Vertical Scar Reduction Mammaplasty

Sir: We have had the opportunity to read with great interest the article entitled “Vertical Scar Reduction Mammaplasty” (Plast Reconstr Surg. 2015;136:23–25) by Lista et al.,1 and have also watched their video presentation. We would like to express our gratitude for sharing their experience as senior surgeons, who have been performing reduction mammaplasty using the vertical scar technique for the past 26 years, through this video presentation. It is a well-known fact that reduction mammaplasty with vertical scar technique is a surgical approach that requires good preoperative planning and that is associated with a prolonged learning curve. For providing guidance to plastic surgeons inexperienced using this technique, a number of problems and questions exist that should be addressed and that we have attempted to address. Hall-Findlay2 and Lejour3 determine the medial and lateral limbs to be excised through preoperative markings, involving the rotation of the breast upward and inward, and upward and outward, respectively. In the preoperative marking procedure of Lista et al., there seemed to be no anatomical landmarks for the determination of the medial and lateral limbs and no upward and inward, and upward and outward rotation. How can it be possible to obtain breast symmetry using this approach? How do they determine the extent (width) of the area to be excised between the medial and lateral limbs, particularly while marking the asymmetric breasts? Other problems that we encountered during our initial experience with this method in patients undergoing surgery include a longer than desired distance between the areola and the inframammary fold, and persistence of the dog-ear under the breast. To address these issues, in our next patient group we have been performing excisions of the subcutaneous tissues from the inframammary fold toward the lateral and medial directions, to achieve a lateral and medial limb length of 6 cm under the areola. We have noticed that after this excision, the distance between the areola and the inframammary fold is shortened, with a more natural appearance. It seems from the video presentation that no intervention on the inframammary fold or on the length of the lateral and medial limbs is being performed. Would this not lead to pseudoptosis in the longer term through an increased distance between the areola and inframammary fold? Also, would it not cause the formation of persistent dog-ear in the inframammary region when subcutaneous excision is not performed? Until now, we have not been able to devise a satisfactory technique that provides complete prevention of dog-ear formation. What do the authors recommend for the prevention of dog-ear formation? They have mentioned that with this technique, a slightly larger breast size is obtained, as can be readily seen in the preoperative and postoperative patient photographs. What is their reduction technique in patients who desire a smaller breast size? DISCLOSURE The authors have no a financial affiliation with any of the products or services discussed in this communication. They have no financial interests to disclose. Serdar Altun, M.D. Department of Plastic and Reconstructive Surgery Firat University School of Medicine Elazğ, Turkey Ramazan Erkin Ünlü Mehmet Onur Öztürk, M.D. Department of Plastic and Reconstructive Surgery Ankara Numune Training and Research Hospital Ankara, Turkey Enver Arpaci, M.D. Department of Plastic and Reconstructive Surgery Başkent University Konya Hospital Konya, Turkey