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Sir: We thank the authors for their comments on our updated technique and accompanying video in the article “Vertical Scar Reduction Mammaplasty.”1 In our experience, this technique has been effective in addressing both functional and aesthetic concerns of patients with symptomatic mammary hypertrophy. We believe that vertical scar reduction mammaplasty is an important technique for all plastic surgeons to be comfortable with when dealing with this patient population. However, it is important that we begin to dispel the perception that vertical scar breast reduction is a difficult procedure to learn and master—the learning curve is no longer than that of any other breast reduction technique. Where the “difficulty” in vertical scar breast reduction primarily lies is that the final shape of the breast on the operating room table is different than the final postoperative appearance. Once the surgeon is comfortable with this, vertical scar breast reduction is actually a simpler, safer, and more efficient approach to reduction mammaplasty.1 With regard to their question about marking the medial and lateral limbs of the vertical skin pattern, it is important to have the vertical pillars meet in the midline of the breast. This can be accomplished through medial and lateral displacement of the breast2 or by approximating the planned position of the medial and lateral pillars to ensure that they meet in the midline with a skin pinch.3 The width of the vertical resection is not as important as ensuring that the vertical pillars will meet in the midline, and it is important to err on the side of caution when marking the vertical limbs—avoid overresection, which can lead to poor inferior pole shape. Cases of breast asymmetry are more difficult with any breast reduction technique, not only the vertical scar pattern techniques. In these cases, it is up to the surgeon to determine whether there are differences in the volume or skin laxity of the breasts, and adjust the markings to account for these differences. With regard to their point about excess vertical scar length, we manage this by gathering the skin of the vertical scar with the four-point gathering box stitch technique.4 The absolute length of the scar itself is not as important as the breast shape. Lassus previously described measurements of the distance between the inferior border of the areola and the inframammary crease in aesthetically pleasing breasts that ranged from 4.5 to 10 cm,3 whereas other authors have shown good results in vertical reductions with distances of up to 12 cm.5 In addition, the length of the vertical scar does not increase, and actually may decrease, following vertical scar reduction mammaplasty.6 We believe that gathering of the vertical scar is important to shorten the vertical scar to within the “normal range” described by Lassus, instead of focusing on one particular number.3 Dog-ear formation at the inferior aspect of the vertical incision is managed prophylactically using multiple methods. As we describe in the marking of the inferior resection margin, the vertical limbs are brought together in the shape of a V instead of rounding them off as a U. The aforementioned skin gathering of the vertical limbs also helps to control dog-ear formation. Furthermore, subcutaneous resection at the level of the inframammary crease is an important part of our technique for management of inferior scar puckering/dog-ear formation. It is important to note that we have not found it necessary to perform any horizontal extension of the vertical scar, the so-called short inverted-T or “owl” incision, in our vertical scar reduction technique. Finally, to the point of limitations of the vertical scar technique in patients desiring a small postoperative breast size, this can be a difficult problem. However, in many cases, patients with larger breasts have a larger body habitus, and we therefore educate the patients about creating a postoperative breast size that is proportional to their body size and shape. We also encourage these patients to lose weight through diet and exercise before surgery if a smaller size is desired. However, in cases of extremely large breast size in a smaller patient, the vertical scar technique may not provide an adequate reduction. In these cases, an L-scar, short inverted-T, of full inverted-T resection pattern may be required. Our video is intended to simplify and demystify the vertical scar reduction mammaplasty technique, and we encourage all plastic surgeons to not only adopt this technique themselves but to educate their trainees in this technique to avoid making vertical scar reduction mammaplasty seem overly difficult or complex. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. The authors received no financial support for the research, authorship, and publication of this communication. Frank Lista, M.D. The Plastic Surgery Clinic Mississauga, Ontario, and Division of Plastic and Reconstructive Surgery Department of Surgery University of Toronto Toronto, Ontario, Canada Ryan E. Austin, M.D. Division of Plastic and Reconstructive Surgery Department of Surgery University of Toronto Toronto, Ontario, Canada Yashoda Singh School of Medicine Royal College of Surgeons in Ireland Dublin, Ireland Jamil Ahmad, M.D. The Plastic Surgery Clinic Mississauga, Ontario, and Division of Plastic and Reconstructive Surgery Department of Surgery University of Toronto Toronto, Ontario, Canada

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