Improving Immediate Shape And Long Term Stability In Vertical Scar Breast Reduction By The Dermal Suspension Flap Technique

Oliver Scheufler, M.D., Klaus Exner, M.D., Ph.D., Dirk J. Schaefer, M.D., Martin Haug, M.D., Gerhard Pierer, M.D., Ph.D.

Despite enthusiastic reports about vertical scar reduction mammaplasty in the early 90th, many surgeons still feel uncomfortable with this technique for several reasons. An important issue to the patient is the distorted breast shape immediately after surgery with excessive upper pole fullnessand contracture with considerable wrinkling of the lower pole. This reflects on the attitude of the surgeon who may have to deal with a concerned or distressed patient for some time after surgery. Although these early deformities usually resolve with time, additional surgery for correction of residual skin excess or contour deformities is not uncommon. In addition to a considerable learning curve these limitations have prompted many surgeons to adhere to more predictable inverted T-scar techniques.

Methods: To improve the breast shape immediately after surgery we have modified several aspects of the original vertical scar technique. Incorporation of a superiorly pedicled dermal flap allows even distribution of the lower pole skin excess and acts as an „inner brassiere“ to maintain breast shape. In addition, the technique abandons liposuction, wide undermining, and inner suspension sutures1.

In 50 patients with moderate breast hypertrophy a total of 96 breasts were operated with the modified vertical scar technique from 1996 to 2000. Patient age ranged from 18 to 58 years (mean ± SD = 29.2 ± 9.5 years) and body mass index from 20 to 31 (mean ± SD = 22.1 ± 2.8). In 42 of 50 patients breast dimensions were assessed preoperative, 1 week after surgery and at late postoperative follow-up (≥ 2 years), and included jugular notch-to-nipple distance (J-N), areola-to-inframammary fold distance (A-IFM), cup size, and chest circumference. These patients were contacted via mail for late postoperative follow-up and requested to complete a detailed questionnaire to evaluate patient satisfaction.

Results: The amount of breast reduction ranged from 110 to 1060 g (mean ± SD = 496 ± 215 g). Cup size changed from preoperative C to F cups to postoperative B to D cups with an average decrease of 2 cup sizes after surgery. There was no significant difference in pre- and postoperative chest circumference. Postoperative complications included hematoma in 1%, infection in 0.5%, and fat necrosis in 2%. Vertical scar widening or dog ear formation at the lower pole occurred in 8 patients (16%) and required conversion of the vertical scar to a short inverted t-scar in 2 patients (4%).Comparison of early and late postoperative measurements revealed a slight but not statistically significant increase of the J-N and A-IMF distance (Table I). This can be attributed to the postoperative settling of the glandular tissue. No recurrent ptosis or bottoming out was observed at late postoperative follow-up. Of 42 patients that were available for late postoperative follow-up 40 patients (95%) completed the questionnaire. revealing a high degree of patient satisfaction regarding postoperative breast size, shape, and symmetry (Table II). Fig. 1-3 demonstrate a clinical result of a young patient with moderate breast hypertrophy, ptosis and good skin quality before and late after surgery.

In conclusion, the modified vertical reduction mammaplasty with dermal suspension flap improves immediate shaping and long term stability in patients with moderate breast hypertrophy (reduction ≤ 800 g). The technique meets limitations in cases of massive breast hypertrophy (reduction > 800 g) in which inverted T-scar techniques are preferred.

TableI. Jugular Notch-to-Nipple (J-N) and Areola-to-Inframmary Fold (A-IMF) Distances

Preop. / Immediate Postop. / Late Postop.
Range / Mean ± SD / Range / Mean ± SD / Range / Mean ± SD
J-N / 21.0-34.5 / 27.3±3.4 / 18.0–22.5 / 19.7±1.2 / 18.0–23.5 / 20.9±1.7
A-IMF / 8.5-16.5 / 12.4±2.5 / 6.0–8.0 / 6.9±0.6 / 6.5–9.0 / 7.7±0.9

All measurements in cm.

Table II. Questionnaire: Patient Satisfaction with Postoperative Results

Shape / Symmetry / Scars / Sensitivity
Periareolar / Vertical / Areola / Breast
Poor / 0 / 0 / 3 (7.5) / 0 / 0 / 0
Moderate / 6 (15) / 7 (17.5) / 9 (22.5) / 13 (32.5) / 10 (25) / 12 (30)
Good / 20 (50) / 12 (30) / 17 (42.5) / 23 (57.5) / 22 (55) / 21 (52.5)
Excellent / 14 (35) / 21 (52.5) / 11 (27.5) / 4 (10) / 8 (20) / 7 (17.5)

Absolute numbers and (percent values) of patient ratings .

Fig. 1 Preoperative

Fig. 2 Preoperative Markings

Fig. 3 Postoperative

References

1. Exner, K., Scheufler, O. Dermal suspension flap in vertical-scar reduction mammaplasty. Plast. Reconstr. Surg. 109: 2289-2298, 2002