As far as the vertical scar in Lejour's technique (superior pedicle) is concerned, one must admit that some patients do not accept the aspect of the vertical scar with multiple wrinkles in the early postoperative period. Furthermore, scar correction at the bottom of the vertical scar is needed for many patients in our experience. The vertical technique is far more than just a scar; it is a concept. Breast shaping and modeling are the most important elements of this technique. We believe in scar reduction, but it should not be done at the cost of a high rate of wound dehiscence and scar revision. The vertical scar can be ended easily with a short horizontal scar if needed. However, in patients who have poor skin quality or long-lasting breast hypertrophy like elderly patients, a short inverted T scar will be more appropriate. Designing the inverted T at the end of the operation provides better scar placement with minimal extension of the scar to the sides. In addition, the skin excess at the inferior part of the breast can be excised in the form of an L or a J, in order to avoid any medial extension of the scar at the IMF.
Moreover, respecting the IMF and using the superficial fascia as we described in Chap. 9 will help to obtain a better definition of the IMF.
My personal algorithm in scar selection is summarized in Fig. 15.1. I choose vertical scar mammaplasty in all patients under 30 years old. These patients usually have good skin quality, and skin retraction is expected. In very large breasts (more than 1000 g), secondary revision of the vertical scar is more likely to be necessary (see Chap. 14).
When the patient is over than 30 years old, I look first at the nipple-to-sternal notch (N-to-SN). If the N-to-SN is less than 30 cm, I choose a vertical scar technique. If this distance is more than 30 cm, I look at the quality of the skin and smoking history. If the skin is still elastic and there is no smoking history, I choose an L or J scar or short inverted T scar. However, a vertical scar can still be chosen if the surgeon has a large experience with the vertical scar technique. If the patient has nonelastic skin associated with strae marks and/or heavy smoking history, I choose an inverted T scar,which is designed at the end of the operation, in order to put the scar exactly in the new IMF.
By using this algorithm, any surgeon can achieve a good result with a minimal scar revision rate. It is extremely important to discuss these options with the patient during the preoperative consultation. The patient will be happier with the outcome and will more easily accept any necessary corrections later on.
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