Operative Design and Markings

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There are numerous approaches to breast reduction surgery using a vertical skin resection pattern. Lassus [23-25] usually uses a superior pedicle and does not bevel his resection or undermine the skin. He resects the breast tissue directly down to the chest wall and does not resect the parenchyma along the Wise pattern. His inframammary fold stays in place. Marchac [26] uses a superior pedicle but adds a small horizontal scar or T to the bottom of the vertical incision. Lejour [27-30] uses a superior pedicle and undermines the skin. She sutures the breast tissue up to the pectoralis fascia and gathers the vertical skin incision. Hammond [31] uses an inferior pedicle and takes some of the skin excess into the areolar opening as used in the circumareolar approaches.

I use a medially or superomedially based pedicle for the nipple-areola complex, and this has simplified the

The key to achieving a good cosmetic result lies in determining the ideal nipple position. This will not be the same in all procedures. Because the vertical approach results in significant breast projection, the new nipple position needs to be lower than expected (Fig. 7.1). The nipple will have the illusion of being higher because of the increased slope of the upper portion of the breast. The new nipple position needs to be lowered about 2 cm below what one is used to using in a typical Wise pattern [31] approach in order to accommodate this increased projection.

Gradinger's [32,33] technique of using a measuring tape under the inframammary fold on one side and over the breast on the other gives a more accurate determination of the inframammary fold. At this point, he uses the tape to mark the top of the areola. No matter what technique is used for new nipple position, surgeons need to drop the design at least 2 cm from their usual design with an inverted T approach.

Nipple Correct Position

Fig. 7.1. This is an exaggerated drawing to show how the new nipple position appears to be higher with the vertical skin pattern techniques. The line ab is the same in both drawings, but the nipple appears higher because of the increased projection that is achieved with the coning of the breast parenchyma. The new nipple position must be marked at least 2 cm below what a surgeon would normally have marked with the Wise pattern to accommodate both the increased projection and the effect that is achieved from closure of the vertical ellipse

Fig. 7.1. This is an exaggerated drawing to show how the new nipple position appears to be higher with the vertical skin pattern techniques. The line ab is the same in both drawings, but the nipple appears higher because of the increased projection that is achieved with the coning of the breast parenchyma. The new nipple position must be marked at least 2 cm below what a surgeon would normally have marked with the Wise pattern to accommodate both the increased projection and the effect that is achieved from closure of the vertical ellipse

Vertical Scar Technique Breast Reduction
Fig. 7.2. Design of the vertical skin resection pattern compared to lined in dotted red lines,whereas the vertical pattern is outlined in the inverted T skin resection pattern. a The Wise pattern is out- solid blue lines. b Similar comparison as seen drawn on a patient

It is important to note that, in cases of asymmetry, the new nipple position needs to be lowered in the larger breast. The closure of the vertical ellipse and the coning of the pillars not only pushes the vertical scar lower inferiorly, it also pushes the vertical scar higher superiorly. This results in a higher nipple position at the end of the procedure. It is important to keep the new nipple design lower in all large breasts, but especially in the larger side in cases of significant asymmetry.

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How To Reduce Acne Scarring

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  • hazel
    How to measure breast projection?
    1 year ago

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