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After 10 years of performing inverted T,inferior pedicle breast reductions, I can say that I was not particularly unhappy with the procedure. In my hands, the pedicle was very reliable and I had had only one instance (in approximately 400 cases) of a partial nipple necrosis that healed completely without intervention. There were, however, some patients who had developed very unsightly scars in the inframammary fold. Of the three scars (around the areola, vertically down to the fold, and along the fold itself), the vertical one was the least problematic. The areolar scar was variable, but the in-framammary scar could be quite thick. Although it could often be hidden, patients did complain.

The shape was usually quite acceptable with the inverted T, but the longer I have been in practice (20 years), the more patients I have been seeing who had developed some significant bottoming out, or pseudoptosis, with time. In retrospect, I realize that I had also accepted the persistence of the lateral and medial dog ears as an inevitable problem that could not be solved.

I have occasionally used a superior pedicle when the nipple did not have far to move. But it is not as satisfactory as the medial pedicle for two reasons. The first is a practical one in that it is still easier to resect the lateral breast tissue when the pedicle is based medially. But this was not a significant issue. On the other hand, there is something inherently better about the medial pedicle, and it involves not only the rotation of the part of the pedicle that carries the nipple and areola, but the fact that the whole pedicle, including the base, rotates. The inferior border of the medial pedicle becomes the medial pillar; this allows a shape and closure that is better than that achieved when a superior pedicle is used.

Now that I have had over 10 years' experience with the vertical technique, my analysis has led me to some other thoughts. There is no question that the procedure has resulted in fewer scars and has allowed me to eliminate the most unsightly scar - the one along the inframammary fold. But early on I realized that the shape that I was achieving was better than what I had seen in my patients with the inverted T reductions. Why was this happening? The breasts were coned more, resulting not only in better projection but in a shape where the problem of the lateral and medial dog ears completely disappeared. There is no question that these two dog ears were replaced by one inferior one (or pucker), but this pucker would often (but not always) settle with time. The increased projection meant not only that the nipple position needed to be designed at a lower level, but that a much longer vertical scar was not only acceptable but necessary to accommodate the increased projection.

The initial breast shape was better because of the coning and shaping of the parenchyma. It appears that the longevity of the shape may be due to the fact that we are not using the skin to hold the shape and because we are removing the heavy inferior breast tissue. We used the 5-cm rule for the vertical scar to try to prevent bottoming out, but instead the weight of the breast tissue - when an inferior pedicle was used - would cause either the scar to stretch or the breast tissue to push down the inframammary fold.

On the other hand, the vertical approach has its own problems. It is far from perfect. I do have a higher revision rate with the vertical technique (about 5%). But when I look back, part of the reason that I did not revise the inverted T procedures was because I did not have a solution to the problem of the medial and lateral dog ears. Once I realized that it is important to keep the vertical scar well above the inframammary fold, the problem of a scar falling onto the chest wall was eliminated. Once I realized that the inframammary fold was rising and that the pucker was more a problem of excess subcutaneous fat rather than excess skin, the need to revise puckering was reduced. I still need to revise some breasts because of puckers,but that can often be performed under local anesthesia in the office. I still need to revise patients who are asymmetrical, and I have patients who ask for a further reduction because I have been unable to make their breasts small enough.

The other problem with the vertical approach is that the inverted T procedure is more universally adaptable to all breast sizes. The vertical approach has definite limitations when volume resections are greater than 1200 g per breast. It can be done, and I believe that in these cases a vertical resection pattern with a small added horizontal scar would still give a better shape than the straight inverted T approach.

The final problem has to do with nipple circulation. Is the medial pedicle as reliable as the inferior pedicle? It does not seem to be as safe in my hands - but there are surgeons who have had fewer instances of nipple necrosis than I have experienced. Dr. Frank Lista has performed over 1800 vertical reductions using a superior or medial pedicle without any instances of complete nipple-areolar necrosis. Both the size of the breast reduction and the distance the pedicle needs to move need to be assessed. There are times when a free nipple graft may be the best solution.

Short-term satisfaction with the vertical approach is high, especially in preoperatively informed patients. As long as they have seen photographs of puckers and their resolution, they are very accepting. And there is no question that long-term satisfaction is far higher than with my patients who had the inverted T inferior pedicle approach.

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