Clin Plastic Surg 29 (2002) 365 – 377
Areolar vertical approach (AVA) mammaplasty:
Lejour’s technique evolution
Carlos E. Van Thienen, MD
Clı́nica Van Thienen, Chacabuco 250, San Isidro 1642, Buenos Aires, Argentina
During the past few decades, periareolar and ver-
tical scar mammaplasties were introduced as a novel
way of approaching breast reductions. Many surgeons
worldwide are still reluctant to apply them as a
standard. The surgeon faced with a breast reduction
case needs to consider three fundamental aspects.
Nipple areola pedicle
The options are: (1) superior, (2) inferior, (3)
medial, (4) lateral, and (5) combined. The goal here
is to select the pedicle that can assure an adequate and
reliable blood supply and innervation when the nipple
areola is relocated in the new position. All of these
pedicles are satisfactory for achieving these goals.
Parenchyma resections
The surgeon needs to keep in mind that the long-
term shape of the breast will depend mainly on the
reconfiguration of the parenchyma, not on the skin
closure. Therefore, the glandular and adipose tissue
can be treated independently from the skin. The
breast reduction technique should not be the deciding
factor of how the skin incision is made.
Scar
There are three possible areas to consider: (1)
areola, (2) lower pole/vertical or oblique, and (3)
E-mail address: cvanthienen@clinicavanthienen.com
(C.E. Van Thienen).
0094-1298/02/$ – see front matter D 2002, Elsevier Science (USA). All rights reserved.
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submammary sulcus (total from one side to the other,
short in the middle portion or lateral).
We know that the areola region is very adequate
because it offers a good scar for the kind of design that
is needed; ie, naturally irregular on its borders,
dynamic with constriction or dilatations, and pigented.
The vertical scar is usually under tension in its
postoperative healing period, with a very low tend-
ency to pathologic scarring (it is under physiological
scar presotherapy) and is usually very acceptable. The
submammary scar is placed on transitional skin
between the abdomen and the chest wall, ie, thicker,
(the end portions medial and lateral are the most
visible). Therefore, the incidence of pathologic scar-
ring is increased, which is obviously less acceptable
by the patient.
The surgeon should consider which approach will
be the best for breast tissue reduction, with the best
cosmetic result. My preferences are: (1) for nipple
areola pedicle (NAP), the superior pedicle, based on
dermocutaneous angiosomas of the chest wall and the
understanding that it provides the necessary versati-
lity to do the breast reduction, (2) for parenchyma
resection, selection of the pedicle usually determines
the kind of parenchyma resections that can be per-
formed to reduce and reshape the breast, and (3) for
scars, I prefer the areolar and the vertical areas of
the breast skin where the final scar will be located
after compensating for differences between the ideal
measurements of the final scar and the amount of
redundant skin. I believe that resections of the central
lower pole, lateral quadrants, and base of the disk
provide the best results.
I have learned to keep an open mind in dealing
with breast reductions. I started with the old-fash-
ioned inverted-T scar technique (superior pedicle)
366 C.E. Van Thienen / Clin Plastic Surg 29 (2002) 365–377
Fig. 1. Measurements from sternal notch to nipples are taken
and written between brakets.
as described by Pitanguy [1] but changed my
approach to the skin management and final scar
technique described by Lejour [2 – 5]. The skin in-
cision provides access to the glandular tissue that
needs to be reduced; it is not the support of breast
reshaping. In all cases, my goal is to select a tech-
nique that provides: (1) adequate long-term breast
shape and contour, (2) less noticeable scars, and (3)
minimal complications.
Patient marking
The patient should stand up before surgery and
premedication. She needs to move and shake her
arms and shoulders in order to be relaxed. Her initials
and age are written on the left side of her chest.
The markings have some fixed points as refer-
ences but do not follow a standard pattern. This is a
dynamic and freehand delineation following specific
steps. Measurements are always taken afterward only
Fig. 2. Sternal notch, clavicula and midclavicular point
are marked.
Fig. 3. Submammary sulcus.
as a control. It is very important to learn to move, see,
and draw on the breast skin, thinking symmetrically
and how much tissue will be removed to obtain the
desired result. With a non-permanent black pen, the
surgeon draws the following: (1) midsternal line,
from the sternal notch to the abdominal skin, (2)
clavicle and mid-clavicular point (8 – 11 cm), and (3)
the submammary fold.
Measurements from the sternal notch to the nip-
ples are taken, and written between brackets on each
side of the chest skin (Figs. 1 – 3). Then the breast
meridian is delineated, projecting perpendicularly and
down the side from the mid-clavicular point to join
and cross the submammary sulcus to obtain another
important reference point (point S, sulcus: 9 – 12 cm
from midsternal line).
From this point (Fig. 4), the middle finger is placed
perpendicular to the sulcus. Hanging the breast on the
palmar side of the hand, project the top of the finger in
a upward direction, always vertically. Then apply the
other hand to the breast skin and, with the same
opposite finger, try to touch or sense (like a breast
Fig. 4. The prosection of the breast meridian crossing the
submammary sulcus to obtain the ‘‘S’’ point.
 C.E. Van Thienen / Clin Plastic Surg 29 (2002) 365–377
Fig. 5. Marking the new position for the areola. The
‘‘A’’ point.
sandwich) where the tip of both middle fingers
must meet. This point is the future superior limit of
the newly located areola (point A, areola: 18 – 22 cm
from the sternal notch, and 10 – 14 cm to the mid-
sternal line).
With point A (areolar) as the most cephalic limit
and point S (sulcus) as the caudal limit, then delineate
the lateral markings (Fig. 5). As Lejour explained so
well, the breast is gently mobilized laterally and with
upward rotation, the vertical line is drawn (meridian,
from mid-clavicular mark to point S. The same
maneuver is performed medially. Next, two vertical
lines (internal and external) that touch at point S but
are divergent in the mid-portion and joint, mark
point A in an ill-defined fashion.
At this point, the limits of the areola must be
defined in its caudal (6 o’clock) portion and vertical
cephalic limit, or point V (Figs. 6,7). The skin is
pinched from the lateral markings at a point where it
forms a circumference similar to the future areola-
nipple area. Where the fingers meet is the new point
(vertical origin, and in > < fashion).
Fig. 6. Mobilization lateral and upward to delineate the
lateral external limit of skin and tissue resection.
367
Fig. 7. Performing the same maneuver for the medial limit of
skin and tissue resection.
The final steps are as follows: (1) delineate the
areola (to do this between point A (areolar) and point V,
> < vertical, a slightly curved or elliptical line is
drawn; usually, the distance of each arm is not more
than 8 cm) (Fig. 8), and (2) delineate the lower limit of
the vertical line as a curved-shape line between the two
verticals, 1 – 2 cm above point S (Fig. 9).
At this step, both breasts are gently pushed
together toward the midline, for checking that the
medial portion of the markings touch (Fig. 10 – 12).
Stand back some distance from the patient and
observe all your marks in order to detect asymmetries
and, as a final control, take new measurements. In
this way, there is no need to touch the markings any
more. Do the final control with the patient supine on
the preanesthesic table. As a curiosity, in my experi-
ence, what I do with the patient in the standing
position is enough, and it is unlikely that I will need
to change the original marks. This is the planning
stage of the surgical skin approach to breast reduc-
Fig. 8. Defining the ‘‘V’’ points by pinching both sides of
lateral marks.
368 C.E. Van Thienen / Clin Plastic Surg 29 (2002) 365–377
Fig. 9. The lateral marks meet in a curve shaped line 1 or
2 cm. above the ‘‘S’’ point.
tion, and the way to obtain a final periareolar and
vertical closure. Photos are then taken.
Surgical technique
The patient is positioned in a 30° semi-seated
fashion, arms abducted 90°; preparation and draping
are performed in the usual sterile routine. General
anesthesia is delivered by endotracheal intubation.
The surgeon stands on the preferred side of the table
and operates on both breasts from the same side.
Skin and breast approach
The breast is retracted upward, with the surgeon
grasping the nipple areolar skin held by the assist-
ant. The base is constricted with a plastic auto-fixed
band in order to obtain enough tension to slightly
incise the skin with a #24 knife blade. First, the intra-
Fig. 10. The future place of the areola, between ‘‘A’’ point
and both medial and external ‘‘V’’ points.
Fig. 11. Final appearance of markings for the future place of
breast sulcus.
areolar perinipple skin is incised in a circular fashion
4 – 4.5 cm diameter, and then all the skin marks are
incised in order to avoid demarcation.
For the superior areolar nipple pedicle, deepithelia-
lization of the entire area is performed where the areola
nipple (AN) complex will be repositioned, extending
the inferior limits below the points V (> < ) 2 or 3 cm
below the inferior limit of the areola. This will preserve
a good areolar subdermal neurovascular blood supply.
Tension is released and, with two forceps, the
assistant holds the breast placed on each internal
deepithelialized side of the points V (> < ).
Projection of the inferior pole is obtained by
pressure on the upper pole by holding the forceps
on the chest wall with a gauze pad that serves as
hemostatic for the deepithelialized area as well. In
this way, incision of the lower half of the vertical
lines up to the curved area (1 – 2 cm above point S), is
made, and surgery to the breast and adipose tissue is
performed, first from the lower portion subdermally
to create thinner flaps at this time, leaving not too
much adipose tissue attached to the dermis, and
Fig. 12. Last view of breast markings after surgery.
 C.E. Van Thienen / Clin Plastic Surg 29 (2002) 365–377
Fig. 13. Resection of the breast tissue from medial side
perpendicularly above the anatomical submammary
sulcus. The submammary sulcus is not touched.
The dissection continues down to the pectoralis
fascia in order to develop the retromammary space
laterally and centrally upward (Fig. 15). How far? (1)
medially, not too much; always keep in mind the
blood supply and consider that the thickness of breast
tissue at this location is usually insignificant, (2)
laterally, enough to gain access to the axillary and
lateral tissue excess that will be resected, and (3)
upward, as far as the areolar nipple complex will
be relocated.
Parenchymal resection
Be conservative with the neurovascular breast
tissue and skin supply. Once the gland is dissected
from the pectoralis fascia, I introduce my hand and
hang it like a disk. The assistant changes the direction
of traction toward the ceiling and, in this way, a more
conical shape is obtained. As the superior pedicle
for the areolar nipple flap has been selected, most of
the excess tissue must be removed from the lower
Fig. 14. The dissection continues down to the pectoralis
fascia.
369
Fig. 15. The medial and lateral pillars ready to be sutured.
pole. I incise the breast tissue perpendicular to the
chest wall, from V to S (> < ), until I reach the palm
of my hand on both the lateral and medial sides.
With this maneuver, I have freed up the central
inferior pole and created two pillars, one lateral and
the other medial.
The amount of breast tissue that will be resected,
according to the preliminary resection strategy, will
depend on each case. The following principles, how-
ever, must be followed: (1) the central lower pole can
be resected as needed, preserving the subdermal
vascular network of the areolar nipple; this is per-
formed in an infundibular fashion, ie, that resection
from the base is wide and thick upward, and retro-
mamillar and cephalic to point A, is thinner and
narrower, (2) the lateral pillar and its axillary projec-
tion is resected from the base or deep plane of the
parenchyma, (3) the medial pillar is resected from the
base, with the surgeon also being very conservative in
the amount of tissue removed (Figs. 13,14), and (4)the
superior-based dermoglandular areolar nipple flap
must be released from the lateral and medial pillar,
enough to achieve an easy, no-tension transposition.
Fig. 16. The dermocutaneous flap for the nipple-areola
complex.
370 C.E. Van Thienen / Clin Plastic Surg 29 (2002) 365–377
Fig. 17. Undermined the lower portion of the breast to relax
skin tension.
Preserving the neurovascular blood supply maintains
viability. The base should be as wide as possible and
as thin as needed. This is an axial dermocutaneous
flap according to its vascular anatomy (Fig. 16).
All the removed tissue is weighed, asymmetries
corrected, and the specimen sent to the pathology
department (Fig. 15). Meticulous hemostasia is per-
formed. The surgeon must decide how much tissue to
remove in each individual case, but to my mind, the
principle of ‘‘Less is more’’ applies here, especially
from the medial and upper portion of the gland.
Reshaping and suturing the breast mound
The first stitch is on point A, joining the 12 o’clock
point of the areolar border (Fig. 17 – 19). The second is
on points V (> < ). At this point, the assistant holds the
breast toward the ceiling with forceps, and the pillars
tend to approximate. Looking from the top (point V)
to the base, one can measure the length of the pillars
and resect more at its foots in a triangular shape in
order to obtain a more curved shape at the base.
Sutures from deep to superficial are placed on the
Fig. 18. Sutures are placed from deep to superficial breast
parenchyma.
Fig. 19. Using one stitch to avoid dead space in the lower
limit including chest wall.
parenchymal tissue, achieving the desired conical
shape and avoiding dead spaces. All sutures are ny-
lon monofilament.
Sutures to the chest wall or pectoralis fascia are not
the key for long-term results in the shape. They must be
used only with the aim of reducing tension on the skin
suture. The original Lejour technique was one stitch
deep in the areolar pedicle to the pectoralis fascia,
upward as the dissection was done, with some down-
ward retraction of the areola and fullness of the upper
pole. I do not use this method if it creates such defects.
On the other hand, I use one stitch on the point
where the pillars are joined at the base, including
chest wall tissue. The intention is to avoid dead space
when draping the overlaying skin at this point.
Skin redraping and closure
In periareolar vertical mammaplasty techniques,
the excess skin must be redraped either on the areolar
region or the vertical portion. In the areolar vertical
mammaplasty with superior pedicle as described by
Fig. 20. Length and wrinkles of vertical scar.
 C.E. Van Thienen / Clin Plastic Surg 29 (2002) 365–377 371

Fig. 21. 4 cm. diameter obtained for the areola.

Lejour, most compensation is on the vertical portion
of the surgical approach.
For areolar closure, begin placing 5-0 nylon
intradermal single stitches around the areola on
the 12-6-9-3-2-5-7-10-o’clock positions (in this
order). All the stitches must be placed without
tension. This is followed by 4-0 nylon subcuticular
running sutures.
For vertical closure, the goal is to create a max-
imum 8-cm final vertical scar from the excess skin
that is usually 12 cm or more. This is achieved by

Fig 23. Adhesive elastic tape with gentle compression over

Fig 22. Tapes placed over the scars and drains. the breasts.
372 C.E. Van Thienen / Clin Plastic Surg 29 (2002) 365–377

Fig. 24. (A, C, E, G): Preoperative pictures of a 35 year old patient with mild breast hypertrophy. (B, D, F, H): 8 month
postoperative pictures from the same patient.
 C.E. Van Thienen / Clin Plastic Surg 29 (2002) 365–377 373

Fig. 25. (A, C, E, G): Preoperative pictures of a 20 year old patient with moderate breast hypertrophy. (B, D, F, H): 6 month
postoperative pictures from the same patient.
374 C.E. Van Thienen / Clin Plastic Surg 29 (2002) 365–377

Fig. 26. (A, C, E, G): Preoperative pictures of a 17 year old patient with severe breast hypertrophy. (B, D, F, H): 1 year
postoperative pictures from the same patient.
 C.E. Van Thienen / Clin Plastic Surg 29 (2002) 365–377
placing several subdermal pursestring stiches with
3-0 nylon. Usually, 3 – 4 stitches are required. Prior to
placement of stitches, subcutaneous dissection of the
skin is performed as needed to release tension on the
suture; this creates multiple fine wrinkles. The purse-
string stitches are placed from the base to the top.
The first one is placed above point S. This stitch is
the most artistic and difficult to explain, but on the
curved shape of this area, a pursestring stitch should
be deep on the hypodermis, including the glandular
tissue, without too much tension in placement. Also,
eversion of the cuticular borders and wrinkles is
critical. Avoid leaving superficial skin inverted
because it dilates the scar.
The wrinkles created are going to disappear in the
postoperative period (Figs. 20,21). Finally, subcutic-
ular 4-0 nylon running sutures are placed.
If any tension is placed on the skin closure, the
shape of the breast could change. At this time,
remember that during patient marking all the lateral
movements of the breast must be gentle because if the
skin is stretched and wider marks are made, skin
resection will be excessive and compromise the final
result. Additionally, liposuction can be done in order
to refine little details of the final shape. This is
sometimes necessary in obese patients or in fatty
breasts. In my experience, I do not routinely need
to use it. The skin only redrapes the obtained par-
enchymal shape, contour, and volume.
Drains and dressing
Percutaneous tube drains are routinely placed and
opened to gauze integrated to the final dressing. The
suture lines are covered with micropore tape. Adhes-
ive elastic tape is placed over the breast with gentle
pressure (Figs. 22,23).
Results
From April 1991 to June 2000, I performed
240 breast reductions using the Areolar Vertical Ap-
proach (AVA) mammaplasty evolved from the original
Lejour Vertical mammaplasty (Figs. 22,23). The aver-
age age was 34.6 years, ranging from 16 to 68 years of
age. The average resection weight was 372 g per
breast, ranging from 120 g to 1250 g per breast.
The distribution on the different grades of hyper-
trophy was classified according to the amount of tis-
sue resected: (1) less than 200 g per breast: 84 cases
(35%), (2) 200 – 500 g per breast: 101 cases (42.08%),
and (3) more than 500 g per breast: 55 cases (22.92%).
The maximum in this series was 1250 g per breast.
The maximum nipple areolar transposition was
33 cm from the sternal notch to the nipple, without
vascular damage: (Fig. 24A – H) less than 200 g,
375
(Fig. 25A – H) 200 – 500 g, and (Fig. 26A – H) more
than 500 g.
Complications
The incidence of complications was very low and
was related to wound healing delay (3: 240). There
have been no cases of nipple areolar necrosis, infec-
tion, wound dehiscence, or hematoma. Changes in
sensitivity did not seem to differ from other classic
techniques. Loss of pigentation and enlargement of
the scar were seen only in a few patients.
Discussion
Breast reduction techniques evolved from the
beginning of the twentieth century until today. From
inverted-T scars to ‘‘periareolar only’’ scars, many
surgeons have made efforts to reduce visible scars on
the breast area. For small reductions or mastopexies,
periareolar and vertical-added scars were reported
earlier [6 – 12]. Blood supply to the areola and skin
retraction were well documented by Emil Scwarz-
mann in 1930 in a magistral article [13,14].
Inverted-T techniques based on the safe areolar
pedicle evolved from this principle [1,15 – 19] as dif-
ferent approaches to positioning the dermoglandular
flap of the nipple areola. They also defined the strategy
of breast parenchymal resection. But one principle was
still always present. Skin and breast parenchyma were
handled together in order to obtain good shaping.
Satisfactory intraoperative and long-term results were
obtained, leaving a nonaesthetic submammary scar
with its lateral and medial projections that sometimes
leads to pathological scarring (higher incidence than
the areolar and vertical areas).
Attempts to reduce scars for most breast reduc-
tions (medium and large hypertrophies) were done
with major emphasis during the 1980s, mostly by
surgeons from France, Brazil, and Belgium [2,20 –
37]. The common objective was a change in the
approach to breast reductions. The skin can be used
as a surgical approach and final scar independently
from the treatment of the parenchyma, preserving a
safe and reliable blood supply to all components.
Suturing of the gland has also proven to be an
important step in reshaping.
Most reported periareolar and vertical techniques
used superior pedicles, and this determined the type
of parenchymal resections needed to be performed.
This is why I think it was so difficult to understand
these approaches, particularly for the surgeons trained
with the inferior pedicle technique [15,38 – 46]. A
376 C.E. Van Thienen / Clin Plastic Surg 29 (2002) 365–377
recent report from the United States describes the
combination of the most popular technique (inferior
pedicle) with a finer interpretation of the periareolar
vertical closure scar [47].
I believe that all efforts should lead in the di-
rection of ‘‘making it easy.’’ Treat the parenchyma,
and choose the areolar pedicle as desired or learned.
Use the skin marks that you obtain in a nonstandard
fashion; this is a more dynamic and artistic approach
that is easy to perform. Obviously, standard patterns
can be developed [48], but it is not the essence of this
approach. Skin closure needs to be considerd a
redraping of the breast parenchyma. Gathering the
excess skin with pursestring stitches on the areolar
area or in the vertical portion creates wrinkles. Intra-
operative wrinkles should not be of concern because
they will disappear, and the benefits of a shorter and
more aesthetic scar outweigh this consideration.
Twenty first century breast surgery is in our
hands, including its creative and artistic boundaries.
No chips or high technology can do for us.
Summary
The areolar-vertical approach (AVA) mammma-
plasty, derived from the Vertical Mammaplasty
described by Lejour, offers us the opportunity to
achieve good cosmetic results in breast reduction even
in larger hypertrophies and makes it available to all
patients. In marking, the skin there are certain fixed
landmarks, but the final skin design is obtained by
dynamic maneuvers (points A, V, and S). They do not
follow a rigid pattern. This technique is based on the
superior areolar pedicle and parenchymal resection,
mostly from the central-lower pole. Shape and final
contour rely on breast parechymal sutures and the
gathering of excess skin mainly on the vertical portion
of the scar. Complications are minimal; changes of
sensitivity and function do not differ from those found
with classic techniques [49]. Finally, it seems that with
this technique, the rate of complications is not related
to the areolar-vertical approach, primarily because the
vascular blood supply is equal to or more reliable than
other superior pedicle techniques. Long-term results,
symmetries, aesthetic scars, and patient satisfaction
encourage me to continue with this procedure.
Acknowledgments
The author would like to thank Drs. Emilio
Quesada and Ignacio Goyenechea for their assistance
in manuscript preparation, and Drs. Gabriel Bouzo
and Guillermo Garay for the compilation of revised
patient data.
References
[1] Pitanguy I. Surgical treatment of breast hypertrophy.
Br J Plast Surg 1967;20:78.
[2] Lejour M, Abboud M. Vertical mammaplasty without
inframammary scar and with liposuction. Perspect
Plast Surg 1990;4(2):67.
[3] Lejour M. Vertical mammaplasty and liposuction of the
breast. Plast Reconstr Surg 1994;94(1):100 – 14.
[4] Lejour M. Vertical mammaplasty as secondary surgery
after other technique. Aesthetic Plast Surg 1997;21(6):
403 – 7.
[5] Lejour M. Vertical mammaplasty and liposuction. Qua-
lity Medical Publishing, Inc; St. Louis, Missouri 1994.
[6] Abboud LM, Declety M, Kertesz AP. Reduction des
cicatrices de plastie mammaire: de l’ancre courte a la
verticale. Ann Chir Plast Esth 1989;35:369.
[7] Arie J. Una nueva técnica de mastoplastı́a. Rev Lati-
noam Cir Plast 1957;3:23.
[8] Dartigues M. Les anomalies du sein en dehors des
hypertrophies et des prolapsus. Bull Mem Soc Med
Paris 1935;139:575.
[9] Dufourmentel C, Mouly R. Développements récents de
la plastie mammaire par la méthode oblique latérale.
Ann Chir Plast 1965;10(4):227 – 41.
[10] Kraske H. Die operation der atrophischen und hyper-
trophischen hängebrust Münch. Med.Wschr 1923;
70:672.
[11] Lexer E. Hypertrophie beider mammae. München Med
Wochenschr 1912;59:1702.
[12] Lexer H. Zur operation der mammahypertrophie und
der hängebrust. Dtsch Med Wochenschr 1925;51:26.
[13] Schwarzmann E. Die technik der mammaplastik. Chi-
rurgie 1930;2:932.
[14] Schwarzmann E. The technique of mammoplasty. Plast
Reconstr Surg 1977;59:107 – 12.
[15] Skoog T. A technique of breast reduction. Acta Chir
Scand 1963;126:453 – 65.
[16] Strömbeck JO. Report of a new technique based on the
two pedicle procedure. Br J Plast Surg 1960;13:79.
[17] Strömbeck JO. Macromastia in woman and its surgical
treatment. A clinical study based in 1042 cases. Acta
Chir Scand 1964;(Suppl 341).
[18] Strömbeck JO. Reduction mammaplasty. Surg Clin
Amer 1971;51:453.
[19] Wise RJ. Treatment of breast hypertrophy. Clin Plast
Surg 1976;3:289.
[20] Benelli L. Technique de plastie mammaire: le ‘‘round
bloc. Rev Fr Chir Esthet 1988;50:7.
[21] Benelli L. A new Periareolar mammoplasty: round
block technique. Aesthetic Plast Surg 1990;14:99.
[22] Bustos RA. Periareolar mammoplasty with silicone sup-
porting lamina. Plast Reconstr Surg 1992;89:646 – 57.
[23] Felicio Y. Periareolar reduction mammoplasty. Plast.
Reconstr. Surg. 1991;88:789.
 C.E. Van Thienen / Clin Plastic Surg 29 (2002) 365–377
[24] Goes JCS. Periareolar mammoplasty: double skin tech-
nique with application of polyglactine or mixed mesh.
Plast Reconstr Surg 1996;97:959.
[25] Juri J, et al. Vertical mammoplasty. Ann Plast Surg
1982;9:298.
[26] Lassus C. A technique for breast reduction. Int J Surg
1970;53:69.
[27] Lassus C. New refinements in vertical mammaplasty.
Chir Plast 1981;6:81.
[28] Lassus C. Reduction mammaplasty with short infra-
mammary scars. Plast Reconstr Surg 1986;77:680 – 1.
[29] Lassus C. An all-season mammaplasty. Aesthetic Plast
Surg 1986;10:9 – 15.
[30] Lassus C. Breast reduction: evolution of a technique
a single vertical scar. Aesthetic Plast Surg 1987;11:
107 – 12.
[31] Lassus C. A 30 year experience with vertical mamma-
plasty. Plast Reconstr Surg 1996;97:373 – 80.
[32] Marchac D, de Olarte G. Reduction mammaplasty and
correction of ptosis with a short inframammary scar.
Plast Reconstr Surg 1982;69:45.
[33] Marchac D, Sagher U. Mammaplasty with a short ho-
rizontal scar. Evaluation and results after 9 years. Clin
Plast Surg 1988;15:627.
[34] Peixoto G. Reduction mammaplasty: a personal tech-
nique. Plast Reconstr Surg 1980;65:217.
[35] Peixoto G. Reduction mamoplasty. Aesthetic Plast.
Surg. 1984;8:231.
[36] Perenteau JM, Regnault P. The Regnault ’’B’’ tech-
nique in mastopexy and breast reduction: A 12 years
review. Aesthetic Plast Surg 1990;4:67.
[37] Regnault P. Reduction mammaplasty by the B tech-
nique. Plast Reconstr Surg 1974;53:19.
[38] Courtis EH, Goldwyn RM. A reduction mammaplasty
by the inferior pedicle technique. An alternative to free
377
nipple and areola grafting for severe macromastia and
extreme ptosis. Plast Reconstr Surg 1980;66:646.
[39] Freiberg A, Boyd JB. Reduction mammaplasty: a com-
parison between the Robbins and Pontes techniques.
Plast Reconstr Surg 1986;78:773.
[40] Goldwyn RM. Reduction mammaplasty. Boston: Little,
Brown, and Co.; 1990.
[41] Hester TR, Bostwick J, Miller L, Cunningham SJ.
Breast reduction utilizing the maximally vascularized
central breast pedicle. Plast Reconstr Surg 1985;
76:890.
[42] Mandrekas AD, Zambacos GJ, Anastasopoulos A,
Hapsas DA. Reduction mammaplasty with the inferior
pedicle technique: early and late complications in
371 patients. Br J Plast Surg 1996;49:442.
[43] McKissock PK. Reduction mammoplasty with vertical
dermal flap. Plast Reconstr Surg 1972;49:245.
[44] Robbins T. A reduction mammoplasty with the areola-
nipple based on an inferior dermal pedicle. Plast Re-
constr Surg 1977;59:64.
[45] Wallace WH, et al. Reduction mammaplasty using
the inferior pedicle technique. Ann Plast Surg 1998;
40:235.
[46] Weiner D, et al. A single dermal, pedicle for nipple
transportation in subcutaneous mastectomy, reduction
mammoplasty, or mastopexy. Plast Reconstr Surg
1973;51:115.
[47] Hammond D. Short scar periareolar inferior pedicle
reduction (SPAIR) mammaplasty. Plast Reconstr Surg
1999;103:890 – 901.
[48] Paloma V, Samper A, Sanz J. A simple device for
marking the areola in Lejour’s mammaplasty. Plast
Reconstr Surg 1998;102(6):2134 – 38.
[49] Farina M, et al. Inervation of the nipple areola com-
plex. Plast Reconstr Surg 1980;66:497 – 501.