Areolar Vertical Approach (AVA) Mammaplasty

Areolar vertical approach (AVA) mammaplasty:

Lejour’s technique evolution

Carlos E. Van Thienen, MD

Clınica Van Thienen, Chacabuco 250, San Isidro 1642, Buenos Aires, Argentina

During the past few decades, periareolar and ver-

tical scar mammaplasties were introduced as a novel

way of approaching breast reductions. Many surgeons

worldwide are still reluctant to apply them as a

standard. The surgeon faced with a breast reduction

case needs to consider three fundamental aspects.

Nipple areola pedicle

The options are: (1) superior, (2) inferior, (3)

medial, (4) lateral, and (5) combined. The goal here

is to select the pedicle that can assure an adequate and

reliable blood supply and innervation when the nipple

areola is relocated in the new position. All of these

pedicles are satisfactory for achieving these goals.

Parenchyma resections

The surgeon needs to keep in mind that the long-

term shape of the breast will depend mainly on the

reconfiguration of the parenchyma, not on the skin

closure. Therefore, the glandular and adipose tissue

can be treated independently from the skin. The

breast reduction technique should not be the deciding

factor of how the skin incision is made.

Scar

There are three possible areas to consider: (1)

areola, (2) lower pole/vertical or oblique, and (3)

submammary sulcus (total from one side to the other,

short in the middle portion or lateral).

We know that the areola region is very adequate

because it offers a good scar for the kind of design that

is needed; ie, naturally irregular on its borders,

dynamic with constriction or dilatations, and pigented.

The vertical scar is usually under tension in its

postoperative healing period, with a very low tend-

ency to pathologic scarring (it is under physiological

scar presotherapy) and is usually very acceptable. The

submammary scar is placed on transitional skin

between the abdomen and the chest wall, ie, thicker,

(the end portions medial and lateral are the most

visible). Therefore, the incidence of pathologic scar-

ring is increased, which is obviously less acceptable

by the patient.

The surgeon should consider which approach will

be the best for breast tissue reduction, with the best

cosmetic result. My preferences are: (1) for nipple

areola pedicle (NAP), the superior pedicle, based on

dermocutaneous angiosomas of the chest wall and the

understanding that it provides the necessary versati-

lity to do the breast reduction, (2) for parenchyma

resection, selection of the pedicle usually determines

the kind of parenchyma resections that can be per-

formed to reduce and reshape the breast, and (3) for

scars, I prefer the areolar and the vertical areas of

the breast skin where the final scar will be located

after compensating for differences between the ideal

measurements of the final scar and the amount of

redundant skin. I believe that resections of the central

lower pole, lateral quadrants, and base of the disk

provide the best results.

I have learned to keep an open mind in dealing

with breast reductions. I started with the old-fash-

ioned inverted-T scar technique (superior pedicle)

0094-1298/02/$ – see front matter D 2002, Elsevier Science (USA). All rights reserved.

PII: S0094 -1298 (02 )00009 -3

E-mail address: [email protected]

(C.E. Van Thienen).

Clin Plastic Surg 29 (2002) 365–377

as described by Pitanguy [1] but changed my

approach to the skin management and final scar

technique described by Lejour [2–5]. The skin in-

cision provides access to the glandular tissue that

needs to be reduced; it is not the support of breast

reshaping. In all cases, my goal is to select a tech-

nique that provides: (1) adequate long-term breast

shape and contour, (2) less noticeable scars, and (3)

minimal complications.

Patient marking

The patient should stand up before surgery and

premedication. She needs to move and shake her

arms and shoulders in order to be relaxed. Her initials

and age are written on the left side of her chest.

The markings have some fixed points as refer-

ences but do not follow a standard pattern. This is a

dynamic and freehand delineation following specific

steps. Measurements are always taken afterward only

as a control. It is very important to learn to move, see,

and draw on the breast skin, thinking symmetrically

and how much tissue will be removed to obtain the

desired result. With a non-permanent black pen, the

surgeon draws the following: (1) midsternal line,

from the sternal notch to the abdominal skin, (2)

clavicle and mid-clavicular point (8–11 cm), and (3)

the submammary fold.

Measurements from the sternal notch to the nip-

ples are taken, and written between brackets on each

side of the chest skin (Figs. 1–3). Then the breast

meridian is delineated, projecting perpendicularly and

down the side from the mid-clavicular point to join

and cross the submammary sulcus to obtain another

important reference point (point S, sulcus: 9–12 cm

from midsternal line).

From this point (Fig. 4), the middle finger is placed

perpendicular to the sulcus. Hanging the breast on the

palmar side of the hand, project the top of the finger in

a upward direction, always vertically. Then apply the

other hand to the breast skin and, with the same

opposite finger, try to touch or sense (like a breast

Fig. 1. Measurements from sternal notch to nipples are taken

and written between brakets.

Fig. 2. Sternal notch, clavicula and midclavicular point

are marked.

Fig. 3. Submammary sulcus.

Fig. 4. The prosection of the breast meridian crossing the

submammary sulcus to obtain the ‘‘S’’ point.

C.E. Van Thienen / Clin Plastic Surg 29 (2002) 365–377366

sandwich) where the tip of both middle fingers

must meet. This point is the future superior limit of

the newly located areola (point A, areola: 18–22 cm

from the sternal notch, and 10–14 cm to the mid-

sternal line).

With point A (areolar) as the most cephalic limit

and point S (sulcus) as the caudal limit, then delineate

the lateral markings (Fig. 5). As Lejour explained so

well, the breast is gently mobilized laterally and with

upward rotation, the vertical line is drawn (meridian,

from mid-clavicular mark to point S. The same

maneuver is performed medially. Next, two vertical

lines (internal and external) that touch at point S but

are divergent in the mid-portion and joint, mark

point A in an ill-defined fashion.

At this point, the limits of the areola must be

defined in its caudal (6 o’clock) portion and vertical

cephalic limit, or point V (Figs. 6,7). The skin is

pinched from the lateral markings at a point where it

forms a circumference similar to the future areola-

nipple area. Where the fingers meet is the new point

(vertical origin, and in > < fashion).

The final steps are as follows: (1) delineate the

areola (to do this between point A (areolar) and point V,

> < vertical, a slightly curved or elliptical line is

drawn; usually, the distance of each arm is not more

than 8 cm) (Fig. 8), and (2) delineate the lower limit of

the vertical line as a curved-shape line between the two

verticals, 1–2 cm above point S (Fig. 9).

At this step, both breasts are gently pushed

together toward the midline, for checking that the

medial portion of the markings touch (Fig. 10–12).

Stand back some distance from the patient and

observe all your marks in order to detect asymmetries

and, as a final control, take new measurements. In

this way, there is no need to touch the markings any

more. Do the final control with the patient supine on

the preanesthesic table. As a curiosity, in my experi-

ence, what I do with the patient in the standing

position is enough, and it is unlikely that I will need

to change the original marks. This is the planning

stage of the surgical skin approach to breast reduc-

Fig. 5. Marking the new position for the areola. The

‘‘A’’ point.

Fig. 6. Mobilization lateral and upward to delineate the

lateral external limit of skin and tissue resection.

Fig. 7. Performing the same maneuver for the medial limit of

skin and tissue resection.

Fig. 8. Defining the ‘‘V’’ points by pinching both sides of

lateral marks.

C.E. Van Thienen / Clin Plastic Surg 29 (2002) 365–377 367

tion, and the way to obtain a final periareolar and

vertical closure. Photos are then taken.

Surgical technique

The patient is positioned in a 30� semi-seated

fashion, arms abducted 90�; preparation and draping

are performed in the usual sterile routine. General

anesthesia is delivered by endotracheal intubation.

The surgeon stands on the preferred side of the table

and operates on both breasts from the same side.

Skin and breast approach

The breast is retracted upward, with the surgeon

grasping the nipple areolar skin held by the assist-

ant. The base is constricted with a plastic auto-fixed

band in order to obtain enough tension to slightly

incise the skin with a #24 knife blade. First, the intra-

areolar perinipple skin is incised in a circular fashion

4–4.5 cm diameter, and then all the skin marks are

incised in order to avoid demarcation.

For the superior areolar nipple pedicle, deepithelia-

lization of the entire area is performed where the areola

nipple (AN) complex will be repositioned, extending

the inferior limits below the points V (> < ) 2 or 3 cm

below the inferior limit of the areola. This will preserve

a good areolar subdermal neurovascular blood supply.

Tension is released and, with two forceps, the

assistant holds the breast placed on each internal

deepithelialized side of the points V (> < ).

Projection of the inferior pole is obtained by

pressure on the upper pole by holding the forceps

on the chest wall with a gauze pad that serves as

hemostatic for the deepithelialized area as well. In

this way, incision of the lower half of the vertical

lines up to the curved area (1–2 cm above point S), is

made, and surgery to the breast and adipose tissue is

performed, first from the lower portion subdermally

to create thinner flaps at this time, leaving not too

much adipose tissue attached to the dermis, and

Fig. 9. The lateral marks meet in a curve shaped line 1 or

2 cm. above the ‘‘S’’ point.

Fig. 10. The future place of the areola, between ‘‘A’’ point

and both medial and external ‘‘V’’ points.

Fig. 11. Final appearance of markings for the future place of

breast sulcus.

Fig. 12. Last view of breast markings after surgery.


perpendicularly above the anatomical submammary

sulcus. The submammary sulcus is not touched.

The dissection continues down to the pectoralis

fascia in order to develop the retromammary space

laterally and centrally upward (Fig. 15). How far? (1)

medially, not too much; always keep in mind the

blood supply and consider that the thickness of breast

tissue at this location is usually insignificant, (2)

laterally, enough to gain access to the axillary and

lateral tissue excess that will be resected, and (3)

upward, as far as the areolar nipple complex will

be relocated.

Parenchymal resection

Be conservative with the neurovascular breast

tissue and skin supply. Once the gland is dissected

from the pectoralis fascia, I introduce my hand and

hang it like a disk. The assistant changes the direction

of traction toward the ceiling and, in this way, a more

conical shape is obtained. As the superior pedicle

for the areolar nipple flap has been selected, most of

the excess tissue must be removed from the lower

pole. I incise the breast tissue perpendicular to the

chest wall, from V to S (> < ), until I reach the palm

of my hand on both the lateral and medial sides.

With this maneuver, I have freed up the central

inferior pole and created two pillars, one lateral and

the other medial.

The amount of breast tissue that will be resected,

according to the preliminary resection strategy, will

depend on each case. The following principles, how-

ever, must be followed: (1) the central lower pole can

be resected as needed, preserving the subdermal

vascular network of the areolar nipple; this is per-

formed in an infundibular fashion, ie, that resection

from the base is wide and thick upward, and retro-

mamillar and cephalic to point A, is thinner and

narrower, (2) the lateral pillar and its axillary projec-

tion is resected from the base or deep plane of the

parenchyma, (3) the medial pillar is resected from the

base, with the surgeon also being very conservative in

the amount of tissue removed (Figs. 13,14), and (4)the

superior-based dermoglandular areolar nipple flap

must be released from the lateral and medial pillar,

enough to achieve an easy, no-tension transposition.

Fig. 13. Resection of the breast tissue from medial side

Fig. 14. The dissection continues down to the pectoralis

fascia.

Fig. 15. The medial and lateral pillars ready to be sutured.

Fig. 16. The dermocutaneous flap for the nipple-areola

complex.


Preserving the neurovascular blood supply maintains

viability. The base should be as wide as possible and

as thin as needed. This is an axial dermocutaneous

flap according to its vascular anatomy (Fig. 16).

All the removed tissue is weighed, asymmetries

corrected, and the specimen sent to the pathology

department (Fig. 15). Meticulous hemostasia is per-

formed. The surgeon must decide how much tissue to

remove in each individual case, but to my mind, the

principle of ‘‘Less is more’’ applies here, especially

from the medial and upper portion of the gland.

Reshaping and suturing the breast mound

The first stitch is on point A, joining the 12 o’clock

point of the areolar border (Fig. 17–19). The second is

on points V (> < ). At this point, the assistant holds the

breast toward the ceiling with forceps, and the pillars

tend to approximate. Looking from the top (point V)

to the base, one can measure the length of the pillars

and resect more at its foots in a triangular shape in

order to obtain a more curved shape at the base.

Sutures from deep to superficial are placed on the

parenchymal tissue, achieving the desired conical

shape and avoiding dead spaces. All sutures are ny-

lon monofilament.

Sutures to the chest wall or pectoralis fascia are not

the key for long-term results in the shape. Theymust be

used only with the aim of reducing tension on the skin

suture. The original Lejour technique was one stitch

deep in the areolar pedicle to the pectoralis fascia,

upward as the dissection was done, with some down-

ward retraction of the areola and fullness of the upper

pole. I do not use this method if it creates such defects.

On the other hand, I use one stitch on the point

where the pillars are joined at the base, including

chest wall tissue. The intention is to avoid dead space

when draping the overlaying skin at this point.

Skin redraping and closure

In periareolar vertical mammaplasty techniques,

the excess skin must be redraped either on the areolar

region or the vertical portion. In the areolar vertical

mammaplasty with superior pedicle as described by

Fig. 17. Undermined the lower portion of the breast to relax

skin tension.

Fig. 18. Sutures are placed from deep to superficial breast

parenchyma.

Fig. 19. Using one stitch to avoid dead space in the lower

limit including chest wall.

Fig. 20. Length and wrinkles of vertical scar.


Lejour, most compensation is on the vertical portion

of the surgical approach.

For areolar closure, begin placing 5-0 nylon

intradermal single stitches around the areola on

the 12-6-9-3-2-5-7-10-o’clock positions (in this

order). All the stitches must be placed without

tension. This is followed by 4-0 nylon subcuticular

running sutures.

For vertical closure, the goal is to create a max-

imum 8-cm final vertical scar from the excess skin

that is usually 12 cm or more. This is achieved by

Fig. 21. 4 cm. diameter obtained for the areola.

Fig 22. Tapes placed over the scars and drains.

Fig 23. Adhesive elastic tape with gentle compression over

the breasts.


Fig. 24. (A, C, E, G): Preoperative pictures of a 35 year old patient with mild breast hypertrophy. (B, D, F, H): 8 month

postoperative pictures from the same patient.


Fig. 25. (A, C, E, G): Preoperative pictures of a 20 year old patient with moderate breast hypertrophy. (B, D, F, H): 6 month



Fig. 26. (A, C, E, G): Preoperative pictures of a 17 year old patient with severe breast hypertrophy. (B, D, F, H): 1 year



placing several subdermal pursestring stiches with

3-0 nylon. Usually, 3–4 stitches are required. Prior to

placement of stitches, subcutaneous dissection of the

skin is performed as needed to release tension on the

suture; this creates multiple fine wrinkles. The purse-

string stitches are placed from the base to the top.

The first one is placed above point S. This stitch is

the most artistic and difficult to explain, but on the

curved shape of this area, a pursestring stitch should

be deep on the hypodermis, including the glandular

tissue, without too much tension in placement. Also,

eversion of the cuticular borders and wrinkles is

critical. Avoid leaving superficial skin inverted

because it dilates the scar.

The wrinkles created are going to disappear in the

postoperative period (Figs. 20,21). Finally, subcutic-

ular 4-0 nylon running sutures are placed.

If any tension is placed on the skin closure, the

shape of the breast could change. At this time,

remember that during patient marking all the lateral

movements of the breast must be gentle because if the

skin is stretched and wider marks are made, skin

resection will be excessive and compromise the final

result. Additionally, liposuction can be done in order

to refine little details of the final shape. This is

sometimes necessary in obese patients or in fatty

breasts. In my experience, I do not routinely need

to use it. The skin only redrapes the obtained par-

enchymal shape, contour, and volume.

Drains and dressing

Percutaneous tube drains are routinely placed and

opened to gauze integrated to the final dressing. The

suture lines are covered with micropore tape. Adhes-

ive elastic tape is placed over the breast with gentle

pressure (Figs. 22,23).

Results

From April 1991 to June 2000, I performed

240 breast reductions using the Areolar Vertical Ap-

proach (AVA) mammaplasty evolved from the original

Lejour Vertical mammaplasty (Figs. 22,23). The aver-

age age was 34.6 years, ranging from 16 to 68 years of

age. The average resection weight was 372 g per

breast, ranging from 120 g to 1250 g per breast.

The distribution on the different grades of hyper-

trophy was classified according to the amount of tis-

sue resected: (1) less than 200 g per breast: 84 cases

(35%), (2) 200–500 g per breast: 101 cases (42.08%),

and (3) more than 500 g per breast: 55 cases (22.92%).

The maximum in this series was 1250 g per breast.

The maximum nipple areolar transposition was

33 cm from the sternal notch to the nipple, without

vascular damage: (Fig. 24A–H) less than 200 g,

(Fig. 25A–H) 200–500 g, and (Fig. 26A–H) more

than 500 g.

Complications

The incidence of complications was very low and

was related to wound healing delay (3: 240). There

have been no cases of nipple areolar necrosis, infec-

tion, wound dehiscence, or hematoma. Changes in

sensitivity did not seem to differ from other classic

techniques. Loss of pigentation and enlargement of

the scar were seen only in a few patients.

Discussion

Breast reduction techniques evolved from the

beginning of the twentieth century until today. From

inverted-T scars to ‘‘periareolar only’’ scars, many

surgeons have made efforts to reduce visible scars on

the breast area. For small reductions or mastopexies,

periareolar and vertical-added scars were reported

earlier [6–12]. Blood supply to the areola and skin

retraction were well documented by Emil Scwarz-

mann in 1930 in a magistral article [13,14].

Inverted-T techniques based on the safe areolar

pedicle evolved from this principle [1,15–19] as dif-

ferent approaches to positioning the dermoglandular

flap of the nipple areola. They also defined the strategy

of breast parenchymal resection. But one principle was

still always present. Skin and breast parenchyma were

handled together in order to obtain good shaping.

Satisfactory intraoperative and long-term results were

obtained, leaving a nonaesthetic submammary scar

with its lateral and medial projections that sometimes

leads to pathological scarring (higher incidence than

the areolar and vertical areas).

Attempts to reduce scars for most breast reduc-

tions (medium and large hypertrophies) were done

with major emphasis during the 1980s, mostly by

surgeons from France, Brazil, and Belgium [2,20–

37]. The common objective was a change in the

approach to breast reductions. The skin can be used

as a surgical approach and final scar independently

from the treatment of the parenchyma, preserving a

safe and reliable blood supply to all components.

Suturing of the gland has also proven to be an

important step in reshaping.

Most reported periareolar and vertical techniques

used superior pedicles, and this determined the type

of parenchymal resections needed to be performed.

This is why I think it was so difficult to understand

these approaches, particularly for the surgeons trained

with the inferior pedicle technique [15,38–46]. A


recent report from the United States describes the

combination of the most popular technique (inferior

pedicle) with a finer interpretation of the periareolar

vertical closure scar [47].

I believe that all efforts should lead in the di-

rection of ‘‘making it easy.’’ Treat the parenchyma,

and choose the areolar pedicle as desired or learned.

Use the skin marks that you obtain in a nonstandard

fashion; this is a more dynamic and artistic approach

that is easy to perform. Obviously, standard patterns

can be developed [48], but it is not the essence of this

approach. Skin closure needs to be considerd a

redraping of the breast parenchyma. Gathering the

excess skin with pursestring stitches on the areolar

area or in the vertical portion creates wrinkles. Intra-

operative wrinkles should not be of concern because

they will disappear, and the benefits of a shorter and

more aesthetic scar outweigh this consideration.

Twenty first century breast surgery is in our

hands, including its creative and artistic boundaries.

No chips or high technology can do for us.

Summary

The areolar-vertical approach (AVA) mammma-

plasty, derived from the Vertical Mammaplasty

described by Lejour, offers us the opportunity to

achieve good cosmetic results in breast reduction even

in larger hypertrophies and makes it available to all

patients. In marking, the skin there are certain fixed

landmarks, but the final skin design is obtained by

dynamic maneuvers (points A, V, and S). They do not

follow a rigid pattern. This technique is based on the

superior areolar pedicle and parenchymal resection,

mostly from the central-lower pole. Shape and final

contour rely on breast parechymal sutures and the

gathering of excess skin mainly on the vertical portion

of the scar. Complications are minimal; changes of

sensitivity and function do not differ from those found

with classic techniques [49]. Finally, it seems that with

this technique, the rate of complications is not related

to the areolar-vertical approach, primarily because the

vascular blood supply is equal to or more reliable than

other superior pedicle techniques. Long-term results,

symmetries, aesthetic scars, and patient satisfaction

encourage me to continue with this procedure.

Acknowledgments

The author would like to thank Drs. Emilio

Quesada and Ignacio Goyenechea for their assistance

in manuscript preparation, and Drs. Gabriel Bouzo

and Guillermo Garay for the compilation of revised

patient data.

References

[1] Pitanguy I. Surgical treatment of breast hypertrophy.

Br J Plast Surg 1967;20:78.

[2] Lejour M, Abboud M. Vertical mammaplasty without

inframammary scar and with liposuction. Perspect

Plast Surg 1990;4(2):67.

[3] Lejour M. Vertical mammaplasty and liposuction of the

breast. Plast Reconstr Surg 1994;94(1):100–14.

[4] Lejour M. Vertical mammaplasty as secondary surgery

after other technique. Aesthetic Plast Surg 1997;21(6):

403–7.

[5] Lejour M. Vertical mammaplasty and liposuction. Qua-

lity Medical Publishing, Inc; St. Louis, Missouri 1994.

[6] Abboud LM, Declety M, Kertesz AP. Reduction des

cicatrices de plastie mammaire: de l’ancre courte a la

verticale. Ann Chir Plast Esth 1989;35:369.

[7] Arie J. Una nueva tecnica de mastoplastıa. Rev Lati-

noam Cir Plast 1957;3:23.

[8] Dartigues M. Les anomalies du sein en dehors des

hypertrophies et des prolapsus. Bull Mem Soc Med

Paris 1935;139:575.

[9] Dufourmentel C, Mouly R. Developpements recents de

la plastie mammaire par la methode oblique laterale.

Ann Chir Plast 1965;10(4):227–41.

[10] Kraske H. Die operation der atrophischen und hyper-

trophischen hangebrust Munch. Med.Wschr 1923;

70:672.

[11] Lexer E. Hypertrophie beider mammae. Munchen Med

Wochenschr 1912;59:1702.

[12] Lexer H. Zur operation der mammahypertrophie und

der hangebrust. Dtsch Med Wochenschr 1925;51:26.

[13] Schwarzmann E. Die technik der mammaplastik. Chi-

rurgie 1930;2:932.

[14] Schwarzmann E. The technique of mammoplasty. Plast

Reconstr Surg 1977;59:107–12.

[15] Skoog T. A technique of breast reduction. Acta Chir

Scand 1963;126:453–65.

[16] Strombeck JO. Report of a new technique based on the

two pedicle procedure. Br J Plast Surg 1960;13:79.

[17] Strombeck JO. Macromastia in woman and its surgical

treatment. A clinical study based in 1042 cases. Acta

Chir Scand 1964;(Suppl 341).

[18] Strombeck JO. Reduction mammaplasty. Surg Clin

Amer 1971;51:453.

[19] Wise RJ. Treatment of breast hypertrophy. Clin Plast

Surg 1976;3:289.

[20] Benelli L. Technique de plastie mammaire: le ‘‘round

bloc. Rev Fr Chir Esthet 1988;50:7.

[21] Benelli L. A new Periareolar mammoplasty: round

block technique. Aesthetic Plast Surg 1990;14:99.

[22] Bustos RA. Periareolar mammoplasty with silicone sup-

porting lamina. Plast Reconstr Surg 1992;89:646–57.

[23] Felicio Y. Periareolar reduction mammoplasty. Plast.

Reconstr. Surg. 1991;88:789.


[24] Goes JCS. Periareolar mammoplasty: double skin tech-

nique with application of polyglactine or mixed mesh.

Plast Reconstr Surg 1996;97:959.

[25] Juri J, et al. Vertical mammoplasty. Ann Plast Surg

1982;9:298.

[26] Lassus C. A technique for breast reduction. Int J Surg

1970;53:69.

[27] Lassus C. New refinements in vertical mammaplasty.

Chir Plast 1981;6:81.

[28] Lassus C. Reduction mammaplasty with short infra-

mammary scars. Plast Reconstr Surg 1986;77:680–1.

[29] Lassus C. An all-season mammaplasty. Aesthetic Plast

Surg 1986;10:9–15.

[30] Lassus C. Breast reduction: evolution of a technique

a single vertical scar. Aesthetic Plast Surg 1987;11:

107–12.

[31] Lassus C. A 30 year experience with vertical mamma-

plasty. Plast Reconstr Surg 1996;97:373–80.

[32] Marchac D, de Olarte G. Reduction mammaplasty and

correction of ptosis with a short inframammary scar.


[33] Marchac D, Sagher U. Mammaplasty with a short ho-

rizontal scar. Evaluation and results after 9 years. Clin

Plast Surg 1988;15:627.

[34] Peixoto G. Reduction mammaplasty: a personal tech-

nique. Plast Reconstr Surg 1980;65:217.

[35] Peixoto G. Reduction mamoplasty. Aesthetic Plast.

Surg. 1984;8:231.

[36] Perenteau JM, Regnault P. The Regnault ’’B’’ tech-

nique in mastopexy and breast reduction: A 12 years

review. Aesthetic Plast Surg 1990;4:67.

[37] Regnault P. Reduction mammaplasty by the B tech-

nique. Plast Reconstr Surg 1974;53:19.

[38] Courtis EH, Goldwyn RM. A reduction mammaplasty

by the inferior pedicle technique. An alternative to free

nipple and areola grafting for severe macromastia and

extreme ptosis. Plast Reconstr Surg 1980;66:646.

[39] Freiberg A, Boyd JB. Reduction mammaplasty: a com-

parison between the Robbins and Pontes techniques.


[40] Goldwyn RM. Reduction mammaplasty. Boston: Little,

Brown, and Co.; 1990.

[41] Hester TR, Bostwick J, Miller L, Cunningham SJ.

Breast reduction utilizing the maximally vascularized

central breast pedicle. Plast Reconstr Surg 1985;

76:890.

[42] Mandrekas AD, Zambacos GJ, Anastasopoulos A,

Hapsas DA. Reduction mammaplasty with the inferior

pedicle technique: early and late complications in

371 patients. Br J Plast Surg 1996;49:442.

[43] McKissock PK. Reduction mammoplasty with vertical

dermal flap. Plast Reconstr Surg 1972;49:245.

[44] Robbins T. A reduction mammoplasty with the areola-

nipple based on an inferior dermal pedicle. Plast Re-

constr Surg 1977;59:64.

[45] Wallace WH, et al. Reduction mammaplasty using

the inferior pedicle technique. Ann Plast Surg 1998;

40:235.

[46] Weiner D, et al. A single dermal, pedicle for nipple

transportation in subcutaneous mastectomy, reduction

mammoplasty, or mastopexy. Plast Reconstr Surg

1973;51:115.

[47] Hammond D. Short scar periareolar inferior pedicle

reduction (SPAIR) mammaplasty. Plast Reconstr Surg

1999;103:890–901.

[48] Paloma V, Samper A, Sanz J. A simple device for

marking the areola in Lejour’s mammaplasty. Plast

Reconstr Surg 1998;102(6):2134–38.

[49] Farina M, et al. Inervation of the nipple areola com-

plex. Plast Reconstr Surg 1980;66:497–501.


Areolar Vertical Approach (AVA) Mammaplasty

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