Many techniques exist for post-bariatric mammoplasty, and vertical and inverted-T mammoplasty are most commonly used. In general, inverted –T incision is easier than vertical incision in achieving symmetry as precise skin markings and skin/glandular excision are easier to achieve.
It is more difficult to achieve symmetry in vertical mammoplasty. In vertical mammoplasty, preoperative markings should be done carefully. Position the new nipple-areola complex is lowered 1–2 cm on the larger side in cases of asymmetry. After glandular excision, remaining glandular tissue should be assessed for symmetry bilaterally at all quadrants before inset and pillar closure. After closure of glandular pillars, skin is temporarily closed with stapler to assess volumetric symmetry in all four quadrants. NAC skin is temporally closed with stapler. Then patient is sit up to assessed symmetry. In this step, symmetry is assessed as follows: (1) Height of NAC (2) Curvature of lower pole breast (3) Diameter of NAC (4) Nipple-IMF distance (5) lower pole puckering. (1) (2) (3) can be adjusted by tailor-tacking the breast skin. If two much Nipple-IMF distance (4) or obvious puckering (5) is observed, either direct glandular excision or liposuction can be used to decrease N-IMF distance and/or puckering. During inset of NAC, it is important to place purse string sutures with non-absorbable sutures to control the areola diameter; breast skin around the new areola should be trimmed as necessary to obtain a round-shaped areola.
Methods to address the upper pole fullness in vertical mammoplasty include glandular transposition, fat grafting and breast implant. Glandular transposition is the first choice if the native breast volume is adequate. If the native breast volume is inadequate, either fat graft or implant can be used.

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