A Matched Cohort Study of Superomedial Pedicle Vertical Scar Breast Reduction (100 Breasts) and Traditional Inferior Pedicle Wise-Pattern Reduction (100 Breasts)

Sir: Drs. Antony et al.1 compare vertical and inverted-T inferior pedicle breast reductions. Although the authors suggest a deficiency, there are several publications on this topic.2–6 Notably, this study does not include a power analysis. With 50 patients in each study group, the label “large-volume” is questionable. Limited sample sizes allow for type II (false-negative) statistical errors,7 undermining the authors’ conclusions of equivalence. Moreover, a 3-month minimum follow-up time is too short for evaluation of nipple sensation. Studies with mean follow-up times of 2 years or more find a higher rate of nipple numbness for inverted-T inferior pedicle reductions8 than vertical medial pedicle reductions,9 consistent with anatomical considerations.6 By matching vertical patients with inverted-T inferior pedicle patients drawn from a much larger sample of patients treated by three different surgeons (inclusion rate, 31 percent), the authors invite selection bias and confounders. Such sampling bias might have been avoided by comparing one series of consecutive cases performed by the lead author, who (admirably) used the vertical technique without excluding higher volume reductions, with another series of consecutive cases performed by a single surgeon using the inverted-T technique. An outcomes study typically reports patient-derived data.9,10 Patient surveys9,10 and objective measurements of breast shape6,11,12 are most helpful in assessing the aesthetic result. Curiously, the authors report two “major complications” after vertical mammaplasty requiring a return to the operating room1 but do not disclose the nature of these complications. What event was responsible for these reoperations? The authors do not categorize scar deformities, asymmetry, or persistent ptosis (all common problems)13 as complications. Complication and revision rates are heavily influenced by the surgeon’s definition of a complication and threshold for reoperation, limiting their usefulness as standards for comparison in cosmetic surgery.13 Although the authors do not mention it when reporting complication rates in the text, these percentages relate to total breasts, not patients. Using breasts (n = 100) instead of patients (n = 50) as the denominator makes the group sizes appear larger and the complication rates appear smaller. For example, the incidence of major complications is listed as 4 percent in Table 2 and in the text. This rate doubles to 8 percent when the denominator is patients, not breasts, assuming no patient suffered two major complications. The numbers of patients experiencing complications are not provided. Consequently, the reported complication rates, which are effectively reduced by as much as 50 percent depending on the number of patients with more than one complication (also not disclosed), cannot be compared with other studies. This inconsistency underscores the importance of citing complications among patients—the accepted convention2–4,13—rather than breasts. After all, it is the patient who suffers the complication, not the breast. Moreover, Tables 3 and 4 contain a surprising number of typographic errors that create confusion. Both tables feature headers that should read “>744 g.” The second row should be labeled “≥1 complication.” A footnote under Table 4 incorrectly refers to the “IMP, inferomedial pedicle” rather than “IFP, inferior pedicle.” To their credit, Antony et al.1 challenge a dogma that large breast reductions are more suitable for inverted-T breast reductions. On the contrary, these patients are particularly good candidates for vertical mammaplasty with a medial pedicle, which is far safer for nipple-areola viability.13 These investigators also endorse an all-seasons mammaplasty,13 a concept that goes against the conventional wisdom. Today, many operators use the vertical reduction technique exclusively.13 The authors suggest that skin elasticity and striae are important prognostic factors. They describe a “rebound of the soft-tissue envelope,” an undefined entity. Skin elasticity is not particularly relevant in vertical mammaplasty because this technique relies on the parenchymal repair for support, not the skin, as noted by the authors. The vertical technique refers to the pattern of parenchymal dissection, not necessarily the skin closure, which is why the label “vertical scar” is best avoided.13 In large reductions, the surgeon may modify the lower end closure with a (short) inverted-T to avoid extension of the incision onto the abdomen, especially as the inframammary crease moves superiorly after a vertical mammaplasty.11,13 A medial (not superomedial) pedicle is ideal for incorporating medial sensory input, maintaining a deep parenchymal attachment (possibly preserving deep innervation), and avoiding vascular compromise that can occur with superior pedicles.6 The authors’ claim of improved breast projection1 is not supported by their photographs, which are not standardized (Fig. 1). However, other studies confirm that upper pole projection and breast projection can be improved using the vertical technique (Fig. 2),11,12 unlike inverted-T inferior pedicle reductions.6,12Fig. 1: The preoperative (left) and 1-year postoperative (right) lateral photographs of a 31-year-old woman illustrated in the authors’ Figure 2 are matched for size and orientation using the Canfield 7.1.1 Mirror Imaging software (Canfield Scientific, Fairfield, N.J.). The reported resection weight was 429 g. A 25 percent magnification of the postoperative photograph and a 4-degree tilt (creating the triangular black margin) are corrected. Upper pole projection is essentially unchanged. Breast projection is slightly decreased after the authors’ vertical breast reduction. The nipple is overelevated. A 32-cm upper arm length was used for calibration.Fig. 2: This 36-year-old woman is seen before (left) and 3 months after (right) a vertical breast reduction using a medial pedicle. The right breast resection weight was 221 g. The images are matched for size and orientation. Upper pole projection and breast projection are modestly increased.The goal of breast reduction today is no longer simply a functional benefit from reduction of bulk and preservation of the nipple-areola. The modern plastic surgeon aspires to an improved aesthetic result.11,13 We need to attend to the same aesthetic issues that concern our patients.9 To this end, we must be critical of our aesthetic results and use appropriate measures to evaluate them.9,11 Vertical mammaplasty offers improvements in safety (especially in combination with implants),6,13 shape,6,11–13 scars,2–4 and nipple sensation.8,9 Even the most accomplished surgeon cannot overcome the anatomical and shape limitations6 inherent in the inverted-T design. DISCLOSURE The author has no financial interest to declare in relation to the content of this communication. There was no outside funding for this study. Eric Swanson, M.D. Swanson Center 11413 Ash Street Leawood, Kan. 66211 [email protected]