Improving Safety and Aesthetic Results in Inverted T Scar Breast Reduction:

Using Laser-Assisted Indocyanine Green Angiography to Assess Nipple-Areolar Complex Survival During Reduction Mammoplasty

BACKGROUND

In reduction mammoplasty, preserving an appropriate skin flap is crucial to achieve a favorable postoperative appearance and prevent blood supply disorders in the nipple-areolar complex (NAC). Previous studies have indicated that a thinner or narrower flap is more favorable for breast shaping, but also increases the risk of blood supply disorders. Accessing the blood perfusion of the NAC and determining the critical threshold for NAC viability are essential aspects of reduction mammoplasty.

OBJECTIVES

The aim of this study was to utilize indocyanine green (ICG) angiography to assess NAC perfusion during reduction mammoplasty. It also sought to identify critical thresholds of various indicators affecting NAC survival and provide guidance for skin flap trimming.

METHODS

Thirty-eight patients who underwent reduction mammoplasty were included. Each patient received ICG angiography before and after skin flap trimming. Data on NAC perfusion, skin flap length, width, thickness, and other relevant indicators were collected.

RESULTS

Among the patients, 5 experienced NAC blood supply disorders. Multiple linear regression analysis demonstrated that the NAC blood supply had a significant correlation with the tissue thickness at the pedicle base (P < .001) and with the length-to-width ratio across the nipple (P < .05). To optimize NAC survival and achieve favorable breast shaping, cutoff points for the thickness at the pedicle base and the length-to-width ratio across the nipple of 1.15 cm and 1.71, respectively, were established.

CONCLUSIONS

ICG angiography provides an effective means to assess NAC blood supply and postoperative survival. The cutoff points established in this study help to predict the survival of the NAC and guide flap trimming.

LEVEL OF EVIDENCE: 3

Analysis of Incidentally Found Proliferative Lesions in Oncoplastic and Macromastia Breast Reductions

BACKGROUND

Reduction mammaplasty pathologic specimens can reveal incidentally found proliferative lesions. However, there is a lack of data investigating the comparative incidences and risk factors for such lesions.

METHODS

A retrospective review was conducted of all consecutively performed reduction mammaplasty cases at a single large academic medical institution in a metropolitan city by two plastic surgeons over a 2-year period. All reduction mammaplasties, symmetrizing reductions, and oncoplastic reductions performed were included. There were no exclusion criteria.

RESULTS

A total of 632 breasts were analyzed-502 reduction mammaplasties, 85 symmetrizing reductions, and 45 oncoplastic reductions-in 342 patients. Mean age was 43.9 ± 15.9 years, mean body mass index was 29.2 ± 5.7 kg/m 2 , and mean reduction weight was 610.0 ± 313.1 g. Patients who underwent reduction mammaplasty for benign macromastia had a significantly lower incidence (3.6%) of incidentally found breast cancers and proliferative lesions compared with patients with oncoplastic reductions (13.3%) and symmetrizing reductions (17.6%) ( P < 0.001). On univariate analysis, personal history of breast cancer ( P < 0.001), first-degree family history of breast cancer ( P = 0.008), age ( P < 0.001), and tobacco use ( P = 0.033) were all statistically significant risk factors. Using a backward elimination stepwise reduced multivariable logistic regression model for risk factors associated with breast cancer or proliferative lesions, age ( P < 0.001) was the only retained significant risk factor.

CONCLUSIONS

Proliferative lesions and carcinomas of the breast found in reduction mammaplasty pathologic specimens may be more common than previously reported. The incidence of newly found proliferative lesions was significantly lower in cases of benign macromastia compared with oncoplastic and symmetrizing reductions.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

Meme küçültme operasyonlarında çıkarılan doku miktarı ile semptomların değişmesi arasındaki ilişkinin araştırılması

Amaç: Meme küçültme operasyonları sıklıkla yapılan hem estetik hem de fonksiyonel sonuçları yüz güldürücü olan operasyonlardır. Çıkartılan doku miktarı ile semptomların iyileşmesi ile ilgili literatürde kısıtlı sayıda çalışma mevcuttur. Biz bu yazımızda meme küçültme operasyonu sırasında rezeke edilen doku miktarının semptomlara etkisini araştırdığımız çalışmamızı sunduk. Gereç ve Yöntem: Çalışmamız Ocak 2018-Nisan 2021 tarihleri arasında yapılmış retrospektif bir çalışmadır. Çalışmaya 57 hasta dahil edildi. Gruplar her iki memeden çıkarılan dokunun ağırlığına göre üç gruba ayrıldı. Grup 1: 1000 gram ve daha az doku, grup 2: 1000-2000 gram arası doku, grup 3: 2000 gram ve daha fazla dokunun çıkarıldığı grup. Hastaların yaşları, beden kitle indeksleri (BKİ), bilateral memeden çıkartılan toplam doku miktarları not edildi. Operasyon öncesi ve sonrası boyun ağrısı, sırt ağrısı, omuz ağrısı, meme bölgesindeki kızarıklık ve kaşıntı, sutyen izi ve hastaların günlük hayattaki hareket kısıtlılığı semptomları değerlendirilmiş ve karşılaştırılmıştır. BKİ ile çıkartılan doku miktarı arasındaki korelasyon değerlendirildi. Bulgular: Çıkartılan doku miktarı ve BKİ açısından gruplar arasında anlamlı bir fark varken, yaş arasından anlamlı bir fark saptanmadı. Operasyon öncesi ve sonrası değerlendirildiğinde, sırt ağrısı, omuz ağrısı grup 2 ve grup 3’te, boyun ağrısı, kızarıklık-kaşıntı grup 3’te, sutyen izi ve hareket kısıtlılığı ise üç grupta da anlamlı olarak değişmiştir. Grupların preoperatif ve postoperatif değerleri kendi arasında değerlendirildiğinde; Grup 3’te preoperatif omuz ağrısı, sutyen izi ve hareket kısıtlılığı skoru ve yine grup 3’te postoperatif sutyen izi skoru diğer gruplardan anlamlı olarak büyük saptanmıştır. Çıkartılan doku miktarı ve BKİ arasındaki korelasyon değerlendirildiğinde grup 3’te iki değer açısından anlamlı bir pozitif korelasyon saptandı. Sonuç: Meme küçültme operasyonu sonrası oluşan semptomatik iyileşme, farklı meme boyutlarına sahip kadınlar arasında önemli ölçüde farklı değildir.

Three-Flap Mastopexy with Reduction or Augmentation

BACKGROUND

Many authors have studied breast ptosis and made contributions to the search for a procedure that allows its correction with long-lasting results and minimal scars. Collective evolution has allowed us to reach the point where we are today and will allow us to continue improving techniques in the future.

OBJECTIVES

The mastopexy procedure that we have used for the last 11 years, resulting from our surgical practice and countless observations at conferences, is a versatile procedure, applicable to different types of breasts and mastopexies with and without reduction or augmentation.

METHODS

Analysis and the clinical review of the patients and the records of the mastopexy cases that we operated on using the technique from January 2009 to March, 2020, are presented here. Using a periareolar approach for grade I ptosis and an inverted "T" approach for more severe ptosis, the excess skin is removed, and three flaps of breast tissue, superior, medial and lateral, are carved. A retromammary dissection is performed to anchor the end of the flaps, medial and lateral, to the pectoral aponeurosis, followed by invagination of these flaps to concentrate the breast tissue in the upper and central area of the breast. Closure of the wound is then performed, transforming its excess length into a short horizontal one, into the inframammary grove.

RESULTS

Sixty-seven female patients, between 36 and 59 years old, underwent this procedure. Complications included hematoma (4%), overcorrection (4%), dehiscence (3.3%), residual ptosis (2.7%), pathological scarring (2.7%) and rotation folds (2%). Maximum follow-up was 8 years 2 months, mean follow-up 2 years 9 months, with satisfactory results for the patients and surgeon.

CONCLUSIONS

The mastopexy procedure that we present here is a versatile technique, which can be applied to most cases requiring correction of ptosis. It provides the breast with proper shape, size and location with fewer scars. It is a logical, safe, efficient, reproducible procedure, which is easy to learn.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Central pedicle reduction mammaplasty with a vertical scar: a technical modification

BACKGROUND

This study introduces a central pedicle reduction mammaplasty with a vertical scar technique.

OBJECTIVES

This study is aimed to create a more conical breast shape and long-lasting better projection by modifying reduction mammaplasty by central pedicle flap.

METHOD

Preoperative markings were made including the meridian line of breast and the new location of the nipple-areola complex (NAC). The new location of the inframammary fold was marked ∼2 ∼ 4 cm above the original inframammary fold. An incision was made around the areola, the area between the resection margins and NAC was excised en bloc. The breast parenchyma was excised circumferentially, so that a cone shaped central mound was formed. An inferior and inferolateral glandular resection was performed to reduce the area of the breast base by elevating the position of the inframammary fold. After completion of dissection, the central pedicle surmounted by the NAC was transposed to its new location.

RESULT

Fifty-six patients were operated with our modified central pedicle technique. The mean amount of resection was 475 g (range = 130-1080 g). The mean length of follow-up was 18 months (range = 12-53 months). The mean postoperative satisfaction score was 4.23 (SD = 0.81). The breast parenchymal ratio significantly increased from 1.2 preoperatively to 3.9 postoperatively.

CONCLUSION

The modified central pedicle reduction mammaplasty with a vertical scar technique is a versatile breast reduction technique for all shapes and tissue conditions, by providing an attractive conical shape of the breast with minimum scar burden and maximum preservation of breast function.

Breast Reduction

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Identify the anatomy of both the vascular supply and the innervation to the breast to design the appropriate pedicle in breast reduction. 2. Understand various approaches to breast reduction to be able to maximize both functional and aesthetic results. 3. Understand each step in the operative procedure to be able to provide consistent predictable results in breast reduction.

SUMMARY

The objective with breast reduction surgery is to reposition the nipple, remove excess parenchyma, and tailor the skin to fit the new shape. This is a CME article meant to provide an overview of principles while trying not to provide a single practitioner viewpoint. The article includes a brief history, a review of the anatomy, and patient selection. The preoperative markings and operative technique for both inverted-T and vertical approaches are detailed. Postoperative care and potential complications are included.

The inverted-T mammaplasty: a modified winch suture to reduce horizontal scar length

Mammaplasty performed with an inverted-T skin resection pattern is a useful technique to treat moderately or severely ptotic breasts. This method of skin resection is conducted via 3 incisional components: periareolar, vertical, and horizontal. In this report, the authors describe a simple modified winch suture that can be inserted with the inverted-T technique to reduce the length of the horizontal incision.

An innovative method for intraoperative shaping and positioning of the nipple-areola complex in reduction mammaplasty and mastopexy

Issues of hypertrophic circumareolar scars and malpositioning or irregularity of the nipple-areola complex (NAC) are frequently associated with breast reduction or mastopexy techniques that rely on an ample excision of skin around the areola, either alone or associated with a vertical incision. To avoid such problems, many efforts have been made to improve the accuracy of preoperative marking for the future NAC. However, the correct design and position of the NAC may be difficult to achieve for the patient at the end of the procedure after closure of the skin incisions. This article describes a novel, simple, and effective method for intraoperative shaping and positioning of the NAC. The described method is based on using a specially designed surgical instrument to determine the best position, diameter, shape, and configuration of a new NAC. This study aimed to demonstrate the efficacy of this method to reduce the common complications of the periareolar region in reduction mammaplasty and mastopexy.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors at www.springer.com/00266.

Choosing the superomedial pedicle for reduction mammaplasty in gigantomastia

BACKGROUND

The optimal reduction technique for the treatment of macromastia greater than 1 kg remains controversial. Conventionally, breast amputation and free nipple grafting has been used, but this leaves a flat and insensate nipple. Anatomical studies have suggested the superomedial technique to be a safe choice in these patients.

METHODS

A retrospective study analyzing the outcome of reduction mammaplasty for macromastia greater than 1 kg using the superomedial pedicle technique was performed. Data were collected over a 10-year period from 1995 to 2005. All reduction mammaplasty patients with resection weights greater than 1 kg per breast were included in the study.

RESULTS

Sixty-one patients were included (122 breasts). The mean age was 29 years. The mean suprasternal notch to nipple distance was 35 cm on the left and 35 cm on the right, and the mean nipple to inframammary crease distance was 19 cm on the left and 20 cm on the right. The Wise keyhole reduction pattern technique was used for all patients. Mean follow-up was 12 months. The mean resection weight per breast was 1360 g for the left breast and 1398 g for the right breast. Fifteen different surgeons performed the operations over this period. All patients had viable nipples postoperatively; there was partial areola necrosis in eight breasts (6.5 percent), with only minor other complications, including T-junction breakdown in 22 breasts (18 percent) and dog-ear excisions.

CONCLUSIONS

This study has confirmed the superomedial pedicle technique to be safe and reliable for resections greater than 1 kg.

Gigantomasty: treatment with a short vertical scar

BACKGROUND

During the past 15 years, reduction mammoplasty with a short vertical scar has become increasingly common in the world of plastic surgery. Still, the indication for this technique often is limited to smaller reduction weights, so that the inverted T-scar techniques have yet to be regarded as the gold standard for excessive breast hypertrophy.

METHODS

In the authors' department, their own modification of vertical scar reduction mammoplasty, based on the techniques of C. Lassus, G. Maillard, and M. Lejour, has been performed since 1990. During the past 10 years, the authors have used it for all breast sizes. To investigate the safety and the results for patients with very large breast volumes (gigantomasty involving at least > or =1,000 g of excised tissue per one side), this study retrospectively evaluated 25 women with a mean age of 43.1 +/- 11.2 years who underwent surgery from January 2002 to June 2003. A protocol was used to record patient satisfaction and complaints and to quantify the final result objectively.

RESULTS

The average resection weight for the 25 women was 1,227 +/- 300 g (maximum, 2,300 g) on the right side and 1,218 +/- 343 g (maximum, 2,100 g) on the left side. The sternal notch-to-nipple distance was reduced from 37.1 +/- 4 cm to 23.4 +/- 2.1 cm on the right side and from 37.4 +/- 3.5 cm to 24 +/- 2 cm on the left side. The brassiere size was reduced by about three cup sizes on the average. During an average follow-up period of 2 years (n = 15), patient satisfaction was high, with good acceptance of the breast shape and a low rate of major complications (12%).

CONCLUSION

The results suggest that the authors' modified vertical scar technique can be used successfully for all dimensions of reduction mammoplasty regardless of breast weight.

Reduction Mammaplasty: A Significant Improvement at Any Size

BACKGROUND

Reduction mammaplasty has been shown to be efficacious in reducing the burden of symptoms and improving the quality of life for patients with macromastia. However, most insurance carriers will not reimburse for mammaplasties involving less than 1000 g of total tissue resected. To refute this arbitrary policy, the authors set out to examine the effect of reduction mammaplasty in which less than 1000 g of breast tissue was resected on patients' macromastia-related symptoms and macromastia-related quality-of-life factors.

METHODS

All patients were given a custom-designed questionnaire designed to evaluate macromastia-related symptoms and other macromastia-related quality-of-life issues. Patients were then provided the same questionnaire at their final postoperative visit between 3 and 12 months after surgery.

RESULTS

A total of 59 patients underwent reduction mammaplasty of less than 1000 g. Reduction mammaplasty less than 1000 g resulted in significant decreases in all macromastia-related symptoms analyzed, including upper back pain, lower back pain, neck pain, arm pain, shoulder pain, hand pain, breast pain, headaches, rashes, and/or itching and painful bra strap grooving (all p < 0.00002). Furthermore, reduction mammaplasty resulted in significant improvement in all quality-of-life factors analyzed, including difficulty buying clothes and bras, difficulty participating in sports, and difficulty running (all p < 0.00001).

CONCLUSIONS

Reduction mammaplasty totaling less than 1000 g offers substantial relief of macromastia-associated symptoms and results in significant improvement in patients' quality of life. This prospective study conclusively demonstrates that reduction mammaplasty totaling less than 1000 g should be a fully reimbursable procedure.

The Vertical Reduction Mammaplasty: A Prospective Analysis of Patient Outcomes

BACKGROUND

In the United States, breast reductions based upon a Wise pattern incision remain common. However, dissatisfaction with this procedure, on the part of the patient and the surgeon alike because of unsightly scars and long-term "bottoming out" of the breast, has promoted the search for alternative methods of breast reduction. The purpose of this study was to analyze patient outcomes after vertical reduction mammaplasty utilizing prospectively collected data.

METHODS

All patients were given a custom-designed questionnaire designed to evaluate their macromastia-related symptoms and other macromastia-related quality-of-life issues. Patients were then provided the same questionnaire at their final postoperative visit between 3 and 6 months after surgery.

RESULTS

A total of 63 patients underwent vertical reduction mammaplasty and 40 patients underwent Wise pattern inferior pedicle reduction mammaplasty. Vertical reduction mammaplasty resulted in significant decreases in all macromastia-related symptoms analyzed, including upper back pain, lower back pain, neck pain, arm pain, shoulder pain, hand pain, breast pain, headaches, rashes and/or itching, and painful brassiere strap grooving (all, p < 0.00001). Furthermore, vertical reduction mammaplasty resulted in significant improvement in all quality-of-life factors analyzed, including difficulty buying clothes and brassieres, difficulty playing sports, and difficulty running (all, p < 0.00001). Minor complications (superficial infection, seroma, or delayed wound healing) occurred in 16 patients (25 percent) in the vertical reduction mammaplasty group. Minor office revisions (scar revision or excision) were performed in four patients (6 percent) in the vertical reduction mammaplasty group.

CONCLUSION

The authors' method of vertical reduction mammaplasty offers substantial relief of macromastia-associated symptoms with a low complication/revision rate.

Nipple migration in a pig using the technique of serial excision

Moving a misplaced nipple-areola complex (NAC) without causing additional scarring has proved to be difficult, especially if it is to be moved medially, laterally or inferiorly. This study investigated the possibility of migrating the NAC without leaving additional scarring by using the technique of serial excision. Two adult female pigs were used. Three pairs of pseudo-areolas of similar size were tattooed around a teat in each pig. Crescentic serial excisions of skin were undertaken at 2 weekly intervals on the upper and middle pairs of pseudo-areolas in each pig and the lower pairs were left as controls. The crescentic excision on the upper set of nipples consisted of skin only. The crescentic excision on the middle set of nipples consisted of 75% skin and 25% tattooed pseudo-areola. Results showed that nipple migration by serial excision is possible. However, each set of nipple pseudo-areola complex (NPAC) behaved differently. When skin only was excised, the NPAC's became distorted and enlarged but when skin and areola was excised, the NPAC maintained its dimensions. Taking our findings into account, an approach to moving a misplaced NAC using this technique in the clinical situation is described. Its use to move a misplaced NAC in two women is demonstrated.

Deskinning versus deepithelialization for inferior pedicle reduction mammoplasty: a prospective comparative analysis

BACKGROUND

Deepithelialization is time consuming, but has been performed traditionally in reduction mammaplasty to ensure a better blood supply to the transposed nipple-areolar complex.

METHODS

For this study, 18 patients were recruited, and each patient served as an individual control by undergoing both deskinning and deepithelialization of the contralateral breast. The patient's age, body mass index, specimen weight, complications, and subjective cosmetic assessment were recorded.

RESULTS

The mean age was 42 years, and the mean body mass index was 27.94 respectively. There were no differences recorded in terms of complications or patient perceived cosmetic outcomes. The only statistical difference involved the times required for deepithelialization (15.5 min) and deskinning (6 min). Deskinning thus saved approximately 9 min.

CONCLUSIONS

Deskinning is as effective as deepithelialization and is significantly more expedient, with no added risk to the patient.

Vertical Mammaplasty

Current criticisms regarding vertical mammaplasty include problems with poor immediate postoperative appearance, nipple-areola complex malposition, and excessive lower pole length. These problems can be avoided by proper patient selection, by utilizing correct concepts of skin design, and by observing correct glandular resection and closure concepts. Vertical mammaplasty also can result in other problems, such as hypertrophic circumareolar scars and lower pole deformities, including notching, boxy shape, infra-areolar depression, and flatness. These problems are also largely avoidable by using correct technique. Several basic concepts described previously have not proven necessary to achieve good results. Abandoning some of these principles has contributed to the ability to establish an aesthetically ideal breast shape intraoperatively as well as to a decrease in morbidity. This includes eliminating liposuction as a major integral component of the procedure, eliminating suturing the gland to the pectoralis muscle, not undermining the lower pole skin, and avoiding overly wide skin resection and tight wound closure that produces significant lower pole distortion in the early postoperative period. An important concept that has proven reliable is to use a "closed" design that does not predetermine the areolar opening whenever circumstances permit. When this is not possible, a modification that utilizes the smallest possible circumference as an open design is better than a large "mosque." These alternatives allow greater flexibility in determining final nipple position and also reduce the risk of hypertrophic circumareolar scars. Important glandular resection concepts include creating pillars that are attached to both the skin and the chest wall; making them of adequate dimension to avoid postoperative lower pole shape problems, such as flattening; resecting closer to the skin lateral to the pillars to avoid a boxy breast shape; and using a drain both to assist in accurately determining the endpoint of resection and to avoid postoperative seromas. Key closure concepts include approximation of the superior surfaces of the pillars at their base to maintain vertical height and thereby prevent lower pole flattening; approximation of the inferior surfaces of the pillars to the base of the breast to prevent notching; and proper management of the vertical incision by restricting the purse-string suture effect to only the inferior portion of the incision, where there may be skin excess present. Inclusion of these concepts leads to predictable and improved aesthetic results in vertical mammaplasty. This allows full realization of the purported advantages of vertical mammaplasty and allows this method to be utilized with a level of confidence similar to that seen with inverted-T techniques.

The crossed dermal flaps technique for breast reduction

BACKGROUND

More than100 techniques and variations of breast reduction have been published. In most, the principal differences involve the method of transpositioning the nipple-areola complex and the pattern of skin resection. Skin resection inevitably causes scarring, which has given rise to an ongoing debate over long scar techniques and short scar techniques. The debate would be mute if only the extent of the scar was evaluated: ideally, the shorter the better. However, this limitation of scar extension conditions other elements to be evaluated in the results. On the other hand, there is a great variety of clinical cases in which not only the volume must be considered, but also the degree of ptosis, the quality of the skin, the age, and, most importantly, the wishes of the patients.

OBJECTIVES

The objective of the crossed dermal flaps procedure was to obtain optimum volume, position, and shape of the breast; well-located good-quality scars as short as possible; and early satisfactory and long-lasting results.

METHODS

Between June 1986 and June 2003 136 women underwent this procedure, performed under controlled hypotension (median arterial blood pressure, 60 mmHg). The technique is based on Wise-type skin marking associated with glandular resection in the lower and lateral poles, and transpositioning of the nipple-areola complex with a superior medial dermoglandular pedicle. Two rectangular areas under each cutaneous vertex are delimited, which will correspond with the future dermal flaps. These flaps are crossed, then fixed to the musculoaponeurotic chest wall, and the rest of the wound is sutured by planes in a conventional manner.

RESULTS

Two patients (1.4%) experienced minimum cutaneous epidermolysis without dehiscence at the union of the vertical and horizontal sutures, which later healed by second intention without interference with the aesthetic result. Three cases (2%) showed partial and superficial necrosis of one of the areolae, but healed during the following 3 weeks without secondary surgery. In three patients (2%), hematomas developed, which were drained in the dressing room with no complications. One patient experienced thickening of the scar. No infections were observed.

CONCLUSIONS

The authors believe the cross dermal flaps technique is safe and applicable to an extensive variety of cases. It is easy to execute and to teach, and therefore, those who are beginning to use inverted T techniques such as that described, can, from the beginning, diminish the incidence of short- and long-term complications such as dehiscence that lead to scarring at the convergence of the flaps and bottoming out of the inferior pole, with the horizontal scar displaced upward and an increase in the distance between the later and the nipple areola complex.

Vertical versus Wise Pattern Breast Reduction: Patient Satisfaction, Revision Rates, and Complications

A prospective, randomized study was designed to compare the outcome of inferior pedicle/Wise pattern reduction (group I) with medial pedicle/vertical pattern reduction (group II) in moderate resections averaging 500 g per breast. There were 105 women in group I and 103 women in group II. All surgical procedures were performed by the same plastic surgeon. Patient information recorded included age, body mass index, type of surgery, weight of specimen, need for surgical revision, and complications. Six months postoperatively the patients were asked to complete a questionnaire, which rated their satisfaction with the surgical outcome. The questionnaire used a 10-point response format ranging from very disappointed (score of 1) to very pleased (score of 10). The results demonstrated that there was no significant difference between the groups in age (31 +/- 12 versus 29 +/- 13 years), body mass index (26 +/- 4 versus 27 +/- 5), and amount of tissue excised (553 +/- 203 g versus 548 +/- 205 g). Group I required no surgical revisions, but in group II revisions for dog-ears were required in 11 percent. The rate of other complications was similar in both groups. Patients' evaluations of breast size, shape, symmetry, nipple sensation, symptom relief, ease of brassiere/clothing fitting, and overall satisfaction were not significantly different. The vertical mammaplasty was ranked significantly (p < 0.05) higher by patients in regard to scars (6 +/- 2 versus 3 +/- 3) and overall aesthetic results (8 +/- 1 versus 6 +/- 3). In the management of moderate macromastia, this study indicates that patients who have a vertical reduction are less disappointed with the scars but require a significantly higher rate of surgical revisions compared with patients who have a Wise pattern reduction.

Breast augmentation and breast reduction

Breast enhancement through augmentation improves not only the woman's physical appearance but also contributes to her psychologic well-being. With the current emphasis placed on women's breasts in the media, it is not surprising that small-breasted women feel inadequate. Recent US Federal Drug Administration approval of saline implants has given them a new image, and more women are seeking breast augmentation. (27) As long as the woman understands that this operation has associated risks, a physician-patient relationship may be developed resulting in many years of happiness and increased self-esteem. The shape, contour, and size of a woman's breasts are permanently altered by augmentation mammaplasty and breast reduction. Although each case is unique, the outcome of each procedure should result in a satisfied patient.

Short-scar breast reduction: why all the fuss?

The breast can be considered conceptually as a cone. This article compares and contrasts short-scar breast reduction techniques with inverted T techniques using the cone model. Four issues are examined-the base of the breast, breast projection, the inframammary fold, and the pedicle. The short-scar techniques focus on reshaping the breast parenchyma, and skin redraping occurs secondarily. Application of this model suggests that these techniques have the advantage of better projection and greater longevity. These techniques seldom give a square shape and are better at dealing with upper pole deficiency. However, the ability of the skin to redrape is the limiting factor; hence, results are less predictable with large-volume breast reductions. The emphasis of this article is on increasing the understanding of the mechanics of breast reduction. It is this factor that will enable appropriate selection of a particular technique.