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The Ruth Graf Technique: Measurements Do Not Support the Efficacy of an Inferior Pedicle and Pectoralis Muscle Loop in Mammaplasty

Swanson, Eric M.D.

Plastic and Reconstructive Surgery: July 2013 - Volume 132 - Issue 1 - p 168e–170e
doi: 10.1097/PRS.0b013e3182910d0e

Swanson Center, 11413 Ash Street, Leawood, Kan. 66211,

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Neto et al. promote an inferior pedicle technique with a pectoralis muscle loop for secondary mammaplasty,1 a technique they attribute to the senior author (including her first name), although the method was previously described by Daniel and published by de Araujo Cerqueira.2 This communication revives the familiar theme of autoaugmentation. The senior author has previously claimed that this technique can replicate the effect of a 100- to 200-cc breast implant3 and that the results are permanent.

Unfortunately, the authors’ photographs are not properly standardized and they are overly cropped, and the arm positions are different. When the photographs are matched for size and orientation (Fig. 1), any increase in upper pole projection appears negligible. There is no evidence presented here or in other publications to suggest that either the muscle loop or fascial sutures are effective.4 One would have to measure patients treated with and without these maneuvers using standardized photographs and breast measurements to support such a claim. However, an inverted-T inferior pedicle technique is likely to disappoint because of its geometric shortcomings.4 The vertical mammaplasty, because of its design, trading width for projection, is more likely to improve breast projection and upper pole projection (Fig. 2), with no need for risky pedicle manipulation and muscle dissection.

Fig. 1

Fig. 1

Fig. 2

Fig. 2

The magnetic resonance image depicted in the authors’ Figure 2 shows a breast without any description of the patient’s position. Labeling the cephalad portion of the breast “upper” is not strictly correct if she was lying prone with the breasts hanging free, which is the customary position. The convexity evident on the image is likely a product of gravitational dependency, not upward tissue mobilization. The image does not support the efficacy of the authors’ tissue manipulation in terms of augmenting upper pole volume (a preoperative view would be needed for such a comparison). The flap is likely to lie flattened against the chest wall by fascial sutures and scarring, bearing little resemblance to an oval implant as depicted in an artist’s illustration.3

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.

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The author has no conflicts of interest to disclose. There was no outside funding for this


Eric Swanson, M.D.

Swanson Center

11413 Ash Street

Leawood, Kan. 66211

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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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