We appreciate the interest Dr. Monarca and colleagues have shown in our article describing the fate of nipple-areola complex position and inferior pole length after vertical scar reduction mammaplasty.1 They should be commended for their effort and dedication in following their patients for 4 years to collect the useful information reported in their letter. Dr. Monarca and colleagues found that 4 years after using their breast reduction technique combining a vertical scar and round block technique with an inferior dermal flap, the nipple-areola complex was located on average 0.6 cm higher. They also found that the average distance from the inframammary crease to the inferior border of the nipple-areola complex had decreased 0.2 cm. Their findings corroborate those reported in our study, namely, that the nipple-areola complex was located significantly higher and the distance from the inframammary crease to the inferior border of the nipple-areola complex was significantly shorter at long-term follow-up.1
Several techniques for breast reduction have been described that use dermal flaps2 or a “dermal bra,”3 including a technique using a dermal suspension flap in vertical scar reduction mammaplasty4; all report good aesthetic results. Although it may be possible for a dermal flap to help control immediate breast shape, limit vertical scar length, and prevent inferior pole “herniation and flattening” during breast reduction as reported by Dr. Monarca and colleagues, our experience has shown that these maneuvers are not a necessary step in achieving excellent long-term results in vertical scar breast reduction. We have clearly demonstrated maintenance of inferior pole shape with simple suturing of medial and lateral pillars, a technique that greatly simplifies the procedure when compared with dermal suspension methods. We believe that it is the inferior wedge resection and subsequent suturing of the medial and lateral pillars that result in coning of the breast and are responsible for the long-term shape.1 In particular, the parenchymal pillar sutures through the superficial fascial system are critical for providing support for the remaining breast tissue, and likely help to prevent pseudoptosis. In addition, vertical scar techniques do not violate the structural integrity of the inframammary crease, thus preventing downward migration of the inframammary crease and subsequent pseudoptosis, a problem commonly seen with breast reduction techniques that involve a horizontal scar.
In our 20-year experience of more than 2000 patients, we have found that our technique5 using a superior or medial pedicle to transpose the nipple-areola complex, allowing for the critical inferior wedge resection and subsequent suturing of the medial and lateral pillars, results in a narrower, more projecting breast, superomedial breast fullness, minimal scar burden, and long-lasting breast shape, which are the sine quibus non of aesthetic breast surgery.
Jamil Ahmad, M.D.
Department of Plastic Surgery
University of Texas Southwestern Medical Center
Frank Lista, M.D.
The Plastic Surgery Clinic and Division of Plastic Surgery
Trillium Health Centre
Mississauga, Ontario, Canada
1. Ahmad J, Lista F. Vertical scar reduction mammaplasty: The fate of nipple-areola complex position and inferior pole length. Plast Reconstr Surg.
2. de la Plaza R, de la Cruz L, Moreno C, Soto L. The crossed dermal flaps technique for breast reduction. Aesthetic Plast Surg.
3. Qiao Q, Sun J, Liu C, Liu Z, Zhao R. Reduction mammaplasty and correction of ptosis: Dermal bra technique. Plast Reconstr Surg.
4. Exner K, Scheufler O. Dermal suspension flap in vertical-scar reduction mammaplasty. Plast Reconstr Surg.
2002;109:2289–2298; discussion 2299–2300.
5. Lista F, Ahmad J. Vertical scar reduction mammaplasty: A 15-year experience including a review of 250 consecutive cases. Plast Reconstr Surg.
2006;117:2152–2165; discussion 2166–2169.
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