Although submitted as a Letter to the Editor, this communication from Dr. Pereira et al. is really an original abstract rather than a commentary on my article.1 A more suitable title might have been, “The Divine Proportion Applied to Breast Reduction.” The subjects are different. The article by Pereira et al. describes a formula for breast marking; mine evaluates surgical results with measurements.
Pereira et al. advocate two concepts purported to improve breast shape and reduce complications. The first concept is the “divine proportion,” known to ancient Greek mathematicians as phi (ϕ). Historically, this ratio has been attributed to a wide range of natural phenomena. Familiar examples include the pattern of spirals in a nautilus shell and the features of an attractive human face. Recently, however, investigators have challenged its validity.2,3 This rectangular ideal bears little resemblance to the curved shape of the female breast. In fact, another mathematical constant, intrinsic to many of the physical properties of the universe and also discovered by ancient Greek mathematicians, may be more applicable. The value pi (π) appears in equations dictating the form of spheroids, ellipsoids, and paraboloids. These shapes, beautiful in their symmetry and simplicity, more readily characterize breast geometry.4
Analysis of the authors' method reveals problems. The umbilical position varies with the length of the torso, making reliance on a fixed 60-degreee angle risky. In fact, this angle measured 48 degrees preoperatively and 43 degrees postoperatively in the patient illustrated. In a vertical mammaplasty, the inframammary crease rises, making it an unreliable landmark.4 Contrary to the authors' statement, point P2 is situated above the breast apex, which is not a recommended site for nipple placement and therefore of questionable relevance. The authors' claim of improved shape could be tested by evaluating their patients after swelling has subsided (1 week is much too early), including lateral photographs to measure breast projection and nipple level (Fig. 1). However, such a study might not be clinically useful because the authors (wisely) do not actually use the divine proportion to guide their incisions or nipple placement.
The second concept is quilting sutures, sometimes used to prevent seromas in abdominoplasty. This complication is unusual in breast reduction surgery. The vertical technique avoids dead space by resecting the parenchyma as a central wedge, making quilting sutures unnecessary. These sutures might compromise breast projection by compressing the breast tissue tightly against the chest wall. Of course, clinical data would be needed to support the authors' claim of reduced complications. Pereira et al. appropriately abandoned the use of an inferior pedicle as a “biological implant.” Measurements reveal that fascial sutures and autoaugmentation techniques are ineffective.1
The history of mammaplasty is replete with complicated surgical designs,5 memorably derided by McKissock as “cabinetmaking fantasies.”6 A reasoned approach includes an understanding of desired breast shape,4 geometrically valid operative techniques,1 and, most importantly, measurements to determine efficacy.1,4 This process is simply the scientific method applied to cosmetic breast surgery. Unsupported claims and reliance on untested formulae are best avoided. Our remedies for excess breast size and sagging (Fig. 1) should be elegant in their simplicity.
Eric Swanson, M.D.
Swanson Center, 11413 Ash Street, Leawood, Kan. 66211, email@example.com
The author has no conflicts of interest to disclose. There was no outside funding for this communication.
1. Swanson E. A retrospective photometric study of 82 published reports of mastopexy and breast reduction. Plast Reconstr Surg. 2011;128:1282–1301.
2. Falbo C. The golden ratio: A contrary viewpoint. Coll Math J. 2005;36:123–134.
3. Pallett PM, Link S, Lee K. New “golden” ratios for facial beauty. Vision Res. 2010;50:149–154.
4. 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.
5. Aufricht G. Mammaplasty for pendulous breasts: Empiric and geometric planning. Plast Reconstr Surg (1946) 1949;4:13–29.
6. McKissock PK. Precision in breast reduction (Discussion). Plast Reconstr Surg. 1988;82:642–643.
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