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).
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
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, email@example.com
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.
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.
Letters to the Editor, discussing material recently published in the Journal, are welcome. They will have the best chance of acceptance if they are received within 8 weeks of an article's publication. Letters to the Editor may be published with a response from the authors of the article being discussed. Discussions beyond the initial letter and response will not be published. Letters submitted pertaining to published Discussions of articles will not be printed. Letters to the Editor are not usually peer reviewed, but the Journal may invite replies from the authors of the original publication. All Letters are published at the discretion of the Editor.
Letters submitted should pose a specific question that clarifies a point that either was not made in the article or was unclear, and therefore a response from the corresponding author of the article is requested.
Authors will be listed in the order in which they appear in the submission. Letters should be submitted electronically via PRS' enkwell, at www.editorialmanager.com/prs/.
We reserve the right to edit Letters to meet requirements of space and format. Any financial interests relevant to the content of the correspondence must be disclosed. Submission of a Letter constitutes permission for the American Society of Plastic Surgeons and its licensees and asignees to publish it in the Journal and in any other form or medium.
The views, opinions, and conclusions expressed in the Letters to the Editor represent the personal opinions of the individual writers and not those of the publisher, the Editorial Board, or the sponsors of the Journal. Any stated views, opinions, and conclusions do not reflect the policy of any of the sponsoring organizations or of the institutions with which the writer is affiliated, and the publisher, the Editorial Board, and the sponsoring organizations assume no responsibility for the content of such correspondence.
The Journal requests that individuals submit no more than five (5) letters to Plastic and Reconstructive Surgery in a calendar year.