A New Flexible Curved Ruler to Shorten the Learning Curve Markings in the Hall-Findlay Mammaplasty (2010)

Sir: Vertical scar mammaplasty has now been accepted worldwide, and many plastic surgeons use it as a preferred technique for breast reduction and mastopexy in their current practice. Among these, the Lejour and the Hall-Findlay techniques1,2 are the most common mammaplasties performed, with the advantages of less scarring, better projection, and faster recovery for the patient. However, because of the difficulties in marking and resection, many plastic surgeons are still reluctant to use the vertical approach. The most difficult aspect of vertical mammaplasty is the lack of a simple pattern to follow, especially when marking the nipple-areola opening. The authors introduce a new, novel, simple, and effective tool (Fig. 1) to facilitate marking on breast reduction more accurately, but we mainly use it in the Hall-Findlay procedure, as this is the preferred technique in our practice.Fig. 1.: Flexible curved ruler.Such a device is an ellipsometer used for geometric drawings, and is easy to find in any stationary store. The authors marked a ruler on it to take measurements at the same time of the markings. In the Hall-Findlay technique, the preoperative markings are made using a freehand design, whereas the authors had been using the flexible curved ruler. The malleable ruler is positioned on the breast meridian 2 cm below the inframammary fold and is shaped as a semicircle with its circumference measuring no more than 16 to 18 cm to match an areola diameter of 4.5 to 5 cm (Fig. 2).Fig. 2.: Marking the areola opening.The medial and lateral vertical limbs are marked by rotating the breast on each side using the ruler to mark them 5 to 7 cm. These lines are joined in a U shape, staying 2 to 6 cm above the inframammary fold. Vertical scar breast reduction as described by Lassus3 and popularized by Lejour1 has now gained popularity over the past decade. However, many surgeons still view it as a technique with certain limitations. Many modifications have been suggested, claiming improved results and fewer complications.4–7 One such technique is described by E. Hall-Findlay2 in which a superomedial pedicle is used with no pectoralis fascial suspension sutures, no or minimal liposuction, and no skin undermining. The most difficult aspect of the Hall-Findlay technique is the lack of a simple pattern to follow, especially for the markings of the nipple-areola opening. Few methods have been described to simplify the markings and shorten the learning curve.8,9 Our method using the malleable ruler has simplified the preoperative markings and shortened the learning curve, especially at the beginning of our experience with the Hall-Findlay technique. Its pliability and adaptability allowed us to use it in breasts of different sizes and shapes, and the possibility of varying the area of the semicircle gave us the chance to remove more breast tissue from the upper pole, especially in large breast reduction. Furthermore, we found it useful not only for those who began their experience with the vertical mammaplasty, but also as a teaching device, because we noticed that the upper part of the marking was somewhat difficult to make clear when explaining the technique. DISCLOSURE The authors have no financial interest to disclose in relation to the content of this article. M. Paola Serra, M.D. Paola Longhi, M.D. G. Sam Rao, M.S., F.R.C.S.Ed.(Plast. Surg.) Plastic Surgery Unit University Hospital North Durham Durham, United Kingdom