The three flap mammaplasty is essentially a variation on
a theme. It is a variation on the vertical reduction
described by Lassus in the late 1960s, which was modified
and popularized by Lejour in the mid-1980s. The principle
is the same: a superiorly based pedicle for the nipple
areola, resection of central and lower breast tissue, and
then the approximation of lateral and medial pillars.
There is a current trend in breast reduction and masto-
pexy toward improving the shape and reducing the scar.
The authors here attempt to do both. Although they
emphasize shape and longevity of results, they also
demonstrate scar reduction. They point out that some of
the extremely large reductions may require a small
“horizontal extraction” at the base of the vertical scar.
While I concur with this opinion, it has been my experience
that these patients are very few and far between. We
have always been able to complete a vertical reduction
without a horizontal scar component, as was advocated
originally by Marchac.
There are essentially two modifications or variations
on the classic vertical reduction theme here: the traction
device and the so-called septum, the de-epithelialized
part of the upper portions of the medial and lateral
I commend the authors on their ingenious traction
device that definitely assists in resecting the breast tissue
and in all likelihood takes several minutes off the length
of the operation. I tend to use various retractors and
clamps to hold the breast in that position to facilitate
the resection. Proper positioning of the breast during
resection is essential to avoid under or over resection.
The traction device helps make this possible.
The authors advocate the de-epithelialization and
formation of the septum as a method to reduce the post-
operative “bottoming out or recurrence of ptosis”. As
supported by their case in Fig. 9, this certainly is not
always the case. As Lassus has pointed out, bringing
together the medial and lateral pillars forms a so-called
dam that holds up the breast tissue and reduces the recur-
rence of ptosis or bottoming out. However, the problem
is complex and a solution is not that simple. I personally
believe that resecting the central and lower breast tissue
and suturing the medial and lateral pillars contribute to a
better result with the vertical technique and reduces the
possibility of bottoming out and a recurrence of ptosis.
Moreover, in my experience the wider the resection –
that is, the further lateral and the further medial that we
resect the lateral and medial pillars and the more unusual
and constricted the lower part of the breast is on the
operating table – the better the quality of the eventual
result in terms of shape and longevity. It is difficult to
place sutures through the fatty tissue in a very fatty
breast to hold the medial and lateral pillars together. It
may be that the authors’ de-epithelialized septum would
be beneficial and would allow a better approximation of
the medial and lateral pillars in fatty breasts.
I congratulate the authors on this modification and
their thoughtfulness in concentrating on the traction
device to ease resection and the de-epithelialized flap to
approximate the medial and lateral pillars. I believe that
Fig. 10 represents their best result in this paper with
excellent conical shape and upper pole fullness. I would,
however, differ with them when they refer to the patient
in Fig. 11b as having almost perfect symmetry. Although
the mounds approximate each other rather closely
in size, the nipple areola complex on the right side is
This commentary refers to the article at http://dx.doi.org/
F. Nahai (
Paces Plastic Surgery and Recovery Center,
3200 Downwood Circle, Suite 640, Atlanta, GA 30327
Eur J Plast Surg (2001) 24:296
The three flap mammaplasty, by G. Borsetti et al.
Published online: 19 September 2001
© Springer-Verlag 2001