Drs. Gurunluoglu et al. perpetuate the notion of autoaugmentation.1 The authors claim that an inferior parenchymal flap can restore volume in women after removal of breast implants, averaging 225.7 cm3. This claim exceeds the previous estimate by Graf et al.2 of 100 to 200 cm3. The autoaugmentation concept dates back to Ribeiro’s description of a “prosthesis in natura”3 and has been published previously in combination with explantation.4 The authors believe that adding the BREAST-Q survey5 provides missing validation.
The authors report that all patients were surveyed preoperatively and at least 6 months after surgery. A 100 percent compliance rate is unusual. It is also unusual in a retrospective study to have preoperative questionnaires available. Were these investigators already in the habit of surveying their patients preoperatively with the BREAST-Q in 2007, the beginning of the study period, and 2 years before the BREAST-Q with the breast reduction module5 was published?
Its developers caution that the “BREAST-Q scales are not considered valid for patient groups that were not represented in the development process.”5 This limitation clearly extends to augmentation patients with complications undergoing explantation and autoaugmentation. The improvement in scores may be related to successful treatment of the complication irrespective of this tissue manipulation. There is no comparison with another cohort of patients treated with explantation alone, or with explantation and mastopexy without flap transposition. In the absence of such comparative data, these survey results cannot be used to support a conclusion that this dermoglandular flap is effective.
My 2011 review6 analyzed 82 publications of mammaplasty techniques, many of which claimed autoaugmentation. Measurements on photographs matched for size and orientation failed to corroborate the authors’ claims. An inverted-T, inferior pedicle mammaplasty is incapable of increasing breast projection because of its geometry, trading projection for horizontal width.6 Measurements reveal that only a vertical mammaplasty can (modestly) boost breast projection without an implant,7 because of its geometry, trading width for projection.
The authors use several modalities to assess their results but fail to use the one that matters most—measurements on standardized photographs. In the past, there were no standard definitions and no measurement systems available to make such comparisons. However, such a system is available today.8 An advantage of this measurement system is that it can be used to compare regular lateral photographs, making it applicable even to retrospective studies such as this one (Fig. 1). Bra sizes are much too subjective to be of much value. The BREAST-Q provides general indices of patient satisfaction and well-being, but it does not include measurements. When evaluating changes in breast morphology, there is no substitute.
Although it has been used for decades, an inferior pedicle is a particularly unsuitable selection because (1) the base of the pedicle remains fixed at the level of the inframammary crease and cannot rise, (2) there is no axial blood supply that enters the flap from below and courses vertically, (3) there is no inferiorly based sensory nerve to the nipple, and (4) the pedicle is the longest of the available options and is therefore most at risk (particularly in a patient with an old inframammary scar). Accordingly, these investigators and others2,4 have kept the inferiorly based parenchymal flap but substituted a superior or superomedial pedicle to the nipple. The problems with this remedy are as follows: (1) it sacrifices the most important deep innervation to the nipple and dominant medial superficial sensory nerves, causing more nipple numbness9; and (2) a superior pedicle is less maneuverable than a medial pedicle in large breasts and can suffer vascular compromise.10 Hall-Findlay’s vertical mammaplasty with a medially based pedicle and preservation of the deep parenchyma10 offers a more rational approach from anatomical and geometric perspectives. There is no evidence that fascial sutures are effective.6 Other “critical” measures such as mandatory capsulectomies, quilting sutures, and drains1 are unsupported.
Investigators who claim autoaugmentation often display nonstandardized photographs without measurements, or they exclude lateral photographs.2–4,6 The authors’ examples are no exception (Fig. 1). No manipulation of existing breast tissue can create something from nothing. McKissock memorably called these maneuvers “cabinet-making fantasies.”11 If there were any net increase, theoretically, any woman wanting breast implants up to 300 cm3 would be better served with autoaugmentation, skipping the breast implants entirely. By transposing existing tissue, the authors are simply borrowing from Peter to pay Paul.
Patient’s choices are influenced heavily by their surgeon’s recommendations. We need to be careful when speaking about “reorientation of breast volume,” “configuring breast shape,” and suggesting that breast volume may be “replaced.”1 Women undergoing explantation should be informed that their breasts will be smaller and lack upper pole fullness; manipulation of existing breast tissue is not a substitute for implants (Fig. 1). With this knowledge, most women will choose to have their implants replaced. A history of leaking silicone gel implants or a capsular contracture is not necessarily a contraindication. Existing breast asymmetry or a hematoma is not particularly relevant to this decision. Asymmetry is more easily treated with implants12 and a hematoma is evacuated. If patients are hesitant to have new silicone gel implants inserted, they have the option of saline-filled implants.
An addendum provides billing codes, raising the question of financial motives. Might some patients elect to have this procedure rather than implants because it is covered by their insurance plan? Is it appropriate for a surgeon to bill an insurance company for a (still invalidated) procedure that is supposed to provide cosmetic breast augmentation?
Implants are imperfect and they are lifetime devices, but they are highly effective and hold shape better than breast tissue,7 and complications can almost always be managed to a successful conclusion.12 The rare exception is better treated with a vertical mammaplasty. Vertical augmentation/mastopexy12 is the key to a consistently high rate of patient satisfaction.
The author has no financial interest in any of the products or devices mentioned in this communication. The author has no conflicts of interest to disclose. There was no outside funding for this study.
Eric Swanson, M.D.
11413 Ash Street
Leawood, Kan. 66211
1. Gurunluoglu R, Sacak B, Arton J. Outcomes analysis of patients undergoing autoaugmentation after breast implant removal. Plast Reconstr Surg. 2013;132:304–315 discussion 316–317.
2. 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
3. Ribeiro L. A new technique for reduction mammaplasty. Plast Reconstr Surg. 1975;55:330–334
4. Hönig JF, Frey HP, Hasse FM, Hasselberg J. Inferior pedicle autoaugmentation mastopexy after breast implant removal. Aesthetic Plast Surg. 2010;34:447–454
5. Pusic AL, Klassen AF, Scott AM, et al. Development of a new patient-reported outcome measure for breast surgery: The BREAST-Q. Plast Reconstr Surg. 2009;124:345–353
6. Swanson E. A retrospective photometric study of 82 published reports of mastopexy and breast reduction. Plast Reconstr Surg. 2011;128:1282–1301
7. Swanson E. Prospective photographic measurement study of 196 cases of breast augmentation, mastopexy, augmentation/mastopexy, and breast reduction. Plast Reconstr Surg. 2013;131:802e–819e
8. Swanson E. A measurement system for evaluation of shape changes and proportions after cosmetic breast surgery. Plast Reconstr Surg. 2012;129:982–992 discussion 993.
9. Schlenz I, Rigel S, Schemper M, Kuzbari R. Alteration of nipple and areola sensitivity by reduction mammaplasty: A prospective comparison of five techniques. Plast Reconstr Surg. 2005;115:743–751 discussion 752.
10. Hall-Findlay EJ. A simplified vertical reduction mammaplasty: Shortening the learning curve. Plast Reconstr Surg. 1999;104:748–759 discussion 760.
11. McKissock PK. Precision in breast reduction (Discussion). Plast Reconstr Surg. 1988;82:642–643
12. Swanson E. Prospective comparative clinical evaluation of 784 consecutive cases of breast augmentation and vertical mammaplasty, performed individually and in combination. Plast Reconstr Surg. 2013;132:30e–45e discussion 46e–47e.
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