Breast Reduction Skin Excision Patterns
Wise Pattern Breast Reduction
The Wise pattern places incisions along the inframammary fold of the breast, a vertical incision from the fold up to the areola border, and an incision around the border of the areola. The resulting incision looks like an inverted –“T” or an anchor after final closure. This pattern is usually employed for patients with very large breasts, but can be used for almost any reduction volume. In addition, this technique is commonly used when the patient has poor skin quality and the breast is very loose, or when the NAC has to be raised a significant length in order for the breast to have a youthful appearance.
Vertical breast reduction
The vertical breast reduction eliminates the inframammary incision. Dr. Wallach will commonly employ a vertical breast reduction technique (usually a modified LeJour technique) that minimizes the amount of scarring on the breast using a “lollipop-type” pattern that encompasses a circular incision around the areola with a lower breast vertical incision. This technique is often used for smaller breast reductions, when the patient’s skin quality is good, and the NAC does not have to be raised a significant length.
Horizontal incision technique
This is a technique that employs an inframammary incision and an incision only around the areola. There is no vertical incision component from areola border to the breast fold that is seen with the Wise pattern or vertical pattern. This is performed using an inferior pedicle technique, and can be used for larger breast reductions and long pedicle lengths. A disadvantage of this technique is that the breast can look a bit “boxy.
Wise Pattern Breast Reduction Techniques
There are numerous named reduction techniques employing the Wise skin pattern excision based upon the orientation of the blood supply feeding the pedicle to the nipple areola complex (NAC). The three most common are:
The inferior pedicle technique is probably the most popular one used today, because it is considered the most versatile. Some studies suggest that patients undergoing this technique have the best post-surgical sensation of the NAC and also have the best chance to adequately breast feed.
Is a reasonable approach for patients who only need the NAC moved a short distance. It is good for smaller reductions than what can be achieved with the inferior pedicle technique.
Is a technique that employs a pedicle based superomedially on the chest. It can be used for large reductions and in those with low hanging breasts.
There are other pedicle designs including those using the central mound, the lateral pedicle, the medial pedicle, various bipedicle forms, and the supero-lateral pedicle.
Vertical Breast Reduction Techniques
There are many procedures that can incorporate the “lollipop” skin closure. The three most common are:
Superior Pedicle Technique (LeJour)
This is a great technique to be used for patients who have moderately good skin quality, require a relatively short pedicle, and do not require a very large reduction. The pedicle is based superiorly and the skin closure results in a lollipop design. Dr. Wallach uses this technique often and has published his modifications on the LeJour technique and has presented it to other surgeons at the Aesthetic Society’s national meeting.
This is a very versatile technique that can be used for larger reductions than the LeJour technique because the pedicle is turned from the superomedial aspect and more tissue laterally and superiorly can be removed. The closure is similar to the Lejour in that the resulting closure looks like a “lollipop.”
SPAIR ( Short-scar Periareolar-Inferior pedicle Reduction) Technique (Hammond)
This is different than the superior pedicle or superomedial techniques described above because the pedicle is inferiorly based. Similar to the inferior pedicle technique using the Wise pattern skin closure, more tissue can be removed superiorly than with the above techniques described.
Massive Weight Loss Patients
Most massive weight loss patients are often not good candidates for a vertical breast reduction technique because they often have poor skin quality and the skin envelope is very loose. For these patients, a Wise pattern skin incision pattern will often achieve the desired result. For massive weight loss patients, Dr. Wallach has used both types of skin incision designs to achieve nice results for his patients.
Liposuction Only Breast Reduction
Some plastic surgeons perform breast reductions using only liposuction. This limits the use of breast incisions. However, in the majority of patients it will not adequately “lift” the breast or reduce the skin envelope. Thus, the breast will potentially be looser after the procedure. If the breast is primarily fatty tissue, then liposuction can be successful in removing the excess breast weight, but this technique will usually not consistently improve the aesthetic appearance of the breast. If there is significant ptosis (sagging) and the NAC is low on the breast mound, it will not provide the lift needed to create a more youthful look.
Free Nipple Graft Technique
The free nipple graft technique is used for patients that have extremely large breasts and whose NAC are very low on the chest. When the potential pedicle length is too long, there is a risk that the NAC will not survive. Therefore, a free nipple graft technique is an option. A pedicle of tissue is used to restore an aesthetic breast mound. The NAC is removed and replaced on the chest skin at an aesthetically pleasing position as a free graft. This technique will eliminate the ability to breast feed, and may result in partial or incomplete NAC survival. It may also lead to hypopigmentation of the NAC.
In general, breast reduction surgery takes between two to four hours to complete with a recuperation time of one to two weeks. Often patients will have a drain in each breast that is commonly removed a few days after surgery. Patients wear a support bra without an under-wire or a sports type bra for about 3-6 weeks before they can go back into an under-wire bra. Dr. Wallach recommends that patients avoid aerobic type exercise for at least three weeks and strenuous exercise for at least six weeks after surgery. The surgical procedure usually takes between two to four hours with a recuperation time of one to two weeks. Dr. Wallach has presented and published papers on breast reduction and has presented his experience and techniques to other plastic surgeons. For many years, Dr. Wallach has given an instructional course to fellow plastic surgeons on his preferred techniques at the American Society of Aesthetic Plastic Surgery (ASAPS) national meeting.
If you would like more information about Dr. Wallach and his success with New York City Breast Reduction procedures, we hope that you will not hesitate to contact our Manhattan offices or by mail at 1049 5th Avenue, Suite 2D in New York, NY 10028; or using our contact form to request additional details.