ElevéL: Superior Pedicle Reduction Mammoplasty With L-shaped Scar

Abstract

Background:

An L-shaped scar in reduction mammoplasty is a scar pattern that has been gaining popularity among plastic surgeons because of the lower number of complications and improved aesthetic results. The main objective of this article was to describe a new technique of upper pedicle reduction mammoplasty with large tissue resections, always using an L-scar pattern.

Methods:

The ElevéL technique was performed in 270 patients who underwent surgery between 2023 and 2025; follow-up examination was carried out for an average of 1 year. A patient satisfaction survey was conducted (BREAST-Q).

Results:

Two (0.8%) patients presented partial necrosis of the nipple–areola complex, 0 patients had surgical infections, 3 patients had wound dehiscence, no patients presented hematoma, and 13 (4.8%) had widening of the areola. Alterations in the sensibility of the nipple–areola complex occurred in 23 patients who had partially recovered sensibility (subjectively reported by the patients).

Conclusions:

Compared with other reduction mammoplasty techniques, the ElevéL technique has shown lower complication rates, coupled with less scarring, making it a good technique for all plastic surgeons to routinely perform.

Takeaways

Question: Is it possible to perform large ascents of the nipple–areola complex safely, always using a superior pedicle and with an L-shaped scar?

Findings: We performed 270 reduction mammoplasty using the ElevéL technique demonstrating that it is possible to perform large ascents of the nipple–areola complex using a superior pedicle and with an L-shaped scar.

Meaning: An L-shaped scar in reduction mammoplasty delivers all the advantages of the inverted-T while offering added benefits and lower complication rates.

INTRODUCTION

Because breasts have both aesthetic and functional importance, any surgery in this area should pursue 3 clear goals: restore a natural and balanced contour, relieve the symptoms related to breast hypertrophy, and reduce complications as much as possible.

Since Dieffenbach’s description of reduction mammoplasty in 1848,¹ the technique has undergone numerous modifications including those introduced by Biesenberger 1931,² Maliniac 1950,³ Pitanguy,⁴ and Ribeiro 1975.⁵ These techniques have significantly elevated breast-reduction surgery, with the inverted-T incision enduring as the hallmark technique.

Breast surgery has undergone significant advancements, particularly in minimizing the length of scars. Notable examples include the periareolar approach first described by Noel 1927⁶ and the circumvertical pattern introduced by Arie 1958,⁷ which was later modified and popularized by Lassus⁸ and Lejour.⁹

An alternative approach to reduction mammoplasty involves the use of an oblique incision described by Hollander¹⁰ and later adopted by Berrocal.¹¹ Similarly, Meyer et al¹² and Bozola¹³ implemented the L-scar technique. These methods match the results of the inverted-T approach leaving a shorter scar, improving postoperative aesthetics, and keeping the cleavage untouched.

In this article, we present a novel reduction mammoplasty technique utilizing an “L” incision. This approach incorporates a large dome with a wide periareolar design as previously described by the authors.¹⁴ The name “ElevéL” reflects the dual objective of elevating the breast through a superior pedicle (Elevé) and the characteristic L shape of the final scar.

MATERIALS AND METHODS

This observational case series, drawn from the authors’ own surgical experience, details the ElevéL technique, its operative steps, technical nuances, and postoperative management. There are no sources of funding or conflicts of interest in the development of this study.

We reviewed outcomes for 270 women (aged 15–60 y, mean age = 31 y) treated for breast hypertrophy and ptosis, with a mid-clavicular to nipple distance up to 45 cm and nipple-to-inframammary fold distances up to 23 cm who underwent surgery in Barranquilla, Colombia, between February 2023 and February 2025. Body mass index, medical history, and comorbidities were also analyzed (Table 1).

Table 1.

Distribution of Patients by Age, Related Medical History in Each Group, and Body Mass Index

Age (y)	Medical History	No. of Patients		Percentage (%).
15–26	Arterial hypertension	0	93	34.4
	Diabetes	0
	Active smoking	5
27–36	Arterial hypertension	3	105	38.8
	Diabetes	1
	Active smoking	5
37–46	Arterial hypertension	2	49	18.2
	Diabetes	1
	Active smoking	3
>46	Arterial hypertension	8	23	8.6
	Diabetes	7
	Active smoking	0
Total		270		100
Body mass index, kg/m2	Between 30 and 35	128		47.4
	Between 25 and 29,9	130		48.1
	Less than 25	12		4.5

Preoperative Markings

(See Video 1 [online], which demonstrates preoperative markings for a 25-year-old patient, Regnault grade III ptosis.)

Video 1. This video displays the markings of the technique, which are crucial for the surgical procedure.

Download video file ^{(36.8MB, mp4)}

Patients in Standing Position

1. Mid-body line: extending from the most caudal point of the suprasternal notch to the umbilicus.

2. A vertical line is drawn from the mid-clavicular line to the nipple (line A).

3. The new location of the nipple–areola complex (NAC) was defined using the Pitanguy maneuver (point A), and the superior margin of the NAC was defined, on average, between 18 and 20 cm from the mid-clavicular line.

4. A horizontal line—line B—was marked perpendicular to the breast midline, positioned 4–12 cm above the nipple. Line B’s height was tailored to the needed NAC elevation: it was drawn halfway between the nipple’s present level and its planned new location (point A). Thus, if the nipple lays at 36 cm and point A at 18 cm, the 18-cm vertical span dictated placing line B 9 cm above the nipple.

Patients in Supine Position

• 5. A vertical abdominal line is drawn between 9 and 10 cm from the midline.

• 6. The medial vertical lines are drawn with the lateral tilt of the breast as a prolongation of the lower abdominal line and up to line b, this point corresponds to B1.

• 7. The inframammary fold is marked.

• 8. Point C is located midway between points A and B1—9.5 cm lateral to the midline—marking the inner edge of the dermal dome.

Patients in Standing Position

• 9. The lateral vertical lines were marked by tilting the breast medially, and a prolongation of the abdominal vertical line was made, with a constant length of 5.5 cm, starting from line B, marking point B2.

• 10. The periareolar dome is outlined by connecting the cephalic ends of the medial and lateral verticals (points B1 and B2), tracing a smooth arc that passes through points A and C.

Patients in Supine Position

• 11. From the end of the lateral vertical lines, a spindle marking is made joining the most lateral and medial points of the inframammary fold.

Surgical Procedure

All patients underwent surgery under general anesthesia. (See Video 2 [online], which demonstrates the surgical ElevéL technique for reduction mammoplasty.)

Video 2. This video displays the surgical technique.

Download video file ^{(47.9MB, mp4)}

1. Scalpel incisions are made up to the dermis of all the demarcated lines, 42 mm areolotome is placed, and the areola is incised.

2. De-epithelization of the superior pedicle flap is performed extending 1–3 cm below the caudal end of the neo-areola.

3. The superior pedicle is dissected to a thickness of roughly 1.5 cm. Elevation begins 2 cm cephalad to points B1 and B2 and proceeds caudally and then deepens to the pectoralis major fascia, creating a wedge resection across the upper pole.

4. The vertical and horizontal marked incisions are dissected up to the pectoralis major fascia, and the breast tissue is resected.

5. Two sutures shape the skin envelope: the first advances the NAC to point A, and the second, placed between points B1 and B2 with 2-0 nylon, defines the circumference of the new areola.

6. An intradermal periareolar suture (round block) was made to establish a new diameter for the areola, and an intradermal suture of the areolar skin was made with nylon 2.0.

7. The medial part of the gland is separated from its overlying skin for independent handling. An inverted-T glandular excision in the medial pillar is done, permitting vertical skin gathering and leaving a 6-cm medial pillar.

8. Subsequently, for the centralization of the glandular tissue, multiple stitches of polyglactin 1.0 (Unilene, Inc.) are made from the lateral flap to the lateral border of the pectoralis major muscle to centralize the breast and provide greater projection, and breast pillars are sutured.

9. Layered closure was achieved with 2-0 polyglactin, followed by an intradermal skin suture of 2-0 mononylon. The medial vertical was plicated to match the length of the lateral vertical, after which 4-0 mononylon interrupted stitches were placed. A quarter-inch Hemovac was then inserted.

Postsurgical Care

At the end of the procedure, nitrofurazone-impregnated gauze was applied to the incisions, and hypoallergenic tape reinforced the lower pole to support the sutures. A wire-free sports bra with front fastening was fitted. NAC viability was checked six hours postoperative, after which the patient was discharged; drains were removed once output fell to less than or equal to 30 mL/d. Intradermal skin sutures were taken out on day 25. Follow-up visits were scheduled monthly for the first three months and annually thereafter. Two patients who underwent surgery were randomly selected for photographic follow-up (Figs. 1, 2).

Fig. 1.

Preoperative anterior (A), and left lateral (B) view of a 22-year old patient with an suprasternal notch-to-nipple distance of 40 and 39 cm right and left, respectively. Repositioning of the nipple at 20 cm. Nipple lift: 20 and 19 cm right and left, respectively, resection weight was 1330 and 1230 g for the right and left breasts, respectively. Postoperative anterior (C), left lateral (D), and from below view (E) at 4 months showing breast symmetry. Note the nipple pointing upward at a 15-degree angle as well as the central projection of the breast, the satisfactory upper pole fullness, the lower pole convexity, and the short L-scar.

Fig. 2.

Preoperative anterior (A), and left lateral (B) view of a 35-year old patient with an suprasternal notch-to-nipple distance of 36 and 34 cm right and left, respectively. Repositioning of the nipple at 19 cm. Nipple lift: 17 and 15 cm cm right and left, respectively, Resection weight was 1120 and 940 g for the right and left breasts, respectively. Postoperative anterior (C), left lateral view (D) and from below view (E) at 10 months showing breast symmetry. Note the short L-scar, as well as the straight upper pole, lower pole convexity, and the nipple pointing upward at a 5-degree angle.

Ethical Considerations

All patients gave written informed consent, including permission for the use of clinical photographs. The study conformed to the Declaration of Helsinki as well as all applicable local regulations for research involving human subjects, and it received ethics committee approval from each participating plastic surgery center.

RESULTS

We evaluated 270 consecutive procedures performed from February 2023 to February 2025. Patients were 15–60 years of age, and operative times averaged 3 hours 10 minutes (range, 2 h 20 min to 4 h). A total of 119 (44%) patients presented with severe breast hypertrophy or gigantomasty according to Berrocal Revueltas classification¹⁵ (Table 2); 2 (0.8%) patients presented partial necrosis of the NAC that healed by second intention with wound dressings; 0 patients had surgical infections; 3 (1.1%) patients had wound dehiscence; no patients presented hematoma; and 13 (4.8%) patients had widening of the areola. Alterations in the sensibility of the NAC occurred in 23 (8.5%) patients, who partially recovered sensibility (subjectively reported by the patients) (Table 3). The patient satisfaction index was reported as very satisfied in 93%, satisfied in 5%, and dissatisfied in 2% (BREAST-Q).

Table 2.

Classification of Breast Hypertrophy According to Berrocal Revueltas,¹⁵ Resected Breast Tissue Volume and Incidence in Each Group of Partial Necrosis of the NAC

Degree of Breast Hypertrophy	Resected Amount (g)	Total Patients		Partial Necrosis of the NAC
		No. Patients	Percentage (%)	No. NAC	Percentage (%)
Grade I or light	<500	96	35.6	0	0
Grade 2 or moderate	500–800	55	20.3	0	0
Severe hypertrophy	800–1000	62	23	1	0.4
Gigantomasty	>1000	57	21.1	1	0.4

Table 3.

Complication Rate

Complication		No. of Patients		Percentage (%)
Total necrosis of the areola		0		0
Infection		0		0
Wound dehiscence		3		1.1
Widened areolar scar		13		4.8
Altered sensibility		23		8.5
Hematoma		0		0
Round block suture breakage		4		1.5
Partial necrosis of the areola	Extent of partial necrosis of the NAC: 10%–20%	2	2	0.8
	Extent of partial necrosis of the NAC: 21%–40%	0
	Extent of partial necrosis of the NAC: 41%–60%	0

DISCUSSION

Numerous vascular pedicles have been described in the literature; however, the inferior pedicle remains the most widely used technique for reduction mammoplasty worldwide. Extensive evidence supports the safety of the superior pedicle regardless of the degree of ptosis, enabling significant elevation of the NAC,^14,16,17 while demonstrating lower complication rates compared with other pedicles.^14,18 Furthermore, the superior pedicle offers distinct advantages over alternative techniques, including enhanced upper pole fullness, improved breast projection, and higher patient satisfaction rates.¹⁹ When combined with the scar-minimizing benefits of an L-shaped incision, this approach constitutes a surgical technique with significant advantages for patients.

We compared our previous study¹⁴ with the ElevéL technique. In terms of patient selection, there was no difference. Surgical time was on average 2.30 hours in our present study, and 3 hours in our previous technique. In our previous study, 90% of patients reported being very satisfied, whereas with the ElevéL technique, 93% reported being very satisfied (BREAST-Q). This represents an increase in the degree of patient satisfaction with the ElevéL technique. We believe that this occurs due to the decrease in the size of the scars and leaving cleavage free of scars. In both studies, we observed wound dehiscence in only 1.7% of patients. This improvement stems chiefly from shorter scars and a lower complication rate when comparing both techniques.

The L-shaped incision pattern presents several advantages over the inverted-T technique. A primary benefit is the absence of a scar in the inferomedial breast pole, unlike other methods, where the medial scar can stretch all the way to the sternal midline^15,20,21; this allows patients greater flexibility in clothing choices without concerns about scar concealment in this area. Another significant advantage is the reduced incidence of surgical wound dehiscence. In reduction mammoplasties that avoid the inverted-T pattern, the lack of a junction between the vertical and horizontal scars eliminates the most common site of wound dehiscence.^22,23

Despite these benefits, circumvertical and L-shaped incisions have not gained the same widespread acceptance as the traditional inverted-T approach; this may be due to the perception that these approaches require complex preoperative markings and surgical execution,²⁴ potentially limiting their reproducibility. Our technique, by contrast, is straightforward, reproducible, and suitable even for surgeons with limited experience in L-scar reduction mammoplasty. It delivers reliable results while preserving all of the aforementioned advantages. Crucially, it relies on dynamic, patient-specific markings rather than a rigid template, recognizing that no single pattern can accommodate the full spectrum of breast anatomies.

The concept of glandular-skin separation was first introduced by Lejour^25–28 and later adopted by several other authors.^29–31 In recent years, this technique has regained prominence, notably through the work of Bark et al.³² These authors primarily use this technique in the context of inverted-T glandular resections to facilitate vertical skin pleating. However, our approach represents a distinct adaptation. We selectively individualize only the medial breast pole to achieve a consistent vertical scar length of 5.5–6.5 cm. This is accomplished through 3 key modifications: (1) wide periareolar marking to prevent excessive vertical scar length, (2) maintaining the lateral vertical scar at a length of 5.5–6.5 cm without separating the skin from the gland in this area, and (3) by allowing the longer medial vertical scar to pleat down to match the lateral scar length, as Chiari³³ described.

We have named this technique ElevéL, highlighting the consistent elevation of the NAC using a superior pedicle (Elevé). This approach contrasts with the recommendations of numerous authors and studies advocating for the use of an inferior pedicle^34,35 or a free nipple graft^36,37 in patients with severe ptosis and with a resultant inverted-T scar. The final “L” in the name represents the resulting L-shaped scar, which remains consistent across all patients.

CONCLUSIONS

Applying the described technique, the risks of surgical complications are not increased in comparison with other techniques previously used for breast reduction, even being applied in gigantomasty and with ascent of the NAC up to 25 cm with superior pedicle. The ElevéL technique is easy to reproduce and yields natural, long-lasting results with low complications rates, making it a good surgical option.

DISCLOSURES

Dr. Sergio A. Arbelaez, Dr. Sergio Arbelaez and Dr. Eslait served as plastic surgeons in Bonadona Clinic, La Merced Clinic and Clinica Reina Catalina in Barranquilla, Colombia, where all surgical procedures were performed. The other authors have no financial interest to declare in relation to the content of this article.

PATIENT CONSENT

All patients consented to a standardized clinical protocol and a photographic work-up.

ACKNOWLEDGMENTS

The authors would like to thank Dr. Adel Bark, an outstanding breast surgeon from Brazil, from whom the first author learned the multiplane concept. His guidance greatly contributed to the refinement of the author’s surgical technique.