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The Inferiorly Based Parenchymal Flap Mammaplasty: The Need for Measurements to Support Claims

Swanson, Eric M.D.

Plastic and Reconstructive Surgery: February 2013 - Volume 131 - Issue 2 - p 288e–290e
doi: 10.1097/PRS.0b013e318278d613
Letters

Swanson Center, 11413 Ash Street, Leawood, Kans. 66211, eswanson@swansoncenter.com

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Sir:

Figure

Figure

Borrowing from Ribeiro's description of a “prosthesis in natura,”1 Bonomi et al. combine an inferiorly based parenchymal flap with a superiorly based pedicle to the nipple.2 The authors claim that their mammaplasty technique provides long-lasting upper pole fullness and increased projection of the nipple-areola complex. To support this claim, they report the subjective judgment of their patients and four examiners (two plastic surgeons, a resident, and a nurse) who reviewed photographs. The authors cite my article, which concluded that similar claims made by other investigators were unfounded, and that autoaugmentation was ineffective.3 Evidently, the authors remain unconvinced. Have they accomplished the goal that has eluded their predecessors?

Of course, the answer is only to be determined by measuring the results.4 Personal opinion, even from experienced surgeons, is no substitute for the facts. As in previous studies, a lack of measurements on standardized photographs undermines the authors' conclusions, making their technical description and much of their discussion a moot point. Measurements reveal that the postoperative lateral photographs of the two patients presented by the authors are enlarged 80 percent and 125 percent, respectively. Both patients are tilted forward approximately 5 degrees preoperatively. These factors contribute to the illusion of increased upper pole fullness and breast projection after surgery, an effect that disappears after correction for size and orientation (Fig. 1).

Fig. 1

Fig. 1

Is this finding surprising? Not when one considers the geometry. In fact, no nonvertical technique is capable of significantly increasing breast projection.3 By virtue of its elliptical parenchymal resection, trading width for projection, the vertical technique can boost breast projection (Fig. 2). Boxy lower poles, bottoming out, and nipple overelevation are all predicted by the geometry of an inferior flap and inverted-T resection (authors' Fig. 4).3

Fig. 2

Fig. 2

Ironically, an inferiorly based flap uses the one orientation that does not include a known axial blood supply, making it a random flap. An inferior base is also the one orientation that maintains a fixed base at the inframammary crease, preventing its elevation. Fascial sutures no doubt contribute to tissue compression and scarring. Preserving the nipple on a medial pedicle maintains its medially based superficial innervation and blood supply. However, dissecting the nipple from its deep parenchymal attachment sacrifices its most consistent innervation, provided by the lateral cutaneous branch of the fourth intercostal nerve.

References to the parenchymal flap as a natural breast implant by these authors and others1,5 are overstatements. As a semirigid inorganic material, a breast implant resists deformation,6 aided by capsular contraction, and in this sense is superior to natural, amorphous breast tissue. Measurements confirm that only a breast implant can provide a substantial boost in upper pole fullness.3,4 Furthermore, there is no factual support for the concept that some breast tissue is more resistant to gravity or that fascial sutures are effective.3

Inexplicably, plastic surgeons have often ignored photographic standards in presenting their results.7 Without these standards, it is easy to be misled by one's beliefs. It is time to insist on techniques that have a sound basis in anatomy and geometry, and measurements that support their validity. Our patients deserve no less.

Eric Swanson, M.D.

Swanson Center, 11413 Ash Street, Leawood, Kans. 66211, eswanson@swansoncenter.com

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DISCLOSURE

The author has no financial interests 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.

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REFERENCES

1. Ribeiro L. A new technique for reduction mammaplasty. Plast Reconstr Surg. 1975;55:330–334.
2. Bonomi S, Salval A, Settembrini F, Gregorelli C, Musumarra G, Rapisarda V. Inferiorly based parenchymal flap mammaplasty: A safe, reliable, and versatile technique for breast reduction and mastopexy. Plast Reconstr Surg. 2012;130:116e–125e; discussion 126e–127e.
3. Swanson E. A retrospective photometric study of 82 published reports of mastopexy and breast reduction. Plast Reconstr Surg. 2011;128:1282–1301.
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. 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.
6. Brandon HJ, Jerina KL, Wolf CJ, Young VL. In vivo aging characteristics of silicone gel breast implants compared to lot-matched controls. Plast Reconstr Surg. 2002;109:1927–1933.
7. Riml S, Piontke AT, Larcher L, Kompatscher P. Widespread disregard of photographic documentation standards in plastic surgery: A brief survey. Plast Reconstr Surg. 2010;126:274e–276e.
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