been performed successfully for 50 years is troublesome, because it establishes a platform for patient dissatisfaction and malpractice litigation that may be based solely on the presence or absence of a horizontal incision. Fortunately, the medical and legal standards are based on the common practice within a community and not solely upon what is opined at national symposia. The reality of the situation is that we all work in a highly competitive environment and all of us feel that to remain competitive we must adapt to the changes in our specialty; otherwise, our clinical volumes may decline. It is important, however, not to forget the basic principles and concepts in the planning of operations to obtain an outcome that is predictable, safe, individualized, and aesthetically appealing. This said, plastic surgeons should strive to provide their patients with the “best option” rather than “one option” for a procedure such as a reduction mammaplasty.

REFERENCES

1. Wise, R. J. A preliminary report on a method of planning the mammaplasty. Plast. Reconstr. Surg. 17: 367, 1956.
2. Lassus, C. A technique for breast reduction. Int. Surg. 53: 69, 1970.
3. Lejour, M., Abboud, M., Declety, A., and Kertesz, P. Reduction of mammaplasty scars: From a short inframammary to a vertical scar. Ann. Chir. Plast. Esthet. 35: 369, 1990.
4. Goldwyn, R. M. Plastic and Reconstructive Surgery of the Breast. Boston: Little, Brown, 1976.
5. Guinard, A. Chirurgien de l’Hotel-Dieu Chevalier de la Legion d’honneur. Discours, Provinces aux Obseques, June 21, 1911.
6. Morestin, H. Hypertrophie mammaire. Bull. Mem. Soc. Anat. Paris p. 682, 1905.
7. Passot, R. La chirurgie esthetique pure. Hopital (Paris) 11: 184, 1923.
8. Lexer, E. Zur Operation der mammahypertrophie und der Hangebrust. Dtsh. Med. Wochenschr. 51: 26, 1925.
9. Lotsch, F. Uber Hangebrustplastik. Zentralbl. Chir. 50: 1241, 1923.
10. Dartigues, L. Traitment chirurgical du prolapsus mammaire. Arch. Franco-Belg. Chir. 28: 313, 1925.
11. McCraw, J. B. In Proceedings from the American Association of Plastic Surgeons, Baltimore, Md., May 4–7, 2003.
12. Wise, R. J., Gannon, J. P., and Hill, J. R. Further experience with reduction mammaplasty. Plast. Reconstr. Surg. 32: 12, 1963.
13. Nahabedian, M. Y., and Mofid, M. M. Viability and sensation of the nipple-areolar complex after reduction mammaplasty. Ann. Plast. Surg. 49: 24, 2002.
14. Cruz-Korchin, N., and Korchin, L. Vertical versus Wise pattern breast reduction: Patient satisfaction, revision rates, and complications. Plast. Reconstr. Surg. 112: 1573, 2003.
15. Godwin, Y., Wood, S. H., and O’Neil, T. J. A comparison of the patient and surgeon opinion on the long-term aesthetic outcome of reduction mammaplasty. Br. J. Plast. Surg. 51: 444, 1998.
©2005American Society of Plastic Surgeons