CLINICAL PAPER

Comparative Outcomes and Quality Analysis of Inverted-T

and Pure Vertical Scar Techniques in Superomedial
Pedicle Reduction Mammaplasty
Sarah Fernandez, MD, Loretta Coady, MD, Rachel Cohen-Shohet, MD,
Justine Molas-Pierson, MS, and Bruce A. Mast, MD

Multiple techniques for designing breast pedicles to preserve

Introduction: Multiple techniques exist for reduction mammoplasty, but no sin-
blood flow to the nipple, as well as patterns for excising excess skin,
gular consensus exists as to which method is the most effective in providing an
exist.2 In 1979, Georgiade3 described an inferior pedicle technique
aesthetically pleasing breast. We reviewed our institution's reduction mammo-
which provided superior retention of nipple sensation as well as consis-
plasty experience over a 2-year period to evaluate aesthetic and surgical outcomes
tency in removing both large and small volumes of breast tissue. This
comparing superiorly based pedicles with skin excisions resulting in either an
technique, combined with an inverted T or Wise pattern skin excision,
inverted T or vertical scar.
is commonly used by many plastic surgeons as a reliable means for
Methods: An IRB-approved retrospective review of our institution's surgical
a large volume reduction while preserving nipple sensation. Alterna-
database identified patient characteristics and outcomes of all breast reductions
tively, Hall-Findlay4 has described the vertical reduction mammoplasty
performed over a 2-year period (n = 104). A subgroup analysis of patients with
with a superomedial pedicle reporting improved contour and decreased
complete preoperative and postoperative photographs (n = 56) evaluated postop-
scar burden compared with prior techniques.
erative aesthetics on a scale of 1 to 5 (1, poor; 5, excellent).
Outcomes studies for breast reduction have largely focused on
Results: Techniques included a superomedial pedicle with an inverted T-pattern
preserving nipple viability while maximizing the volume of reduction
skin excision (n = 81) and pure vertical reduction (n = 23). There was no signif-
and alleviating patient symptoms. Although these studies help to mold
icant difference in complications between techniques. Common patient risk fac-
our techniques, they do not refine our practice in maximizing aesthetic
tors (age, body mass index [BMI], and smoking status) did not correlate with
outcome. There are several studies that have used outcomes, such as pa-
postoperative complications. In the photograph analysis subgroup, inverted T
tient satisfaction. In a randomized controlled trial, Thoma et al5 compared
scar pattern reductions had a significantly better scar quality score (3.5 vs 3.2,
health-related quality of life in patients undergoing vertical scar and
P < 0.05). In analysis of all subjects, volume of tissue resected was a significant
inverted T–shaped reduction, finding similar quality of life outcomes, al-
factor in determining overall aesthetic score, with resections of less than 1300 g
though no comparative evaluation of aesthetic outcomes was provided.
being significantly associated with an overall aesthetic score of 4 or higher. Lo-
The superomedial pedicle technique has been found to be safe
gistic regression demonstrated patient age younger than 40 years was a signifi-
and reliable.6 Patients generally prefer to minimize their scar burden
cant contributor to aesthetic score of 4 or higher (P < 0.05).
and have indicated dissatisfaction with both the horizontal and vertical
Discussion: We reviewed our institution's experience with 2 common breast re-
components.7 Although the majority of breast reductions in our prac-
duction techniques. Better scarring was associated with inverted T scar pattern
tice use a superomedial pedicle, 2 common skin excision patterns are
versus vertical pattern. Additionally, rather than pedicle type or skin excision
used: a vertical skin excision similar to that described by Hall-Findlay
pattern, patient age and weight of tissue resected were the most important contrib-
and a Wise pattern skin excision which incorporates an inframammary
utors to an aesthetically optimal outcome. This study suggests that a single super-
incision to allow horizontal inferior pole skin resection. Proponents
lative technique does not exist. Rather, inherent patient characteristics are most
of the vertical approach feel that avoiding the inframammary incision
important in provision of the best aesthetic outcome.
reduces risk of wound healing complications and dehiscence. Further-
Key Words: scar, breast reduction, mammaplasty, outcomes more, the elimination of the inferior scar is touted as being aesthetically
(Ann Plast Surg 2016;76: S328–S331)
superior.8 The shorter operative time in some hands is another advan-
tage.9 On the other hand, the purely vertical skin excision can result
in “bunching” of excess skin which, at least in the short term, can com-
B reast reduction is one of the most commonly performed plastic sur-
gical operations, with over 100 000 procedures performed in 2014
alone based on America Society of Plastic Surgeons data.1 Mammary
promise the aesthetic outcome of the postoperative breast. Further-
more, without lower pole skin excision, concern exists that insufficient
inferior tissue support is provided which may lead to glandular descent
hypertrophy, or macromastia, can be an extremely morbid condition, and “bottoming out,” as well as greater tensile demands on the periareolar
leading to significant physical and mental suffering due to back pain, and vertical scars.
neck pain, headaches, upper extremity radiculopathy, intertriginous infec- In addition to the skin excision and pedicle technique, many pa-
tions, inability to find clothes that fit, and participate in sports. However, tient factors can influence both postoperative complications and aes-
there is relatively little literature comparing techniques of breast reduction thetic outcomes.10 Many breast reduction patients have a BMI which
in regards to outcomes such as aesthetics and patient satisfaction. places them in the overweight or obese category. BMI has been well
documented to be a risk factor for wound healing complications. Addi-
tionally, the volume of tissue excised can impact the final shape and
Received December 8, 2015, and accepted for publication, after revision December contour of the breast. Finally, although patients are strongly encouraged
13, 2015.
From the Division of Plastic and Reconstructive Surgery, Department of Surgery,
to stop smoking for at least 1 full month before elective surgery, a subset
University of Florida, Gainesville, FL. elect to continue actively using tobacco. This can impact wound healing
Conflicts of interest and sources of funding: none declared. as well as increase the risk of nipple loss in breast reduction patients.
Reprints: Bruce A. Mast, MD, University of Florida Plastic Surgery PO Box 100138 Our primary goal in reviewing our breast reduction experience
Gainesville, FL 32610. E-mail: bruce.mast@surgery.ufl.edu.
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
was to compare the vertical and the inverted T skin excisions in respect
ISSN: 0148-7043/16/7606–S328 to aesthetic superiority. Additionally, assessment of contributors to
DOI: 10.1097/SAP.0000000000000732 postoperative complications and optimal aesthetic outcomes would be

S328 www.annalsplasticsurgery.com Annals of Plastic Surgery • Volume 76, Supplement 4, June 2016

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Annals of Plastic Surgery • Volume 76, Supplement 4, June 2016
FIGURE 1. Study design. A total of 104 patients were reviewed
in our study, with 56 contributing to the photograph
subgroup analysis.
made. Understanding factors which predict optimal postoperative out-
comes can improve both patient selection and patient expectations.
METHODS
After obtaining approval for the study from our institutional re-
view board, a retrospective chart review was performed of all breast
reductions performed at our institution from January 1, 2011, to
December 31, 2012. This encompassed the practice of 4 surgeons
and included both Wise and vertical skin excision patterns. A total of
104 charts were reviewed. Each chart was reviewed for pedicle type,
skin excision pattern, patient characteristics, weight of tissue resected,
and postoperative complications. Complications included wound de-
hiscence, postoperative cellulitis requiring postoperative antibiotics and
hematoma/seroma. We defined postoperative cellulitis as erythema noted
at postoperative evaluation and requiring prescription of oral antibi-
otics. Complication rates were compared between surgical techniques
and among smokers, former smokers, and nonsmokers.
A subset of patients (n = 56) had complete preoperative and post-
operative photographs in their charts. These patients included both
inverted T scar (n = 40) and vertical (n = 16) skin excision patterns.
The photographs were reviewed separately by 3 blinded independent re-
viewers and graded on a numerical scale1–5 in 3 outcome categories:
overall aesthetics, scar quality, and nipple symmetry. A score of 1 was
considered to be an unacceptably poor outcome, whereas a score of
5 was assigned to the best outcome. Average scores were tabulated
and compared between the 2 skin excision patterns. Finally, a logistic
regression was used to determine whether any patient factors—BMI,
age, and weight of tissue resected—correlated to higher scores in each
of the 3 categories.
A summary of the study design is shown in Figure 1.
RESULTS
During the study period, 23 vertical and 81 Wise skin excision
pattern reductions were performed. Average follow-up for each group
was approximately 4 months.
TABLE 1. Comparison of Complications Between the 2 Groups
Complication Inverted T (n = 81) Vertical (n = 23) P Inverted T (n = 40)
Wound dehiscence 30 4 0.746
Cellulitis 15 3 0.128
Hematoma/seroma 7 2 1 Nipple symmetry (P = 0.5)
Total complications 52 9 0.056
Overall complication rate 64.2% 39.1%
© 2016 Wolters Kluwer Health, Inc. All rights reserved.
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Inverted-T Versus Pure Vertical Scar Reduction
TABLE 2. Role of Smoking in Complication Rates in Breast
Reduction
No. Complication Rate
Smoking Status Patients Complications (P = 0.571)
Current smoker 6 5 83.3%
Former smoker (>3 mo) 12 7 58.3%
Nonsmoker 86 49 56.9%
Overall complication rate was 58.7%, the majority of which were
minor wound dehiscences (Table 1). The overall complication rate was
higher in the inverted T group (64.2%) versus the vertical group
(39.1%), but this was not statistically significant (P = 0.056). Addition-
ally, the individual rates of wound dehiscence, cellulitis, or fluid collec-
tion were not significantly different between the groups. There were no
reoperations in our study population.
The role of smoking in postoperative complications was evalu-
ated by comparing complication rates among smokers, nonsmokers,
and former smokers who had quit at least 3 months before the surgery
(Table 2). No statistically significant difference was found in complica-
tion rates among these 3 groups.
Photograph analysis results of a 56-patient subgroup comparing
aesthetic outcomes between vertical and Wise pattern skin excision
techniques are summarized in Table 3. There was a statistically signifi-
cantly higher scar quality score in the Wise pattern group (3.5 compared
with 3.2 in the vertical group, P = 0.009). However, there was other-
wise no significant difference between the 2 groups in terms of nipple
symmetry or overall aesthetics. Figure 2 demonstrates a patient with a
low overall aesthetic score. Figure 3 shows a patient with a high overall
aesthetic score.
Further analysis of this 56-patient subgroup attempted to evalu-
ate the role of patient factors in obtaining the best aesthetic outcome.
We used a 2-sample t test to determine whether age, BMI, or weight
of tissue resected was statistically correlated with aesthetic scores of 4
or greater. Results are summarized in Table 4. Total weight resected
was a statistically significant predictor of overall aesthetic score of at
least 4. BMI >30 approached but did not reach statistical significance
in impacting overall aesthetic score (P = 0.064).
Finally, a logistic regression model for overall aesthetics was
used to evaluate covariates associated with aesthetic score of at least
4. Age and incision type were covariates associated with a P value of
0.039. For every increase in age of 1 year over 40 years, there was a
4% reduction in probability of receiving a score of at least 4. The pres-
ence of a vertical incision was associated with an 81% reduction in
odds of receiving a score of at least 4.
DISCUSSION
As one of the most commonly performed plastic surgery
breast operations, reduction mammoplasty incorporates both functional
(reducing the excess breast tissue and its resultant symptoms) and
TABLE 3. Results of Photograph Subgroup Analysis—Scores
on 1–5 Scale
Vertical (n = 16)
Postoperative Postoperative
Time = 4.4 mo Time = 3.8 mo
3.6 3.4
Scar quality (P = 0.009) 3.5 3.2
Overall aesthetics (P = 0.305) 3.4 3.2
www.annalsplasticsurgery.com S329
Fernandez et al Annals of Plastic Surgery • Volume 76, Supplement 4, June 2016

FIGURE 2. A patient with a low overall aesthetic score. Lack

of upper pole fullness, inframammary asymmetry, scar FIGURE 3. A patient with a high overall aesthetic score.
irregularity, and an overall “bottomed out” appearance to
the breast are noted. Although we typically encourage our patients to stop smoking
before undergoing elective breast surgery, we did have a small propor-
tion of patients in our study who were active smokers as well as several
who had recently stopped smoking. This allowed us to evaluate the risk
cosmetic (preserving or enhancing the aesthetics of the breast) aspects. of complications in patients who were recent or active smokers. There
A variety of techniques exist to allow the surgeon to achieve both these was no statistically significant difference in complications among these
goals. Our study reviews our 2-year experience with superomedial ped- groups, although there was a nonsignificant increase in wound healing
icle breast reductions, using 2 common skin excision patterns. complications in the active smoker cohort (83% compared with 57%).
We did not note any difference in postoperative complica- Patients who had stopped smoking at least 3 months before surgery
tions between the 2 techniques. Proponents of vertical reduction mam-
moplasty advocate the smaller incision burden and avoidance of a
“T-point” when compared with a Wise pattern skin excision. Presum- TABLE 4. Logistic Regression Model Results for Correlation of
ably, the closure of 3 skin flaps at a single point creates excess tension Patient Factors With Overall Aesthetic Scores
and tissue ischemia and a risk for breakdown at that point. However,
we did not find a statistically significant increase in wound dehiscence Score ≥ 4 Score <4 P
between our 2 groups. In superomedial reduction, the inferior tissue is Age 39.4 45.7 0.185
wedge-resected, and extensive skin flaps are usually not created. This BMI 29.99 30.80 0.064
suggests that, with such a surgical technique, there is no increased risk Weight resected (g) 1269.3 1588.2 0.049
for significant wound breakdown in Wise pattern reductions.

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Annals of Plastic Surgery • Volume 76, Supplement 4, June 2016
had a complication risk almost identical to that of nonsmokers (58%).
Notably, the population of smokers in our study was too small to draw
statistically meaningful conclusions; however, our results are in accor-
dance with previous data which note an increased risk for wound
healing complications in smokers.10–15
Evaluation of our aesthetic results specifically compared nipple
symmetry, scar quality, and overall aesthetics. One of the criticisms of
vertical skin excision is that the lack of an inframammary incision can
place excessive tension on the closure. The overall aesthetics between
the 2 groups were not significantly different, suggesting that both surgi-
cal techniques can produce acceptable aesthetic outcomes. This is con-
sistent with a previous study from our institution.16
The results of this study support that the final aesthetic outcome
of breast reduction surgery is more dependent on patient factors than
the specific surgical technique. Our results indicate that the most sig-
nificant predictor of a good aesthetic outcome was weight of tissue
resected, whereas lower BMI likely contributes as well. These data cor-
relate with the anecdotal experience of our practice in that the patients
with the best aesthetic outcomes have smaller-volume reductions in the
setting of a normal or slightly above-normal BMI. The literature sup-
ports our findings that increased BMI10,13,16 and resection weight10,15,17
are risk factors for complications. On the other hand, extremely large re-
ductions (especially in the overweight or obese population) tend to be
associated with a less-optimal aesthetic result. Finally, logistic regres-
sion analysis suggests that increasing patient age also impacts aesthetic
outcomes. Increasing age has been found to be a risk factor for com-
plications.10,17 Understanding the correlation between intrinsic patient
factors and surgical results is important in preoperative counseling of
patients to manage expectations of postoperative outcomes.
It should be noted that our study focused on early postoperative
outcomes, with follow-ups limited to an average of 4 months. This
limits the ability to fully evaluate postoperative aesthetic outcomes, es-
pecially with regards to scar quality, because scar remodeling takes
place over a much longer period. Nevertheless, objective measurement
of changes after breast reduction indicates that the edema is fully re-
solved at 3 months, with the majority of contour changes occurring
within the first 6 months.18 Long-term changes have been reported with
inverted T scar reductions; however, when evaluated, this was most of-
ten with an inferior or central pedicle. The superior or superior medial
pedicle appears to be more resistant to late “bottoming out.”19 At the
time point studied here, the outcomes evaluated usually remain qualita-
tively consistent. In other words, the better the results at 4 months, the
better the results are at 12 months, in most cases. Additionally, as the
majority of our surgeons utilize a superomedial pedicle, we did not in-
vestigate the role of pedicle choice in postoperative appearance.
CONCLUSIONS
Breast reduction is a surgery performed by a majority of plastic
surgeons on a regular basis. The surgical techniques used by each sur-
geon are chosen based on a combination of the surgeon's comfort level
© 2016 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Inverted-T Versus Pure Vertical Scar Reduction
with a technique and the patient characteristics. Our study suggests that
a good aesthetic outcome can be achieved with more than 1 technique,
and that patient factors play a more critical role in determining postop-
erative aesthetics. Specifically, pure vertical scar technique is not supe-
rior to using an inverted T scar pattern. Expanding on this initial data,
we plan to evaluate more long-term outcomes in our patients, as well
as investigating the outcomes associated with other modifications and
pedicle designs in reduction mammoplasty.
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