Long-term Breast Shape Analysis After Short-scar Reduction Mammaplasty: A Critical View

Abstract

Background:

Over the past 2 decades, vertical scar reduction mammaplasty techniques have been gaining more acceptance. However, many surgeons are still hesitant to use it routinely because of the uncertainty of the effectiveness of vertical scar techniques in managing lower pole skin excess. We aimed to test its efficacy by using objective anthropometric measurements to evaluate long-term breast shape and lower pole stability.

Methods:

The study population included 40 of 129 consecutive women with short-scar reduction mammaplasty followed up for at least 1 year. Breasts were measured preoperatively, perioperatively, and at least 1 year postoperatively. All women also completed the BREAST-Q questionnaire at their most recent visit.

Results:

The mean sternal notch-to-nipple and upper breast-to-nipple distances decreased postoperatively by 22% and 43%, respectively, and remained stable over a mean time of 110.1 ± 65.58 weeks. The nipple-to-inframammary fold distance, which was intraoperatively shortened by an average of 63%, elongated back to 88% of its preoperative measurements. No correlation was detected between the long-term changes across all 3 measurements, the amount of tissue removed or the satisfaction reported by patients. Mean BREAST-Q satisfaction rates in all parameters evaluated were 75.79–98.12.

Conclusions:

The 12% improvement in the nipple-to-inframammary fold measurement implies that the short-scar technique might properly address the horizontal dimension of the hypertrophic-ptotic breast but falls short in addressing its vertical dimension. The search for a modification that mirrors the advantages of the vertical scar technique in terms of shape and projection, while guaranteeing a steady lower pole, remains ongoing.

Takeaways

Question: Is vertical scar reduction mammaplasty an effective long-term solution for managing inferior pole skin excess and achieving a desirable final breast shape?

Findings: A retrospective study of prospectively collected anthropometric breast measurements of 40 women, taken 110 weeks after vertical scar reduction mammaplasty, showed that the sternal notch-to-nipple and upper breast-to-nipple distances remained stable over time. However, the nipple-to-inframammary fold distance improved by only 12% compared with its preoperative measurement.

Meaning: Short-scar vertical reduction mammaplasty does not provide a stable lower pole over time, and modifications to the technique may be needed.

INTRODUCTION

With more than 70,000 procedures performed yearly in the United States alone and a 54% increase reported by the American Society of Plastic Surgeons in 2022 compared with 2019, breast reduction is one of the most performed plastic surgical procedures. Its beneficial effects both on physical and psychosocial well-being have long been reported.^1–11

Inverted T-scar reduction mammaplasty is the most commonly used technique due to its consistent results, ease in teaching, and applicability for all breast sizes.^12–14 However, concerns about breast projection loss and heavy scar burden have led to the evolution of additional surgical approaches.^15,16

The vertical scar techniques, described by Lassus and later popularized by Lejour¹⁸ and Hall-Findlay, have been gaining more acceptance recently.^1,17,19,20 The vertical approach offers the advantages of less scarring, fewer wound-healing complications, and improved breast shape.^1,17–23 Despite its described benefits, there is still hesitancy in applying the vertical scar for large breast sizes, and it is usually reserved for smaller volume reductions.¹

One major reason why surgeons avoid vertical scar techniques is the impression that the vertical scar does not offer a proper solution to the inferior pole skin excess.¹ In a study published by Misani and Mey²⁴ on 1030 consecutive cases, 47% of the cases resulted in the addition of horizontal scar to address to excess skin.¹ The horizontal submammary scar might be planned in advance, but it is more often an intraoperative decision.^24–26

Many studies have been published describing short-scar techniques, mainly focusing on complications and patient satisfaction.^15,27,28 Few address the lower pole skin removal techniques and their implications on the long-term breast shape. Several skin “gathering” options were described to prevent vertical scar extension onto the chest wall.^29–32 Synching,¹⁷ 4-points box sutures³³ or purse-string^24,25 are usually mentioned as good solutions. Synching, however, was abandoned by Hall-Findlay in 2004 because of no long-term advantages in terms of nipple-to-inframammary fold (Ni-IMF) distance shortening and the risk for distorted breast shape.¹⁷ In this study, we offer a critical look at the long-term breast shape after the short-scar reduction mammaplasty technique.

We hope to shed more light on 3 questions:

1. What impact does the short-scar technique have on breast shape? This article will closely examine its effects on the lower pole, analyzing measurements taken before surgery, during surgery, and in the long term.

2. Is there a correlation between patients’ satisfaction and a “favorable” breast shape measured by anthropometric values?

3. What impact does the vertical scar extension to a J-shaped scar have on the long-term breast shape, as reflected in the Ni-IMF measurements?

METHODS

The study was a retrospective analysis of prospectively collected chart data. The study was approved by the institutional review committee at Rabin Medical Center.

A total of 129 consecutive patients who were operated on by the senior author from 2016 to 2023 with a minimum follow-up time of 1 year were found eligible to participate in the study. All patients were operated on using a short-scar reduction mammaplasty that included a superomedial pedicle with a vertical or a J-shaped scar. Forty patients (31%) completed the evaluation and were included in the study.

The following measurements were collected for each breast independently: sternal notch-to-nipple (SN-Ni), upper breast border to nipple, and Ni-IMF. Participants were also asked to complete the BREAST-Q questionnaire (BREAST-Q version 2.0 Reduction/Mastopexy Module) at the same visit. In addition, demographic and clinical data were extracted from their medical records that included age, tissue resection weight, preoperative and intraoperative measurements, time elapsed from surgery, and the scar shape, either straight, vertical, or J-shaped.

First, the study population was analyzed as a single group. Further analysis was performed based on scar shape: vertical versus J-shaped scar.

Formula 1 represents Ni-IMF length change in percentage, immediately after surgery:

$${\displaystyle \begin{array}{l}{\displaystyle \frac{\mathrm{P}\mathrm{r}\mathrm{e}\mathrm{o}\mathrm{p}\mathrm{e}\mathrm{r}\mathrm{a}\mathrm{t}\mathrm{i}\mathrm{v}\mathrm{e}\mathrm{l}\mathrm{e}\mathrm{n}\mathrm{g}\mathrm{t}\mathrm{h}-\mathrm{I}\mathrm{m}\mathrm{m}\mathrm{e}\mathrm{d}\mathrm{i}\mathrm{a}\mathrm{t}\mathrm{e}\mathrm{p}\mathrm{o}\mathrm{s}\mathrm{t}\mathrm{o}\mathrm{p}\mathrm{e}\mathrm{r}\mathrm{a}\mathrm{t}\mathrm{i}\mathrm{v}\mathrm{e}\mathrm{l}\mathrm{e}\mathrm{n}\mathrm{g}\mathrm{t}\mathrm{h}}{\mathrm{P}\mathrm{r}\mathrm{e}\mathrm{o}\mathrm{p}\mathrm{e}\mathrm{r}\mathrm{a}\mathrm{t}\mathrm{i}\mathrm{v}\mathrm{e}\mathrm{l}\mathrm{e}\mathrm{n}\mathrm{g}\mathrm{t}\mathrm{h}}\times 100.}\end{array}}$$ (1)

Formula 2 represents Ni-IMF length change in percentage at the long-term postoperative visit:

$${\displaystyle \begin{array}{l}{\displaystyle \frac{\mathrm{P}\mathrm{r}\mathrm{e}\mathrm{o}\mathrm{p}\mathrm{e}\mathrm{r}\mathrm{a}\mathrm{t}\mathrm{i}\mathrm{v}\mathrm{e}\mathrm{l}\mathrm{e}\mathrm{n}\mathrm{g}\mathrm{t}\mathrm{h}-\mathrm{F}\mathrm{o}\mathrm{l}\mathrm{l}\mathrm{o}\mathrm{w}\text{-}\mathrm{u}\mathrm{p}\mathrm{v}\mathrm{i}\mathrm{s}\mathrm{i}\mathrm{t}\mathrm{l}\mathrm{e}\mathrm{n}\mathrm{g}\mathrm{t}\mathrm{h}}{\mathrm{P}\mathrm{r}\mathrm{e}\mathrm{o}\mathrm{p}\mathrm{e}\mathrm{r}\mathrm{a}\mathrm{t}\mathrm{i}\mathrm{v}\mathrm{e}\mathrm{l}\mathrm{e}\mathrm{n}\mathrm{g}\mathrm{t}\mathrm{h}}\times 100.}\end{array}}$$ (2)

Statistical Analysis

Categorical variables were presented numerically with adjusted frequencies. Normality was assessed using the Kolmogorov–Smirnov test. Demographic criteria and breast measurements were calculated and presented as mean ± SD. The independent samples t test compared demographic criteria, measurements over the research term, and immediate and long-term change. Differences in the BREAST-Q scores between the V and J groups were assessed by the Mann-Whitney test. Pearson correlation analysis evaluated the relationship between the weight of removed tissue and the long-term change for each breast measurement. It was also used to explore the relationship between the long-term change in measurements and the BREAST-Q score. Data analysis was performed using SPSS software (SPSS, Inc.), with statistical significance set at a P value less than or equal to 0.05.

Surgical Technique

The surgical approach was based on Hall-Findlay’s vertical scar, superomedial pedicle breast reduction technique. The new nipple position was determined in relation to the upper breast border because it is a stable reference that does not change after surgery.³⁴ The new upper areola was marked 6–8 cm inferiorly to the upper breast border. It was often higher than the preoperative IMF position because the IMF is usually elevated by an average of 1.5 cm.³⁴

The breast pillars are marked by a medial and lateral displacement of the breast in accordance with the meridian line (Lassus maneuver). Their length is rigorously kept no longer than 5 cm from the lower margin of the new areola, taking into consideration the expected elongation of the Ni-IMF distance with time. The skin is resected up to 2–4 cm above the IMF. The gland, however, is further resected inferiorly to the IMF, with a lateral and medial extension, thinning the skin to achieve better skin gathering. Intraoperatively, based on the amount of skin excess and its quality, either a vertical or a J-shaped scar is depicted. Inferior to the 5-cm breast limb, the skin is cinched a little with extra care not to pinch the lower pole and harm the breast shape.

RESULTS

The average age of the 40 study participants was 42.78 ± 14.66 years with an average body mass index of 24.94 ± 3.17 kg/m². The average time elapsed from the day of surgery to the follow-up visit was 110.1 ± 65.58 weeks. The average weight of tissue removed from a single breast was 377.55 ± 183.60 g. Twenty patients (50%) ended with a straight vertical (V) scar and 20 patients (50%) had a J-shaped (J) scar. The mean age and the elapsed time from day of surgery to the follow-up visit was not statistically different between the 2 groups. The mean weight of tissue removed was significantly higher in the J scar group (Table 1).

Table 1.

Demographic Characteristics

	Total Patients (N = 40)	Groups		P
		V Group (N = 20)	J Group (N = 20)
Age, y	42.78 ± 14.66	44.06 ± 14.54	41.36 ± 14.65	0.429
Elapsed time from surgery day till follow-up visit, wk	110.1 ± 65.58	118.4 ± 77.54	101.8 ± 51.66	0.264
BMI, kg/m2	24.94 ± 3.17	23.73 ± 2.84	26.16 ± 3.08	0.013
Weight of tissue removed, g	377.55 ± 183.60	312.85 ± 164.3	442.25 ± 179.03	0.001

All values are mean ± SD.

BMI, body mass index.

Table 2 presents preoperative, intraoperative, and most recent postoperative visit measurements. The mean SN-Ni distance was shortened from 30.29 ± 2.86 to 23.38 ± 1.48 cm at surgery but gradually elongated to 24.9 ± 1.73 cm at the most recent follow-up visit. The upper breast-to-nipple (UB-Ni) distance average was adjusted from 15.65 ± 2.94 to 8.54 ± 1.01 cm at surgery and elongated to 9.56 ± 1.2 cm at the most recent follow-up visit. Ni-IMF distance average was corrected from 16.66 ± 2.77 to 7 cm at surgery and elongated back to 14.45 ± 2.33 cm at the last follow-up visit. The study population is further divided based on the type of surgical scar, with the following measurements listed in Table 2.

Table 2.

Measurements at Different Time Points, Divided by Groups

Measurement	Time Point	Total Patients (N = 80)	Groups		P
			V Group (n = 40)	J Group (n = 40)
Sternal notch nipple	Before operation	30.29 ± 2.86	30.06 ± 2.9	30.52 ± 2.87	0.476
	Intraoperative	23.38 ± 1.48	23.4 ± 1.49	23.36 ± 1.5	0.917
	Follow-up	24.9 ± 1.73	24.63 ± 1.77	25.19 ± 1.66	0.146
Upper breast nipple	Before operation	15.65 ± 2.94	15.2 ± 3.31	16.08 ± 2.61	0.161
	Intraoperative	8.54 ± 1.01	8.38 ± 0.76	8.68 ± 1.16	0.154
	Follow-up	9.56 ± 1.2	9.36 ± 1.2	9.75 ± 1.19	0.135
Ni-IMF	Before operation	16.66 ± 2.77	16.76 ± 2.71	16.55 ± 2.89	0.735
	Intraoperative	7	7	7	—
	Follow-up	14.45 ± 2.33	14.68 ± 2.7	14.22 ± 1.88	0.376

Table 3 presents the immediate and long-term change in the SN-Ni, UB-Ni, and Ni-IMF measurements (calculated by the above-mentioned formulas). Our analysis revealed that there was no statistically significant difference between the V and J scar groups in both the immediate and long-term comparisons. In addition, it shows no correlation between the long-term change across all 3 measurements (SN-Ni, UB-Ni, and Ni-IMF) and the weight of tissue removed (Pearson correlation = 0.303, P = 0.006 and 0.267, P = 0.017 and 0.109, P = 0.335, respectively). This implies that patients with smaller breasts did not necessarily exhibit better long-term outcomes, as measured by retained postoperative Ni-IMF distance. The findings for 2 representative patients are depicted in Figures 1 and 2.

Table 3.

Immediate and Long-term Improvement of Breast Size

	Immediate Improvement (%)				Long-term Improvement (%)
	Total Patients (N = 80)	V Group (n = 40)	J Group (n = 40)	P	Total Patients (N = 80)	V Group (n = 40)	J Group (n = 40)	P
Sternal notch nipple	22.41 ± 5.71	21.76 ± 5.78	23.06 ± 5.63	0.311	17.31 ± 7.28	16.95 ± 7.87	16.88 ± 8.25	0.657
Upper breast nipple	43.82 ± 12.51	45.31 ± 7.39	45.31 ± 7.39	0.290	37.09 ± 12.62	37.88 ± 11.87	38.13 ± 11.97	0.579
Nipple-inframammary fold	63.02 ± 5.88	62.71 ± 6.14	56.49 ± 7.16	0.643	12.12 ± 13.44	12.54 ± 12.98	13.69 ± 12.96	0.782

Fig. 1.

A 42-year-old patient underwent short-scar reduction in 2019, during which 500 g of tissue was excised from the right breast and left breast. The figure shows photographs taken before surgery (A–C) and 3 years postoperatively (D–F). The Ni-IMF distance was shortened bilaterally from 14.5 to 14 cm.

Fig. 2.

A 42-year-old patient underwent short-scar reduction in 2021, during which 515 g of tissue were excised from the right breast and 340 g from the left breast. The figure shows photographs taken before surgery (A–C) and 2 years postoperatively (D–F). The Ni-IMF distance was shortened from 20 to 17.5 cm in the right breast and did not change (17 cm) in the left breast.

The BREAST-Q questionnaires are presented in Table 4. Mean satisfaction rates in all the parameters evaluated were 75.79–98.12. Comparing the V and J scar groups, we found no difference in patients’ satisfaction with the breast appearance and their physical well-being. However, the general outcome and the psychological well-being measures were significantly higher in the V group (P = 0.015 and 0.025, respectively). There was no statistically significant correlation detected between the long-term change in measurements and the ratings submitted by patients across different criteria of the BREAST-Q.

Table 4.

BREAST-Q Results (Total Population and Division by Groups)

	Total Patients (N = 40)	Groups		P
		V Group (n = 20)	J Group (n = 20)
Psychosocial well-being	78.44 ± 17.61	84.89 ± 24.52	72.30 ± 16.4	0.025
Physical well-being	74.79 ± 14.98	78.35 ± 31.51	71.24 ± 28.23	0.176
Breasts postoperative	76.37 ± 12.08	79.60 ± 40.76	74.47 ± 28.61	0.305
Outcome	84.77 ± 15.58	90.95 ± 23.69	78.90 ± 15.3	0.015
Information	78.42 ± 17.06	84.33 ± 30.09	73.10 ± 15.09	0.044
Surgeon	97.59 ± 7.06	96.95 ± 22.88	98.20 ± 4.42	0.591
Medical team	95.76 ± 11.95	97.71 ± 35.29	94.10 ± 15.16	0.347
Office staff	98.12 ± 7.45	98.78 ± 29.81	97.38 ± 40	0.597

DISCUSSION

Short-scar reduction mammaplasty supporters focus mainly on the favorable breast shape and less scarring it offers. Studies discussing short-scar breast reduction in terms of technique, complications, and patient satisfaction are abundant.^{1,15,27,28,35} Few discuss the long-term changes in breast shape anthropometrically. Lista and Ahmad²⁹ report stable long-term Ni-IMF distance over time using 4-points gathering box sutures to shorten the distance. Moreover, they found minimal shortening of the “lower areola border”—IMF distance over time when compared with the immediate postoperative results.³³ Matthews et al¹⁷ on the other hand, report 76%–78% return to the preoperative Ni-IMF distance in both the skin-gathering and non-skin-gathering groups. They describe a plateau in the measurements after approximately 36 weeks but mention that fewer patients were seen for follow-up after 36 weeks.

The significant variance observed between these 2 comprehensive studies underscores the importance of further research to evaluate the short-scar technique. It is noteworthy that the measurements done by Lista and Ahmad were vertically obtained using a ruler, whereas the assessments in both Hall-Findlay’s study and ours were conducted along stretched skin in a standing position.

In our study, we successfully illustrated that after an average follow-up period of 110 weeks, both the distances between SN-Ni and the upper border of the breast to nipple decreased by 22% and 43%, respectively, and these results were sustained over time. However, the Ni-IMF distance, which was intraoperatively shortened by an average of 63%, has now elongated back to 88% of its preoperative measurements.

A 12% long-term improvement only in the Ni-IMF measurement implies that the short-scar technique might address the horizontal dimension of the hypertrophic–ptotic breast properly but falls short in addressing its vertical dimension. One might claim that the T scar better shortens the vertical dimension of the lower pole because it less succumbs to the glandular weight. The results are not consistent in that matter. Reus and Mathes³⁶ with their 4.7 years of follow-up after Wise pattern breast reduction showed a stable SN-Ni distance with an increase in the length of the vertical limb. Freiberg and Carr,³⁷ however, demonstrated a stable vertical limb in their 2.9 years of follow-up. Both were using an inferior pedicle so a proper anthropometric randomized study comparing the 2 scars while using the superomedial pedicle is still in need.

Interestingly, our analysis has not shown a correlation between the removed tissue weight and the long-term improvement in the Ni-IMF distance. Contrary to our assumptions, this suggests that larger breasts may not consistently return to their preoperative measurements more frequently. Therefore, in our opinion and based on these data, transitioning from a vertical scar to a T scar in cases of heavier breasts should not be an obvious decision.

The BREAST-Q is often used for measuring quality of life and patient satisfaction after reduction mammaplasty.^{27,35,38–40} It usually reflects high satisfaction rates from the procedure, regardless of the chosen technique. Our findings are no different (Table 4), showing grades that go in line with previous studies. Furthermore, our investigation revealed a lack of correlation between patients’ reported satisfaction and the stability of the Ni-IMF distance, suggesting a minimal impact of a short-stable lower pole on overall patient satisfaction.

Contrary to this perspective, as Hall-Findlay³⁵ argued, although patient satisfaction is a major determinant of surgical success, we should also be looking at aesthetic improvement from a surgical standpoint. Comparing the preoperative measurements with the long-term, postoperative measurements might be one of the ways to objectively analyze the aesthetic results. Through this comparison, we found that the short scar fails to sustain an optimal Ni-IMF distance. The significantly lower grades both for the general results and psychological well-being when a short J extension was added suggest that the scar burden is not to be overlooked and explains the increasing popularity of the short-scar techniques in relation to the Wise pattern approach. However, there is still a need for a modification or adjustment that provides the advantages of the vertical scar in terms of shape and projection, while guaranteeing a stable lower pole.

Study Limitations

1. In contrast to the larger study populations of 400 patients in the study by Matthews et al¹⁷ and 250 patients in the study by Lista and Ahmad²⁹, our study includes a relatively small sample size of 40 patients out of 40 patients.

2. The average weight of the excised tissue was 377.55 ± 183.60 g, which is relatively lower compared with the findings from other studies.

3. The patients were not assessed at uniform time intervals. A more robust study design would involve monitoring all patients consistently over a predetermined duration at defined time intervals.

CONCLUSIONS

Although significant attention is given to reducing the Ni-IMF distance during vertical scar reductions, our long-term assessment reveals a gradual elongation of this distance after surgery, indicating enduring alterations in breast shape. Remarkably, this enhancement does not exhibit a correlation with the quantity of tissue excised or with patient satisfaction. Although breast reduction patients typically report high levels of satisfaction, it is imperative not to let a relatively high patient-reported satisfaction rate overshadow our commitment to achieving greater stability in the lower pole through this technique.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.