The Quest for the Invisible Scar

In the world of breast surgery, the "Vertical" (Lollipop) reduction was a major leap forward because it eliminated the horizontal anchor scar. But for some surgeons, even the circle around the areola was too much.

In December 2007, Dr. David Hidalgo published a study in Plastic and Reconstructive Surgery proposing a radical modification: Deleting the top half of the scar.

He explains Breast Reduction with Minimal Y Scar

This work was done at Weill-Cornell University Medical College in New York.

This paper introduces a refined technique for patients who need a "mini" Breast reduction and want the absolute minimum amount of scarring.

He argued that for certain young patients with mild enlargement, the upper part of the incision is unnecessary and actually harms the aesthetic result.

The Innovation: Saving the Upper Border

The "Y-Scar" technique is essentially a vertical reduction where the surgeon leaves the upper half of the areola completely untouched.

• The Theory: The transition between the darker areola skin and the lighter breast skin is often soft and natural. When you cut through it (as in a standard donut lift), you replace that soft transition with a sharp white scar line.





• The Solution: By leaving the top half of the areola attached to the skin, the surgeon preserves that natural "blur," making the breast look virtually untouched from the top down. The resulting scar looks like a "Y" (or a lollipop with the top of the circle missing).

Who is the "Y-Scar" Candidate?

This technique is not for everyone. Dr. Hidalgo specifically designed it for a "niche" group of patients who often fall into the gap between a lift and a reduction:

1. Mild Macromastia: Patients who only need a small amount of weight removed (the study average was 198 grams, compared to 500g+ for standard reductions).





2. Minimal Ptosis: Women with only mild drooping.





3. Young Patients: Younger skin has better elasticity, which is crucial for this technique to settle smoothly without bunching.

The Results: High Satisfaction for "Mini" Reductions

The study reviewed 10 patients (8 reductions/lifts and 2 augmentations/lifts).

• Aesthetic Outcome: All patients were pleased with the reduced scar burden. The removal of the upper scar significantly reduced the "perception" of having had surgery.





• Minor Issues: Because the skin is less managed than in full reductions, some patients experienced "inferior fullness" (fullness at the bottom of the areola), but this was considered a minor trade-off for the lack of scarring.

Conclusion

For young women seeking a "perk-up" and a small reduction, the full Lollipop or Anchor scar might feel like overkill. The Y-Scar Vertical Mammaplasty offers a tailored, minimalist approach that respects the natural anatomy of the areola, leaving the upper breast looking completely natural.

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Breast Reduction Surgery Cost varies between individuals!

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Frequently Asked Questions (FAQ)

Q: Can this be done if I have very large breasts?

A: Likely not. The study specifically focused on "mild macromastia" (under 400g removal). Larger reductions usually require the full skin tightening power of the Anchor or full Vertical patterns.

Q: Is this different from a "Circumvertical" lift?

A: It is a variation of it. Most vertical lifts cut all the way around the areola. This specific "Y" variation spares the top 180 degrees of the areola rim.

Q: Does it affect nipple sensation?

A: Since the upper skin bridge is left intact, the nerve supply is generally well-preserved, similar to other vertical techniques.

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References

• [1] Hidalgo, David A. M.D. "Y-Scar Vertical Mammaplasty." Plastic and Reconstructive Surgery 120(7):p 1749-1754, December 2007.





• [2] Hammond, Dennis C. M.D. "Short Scar Periareolar-Inferior Pedicle Reduction (SPAIR) Mammaplasty." Plastic and Reconstructive Surgery, 1999.

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The Problem: The "Artistic" Guess

For a long time, breast reduction and lift (mastopexy) planning relied heavily on the surgeon's "artistic eye." A surgeon would pinch the skin, draw some markings, and estimate how much tissue to remove.

While often successful, this subjective approach has a flaw: Imprecision. "Eyeballing" the skin excision can lead to nipples that are too high, scars that stretch, or breasts that "bottom out" because the skin envelope was left too loose.

The Solution: The Tebbetts Process

In March 2014, Dr. John Tebbetts published a landmark study from his practice in Dallas, Texas, detailing a strictly mathematical approach to planning these surgeries.

This paper represents a major shift from surgery as an "art" to surgery as an "objective science".

Instead of guessing, he developed a process to quantify the skin envelope—measuring exactly how much excess skin exists down to the millimeter. He applied this rigorous measuring process to 124 mastopexy and 122 breast reduction patients.

1. Measuring "Vertical Skin Excess" (VSE)

The core of this technique is measuring Vertical Skin Excess. This is the specific amount of skin between the nipple and the breast crease that needs to be removed to lift the breast correctly.

Dr. Tebbetts found that this number—not a guess—should dictate which incision pattern is used:

• Low VSE: Only a Periareolar (Donut) lift is needed.





• Medium VSE: A Vertical (Lollipop) incision is added to manage the excess.





• High VSE: An Inverted-T (Anchor) pattern is required to remove the massive amount of skin.

Simple Formula:

$VSE=\text{Actual Nipple-to-IMF Distance}-\text{Desired Nipple-to-IMF Distance (typically 8-10 cm)}$

Quantified approach (More Detailed Calculation):

$VSE=\text{Existing Nipple-to-IMF Dimension}-(\text{Desired Nipple-to-IMF Distance}+\frac{\text{Areola Diameter}}{2})$

2. Designing the "New" Envelope

Once the excess is measured, the surgeon calculates exactly where the new nipple position should be. In Dr. Tebbetts' study, the planning was so precise that 0% of the 246 patients required nipple repositioning after surgery.

The Results: Why Math Wins

The study followed patients for an average of 4.6 years, providing long-term data on how these "quantified" breasts aged.

• High Accuracy: As mentioned, no patient needed their nipples moved again.





• Low Complications: "Bottoming out" (excessive lower pole stretch) occurred in only 4% of cases.





• Learning Curve: Interestingly, the reoperation rate dropped from 6.5% in the first five years of using this method to just 1.6% in the later years, proving that once a surgeon masters the math, the results are incredibly consistent.

What This Means for You

If you are considering a breast reduction or lift, you want a surgeon who plans, not one who guesses.

This "Quantified Dimensions" approach ensures that the surgery is tailored to your specific skin elasticity and measurements. It removes the "surprise" factor, ensuring that the incision chosen is exactly the right one to handle your specific amount of excess skin.

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Ask yourself “Who is the Best Plastic Surgeon Near Me?”.

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Breast Reduction Surgery Cost varies between individuals!

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Frequently Asked Questions (FAQ)

Q: Does "quantifying" mean I get a cookie-cutter breast?

A: No, it means the opposite. Because the measurements are specific to your body, the surgical plan is customized to your exact anatomy rather than a generic template.

Q: Can this method prevent all stretching?

A: No surgery can stop gravity completely. However, this study showed that "excessive restretch" was rare (4%), meaning the results are stable for years.

Q: Is this technique used for implants too?

A: Dr. Tebbetts is famous for applying similar mathematical principles ("High Five" system) to breast augmentation, ensuring that implants fit the patient's footprint perfectly.

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References

• [1] Tebbetts, John B. M.D. "A Process for Quantifying Aesthetic and Functional Breast Surgery II. Applying Quantified Dimensions of the Skin Envelope to Design and Preoperative Planning for Mastopexy and Breast Reduction." Plastic and Reconstructive Surgery 133(3):p 527-542, March 2014.





• [2] Tebbetts, John B. M.D. "A Process for Quantifying Aesthetic and Functional Breast Surgery I." Plastic and Reconstructive Surgery, 2013.

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Estimated reading time: 4 minutes

The Surgeon's Struggle: The "Goldilocks" Layer

In many breast reduction techniques (like the Inferior Pedicle or McKissock Vertical), the surgeon must perform a step called "de-epithelialization." This involves removing the very thin top layer of skin (epidermis) while leaving the white, blood-rich layer underneath (dermis) perfectly intact.

It is a difficult balancing act:

• Too Shallow: If the cut is too thin, it leaves behind islands of skin cells which can cause cysts later.





• Too Deep: If the cut is too thick, it slices into the blood vessels (dermal plexus) that are keeping the nipple alive.

Traditionally, this required two assistants pulling the skin tight in different directions while the surgeon tried to slice a perfect, continuous sheet—a time-consuming and frustrating process.

The Solution: The Zebra Technique

Dr. Richard H. McShane developed a method to simplify this process by changing how the tension is applied. He called it the Zebra Technique because of the striped pattern it creates on the breast.

This technical innovation from the University of Iowa College of Medicine. This research was published in 1977.

This post describes a clever surgical "hack" designed to make one of the most tedious parts of breast reduction surgery faster, safer, and more precise.

How It Works

Instead of trying to remove the skin in one giant sheet, the surgeon breaks the task down:

1. The Stripes: The surgeon makes a series of parallel shallow cuts, about 1 cm apart, across the area to be removed. This creates long "strips" of skin, looking like zebra stripes.





2. The Grip: The surgeon grabs the end of one strip with forceps.





3. The 90-Degree Pull: By pulling the strip straight up (at a 90-degree angle), the tension is concentrated exactly where the knife needs to cut.

Why It Is Safer

The magic of this technique is in the traction. When the strip is pulled upward, the connective tissue stretches, allowing the surgeon to see exactly where the dermis begins and ends.

• Precision: The "point of maximum tension" guides the blade, ensuring the cut stays perfectly level.





• Efficiency: It eliminates the need for multiple assistants to stretch the breast, allowing the surgeon to work independently.





• Safety: By stabilizing the tissue strip-by-strip, there is less risk of accidentally diving too deep and cutting the blood supply.

The Debate: How Deep is Too Deep?

An interesting editorial note attached to the original paper raised a question: Does this technique remove too much dermis?

• Some experts argued that if the cut is too easy, it might be removing the superficial vessels along with the skin.





• However, clinical use suggests that as long as the deep "dermal plexus" remains, the nipple will survive and thrive.

Conclusion

The Zebra Technique is a classic example of surgical ingenuity. By turning a complex, two-person task into a simple, repetitive motion, Dr. McShane increased the speed and reliability of creating the "dermal pedicle"—the lifeline of the new breast.

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Breast Reduction Surgery Cost varies between individuals!

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Frequently Asked Questions (FAQ)

Q: Why is de-epithelialization necessary?

A: If the surgeon just buried normal skin under the breast tissue, the body would react to it, forming cysts or infection. Removing the top layer allows the tissue to heal together internally while keeping the blood supply attached.

Q: Does this leave "zebra stripes" on the final breast?

A: No. These strips are removed during the surgery. The "Zebra" name refers only to how the tissue looks during the procedure before it is discarded.

Q: Is this technique still used?

A: Yes, many surgeons use variations of the "strip" method today because it offers excellent control, especially when working without a large surgical team.

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Reference

• [1] McShane, Richard H. M.D. "Zebra Technique for 'De-Epithelialization' of Dermal Pedicles." Plastic and Reconstructive Surgery 60(1):p 128-130, July 1977.

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The Problem: Skin Cannot Hold Weight

Estimated reading time: 3 minutes

For decades, standard breast reductions relied on "dermal suspension." Essentially, surgeons used the skin itself to hold up the weight of the reshaped breast.

The problem? Skin is elastic—it stretches. When you use skin to support weight, it creates high tension on the incision lines.

• The Consequence: High tension leads to "hypertrophic" (thick, raised) scars. In traditional methods, these bad scars occurred in 50% to 55% of patients within 6 months.





• The Droop: Because the skin stretches, the lift often fails over time, leading to a recurrence of sagging.

The Solution: The Superficial Fascial System (SFS)

In April 1999, Dr. Ted Lockwood published a study in Plastic and Reconstructive Surgery introducing a powerful alternative. He argued that surgeons should anchor the breast not to the skin, but to the Superficial Fascial System (SFS).

What is the SFS?

The SFS is a distinct layer of connective tissue that lies just beneath the skin but is much stronger than the skin itself. It is the body's natural "casing."

The Lockwood Technique

Instead of sewing the skin tight, Dr. Lockwood used permanent (non-absorbable) sutures to lock the SFS layers together.

1. Internal Locking: The weight of the breast is supported by the fascia.





2. Tension-Free Skin: Because the fascia is holding the weight, the skin can be draped gently over the top without any tension.

The Results: A Massive Drop in Scarring

The study analyzed 109 patients (218 breasts) operated on in Kansas between 1993 and 1996. The results were dramatic:

• Traditional Methods: 50–55% rate of hypertrophic scarring.





• Lockwood SFS Technique: 3% rate of hypertrophic scarring.

By taking the tension off the skin, the scars remained thin, flat, and faint. Additionally, the "internal bra" created by the SFS suspension resulted in "longer-lasting contour results" that didn't bottom out as quickly as dermal suspension.

Conclusion

If you are worried about ugly scars or your breasts drooping again after surgery, the "fascial suspension" technique addresses the root cause of both. By using the body's own connective tissue strength rather than relying on stretchy skin, surgeons can deliver results that are stable, secure, and beautifully healed.

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Ask yourself “Who is the Best Plastic Surgeon Near Me?”.

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Breast Reduction Surgery Cost varies between individuals!

Contact us to know if you are a suitable candidate for Breast Reduction Surgery!

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Frequently Asked Questions (FAQ)

Q: Are permanent sutures dangerous inside the breast?

A: Generally, no. Permanent sutures in the SFS layer are standard in many body contouring procedures (like tummy tucks). They provide the long-term strength needed to resist gravity.

Q: Does this technique take longer to perform?

A: It may take slightly longer than a standard reduction because the surgeon must carefully identify and suture the specific fascial layers, but the long-term scar benefits are significant.

Q: Is this the same as an "Internal Bra" mesh?

A: Not exactly. "Internal Bra" mesh uses a foreign material (like GalaFLEX) to support the breast. The Lockwood technique uses your body's own natural tissue (fascia) to create that support, avoiding the risks of foreign objects.

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Reference

• [1] Lockwood, Ted M.D. "Reduction Mammaplasty and Mastopexy with Superficial Fascial System Suspension." Plastic and Reconstructive Surgery 103(5):p 1411-1420, April 1999.





• [2] Song, A.Y., et al. "Biomechanical Analysis of the Superficial Fascial System." Plastic and Reconstructive Surgery, 2006.

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• Female Breast Reduction
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• Natural Volume Without Implants: A New Brazilian Technique for Restoring Breast Volume in Breast Lift & Breast Reduction

The Discovery in Vienna

Before the late 90s, breast anatomy was often viewed simply as a mass of glands and fat. Surgeons knew where the blood vessels generally were, but the internal "architecture" was not fully mapped.

In April 1999, Dr. Elisabeth Würinger published a groundbreaking study in Plastic and Reconstructive Surgery based on her work at the Wilhelminenspital in Vienna, Austria. Through meticulous dissection of 20 female breasts, she discovered a distinct connective tissue structure that acts as a "suspension apparatus" for the breast.

This structure is now known globally as Würinger’s Septum.

What is the Ligamentous Suspension?

Dr. Würinger found that the breast is not just a loose bag of tissue. It has a constant, definable internal structure:

• The Horizontal Septum: A strong band of tissue that originates at the level of the 5th rib.





• The Curve: This septum curves upward, turning into vertical medial and lateral ligaments.





• The Superhighway: Most importantly, this septum acts as a "guide," carrying the main blood vessels and nerves directly to the nipple.

The Technique: Refined Central Pedicle

Using this new anatomical map, Dr. Würinger refined the Central Pedicle technique. Instead of relying on the skin to carry the blood supply (dermal pedicle), this method relies entirely on the internal ligaments.

1. Maximum Sensation & Safety

Because the septum contains the primary nerve supply, keeping it intact provides a "predictable and reliable" way to preserve nipple sensation. It also guarantees blood flow, making the surgery safe regardless of the patient's risk factors or the size of the reduction.

2. True Symmetry

The study revealed that the horizontal septum divides the breast into regular, measurable sections. Surgeons can use this septum as a built-in ruler, ensuring that the left breast matches the right breast internally, not just externally.

3. Better Shape, Smaller Scars

Because the blood supply comes from deep inside (the septum) rather than the skin, the surgeon does not need to leave a thick bridge of skin attached to the nipple. This allows for:

• Smaller Scars: The skin can be tightened more effectively.





• Better Projection: The ligaments maintain their "suspending function," acting like an internal bra to hold the shape long-term.

Conclusion

Dr. Würinger’s work proved that understanding the breast's "ligamentous suspension" allows for safer, more precise Breast Reduction surgery. For patients, this translates to a lower risk of complications, better nipple sensation, and a more natural, perky shape that lasts.

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Breast Reduction Surgery Cost varies between individuals!

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Frequently Asked Questions (FAQ)

Q: Is this technique used today?

A: Yes. The "Septum-Based" or "Würinger’s Septum" technique is considered one of the most anatomically sound methods in modern plastic surgery, used for both reductions and lifts.

Q: Does this help with very large breasts?

A: Absolutely. The study explicitly states that this approach allows for safe resections "irrespective of the amount of resection," making it ideal for patients with gigantomastia.

Q: Why does the septum matter for sensation?

A: The septum acts as a conduit (protective tunnel) for the anterior branch of the 4th lateral intercostal nerve, which provides the primary feeling to the nipple. If the septum is saved, the nerve is saved.

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Reference

• [1] Würinger, Elisabeth M.D. "Refinement of the Central Pedicle Breast Reduction by Application of the Ligamentous Suspension." Plastic and Reconstructive Surgery 103(5):p 1400-1410, April 1999.

The Study: A Solution from South Africa

In September 2010, plastic surgeons from the University of Stellenbosch (Bellville, South Africa) published a landmark study in Plastic and Reconstructive Surgery. Their goal was to address one of the most feared complications in breast surgery: nipple necrosis (tissue death).

After analyzing 106 consecutive patients (211 breasts) between 2001 and 2009, they proposed a technique that relies on a specific "anatomical highway" to keep the nipple safe.

The Anatomy: What is Würinger’s Septum?

To understand why this technique works, you must understand the anatomy of the breast.

• Würinger’s Septum: This is a horizontal band of connective tissue that runs through the breast.It acts like a "shelf" or a hammock supporting the breast tissue.





• The Highway: More importantly, this septum carries the nerves and blood vessels from the chest wall directly to the nipple.

Most traditional techniques cut through parts of this supply. The authors of this study argued that by preserving this specific ligament, surgeons can maintain a "dual" blood supply that is nearly bulletproof.

Würinger’s Septum to prevent Nipple Loss in Breast Reduction Surgery.

The Technique: The "Posteroinferomedial" Pedicle

The authors developed a pedicle (the bridge of tissue carrying the nipple) that captures blood from two distinct sources, making it exceptionally reliable.

1. The Medial Source (Internal Thoracic Artery)

By keeping the medial vertical ligament intact, the surgeon preserves the large perforating arteries (2nd, 3rd, and 4th) coming from the center of the chest.

2. The Inferior Source (Anterior Intercostal Arteries)

By keeping the horizontal septum intact, the surgeon captures the inferior mammary branches coming from the ribs.

This "Posteroinferomedial" approach ensures that even if one blood supply is weak, the other takes over, dramatically reducing the risk of the nipple dying.

Results: Versatility and Safety

The study showed that this technique is not only safe but also highly versatile.

• Shape: It provided good nipple projection and upper breast fullness.





• Flexibility: It can be used with almost any skin incision—whether "donut" (periareolar), "lollipop" (vertical), or "anchor" (inverted-T).





• Learning Curve: The authors noted that the technique is easy to learn for surgeons familiar with breast anatomy.

Conclusion

For patients with risk factors like smoking or very large breasts, blood supply is everything. The Posteroinferomedial Pedicle offers a surgical "insurance policy" by utilizing Würinger’s septum to double the blood flow to the nipple.

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Ask yourself “Who is the Best Plastic Surgeon Near Me?”.

Revera Clinic caters with the Best Plastic Surgeon in Hyderabad!

Breast Reduction Surgery Cost varies between individuals!

Contact us to know if you are a suitable candidate for Breast Reduction Surgery!

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Frequently Asked Questions (FAQ)

Q: Does this technique preserve nipple sensation?

A: Yes. Because Würinger’s septum carries the main nerves to the nipple alongside the arteries, preserving it typically results in excellent sensation retention.

Q: Is this technique used for breast lifts (mastopexy) too?

A: Yes. The study confirmed its safety for both reduction mammaplasty and mastopexy (lifts).

Q: Why is "dual blood supply" better?

A: Human anatomy varies.18 Some people have strong medial arteries, while others have strong inferior ones. Capturing both ensures the nipple survives regardless of your specific anatomy.

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References

• [1] van Deventer, Petrus V. M.B.Ch.B., M.Med.Sc.(Anat.), M.Med.; Graewe, Frank R. M.B.Ch.B., M.Med., Dr.med.¹⁹ "Enhancing Pedicle Safety in Mastopexy and Breast Reduction Procedures: The Posteroinferomedial Pedicle, Retaining the Medial Vertical Ligament of Würinger." Plastic and Reconstructive Surgery 126(3):p 786-793, September 2010.²⁰





• [2] Würinger, Elisabeth M.D., et al. "Nerve and Vessel Supplying Ligamentous Suspension of the Mammary Gland." Plastic and Reconstructive Surgery 101: 1486, 1998.²¹





• [3] Hamdi, Moustapha M.D., et al. "The Septum-Based Pedicle in Reduction Mammaplasty."²² Plastic and Reconstructive Surgery, 2009.

The Fear of the "Droop"

One of the biggest concerns patients have about breast reduction is: "Will they just sag again in a few years?"

In traditional Anchor (Wise Pattern) reductions, a phenomenon called pseudoptosis (or "bottoming out") is common. This happens when the breast tissue slides down the chest wall, stretching the lower skin and leaving the nipple looking too high.

However, a landmark study published in Plastic and Reconstructive Surgery confirms that the Vertical Scar (Lollipop) technique behaves very differently. In fact, it seems to defy gravity. It was conducted at USA and Canada. The Study was published in 2007.

The Anti Gravity Lift with Vertical Breast Reduction Surgery

The Study: 4 Years of "Settling"

Dr. Lista and Dr. Ahmad analyzed 49 women who underwent Vertical Scar Reduction Mammaplasty. They measured the breast position before surgery, 5 days after, and again 4 years later.

They wanted to answer two questions:

1. Does the bottom of the breast stretch out?





2. Does the nipple stay where we put it?

Discovery 1: The "Shrinking" Bottom

Contrary to the "bottoming out" seen in other techniques, the researchers found that the bottom of the breast (the inferior pole) actually tightened over time.

• The Data: The distance from the breast crease (inframammary fold) to the bottom of the nipple decreased by 0.4 cm over four years.





• The Result: Instead of sagging, the vertical technique relies on skin retraction that maintains a tight, perky lower breast shape for years.

Discovery 2: The Rising Nipple

This was the most surprising finding. In most surgeries, surgeons expect gravity to pull everything down. In the Vertical reduction, the nipple actually moved up.

• Post-Op Day 5: The nipple was found 1.3 cm higher than where it was marked on the skin before surgery.





• 4 Years Later: It remained 1.0 cm higher than the original markings.

This "upward migration" is unique to the way the vertical technique reshapes the internal tissue (coning), pushing the breast mound upward.

The Surgeon's Secret: "Marking High"

Because of this study, Dr. Lista changed the way he marks patients. To ensure the nipple lands in the perfect "sweet spot," he anticipates this upward movement.

• The Old Way: Marking the center of the nipple at the breast crease.





• The New Rule: Marking the superior border (top edge) of the nipple at the level of the breast crease.

By placing the nipple lower initially, it naturally rises into the perfect position as the breast heals and settles.

Conclusion

If you are looking for long-term projection and want to avoid the "bottomed out" look, the Vertical Scar technique has the data to back it up. Unlike other methods where gravity wins, this technique uses the skin's own elasticity to keep the breast lifted and compact for years after surgery.

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Ask yourself “Who is the Best Plastic Surgeon Near Me?”.

Revera Clinic caters with the Best Plastic Surgeon in Hyderabad!

Breast Reduction Surgery Cost varies between individuals!

Contact us to know if you are a suitable candidate for Breast Reduction Surgery!

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Frequently Asked Questions (FAQ)

Q: What is "Pseudoptosis"?

A: It is a condition where the breast tissue sags below the nipple, while the nipple itself remains high on the chest. It creates a "snoopy nose" deformity. This study proved that pseudoptosis does not occur with the vertical technique.

Q: Why does the vertical scar technique heal differently?

A: It relies on "coning" the tissue and allowing the skin to retract (shrink-wrap) around the new shape, rather than just cutting away skin and stitching it tight.

Q: Will my nipples look too low right after surgery?

A: They might! Because your surgeon knows the nipple will migrate upward by about 1 cm, they may intentionally place it slightly lower during the operation.

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References

• [1] Ahmad, Jamil M.D.; Lista, Frank M.D. "Vertical Scar Reduction Mammaplasty: The Fate of Nipple-Areola Complex Position and Inferior Pole Length." Plastic and Reconstructive Surgery 121(4):p 1084-1091, April 2008.





• [2] Hofmann, Albert K. M.D.; et al. "Breast Reduction: Modified 'Lejour Technique' in 500 Large Breasts." Plastic and Reconstructive Surgery 120(5):p 1095-1104, October 2007.