Response to "Limitations of the horizontal (no vertical scar) breast reduction".

We thank Dr Swanson for his detailed analysis of our article.1 In recent years, aesthetic surgeons have been heavily biased toward the vertical scar breast reduction technique. Horizontal breast reduction has generally been excluded from the literature. None of the articles referenced in Dr Swanson’s letter include horizontal reduction, thus rendering most of the comments inapplicable. Our study was, to our knowledge, the first comparing the horizontal scar pattern with the other 2 common types of scar patterns. Our primary objective was to determine which scar pattern was preferred by breast reduction patients. Although breast shape and projection are important elements of the final result, these items were not evaluated in our study. We make no claim that the horizontal breast reduction technique is superior overall, only that our results suggest a particular outcome: women prefer the breast reduction pattern with the lowest visible scar burden. Dr Swanson also commented that our study was a survey, not a prospective study. On this point, we entirely agree. In fact, the title of the article indicates clearly that it was a prospective survey. Dr Swanson also made several understandable criticisms about the clinical photographs. This issue is a longstanding problem in the aesthetic surgery literature and is unfortunately unavoidable in this type of study. The frontal views alone were shown, as this is the view of the scars the patient would have when standing in front of a mirror. If the horizontal technique is properly performed, the scar does not extend to the axillae, as claimed by Dr Swanson.2 Regarding the comment that the areolae appeared more circular in the horizontal breast reduction photograph published in our original article, this is, in fact, an additional advantage of the horizontal technique. Patients who have undergone horizontal breast reduction surgery have superior areola shape compared with those who have undergone surgery with vertical and Wise patterns, as the absence of the vertical limb prevents the teardrop deformity.2,3 Dr Swanson’s comments regarding the “superiority” of the vertical technique with respect to upper pole projection are simply not applicable to our study. As previously mentioned, our article did not address breast shape or projection. We exclusively focused on scar pattern. Given that none of the studies quoted in Dr Swanson’s letter included the horizontal technique, there is no scientific evidence that supports the letter writer’s final assertion that “prospective patients are unlikely to choose the horizontal technique.”