For patients with severe macromastia (F or larger cup size) and severe ptotic breasts appearing like a potato sack, a larger amount of the breast tissue needs to be removed. A traditional inverted T incision in combination with a periareolar lift is recommended to obtain more flexibility in reduction volume and shape remodeling. It uses a similar technique as inferior pedicle breast reduction, but a larger amount of the breast tissue is removed, including the medial, lateral, and lower parts. The inferior pedicle should be kept intact to ensure the blood supply to the nipple–areolar complex and lower-third of the breast tissue. Finally, the remaining breasts, nipple/areola, and pedicle flap are moved and stitched toward the vertical incision at the center of the breast to sculpt breast shape and perkiness. Loose and redundant skin can also be excised and tailored simultaneously. This surgery can remove most parts of the breasts and create the best result in patients with severe macromastia and ptosis. However, this is a relatively time-consuming procedure with the largest field of excision and the most damage to the breast tissue. There is a higher chance for inflammation or poor healing of the wound to occur. Moreover, the circulation to the nipple and areola could be damaged to cause necrosis or atrophy, leading to the loss of ability to breastfeed. The surgery would also leave a noticeable vertical scar between the nipple and inframammary fold, resulting in a longer period of wound and scar care. Thus, it is still less accepted by those who have scar tendency, especially in Asian patients.