Breast reduction is one of the most difficult operations in plastic surgery because it should produce a beautiful, symmetrical, and durable result with minimal scarring. Raymond Vilain, the humorist of our profession, used to say that it takes 5 years to learn how to operate a breast properly...and 5 more years for the other. In addition, so many techniques are described that it is a real challenge to choose the best.
Twenty years ago vertical mammaplasty was practically unknown by most surgeons performing masto-pexies and breast reductions. Devised by a French surgeon, Dartigues (1925), it was nearly forgotten until Arie (1957) and Lassus (1970) brought it to the attention of their colleagues. I admire Claude Lassus, a man with a vision who understood early that vertical mammaplasty not only reduced scarring but also produced better late results and that this justified the temporary strange appearance of the breasts.
Changes in our habits are difficult to make. I started using the technique in the late 1980s and was soon enthusiastic about the results. With the considerable experience accumulated by our team at the Department of Plastic Surgery of the University of Brussels, I had the opportunity to demonstrate and teach it in many meetings during the last decade of the century, adding my efforts to those of Lassus. Other surgeons who tried vertical mammaplasty contributed to the spread of the technique with a snowball effect, and I believe that all trainees in plastic surgery are now aware of its possibilities.
Changes in any technique are common, and most surgeons adapt operations for their personal practice. The changes aim for a better shape, a more durable result, and fewer complications. This requires a careful and honest evaluation of the results, which is not an easy task. First, recording all the data about the pre-and postoperative states of a patient is an endless fight for precision. Also, how do we explain major changes in the rate of complications when the technique is used in the same department during various periods? It may be that supervision of the residents was reduced if the team lacked trained surgeons for a period or that other, more impalpable factors intervened. Another example is the attention paid to certain data like obesity or preoperative volume of the breasts in the appreciation of complications. I was able to observe from my own experience that obesity per se increases the rate of complications and that the major factor of risk is a combination of obesity and very large breasts. All these major or minor factors explain why it is so difficult to obtain comparable evaluations. For a long time, evaluations were not even done. The rate of complications presented in publications was too vague to be taken into account. I am really very pleased to see that recent articles tend to better analyze and discuss complications. This is the best way to reduce them, improve the technique, and satisfy the patients who have placed their trust in us.
Development of our knowledge in areas other than surgical techniques deserves interest, for example, vascular anatomy in relation to surgery; breast content, which varies with menstrual cycle, parity, age, weight, and heredity; capacity for lactation, which combines hereditary and hormonal factors; variable fat degeneration after menopause; and so on. Let us hope that the interest will increase with time, just as it did for vertical mammaplasty.
A large number of presentations and publications in recent years have been devoted to vertical mamma-plasty, and the time has come for an update of recent ideas, observations, technical modifications, and results. I do not doubt that the technique is now in its era of maturity and will survive the test of time.
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