Horizontal or Vertical? An Evaluation of Patient Preferences for Reduction Mammaplasty Scars Amy M. Sprole, MD; Ife Adepoju; Jeffrey Ascherman, MD; Lloyd B. Gayle, MD; Robert T. Grant, MD; and Mia Talmor, MD Dr. Sprole is in private practice in Wichita, KS. Ms. Adepoju is a student at Weill Medical College of Cornell University, New York, NY. Drs. Ascherman, Gayle, Grant, and Talmore are affiliated with New York-Presbyterian Hospital and Weill Medical College of Cornell University, New York, NY. Background: In the United States, the inferior pedicle Wise pattern technique of reduction mammaplasty has been well established as a safe and reliable method of reducing breast size while maintaining nipple-areolar vascularity and sensation. Nonetheless, the typical inverted-t scar of the Wise pattern reduction is a consistent source of patient and surgeon dissatisfaction with the operation, which has led to the increased popularity of limited-incision techniques of breast reduction. Objective: In this study, it was our goal to evaluate patient preferences for breast reduction scar location. Methods: A retrospective chart review was undertaken that identified 121 patients who underwent bilateral Wise pattern reduction mammaplasty between July 1999 and June 2004. The patients were asked to rate their satisfaction with the surgery on a 1 to 10 scale and to rate the extent, if any, to which they were bothered by their scars. Those patients who were bothered by their scars were asked to delineate which part of the scar bothered them most the horizontal component, the vertical component, or the areolar component. A statistical analysis of the results was performed with a standard two-tailed t test and a 2 analysis. Results: Of the 121 surveys mailed out, 27 surveys were undeliverable. Fifty-seven of the remaining 94 surveys were returned, for a response rate of 61%. Although 49 of the respondents (86%) were highly satisfied with their surgery, 37 patients (65%) indicated dissatisfaction with their scars. Forty-one patients (72%) responded to the question asking which of the scars was most bothersome. Of these 41 respondents, 10 were bothered by all scars equally. Among the remaining 31 patients, 20 (65%) indicated that the horizontal component bothered them most a statistically significant proportion (P <.001). Twentythree of 46 patients (50%) who responded to the questions asking which scar they would erase if they were able to do so indicated that they would erase the vertical scar, which was also statistically significant (P <.001). Conclusions: Our survey confirms the widespread satisfaction reported by patients who have undergone Wise pattern breast reduction surgery. However, it also demonstrates that a statistically significant number of patients are bothered by their scars. These results underscore the importance of developing techniques that minimize breast reduction scars and suggest that shortscar options would be welcomed by women considering breast reduction surgery. (Aesthetic Surg J 2007;27:257 262.) In the United States, the inferior pedicle Wise pattern technique of reduction mammaplasty, as described and popularized by multiple authors in the 1970s, 1-4 has been well established as a safe and reliable method of reducing breast size while maintaining nipple-areolar vascularity and sensation. It has been demonstrated to provide excellent symptomatic relief and high patient satisfaction overall. 1-8 Complication and revision rates for the operation are low in most recent series. 5,6,9 A recent survey by Rohrich et al 10 demonstrated that this technique remains by far the most commonly used technique for breast reduction in the United States, with 75.5% of survey respondents citing a preference for the inferior pedicle Wise pattern technique. Nonetheless, the typical inverted-t scar of the Wise pattern reduction mammaplasty is a consistent source of patient and surgeon dissatisfaction. 11,12 This may explain the increased popularity of limited-incision techniques of breast reduction. Most short-scar techniques of breast reduction use a superior or superiormedial dermoglandular pedicle with circumareolar and vertical incisions only, omitting the horizontal component of the inverted-t of the traditional Wise pattern. 13-15 Excellent aesthetic results and increased patient satisfaction with vertical reduction mammaplasty scars have been well documented, but at the cost of increased complication and revision rates in some series. 16-18 Aesthetic Surgery Journal ~ May/June 2007 257
A review of the recent plastic surgery literature makes it clear that substantial effort has been put forth to eliminate the horizontal component of the inverted-t scar of the traditional Wise pattern reduction mammaplasty and to understand and quantify the consequences of that surgical modification. However, it seems that relatively little attention has been paid recently to the elimination of the vertical scar. Passot 19 is credited with the first description of the no-vertical scar procedure in 1925. More recently, it was described by Lalonde et al, 20 with a demonstration of excellent aesthetic results. While this technique is not as widely studied as the vertical reduction techniques in terms of complications, revision rates, and patient satisfaction, it certainly represents another safe, effective, and aesthetically sound option. As suggested by Lalonde et al, 20 the no-vertical scar technique may represent a superior aesthetic option, because it eliminates non-areolar scars on the visible breast mound. Although not all patients are good candidates for all of the available reduction mammaplasty techniques, most patients are good candidates for several different options. In this study, it was our goal to evaluate patient preferences for breast reduction scar location, in terms of its position on the breast mound horizontal, vertical, areolar, or no preference. Evaluation of patient preferences for breast reduction scars is an important component in our efforts to develop the ideal breast reduction operation. In addition, it is useful to learn whether the most commonly performed breast reduction techniques deliver scars that match with current trends in patients aesthetic priorities. Methods The patients in the study group were selected by retrospective chart review. All patients who had undergone bilateral Wise pattern reduction mammaplasty between July 1999 and June 2004 in the practices of the four senior authors were included. This time interval ensured that all the selected patients were greater than or equal to 1 year after surgery, to allow maximal scar maturation before patient assessment. Patients who underwent surgery before 1999 were difficult to consistently locate, so we limited our study group to this 5-year increment. This method generated 121 patients as potential subjects for this study. A survey was designed that asked patients about their feelings about their breast reduction surgery scars (Figure). Specifically, patients were asked about their overall satisfaction with their breast reduction surgery and to what extent, if any, they were bothered by their scars. If they were bothered by their scars, they were further asked to delineate which part of the inverted- T shaped scar bothered them most the horizontal component, the vertical component, the areolar component, or all parts equally. The survey was sent to all 121 patients identified as potential participants in the study. Twenty-seven surveys were undeliverable, because of a change of address without forwarding information, thus leaving us with 94 potential respondents. Of these, 57 surveys were returned, giving us a response rate of 61%. Statistical analysis of the responses was performed with Microsoft Excel with a standard two-tailed t test for Table 2 and a 2 analysis for Tables 3 and 4. The null hypothesis for Table 1 was that one half of the respondents would be bothered by scars and one half would not. For Tables 3 and 4 the null hypothesis in each case was that each scar type (horizontal, vertical, areolar) would represent one third of the responses and the alternate hypothesis was that each scar type would represent a proportion different from one third of the responses. A P value <.05 was used to delineate statistical significance. All components of this study, including its methodologic design and survey implementation, were evaluated and approved by the Institutional Review Board of the New York Presbyterian Hospital Cornell Medical Center. Results Of the 57 survey respondents, 49 (86%) were highly satisfied with their breast reduction surgery overall, as indicated by a score of 7 to 10 on the questionnaire. Another 5 patients (9%) were moderately satisfied, as indicated by a score of 4 to 6 on the survey. Only 3 patients (5%) indicated that they were dissatisfied with their experience (Table 1). In spite of the large proportion of highly satisfied patients in this breast reduction surgery cohort, 37 respondents (65%) indicated dissatisfaction with their surgical scars. To quantify the extent of their dissatisfaction, patients were asked to quantify the extent to which they were bothered on a scale of 1 to 10. Of the 37 patients that were bothered by scarring, 17 (46%) were highly bothered, as indicated by a score of 7 to 10 on the survey. Another 5 patients (14%) were moderately bothered, as indicated by a score of 4 to 6. Fifteen patients (40%) were minimally bothered by their scars (Table 2). Patients were next asked to indicate which part of their Wise pattern breast reduction scar bothered them the most the horizontal component, the vertical com- 258 Aesthetic Surgery Journal ~ May/June 2007 Volume 27, Number 3
Please answer the following questions: How many years ago was your breast reduction surgery performed? Please rate your satisfaction with your breast reduction surgery overall: 1 2 3 4 5 6 7 8 9 10 not satisfied extremely satisfied Are you bothered by your breast reduction scars? Yes No If you answered Yes, please quantify your response: 1 2 3 4 5 6 7 8 9 10 minimally extremely bothered bothered Which part of the scar bothers you the most (see figure below): Horizontal Scar Vertical Scar Areolar All parts of scar (red arrows) (blue arrows) (black arrow) bother me equally If you could erase one part of your scar, which would it be: Horizontal Vertical Areolar (red arrows) (blue arrows) (black arrow) Figure. Breast reduction scar survey. Horizontal or Vertical? An Evaluation of Patient Preferences for Reduction Mammaplasty Scars Aesthetic Surgery Journal ~ May/June 2007 259
Table 1. Satisfaction with breast reduction surgery Satisfaction level No. of patients % Highly satisfied 7-10 49 86 Moderately satisfied 4-6 5 9 Dissatisfied 1-3 3 5 Scale: 1 = not satisfied, 10 = extremely satisfied. ponent, the areolar component, or all parts equally. Although only 37 patients indicated in the preceding question that they were bothered by their scars, 41 patients (72%) responded that one or more components of the scar was most bothersome. Of these 41 patients, 10 (24%) were bothered by all components of the scar equally. Of the 31 respondents who were bothered by one component of the scar more than other components, 20 (65%) indicated that the horizontal component was most bothersome. Eight patients (25%) indicated that the vertical component was most bothersome. The areolar component of the scar was most bothersome to 3 patients (10%) The large proportion of patients bothered most by the horizontal scar (65%) was statistically significant (P <.001) (Table 3). The final question of the survey asked patients which one part of the scar they would erase, if they were able to do so. Forty-nine patients (86%) provided a response to this question. Of these respondents, 3 patients (6%) would erase all scars. Of the 46 respondents who would choose to erase only one component of the scar, 20 (43%) indicated that they would erase the horizontal component. Twenty-three patients (50%) indicated that they would erase the vertical component. Three patients (7%) indicated that they would eliminate the areolar component. The highest percentage of respondents indicated a desire to have the vertical scar erased, which was statistically significant (P <.001) (Table 4). Table 2. Patients bothered by breast reduction scarring Discussion Although this study involved a relatively small study group, it yielded a number of important results. It confirms yet again the high satisfaction reported by patients undergoing Wise pattern breast reduction surgery, with a striking 86% of survey respondents indicating 7 to 10 on the satisfaction scale of 1 to 10, where 10 equaled greatest satisfaction. However, despite this widespread overall satisfaction with the operation, a statistically significant majority of patients indicated that they were bothered by their scars. Among those who indicated dissatisfaction with scarring, there was a fairly even distribution among respondents of those who were minimally bothered and those who were extremely bothered by their scars. Of the patients bothered by scarring, a significant majority indicated that the horizontal component was most bothersome. Anecdotally, patients wrote additional comments on the survey that helped explain their discontent with this component of the scar. Patients indicated that the scar was irritating and itchy, because of its juxtaposition to the bra. Other patients complained that the horizontal scar extended into the axilla, where it was apparent in clothing or created unsightly dog ears. In contrast to the response obtained to the question about the most bothersome component of the scar, the highest percentage of patients indicated a preference for eliminating the vertical component of the scar. The divergence in the responses to the two questions about preferences regarding scar components (most bothersome vs which to erase) was somewhat surprising it was anticipated that one question would reinforce, rather than contradict, the other. One possible explanation for this divergence in the responses lies in an anecdote that one patient shared on her survey the horizontal component was most bothersome because of its discomfort, but the vertical component was the most visually unacceptable because it was the only part of the scar that she saw when she looked in the mirror. Response No. of patients % P value Yes 37 65 P =.02 No 20 35 Quantified Highly bothered by scars (7-10) 17 46 Moderately bothered by scars (4-6) 5 14 Minimally bothered by scars (1-3) 15 40 260 Aesthetic Surgery Journal ~ May/June 2007 Volume 27, Number 3
Table 3. Most bothersome part of scar No. of Component patients %* P value Horizontal component 20 65% P <.001 Vertical component 8 25% P <.001 Areolar component 3 10% P <.001 All scars bother equally 10 Scars do not bother 16 *Percentage of patients indicating only 1 component. Table 4. Scar component most desired to have erased No. of Component patients %* P value Horizontal component 20 43 P <.001 Vertical component 23 50 P <.001 Areolar component 3 7 P <.001 All scars bother equally 3 Scars do not bother 8 * Percentage of patients selecting only 1 component. The data in Table 3 suggest that the preponderance of effort that has been invested in improving the vertical mammaplasty technique is appropriately directed. Patients in this study indicated that the horizontal component of the Wise-pattern breast reduction scar bothered them most. However, the near-equal distribution of patient wishes for elimination of horizontal and vertical components demonstrated in Table 4 suggests that there are factors in addition to the extent to which they are bothered by the scar that affect which part of the scar they are willing to accept permanently. Additional factors may include a tendency toward hypertrophic scars, clothing style preferences, body habitus, and breast shape or extent of ptosis. Conclusion This study underscores the importance of developing and perfecting techniques that minimize breast reduction scars. The most extensive scar is the one resulting from the traditional Wise pattern mammaplasty, which is the approach most commonly used by plastic surgeons in the United States. 10 One can deduce from the patient opinions expressed in this study that short-scar breast reduction options both pure vertical and pure horizontal techniques would be welcomed by these patients. The choice of technique must be tailored to a particular patient, taking into account patient preferences, body habitus, breast size, and surgeon experience, to minimize the overall scar burden, while maximizing symptom relief and aesthetic outcome. The authors have no disclosures wiith regard to any products mentioned in this article. Acknowledgments: We gratefully acknowledge the assistance of Professor David Juran, PhD of the Columbia Business School, New York, NY with the statistical analysis of this data. References 1. Courtiss E, Goldwyn RM. Reduction mammaplasty by the inferior pedicle technique. Plast Reconstr Surg 1977;59:500-507. 2. Georgiade NG, Serafin D, Morris R, Georgiade G. Reduction mammaplasty utilizing an inferior pedicle nipple-areolar flap. Ann Plast Surg 1979;3:211-218. 3. Ribeiro L. A new technique for reduction mammaplasty. Plast Reconstr Surg 1975;55:330-334. 4. Robbins TH. A reduction mammaplasty with the areola-nipple based on an inferior dermal pedicle. Plast Reconstr Surg 1977;59:64-67. 5. Mizgala CL, MacKenzie KM. Breast reduction outcome study. Ann Plast Surg 2000;44:125-133. 6. Wallace WH, Thompson WO, Smith RA, Barraza KR, Davidson SF, Thompson JT 2nd. Reduction mammaplasty using the inferior pedicle technique. Ann Plast Surg 1998;40:235-240. 7. Harbo SO, Jorum E, Roald HE. Reduction mammaplasty: a prospective study of symptom relief and alterations of skin sensibility. Plast Reconstr Surg 2003;111:103-110. 8. Davis GM, Ringler SL, Short K, Sherrick D, Bengtson BP. Reduction mammaplasty: long-term efficacy, morbidity, and patient satisfaction. Plast Reconstr Surg 1995;96:1106-1110. 9. O Grady KF, Thoma A, Dal Cin A. A comparison of complication rates in large and small inferior pedicle reduction mammaplasty. Plast Reconstr Surg 2005;115:736-742. 10. Rohrich RJ, Gosman AA, Brown SA, Tonadapu P, Foster B. Current preferences for breast reduction techniques: a survey of board-certified plastic surgeons 2002. Plast Reconstr Surg 2004;114:1724-1733. 11. Godwin Y, Wood SH, O Neill TJ. A comparison of the patient and surgeon opinion on the long-term aesthetic outcome of reduction mammaplasty. Br J Plast Surg 1998;51:444-449. 12. Shakespeare V, Cole RP. Measuring patient-based outcomes in a plastic surgery service: breast reduction surgical patients. Br J Plast Surg 1997;50:242-248. 13. Lejour M. Vertical mammaplasty and liposuction of the breast. Plast Reconstr Surg 1994;94:100-114. 14. Hall-Findlay EJ. A simplified vertical reduction mammaplasty: shortening the learning curve. Plast Reconstr Surg 1999;104:748-759. 15. Hall-Findlay EJ. Vertical breast reduction with a medial-based pedicle. Aesthetic Surg J 1992;22-185-194. Horizontal or Vertical? An Evaluation of Patient Preferences for Reduction Mammaplasty Scars Aesthetic Surgery Journal ~ May/June 2007 261
16. Cruz-Korchin N, Korchin L. Vertical versus Wise pattern breast reduction: patient satisfaction, revision rates, and complications. Plast Reconstr Surg 2003;112:1573-1578. 17. Berthe JV, Massaut J, Greuse M, Coessens B, De Mey A. The vertical mammaplasty: a reappraisal of the technique and its complications. Plast Reconstr Surg 2003;111:2192-2199. 18. Schlenz I, Rigel S, Schemper M, Kuzbari R. Alteration of nipple and areola sensitivity by reduction mammaplasty: a prospective comparison of five techniques. Plast Reconstr Surg 2005;115:743-751. 19. Passot R. La correction du prolasus mammaire par le procede de la transposition du mamelon. La Presse Medicale 1925;19:33. 20. Lalonde DH, Lalonde J, French R. The no vertical scar breast reduction: a minor variation that allows you to remove vertical scar portion of the inferior pedicle Wise pattern T scar. Aesthetic Plast Surg 2003;27:335-344. Accepted for publication February 7, 2007. Reprint requests: Amy M. Sprole, MD, 1861 N. Webb Rd., Wichita, KS 67206. Copyright 2007 by The American Society for Aesthetic Plastic Surgery, Inc. 1090-820X/$32.00 doi:10.1016.j.asj.2007.04.007 262 Aesthetic Surgery Journal ~ May/June 2007 Volume 27, Number 3