The “dermal bra” mammaplasty described by Guo et al. combines a periareolar incision and central mound dissection with plication of the dermis to the chest wall.1 Surgical treatment of ptosis and hypertrophy might be expected to remove tissue from the region where it is excessive—the lower pole. The logical shortcoming of the periareolar technique is that it removes tissue from the area where the surgeon would like to place the incision (around the areola) rather than where the incision needs to be (on the lower pole). Not surprisingly, there is typically less lower pole elevation compared with other mastopexy techniques.2 Persistent ptosis frequently requires reoperation.3
Of even greater concern is that a central mound dissection cuts through the superficial blood vessels and nerves to the nipple on all sides, predictably causing nipple numbness and reduced vascularity. Fascial sutures may limit projection by compressing the breast tissue on the chest wall. The W-pattern resection removes upper pole tissue, just where volume is needed. Glandular manipulations have not been shown to improve projection.2 Contrary to the authors' claims, measurements reveal that breast projection is reduced (Fig. 1). The massive periareolar skin resection makes periareolar folds inevitable.
A vertical resection selectively reduces lower pole volume and can boost projection (Fig. 2).2 Intraoperative (“closed”) nipple positioning balances the skin tension, reducing areolar distortion.2 Skin is removed mainly from the lower pole, rather than from around the areola, avoiding periareolar skin pleating. Ironically, the scar from a periareolar mammaplasty—its one purported advantage—tends to be less favorable than the periareolar scar from a vertical mammaplasty (Fig. 2).
The authors stipulate that a vertical scar is too obvious and unacceptable in Asian women with ptotic breasts,1 inaccurately citing another study that in fact supported the vertical technique.4 When properly informed of its shape and scar advantages, women of all ethnicities report high satisfaction rates after vertical mammaplasty.4 The vertical resection takes place safely in the midline, where there is no vascular risk. A medially based pedicle preserves the blood supply to the nipple from branches of the internal thoracic artery (dominant in approximately 70 percent of women)5 and the important third and fourth anterior cutaneous sensory branches.6 This surgical approach is anatomically sound, making it clinically safe. The authors' statement that their incidence of nipple necrosis (four cases) is “lower than ever reported” is incorrect.7 I have not encountered this catastrophic complication using the vertical technique with a medial pedicle, an experience shared by others.4,7
The authors claim that 99 percent of their recent patients were satisfied, a rate that contrasts sharply with the experience of other operators.3 Guo et al. do not provide reoperation rates, but other surgeons report revision rates of approximately 50 percent after periareolar mastopexy, making it the least-favored (and most litigated) mastopexy technique.3 The authors' introduction of three major modifications to remedy flatness, persistent ptosis, and areolar deformity—all hallmarks of this technique3—attests to the problems inherent in this surgical design itself, which no attention to detail can finesse.
Finally, measurements made on standardized photographs are essential (Figs. 1 and 2). To properly evaluate our techniques, there is no substitute.
Eric Swanson, M.D.
Swanson Center, 11413 Ash Street, Leawood, Kans. 66211, email@example.com
The author has no conflicts of interest to disclose. There was no outside funding for this study.
1. Guo K, Sun J, Qiao Q, Guo N, Guo L. Safety, efficacy, and modifications of the dermal bra technique for reduction mammaplasty and ptosis correction: A 10-year retrospective study. Plast Reconstr Surg. 2012;129:1237–1245.
2. Swanson E. A retrospective photometric study of 82 published reports of mastopexy and breast reduction. Plast Reconstr Surg. 2011;128:1282–1301.
3. Rohrich RJ, Gosman AA, Brown SA, Reisch J. Mastopexy preferences: A survey of board-certified plastic surgeons. Plast Reconstr Surg. 2006;118:1631–1638.
4. Akyurek M. Short scar reduction mammaplasty in the bariatric patient. Ann Plast Surg. 2011;66:602–606.
5. Palmer JH, Taylor GI. The vascular territories of the anterior chest wall. Br J Plast Surg. 1986;39:287–299.
6. Schlenz I, Kuzbari R, Gruber H, Holle J. The sensitivity of the nipple-areola complex: An anatomic study. Plast Reconstr Surg. 2000;105:905–909.
7. Lista F, Ahmad J. Vertical scar reduction mammaplasty: A 15-year experience including a review of 250 consecutive cases. Plast Reconstr Surg. 2006;117:2152–2165; discussion 2166–2169.
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