Various approaches to breast reduction have been attempted to combine the safety of the pedicle with the appeal of the short-scar techniques. No one method is best, but the ability to use different approaches in different situations can expand the breast reduction and mastopexy repertoire of the plastic surgeon.  The key is to realize that the pedicle, the skin-resection pattern, and the parenchymal-resection pattern must all be viewed separately. The phrases vertical and inverted-T apply to the skin resection pattern. Both approaches can use different pedicles and different parenchymal resection patterns.
Vertical breast reduction follows the basic principles of plastic surgery, with a complete dermoglandular pedicle (rather than a dermal pedicle) and no skin undermining. Flap thickness and outward beveling are used to preserve the blood supply. This technique relies on breast resection and suturing for shaping and not on skin tension for shape maintenance.
Simplified vertical breast reduction is a variation on the vertical technique that uses a full-thickness medial pedicle for nipple circulation and breast shaping and resection of a vertical (not horizontal) wedge of tissue to improve the initial result and provide a long-lasting shape. The procedure is simple, fast, reproducible, and reliable. The learning curve is relatively short, and the improved results are well worth the change from the reliable inferior pedicle inverted-T techniques to the medial-pedicle vertical technique, in terms of both scarring and shape.
History of the Procedure
Vertical reduction mammaplasty techniques have only recently achieved a measure of acceptance in North America. [2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12] Although the desire to eliminate some of the extensive scarring of the anchor-shaped techniques is certainly strong, most surgeons are still not willing to compromise their comfort with the safety of the inferior pedicle technique.
Use of the superior pedicle in the initial vertical techniques that Lassus [2, 3, 4] and Lejour or Lejour et al [6, 7, 8, 9] describe prevented wide acceptance of the vertical approach. The superior pedicle can be difficult to inset; either the pedicle needs to be thinned to allow it to be folded into place, or the blood supply is at risk because of vascular kinking or compression. Thinning may improve circulation by avoiding compression, but the ability to retain sensation or allow for breastfeeding is reduced.
Different pedicles have been described over the years, including the lateral pedicle, [13, 14] the horizontal bipedicle and the lateral pedicle, [15, 16, 17] the vertical bipedicle, [18, 19] the inferior pedicle, [20, 21, 22] and the superior pedicle.  All these pedicles were used with the anchor-shaped reduction techniques while surgeons in Europe [13, 2, 3, 4, 5, 7, 6, 8, 9] and in South America [24, 25, 26, 27] tried techniques that reduced scarring. However, the inferior-pedicle and central-mound techniques [28, 29] had proven so reliable and safe that surgeons in North America were reluctant to switch to a method that they thought was riskier, even though scarring could be reduced. Hammond has combined the vertical approach (circumvertical) with an inferior pedicle,  but surgeons are still reluctant to switch away from the inverted-T inferior pedicle technique.
Surgeons initially believed that they had to choose between an improved shape and an improved scar.  However, many practitioners started to realize that both the shape and the scars could be improved and that some vertical techniques improved the longevity of the shape.
Although many surgeons started using the vertical approach because of the reduced scarring, it has become clear that the key is about concepts not scars. Reduced scarring is only a small part of the appeal. Improvement occurs because the parenchymal (and skin) resection is performed through a vertical ellipse. The breast is coned rather than being pushed up and flattened by a horizontal ellipse. This coning improves projection. The vertical elliptical excision also means that the lateral and medial parenchymal pillars are brought together; the resultant healing process holds the shape in the long term.
The inverted-T techniques usually rely on the skin brassiere to shape the breast, whereas the vertical techniques usually use the breast to shape the skin. Medial-pedicle vertical breast reduction also leaves the tissue attached to the skin superiorly, and the heavy inferior breast tissue is removed. The skin is then allowed to conform to the new shape.
With many of the inverted-T inferior-pedicle techniques, the surgeon undermines the skin to remove the superior tissue, leaving the heavy inferior breast tissue behind. This tissue is then pushed up by tightly closing the skin horizontally. Skin (dermis) is an elastic structure that stretches. Therefore, the fact that the vertical incision stretches with inverted-T techniques and that the tissue bottoms out is not surprising. By comparison, medial-pedicle vertical reduction uses the healing of the relatively inelastic medial and lateral pillars to hold the shape. No tension is applied to the skin. The best results are also achieved when very little tension is applied to the parenchymal closure.
The breast is a superficial ectodermal structure, and most of its blood supply is superficial. The breast is a skin structure that is relatively mobile on the chest wall. It is attached to the skin at the nipple level. The breast is held in place on the chest wall not by deep attachments but by the skin structures of the inframammary fold and the sternum. The upper and lateral breast borders are not held in place in the same way. The illustration below depicts the anatomy of the breast.
Arterial input comes from the medial perforators of the internal thoracic system, from the thoracoacromial system, and from the lateral thoracic system. These vessels are deep at their origin and become progressively superficial as they reach the breast mound. An arterial system also comes from the internal thoracic vessels, which run beneath and then perforate the pectoralis muscle around the fourth interspace. This system supplies an inferior or central pedicle and is accompanied by veins. The rest of the arteries are superficial and do not have venae comitantes. The venous system is also superficial and can be seen just below the dermis separate from the arteries. 
The superior pedicle is supplied from a strong medial vessel from the second or third interspace. It is superficial by the time it reaches the center of the breast. For this reason, a superior pedicle can be easily and safely thinned. The medial pedicle is supplied from medial vessels from the third to fifth interspaces. The pedicle may appear to be superomedial when the patient is standing, but the blood supply is medial. The medial pedicle can be thinned.  The author likes to use a full-thickness medial pedicle for both innervation and breastfeeding potential.
The breast can be visualized as a cylinder, especially when the patient leans forward and the breast hangs. Regardless of the level on the cylinder at which breast tissue is removed, the distance around the circumference of the cylinder should be the same. This means that the vertical limb of the breast reduction should be manageable at any size. On the converse, if the pedicle is to be retained, the large (ie, long-cylinder) breast has a long pedicle, which makes reducing lower-pole fullness more difficult. As with most breast reductions, small reductions often give the best cosmetic results.
Sensation in the nipple-areola complex is an important consideration. Inferior- and central-pedicle reductions often maintain good sensation, and free nipple grafts result in permanent loss of sensation. Surgeons are taught that the main sensation comes laterally from the fourth intercostal nerve. Therefore, a lateral-pedicle technique should result in sensation better than is present after a superior- or medial-pedicle technique is used. However, sensation comes from several directions.
Surgeons in Austria  demonstrated that the deep branch of the lateral fourth intercostal nerve runs across the breast just above the level of the pectoralis fascia until the mid portion of the breast, where it then runs superiorly toward the nipple. Because the pectoralis fascia is not exposed and because the pedicle is full thickness, this anatomy explains why the medial-pedicle technique maintains sensation as good as that associated with the lateral-pedicle technique.
Thinning of a pedicle likely reduces breastfeeding potential. The medial pedicle used in this technique is full thickness. About 60% of patients can breastfeed, with 25% needing to supplement.  Of interest, the same statistics also apply to large-breasted women whether or not they undergo breast-reduction surgery.
For more information about the relevant anatomy, see Breast Anatomy.
Medial-pedicle vertical reduction mammaplasty is simple and reliable. [32, 35, 36, 37, 38, 39] The procedure is fast and involves few adjustments. The pedicle is full thickness, and the resection is beveled out as the tissue is removed en bloc. The desirable breast tissue (superior portion) is left in place, and the undesirable breast tissue (inferior and lateral portion) is removed. The durability of the shape of the breast appears to be due to the removal of the heavy inferior breast tissue and the lack of reliance on skin for shaping.
The often quoted rule of the Wise-pattern inferior-pedicle technique is to keep the vertical incision shorter than 5 cm.  Although this rule was designed to prevent bottoming-out with time, it prevents good projection. The coning of the breast with the medial-pedicle vertical technique improves projection, and the lengthened vertical scar is far from undesirable. Vertical techniques are based on vertical wedge resection of the tissue (and skin) instead of horizontal excision of the tissue (and skin). This vertical ellipse allows the breast tissue to be coned and improves the projection.
Large breast reductions (>1500-2000 g) can be performed using this technique, but the size of the pedicle causes heaviness and increases the potential for bottoming-out with time. As with most breast reductions, small reductions often result in the best cosmetic results. For massive breast reductions, the medial pedicle can be used, and the heavy inferior breast tissue can be removed. At the end of the resection, the excess skin must be treated separately. It may need to be removed as a J, L, or inverted-T shape. Good-quality skin retracts better than poor-quality skin.
The limit of pedicle length has not been established, but the author considers using a free nipple graft when the pedicle approaches 15 cm (from the edge of the de-epithelialized area to the nipple). The patient is preoperatively warned that, if the circulation is not good with the medially based pedicle, free nipple grafts will be used. If sensation or breastfeeding is more important than shape, an inferior pedicle may be the best choice.
Markings can easily be learned and are less intuitive than they first appear (see section A of the first image below and sections A and B of the second image below).
Surgeons can follow the Wise pattern; however, instead of carrying the vertical lines out laterally and medially, the surgeon joins the lines together, staying at least 4-6 cm above the level of the inframammary fold. The small areolar opening of the Wise pattern is increased so that the resulting diameter fits an areola of 4.5- to 5-cm diameter (ie, approximately 16 cm). Because medial-pedicle vertical breast reduction does not rely on the skin to hold the shape, precise skin markings are less important than they are with the inverted-T techniques.
Because projection is better with this method than with the inferior-pedicle method, initial nipple placement should be somewhat lower than it is with the inverted-T techniques. As a rule, the nipple is best placed at the level of the inframammary fold, but care must be taken in patients with excessively high or low inframammary folds. The junction of the chest wall and the breast (upper breast border) does not change with surgical maneuvers, and this junction is often a more reliable landmark for determining nipple position. The nipple is actually best positioned about 8-10 below the upper breast border.
Surgeons use different methods to determine the ideal nipple position. The finger technique of Pitanguy puts the mark higher than the fold.  If the surgeon is sitting in front of the patient, he or she marks the inframammary fold lower than where a surgeon who is standing marks it. This difference makes it difficult to give precise advice, but a good guideline is for the surgeon to place the new nipple 2 cm below where he or she is used to placing it. This position is needed to accommodate the increased projection that results. In most patients, this distance is 23-26 cm from the suprasternal notch.
Different patients have inframammary folds at different levels. Some patients are "high-breasted" and some patients are "low-breasted." Patients need to know that surgeons cannot actually change the "footprint" of the breast on the chest wall. The upper breast border, not some arbitrary number from the suprasternal notch, should be the determining factor for the new nipple position. Many surgeons are more comfortable with an intraoperative determination of the new nipple position, but this does not make sense to the present author. The distortion of the surgery makes this determination more difficult than just marking the ideal position with the patient standing, especially since the footprint does not change with surgery.
That said, this method can raise the level of the inframammary fold; therefore, if the incision is carried down to the fold, the scar will extend below the fold. This is one of the early criticisms of the technique. The lower end of the marking, where it curves above the fold, should be at least 2-6 cm (mean, 4 cm) above the fold. The fold itself does not move up with the technique Lassus uses because he removes only a vertical wedge and does not remove tissue above and along the fold. The present author removes tissue below the Wise pattern. Aggressively removing the fibers around the inframammary fold allows the fold to rise. The opposite occurs and the fold drops if weight is then added to the inframammary fold (as with an implant or inferior pedicle).
Surgeons comfortable with raising the fold (it rarely goes up more than 1 or 2 cm) can place the new nipple relatively high. When a patient has good upper-pole fullness, the new nipple position will have a better safety margin. Surgeons must be careful not to place the nipple high in a patient with a ski-jump type of breast with little fullness of the upper pole. In these cases, a high nipple points upward on the upper slope of the breast. A nipple that is placed too high is very difficult to correct, so placing a nipple too low is always better than placing it too high.
The areolar opening is shaped so that it forms a circle after the lower ends are joined together. The actual shape is less relevant than assumed, and it can always be trimmed to create a circle before final suturing. Lejour brings the shape out somewhat laterally, but a better technique may be to try to take up additional vertical distance if possible. The original Wise pattern had an areolar opening of 14 cm, which matches an areola 4.5 cm in diameter. The author prefers a 16-cm opening, which matches an areola 5.0 cm in diameter. A large paper clip measures 16 cm.
An important precaution is to not take too much skin. The skin does not hold the shape; rather, breast parenchymal resection determines shape. If too much skin is taken, not enough remains to accommodate projection, and horizontal tension results. This precaution can be difficult for surgeons who are accustomed to using the anchor-shaped techniques. In anchor-shaped techniques, tension of the skin is necessary for shaping, and the technique tends to flatten the breast somewhat rather than allowing for the projection that results from the coning of breast tissue.
The medial pedicle is the author's pedicle of choice (see section B of the first image below and section C of the second image below).
It easily rotates into position, it allows for adequate lateral breast resection, and it retains sensation as good as that of the lateral or superior pedicles. (More than 85% of patients recover sensation close to preoperative levels.) The whole base of the pedicle rotates and this gives an elegant curve to the lower aspect of the breast.
The position of the areola determines the base of the pedicle, which is best designed by placing half of the base into the areolar opening and half down the medial vertical margin. As long as the pedicle does not occupy too much of the areolar opening, it easily rotates into position. If the pedicle becomes too superiorly oriented rather than medially oriented, it does not rotate easily. If the pedicle is based too far inferiorly, excessive pillar height and bottoming out may result.
The ideal width of the pedicular base has not been scientifically determined. However, after performing more than 1800 breast reductions using this technique, the author has found that the base measures 6-10 cm. In a 300-g reduction, the base is usually approximately 6 cm; in an 800-g reduction, it may measure 8-10 cm.
Xylocaine 0.5% with adrenalin 1:400,000 is no longer infiltrated into the proposed incision lines. The injection needle often hits one of the veins, which should be preserved. Instead, infiltration is confined to the areas where liposuction is used for final contouring, namely, in the lateral chest wall, in the preaxillary fullness, and along the inframammary fold. A total of 40 mL is used per side.
If the patient is obese and if considerable liposuction of the lateral chest wall is anticipated, 1 L of tumescent fluid is infiltrated (500 mL per side), with most of the fluid infiltrated laterally on the chest wall.
A number 15 blade is used to incise the skin. The pedicle is de-epithelialized in the usual fashion by using a lap pad around the base of the breast for tension. A scalpel or cutting cautery is used to create the pedicle by vertically cutting down toward the chest wall. Care is taken to avoid undermining the pedicle (see section C of the first image below and sections D and E of the second image below).
The breast tissue to be excised is beveled outward, especially laterally and inferiorly. The flap is at least 1 cm thick at the margins, and beveling is performed as needed to resect the necessary breast tissue. A lateral pillar about 2 cm thick and about 5-7 cm long is maintained before beveling out under the lateral flap.
Exposure of the pectoralis fascia is not necessary. Retaining some of the tissue just superficial to the pectoralis may account for the retention of sensation with the medial pedicle.
Visualizing the Wise pattern is important when resection is performed. The Wise pattern originally came from a brassiere and is a good design to leave behind. The vertical incision length corresponds to the vertical pillar height. For an average C cup, it is important to leave behind a lateral pillar of parenchyma that measures about 7 cm. The tissue below the Wise pattern can then be removed by beveling out with direct excision and by subsequently feathering out beyond the breast margins with liposuction.
The lateral breast tissue is usually fibrous and cannot be suctioned; it must be directly excised. Leaving breast tissue superiorly is important. Remove only enough to allow the pedicle to be rotated into position without any compression. Leaving a small platform of tissue superiorly and laterally in the areolar opening for the pedicle to sit on is good to prevent nipple retraction, but it is important not to try to push tissue into the upper pole because it inevitably drops out.
Although skin resection is not carried down to the inframammary fold, resection of the breast tissue must be carried down to this point (see section D of the image below). This step is achieved by again undermining the resection to the level of the fold, leaving the flap approximately 1 cm thick. If the skin flap is too thin, scar contracture to the chest wall can occur. If it is too thick, a pucker may need to be removed secondarily. However, correcting a pucker at a later date is easier than correcting scar contracture. Most puckers are more a problem of excess subcutaneous tissue rather than skin excess (which is why the skin resection pattern should be designed as a U rather than a V).
Any remaining fullness or asymmetry can be corrected with liposuction after initial suturing. The area along the inframammary fold can be suctioned to achieve the desired contour. If too much medial fullness is present, this area can also be safely suctioned. However, suctioning the base of the medial pedicle is a mistake because the arterial supply comes from the internal mammary system and progresses superiorly toward the nipple. The liposuction cannula can damage the blood vessels.
Thinning the area below the position of the new inframammary fold is critical; otherwise, fullness and puckering result. As opposed to the position of the inframammary fold with the inferior pedicle of the Wise-pattern technique, the inframammary fold after the medial pedicle vertical technique rises a mean of 1-2 cm. The tissue between the original inframammary fold and the new one must be thinned; otherwise, fullness and puckering result. The lateral curve of the inframammary fold can be substantially improved by using liposuction.
When the surgeon first learns this technique, under-resection is common. It is important to retain as much superior tissue as possible to maintain upper-pole fullness with removal of only the amount needed to allow for insetting of the areola. It is best to remove excess parenchyma laterally and inferiorly. Taking even more tissue laterally parallel to the chest wall allows the surgeon to leave behind good tissue for pillars. For some reason, the breasts look smaller on the table with this technique than they do with the inverted-T techniques. If the surgeon thinks that the reduction should be about 800 g, he or she should keep removing tissue to achieve enough reduction. The author always warns patients preoperatively that they might not be as small as they would like to be.
The medial pedicle (even one of full thickness) is floppy and easily rotates into position (see section E of the first image below and sections F and G of the second image below). This rotation is not dissimilar to the ease with which the inferior pedicle can be manipulated. The base of the areolar opening is closed with 3-0 Monocryl suture. No undermining of the base of the pedicle is needed for this suture.
The pedicle is then easily rotated into position. No suturing of the pedicle is needed unless the surgeon is concerned that the length of the pedicle will cause inferior sagging in a large breast. If it appears that drag will be created on the pedicle, suturing may be indicated to prevent a hollowing of the breast, which can occur around the areola superiorly as the pedicle pulls away from the remaining breast tissue.
Closure and healing of the medial and lateral pillars hold up the breast tissue. The inferior border of the medial pedicle becomes the medial pillar. It is important to rotate the base of the pedicle up enough to visualize (and suture) the medial pillar to the lateral pillar to create and hold the breast parenchyma in a Wise pattern.
The medial and lateral pillars of breast tissue are then sutured together with 3-0 Monocryl suture. This shaping causes coning of the breast tissue, and more or less projection can be achieved as desired. If little tissue is left inferiorly, not much is present to bottom out with time. Some sagging of the medial pedicle occurs centrally, giving the breast the desired shape. The medial pedicle gives an elegant curve to the lower half of the breast and avoids the "Snoopy" type of shape with a concave lower pole on the operating table that often results when using a superior pedicle.
If the pedicle is large and/or long, as with a large (eg, 1500 g) breast reduction, suturing some of the pedicle to the chest wall may be indicated.
If the medial and lateral pillars are sutured with excessive tension that causes lateral indentation of the skin, the indentation persists indefinitely or requires several months to soften. The present author initially tried to pull lateral tissue medially when using the lateral pedicle, but this returned to its original position, leaving too much lateral fullness. A comparison of shapes with the medial and lateral pedicles showed that the medial pedicle improved the shape while maintaining equal sensation (see Relevant anatomy section above). The medial pedicle allows all of the excess lateral tissue to be resected. The problem with the lateral pedicle is that it is the tissue at the base of the pedicle that must be removed to achieve a good shape.
Only a few sutures are needed to bring the pillars into position. The role of the sutures is to hold the pillars against each other in position long enough for them to heal together. It is important to take small bites and to suture fibrous tissue to fibrous tissue for this healing to occur. The author has yet to find a patient in whom this fibrous tissue cannot be found. Taking large bites of fat can result in fat necrosis and poor healing. Lassus does not suture the pillars, but his skin closure holds the pillars close to each other so that this healing process can take place.
It is incorrect to try to push tissue into the upper pole and expect it to stay. Instead of increasing upper-pole fullness, the tissue drops out and causes bottoming out. The vertical technique can increase projection, but it cannot increase fullness of the upper pole.
Liposuction is then performed in the lateral chest wall and the preaxillary areas as needed for further shaping of the chest wall.
The skin is closed with interrupted deep dermal sutures with 3-0 Monocryl suture (see section E of the image below). Suturing the skin to the breast tissue is not necessary. The skin does not need to be undermined for any release, even from the base of the pedicle. The skin is then closed with subcuticular 3-0 Monocryl suture. The skin is no longer gathered with closure. Postoperative measurements show that this vertical incision stretches back close to its original length. If it does not stretch, it causes scar contracture and delays resolution of the result.
Lejour used to gather the whole vertical incision. The author modified the technique and only performed some gathering at the inferior end. Measurements showed that gathering either eventually stretched or resulted in permanent pleats. Currently, the author no longer performs any gathering or cinching of the vertical incision. Although gathering the skin was originally believed to reduce the length of the vertical scar, this does not appear to happen. If the skin is of poor quality or substantially redundant, it can be removed as a J, L, or short T. Gathered skin, especially if any skin tension is present, constricts the wound edges, interferes with blood supply, and delays healing.
A study by Matthews et al found that although gathering the sutures during vertical breast reduction significantly reduced the incision length during surgery, it did not ultimately change the distance from the areola to the inframammary fold. In the study, of 396 women who underwent vertical reduction mammaplasty, including 193 in whom the sutures were gathered, the postoperative distance from the areola to the inframammary fold was found to gradually increase. It was also found that suture gathering did not affect the pucker revision rate but did increase healing complications and have a negative impact on vascularity. 
The idea that the vertical incision should only be 5 cm is related to the anchor-shaped breast reductions in which the skin is used to hold the shape. Also, this inferior skin stretches with time in the inferior pedicle inverted-T techniques because of the weight of the breast in the lower pole. With the vertical breast reduction, this length is needed to accommodate the increased projection that results from this technique.
The areola is sutured with a few interrupted sutures of 3-0 Monocryl in the deep dermis and with continuous subcuticular 3-0 or 4-0 Monocryl suture around the circumference (see sections H and I of the image below).
Drains are rarely used. Patients are now given one preoperative dose of antibiotics. Intravenous cephalosporin is used intraoperatively, the patient is prepped with chlorhexidine, and an antibacterial suture is used for skin closure.
Micropore paper tape is used over the incisions (the adhesive in some generic tapes tends to ball up). Patients are instructed to wash over the tape and pat it dry. The tape is left in place for 3-4 weeks, when it peels off easily, and the incisions are nicely healed underneath. A surgical brassiere is used only to hold gauze bandages (and then pantiliners) in place. The breasts themselves are not taped. The patient is instructed to shower the day after surgery.
Patients are advised to use the surgical bra continuously for approximately 2 weeks if they wish and then to progress to a sports bra or an otherwise minimally shaped brassiere.
The vertical-wedge concept applies equally to mastopexy. It is wrong to think that the skin-resection pattern alone is sufficient to hold up the improved shape. Overlapping skin and dermis is doomed to failure because they stretch. Skin expansion relies on this ability for skin to stretch. Most mastopexy patients have already proven that they have poor quality skin that stretches.
The tissue that is "removed" as a wedge resection in a breast reduction must be "moved" in a mastopexy. This parenchyma can be moved and rearranged in several ways so that it heals in a new position. Again, this method relies on healing of fibrous tissue to fibrous tissue (rather than fat tissue to fat tissue) to hold the shape. Expecting the breast tissue to hold to itself is more reasonable than expecting the breast tissue to heal and hold to the slippery pectoralis fascia. The breast is not attached to the chest wall but is held in place by the skin structures of the inframammary fold and the medial breast border at the sternum.
Patients need to be warned that a mastopexy can only lift sagging tissue. The whole breast cannot be raised on the chest wall. The breast footprint determines whether a patient is "high-breasted" or "low-breasted." The breast falls off the footprint like an awning or a Slinky (Corduff, personal communication, 2009) and it can be lifted back up onto the footprint. The breast will still hang off the footprint to some degree; it is actually very difficult to prevent some breast skin from sitting down and resting on the chest wall to some degree. When patients understand that the inframammary fold (the level where the brassiere underwire sits) does not change, they can better understand the limitations of the procedure.
Patients also need to understand that upper-pole fullness is elusive. It can often be achieved only with a breast implant.
Medially based lateral recruitment flap
The procedure for mastopexy (see image below) is similar to breast reduction, but a superior pedicle is used to carry the areola.
In this manner, the inferior and lateral breast tissue is recruited, mobilized, and rotated up under the pedicle carrying the areola. This method prevents the inferior fullness that can result. This flap of tissue is based medially and extends laterally and inferiorly beyond where the skin was de-epithelialized for skin resection.
The pedicle carrying the areola is created as described for the breast reduction, and the tissue that is normally resected is then mobilized by incising it inferiorly. This inferior flap is moved underneath the lateral pedicle. (Remember that the pedicle is malleable, and the full-thickness part of the pedicle can easily be maneuvered to the side to allow the inferior breast tissue to be rotated up and sutured into position.)
If the areola needs to be moved a considerable distance, a third flap can be created above the areola. This third flap can be folded up under the breast above the new areolar site and thereby acts as a slight augmentation flap. This flap is also best designed with a medially based pedicle to ease its inset.
As with the breast reduction, suturing to the pectoralis fascia is not believed to be as valuable as suturing breast tissue to breast tissue. Closure for the mastopexy is similar to that for the reduction.
Superior pedicle extension flap
The superior pedicle can be extended into the vertical wedge area inferiorly, and this extension can then be folded up under the nipple-areolar complex. Insetting this flap can be difficult, and it is important not to take too much skin when the skin-resection pattern is designed. This flap is effective for rearranging the breast tissue and for increasing projection of the breast. It is not long enough to be particularly effective for increasing upper-pole fullness (F. Nahai, verbal communication, August 2006).
Medial-pedicle extension flap
The design of the medial pedicle sometimes allows it to be extended inferiorly into the vertical wedge area that needs to be mobilized. The superior pedicle extension flap is folded up under the nipple, but the medial pedicle extension flap is rotated up into the upper pole. Both methods are good for moving and rearranging the breast parenchyma to allow the breast to be reshaped. If the breast is not reshaped, the skin stretches and a good result is not achieved (Siegel, email communication, 2004; Corduff, personal communication, 2009). 
Inferior flap with pectoralis sling
Graf popularized Daniel’s modification of Ribeiro's inferior flap [43, 44] (without the nipple-areola complex) by holding it up with a pectoralis muscle-fascial sling.  Ribeiro sutures the flap up to the chest wall without using the sling. Both methods are effective at taking the vertical wedge of tissue that needs to be moved in a mastopexy and rearranging it. The author prefers Graf's method because it not only provides longevity to the shape but can also sometimes increase upper-pole fullness. The sling is only partial thickness, and the retropectoral space is not entered. The argument that this method somehow violates an oncologic plane does not make much sense.
The scars associated with vertical mastopexy are superior to those of anchor-shaped techniques. The vertical scar is the least obvious of the 3 (periareolar, vertical, inframammary), and the addition of the vertical scar is worth the results.
Periareolar mastopexy tends to flatten the breast, and most patients prefer projection. To be effective with the Benelli  technique (and that of Sampaio Goes  ), the surgeon must separate the skin from the breast tissue and not just advance the skin. Suturing the outer circle of skin to the inner circle of the areola without skin undermining leads to a starburst shape and/or stretching of the areola, along with flattening of the breast. The author has had limited success with the permanent periareolar suture techniques. Although these results may be due to a lack of experience, flattening of the breast has discouraged the author from persisting with these techniques.
The vertical form of mastopexy in which the vertical wedge of tissue is moved is more durable than traditional techniques that rely on the skin to maintain the shape over time.
Drains are rarely used. Patients are now only given one dose of preoperative antibiotics. Intravenous cephalosporin is used, along with an antibacterial skin suture.
Micropore paper tape is used over the incisions. Patients are instructed to wash over the tape and pat it dry. The tape is left in place for 3-4 weeks, when it peels off easily, and the incisions are nicely healed underneath. A surgical brassiere is only used to hold gauze bandages (and then pantiliners) in place. The breasts themselves are not taped. The patient is instructed to shower the day after surgery.
Patients are advised to use the surgical bra continuously for approximately 2 weeks and then to progress to a sports bra or an otherwise minimally shaped brassiere.
General follow-up considerations
Weeks to months can be required in the larger breast reductions for the puckering to settle inferiorly. The inferior end of the vertical incision is the most likely spot for healing problems. Local wound care and reassurance are sufficient. Puckers rarely need to be excised and not before 6-12 months (see images below). If puckers must be excised, a small vertical scar is usually all that is needed, and the fat underlying the pucker medially and laterally can be removed with direct excision beveling out from the small skin excision or with liposuction.
The fullness and puckering that result are less of a result of excess skin than a result of excess subcutaneous tissue that was inadvertently left between the original inframammary fold and the new, higher inframammary fold.
The same concepts apply when mastopexy is performed and an implant is added. However, incorporating the principle of excision or rearrangement of the inferior vertical wedge of tissue becomes more difficult with the combined procedure. Adding the weight of the implant to a procedure, which should not rely on the skin to hold the shape, is also a problem that often results in failure.
Surgeons in North America are now permitted to use some of the silicone gel implants, and many surgeons still place all their implants in the subpectoral position. Their experience with saline implants resulted in more problems with rippling than with the gel implants. The author believes that the muscle holds the implant up on the chest wall only when it heals in an abnormally high position because of postoperative muscle spasm. When the implant heals in an ideal position, the muscle does not hold it up; in fact, muscular movement can push the implant inferiorly when the dual plane is used. The muscle is good for padding, and the dual plane is best for minimizing postoperative muscular distortion. When a patient has sufficient padding (3 cm superiorly and 2 cm medially), the author uses the subglandular position.
In much of the rest of the world, surgeons have additional options both in implant choice and, therefore, implant placement. Several authors prefer a cohesive gel implant placed in the subfascial position. [47, 48] The author tried a subfascial sling to help hold the implant up but did not find that it held long term. Sampaio Goes and Graf believe that the creation of a superior flap also helps blunt the edges of the implant.
Because the risk of complications with mastopexy-augmentation are more than the sum of the risk of complications with mastopexy and with augmentation,  it is important not to remove the excess skin until the implant is put in place. After the implant is inserted (the author usually uses a vertical incision through the inferior area where the skin will be removed), the amount of skin excess can be judged and marked again. The markings are often the same as the preoperative markings, but it is best to confirm them.
Of course, the larger the implant used, the greater the forces of gravity. Large implants speed deterioration of the shape, with bottoming out and movement of the implant out of the upper pole.
The simplified vertical technique for breast reduction has been used in more than 1800 patients. A superior pedicle was initially used, and the same problems were encountered with inserting the pedicle. Unfortunately, this resulted in some problems with nipple necrosis. Because the author had not had any patients with nipple necrosis during more than 10 years' experience with the inferior-pedicle technique, she was tempted to abandon the procedure. However, improved results warranted some persistence.
The lateral pedicle was first used because surgeons assumed that it improved sensation compared with the medial pedicle, but this method prevented adequate resection of lateral breast tissue, with resulting lateral fullness. This fullness is in the area where the breast tissue is most fibrous and where it cannot be removed with liposuction and must be directly excised.
The medial pedicle improved shaping and achieved surprisingly good sensation (equal to that of the lateral and superior pedicles). The versatility of the pedicle was unmatched by the superior pedicle, as described for the classic vertical techniques. Although the inferior pedicle can be used, it is reserved for revision in a patient who underwent a previous inferior pedicle procedure.
The incidence of complete nipple necrosis is 0.5%. Partial nipple necrosis occurs in a similar percentage of patients. The author has been pleasantly surprised at how well the nipple and areola turn out without intervention. It is tempting to debride the necrotic tissue, but it is often best to leave it to separate and heal by secondary intention. If the whole pedicle develops necrosis, then active debridement may be necessary.
Patients were not given antibiotics until an infection rate of 10% became evident in the larger breast reductions. This rate might have been partly related to the skin undermining performed in the classic Lejour technique in the initial patients. Because this undermining has been eliminated (the resection is beveled instead) and because patients are given perioperative cephalosporins, the infection rate has decreased to less than 0.5%.
Many patients had minor problems with wound healing with no evidence of clinical infection. After all patients were given perioperative antibiotics, the incidence of such problems was dramatically reduced. This observation raised an interesting issue about minor wound-healing problems and their relationship to infection. Nothing else was changed except for the addition of antibiotics. However, wound-healing problems also occur if the edges of the incision are constricted because of excessive gathering of the skin or if the skin is pulled too tight. The author tried various maneuvers to reduce the use of antibiotics and has now settled on a single intraoperative dose of antibiotics and use of an antibacterial suture for the skin closure.
As with any new procedure, the revision rate was high with the initial series of patients (7%). The main problem was and still is underresection. Puckers may need to be excised; these more frequently occurred in the initial patients (see image below). Puckers are often more of a problem of residual subcutaneous tissue than of excessive skin. For this reason, the excessive skin can often be excised vertically, and the excessive subcutaneous tissue can be excised horizontally under the skin flaps. Adding a horizontal scar often leads to the need to revise the revisions.
Until surgeons realized that the inframammary fold rises with this procedure, a few patients had scars that extended below the fold. This situation can be corrected with a horizontal excision.
Fat necrosis is uncommon. When it occurs, fat necrosis is usually minor and related to what is thought to be parasitic fat along the margins of the pedicle. Minor amounts of fat necrosis can be missed unless the breast is specifically examined for this complication. No treatment is needed except for explanation and reassurance. No patients have required surgery to treat this complication unless it was associated with a full nipple necrosis.
Large suture bites in the pillars can also apparently lead to fat necrosis. The author believes that it is important to take small bites of fibrous tissue so that fibrous tissue in the pillars can heal to fibrous tissue and not fat to fat.
Delayed healing of the skin was evident in the initial series of patients in whom skin undermining was performed. Delayed healing may occur and is most likely to be a problem at the inferior end of the vertical incision in the larger reductions. This was worse when skin gathering was performed. Care must be taken to close the vertical incision loosely and with superficial bites so that the skin is not constricted.
Wound breakdown at the inferior aspect of the vertical incision occurred most frequently when the skin was gathered excessively. This was more common with large reductions in the obese patients.
Only 3 out of 1800 patients have undergone repeat surgery because of hematoma. Three patients had minor hematomas that were treated conservatively. When a hematoma was observed at the 2-wk follow-up appointment in a patient who had had an overnight drain in place, the author decided that the hematoma had probably been caused during the drain removal. Drains have rarely been used since that time.
Outcome, Prognosis, Future, and Controversies
Outcome and prognosis
Without question, vertical reduction mammaplasty has improved scars.
Now that the author has had more than 16 years' experience, the results have proven that the shape is better and more durable with vertical reduction mammaplasty than with other techniques. The shape appears to resist the effects of gravity better with this method than with inferior pedicle. This outcome is believed to be because the tissue removed is the heavy inferior tissue and because the desirable superior breast tissue is preserved and left attached to the skin. This technique relies on the tissue resected, the shaping of the breast tissue, and the lack of reliance on the skin to hold and maintain the shape.
A study by Swanson using photographic measurements found upper pole projection to be significantly increased in breast reduction using the vertical technique but not the inverted-T method. In addition, breast projection was found to be better preserved in vertical reduction than in inverted-T surgery, while breast constriction was reportedly greater using the inverted-T method than with vertical reduction. 
However, a retrospective study by Fernandez et al comparing outcomes of breast reductions using either an inverted-T or pure vertical technique indicated that younger patient age and lower resected tissue weight had a greater positive influence on aesthetic results than did the reduction method used. The study included 104 patients. 
A small study of a single surgeon experience analyzed 84 patients who underwent breast reduction surgery. In all, 49 patients had inferior pedicle reductions and 35 patients had medial pedicle reductions. The medial pedicle group experienced less complications and hypertrophic scarring than the inferior pedicle group.  Current techniques for coning of the breast tissue do not equal the increased projection and longevity of the shape possible with this type of vertical reduction.
Future and controversies
Surgeons have been taught how to perform breast reduction by using a pedicle to carry the nipple areola and by avoiding undermining of the skin. Several variations have been adopted, but most rely on the skin brassiere to hold the shape.
Vertical breast-reduction techniques were initially adopted to reduce scarring. However, the future lies in a reassessment of the concepts. The skin brassiere can hold the shape initially, but it fails over the long term. The controversy is whether the skin brassiere or the breast parenchyma sutures are most important. Although both can be important, the key factors may be the nature of the resection and the reliance on the healing of the breast pillars to each other to hold the shape. Medial-pedicle vertical breast reduction removes the inferior tissue susceptible to the effects of gravity and leaves the superior tissue desired for shaping. Unfortunately, many Wise-pattern techniques leave tissue inferiorly. These techniques then rely on the skin brassiere to hold the shape. Therefore, the question that must be answered is this: Why should one rely on the skin to prevent ptosis when the skin fails and allows ptosis to develop in the first place?