PUBLICACIONES
EN REVISTAS CIENTIFICAS DE CIRUGIA ESTETICA Y
PLASTICA
CIRUGIA ESTETICA DE LA MAMA.
REDUCCION MAMARIA.
New Marking Designs for Vertical Scar Breast Reduction
According to the authors, a new marking design
for vertical scar breast reduction avoids the
tension at nipple level that may occur with the
use of a mosqueshaped marking (Lejour technique).
Furthermore, better symmetry may be achieved in
placement of the areola and nipple. (Aesthetic
Surg J 2004;24:171-175)
The vertical scar technique described by Lassus
and Lejour has been our technique of choice for
breast reduction. Lejour’s design involves
a “mosqueshaped” tissue resection
in the area of nipple-areola-comple (NAC) placement.
However, we have found that in some patients the
Lejour technique produces excessive tension, which
ultimately affects placement of the NAC.
The goal of our new design for breast reduction
is to achieve symmetrical breast shape without
excessive tension on the NAC.1-4
Markings
With the patient standing, mark the midline from
the sternal manubrium to the umbilicus. Next mark
the midclavicular line on each side through the
nipple and down to the inframammary fold. Then
mark the inframammary fold on each side and place
your index finger in the center of the fold to
mark its projection on the front of the breast
at the crossover on the midclavicular line. This
is the point where the nipple should be placed:
point A. If a limited amount of tissue resection
is planned, locate point A 2 or 3 cm lower (Figure
1).5,6,7 Next, with the palm of your hand on the
breast, displace the breast laterally and mark
the projection of the clavicular line on this
side. Then perform the same
maneuver, but medially, and remark the vertical
line to obtain 2 vertical lines, 1 on each side
of the NAC. Join these 2 lines, making a slightly
curved horizontal line that is parallel and 4
cm from the submammarian fold.
From point A, mark a circle with the center at
point A and a radius of 7 cm. For bigger breasts,
the radius may be 8 or 9 cm. Mark 2 points, B
and C, in this circle where the 2 lateral vertical
lines cross over. Then join points B, A, and C
to form an acute downward angle.
Surgical Technique
Mark the NAC with a 40-mm circle. Apply a tourniquet
at the base of the breast to prevent bleeding
and also to provide tension during deepithelialization.
After the area surrounding the NAC has been deepithelialized,
make a lateral 2-cm incision parallel to the skin
in the subcutaneous tissue on both sides of the
triangle limbs, A–B and A–C. Then
make 0.5-cm-deep incisions in the vertical part
of the design and on both sides, as well as in
the inferior horizontal line and through the subcutaneous
tissue. Undermine the mammary gland until the
inframammary sulcus is reached laterally and medially.
At this point, excellent hemostasis may be achieved
with the use of electrocautery. Next, perform
superior dissection on the pectoral fascia, starting
at the inframammary fold, to produce a tunnel
that extends upward to the second or third rib
in the central breast area. Avoid excessive lateral
dissection and leave the glandular tissue connected
to the pectoral fascia to form the pillars.
Then design the superior pedicle containing the
NAC with a 1-cm lateral margin and a 2-cm caudal
thickness. Trace this with a Lillys forceps and
make an oblique flap that progressively widens
towards the base. Mark the lateral pillars with
a height of 5 to 7 cm and cut until you reach
the pectoral fascia vertically and horizontally
to the lateral and medial breast margins. After
cutting the pillars, remove breast tissue between
them and the breast tissue below down to the inframammary
fold. (Figures 2 and 3). Perform careful hemostasis
after tissue removal is complete.8
Once redundant breast tissue has been resected,
place a 2-0 suture (Dexon Davis-Geck, Wayne, NJ)
from the vertex of the pedicle to the skin about
2 cm above point
A. This places the NAC in the correct position.
Once the NAC has been elevated, determine where
to anchor the superior pedicle (using 3-0 Ethilon
sutures) (Ethicon Inc., Somerville, NJ) on the
pectoral fascia at the height of the second or
third rib.9 After anchoring the central pedicle,
suture the lateral pillars together in the midline.
 Once
the breast mound has been formed, place one hook
in the superior part and another in the inferior
part of the cutaneous incision for skin closure.
Place a closed wound suction drain in the subglandular
position and bring it out at the midpoint of the
vertical incision. Then shorten this incision
with a subcutaneous 4-0 nylon suture beginning
distally 4 cm
from point A, extending to the end of the cutaneous
incision, and gather this until it is hidden within
the inframammary fold.
If there is excessive tension at the level of
the breast cone in the new location of the NAC,
it is possible to approximate the sutures without
tension just to support the skin.
After finishing the longitudinal suture on each
side, place a large silk suture in the sternal
manubrium and another in the medial line to the
xiphoid to serve as reference when checking symmetry
and NAC placement.
With the patient raised to a 45-degree angle,
use the areola marker to measure the exact point,
symmetrical on the two sides, at which to place
the NAC.
After resecting a circle of skin, inset the nipple
with reabsorbable 4-0 subcutaneous and interdermal
sutures (Figures 4 and 5). Then place a paper
dressing and a petroleum-jelly gauze on the incision
lines and maintain these for 1 week.
Results
This technique was used in 46 patients, ranging
in age from 18 to 45 years, undergoing breast
reduction. The resected tissue ranged in weight
from 250 to 1200g. No complications occurred.
This design achieves symmetrical, precise NAC
placement without undue tension. The quality of
the scar is generally good, and the initial bunching
disappears within a few weeks (Figures 6 and 7).
Conclusion
Once the breast has been reduced, there is sometimes
insufficient available skin, resulting in tension
in the periareolar suture area. With this new
marking design, the tension that sometimes results
with the use of the mosque-shaped marking described
in the Lejour technique is avoided at the level
of the NAC. The technique also is beneficial for
patients who have breast ptosis with flaccidity
or fibrocystic breasts; either condition may lead
to greater tension on the NAC.
Also, this technique may achieve better areola
and nipple symmetry because the area to be resected
may be more symmetrically placed with displacement
a few centimeters
up or down, medially or laterally, until correct
breast placement with good bilateral symmetry
is achieved.
References
1. Beer GM, Morgenthaler W, Spicher I, Meyer VE.
Modifications in vertical scar breast reduction.
Br J Plast Surg 2001;54:341-347.
2. Kandelerof V, Tumerdem B, Aydin H, Emekli U.
Modifications of vertical scar in vertical mammaplasty
technique. Aesthetic Plast Surg 2001;25:40-42.
3. Lassus C. Breast reduction: evolution of a
technique — a single vertical scar. Aesthetic
Plast Surg 1987;11:107-112.
4. Lejour M. Vertical mammaplasty. Plast Reconstr
Surg 1993;92:985- 986.
5. Menke H, Olbrisch RR, Bahr C. Standard technique
of breast reduction surgery with vertical scar.
Handchir Mikrochir Plast Chir 1999;31:134-136.
6. Riascos A. Vertical mammaplasty for breast
reduction. Aesthetic Plast Surg 999;23:213-217
7. Serra-Renom JM, Fondevila J. New marking design
for vertical scar breast reduction [abstract].
ASAPS 35th Anniversary Meeting 2002;1:81-83. (Las
Vegas, NV)
8. Restifo RJ. Early experience with SPAIR mammaplasty:
a useful alternative to vertical mammaplasty.
Ann Plast Surg 1999; 42:428-434.
9. Vogt PM, Muhlberger T, Torres A, Peter FW,
Steinau HU. Method for intraoperative positioning
of the nipple-areola complex in vertical scar
reduction mammaplasty. Plast Reconstr Surg 2000;105:2096-2099.
Reprint requests: José Maria Serra-Renom,
MD, Virgen de la Salud, 78 5°-E 08024, Clinica
Quirán, Barcelona, Spain 1090-820X/$30.00
Copyright © 2004 by The American Society
for Aesthetic Plastic Surgery, Inc.
doi:10.1016/j.asg.2003.12.
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