It is generally claimed that short-scar mammaplasty is limited to small-to-medium reductions. Its use in patients with severe macromastia has been associated with a high rate of complications. This report presents our experience of reduction mammaplasty greater than 1000 g per breast using a short-scar technique. The procedure is based on the following: a) modified breast marking method with conservative placement of the nipple-areola complex, determined not only by the level of the inframammary fold but also degree of upper pole volume loss; b) use of liposuction for contouring the inferior pole; c) vertical design dermoglandular resection; d) superomedial pedicle; and e) skin closure without undermining or gathering. A total of 69 patients were identified (n = 138 breasts). Mean age was 38.0 years with average BMI of 36.4 kg/m. Mean weight of breast removed was 1333.8 g (range, 1002-3275). New nipple position was determined to be inferior to the inframammary fold at a mean distance of 4.6 cm, as predicted by the degree of flatness of upper pole. Complications included delayed healing (7.2%), fat necrosis (10.1%), infection (5.8%), hematoma (2.9%), and seroma (1.5%). There were no instances of nipple-areola complex necrosis. Revision of dog-ears was necessary in 7 patients (10.1%). The authors conclude that in using a modified short-scar mammaplasty approach in cases of severe macromastia, the outcomes can be improved with reduced scar burden, pleasing breast shape, and a low complication rate.