I appreciate Dr. Jia and associate’s questions for clarification of points in my article entitled “A Process for Quantifying Aesthetic and Functional Breast Surgery: I. Quantifying Optimal Nipple Position and Vertical and Horizontal Skin Excess for Mastopexy and Breast Reduction,” published in the July 2013 issue of the Journal.1 The core principle behind the processes described in this article is that an ideal nipple position on the desired postoperative breast result can be defined by (a) considering preoperative base width, (b) defining the desired base width of the postoperative result, and then (c) based on the desired base width of the postoperative result, defining a desired nipple-to–inframammary fold dimension for the result, with the nipple-to–inframammary fold distance always measured under maximal stretch.
Relationships of base width to “ideal” nipple-to–inframammary fold distance were determined from extensive measurements in a large number of breast augmentation patients, and those relationships were then drastically simplified, defining the relationships defined in Table 2 of the article. Those relationships were applied in all cases reported in this study. Obviously, there is a range of positions for the nipple that might be acceptable, depending on patients’ and surgeons’ aesthetic preferences. The firm numbers applied to patients in this study were used in an attempt to inject objectivity instead of subjectivity into preoperative planning and postoperative outcomes analysis. Surgeons can certainly adjust these relationships to their preferences. The goal is simply to have objective parameters for planning and postoperative assessment. Surgeons may also have differing opinions and experience that define the degree to which the base width of the breast can and should be reduced in each of these procedures.
To address the writer’s specific questions:
- Each surgeon must define the desired postoperative base width that the surgeon believes can and will be delivered with optimal safety, and then select the appropriate nipple-to–inframammary fold dimension from Table 2 for the desired postoperative breast width. The superior-most point of the areola depends on the desired areola diameter planned for the postoperative result. For example, if a 4-cm areolar diameter is planned, half of that diameter, or 2 cm, will be located superior to the nipple position. As a result, the superior-most point of the areola:inframammary fold will be whatever nipple-to–inframammary fold distance was chosen for the projected postoperative base width plus 2 cm, and the surgeon marks this point on the breast meridian 2 cm superior to the desired nipple position. If the desired areola diameter is not 4 cm, then the superior-most point of the areola:inframammary fold should be the desired nipple-to–inframammary fold distance (from Table 2) + ½ the planned postoperative areolar diameter. The desired nipple-to–inframammary fold distance is the desired dimension from the nipple to the inframammary fold that the surgeon plans to deliver in the postoperative result. After determining nipple position using the processes described in the article, the surgeon then (a) chooses a desired areolar diameter, (b) marks ½ of that diameter on the meridian superior to the defined nipple position, and (c) measures a desired nipple-to–inframammary fold distance inferiorly along the meridian where a mark defines the point marked by a red slash in Figure 8 of the article. The distance from that point to the existing inframammary fold is the vertical skin excess in the breast. Surgeons can then decide whether to excise part or all of the vertical excess, or to redistribute some or all of it into the vertical and/or periareolar incision closures. These concepts will be further detailed and applied to detailed marking steps for vertical skin excess excision in a second article submission detailing processes for quantifying skin envelope modification in mastopexy and reduction.
- The formula that the writer refers to in the article is stated inaccurately and was revised, but the revision was not incorporated into the published article. That error, and the error with reference 13 (explanation below), is currently being investigated by the editorial office and the publisher. Stated more simply and more accurately, vertical skin excess = superior-most point of the areolar:inframammary fold maximum stretch – (1/2 desired areolar diameter + desired nipple-to–inframammary fold distance).
- Reference 13, which was included in the original submission and in the final revision (no author queries or suggestion of any reference changes were ever made to the author), should read as follows: “Lee MR, Unger JB, Adams WP. Process approach to augmentation mastopexy: The tissue-based triad algorithm (submitted for publication).” This reference was intact on the final version of the submission downloaded from Editorial Manager, but apparently it was switched by someone in the production process to the completely irrelevant and unrelated reference 13 that appeared in the published article. The Editorial Office investigated this substitution and the appropriate Correction was published in the October 2013 issue.2 The erroneous, substituted reference was not the author's error.
Vertical (and horizontal) skin excess in the breast, for planning purposes, should be considered entirely independent of nipple position, regardless of how the surgeon selects desired nipple position. Vertical skin excess is the amount of vertical skin excess remaining in the inferior pole of the breast after a surgeon has defined the desired new nipple position and the desired postoperative nipple-to–inframammary fold distance.
I sincerely appreciate the feedback and questions of Dr. Jia, Dr. Ed Luce, and other colleagues whose astute reading of our efforts inevitably makes us better.
The author has no financial interest to declare in relation to the content of this communication.
John Tebbetts, M.D.
2801 Lemmon Ave West, Suite 300 Dallas, Texas 75204 [email protected]
1. Tebbetts JB. A process for quantifying aesthetic and functional breast surgery: I. Quantifying optimal nipple position and vertical and horizontal skin excess for mastopexy and breast reduction. Plast Reconstr Surg. 2013;132:65–73
2. . A process for quantifying aesthetic and functional breast surgery: I. Quantifying optimal nipple position and vertical and horizontal skin excess for mastopexy and breast reduction: Correction. Plast Reconstr Surg. 2013;132:1040
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