We welcome Dr. Swanson’s comments regarding our recent publication “Design for Natural Breast Augmentation: The ICE Principle.”1 His comments largely ignore previously published work defining concepts of breast beauty,2,3 venting personal opinion in place of objective observation. Our latest publication regarding the ICE principle puts design into practice.1 The ICE principle is a formula for inframammary fold incision planning as part of the process for determining implant selection and placement to reproduce the 45:55 ratio previously described as fundamental to natural breast appearance.1–3 It is a simplification of existing techniques4 taking into consideration just two implant parameters—height and projection—and computing these against the capacity of the breast. Although Swanson points out the complex three-dimensionality of the breast, it is precisely the simplicity of this formula that renders it so effective. We have prospectively demonstrated using the ICE principle for surgical planning in breast augmentation that an ideal natural breast may be achieved with high levels of consistency.1
Swanson insists that “filling the upper pole is the goal” and that “women prefer convex upper poles; they desire an ideal appearance, not necessarily a natural one.” The full upper pole is a desired appearance in clothing; it does not correspond with attractiveness of the naked breast as verified by our population study (82 percent of 660 women preferred the natural profile versus 13 percent who preferred the less natural profile).2 It is a subtlety that he and many others overlook.
With regard to his comments about the inframammary fold, it is perhaps not surprising that Swanson finds it difficult to control its position given his advocacy for oversized implants. His statement that large implants do not cause increased complications is depressingly archaic and goes against all the principles of tissue-based planning: consequences of oversized implants include palpability, rippling, wrinkling, compression, double-bubble deformity, bottoming out, atrophy of parenchymal tissue, tissue thinning, diminished skin blood supply, and increased capsular contracture rates, resulting in increased reoperation rates.5
Swanson comments that “talking down” implant volume in women with limited capacity is “patronizing.” Good medical care dictates that we keep our patients’ best interests at heart and, given the consequences described, this may result in a compromise in size. Swanson’s disregard for anatomy in favor of size is outdated and potentially harmful, ignoring one of the pillars of the Hippocratic oath: “first do no harm.”
The ICE principle puts theory into practice, combining tissue-based planning with aesthetic outcome. Swanson risks being “frozen” out of modern practice by ignoring the advancements in aesthetic breast surgery in favor of his outdated volumetric approach.
The authors have no financial interest to declare in relation to the content of this communication.
Patrick Mallucci, F.R.C.S., F.R.C.S.(Plast.)The Cadogan Clinic
Olivier A. Branford, Ph.D., M.R.C.S., F.R.C.S.(Plast.)The Cadogan ClinicThe Royal Marsden HospitalLondon, United Kingdom
1. Mallucci P, Branford OADesign for natural breast augmentation: The ICE principle.Plast Reconstr Surg201613717281737
2. Mallucci P, Branford OAPopulation analysis of the perfect breast: A morphometric analysis.Plast Reconstr Surg2014134436447
3. Mallucci P, Branford OAConcepts in aesthetic breast dimensions: Analysis of the ideal breast.J Plast Reconstr Aesthet Surg201265816
4. Tebbetts JB, Adams WPFive critical decisions in breast augmentation using five measurements in 5 minutes: The high five decision support process.Plast Reconstr Surg200511620052016
5. Tebbetts JB, Teitelbaum SHigh- and extra-high-projection breast implants: Potential consequences for patients.Plast Reconstr Surg201012621502159