Vertical Mammaplasty

Abstract

Current criticisms regarding vertical mammaplasty include problems with poor immediate postoperative appearance, nipple-areola complex malposition, and excessive lower pole length. These problems can be avoided by proper patient selection, by utilizing correct concepts of skin design, and by observing correct glandular resection and closure concepts. Vertical mammaplasty also can result in other problems, such as hypertrophic circumareolar scars and lower pole deformities, including notching, boxy shape, infra-areolar depression, and flatness. These problems are also largely avoidable by using correct technique. Several basic concepts described previously have not proven necessary to achieve good results. Abandoning some of these principles has contributed to the ability to establish an aesthetically ideal breast shape intraoperatively as well as to a decrease in morbidity. This includes eliminating liposuction as a major integral component of the procedure, eliminating suturing the gland to the pectoralis muscle, not undermining the lower pole skin, and avoiding overly wide skin resection and tight wound closure that produces significant lower pole distortion in the early postoperative period. An important concept that has proven reliable is to use a "closed" design that does not predetermine the areolar opening whenever circumstances permit. When this is not possible, a modification that utilizes the smallest possible circumference as an open design is better than a large "mosque." These alternatives allow greater flexibility in determining final nipple position and also reduce the risk of hypertrophic circumareolar scars. Important glandular resection concepts include creating pillars that are attached to both the skin and the chest wall; making them of adequate dimension to avoid postoperative lower pole shape problems, such as flattening; resecting closer to the skin lateral to the pillars to avoid a boxy breast shape; and using a drain both to assist in accurately determining the endpoint of resection and to avoid postoperative seromas. Key closure concepts include approximation of the superior surfaces of the pillars at their base to maintain vertical height and thereby prevent lower pole flattening; approximation of the inferior surfaces of the pillars to the base of the breast to prevent notching; and proper management of the vertical incision by restricting the purse-string suture effect to only the inferior portion of the incision, where there may be skin excess present. Inclusion of these concepts leads to predictable and improved aesthetic results in vertical mammaplasty. This allows full realization of the purported advantages of vertical mammaplasty and allows this method to be utilized with a level of confidence similar to that seen with inverted-T techniques.