Journal of Plastic, Reconstructive & Aesthetic Surgery (2014) 67, e147ee150
Dermal flaps in breast reduction: Prospective study in 100 breasts* Sophie Domergue*, Makram Ziade, Marine Lefevre, Alexandre Prud’homme, Jacques Yachouh Oral, Maxillo-facial and Plastic Surgery Department, Gui De Chauliac University Hospital, Montpellier, France Received 30 January 2013; accepted 2 February 2014
KEYWORDS Dermal flaps; Breast reduction; Surgical wound dehiscence; Surgical technic
Summary The most common complication of breast reduction with inverted T-scar technique is wound dehiscence at the junction of the vertical and horizontal sutures. In this study, a technique involving three triangular dermal flaps is presented with the results for healing in the junctional T zone. Fifty women were included in a comparative, single-center randomized double-blind prospective study to evaluate the efficiency of the three-triangular dermal-flap technique in healing in the junctional T zone. All patients were seen for follow-up at 7 days, 14 days, 21 days, 28 days, 35 days, 42 days, and 49 days after surgery to evaluate primary healing in the T zone. Average healing time was 19.7 days in the triangular-skin-flap series and 25.48 days in the control series, with a statistically significant difference (p < 0.01). One patient in the triangular-skin-flap series experienced dehiscence in the T zone (2%) versus eight patients (16%) in the control series. A statistically significant difference was noted (p Z 0.012). This technique is based on the association of two principles. First, ischemia on the edges as well as skin necrosis is limited by suturing the two superior skin flaps rather than directly suturing the cutaneous angles. In addition, this technique brings an underlying dermal support. Second, the inferior flap width allows fixing two sutures laterally to limit the central tension. This easy technique does not lengthen total operative time and significantly improves healing time. It is applicable to all breast reductions with inverted T scars. ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
* This work was presented at the National Congress of the French Society of Plastic Reconstructive and Aesthetic Surgery, 26th of November 2012. * Corresponding author. Oral, Maxillo-facial and Plastic Surgery Department, Gui De Chauliac University Hospital, 80, Avenue Augustin Fliche, 34090 Montpellier, France. E-mail addresses: [email protected], [email protected] (S. Domergue).
http://dx.doi.org/10.1016/j.bjps.2014.02.004 1748-6815/ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
e148
S. Domergue et al.
Introduction Breast reduction is a relatively common plastic surgery procedure. Although shorter scars can be achieved with vertical scar techniques,1,2 inverted T-scar techniques are useful for cases of severe ptosis.3,4 The most common complication when breast reduction is treated with inverted T-scar techniques is the dehiscence at the T-junction. In this study, we evaluated treatment outcomes for healing in the T zone with a triangular-dermal-flap technique. We believe that this technique improves healing time in the junctional T zone.
Material and methods Between January 2009 and December 2010, 50 women were included in our comparative, single-center randomized double-blind prospective study. Criteria for exclusion from the study included: smokers (cessation for >2 months), a body mass index over 30, diabetes or high blood pressure, long-term use of corticosteroids or anticoagulants, or postoperative complications other than delayed healing (hematoma, infection, cytosteatonecrosis). The triangular-dermal-flap technique was used on one of the two breasts, alternatively, after obtaining patients’ informed consent. The technique was used for the “triangle” group of breasts versus the “control” group of breasts, for which the technique was not used. The sequence of randomization was established prior to study by the department of the medical information. Ethics approval was not required for our institution. All breast reductions were performed by a single surgeon using Wise pattern marking. The horizontal incision line was marked on the submammary fold, gradually ascending toward the lateral pole of the breast. Three triangles were marked at the onset of the intervention as described in Figure 1. The two superior equilateral triangles measured 1.5 cm long and the inferior isosceles triangle had a 5-cm base and 4-cm-long sides. The triangular flaps were deepidermized eliminating all the subcutaneous fat, and one piece of the excess skin and adipose and glandular tissues of the lower pole, with a wedge-shaped prolongation toward the center of the breast, were resected (Figure 2). We then tailored a pedicled superomedial dermoglandular flap for the transposition of the nipple areolar complex (NAC). The flap was thicker toward its base, ensuring good vascularization, as well as sufficient tissues in the superior mammary pole. The transposition of the superomedial dermoglandular flap was not difficult. It is important that the NAC be rotated easily without tension. Conification of the breast is accomplished by suturing the NAC with 3/0 absorbable suture. Then the three flaps were sutured. The two superior triangle flaps are superposed on the inferior triangle flap with absorbable 3/0 suture. After placement of this suture, two lateral superior sutures are placed 1 cm laterally to the lower triangular flap to decrease the tension on the T zone (Figure 3).
Figure 1 The horizontal incision line was marked on the submammary fold, gradually ascending toward the lateral pole of the breast. Three triangles were marked at the onset of the intervention. The two superior equilateral triangles measured 1.5 cm long and the inferior isosceles triangle had a 5-cm base and 4-cm-long sides.
The vertical and horizontal subcutaneous lines were sutured with absorbable 3/0 suture. Cutaneous suture is performed with two absorbable 3/0 monofilament intradermal continuous sutures horizontally and vertically with one intradermal continuous suture, avoiding the T zone, which was sutured with two absorbable 5/0. In cases requiring additional reduction and remodeling after the breast is assembled, the base of the lateral glandular flap, with a volume usually greater in cases of severe hypertrophy, can be resected. No drains were used. All patients were seen for follow-up at 7 days, 14 days, 21 days, 28 days, 35 days, 42 days, and 49 days after surgery
Figure 2 The triangular flaps were deepidermized eliminating all the subcutaneous fat, and one piece each of the excess skin and adipose and glandular tissues of the lower pole, with a wedge-shaped prolongation toward the center of the breast was resected.
Dermal flaps in breast reduction
e149 The average weight resected was 550 g per breast in the “triangle” group and 490 g in the “control” group, with no statistically significant difference (p Z 0.12). The mean weight in the breast group with breakdown (nine cases) was larger than the mean weight in the breast group without breakdown (528 g versus 496 g), but the difference was not significative (p Z 0.12; Table 1).
Discussion
Figure 3 The two superior triangle flaps are superposed on the inferior triangle flap with absorbable 3/0 suture. After the central triangular suture is placed, the tension-reducing sutures are inserted.
by two surgeons who were blind to the technique used for each breast. The principal evaluated criterion was the breakdown occurrence. Time healing was also noted. Scars were defined as healed when the following criteria were met: good congruence of cutaneous edges for breast without breakdown and end of secondary intention healing, if dehiscence occurred. Dehiscences in the T area and healing time were compared. Statistical analysis was calculated with the Wilcoxon test, a nonparametric pair difference test, and the McNemar’s test.
Results The average age of patients was 41 (18e65 years old). One patient in the triangle series experienced breakdown in the T zone (2%) versus eight cases in the control series (16%), with a statistically significant difference (p Z 0.012). The average healing time was 19.7 days in the triangle group versus 25.5 days in the control group, with a statistically significant difference (p < 0.01) that confirmed our clinical analysis.
Table 1
Our triangular-dermal-flap technique results in shorter healing time and significantly fewer dehiscences at the T-junction. Women with risk factors for poor-quality healing were excluded from our study to provide a more homogeneous patient population and to evaluate healing time as a single variable. Our technique was alternately used for the right or the left breast to limit biases due to lateralization or weight discrepancies between the two breasts. The absence of significant difference in weight resection between the two groups brings better homogeneity to compare them. Even if delayed healing in the inverted T zone only rarely leads to serious complications or unsightly cosmetic outcomes, it entails longer treatment time and delayed resumption of a normal social life. Moreover, it results in an increased cost in terms of public health. Complications with scar formation at the T-junction ranging from 12.6% to 16.8% of the patients3,5e8 have been observed in the literature, as we observed in our control group. Inadequate subcutaneous support and diverging tensions in this zone are most likely the principal cause of scar dehiscences. Furthermore, tensions are increased in case of postoperative swelling and heavier breasts, where we observed more breakdown in bigger breast reduction; but the difference was not significative between the two groups. We used the superomedial pedicle technique with inferior resection because NAC could be fixed without tension. That it removed the underlying dermal support at the level of the inverted T-junction, which is present in McKissock or inferior pedicle techniques,9,10 led to inconvenience. This is the first reason for developing our triangular-dermal-flap technique. Several lower glandular dermal suspension flap techniques have been described and implemented. In 1996, a
Breakdown patients’ results.
Breakdown patient numbers
Groups
Breast side
Weight of reduction (g)
Healing time (days)
2 15 18 31 34 34 40 43 47
Control Control Control Control Triangle Control Control Control Control
Left Right Right Right Left Right Left Right Left
430 570 530 960 390 410 670 320 480 Mean weight Z 528.8 g
35 28 42 28 28 35 35 42 28 Mean time Z 33.4 days
e150 double skin technique was found to reinforce the prosthesis for optimal stability with mastopexies.11 In 2002, a glandular dermal-suspension-flap technique, similar to the Lejour technique, resulted in less dehiscence.12 In 2003, a protection skin flap in the T zone was described for skinsparing mastectomies with T-scars.13 In 2005, the McKissock’s skin flap technique was applied to breast reduction with good results.14 In 2006, an “internal bra” system resulted in 5% shorter healing time at the T-junction.15 In addition to limiting diverging tensions, it is also important to avoid ischemia of the cutaneous and subcutaneous sutures at the angles of scars. In 2004, De La Plaza16 thus carried out a retrospective study in 136 women to evaluate dehiscence having undergone two crossed dermal flaps. No patient experienced dehiscence but healing time was not evaluated. The technique presented in our study is based on the association of two principles. First, ischemia on the edges as well as skin necrosis is limited by suturing the two superior skin flaps rather than directly suturing the cutaneous angles and gives underlying dermal support. Second, the inferior flap width allows fixing two sutures laterally to limit the central tension on the T zone as described by Akhtar in 2007.17 However, it was not possible to compare our results with the results in these studies due to differences in the evaluation criteria. This technique is easy to use and it does not lengthen the total operative time. It is applicable to all cases of breast reduction with inverted T-scars, and is recommended in particular for severe breast ptosis or poor skin quality.
Conflict of interest/funding statement None.
References 1. Lejour M. Vertical mammaplasty: update and appraisal of late results. Plast Reconstr Surg 1999;104:771e81. 2. Hall-Findlay EJ. Vertical breast reduction with a mediallybased pedicle. Aesthet Surg 2002;22(2):185e94.
S. Domergue et al. 3. Okoro SA, Barone C, Bohnenblust M, Wang HT. Breast reduction trend among plastic surgeons, a national survey. Plast Reconstr Surg 2008;122(5):1312e20. 4. Rorich R, Gosma AA, Brown SA, Tonadapu P, Foster B. Current preferences for breast reduction techniques: a survey of board-certified plastic surgeons 2002. Plast Reconstr Surg 2004;114(7):1724e33. 5. Menderes A, Mola F, Vayvada H, Barutcu A. Evaluation of results from reduction mammaplasty: relief of symptoms and patient satisfaction. Aesthetic Plast Surg 2005;29(2):83e7. 6. Zoumaras J, Lawrence J. Inverted T versus vertical scar breast reduction: one surgeon’s 5-year experience with consecutive patients. Aesthet Surg J 2008;28(5):521e6. 7. Hosnuter M, Tosun Z, Kargi E, Babuccu O, Savaci N. No-verticalscar technique versus T-scar technique in reduction mammoplasty: a two centre comparative study. Aesthetic Plast Surg 2005;29(6):496e502. 8. Stevens WG, Gear AJ, Stoker DA, et al. Outpatient reduction mammaplasty: an eleven-year experience. Aesthet Surg J 2008;28(2):171e9. 9. Robbins TH. A reduction mammaplasty with the areola-nipple based on an inferior pedicle. Plast Reconstr Surg 1977;59: 64e7. 10. McKissock PK. Reduction mammaplasty with a vertical dermal flap. Plast Reconstr Surg 1972;49:245e52. 11. Goes JC. Periareolar mammaplasty with mixed mesh support: the double skin technique. Plast Reconstr Surg 1996;97(5): 959e68. 12. Exner K, Scheufler O. Dermal suspension flap in vertical-scar reduction mammaplasty. Plast Reconstr Surg 2002;109(7): 2289e98. 13. Mateucci P, fourie le R. Skin sparing mastectomy using the Wise pattern: protecting the T junction with a dermal pedicle. Br J Plast Surg 2004;57(5):473e5. 14. Menderes A, Mola F, Vayvada H, Yilmaz M, Baytekin C. Dermal suspension flaps for McKissock’s vertical bipedicle flap vs. classical McKissock’s technique: comparison of aesthetic results and patient satisfaction. Br J Plast Surg 2005;58(2): 209e15. 15. Rubin JP. Mastopexy after massive weight loss: dermal suspension and total parenchymal reshaping. Aesthet Surg J 2006; 26(2):214e22. 16. De La Plaza R. The crossed dermal flaps technique for breast reduction. Aesthetic Plast Surg 2004;28:383e92. 17. Akhtar S, Whittaker I, Fourie LA. Tension reducing suture to protect the T junction after reduction mammaplasty. Plast Reconstr Surg 2007;119(4):1386e7.
Dermal flaps in breast reduction: Prospective study in 100 breasts* Sophie Domergue*, Makram Ziade, Marine Lefevre, Alexandre Prud’homme, Jacques Yachouh Oral, Maxillo-facial and Plastic Surgery Department, Gui De Chauliac University Hospital, Montpellier, France Received 30 January 2013; accepted 2 February 2014
KEYWORDS Dermal flaps; Breast reduction; Surgical wound dehiscence; Surgical technic
Summary The most common complication of breast reduction with inverted T-scar technique is wound dehiscence at the junction of the vertical and horizontal sutures. In this study, a technique involving three triangular dermal flaps is presented with the results for healing in the junctional T zone. Fifty women were included in a comparative, single-center randomized double-blind prospective study to evaluate the efficiency of the three-triangular dermal-flap technique in healing in the junctional T zone. All patients were seen for follow-up at 7 days, 14 days, 21 days, 28 days, 35 days, 42 days, and 49 days after surgery to evaluate primary healing in the T zone. Average healing time was 19.7 days in the triangular-skin-flap series and 25.48 days in the control series, with a statistically significant difference (p < 0.01). One patient in the triangular-skin-flap series experienced dehiscence in the T zone (2%) versus eight patients (16%) in the control series. A statistically significant difference was noted (p Z 0.012). This technique is based on the association of two principles. First, ischemia on the edges as well as skin necrosis is limited by suturing the two superior skin flaps rather than directly suturing the cutaneous angles. In addition, this technique brings an underlying dermal support. Second, the inferior flap width allows fixing two sutures laterally to limit the central tension. This easy technique does not lengthen total operative time and significantly improves healing time. It is applicable to all breast reductions with inverted T scars. ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
* This work was presented at the National Congress of the French Society of Plastic Reconstructive and Aesthetic Surgery, 26th of November 2012. * Corresponding author. Oral, Maxillo-facial and Plastic Surgery Department, Gui De Chauliac University Hospital, 80, Avenue Augustin Fliche, 34090 Montpellier, France. E-mail addresses: [email protected], [email protected] (S. Domergue).
http://dx.doi.org/10.1016/j.bjps.2014.02.004 1748-6815/ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
e148
S. Domergue et al.
Introduction Breast reduction is a relatively common plastic surgery procedure. Although shorter scars can be achieved with vertical scar techniques,1,2 inverted T-scar techniques are useful for cases of severe ptosis.3,4 The most common complication when breast reduction is treated with inverted T-scar techniques is the dehiscence at the T-junction. In this study, we evaluated treatment outcomes for healing in the T zone with a triangular-dermal-flap technique. We believe that this technique improves healing time in the junctional T zone.
Material and methods Between January 2009 and December 2010, 50 women were included in our comparative, single-center randomized double-blind prospective study. Criteria for exclusion from the study included: smokers (cessation for >2 months), a body mass index over 30, diabetes or high blood pressure, long-term use of corticosteroids or anticoagulants, or postoperative complications other than delayed healing (hematoma, infection, cytosteatonecrosis). The triangular-dermal-flap technique was used on one of the two breasts, alternatively, after obtaining patients’ informed consent. The technique was used for the “triangle” group of breasts versus the “control” group of breasts, for which the technique was not used. The sequence of randomization was established prior to study by the department of the medical information. Ethics approval was not required for our institution. All breast reductions were performed by a single surgeon using Wise pattern marking. The horizontal incision line was marked on the submammary fold, gradually ascending toward the lateral pole of the breast. Three triangles were marked at the onset of the intervention as described in Figure 1. The two superior equilateral triangles measured 1.5 cm long and the inferior isosceles triangle had a 5-cm base and 4-cm-long sides. The triangular flaps were deepidermized eliminating all the subcutaneous fat, and one piece of the excess skin and adipose and glandular tissues of the lower pole, with a wedge-shaped prolongation toward the center of the breast, were resected (Figure 2). We then tailored a pedicled superomedial dermoglandular flap for the transposition of the nipple areolar complex (NAC). The flap was thicker toward its base, ensuring good vascularization, as well as sufficient tissues in the superior mammary pole. The transposition of the superomedial dermoglandular flap was not difficult. It is important that the NAC be rotated easily without tension. Conification of the breast is accomplished by suturing the NAC with 3/0 absorbable suture. Then the three flaps were sutured. The two superior triangle flaps are superposed on the inferior triangle flap with absorbable 3/0 suture. After placement of this suture, two lateral superior sutures are placed 1 cm laterally to the lower triangular flap to decrease the tension on the T zone (Figure 3).
Figure 1 The horizontal incision line was marked on the submammary fold, gradually ascending toward the lateral pole of the breast. Three triangles were marked at the onset of the intervention. The two superior equilateral triangles measured 1.5 cm long and the inferior isosceles triangle had a 5-cm base and 4-cm-long sides.
The vertical and horizontal subcutaneous lines were sutured with absorbable 3/0 suture. Cutaneous suture is performed with two absorbable 3/0 monofilament intradermal continuous sutures horizontally and vertically with one intradermal continuous suture, avoiding the T zone, which was sutured with two absorbable 5/0. In cases requiring additional reduction and remodeling after the breast is assembled, the base of the lateral glandular flap, with a volume usually greater in cases of severe hypertrophy, can be resected. No drains were used. All patients were seen for follow-up at 7 days, 14 days, 21 days, 28 days, 35 days, 42 days, and 49 days after surgery
Figure 2 The triangular flaps were deepidermized eliminating all the subcutaneous fat, and one piece each of the excess skin and adipose and glandular tissues of the lower pole, with a wedge-shaped prolongation toward the center of the breast was resected.
Dermal flaps in breast reduction
e149 The average weight resected was 550 g per breast in the “triangle” group and 490 g in the “control” group, with no statistically significant difference (p Z 0.12). The mean weight in the breast group with breakdown (nine cases) was larger than the mean weight in the breast group without breakdown (528 g versus 496 g), but the difference was not significative (p Z 0.12; Table 1).
Discussion
Figure 3 The two superior triangle flaps are superposed on the inferior triangle flap with absorbable 3/0 suture. After the central triangular suture is placed, the tension-reducing sutures are inserted.
by two surgeons who were blind to the technique used for each breast. The principal evaluated criterion was the breakdown occurrence. Time healing was also noted. Scars were defined as healed when the following criteria were met: good congruence of cutaneous edges for breast without breakdown and end of secondary intention healing, if dehiscence occurred. Dehiscences in the T area and healing time were compared. Statistical analysis was calculated with the Wilcoxon test, a nonparametric pair difference test, and the McNemar’s test.
Results The average age of patients was 41 (18e65 years old). One patient in the triangle series experienced breakdown in the T zone (2%) versus eight cases in the control series (16%), with a statistically significant difference (p Z 0.012). The average healing time was 19.7 days in the triangle group versus 25.5 days in the control group, with a statistically significant difference (p < 0.01) that confirmed our clinical analysis.
Table 1
Our triangular-dermal-flap technique results in shorter healing time and significantly fewer dehiscences at the T-junction. Women with risk factors for poor-quality healing were excluded from our study to provide a more homogeneous patient population and to evaluate healing time as a single variable. Our technique was alternately used for the right or the left breast to limit biases due to lateralization or weight discrepancies between the two breasts. The absence of significant difference in weight resection between the two groups brings better homogeneity to compare them. Even if delayed healing in the inverted T zone only rarely leads to serious complications or unsightly cosmetic outcomes, it entails longer treatment time and delayed resumption of a normal social life. Moreover, it results in an increased cost in terms of public health. Complications with scar formation at the T-junction ranging from 12.6% to 16.8% of the patients3,5e8 have been observed in the literature, as we observed in our control group. Inadequate subcutaneous support and diverging tensions in this zone are most likely the principal cause of scar dehiscences. Furthermore, tensions are increased in case of postoperative swelling and heavier breasts, where we observed more breakdown in bigger breast reduction; but the difference was not significative between the two groups. We used the superomedial pedicle technique with inferior resection because NAC could be fixed without tension. That it removed the underlying dermal support at the level of the inverted T-junction, which is present in McKissock or inferior pedicle techniques,9,10 led to inconvenience. This is the first reason for developing our triangular-dermal-flap technique. Several lower glandular dermal suspension flap techniques have been described and implemented. In 1996, a
Breakdown patients’ results.
Breakdown patient numbers
Groups
Breast side
Weight of reduction (g)
Healing time (days)
2 15 18 31 34 34 40 43 47
Control Control Control Control Triangle Control Control Control Control
Left Right Right Right Left Right Left Right Left
430 570 530 960 390 410 670 320 480 Mean weight Z 528.8 g
35 28 42 28 28 35 35 42 28 Mean time Z 33.4 days
e150 double skin technique was found to reinforce the prosthesis for optimal stability with mastopexies.11 In 2002, a glandular dermal-suspension-flap technique, similar to the Lejour technique, resulted in less dehiscence.12 In 2003, a protection skin flap in the T zone was described for skinsparing mastectomies with T-scars.13 In 2005, the McKissock’s skin flap technique was applied to breast reduction with good results.14 In 2006, an “internal bra” system resulted in 5% shorter healing time at the T-junction.15 In addition to limiting diverging tensions, it is also important to avoid ischemia of the cutaneous and subcutaneous sutures at the angles of scars. In 2004, De La Plaza16 thus carried out a retrospective study in 136 women to evaluate dehiscence having undergone two crossed dermal flaps. No patient experienced dehiscence but healing time was not evaluated. The technique presented in our study is based on the association of two principles. First, ischemia on the edges as well as skin necrosis is limited by suturing the two superior skin flaps rather than directly suturing the cutaneous angles and gives underlying dermal support. Second, the inferior flap width allows fixing two sutures laterally to limit the central tension on the T zone as described by Akhtar in 2007.17 However, it was not possible to compare our results with the results in these studies due to differences in the evaluation criteria. This technique is easy to use and it does not lengthen the total operative time. It is applicable to all cases of breast reduction with inverted T-scars, and is recommended in particular for severe breast ptosis or poor skin quality.
Conflict of interest/funding statement None.
References 1. Lejour M. Vertical mammaplasty: update and appraisal of late results. Plast Reconstr Surg 1999;104:771e81. 2. Hall-Findlay EJ. Vertical breast reduction with a mediallybased pedicle. Aesthet Surg 2002;22(2):185e94.
S. Domergue et al. 3. Okoro SA, Barone C, Bohnenblust M, Wang HT. Breast reduction trend among plastic surgeons, a national survey. Plast Reconstr Surg 2008;122(5):1312e20. 4. Rorich R, Gosma AA, Brown SA, Tonadapu P, Foster B. Current preferences for breast reduction techniques: a survey of board-certified plastic surgeons 2002. Plast Reconstr Surg 2004;114(7):1724e33. 5. Menderes A, Mola F, Vayvada H, Barutcu A. Evaluation of results from reduction mammaplasty: relief of symptoms and patient satisfaction. Aesthetic Plast Surg 2005;29(2):83e7. 6. Zoumaras J, Lawrence J. Inverted T versus vertical scar breast reduction: one surgeon’s 5-year experience with consecutive patients. Aesthet Surg J 2008;28(5):521e6. 7. Hosnuter M, Tosun Z, Kargi E, Babuccu O, Savaci N. No-verticalscar technique versus T-scar technique in reduction mammoplasty: a two centre comparative study. Aesthetic Plast Surg 2005;29(6):496e502. 8. Stevens WG, Gear AJ, Stoker DA, et al. Outpatient reduction mammaplasty: an eleven-year experience. Aesthet Surg J 2008;28(2):171e9. 9. Robbins TH. A reduction mammaplasty with the areola-nipple based on an inferior pedicle. Plast Reconstr Surg 1977;59: 64e7. 10. McKissock PK. Reduction mammaplasty with a vertical dermal flap. Plast Reconstr Surg 1972;49:245e52. 11. Goes JC. Periareolar mammaplasty with mixed mesh support: the double skin technique. Plast Reconstr Surg 1996;97(5): 959e68. 12. Exner K, Scheufler O. Dermal suspension flap in vertical-scar reduction mammaplasty. Plast Reconstr Surg 2002;109(7): 2289e98. 13. Mateucci P, fourie le R. Skin sparing mastectomy using the Wise pattern: protecting the T junction with a dermal pedicle. Br J Plast Surg 2004;57(5):473e5. 14. Menderes A, Mola F, Vayvada H, Yilmaz M, Baytekin C. Dermal suspension flaps for McKissock’s vertical bipedicle flap vs. classical McKissock’s technique: comparison of aesthetic results and patient satisfaction. Br J Plast Surg 2005;58(2): 209e15. 15. Rubin JP. Mastopexy after massive weight loss: dermal suspension and total parenchymal reshaping. Aesthet Surg J 2006; 26(2):214e22. 16. De La Plaza R. The crossed dermal flaps technique for breast reduction. Aesthetic Plast Surg 2004;28:383e92. 17. Akhtar S, Whittaker I, Fourie LA. Tension reducing suture to protect the T junction after reduction mammaplasty. Plast Reconstr Surg 2007;119(4):1386e7.
