The ideal reduction mammoplasty should produce perfect breast size, shape and projection with minimal scarring, normal nipple sensation, and ability to lactate. Ideally should also be quick to perform, free from complications and reproducible by most surgeons. The authors should be congratulated for their quest attempting to achieve some of these goals by describing a new technique in reduction mammoplasty that eliminates the periareolar and vertical scars.

In their approach, the excess skin is removed from the inferior aspect of the breast, leaving a short distance of 4 cm between the nipple and the new inframammary crease. The breast is then undermined from the pectoral fascia, excess tissue removed from the deep surface of the breast and the breast is then suspended as a superiorly based flap to the chest wall. The redundant skin in the infraclavicular region, which initially appears wrinkled, diminishes with time provided that there is a good skin turgor. The only scar is in the inframammary crease, which is the main advantage of the procedure.

Although this procedure is innovative and reintroduces the inframammary approach in breast reduction, it has its shortcomings, which we believe limits its usefulness to a very selected group of patients. The authors have limited experience and have only performed this procedure in 10 patients who had mild to moderate hypertrophy or ptosis and good skin turgor, which significantly reduces its applicability.

There are other potential disadvantages associated with the technique. Firstly, the excision of skin from the inframammary region has the tendency of lowering the nipple-areola complex (NAC) on the breast mound, which may fail to correct ptosis as the nipple may be at or below the level of the inframammay crease.

Secondly, there is a tendency for the transverse diameter of the breasts to become widened with too much fullness laterally. This may correct itself if the inferior pole of the breast "bottoms out" as occurs with the inferior pedicle technique. The authors do not mention whether or not this occurs and loner follow up will be needed to assess this.

Thirdly, in the patients who have a very wide NAC, the scarless complex is not necessarily any more esthetically appealing than a complex with a "normal" diameter but with a circumareolar scar. This scar is usually inconspicuous and unlike the vertical scar, is often concealed by the junction of aesthetic units.

The authors also report fat necrosis rate of 20% (two out of ten patients), which seems to be an excessive risk to accept for breast reduction despite the smoking history in these patients. This raises uncertainty regarding the reliability of the pedicle in this procedure. Furthermore, the authors have not mentioned how long it takes to perform this procedure and how much intraoperative "fussing" is required before a satisfying result is obtained.

Finally, the wrinkling of the upper part of the breast albeit temporary could be a main deterrent for patient satisfaction and acceptance of the early postoperative result. As the authors correctly state, the ideal "for all seasons" breast reduction procedure remains elusive. We believe that the authors should be applauded for trying to minimize scarring in reduction mammoplasty and that this procedure can be considered in selected cases with mild ptosis and hypertrophy.