The 5 D’s to Dunk the Dog: A Retrospective Clinical Review to Prevent Dog-Ear Contour Abnormalities in Vertical Breast Reductions and Breast Lifts
Abstract
Background. In 2020, reduction mammoplasties and mastopexies comprised 34.2% of all breast surgeries performed by plastic surgeons. Various approaches for the skin incision of these procedures have been described. The vertical pattern has become an increasingly popular option due to its lower scar burden. However, it is prone to dog-ear formation along the caudal aspect of the incision. Herein, we describe 5 technical steps to eliminate the dog-ear in patients undergoing vertical mammoplasties.
Methods. A retrospective chart review was performed on all patients who underwent vertical breast reduction and mastopexy between the years 2008 and 2020 performed by the senior author. The 5 steps employed in eliminating the dog-ear are delineated and depicted pictorially.
Results. A total of 58 patients and 89 breasts were operated upon. A majority of 66.6% were Caucasian, 33.3% were African American, and 1 patient was of Hispanic descent. The mean age was 53.2 years (19-73 years), and average BMI was 31.5 kg/m2 (21.3-42.7 kg/m2). The average resection weights for reduction and mastopexy patients were 479 grams (100-1500 grams) and 58.1 grams (18-100 grams), respectively. Mean follow-up was 10.5 months (1-35 months). Only one patient developed a dog-ear (1.7%) in bilateral breasts (2.2%); however, the patient did not request a revision. Our revision rate over 13 years remained at 0%.
Conclusions. Utilizing these 5 technical steps reduces the risk of dog-ear deformity and thereby diminishes the overall need for revisional surgery in patients undergoing short scar vertical mammoplasties.
Introduction
Reduction mammoplasty is a procedure that embodies plastic surgery, combining fundamental aspects of both aesthetic and reconstructive breast surgery. It is an increasingly common operation, with over 33,000 and 63,000 procedures performed for aesthetic and reconstructive reasons in women in 2020, respectively.1 Multiple variations of this procedure have been described, varying in skin incision and pedicle choice. The inverted-T Wise, vertical, periareolar, L-shaped, and J-shaped patterns are among some of the skin incisions described.2 While each has its own inherent indications and distinct advantages, the scope of this paper is the vertical technique, which can be applied to both breast reductions and mastopexies.
The vertical mammoplasty can be traced to Lötsch and Dartigues in the 1920s.3 This approach has since been refined by many, including Lassus, LeJour, Beer,4 and Hall-Findlay.5 The vertical technique is especially useful in smaller reductions and in patients with lesser degrees of ptosis.2 This approach confers several advantages, including obviation of the inframammary scar and improved initial shape, projection, and longevity.2,5
One distinct disadvantage associated with vertical mammoplasty is an increased incidence of dog-ears, which result from excess skin and underlying tissue bulk that create a conical-like deformity that can be visible protruding anteriorly compared with the natural body/skin contour at the end of a wound. This outcome may be associated with the technique’s steep learning curve and lack of technical familiarity among surgeons.5 Various techniques have been described for both prevention and management of dog-ears; however, these often require lengthening of the incision in the horizontal plane.6 Herein are described 5 reproducible technical steps developed by the senior author to prevent dog-ear occurrence and minimize revision rates. Further, the authors present their clinical experience with a 13-year retrospective review of patients who underwent vertical mammoplasty with this technique.
Methods
Data Source and Collection
A retrospective chart review was performed on all patients who underwent a vertical scar reduction or mastopexy from 2008 to 2020 at the University of Louisville, Louisville, Kentucky. All patients who underwent unilateral and bilateral breast reductions or mastopexy procedures utilizing the vertical technique were included in the study. In all patients, a superior or superomedial pedicle was utilized. Patient demographics including age, sex, ethnicity, and body mass index (BMI) were obtained. Clinical factors identified included resection volume, patient follow-up, and dog-ear revision rate. The senior author used his clinical judgment during the follow-up visits to determine if a dog-ear was present. Additionally, the documentation included any reports of dissatisfaction the patient may have had or requests for revision. Follow-up was recorded based upon each patient’s most recent clinic visit. All analyses were performed on a per-breast basis. The study was approved by the Institutional Review Board at the University of Louisville. The senior author developed the five-step “dunking the dog-ear” technique and performed all operations with the assistance of plastic surgery residents.
Preoperative Markings
Each patient was marked preoperatively in the upright position. The meridian of both the chest (sternal notch to midpoint of the costal margin) and the breasts (clavicle to inframammary fold [IMF]) was initially marked. Utilizing a medial and lateral breast sweep, the vertical limbs were marked, thereby determining the total horizontal component (width of the vertical skin excision). The superior-most aspect of the vertical incision was marked at the level of the IMF to guide marking of the nipple-areola complex (NAC). Once the superior, lateral, and medial aspects of the skin excision were marked, attention was focused on preventing a dog-ear.
The 5-step “Dunking the Dog-ear” Technique
The first step was placement of the inferior skin margin 2 cm above the IMF (Figure 1), which correlates with placement of the NAC 2 to 3 cm above the level of the IMF (Table 1). Intraoperatively, tumescent fluid was infiltrated into the tissue to be excised to both aid in hemostasis and increase overall breast tissue turgor to assist in resection and de-epithelization of the pedicle, respectively. The skin around the NAC and overlying the pedicle was de-epithelialized, and the vertical limbs were incised. The breast tissue inferior to the pedicle was excised, both within the horizontal aspect of the vertical limbs, as well as medial and lateral to the limbs, down to the level of the IMF.
The second step was lipectomy of the inferior skin flap. The central inferior skin flap was “de-fatted” (freed of subcutaneous fat), leaving nearly transparent dermis inferiorly to the IMF (Figure 2). Steps 1 and 2 are demonstrated in Video 1. The pedicle was then carved out, mindful to avoid injuring the laterally based sensory cutaneous nerves to the nipple, and shaped and positioned appropriately.
The third step was drain placement. A 19-French Blake drain was placed under the inferior pole skin to obliterate any dead space created by aggressive inferior skin flap lipectomy (Figure 3).
The fourth step was the deep dermal closure of the vertical scar, starting at least 2 cm superior to the caudal margin of the incision. By avoiding deep dermal approximation in the inferior 2 cm of the incision, puckering in the inferior apex was prevented (Figure 4). During closure, a single hook was placed at the inferior end of the wound to keep the incision on stretch, allowing accurate marking of the midpoint. The dermis was closed using 2-0 polydioxanone monofilament sutures in an interrupted fashion.
The fifth step of the dog-ear elimination technique was the subcuticular closure. This running subcuticular closure began with a small bite at the inferior apex of the wound (Figure 5) then continued cephalically towards the areola, pulling the redundant tissue upwards to avoid a dog-ear. As commonly described, subcuticular bites progressively increasing in length were taken in a caudal to cephalic direction, making sure to pull tightly with each bite. The inferior aspect of wound was therefore “cinched,” effectively shortening the length of the scar and raising the IMF (Figure 6; Table 1). Steps 3 through 5 are demonstrated in Video 2.
After all the wounds were closed, the drain was placed to bulb suction to allow the inferior flap to further collapse (Figure 7). Finally, the breasts were wrapped using elastic bandages. Patients were instructed to wear these additional bandages for 6 to 12 hours each day for 2 weeks to minimize edema. The drains were removed on postoperative day 5 to 7 regardless of output. All patients were seen weekly during their early postoperative course to monitor their progress. Postoperative images can be seen in Figure 8.
Results
A total of 58 female patients who underwent a vertical scar reduction or mastopexy were identified. The procedure utilizing the 5 steps was performed on a total of 89 breasts. The mean age of patients in the cohort was 53.2 years (range, 19-73 years). Thirty-eight patients (66%) were white, 19 (33%) were black, and 1 patient was of Hispanic descent. The average BMI was 31.5 kg/m2 (range, 21.3-42.7 kg/m2) (Table 2).
Reduction mammoplasty was performed on 35 patients (61 breasts). Mean age of this subset of patients was 51.3 years (range, 19-69 years), and mean BMI was 32.9 kg/m2 (range, 21.6-42.7 kg/m2). Twenty-one patients (60%) were white, 13 (37%) were black, and 1 patient was Hispanic. Mean resection weight per breast was 479 g (range, 100-1500 g).
Mastopexy was performed on 23 patients (28 breasts). Mean age of patients in this group was 55.9 years (range, 35-73 years), and mean BMI was 29.3 kg/m2 (range, 21.3-41.9 kg/m2). Seventeen patients (74%) were white, and 6 patients (26%) were black. Mean resection weight per breast was 58.1 g (range, 18-100 g) (Table 2).
Average duration of patient follow-up was 10.5 months (range, 1-35 months). For reduction patients, mean follow-up was 9.3 months (range, 1-28 months); for mastopexy patients, average follow-up was 12.3 months (range, 1-35 months).
In the reduction cohort, 1 patient developed a hematoma (1.6%) on postoperative day 1 that required surgical evacuation. Another patient developed a seroma (1.6%) that required aspiration and drain placement. After the seroma recurred, she underwent surgical evacuation of the seroma and capsulectomy. One reduction patient developed fat necrosis (1.6%) that was confirmed with fine-needle aspiration, but no further intervention was required. Two reduction patients developed unilateral wound dehiscence (3.3%) that resolved with local wound care (n = 1) and in-office debridement and reclosure (n = 1). One reduction patient developed bilateral dog-ears (3.3%) at time of follow-up, although she did not request any intervention to revise this. One reduction patient underwent reduction of her lateral axillary mastectomy, and another underwent repeat reduction mammoplasty after she gained weight and experienced subsequent enlargement of her breasts.
In the mastopexy cohort, only 1 complication occurred: 1 patient developed a small area of wound dehiscence (3.6%) in the inferior pole of the vertical incision that resolved with local wound care alone. No mastopexy patients who underwent the 5 steps developed a dog-ear (Table 2).
Discussion
In breast reduction mammoplasty or mastopexy, it is important to choose the best pedicle and skin excision pattern for each individual patient. Recently, the vertical scar pattern has been growing in popularity among surgeons.5 Women with moderate ptosis or moderate macromastia are particularly good candidates for a vertical scar technique. This pattern combined with a superomedial pedicle can provide aesthetically pleasing projection and a conical breast mound shape.5 Despite superior long-term aesthetic outcomes, many surgeons are hesitant to adopt this technique due to a steep learning curve and a relatively higher dog-ear revision rate.5 This article outlines 5 concrete steps to prevent the formation of dog-ears in vertical mastopexy and reduction mammoplasty, thereby decreasing the overall need for revision.
The phrase “dog-ears are a sign of a lazy plastic surgeon” is commonly echoed by those correcting another surgeon’s complication, but what is a dog-ear really? A dog-ear (or pucker) is the result of excess skin and underlying tissue bulk that creates a conical-like deformity at the end of a wound. The formation of a dog-ear depends on defect shape and size, skin laxity, and wound location. In the setting of a vertical scar pattern, Hall-Findlay attributed this “pucker” in large part to “U” or “V” ellipsoid-shaped skin defects that are closed in a straight line.5 As the wound approaches a circular pattern (length:width ratio = 1), the likelihood of a dog-ear increases.7
Traditional methods to eliminate dog-ear formation include excision of Burrow’s triangles, V-Y advancement flaps, M-plasty, S-plasty, and excision of excess underlying fat. Although an M-plasty reduces the scar length along the long axis, it also produces a double-tailed scar, effectively increasing overall scar length compared with the original wound.8 The overarching theme of these dog-ear elimination techniques is excision of redundant conical tissue.7 Whether the excision extends straight along the length of the wound or in a hockey stick “J” shape, these techniques culminate in extension of the wound.6
Multiple options for pedicle choice and skin excision patterns have been described for breast reduction/mastopexy procedures, each with a varying risk profile. The Wise pattern (inverted-T) technique remains a popular choice and is a good option for large reductions, given it is compatible with several pedicles and permits large skin excision in severely ptotic breasts. This pattern is classically associated with an inferior pedicle, given its reliable vascularity and maintenance of nipple sensation; however, it can lead to a “boxy” breast shape and eventual “bottoming-out.” Further, this technique is associated with increased scar length, predisposing patients to wound healing problems at the T-point as well as hypertrophic or widened scars.9 Despite the ability to excise excess skin, Makki et al reported that 22% of patients who underwent a Wise pattern excision required minor revisional surgery for persistent “dog-ears or ‘ugly’ scars.”10 Schnur et al described a 5% rate of dog-ear revision for breast reduction mammoplasty using an inverted-T design.11 To avoid these shortcomings of the Wise pattern incision, all patients in the current cohort underwent mammoplasty with the vertical technique and either a superior or superomedial pedicle.
The vertical or “short scar” technique was initially described by Lötsch in the 1920s, revived in the 1960s by Lassus, popularized by Lejour in 1989, and revamped by Hall-Findlay in the early 2000s.12 Useful for moderate macromastia, the vertical scar technique has been noted to have a higher patient satisfaction rate than the inverted-T incision.13 When combined with a superomedial pedicle, this technique provides aesthetically pleasing breast projection and mound shape.5 It results in a significantly shorter scar compared with the inverted-T pattern14; however, its ellipse-shaped (U or V) skin excision has been associated with a higher likelihood of inferior dog-ears.
Hall-Findlay noted that the vertical reduction in her hands resulted in a revision rate of 5%, usually to eliminate “puckers.”5 Others, such as Leone, reported a 16% revision rate for “dog-ears or dystrophic scars in the inferior” aspect of the wound.15 Similarly, Atiyeh and colleagues found that 28% of vertical scar reductions required dog-ear revision.12 This excess tissue can be an annoyance to surgeons and patients alike, often requiring a revisional procedure. To address these dog-ears, many surgeons opt for a horizontal scar component or an inverted-T point6; however, this strategy is associated with multiple pitfalls as previously described with the Wise pattern technique.9 Using the 5-step “dunking the dog-ear” technique, the authors of the current study were able to avoid these pitfalls and reduce their dog-ear rate to 1.7% (n = 1) of patients or 2.2% (n = 2) of breasts. The revision rate for vertical scars remains at 0% as the 1 patient who had bilateral dog-ears did not request revision surgery. Similarly, the reported revision rate in the literature may not capture total dog-ears following vertical mammoplasty.
Considering the revision rate in the literature has been reported to be 5% to 28%, various methods have been proposed to alleviate this burden.15 Hall-Findlay explained that although V-shaped excisions are tempting to avoid puckers, there will still be excess skin requiring revisions. U-shaped excisions may pucker but will “tuck in and follow the curve of the new breast.”5 Marconi described a method of de-epithelializing the dog-ear and inverting the excess with a purse-string stitch.16 Others have suggested incorporating a horizontal component, such as a J-scar or L-scar.6 Although the extension can be hidden laterally into the contour of the breast, effectively eliminating puckering of the skin, the scar burden is increased compared with that of a vertical incision.6
The 5-step technique described herein eliminates the inferior dog-ear without an additional horizontal component. This technique minimizes scar length and wound healing complications inherent to horizontal scars in the inframammary crease. Other methods described to tackle dog-ears include the resection of underlying adipose tissue. Chen et al described “aggressive” adipose resection of the inferior pole,17 and Atiyeh et al performed “limited inferior pole subdermal undermining and liposculpture of the inframammary crease” to allow the excess skin at the inferior edge of vertical scar to “settle.”12 Similar to Chen et al,17 the authors highlight an aggressive lipectomy of the inferior pole skin. Placement of a negative pressure drain deep to the inferior pole allows for the overlying skin envelope to contract. In conjunction with no dermal sutures in the inferior apex and a progressive running skin closure in the caudal-to-cranial direction, skin excess can be eliminated. Hall-Findley warned against “cinching” the vertical incision in this fashion, citing issues related to wound healing.18 The authors’ 13-year experience with this closure technique has resulted in a 3.3% incidence of wound breakdown that was managed with local wound care and in-office reclosure, suggesting a lower risk of ischemia to the incision than was previously stated.
Limitations
The current study has inherent limitations as it is from a single institution with all procedures performed by a single surgeon. The lead author developed this dog-ear elimination technique for other applications and applied his existing technique to the vertical scar technique, explaining the lack of direct comparison group in this study. Fortunately, dog-ear incidence and revision rates with the vertical technique are widely available in the literature and serve as a control group for comparison. While certain components of the technique have been described individually as potential methods to address dog-ears, the combination of these 5 steps during a vertical scar reduction has not been previously reported. This technique has reduced formation of the inferior scar dog-ear to 2.2% and has eliminated the need for surgical revision in this cohort. Regarding the limited follow-up, postoperative dog-ears are commonly seen in the first few weeks after surgery19,20 if not already identified intraoperatively. Therefore, dog-ear formation or wound breakdown would have likely been identified within this patient population during the follow-up period.
Conclusions
The 5-step “dunking the dog-ear” technique can reliably eliminate dog-ears from vertical scar reductions: (1) keep the inferior aspect of the skin excision at least 2 cm cranial to the IMF, (2) perform aggressive inferior pole skin lipectomy, (3) utilize a postoperative drain at the inferior pole, (4) do not place dermal sutures in the caudal 2 cm of the wound, and (5) perform subcuticular cinch in caudal-to-cranial direction. Given the benefits of a vertical scar as compared with an inferior-T incision, these 5 steps can further minimize revision rates for the vertical technique.
Acknowledgments
Affiliations: 1Division of Plastic and Reconstructive Surgery, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA; 2Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Louisville, Louisville, KY; 3Department of Orthopaedic Surgery, University of Missouri, Columbia, MO; 4Division of Plastic, Maxillofacial, and Oral Surgery, Department of Surgery, Duke University, Durham, NC; 5Ablavsky Plastic Surgery, San Antonio, TX; 6Department of Psychiatry and Behavioral Sciences, University of Louisville, Louisville, KY
Correspondence: Milind D Kachare, MD; Milind.Kachare@louisville.edu
Funding: This study received no means of outside funding.
Disclosures: The authors report no known or perceived conflicts of interest regarding the material presented in this manuscript.
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