Friday, June 02, 2006

To "T" or not to "T", that is the question...

One of the trends in breast reduction surgery is the trend towards "short-scar" procedures which minimize or eliminate the traditional horizontal part of the incision.

Seen below is a figure of the traditional "Wise Pattern" reduction using tissue from the lower part of the breast (an 'inferior pedicle technique') to keep the nipple & areola alive. It produces a scar that looks like an upside-down anchor and has been the standard procedure used in breast reduction for decades.

Work from surgeons in Europe & South America has trickled down to the United States using both shorter vertical scars with pedicles often oriented superiorly or medially. Below is a figure of a superior-medial pedicle which has been popularized by Canadian Plastic Surgeon, Dr. Elizabeth Hall-Findlay.

The advantages purported by this rethinking of the classic Wise-pattern/inferior pedicle surgery include using breast tissue (as opposed to skin) to maintain shape. Whether this holds up over time, we'll have to see. I've done a number of these & had some unpredictable results. They either are fantastic or just so-so. Unlike the traditional operation you rely on post-op settling of the breast to get the finished result which leads to some funky-shaped breasts leaving the table.

The most common problems I see are too high a nipple position & a persistant "pucker" at the bottom of the incision. Some puckers resolve, but a number require minor revisions in the office. It's always tempting to compromise the technique and use short-T's or j-shaped cut-outs of the pucker during the initial surgery.


Dr. Tony Youn said...

I've tried the Vertical Scar and the Spair (J shaped scar) and have found problems with both. I've gone back to the Wise pattern since it appears to give the most reproducible results. By suturing the pedicle high on the chest and dissecting high, I've found that postop settling is not usually as bad. But I guess time will tell. Which do you use??

Dr. Rob Oliver said...

I've been splitting the difference more with a superior-medial pedicle & the Hall-Findlay desighn incision & then assess the horizontal excess to remove as I close. It keeps the horizontal limb about 50-75% as long.

I agree 100% about predictability. Much less in my hands trying for pure vertical closures. You have to be very aggressive in defatting the whole inferior pole up to the dermal level to flatten it the way Dr Hall-Findlay gets hers.

I also tend to underresect signifigantly by weight. Despite what they look like on the table, they always come back bigger then what I tried. The patients, ironically, usually are pretty happy as it ends up much more like a mastopexy look then a nonprojecting breast like you see with a lot of the inferior pedicle wise-patterns.