Modified “no-vertical-scar” reduction mammoplasty: a safe and versatile oncoplastic surgical technique for patients with extremely large and ptotic breasts

Introduction

In the era of oncoplastic surgery for conservative treatment of breast cancer, large breast usually benefits from reduction techniques that combine skin and parenchymal resection with pedicles to maintain blood supply, especially to the nipple-areola complex (NAC), for adequate reshaping and cosmetics. Currently, there are multiple pedicle and skin excision techniques used in reduction mammaplasty that varies specially according to breast size and tumor location. One of the most used breast reduction surgeries is the inverted-T scar (Wise-pattern). Numerous reports have established its efficacy in oncoplastic procedures and its aesthetically pleasing shape (1-5). However, in extremely large and ptotic breasts (e.g., macromastia), it has some disadvantages and limitations such as extensive scar pattern, risk of dehiscence, especially in the T junction, limitation in the amount of reduction with good cosmetic outcome when removals >800 g per side are required and challenges with the NAC repositioning and pedicle (6).

These limitations make these types of breasts an overt challenge that could be solved by using alternative and often neglected techniques. Semicircular horizontal or here referred to as “no-vertical-scar” reduction mammoplasties that result in transverse scar located in the inframammary fold have been historically proposed in plastic surgery for very large breasts with marked ptosis since early descriptions by Passot in 1925 (buttonhole technique) (7). It has been modified and revived over time by other authors, such as Lalonde et al. (8) and Vazquez et al. (9) but has been frequently underused because of some critics related to difficult reproducibility, odd breast shape, poor projection and need for NAC grafting (10-12). In the context of oncoplastic surgery, this mammoplasty technique has also been neglected, although it may have many advantages in breast cancer patients involving technique, adaptability, feasibility and convenience.

The purpose of this study was to describe an adapted technique designated as modified “no-vertical-scar” reduction mammoplasty and present its critical technical points, adjustments and safety for oncoplastic surgery, allowing for elimination of the vertical scar along with better breast shape and projection, easy performance and for axillary approach through the same incision. This study also aimed to perform a retrospective analysis of surgical outcomes of consecutively performed no-vertical scar mammaplasty cases in the same institution. We present this article in accordance with the SUPER reporting checklist (available at https://abs.amegroups.com/article/view/10.21037/abs-25-14/rc).

Preoperative preparations and requirements

This is a single-center case-series study. The population group comprised women diagnosed with breast cancer who underwent surgical treatment between April 2020 and February 2024 in a the Breast Assessment Center, Botucatu Medical School University Hospital (HC-UNESP) in Southeastern Brazil. Information regarding patient demographics, medical history, surgical technique, anatomopathological data and postoperative outcomes was collected from patient records. This study was approved by the Research Ethics Committee of the Botucatu Medical School, Sao Paulo State University (UNESP) (No. 4.699.347, CAAE: 15747019.8.0000.5422). All procedures performed in this study were in accordance with the Helsinki Declaration and its subsequent amendments. Written informed consent was obtained from the patient for publication of this study and the accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Patient selection

Patients were selected for this technique if they had grade 2 or 3 ptotic breasts according to Regnault Classification and had enough skin above the areola to create the final breast coverage. This latter prerequisite was established by projecting the lower limit of the breast fold onto the breast, which was required to be at least 1–2 cm above the upper edge of the areola.

Preoperative markings

Skin markings are performed with the patient in a standing position, and it is recommended that the surgeon is seated, with the patient’s breasts at eye level. Draw a vertical line from the sternal notch, passing through the xiphoid process towards the umbilicus (midsternal line). Afterwards, draw bilaterally a vertical line from the midclavicular point to divide the breast into two equal parts. Avoid using the nipples as reference points since they may not be centralized.

Mark the entire inframammary fold from the medial skin crease to the lateral limit and transfer the lowest point of the fold to the midline. In the lateral aspect of the breast, ask the patient to abduct her arms by approximately 45–90 degrees so you can draw vertical lines passing through the mid-axillary and posterior axillary lines.

While positioned at the level of the inframammary fold, project its inferior limit onto the anterior aspect of the breast and then mark a point 1–3 cm below it (point X). This point defines the lower edge of the new breast that will be sutured to the inframammary fold. Therefore, it is recommended to ensure that this point is above the superior aspect of the original areola to avoids its darker skin appearing in the new inframammary fold.

From the medial limit of the fold, draw a curvilinear line passing the anterior aspect of the breast towards point X. Respect the original fold curve to avoid excessive skin and to prevent a “boxy” shape of the final breast. For better symmetry, use the mirror technique to mark the contralateral breast, aligning points with the already demarcated breast.

From point X, continue the line towards the mid-axillary line, following the projection of the original inframammary fold. The lateral line is generally straighter than the medial one. The length of the line will vary based on the patient’s lateral tissue. In patients with less lateral adipose tissue, the line should end at the mid-axillary line; in those with more adipose tissue, it should extend to the posterior axillary line to avoid excess tissue and achieve a satisfactory aesthetic result.

With the patient in a side position, complete the marking at the axillary line (mid or posterior), defining point Y. From point Y, draw a curvilinear line towards the patient’s original inframammary fold. Do not curve the lower lateral line inferiorly towards the fold, as this will result in excess skin (dog ears) and an unaesthetic result.

Afterwards, one of the most important steps is to determine the new lateral boundary of the breast mount, especially in wide-based breasts, to narrow the future breast’s transverse base and provide a more natural silhouette. For this, draw a vertical line from the anterior axillary fold down with the patient facing forward. This line delimits the entire lateral area that will be internally resected to avoid excess tissue. This also serves as a reference point for the final suture (Figure 1).

Figure 1 Preoperative markings. (A) Draw the midsternal and midclavicular lines to divide the breast into two equal parts. (B,C) mark the entire inframammary fold and transfer the lowest point of the fold to the midline. (D) Project the fold inferior limit onto the anterior aspect of the breast and mark a point 1–3 cm below it (point X). (E,F) Draw a curvilinear line passing the anterior aspect of the breast towards point X avoiding excessive skin and to prevent a “boxy” shape and use the mirror technique to mark the contralateral breast. (G,H) Continue the line towards the side of the breast, following the projection of the original inframammary fold, and finish the marking at the axillary line (mid or posterior), defining point Y. After, draw a curvilinear line towards the patient’s original inframammary fold to avoid excess skin (dog ears) and determine the new lateral boundary of the breast by drawing a vertical line from the anterior axillary fold down with the patient facing forward. (I) Final aspect of the markings. This image is published with the patient/participant’s consent.

The additional marking and localization of the tumor according to clinical and imaging examination also need to be considered to ensure optimal oncological safety and surgical outcomes.

Step-by-step description

The first step was to define the circular incision of the areola by using an areola marker with the diameter in accordance with the breast shape followed by skin incision based on the preoperative marking. In cases of sentinel lymph node biopsy, it was initially performed through the lateral infra-axillary portion of the incision.

NAC graft removal was performed by subdermal decortication with a cold scalpel or scissors, and after completed, it is kept in a sterile recipient with saline solution until it is finally grafted.

Approach to tumors in the lower quadrants (breast reconstruction with the upper quadrants)

After removing the tumor in the lower quadrants, the upper flap is created, which will serve to fill the entire central region of the breast (“inverted auto-prosthesis”). For this, from the skin incision, the scalpel is kept beveled inferiorly in a subdermal plane to delimit an area of breast tissue that will be spared for filling (usually 5–6 cm of tissue beyond the incision). After ensuring adequate tissue volume, the scalpel proceeds in the direction of the thoracic wall. After reaching the underlying subglandular plane, a posterior detachment of the upper quadrants in made up to the height of the 4^th–5^th intercostal space (central region of the breast), this step is important to allow adequate advancement of the upper flap. Any tissue that is beyond the previously delimited lateral breast border must be removed to avoid the unaesthetic appearance of the breast (“boxy appearance”). Also remove any excess additional tissue located on the lower quadrants. Subsequently, to mount the breast and provide projection, invert and fix the breast parenchyma present at the lower tip of the flap to the fascia of the pectoralis major muscle with single nylon 3-0 sutures at the level of the central breast region. Afterwards, additional lateral and medial sutures can be given as necessary to improve the shape of the breast and avoid excess, especially on the lateral portion (Figure 2).

Figure 2 Approach to tumors in the lower quadrants. (A,B) Front and lateral view of the patient showing the marking of the breast tissue that will be spared for filling (usually 5–6 cm of tissue beyond the incision). (C) Lumpectomy with margins in inferolateral quadrant of the right breast. (D) Delineate the upper flap with lower excess tissue by following the marked skin areas created. (E) Direct the scalpel towards thoracic wall, reach the underlying subglandular plane and detachment of the upper quadrants up to the height of the 4^th–5^th intercostal space. (F-H) Remove extra tissue from the lower and lateral parts of the breast, invert and fix the breast parenchyma present at the lower tip of the flap to the fascia of the pectoralis major muscle at the level of the central breast region. (I) Final aspect after internal and external partial sutures. This image is published with the patient/participant’s consent.

Approach to tumors in the upper quadrants (breast reconstruction with the lower quadrants)

From the skin incision, the superior skin flap is created, usually at the pre-glandular fat tissue plane, with a thickness sufficient to remove the tumor with margins up to the stipulated limit. After lumpectomy, a non-areolated lower pedicle with a base width of 8–12 cm is created following the marking, leaving a central amount of breast sufficient for adequate filling (“auto-prosthesis”). The specific width within this range is adapted to the patient’s thoracic width and breast base diameter. Vascularity of the pedicle is preserved by maintaining the integrity of the inferior pedicle blood supply, which relies mainly on the 5^th perforating branch of the internal thoracic artery and perforators from the intercostal arteries, ensuring robust and reliable perfusion. All lateral excess can be removed or, in cases of larger defects, rotated and sutured medially. The breast parenchyma of the pedicle is then fixed medially and laterally to the fascia of the pectoralis major muscle with single nylon 3-0 sutures to ensure its central stabilization (Figure 3). It can be also fixed superiorly to maintain the upper pole and better long-term projection.

Figure 3 Approach to tumors in the upper quadrants. (A,B) Photograph and schematic drawing showing the non-areolated lower pedicle with a base width of 8–12 cm with adequate central amount of breast that is fixed medially and laterally to ensure its central stabilization. (C) Final aspect of the breast after partial skin suture showing good projection and upper pole fullness and no lateral excess tissue. This image is published with the patient/participant’s consent.

After proper breast mount, the superior “apron” flap is then brought down over the remaining breast tissues and sutured in place. For systematic closure of breast, initially a simple skin suture must be placed in the projection of the anterior axillary line to delimit the lateral border of the new breast silhouette, avoiding divergences in the lateral extension of the incision. Subsequently, another simple suture is made in the medial region and another in the central region of the incision. Between the sutures given, there must be an adequate and symmetrical amount of excess skin on the upper edge of the incision. After adequate symmetry is checked, the subcuticular and cuticular planes are finally closed using Monocryl 4-0 sutures.

NAC repositioning

Before the NAC graft is resutured over the breast, it is thinned by using delicate scissors (e.g., Iris) until the dermal plane is reached and the areolar muscle is removed, creating a split-thickness flap. For repositioning, the patient is placed in a sitting position with arms aligned with the trunk, and the position of the new NAC is marked by using an areola marker or methylene blue. The lower edge of the new NAC is generally marked 5–6 cm above the sulcus in a vertical plane 10–11 cm away from the midline. The patient is then placed back supine and the skin over the recipient marked area is removed by de-epithelialization with a cold scalpel or scissor, taking care not to reach the subcutaneous tissue. Under no circumstances cauterization should be performed nor the subcutaneous tissue be reached. The NAC graft is then sutured in place and secured with 6 or 8 interrupted cardinal and subcardinal sutures placed around the periphery of the areola. During the suturing process, maintain irrigation with saline solution to avoid clotting. The suture is then tied over a bolster dressing made up of a pad of 3–4 gauzes to maintain contact and compression of the graft onto the de-epithelialized bed. Afterwards, the dressing is soaked with essential fatty acid oil or petroleum jelly and this dressing is removed after 7–12 days (Figure 4). Pre- and post-operative photographs are shown in Figure 5.

Figure 4 Breast final sutures and NAC repositioning. (A,B) The superior flap is brought down and sutured in place, initially with 3 interrupted sutures (lateral, medial and central region of the incision) and followed by the subcuticular and cuticular sutures. (C,D) The position of the new NAC is marked with the patient in a sitting position and the skin over the recipient marked area is removed by de-epithelialization. (E,F) The NAC graft is thinned to the dermal plane creating a split-thickness flap. (G,H) The NAC graft is sutured and secured with 6 or 8 interrupted cardinal and subcardinal sutures. (I) The suture is tied in a bolster dressing and soaked with essential fatty acid oil or petroleum jelly. This image is published with the patient/participant’s consent.

Figure 5 Pre- and post-operative photographs of 8 cases. (A-D) Patients with tumors in the lower quadrants and breast reconstruction with the upper quadrants tissue. (E-H) Patients with tumors in the upper quadrants and breast reconstruction with the lower quadrants tissue. This image is published with the patient/participant’s consent.

Results

The study included 66 patients with a mean age of 58.2 years (ranging from 34 to 68 years). The mean body mass index (BMI) was 30.7 kg/m² and, according to WHO classification, 24.2% of the patients were classified as overweight, 36.4% with grade I obesity, 19.7% with grade II obesity and 19.7% with grade III obesity. As for comorbidities, 48 of the 66 patients (72.7%) had cardiometabolic diseases. Systemic arterial hypertension was the most prevalent (57.6%), followed by type 2 diabetes mellitus and dyslipidemia (34.8% each), hypothyroidism (30.3%) and 16 patients (24.2%) had multiple cardiometabolic diseases. Fourteen (21%) of the 66 patients were also smokers.

According to anatomopathological features, the average tumor size was 4.64 cm, ranging from 2.1 to 8.2 cm. Most patients had a unifocal disease (83.3%) and tumors were predominantly located in the upper quadrants (63.7%). Forty patients (60.6%) had received neoadjuvant chemotherapy and 18 of these (45%) had complete pathological response in the final pathological analysis. In all 66 patients, axillary surgery was performed through the same breast incision (42 cases of sentinel lymph node biopsy and 24 cases of axillary dissection).

In the evaluation of surgical specimens, the average weight of the removed tissue was 752 g (100–2,505 g) per breast with cancer and 643 g (120–2,140 g) per contralateral breast. All patients had free surgical margins, and none required surgical reapproach.

Postoperative considerations and tasks

As for postoperative care, surgical drain removal occurred on average on the 8^th postoperative day (4–16 days) and there were only 15 cases (22.7%) of post-operative complications, that included surgical wound dehiscence (8 cases), NAC epidermolysis (4 cases), NAC partial necrosis (2 cases, both smokers), surgical site infection (2 cases) and hematoma (2 cases). There were no cases of NAC total necrosis. All complications were adequately treated with clinical care and were solved by less than 40 post-operative days. Concerning late complications, only 5 cases of radiation dermatitis have been identified to date. All data are presented in Table 1.

Tips and pearls

Key technical refinements that are critical for achieving optimal results with the modified no-vertical-scar mammoplasty need to be recognized. The first essential prerequisite is the presence of adequate skin above the areola, which ensures sufficient tissue to create the final breast coverage. This is assessed by projecting the lower limit of the inframammary fold onto the breast, and the projection must lie at least 1–2 cm above the upper border of the areola.

It is also important to emphasize the systematic removal of medial and lateral excess tissue, a step that prevents the “boxy” breast contour often seen in previous techniques. When combined with careful internal parenchymal reshaping, this maneuver enhances projection and contributes to a more natural breast silhouette. Another critical point relates to closure. Following a precise sequence of sutures—starting at the anterior axillary line, then progressing to the medial and central points—ensures proper parenchymal alignment and avoids misplacement of the breast mound, thereby optimizing the final contour.

Finally, meticulous management of the NAC is fundamental. Free grafting has proven safe and effective when carefully executed: the graft must be adequately thinned into a split-thickness flap, maintaining it at the vascularized dermal plane—avoiding excessive thinning that could jeopardize viability—while the recipient site should be prepared exclusively with cold-knife de-epithelialization. Under no circumstances should cauterization be used, as this may compromises graft viability.

Discussion

The results of this study provide significant insights into the profile and outcomes of patients undergoing this modified no-vertical scar mammoplasty, a good alternative procedure whose first reports in plastic surgery date back to 1925, when Passot described a mammaplasty technique for very large breasts in which an inferior flap was shaped to produce a conical breast after the excision of a central transverse wedge of hypertrophied breast (7). However, this technique has been less studied and improved in aesthetic plastic surgery. In reconstructive and oncoplastic surgery, it has also been underused and not well detailed (9).

Among the new adaptations present in this study, we sought to improve the main topics that were frequently criticized, such as reproducibility, utility in oncoplastics, and to optimize poor cosmetic outcomes frequently observed in previous descriptions, such as a ‘boxy-shaped’ appearance on the medial and lateral contours and absence of projection of the breast mound (13,14).

By establishing parameters, points and reference measurements both for indication and performance of the procedure, this modified technique became easily feasible and can be adapted to different patient profiles, tumor-breast volume ratio, and lesion topography. In relation to the shape of the breast, the systematic removal of the lateral excess tissue usually observed in these patients and the internal reshaping for better projection allowed the improvement of the final aesthetic outcome.

The clinical data related to the population present in the study show the safety profile of the technique. In addition to being an especially challenging group of patients due to issues related to breast volume and consequently greater surgical difficulty, they generally have a higher rate of risk factors for perioperative complications. In our study, 75.8% of patients were obese, more than half had cardiometabolic comorbidities (72.7%) and 21% were smokers. Even so, we only had 22.7% of minor complications and no case required a new surgical approach (due to complications or oncological needs).

When analyzing outcomes according to tumor location—whether in the upper or lower quadrants—no significant differences were observed in key surgical parameters, including complication rates, breast symmetry, and projection. This finding reinforces the versatility and reproducibility of the technique, suggesting that the strategic use of the remaining tissue according to tumor site can achieve consistent aesthetic and functional results regardless of lesion topography. Importantly, the applicability of this approach is not limited to tumors in the upper or lower quadrants but can also be extended to more complex oncologic scenarios, such as centrally located lesions or tumors in close proximity to the skin envelope, including those adjacent to the anticipated site of the neo-nipple-areolar complex. In these situations, particularly in patients with markedly hypertrophic and ptotic breasts, the abundant parenchymal and cutaneous tissue provides an opportunity for geometric compensation, whereby tailored skin resections combined with strategic parenchymal flap mobilization allow the surgeon to accommodate challenging tumor locations while preserving oncologic safety, minimizing contour deformities, and maintaining breast symmetry.

This technique has several additional advantages. It eliminates the vertical scar present in the inverted T (Wise-pattern) techniques and consequently may reduce the risk of dehiscence. Surgical wound dehiscence occurred at an especially low rate in this group of patients. It can result in an ‘unoperated’ look as the periareolar scar is concealed by the junction of the areolar skin and breast skin and the inframammary scar is concealed beneath the breast. Axillary surgery (sentinel lymph node biopsy or lymphadenectomy) could be easily performed through the same breast incision. In addition, it is a very versatile technique as it can be used for any tumor location, including large tumors, multifocal or multicentral lesions and even as a good alternative in cases of skin-reducing adenomastectomy (15-17). Similar breast reduction and mastectomy techniques have been described for chest masculinization surgery in transsexual men and for removal or large and ptotic gynecomastia.

It is well known that there are some challenges with NAC repositioning in cases of large ptotic breast as superior and superomedial pedicle are compromised when distance to point A (new nipple) >8–12 cm and the inferior pedicle provided greater residual volume, little coverage in the upper pole and risk of future pseudoptosis. These facts could be solved with the free NAC graft technique, although it has been little used due to fear of necrosis and loss of nipple projection. In our study, this procedure was performed in all patients and there were only 2 cases of partial necrosis and no cases of total NAC necrosis, showing that, when properly performed, it presents minimal rates of necrosis. In special cases, it can also be replaced by the inferior pedicle nipple-areolar technique.

As limitations of this procedure, there is a greater need for skin compensation during suturing as it does not reduce skin in the latero-lateral direction, and the scar on the chest wall extends more medially and laterally than in the Wise pattern, making it not ideal for all breast types. Furthermore, the retrospective nature of this study inherently limits causal inferences, and the absence of a control group reconstructed with the traditional Wise-pattern technique precludes direct comparative analysis of outcomes. Additionally, validated patient-reported measures of aesthetic satisfaction were not collected, which restricts the assessment of subjective cosmetic results and quality-of-life impact. It should also be noted that all cases were performed by a single surgeon at one institution, which may limit the generalizability of the results to other centers and surgeons with different levels of training or technical expertise. Future prospective, controlled studies incorporating standardized patient-reported outcome measures would evaluate more comprehensively the technique’s functional and aesthetic benefits.

Conclusions

This study highlights that the modified “no-vertical-scar” reduction mammoplasty is a safe and reproducible oncoplastic alternative for patients with large. It the advantage of eliminating the vertical scar present in both the inverted-T (Wise pattern) and vertical scar techniques, a low risk of complications and the ability to perform axillary staging through a single incision. It can also result in an ‘unoperated’ look after surgery with favorable aesthetic and oncologic outcomes. Once learned, it is fairly reproductible to perform, and the results are free of major complications.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the SUPER reporting checklist. Available at https://abs.amegroups.com/article/view/10.21037/abs-25-14/rc

Peer Review File: Available at https://abs.amegroups.com/article/view/10.21037/abs-25-14/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://abs.amegroups.com/article/view/10.21037/abs-25-14/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was approved by the Research Ethics Committee of the Botucatu Medical School, Sao Paulo State University (UNESP) (No. 4.699.347, CAAE: 15747019.8.0000.5422). All procedures performed in this study were in accordance with the Helsinki Declaration and its subsequent amendments. Written informed consent was obtained from the patient for publication of this study and the accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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