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Page 10 of 11 Nicholson et al. Plast Aesthet Res 2018;5:34 I http://dx.doi.org/10.20517/2347-9264.2018.30

Drawbacks to our technique mainly pertain to the dissection of the skin envelope and the suspension
elements: the series of modifications we use in combination add time to the breast reduction overall, of
the order of around 30%, but we believe the benefits of improved aesthetics and longevity make this a
worthwhile trade-off.

The large skin envelope is widely undermined and relatively thin compared to other techniques. Logically,
this introduces a hypothetically increased risk of skin flap necrosis or wound healing complications such
as dehiscence or poor scars, particularly at the t-junction. So far we have not yet seen this borne out in
practice. Our rates of wound healing complications are comparable to those previously reported elsewhere.
Meticulous attention to flap thickness and tissue handling, plus patient selection, may help ameliorate these
risks. The skin flap dissection, among other elements of the technique, produces a learning curve that may
deter others from incorporating these modifications into their breast reduction repertoire.

Most of our patients wish to keep good proportionate volume ranging from C to F cup. As always, we aim to
match the breast volume to the body structure of each individual patient in our population. However those
wishing to keep a large proportion of initial volume but obtain good breast shape and correction of ptosis, as
is possible with this technique, are the challenging patients in the long run due to the rate of recurrent ptosis
or pseudoptosis.

The case that developed fat necrosis requiring surgical washout and debridement had a reduction in nipple-
to-IMF distance of 19 cm. Other cases in our series have had reductions in nipple-to-IMF distance of 17
cm done safely without complications. We therefore feel it is safe to reduce the pre-operative nipple-to-IMF
distance by up to 17 cm without free nipple graft, assuming intrinsic patient factors are optimal.

In conclusion, the technique herein described offers a range of benefits over existing techniques, aimed at
improving predictability, consistency and longevity of aesthetic results. Development of pseudoptosis in
particular, which is a common pitfall with existing breast reduction techniques, is effectively delayed. We
believe the learning curve and extra time required to complete the procedure, with its series of additional
steps, is a very worthwhile trade-off for patients who receive a more lasting improvement in breast shape and
lift. The modifications described have not been shown to increase the rates of surgical complications.

DECLARATIONS
Authors’ contributions
Concept, design and data analysis: Riaz M, Nicholson S
Data acquisition: Riaz M, Khan MAA
Manuscript preparation, critical revision and finalizing of the manuscript: Nicholson S, Riaz M, Khan MAA

Availability of data and materials
The data were strictly obtained from medical records according to the privacy policy and ethics code of our
institute.

Financial support and sponsorship
None.

Conflicts of interest
All authors declared that there are no conflicts of interest.

Ethical approval and consent to participate
Approval from hospital trust audit department. Full consent from all patients obtained.