Autologous Free Dermal Graft Support in Superior Pedicle Vertical Scar Reduction Mammaplasty

Reduction mammaplasty is a well-established procedure performed for symptomatic breast hypertrophy and breast ptosis. In addition to volume reduction, the operation aims to achieve a durable breast shape, stable lower pole contour, and an appropriate nipple-areola complex position. However, even after technically successful surgery, postoperative breast morphology may change over time. Lower pole elongation, pseudoptosis, and bottoming-out remain relevant problems, particularly in patients with large resection volumes, poor tissue elasticity, or increased load on the lower pole.

Several internal support methods have been described to improve long-term shape stability after reduction mammaplasty. These include dermal suspension flaps, dermal bra techniques, parenchymal fixation sutures, and inframammary fold reinforcement. In the present study, we will evaluate an autologous support method in which de-epithelialized dermal tissue obtained during the operation is used as a free dermal graft and placed in the lower pole region. Unlike vascularized dermal flaps, this graft is not maintained on a vascular pedicle. This approach may provide a simple autologous support option without the need for synthetic or biological mesh material.

This study is planned as a prospective, single-center, observational, comparative cohort study. Participants undergoing primary bilateral superior pedicle vertical scar reduction mammaplasty will be followed with a standardized postoperative assessment protocol. The study will not include randomization or any study-related assignment to a surgical technique. The surgical approach will be determined according to the routine practice of the operating surgeon. In the same department, one routine approach includes autologous free dermal graft support in the lower pole, whereas the comparison approach uses the same basic superior pedicle vertical scar reduction mammaplasty technique without free dermal graft placement.

The planned enrollment is 70 participants. Sample size calculation was based on the expected between-group difference in postoperative lower pole change. A 1 cm difference was accepted as clinically meaningful, with an estimated standard deviation of 1.3 cm. Using G\*Power 3.1, with a two-sided alpha level of 0.05, 80% power, an effect size of 0.77, and a 1:1 group ratio, at least 28 participants were required in each group. Considering possible loss to follow-up, the planned sample size was increased to 35 participants per group.

Demographic, clinical, operative, anthropometric, photographic, patient-reported, and postoperative safety data will be collected prospectively. Demographic and clinical variables will include age, body mass index, smoking history, comorbidities, pregnancy and breastfeeding history, and preoperative breast characteristics. Operative variables will include surgical group, resection weights, operative time, drain use, and routine perioperative data. Postoperative follow-up data will include serial breast measurements, standardized photographs, patient-reported satisfaction, complications, and clinically relevant postoperative events.

Anthropometric measurements will be obtained according to a standardized protocol. Measurements will be performed with the participant standing in a natural posture and with the arms relaxed. Right and left breast measurements will be recorded separately. For bilateral continuous breast measurements, the mean value of both breasts will be used for participant-level analysis. Standardized medical photographs will be obtained in predefined views and assessed by independent evaluators blinded to the surgical group.

Eligible participants will be evaluated consecutively during the recruitment period. Data will be recorded on predefined case report forms. Before analysis, range and consistency checks will be performed. When necessary, source data will be verified using clinical records. Missing data will be reviewed before final analysis. Participants without the required follow-up measurement for the primary analysis will not be included in the primary endpoint analysis, and the extent of missing data will be reported.

The statistical analysis will compare the two routine surgical approaches. Potential confounding factors, including baseline patient characteristics and operative variables, will be considered during analysis. The study is expected to provide prospective clinical data on the possible role of autologous free dermal graft support in maintaining lower pole stability after superior pedicle vertical scar reduction mammaplasty.

• Change in Sternal Notch-to-Nipple Distance [Time frame: From postoperative month 1 to postoperative month 6]
• Change in Lower Pole Ratio [Time frame: From postoperative month 1 to postoperative month 6]
• Patient Satisfaction With Breasts [Time frame: Postoperative month 6]
• Blinded Photographic Aesthetic Assessment [Time frame: Preoperative period and postoperative month 6]