Although the authors dismiss the possibility of an association, the complications of fat necrosis and nipple-areola tissue loss are just the problems one might expect when using a random flap that is compressed by being tunneled through a muscle loop. Scarring from previous surgery only adds to the vascular risk. Despite their own experience,1,3 the authors believe that, because Daniel did not mention cases of fat necrosis in his 1995 presentation, there were none. The references to a study by “Lee et al.” and another study of 132 cases without fat necrosis do not include citations (these references would seem more relevant to this article than existing references 4 and 5). Despite my attempts using obvious key words and the search functions of the Journal and PubMed, I could not locate them.
The authors evaluate nonconsecutive patients. There is no mention of the inclusion rate, which leaves the reader wondering about selection bias. Excluding patients whose findings may not support the authors’ claims undermines the value of any contribution.5 The authors’ opening statement that mammaplasty is a largely satisfactory procedure for patients, with minimal need for revisions, is not the general experience of plastic surgeons,6 which is why we need to be especially careful when evaluating mammaplasty. Dissection into the muscle carries additional risk. Oncologic considerations in the event of a future breast cancer are not trivial ones.7 Without a proven benefit, it is difficult to justify dissection into a different tissue plane.
The importance of photographic standardization has been recognized for decades. Consecutive patients and adequate inclusion rates are well-known hallmarks of evidence-based medicine. Without these safeguards, there will be no end to such articles making unsupported claims—an unfortunate tradition in mammaplasty. For the sake of our patients, we need to adhere to these basic standards.
Eric Swanson, M.D.
Leawood, Kan. 66211
1. Neto LG, Reis de Araújo LR, Baggio M, Broer PN, Graf R. The Ruth Graf technique in secondary mammaplasty. Plast Reconstr Surg. 2013;131:125e–127e
2. de Araujo Cerqueira A. Mammoplasty: Breast fixation with dermoglandular mono upper pedicle flap under the pectoralis muscle. Aesthetic Plast Surg. 1998;22:276–283
3. Graf R, Reis de Araujo LR, Rippel R, Neto LG, Pace DT, Biggs T. Reduction mammaplasty and mastopexy using the vertical scar and thoracic wall flap technique. Aesthetic Plast Surg. 2003;27:6–12
4. Swanson E. A retrospective photometric study of 82 published reports of mastopexy and breast reduction. Plast Reconstr Surg. 2011;128:1282–1301
5. Goldwyn RM. Consecutive patients. Plast Reconstr Surg. 1990;86:962
6. Rohrich RJ, Gosman AA, Brown SA, Reisch J. Mastopexy preferences: A survey of board-certified plastic surgeons. Plast Reconstr Surg. 2006;118:1631–1638
7. Adams WP Jr. In search of better shape in mastopexy and reduction mammoplasty (Discussion). Plast Reconstr Surg. 2002;110:321–322
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