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Three Dermoglandular Flap Support in Reduction Mammaplasty: The Importance of Photographic Integrity

Swanson, Eric M.D.

Plastic & Reconstructive Surgery: March 2013 - Volume 131 - Issue 3 - p 440e–443e
doi: 10.1097/PRS.0b013e31827c70dc

Swanson Center, 11413 Ash Street, Leawood, Kans. 66211,

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Pascone et al.1 have embarked on a familiar quest—to provide lasting improvement in breast projection and upper pole fullness by parenchymal rearrangement and at the same time to reduce breast size.13 The authors manipulate and suture three dermoglandular flaps, adding time and complexity to an already lengthy procedure.

Is this modification of the inferior pedicle inverted-T mammaplasty worthwhile? Only measurements can provide the answer. Herein lies the problem. Photographic standards are not observed. The authors present enlarged and cropped postoperative photographs. The arms are pulled back in some postoperative photographs (authors' Figs. 3 and 4). Lateral images are often rotated. A variety of camera angles are used. These maneuvers contribute to an illusion of increased postoperative breast size and projection.

In an attempt to unmask these effects, I attempted to match the authors' last set of photographs for size and orientation. After finding this task impossible, I discovered that these images represent two different sides of the body (Fig. 1). A preoperative left breast photograph was evidently flipped 180 degrees, making it appear to represent a preoperative right breast. Similarly, a skin lesion located adjacent to the lateral end of the inframammary crease reveals that the preoperative photograph in the authors' Figure 4 has been flipped. Vein patterns and moles on the preoperative right upper breast and left bra strap area reveal that photographs in the authors' Figures 6 and 7 have also been reversed, accounting for the appearance of a better surgical result on the more ptotic left side. The preoperative orientation of three moles on the right upper breast and one above the left areola reveal that the postoperative frontal image in the authors' Figure 8 has been flipped. Despite close cropping, this upper breast mole pattern and the contralateral areolar appearance confirm that the authors' Figure 9 is really a right breast masquerading as a left breast postoperatively. At total of six of the authors' figures, depicting all but one of their patients (authors' Fig. 11), feature flipped photographs.

Unfortunately, because the authors do not provide a single set of authentic before-and-after lateral photographs, it is impossible to measure and compare their modified technique with the result from a traditional inferior pedicle, inverted-T mammaplasty (Fig. 2). Their procedure appears to present the same known shortcomings—boxy lower poles, bottoming out, flat upper poles, and nipple overelevation (authors' Figs. 10 and 11),4 with long horizontal scars. These undesirable shape changes occur even when early postoperative photographs appear promising (authors' Figs. 8 and 9); they are inevitable consequences of the surgical design.4 Nipple overelevation can present a practical problem for women. The authors' Figure 6 shows the patient's right (in reality her left) areola extending above her tan line.

It is not surprising that parenchymal manipulations are ineffective.4 If sagging occurred before, what difference might be expected after rearranging the same tissue? There is no evidence that one region of breast tissue is more resistant to gravity or holds its shape better than another. Dermal preservation is also of questionable benefit. The dermis certainly did not prevent the sagging from occurring in the first place.2 Indeed, “solid internal dermal support” may be an oxymoron.

This description of a dermoglandular manipulation intended to improve breast projection brings the total number of such publications to well over 100.4 Photographic standards, known for decades,5 have often been ignored. It is time to insist on such safeguards for the benefit of our patients, who have been subjected to a bewildering variety of remedies without suitable standards and measurements for evaluating efficacy.

Eric Swanson, M.D.

Swanson Center, 11413 Ash Street, Leawood, Kans. 66211,

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The author has no financial interest to declare in relation to the content of this communication. There was no outside funding for this study.

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1. Pascone M, Di Candia M, Pascone C. The three dermoglandular flap support in reduction mammaplasty. Plast Reconstr Surg. 2012;130:1e–10e.
2. Flowers RS, Smith EM Jr. “Flip-flap” mastopexy. Aesthetic Plast Surg. 1998;22:425–429.
3. Caldeira AM, Lucas A, Grigalek G. Mastoplasty: The triple-flap interposition technique. Aesthetic Plast Surg. 1999;23:51–60.
4. Swanson E. A retrospective photometric study of 82 published reports of mastopexy and breast reduction. Plast Reconstr Surg. 2011;128:1282–1301.
5. Zarem HA. Standards of photography. Plast Reconstr Surg. 1984;74:137–146.
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