The inverted T-technique
Authors: Mia Demant, MD, Magnus Balslev Avnstorp, MD and Mia Steffenssen, MD
When drawing an anchor pattern (also called Wise pattern after the plastic surgeon Robert Wise) and resection of tissue and skin is conducted via 3 incisional components; periareolar, vertical, and horizontal, this results in a scar that looks like an inverted T. In Denmark, the inverted T-technique with a superomedial pedicle often is referred to as the Orlando technique.
Comparing to the vertical technique, the inverted T typically involves a longer scar including the IMF and therefore is suitable for cases of severe mamma hypertrophy or mastopexy. The pedicles can have an inferior, medial, or superomedial orientation. It is possible to excise a larger amount of breast tissue in both the medial and lateral aspects of the breasts. However, the removal should mainly be in the lateral aspect, because most patients desire volume in the medial aspect. Incision lines are shown in drawings below and the resulting scars are located around the NAC and create an inverted T on the lower aspect of the breast including the IMF.
The inverted T-technique
Step-by-step surgery
Step 1: Pre-operative markings
The patient is marked in a standing position. Below are the preoperative markings of the breast, which indicate where the skin incisions will be. In general anesthesia, a tourniquet is placed around the breast base for tension. A metal ring is used as a sizer to mark the new NAC.
Step 2: De-epithelization
De-epithelization of the marked pedicle is performed. The new NAC is preserved.
Step 3: Tissue excision and remodeling
A suitable amount of breast tissue is excised, according to the preoperative markings and pedicle chosen. The tissue of the inferior, inferomedial, and inferolateral parts are removed. The pedicle should have a broad base and not be undermined. The NAC remains on the de-epithelized pedicle to secure the neurovascular supply. 
- The breast is remodeled by re-approximating the lateral and medial pillars and the NAC is relocated by either rotation (often 90 degrees from lateral to superior) or by a superior drag.
- The weight of excised tissue from both sides are compared to achieve symmetry.
Step 4: Finishing touches and closing
The remodeled breasts are viewed from different directions, and the patient may be placed in the “beach chair position” while observing for breast symmetry. Further tissue may be removed. Drains may be placed if minor bleeding is expected, e.g. after large tissue removal. 
- The pedicle is sutured with absorbable multifilament sutures 2-0, the pillars with absorbable multifilament sutures 3-0, and the skin sutured with intradermal continuous monofilament sutures 4-0.
- Finally, micropore tape is carefully placed and a low compression bra is put on.
Post-operative care
- At the recovery ward: Check the capillary response of the NAC and observe/palpate for hematomas
- Patients may be discharged if well-being at the day of surgery or the following day No removal of sutures is needed as they are all absorbable
- No sports for at least 4 weeks
- A supportive bra must be worn for 6 weeks
- Patients may also benefit from weight loss and exercise of muscles of the neck, back, and shoulders
Follow-up
Final post-operative clinical control and photos after 3 months.
Acknowledgments
Photos: Emir Hasanbegovic, MD
Illustrators: Christian Paaskesen, med.stud.
References
- WISE, ROBERT J. M.D. A PRELIMINARY REPORT ON A METHOD OF PLANNING THE MAMMAPLASTY, Plastic and Reconstructive Surgery: May 1956 – Volume 17 – Issue 5 – p 367-375
- Brown RH, Siy R, Khan K, Izaddoost S. The Superomedial Pedicle Wise-Pattern Breast Reduction: Reproducible, Reliable, and Resilient. Semin Plast Surg. 2015 May;29(2):94–101.