Which of the following is associated with reduction mammaplasty using the vertical scar (Lejour) technique?

(A) Central vertical glandular excision
(B) Inferiorly based blood supply to the nipple
(C) Keyhole-pattern skin excision
(D) Precision in determining the endpoint of resection
(E) Wide periareolar skin excision

The correct response is Option A.

Features of the vertical (Lejour) mammaplasty include central vertical glandular excision to improve postoperative shape (by narrowing the breast while maximizing breast projection) and excision of skin in one direction only to decrease scar burden. Vertical mammaplasty is a technique of central breast reduction with undermining of the lower skin, as well as use of adjustable markings and an upper pedicle to maintain the blood supply to the areola.

Keyhole-pattern and wide periareolar resections are not features of the vertical mammaplasty; therefore, circumareolar scar quality is not compromised by excess skin tension. However, because of the central and posterior resection used with this technique, it is more difficult to determine the endpoint of resection.

References
1. Hidalgo DA, Elliot LF, Palumbo S, et al. Current trends in breast reduction. Plast Reconstr Surg. 1999;104:806.
2. Lassus C. A 30-year experience with vertical mammaplasty. Plast Reconstr Surg. 1996;97:373.
3. Lejour M. Vertical mammaplasty. Plast Reconstr Surg. 1993;92:985-986.

A 58-year-old man has had moderate gynecomastia with severe skin redundancy for the past eight years. A photograph is shown above. Complete physical examination and laboratory studies show no other abnormalities. Which of the following is the LEAST acceptable technique for management?

(A) Suction lipectomy with subsequent skin shrinkage
(B) Concentric circle resection
(C) Wise-pattern mastopexy
(D) Glandular resection through an areolar incision with adjunctive suction lipectomy
(E) Breast amputation and free nipple grafting

The correct response is Option C.

Gynecomastia can be classified according to three grades. Grade I gynecomastia involves visible mild breast enlargement without skin redundancy. In grade IIA gynecomastia, there is moderate breast enlargement without skin redundancy; in grade IIB gynecomastia, there is moderate breast enlargement with skin redundancy. Grade III gynecomastia is characterized by marked breast enlargement with marked skin redundancy. Although most adolescents with gynecomastia have regression within two years (only 7.7% of affected adolescents have duration of symptoms for a longer time), regression is unlikely to be seen in this older patient, who has had severe ptosis for the past eight years.

Suction lipectomy has eliminated the need for skin resection in many gynecomastia patients, especially adolescents. Fibrous enlargement can be managed with glandular resection through an areolar incision with adjunctive suction lipectomy. However, skin resection is still recommended in older patients with grade III gynecomastia who have significant ptosis. Other procedures, such as resection of a concentric circle of skin, pedicled relocation of the nipple with skin resection, or breast amputation with free nipple grafting, may be considered. The Wise-pattern mastopexy is used to create a projecting, conical breast in women undergoing breast reduction and should not be performed in gynecomastia patients who require a breast elimination procedure.

References
1. Bostwick J. Plastic and Reconstructive Breast Surgery. Saint Louis, Mo: CV Mosby Co; 1990:468-477.
2. Riefkohl R, Zavitsanos GP, Courtiss EH. Gynecomastia. In: Georgiade GS, Riefkohl R, Levin LS, eds. Textbook of Plastic, Maxillofacial and Reconstructive Surgery. Baltimore, Md: Williams & Wilkins; 1997:820-828.
3. Simon BE, Hoffman S, Kahn S. Classification and surgical correction of gynecomastia. Plast Reconstr Surg. 1973;51:48-52.