COSMETIC

Prospective Comparative Clinical Evaluation of

784 Consecutive Cases of Breast Augmentation
and Vertical Mammaplasty, Performed
Individually and in Combination
Eric Swanson, M.D.
Leawood, Kans.
Background: Despite the growing popularity of breast lift surgery, no published
study prospectively evaluates mastopexy and augmentation/mastopexy. Several
investigators suggest an inordinate risk in combining augmentation and mas-
topexy, and recommend staging the surgery in some patients. However, no
existing study includes the necessary individual and combined treatment co-
horts to allow reliable comparisons of safety and efficacy. This study investigates
the clinical outcomes and safety of these cosmetic breast procedures, whether
performed individually or in combination.
Methods: This 10-year prospective study evaluated 759 consecutive women
undergoing 784 consecutive cases of breast augmentation (n = 522), masto-
pexy (n = 57), augmentation/mastopexy (n = 146), reduction (n = 48), and
reduction plus implants (n = 11). All patients were treated by the author us-
ing submuscular implant placement and vertical parenchymal resection with
a medial pedicle and intraoperative determination of nipple positioning. A
power analysis confirmed adequacy of the sample sizes.
Results: The complication rate was 36.3 percent for augmentation/mastopexy,
33.3 percent for mastopexy alone, and 17.6 percent for breast augmentation
alone. Mammaplasties were complicated by persistent ptosis in 9.5 percent
of patients. The revision rate after augmentation/mastopexy was 20.5 per-
cent, compared with 24.6 percent for mastopexy and 10.7 percent for breast
augmentation.
Conclusions: Vertical mammaplasty may be used to correct ptosis in breasts
of all sizes. Vertical augmentation/mastopexy provides complication and
revision rates that are less than the calculated cumulative rates for the pro-
cedures performed separately. The combined procedure offers technical ad-
vantages and permits safe single-stage surgery using the vertical technique. 
(Plast. Reconstr. Surg. 132: 30e, 2013.)
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

B
reast augmentation, mastopexy, augmen-
tation/mastopexy, and reduction are all
cosmetic procedures,1 notwithstanding the
physical benefits of breast reduction and masto-
pexy.2 Mastopexy and augmentation/mastopexy
merit close evaluation because these procedures
have been a source of patient and physician dis-
satisfaction.3–5 Despite the growing popularity of
breast-lift surgery,6 a large prospective study of
mastopexy patients has not been published. This
clinical study is part of a comprehensive evalua-
tion of cosmetic breast surgery that also includes
a prospective measurement study7 and outcome
analysis.2,8
PATIENTS AND METHODS
From January of 2002 to January of 2012,
759 women underwent 784 consecutive cosmetic

From the Swanson Center.

Received for publication December 11, 2012; accepted January
31, 2013. Disclosure: The author has no financial interests
Copyright © 2013 by the American Society of Plastic Surgeons to disclose. This study received no outside funding.
DOI: 10.1097/PRS.0b013e3182910b2e

30e www.PRSJournal.com
Volume 132, Number 1 • Cosmetic Breast Surgery Study
Fig. 1. Cosmetic breast surgery patients, by procedure.
breast procedures (Fig. 1 and Table 1). Breast
reconstruction patients were excluded.
Surgery
All procedures were bilateral. In all cases,
breast implants were placed submuscularly, using
predominantly the inframammary approach (95.0
percent) and saline-filled implants (94.6 per-
cent). Resections of 300 g or more from at least
one breast were categorized as breast reductions.
Eleven reduction patients were simultaneously
treated with implants (Fig. 2). All mammaplasties
were performed by the author using the vertical
technique and medially based pedicle as described
by Hall-Findlay,9 but without a mosque-dome pat-
tern; the nipple position was determined intraop-
eratively (Figs. 3 and 4). Sequential compression
devices were used. No patient received enoxaparin.
Statistical Analysis
Statistical analyses were performed using
IBM SPSS for Windows version 20.0 (IBM Corp.,
Armonk, N.Y.). An independent t test was used to
compare means of continuous variables for two
groups of patients. A one-way analysis of variance
was used for more than two groups. Scheffé post
hoc tests were used. The Pearson chi-square test
of independence was used to compare categori-
cal variables. The “reduction plus implants” group
was not included in group comparisons because of
its small sample size (n = 11). Correlations were
tested using Pearson correlations. A value of p <
0.01 was considered significant. An a priori power
analysis was performed for the one-way analysis
of variance. To achieve 80 percent power, with an
alpha level of 0.01, sufficient to detect a medium-
sized treatment effect (f = 0.25)10 comparing across
four groups, 256 total subjects would be needed.11
RESULTS
Breast augmentation patients were younger,
on average, than the other patients (p = 0.001).
Breast augmentation patients had a lower mean
body mass index and breast reduction patients
had higher a mean body mass index than did
the other procedure groups (p < 0.001). Mean
implant volumes were significantly greater (p <
0.001) for breast augmentation (410 cc) than for
augmentation/mastopexy (354 cc).
Complications
There were no major systemic complications,
deep venous thromboses, or pulmonary emboli.
No patient required a blood transfusion or hospi-
tal admission. Partial areola necrosis occurred in
one reduction patient and healed spontaneously.
There were no cases of nipple loss. The incidence
of complications (Table 2) was 25.0 percent over-
all, and was significantly lower for breast augmen-
tation (17.6 percent) than for vertical mastopexy
(33.3 percent) and augmentation/mastopexy
(36.3 percent) (p < 0.001). Based on the individual
procedural risks, a cumulative complication rate of
45.0 percent was calculated for a theoretical patient
treated with implants followed by mastopexy or vice
versa [100 – (82.4 percent × 66.7 percent)]. There
was a 20.5 percent revision rate after augmenta-
tion/mastopexy (Table 3), significantly more than
after augmentation alone (10.7 percent, p = 0.001),
but not as high as mastopexy alone (24.6 percent).
A significant positive correlation was detected
between the incidence of complications and
patient age, but this correlation was weak (r =
0.10, p < 0.01). No significant correlations were
detected between the incidence of complica-
tions and body mass index, resection weights,
or implant volumes. The chi-square test of inde-
pendence revealed that the incidence of compli-
cations was associated with a smoking history in
patients treated with augmentation/mastopexy
(p < 0.01) and with secondary breast augmentations
(p < 0.01), but not with secondary mastopexies.
DISCUSSION
Study Design
Although breast augmentation and reduction
have traditionally been considered individually,
31e
 Plastic and Reconstructive Surgery • July 2013

Table 1.  Patient Data*

Reduction
Augmentation/ plus All
Augmentation† Mastopexy Mastopexy Reduction Implants Procedures
(%) (%) (%) (%) (%) (%) p‡
No. 522 57 146 48 11 784
Age, yr <0.001
 Mean 34.1 40.1 42.3 39.9 42.9 36.5
 SD 9.6 10.8 11.1 11.9 9.9 10.7
 Range 16.8–80.9 19.6–65.4 17.0–74.2 19.6–63.2 23.2–57.3 16.8–80.9
Follow-up time, mo NS
 Mean 8.3 10.9 8.4 11.1 7.5 8.6
 SD 12.3 11.7 8.0 13.2 9.0 11.6
 Range 0.03–75.1 0.6–48.6 0.2–45.7 0.3–58.6 1.3–32.4 0.03–75.1
Smoking status NS
 Nonsmoker 380 (72.8%) 47 (82.5) 118 (80.8) 39 (81.3) 9 (81.8) 593 (75.6)
 Smoker 142 (27.2) 10 (17.5) 28 (19.2) 9 (18.8) 2 (18.2) 191 (24.4)
Body mass index, kg/m2 <0.001
 Mean 22.1 25.6 25.1 29.9 29.5 23.5
 SD 3.2 3.7 4.1 5.1 5.0 4.2
 Range 15.4–35.8 19.2–40.1 17.3–41.1 20.0–42.7 20.0–38.4 15.4–42.7
Right implant volume, cc <0.001
 Mean 410.2 — 354.1 — 350.0 397.2
 SD 82.0 — 92.7 — 85.0 87.6
 Range 125–925 — 200–575 — 240–510 125–925
Left implant volume, cc <0.001
 Mean 409.9 — 354.4 — 350.9 397.0
 SD 80.4 — 90.0 — 83.8 85.8
 Range 125–925 — 200–570 — 240–510 125–925
Implant style —
 Saline§ 490 (93.9) — 141 (96.6) — 11 (100) 642 (94.6)
  Silicone gel║ 32 (6.1) — 5 (3.4) — 0 37 (5.4)
Right tissue weight, g —
 Mean — 100.2 76.3 496.2 428.3 173.2
 SD — 101.3 64.5 175.3 154.7 198.3
 Range — 5–292 6–289 275–953 129–680 5–953
Left tissue weight, g —
 Mean — 102.4 77.9 492.4 429.7 173.9
 SD — 98.7 66.7 176.3 149.6 196.7
 Range — 5–286 6–286 228–1040 195–724 5–1040
Augmentation 0.01
 Primary 444 (85.1) — 111 (76.0) — 9 (81.8) 564 (83.1)
 Secondary 78 (14.9) — 35 (24.0) — 2 (18.2) 115 (16.9)
Mastopexy NS
 Primary — 50 (87.7) 129 (88.4) 46 (95.8) 8 (72.7) 233 (88.9)
 Secondary — 7 (12.3) 17 (11.6) 2 (4.2) 3 (27.3) 29 (11.1)
In combination with other <0.001
­procedures
 No 355 (68.0) 13 (22.8) 52 (35.6) 24 (50.0) 3 (27.3) 447 (57.0)
 Yes 167 (32.0) 44 (77.2) 94 (64.4) 24 (50.0) 8 (72.7) 337 (43.0)
Operating time for breast <0.001
procedures only, min
 Mean 52.4 105.6 123.0 121.2 143.3 75.2
 SD 11.2 22.1 21.5 24.1 18.5 35.9
 Range 24–127 42–173 42–193 88–206 107–167 24–206
NS, not significant.
*There were 759 total patients; 24 patients had two operations and one patient had three operations.
†An inframammary approach was used in 496 cases (95.0 percent), a periareolar approach was used in 17 cases (3.3 percent), a transnipple
approach was used in eight cases (1.5 percent), and a transaxillary approach was used in one case (0.2 percent).
‡Independent t tests revealed that mean breast implant volumes were higher for breast augmentation than for augmentation/mastopexy (p <
0.001). One-way analyses of variance were used to compare continuously measured variables across procedure groups. Scheffé post hoc tests
indicated that breast augmentation patients were younger on average than the other procedure groups (p = 0.001). The mean body mass index
was lower for breast augmentation patients (p < 0.001) and higher for breast reduction patients than for the other procedure groups (p <
0.001). Breast augmentation patients were less likely to have combination procedures (p < 0.001) and more likely to have primary procedures
than the other groups (p = 0.01). Operating times for breast augmentation were shorter than for the other procedures (p < 0.001). Pearson χ2
tests were used to compare categorical variables across procedure groups. Adjusted standardized residuals with an absolute value greater than
3 were used to indicate when a group’s percentage was higher or lower than for all procedures. The breast reduction plus implants group was
excluded from group comparisons because of its small sample size.
§Mentor (Mentor Corp., Santa Barbara, Calif.) Style 1600 smooth, round, Moderate Profile implant (201 cases); Mentor Style 2000 smooth,
round, Moderate Plus Profile implant (292 cases); Inamed/Allergan (Allergan, Inc., Irvine, Calif.) Natrelle Style 68, smooth, round, Moderate
profile implant (149 cases).
║Mentor Style 1000 MPP Gel (nine cases), Mentor Style 7000 Moderate Profile Gel (three cases), Allergan Style 15 Natrelle Midrange Profile
implant (25 cases).

32e
Volume 132, Number 1 • Cosmetic Breast Surgery Study

Fig. 2. Vertical breast reduction plus implants. Orientation-matched views of a 23-year-old

woman (left) before and (right) 3 months after a vertical reduction using a medial pedicle and
augmentation with submuscular Mentor Moderate Plus Profile saline-filled implants inflated to
240 cc. Her torso appears longer after surgery. Resection weights were as follows: right breast,
466 g; left breast, 314 g.

Fig. 3. Intraoperative photographs of vertical augmentation/mastopexy. (Left) Before and (right)

after elliptical skin resection. With side-to-side tissue approximation, the vertical length increases
from 10.00 cm to 15.33 cm. If the vertical and horizontal dimensions of the resection are the same
(i.e., roughly a circle), an increase in vertical length to π/2 (+57 percent) is expected.

interprocedural comparisons can be useful.12 Today, are essentially the same, differentiated only by the
we recognize an overlap in indications for these resection weight.7
procedures and even in physical benefits.2 When There are no published prospective clinical or
a vertical technique is used, the mammaplasties outcome studies of mastopexy or augmentation/

33e
 Plastic and Reconstructive Surgery • July 2013

Fig. 4. Intraoperative photographs of augmentation/mastopexy. (Above, left) After the superior dog-ear is oversewn, a 39-mm
areola marking ring is used to mark the circular resection at the new site for the nipple-areola. (Above, right) The left augmenta-
tion/mastopexy is complete. (Below, left) Preoperative and (below, right) immediate postoperative views show the increased breast
projection provided by the implant and the position of the nipple-areola, slightly below the level of maximum breast projection.
The implant takes up much of the slack in the lower pole, minimizing the need for skin gathering and keeping the vertical incision
from extending onto the abdominal skin.

mastopexy. This deficiency is remarkable consid-
ering the popularity of breast-lift surgery, which
witnessed a 72 percent surge from 2000 to 2011,6
and by the increasing popularity of augmentation/
mastopexy, an operation that is now performed
more commonly than mastopexy alone in many
practices.7,13 Existing studies of mastopexy14 and
augmentation/mastopexy13,15–22 are all retrospec-
tive and often include multiple techniques13,15,17,18,22
and multiple surgeons.18,22 Prospective studies of
consecutive patients are preferred, to avoid selec-
tion bias and confounding factors.23 A power anal-
ysis is recommended to determine the adequacy
of sample sizes, to avoid type II statistical errors.24
A rigorous 0.01 alpha value reduces the risk of
type I errors.
All-Seasons Mammaplasty
A growing number of plastic surgeons have
adopted the vertical technique as their procedure
of choice for mastopexy and reduction.25 At a
recent meeting of the American Society of Plas-
tic Surgeons, 47 percent of audience members
responding to a poll reported using the vertical
technique for their augmentation/mastopexies,
versus 38 percent who still favored the inverted-
T design, and 10 percent who preferred a peri-
areolar resection.26 Persistent ptosis is a frequent
problem after a periareolar mastopexy.5,16,27 The
shape deficiencies of the inverted-T, inferior pedi-
cle technique have been recognized for decades.27
Although the idea of an “all-seasons” mammaplasty
has been dismissed in the past,28 an increasing
number of plastic surgeons use the vertical tech-
nique exclusively,7,29–34 including the author. Its
versatility is demonstrated in Figures 5 through 8,
which depict not typical cases but more challeng-
ing ones (i.e., very large breasts, tuberous breasts,
asymmetrical breasts, and secondary surgery).
Commonly, a periareolar mastopexy is rec-
ommended for patients with minimal degrees of
ptosis, a vertical technique for more moderate

34e
Volume 132, Number 1 • Cosmetic Breast Surgery Study

Table 2.  Complications*

Reduction
Augmentation/ plus All
Augmentation Mastopexy Mastopexy Reduction Implants Procedures
(%) (%) (%) (%) (%) (%) p
No. 522 57 146 48 11 784
Complications
 No 430 (82.4)† 38 (66.7) 93 (63.7) 23 (47.9) 4 (36.3) 588 (75.0) <0.001†
 Yes 92 (17.6) 19 (33.3) 53 (36.3) 25 (52.1) 7 (63.6) 196 (25.0)
Capsular contracture 31 (5.9) — 9 (6.2) — 0 40
Size asymmetry 20 (3.8) 3 (5.3) 5 (3.4) 3 (6.3) 2 (18.2) 33 (4.2)
Scar deformity 7 (1.3) 6 (10.5) 11 (7.5) 5 (10.4) 2 (18.2) 31 (4.0)
Delayed wound healing 2 (0.4) 2 (3.5) 14 (9.6) 9 (18.8) 3 (27.3) 30 (3.8)
Persistent ptosis — 7 (12.3) 13 (8.9) 3 (6.3) 2 (18.2) 25
Hematoma 17 (3.3) 0 1 (0.7) 2 (4.2) 0 20 (2.6)
Cellulitis/infection 2 0 9 5 1 17
Implant rippling 9 — 0 — 0 9
Seroma 3 1 0 1 0 5
Allergic reaction 1 0 2 1 0 4
Implant deflation 4 — 0 — 0 4
Symmastia 1 — 0 — 0 1
Numbness 0 1 0 0 0 1
Hyperpigmentation 1 0 0 0 0 1
Total 98 20 64 29 10 221
*Twenty-five patients had two complications. Therefore, the total number of complications exceeds the number of patients who had
complications.
†Breast augmentation patients experienced fewer complications than mastopexy and augmentation/mastopexy patients (p < 0.001). The dif-
ference in complication rates between mastopexy and augmentation/mastopexy was not significant. Pearson χ2 tests for independence were
used to compare the complication rate across procedure groups. Adjusted standardized residuals with an absolute value greater than 3 were
used to indicate when a group’s percentage was higher or lower than for all procedures. The reduction plus implants group was excluded from
group comparisons because of its small sample size.

cases, and the inverted-T technique for cases of
moderate or severe ptosis.35,36 However, a vertical
technique is particularly advantageous in large
resections because a long pedicle is unnecessary,7
improving safety for the nipple and areola,31–34
and avoiding the need for nipple grafting. The
anatomical and geometrical advantages of the
vertical technique27 do not change with breast size
(Fig. 5). Elegant in its simplicity, this technique
may be used for all cosmetic mammaplasties, with

Table 3.  Treatment of Complications*

Reduction
Augmentation/ plus All
Augmentation Mastopexy Mastopexy Reduction Implants Procedures
(%) (%) (%) (%) (%) (%) p
No. 522 57 146 48 11 784
Surgical treatment of complications
 No 466 (89.3) 43 (75.4) 116 (75.9) 39 (81.3) 7 (63.6) 671 (85.6) 0.001†
 Yes 56 (10.7) 14 (24.6) 30 (20.5) 9 (18.8) 4 (36.4) 113 (14.4)
Revisions
  Open capsulotomy 22 (4.2) — 9 (6.2) — 0 31
  Lower pole revision for ­
  persistent ptosis — 6 (10.5) 15 (10.3) 6 (12.5) 1 (9.1) 28
  Scar revision 7 (1.3) 7 (12.3) 8 (5.5) 2 (4.2) 2 (18.2) 26 (3.3)
  Evacuation of hematoma 17 (3.3) 0 1 (0.7) 1 (2.1) 0 19 (2.4)
  Implant replacement‡ 9 — 1 — 1 11
  Correction of implant
 malposition 5 — 1 — 0 6
  Revision of areola irregularity — 1 2 0 0 3
  Implant inflation 3 — 0 — 0 3
  Evacuation of seroma 1 0 0 0 0 1
*Thirteen patients had two surgical treatments of complications and one patient underwent three surgical treatments of complications. There-
fore, the total number of treatments exceeds the number of patients who had treatments.
†Breast augmentation patients required fewer revisions than mastopexy and augmentation mastopexy patients (p = 0.001). Pearson χ2 tests for
independence were used to compare the surgical treatment rate across procedure groups, excluding breast reduction plus implants. Adjusted
standardized residuals with an absolute value greater than 3 were used to indicate when a group’s percentage was higher or lower than for all
procedures.
‡Includes seven patients whose implants were replaced with a different size because of patient preference.

35e
 Plastic and Reconstructive Surgery • July 2013

Fig. 5. (Left) Orientation-matched views of a 43-year-old woman before and (right) 6 months after a
vertical breast reduction, using a medial pedicle. This patient had the greatest resection weights among
study patients. The tissue weights were as follows: right breast, 953 g; left breast, 1040 g. Suprasternal
notch–to-nipple distances were 37 cm on the right and 38 cm on the left (these measurements are not
used by the author, but have been used by some surgeons in determining procedure selection). Despite
the severe ptosis, the preoperative right nipple displacement is only 3.77 cm. The skin lesions on the
right lateral breast reveal the upward mobilization of breast skin. BPR, breast parenchymal ratio; LPD,
lower pole distance; BME, breast mound elevation.

the only variables being implant size (if used) and
the resection weight, making it truly an all-seasons
mastopexy. Even small, ptotic breasts and tuber-
ous breasts, traditionally considered the domain
of the periareolar technique,15 respond well to
vertical mastopexy (Fig. 6).
A common recommendation is to keep
the lower end of the vertical incision above the
inframammary crease so that the scar does not
extend onto the abdomen.29,32 In practice, this
worthy goal may prove impossible because the ver-
tical tissue approximation raises the level of the
inframammary crease.37 A short horizontal resec-
tion is a useful remedy,38 although it is seldom
necessary when an implant is used simultaneously
(Fig. 4). The vertical technique applies to the

36e
Volume 132, Number 1 • Cosmetic Breast Surgery Study

Fig. 6. (Left) This 24-year-old woman presented with a tuberous breast deformity and asymmetry.
(Right) She is seen 4 months after vertical augmentation/mastopexy using submuscular, saline-
filled implants, inflated to 450 cc on each side. Resection weights were as follows: right breast,
62 g; left breast, 44 g. She had simultaneous liposuction of the lower body. The vertical resection
removes the herniated periareolar parenchyma, which would otherwise be left behind in a peri-
areolar mastopexy. This maneuver essentially converts a tuberous breast to a nontuberous breast.
The implant fills out the constricted base without the need for scoring. The vertical lower pole
parenchymal approximation relieves periareolar tension, helping to prevent an areola deformity.

pattern of parenchymal resection, which is why
the label “vertical-scar” is best avoided, especially
when the scar may resemble an inverted T.
Breast Lift
Measurements confirm that the infra­
mammary crease level moves up after a vertical
mammaplasty.37 Both vertical and inverted-T tech-
niques can elevate the lower pole.27 An underap-
preciated benefit of elevation of the lower breast
pole is the appearance of a longer torso (Fig. 2).
With the emphasis on fitness in our culture, and
the frequent display of the abdomen, this anatom-
ical area takes on greater importance. However,
upward mobilization of the superior border of the
breast is more challenging.39 “Autoaugmentation”
has not lived up to its billing.27 Breast implants are
needed to substantially boost breast projection
and upper pole projection,7,40,41 providing the wel-
come illusion of breast tissue elevation (Fig. 2).
Augmentation/Mastopexy
Concerns about performing augmentation
and mastopexy simultaneously have been strongly
raised in the literature.42,43 The conventional
wisdom is that augmentation and mastopexy are
two procedures that work at cross purposes,42–47
creating an operation that is more difficult to
perform18,42–48 and less satisfactory for patients,4
has a complication rate that exceeds the sum
(even exponentially) of the complication rates
for the individual procedures, and introduces an
inordinate risk of nipple loss.49 The reasoning is
intuitive—mastopexy tightens the skin envelope
while the implant stretches it (relying on a tradi-
tional concept of mastopexy as a skin-tightening
procedure). Two large retrospective studies, how-
ever, have reported a risk that is no more than
additive.13,18
Which viewpoint is correct? Neither is well-
supported by the evidence. The only way to reli-
ably compare the combined procedure versus
individually performed breast augmentation and
mastopexy is by evaluating patients treated with
the same technique, with and without implants,
in the same study, preferably by the same sur-
geon, using the same parameters (including the
same definition for what constitutes a complica-
tion), and without selection of some patients
for staging,13 to avoid confounding factors. This

37e
 Plastic and Reconstructive Surgery • July 2013

Fig. 7. This 36-year-old woman with two children complained of breast asymmetry and sagging. She
required a D-cup bra to accommodate her right breast, even though this cup size was too big for her left
breast. She is seen (left) before and (right) 1 year after vertical augmentation/mastopexy using submus-
cular, saline-filled implants, inflated to 240 cc on the right side and 290 cc on the left side. The resection
weights were as follows: right breast, 112 g; left breast, 8 g.

38e
Volume 132, Number 1 • Cosmetic Breast Surgery Study

Fig. 8. Secondary mastopexy and primary augmentation, combined with liposuction

of the lower body and abdominoplasty. Orientation-matched views of a 28-year-old
woman who presented with flat upper poles 4 years after an inverted-T, inferior ped-
icle reduction. (Left) Before and (right) 5 years after vertical augmentation/mastopexy
using submuscular Mentor Moderate Plus Profile saline-filled implants inflated to 240
cc, resecting 10 g from each lower pole, with no periareolar incision. In secondary cases,
the nipple-areola typically does not need to be transposed because it is almost never
too low. It is preserved on both a deep glandular pedicle and by a 270-degree superior/
lateral/medial pedicle. Although not visible on these photographs, the existing horizon-
tal scar is shortened, concealing it better within the inframammary crease.

important question is a major focus of the present Positive Synergy

study, and one reason for including all cosmetic A 45 percent complication rate from individ-
breast surgery patients in the same study. ual procedures represents the theoretical risk of

39e

a woman experiencing at least one complication
from either breast augmentation or mastopexy
if these procedures are performed sequentially
(i.e., a complication from one of these procedures
and not the other would still be counted). This
calculated risk is greater than the observed 36.3
percent risk of a patient experiencing at least one
complication after the combined procedure. This
comparison is limited by the fact that patients
treated individually and with the combined pro-
cedures are not identical, but it appears safe to
conclude that the complication rate for combined
surgery is less than additive, even accounting for
the higher incidence of implant rippling among
augmentation-only patients.
Proportionately fewer revisions to treat subop-
timal scars were required among women treated
with augmentation/mastopexy compared with
mastopexy, largely offsetting the additional risk of
capsulotomies for the combined treatment group.
Augmentation/mastopexy patients also benefited
from proportionately fewer hematomas compared
with breast augmentation patients, likely because
of improved operative exposure.
The surprising finding of a positive synergy
does not suggest that the concerns of experienced
plastic surgeons are unfounded. The reported
additional risk derives not from combining pro-
cedures, but rather from the use of geometrically
and anatomically challenged mastopexy tech-
niques.27 Periareolar skin resections remove skin
not from the region where it is excessive (the lower
pole) but from the area to be stretched by the
implant—truly a paradoxical combination.27 Not
surprisingly, this technique does not adequately
treat ptosis.5,15,16,27 The inverted-T, inferior pedicle
technique, which incorporates a long pedicle with
a random blood supply, is known to compromise
nipple/areola vascularity even without implants.
The additional dissection and pressure caused by
implants (Fig. 9) magnifies the shortcomings of
both mastopexy techniques, reducing the margin
of safety and leading to predictable and sometimes
disastrous consequences.15,42–45,50 In response,
some surgeons have recommended staging the
procedures, at least in some cases.4,26,43,51
A more practical solution is simply to adopt a
more logical (i.e., vertical) mastopexy technique.
There is no evidence that women with breast
ptosis are especially difficult to deal with or har-
bor unrealistic expectations.4,40,48,52 When treated
with valid mammaplasty techniques, they report
very high levels of satisfaction, similar to breast
augmentation patients.2,8 Improved technique
is likely to lead to a reduction of malpractice
40e
Plastic and Reconstructive Surgery • July 2013
insurance premiums, which no doubt have been
affected by the disproportionate liability presently
associated with mastopexies3 and augmentation/
mastopexies.50,53
Two operations double many of the risks of
surgery, such as anesthetic risk and the risk of a
deep venous thrombosis. Positive synergy is con-
sistent with technical considerations comparing
single-stage versus two-stage surgery. Contrary
to conventional wisdom, the use of an implant
makes the mastopexy easier, not more difficult,
and vice versa (Table 4). The average operat-
ing time for augmentation/mastopexy was only
approximately 20 minutes longer than mastopexy
alone, compared with 52 minutes for an augmen-
tation performed individually. Any patient who
is a candidate for augmentation and mastopexy
performed individually is a candidate for the com-
bined procedure. The operation is conceptually
simple (Figs. 3 and 4) and the learning curve is
not particularly difficult.54
Breast Asymmetry
Treating asymmetry by varying the masto-
pexy technique from one side to the other can be
challenging. Matching a nonaugmented breast is
notoriously difficult. This problem may be more
easily remedied by placing implants on each side
and then simply resecting more lower pole tissue
from the larger side (Figs. 2 and 7).
Combined Procedures
A practical benefit of the vertical technique
is a greater capability for combination (“mommy
makeover”) procedures (Fig. 8). Operating times
for vertical mammaplasties, typically 60 to 130
minutes,32,34,38 are approximately 1 hour shorter
than for inverted-T procedures.55 Similarly, verti-
cal augmentation/mastopexies, which required
approximately 2 hours of operating time in the
present study, take approximately 1 hour less
time to perform than inverted-T augmentation/
mastopexies.21 By shortening operating times
and reducing blood loss,9,32 combinations with
other cosmetic procedures, such as liposuction
and abdominoplasty, may be undertaken safely,56
with appropriate attention to anesthetic consider-
ations and blood loss.57
Complications
The 5.9 percent incidence of capsular con-
tracture after breast augmentation in this study
compares with a range of 2 to 20.8 percent cited
in previous studies, with increasing rates at longer
Volume 132, Number 1 • Cosmetic Breast Surgery Study

Fig. 9. Illustration comparing vertical augmentation/ mastopexy to augmentation using inverted-T, inferior
pedicle, and periareolar techniques. The inferior pedicle of an inverted-T procedure is prone to pedicle com-
pression by the implant. The nipple is overelevated. The periareolar procedure removes skin in the periareolar
area that will be subject to expansion by the implant, with greater tension on the periareolar scar. Vertical mam-
maplasty avoids pressure on the pedicle (periareolar skin resection is limited), eliminates excess lower pole
tissue, and provides secure lower pole parenchymal closure, allowing the implant to fill out the upper pole.

follow-up intervals.58–65 The 6.2 percent contrac-
ture rate for augmentation/mastopexy is also sim-
ilar to other reported rates.13,16,18,19
Published complication rates for vertical mas-
topexy and breast reduction vary widely, from 11
to 45 percent,29,31,33,34,38,54,66–70 and depend largely
on the surgeon’s definition of a complication.71 If
persistent ptosis, suboptimal scars, areola noncir-
cularity, and minor delays in wound healing are
counted, the “complication rate” approaches 100

41e
 Plastic and Reconstructive Surgery • July 2013

Table 4.  Technical Advantages of Combining Breast Augmentation and Vertical Mastopexy
Augmentation assists mastopexy
  The breast implant increases breast projection, upper pole fullness, and convexity*
  Autoaugmentation is unnecessary; additional breast tissue dissection, which may increase the risk of complications, is avoided
  Implants make it unnecessary to overreduce the larger side to obtain symmetry, leaving the patient with breasts that are too
  small on both sides; it is easier to match an augmented breast than a nonaugmented breast
  Volume adjustment is easier
  By increasing breast projection, the implant makes closure of the vertical wound easier, with less gathering of tissue; the
vertical scar evens out more quickly; fewer scar revisions are necessary
  It is easier to keep the vertical scar from extending below the inframammary crease where it may be visible; an inverted-T
closure at the bottom is usually unnecessary because the implant fills the lower pole
  Nipple-areola transposition is minimized; the base of a medially based pedicle moves up with the implant
  Intraoperative determination of nipple position is made easy with a firm, projecting breast mound
  The tendency for nipple-areola collapse (falling in) is reduced
Mastopexy assists augmentation
  A long incision can be used, up to the width of the skin resection pattern
  Improved exposure makes the pocket dissection easier, with less trauma to the implant and a lower risk of hematoma
  Existing asymmetry of nipple position may be corrected
  Mastopexy provides lower pole elevation, breast mound elevation, and nipple elevation, which are not usually achieved
  with breast implants alone*
  Greater tissue cover over the implant is achieved with buttressing from the medial and lateral pillars
  A tuberous breast deformity may be corrected simultaneously
  Excessive areola size (that may be stretched further by the implant) may be reduced
*Swanson E. Prospective photographic measurement study of 196 cases of breast augmentation, mastopexy, augmentation/mastopexy, and
breast reduction. Plast Reconstr Surg. 2013;131:802e–819e.

percent. Fortunately, patients tend not to consider
these common problems as complications.2,8 With
appropriate preoperative counseling, they accept
that fine-tuning is to be expected39 and report
complication rates approximately half as high as
those of their surgeon.2,8
Similar to the findings of other studies,4,18 per-
sistent ptosis was a frequent complication encoun-
tered by mastopexy and reduction patients (9.5
percent combined rate for all vertical mamma-
plasties), and the most common indication for
reoperation. Adequate lower pole parenchymal
resection is needed to prevent a “mastopexy-
wrecking” bulge.29,41,68,72–74 Intraoperative deter-
mination of nipple placement may reduce the
risk of nipple overelevation and the inverted
teardrop areola deformity.27 Notably, there were
fewer seromas (0.8 percent) encountered among
mammaplasty patients in this study than in some
other series.67,68 This favorable experience may be
related to the use of a wedge-shaped parenchymal
excision without skin undermining, no liposuc-
tion, and the use of scalpel dissection rather than
cutting electrocautery.67
Despite concerns about large implant size,75
no correlation was detected between implant size
and complication rates. On the contrary, surveyed
patients reported a positive correlation between
implant size and result ratings.2,8
Notably, there was no increased risk of compli-
cations for secondary mastopexies or reductions. In
this study, all previous mastopexies had been per-
formed using the inverted-T technique and all were
revised using the vertical technique. Although it
might seem logical to reuse the same resection pat-
tern in secondary cases,76 out of concern for blood
supply across periareolar scars, in practice this pre-
caution appears to be unnecessary (Fig. 8).77,78
Revisions
The 20.5 percent revision rate after augmen-
tation/mastopexy is comparable to other studies
reporting rates between 10 and 23.2 percent.13,16,20
A consideration when interpreting revision rates
is whether reoperation for an implant size change
is considered a revision (these patients were
counted as revisions in the present study).13 The
high rate of revisions after vertical mastopexies
and reductions (7 to 24 percent)38,66,68,70 is a well-
known and frequently cited disadvantage of the
vertical technique.5,38,68 However, this frequency of
revisions is at least partly related to the fact that
such revisions are possible. Problems associated
with an inverted-T technique do not lend them-
selves easily to surgical revision.79 If shape consid-
erations are given the importance they deserve,
the inverted-T technique has a consistently high
level of such “complications” as flattening of the
upper poles, loss of breast projection, squaring
of the lower poles, and nipple overelevation.27 In
fact, most inverted-T results resemble preopera-
tive candidates for augmentation/mastopexy and
appear better after revision using a vertical tech-
nique with implants (Fig. 8).
Many cosmetic procedures have a high revision
rate (e.g., liposuction), and this is not necessarily

42e
Volume 132, Number 1 • Cosmetic Breast Surgery Study
an indictment of the procedure.39,80 Revision rates
may reflect the surgeon’s level of perfectionism
as much as the patient’s, and a favorable pricing
policy. Patient satisfaction remains high despite
the frequency of revisions.2,70
Limitations of the Study
The author adopted the vertical mamma-
plasty technique in 2002; thus, this study includes
his learning curve experience. These findings
are relevant to a vertical mammaplasty and medi-
ally based pedicle. Other techniques are likely
to have different (and, experience suggests, less
favorable) clinical outcomes. The mean follow-up
time was 8.6 months. Cosmetic surgery patients
are not usually motivated to return for research
purposes. Accordingly, long-term complications
are not adequately assessed. The sample sizes are
dissimilar, in keeping with the disproportionate
number of breast augmentations performed in
practice, and necessary if one is to avoid selec-
tion bias.
Strengths of the Study
A prospective study of consecutive patients is
preferred over a retrospective study because inclu-
sion rates are likely to be higher, with fewer con-
founding factors, less selection bias, and less risk
of missing documentation of important data, such
as complications.23,24 A power analysis ensures suf-
ficient sample sizes to allow reliable conclusions.24
The absence of a corporate sponsor avoids com-
mercial bias that may affect studies with corporate
underwriting.
CONCLUSIONS
Complication and revision rates for vertical
augmentation/mastopexy are less than the cal-
culated cumulative rates for mastopexy and aug-
mentation performed separately. The combined
procedure offers technical advantages and per-
mits safe single-stage surgery.
Eric Swanson, M.D.
Swanson Center
11413 Ash Street
Leawood, Kan. 66211
eswanson@swansoncenter.com
ACKNOWLEDGMENTS
The author thanks Jane Zagorski, Ph.D., for statisti-
cal analyses; Lindsey Kroenke, B.S.N., and Sarah Max-
well, R.N., for data collection; and Gwendolyn Godfrey
for illustrations.
REFERENCES
1. Nahai F. Clinical decision-making in breast surgery. In: Nahai
F, ed. The Art of Aesthetic Surgery: Principles & Techniques. St.
Louis: Quality Medical; 2005:1818–1858.
2. Swanson E. Prospective outcome study of 106 cases of vertical
mastopexy, augmentation/mastopexy, and breast reduction. J
Plast Reconstr Aesthet Surg. Epublished ahead of print April 9, 2013.
3. Gorney M. Ten years’ experience in aesthetic surgery mal-
practice claims. Aesthet Surg J. 2001;21:569–571.
4. Spear SL, Pelletiere CV, Menon N. One-stage augmenta-
tion combined with mastopexy: Aesthetic results and patient
satisfaction. Aesthetic Plast Surg. 2004;28:259–267; discussion
1167–1168.
5. Rohrich RJ, Gosman AA, Brown SA, Reisch J. Mastopexy
preferences: A survey of board-certified plastic surgeons.
Plast Reconstr Surg. 2006;118:1631–1638.
6. American Society of Plastic Surgeons. 2011 Cosmetic
Plastic Surgical Statistics. Available at: http://www.plastic-
surgery.org/Documents/news-resources/statistics/2011-
statistics/2011-cosmetic-procedures-trends-statistics.pdf.
Accessed November 28, 2012.
7. Swanson E. Prospective photographic measurement study
of 196 cases of breast augmentation, mastopexy, augmenta-
tion/mastopexy, and breast reduction. Plast Reconstr Surg.
2013;131:802e–819e.
8. Swanson E. Prospective outcome study of 225 cases of breast
augmentation. Plast Reconstr Surg. 2013;131:1158–1166.
9. Hall-Findlay EJ. A simplified vertical reduction mamma-
plasty: Shortening the learning curve. Plast Reconstr Surg.
1999;104:748–759; discussion 760.
10. Cohen J. Analysis of variance. In: Statistical Power Analysis
for the Behavioral Sciences. 2nd ed. Hillsdale, NJ: Lawrence
Erlbaum; 1988:273–406.
11. Faul F, Erdfelder E, Lang AG, Buchner A. G*Power 3: A flexi-
ble statistical power analysis program for the social, behavioral,
and biomedical sciences. Behav Res Methods 2007;39:175–191.
12. Courtiss EH, Goldwyn RM. Breast sensation before and after
plastic surgery. Plast Reconstr Surg. 1976;58:1–13.
13. Calobrace MB, Herdt DR, Cothron KJ. Simultaneous augmenta-
tion/mastopexy: A retrospective 5-year review of 332 consecutive
cases. Plast Reconstr Surg. 2013;131:145–156; discussion 157–158.
14. Stevens WG, Stoker DA, Freeman ME, Quardt SM, Hirsch EM.
Mastopexy revisited: A review of 150 consecutive cases for com-
plication and revision rates. Aesthet Surg J. 2007;27:150–154.
15. Spear SL, Boehmler JH, Clemens MW. Augmentation/mas-
topexy: A 3-year review of a single surgeon’s practice. Plast
Reconstr Surg. 2006;118(Suppl):136S–147S.
16. Stevens WG, Stoker DA, Freeman ME, Quardt SM, Hirsch
EM, Cohen R. Is one-stage breast augmentation with masto-
pexy safe and effective? A review of 186 primary cases. Aesthet
Surg J. 2006;26:674–681.
17. Cárdenas-Camarena L, Ramírez-Macías R. Augmentation/
mastopexy: How to select and perform the proper tech-
nique. Aesthetic Plast Surg. 2006;30:21–33.
18. Stevens WG, Freeman ME, Stoker DA, Quardt SM, Cohen
R, Hirsch EM. One-stage mastopexy with breast aug-
mentation: A review of 321 patients. Plast Reconstr Surg.
2007;120:1674–1679.
19. Cannon CL III, Lindsey JT. Conservative augmentation with
periareolar mastopexy reduces complications and treats a
variety of breast types: A 5-year retrospective review of 100
consecutive patients. Ann Plast Surg. 2010;64:516–521.
20. Tessone A, Millet E, Weissman O, et al. Evading a surgical
pitfall: Mastopexy–augmentation made simple. Aesthetic Plast
Surg. 2011;35:1073–1078.
43e

21. Eisenberg T. Simultaneous augmentation mastopexy: A
technique for maximum en bloc skin resection using the
inverted-T pattern regardless of implant size, asymmetry, or
ptosis. Aesthetic Plast Surg. 2012;36:349–354.
22. Scheer J, Patel A, Blount A, et al. One-stage augmentation
and mastopexy: A review of outcomes in a large patient pop-
ulation. Plast Reconstr Surg. 2012;130:85–86.
23. Pannucci CJ, Wilkins EG. Identifying and avoiding bias in
research. Plast Reconstr Surg. 2010;126:619–625.
24. Ayeni O, Dickson L, Ignacy TA, Thoma A. A systematic
review of power and sample size reporting in randomized
controlled trials within plastic surgery. Plast Reconstr Surg.
2012;130:78e–86e.
25. Okoro SA, Barone C, Bohnenblust M, Wang HT. Breast
reduction trend among plastic surgeons: A national survey.
Plast Reconstr Surg. 2008;122:1312–1320.
26. Panel Discussion. Long-term outcomes in augmentation/mas-
topexy: Consecutive cases. Paper presented at: Plastic Surgery
2011: 80th Annual Scientific Meeting of the American Society
of Plastic Surgeons; September 23–27, 2011; Denver, Colo.
27. Swanson E. A retrospective photometric study of 82 pub-
lished reports of mastopexy and breast reduction. Plast
Reconstr Surg. 2011;128:1282–1301.
28. Georgiade NG, Serafin D, Riefkohl R, Georgiade GS. Is there
a reduction mammaplasty for “all seasons?” Plast Reconstr
Surg. 1979;63:765–773.
29. Chen CM, White C, Warren SM, Cole J, Isik FF. Simplifying
the vertical reduction mammaplasty. Plast Reconstr Surg.
2004;113:162–172; discussion 173.
30. Serra MP, Longhi P, Sinha M. Breast reduction with a supero-
medial pedicle and a vertical scar (Hall-Findlay’s technique):
Experience with 210 consecutive patients. Ann Plast Surg.
2010;64:275–278.
31. Neaman KC, Armstrong SD, Mendonca SJ, et al. Vertical
reduction mammaplasty utilizing the superomedial pedicle:
Is it really for everyone? Aesthet Surg J. 2012;32:718–725.
32. Lista F, Ahmad J. Vertical scar reduction mammaplasty: A
15-year experience including a review of 250 consecutive cases.
Plast Reconstr Surg. 2006;117:2152–2165; discussion 2166.
33. Hofmann AK, Wuestner-Hofmann MC, Bassetto F, Scarpa C,
Mazzoleni F. Breast reduction: Modified “Lejour technique”
in 500 large breasts. Plast Reconstr Surg. 2007;120:1095–1104;
discussion 1105.
34. Amini P, Stasch T, Theodorou P, Altintas AA, Phan V,
Spilker G. Vertical reduction mammaplasty combined with
a superomedial pedicle in gigantomastia. Ann Plast Surg.
2010;64:279–285.
35. Rohrich RJ, Thornton JF, Jakubietz RG, Jakubietz MG,
Grünert JG. The limited scar mastopexy: Current concepts
and approaches to correct breast ptosis. Plast Reconstr Surg.
2004;114:1622–1630.
36. Nahabedian MY. Breast deformities and mastopexy. Plast
Reconstr Surg. 2011;127:91e–102e.
37. Swanson E. Photometric evaluation of inframammary
crease level after cosmetic breast surgery. Aesthet Surg J.
2010;30:832–837.
38. 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; dis-
cussion 2200.
39. McCulley SJ, Hudson DA. Short-scar breast reduction: Why
all the fuss? Plast Reconstr Surg. 2001;107:965–969.
40. Regnault P, Daniel RK, Tirkanits B. The minus-plus masto-
pexy. Clin Plast Surg. 1988;15:595–600.
41. Hall-Findlay EJ. Pedicles in vertical breast reduction and
mastopexy. Clin Plast Surg. 2002;29:379–391.
44e
Plastic and Reconstructive Surgery • July 2013
42. Spear S. Augmentation/mastopexy: “Surgeon, beware.” Plast
Reconstr Surg. 2003;112:905–906.
43. Spear SL. Update discussion. Augmentation/mastopexy:
“Surgeon beware.” Plast Reconstr Surg. 2006;118(Suppl):135S.
44. Handel N. Mastopexy in the previously augmented breast.
In: Spear SL, ed. Surgery of the Breast: Principles and Art. 2nd
ed, Vol. 2. Philadelphia: Lippincott Williams & Wilkins;
2006:1458–1459.
45. Persoff MM. Vertical mastopexy with expansion augmenta-
tion. Aesthetic Plast Surg. 2003;27:13–19.
46. Grotting JC, Chen SM. Control and precision in masto-
pexy. In: Nahai F, ed. The Art of Aesthetic Surgery: Principles &
Techniques. St. Louis: Quality Medical; 2005:1907–1950.
47. Spear SL, Giese SY. Simultaneous breast augmentation and
mastopexy. Aesthet Surg J. 2000;20:155–164.
48. Hammond DC. Augmentation mastopexy: General consider-
ations. In: Spear SL, ed. Surgery of the Breast: Principles and Art.
2nd ed, Vol. 2. Philadelphia: Lippincott Williams & Wilkins;
2006:1403–1416.
49. Spear SL, Dayan JH, Clemens MW. Augmentation masto-
pexy. Clin Plast Surg. 2009:36:105–115.
50. Handel N. Secondary mastopexy in the augmented patient:
A recipe for disaster. Plast Reconstr Surg. 2006;118(Suppl):
152S–163S.
51. Don Parsa F, Brickman M, Parsa AA. Augmentation/masto-
pexy. Plast Reconstr Surg. 2005;115:1428–1429.
52. Elliott LR. Circumareolar mastopexy with augmentation.
Clin Plast Surg. 2002;29:337–347.
53. Gorney M, Maxwell PG, Spear SL. Augmentation mastopexy.
Aesthet Surg J. 2005;25:275–284.
54. Hunter-Smith DJ, Smoll NR, Marne B, Maung H, Findlay
MW. Comparing breast-reduction techniques: Time-to-
event analysis and recommendations. Aesthetic Plast Surg.
2012;36:600–606.
55. Kerrigan C. Maximizing outcomes in breast reduction sur-
gery: A review of 518 consecutive patients (Discussion). Plast
Reconstr Surg. 2005;116:1640–1641.
56. Stevens WG, Gear AJ, Stoker DA, et al. Outpatient reduc-
tion mammaplasty: An eleven-year experience. Aesthet Surg J.
2008;28:171–179.
57. Swanson E. Prospective study of lidocaine, bupivacaine
and epinephrine levels and blood loss in patients under-
going liposuction and abdominoplasty. Plast Reconstr Surg.
2012;130:702–722; discussion 723–725.
58. Mentor Corp. Saline-Filled Breast Implant Surgery: Making
an Informed Decision (product insert). Santa Barbara, Calif:
Mentor Corp; 2005.
59. Handel N, Cordray T, Gutierrez J, Jensen JA. A long-term
study of outcomes, complications, and patient satisfaction
with breast implants. Plast Reconstr Surg. 2006;117:757–767.
60. Spear SL, Murphy DK, Slicton A, Walker PS; Inamed Silicone
Breast Implant U.S. Study Group. Inamed silicone breast
implant core study results at 6 years. Plast Reconstr Surg.
2007;120(Suppl 1):8S–16S; discussion 17S.
61. Cunningham B. The Mentor Study on Contour Profile Gel
Silicone MemoryGel Breast Implants. Plast Reconstr Surg.
2007;120(Suppl 1):33S–39S.
62. Walker PS, Walls B, Murphy DK. Natrelle saline-filled
breast implants: A prospective 10-year study. Aesthet Surg J.
2008;28:19–25.
63. McCafferty LR, Casas LA, Stinnett SS, Lin S, Rho J, Skiles
M. Multisite analysis of 177 consecutive primary breast
augmentations: Predictors for reoperation. Aesthet Surg J.
2009;29:213–220.
64. Spear SL, Jespersen MR. Breast implants: Saline or silicone?
Aesthet Surg J. 2010;30:557–570.
Volume 132, Number 1 • Cosmetic Breast Surgery Study
65. Codner MA, Mejia JD, Locke MB, et al. A 15-year experi-
ence with primary breast augmentation. Plast Reconstr Surg.
2011;127:1300–1310.
66. Pickford MA, Boorman JG. Early experience with the Lejour
vertical scar reduction mammaplasty technique. Br J Plast
Surg. 1993;46:516–522.
67. Lejour M. Vertical mammaplasty: Early complications
after 250 personal consecutive cases. Plast Reconstr Surg.
1999;104:764–770.
68. Spector JA, Kleinerman R, Culliford AT, Karp NS. The verti-
cal reduction mammaplasty: A prospective analysis of patient
outcomes. Plast Reconstr Surg. 2006;117:374–381; discussion
382–383.
69. Adham M, Sawan K, Lovelace C, Jaeger NJ, Adham C.
Unfavorable outcomes with vertical reduction mammaplasty:
Part II. Aesthet Surg J. 2011;31:40–46.
70. Cruz-Korchin N, Korchin L. Vertical versus Wise pattern
breast reduction: Patient satisfaction, revision rates, and
complications. Plast Reconstr Surg. 2003;112:1573–1578; dis-
cussion 1579.
71. Hall-Findlay EJ. Breast reduction: Modified “Lejour tech-
nique” in 500 large breasts (Discussion). Plast Reconstr Surg.
2007;120:1105–1107.
72. Flowers RS, Smith EM Jr. “Flip-flap” mastopexy. Aesthetic Plast
Surg. 1998;22:425–429.
73. Lejour M. Vertical mammaplasty: Update and appraisal of
late results. Plast Reconstr Surg. 1999;104:771–781; discussion
782.
74. Karp NS. Medial pedicle/vertical breast reduction made
easy: The importance of complete inferior glandular resec-
tion. Ann Plast Surg. 2004;52:458–464.
75. Tebbetts JB. The greatest myths in breast augmentation. Plast
Reconstr Surg. 2001;107:1895–1903.
76. Hudson DA, Skoll PJ. Repeat reduction mammaplasty. Plast
Reconstr Surg. 1999;104:401–408.
77. Losee JE, Caldwell EH, Serletti JM. Secondary reduction
mammaplasty: Is using a different pedicle safe? Plast Reconstr
Surg. 2000;106:1004–1008; discussion 1009.
78. Ahmad J, McIsaac SM, Lista F. Does knowledge of the initial
technique affect outcomes after repeated breast reduction?
Plast Reconstr Surg. 2012;129:11–18.
79. Hall-Findlay EJ. Reduction mammaplasty. In: Nahai F, ed.
The Art of Aesthetic Surgery: Principles & Techniques. St. Louis:
Quality Medical; 2005:1951–2043.
80. Pollock H, Pollock T. Is reoperation rate a valid statistic in
cosmetic surgery? Plast Reconstr Surg. 2007;120:569.
45e