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The ICE Principle, 45:55 Breast Ratio, and 20-Degree Nipple Inclination in Breast Augmentation

Swanson, Eric, M.D.

Plastic and Reconstructive Surgery: March 2017 - Volume 139 - Issue 3 - p 799e-801e
doi: 10.1097/PRS.0000000000003116

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

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Mallucci and Branford1 propose their ICE principle, following up on their previous studies advocating “critical ideals for beautiful natural breasts,” consisting of a 45:55 upper-to-lower pole ratio, a 20-degree skyward angulation of the nipples, a straight upper pole slope, and a convex lower pole.2,3 The authors’ frozen acronym,1 “ICE,” is not intuitive; cryolipolysis is not being used. Their formula seeks to determine the distance, if any, between the preoperative inframammary fold and their incision, which is planned to be at the same level as the postoperative inframammary fold.1 The ICE equation relates different parameters—implant projection (one dimension), volume capacity (three dimensions), and skin surface area (two dimensions)—in one linear equation. The actual tissue dynamics, including skin stretch and recruitment, are likely to be much more complex. Nevertheless, the authors report that this equation allows them to precisely determine the level of the postoperative inframammary fold with a mean accuracy of 99.7 percent on the right and 99.6 percent on the left.

A problem with this concept is that the inframammary fold descends after a breast augmentation even when the incision is made at or above the level of the preoperative inframammary fold.4 It is not clear that surgeons really “control” its postoperative level.5 There is no evidence that long-lasting sutures or the suturing method makes a difference.5 Advantages of keeping the incision at or above the preoperative inframammary fold level include avoiding dissection through the inframammary fold ligaments,6 and keeping the scar from being exposed below a bra or bikini top.5 The authors seek to “load” the lower pole.1 The problem for women is often excessive breast sagging over time, not excessive perkiness. Filling the upper pole is the goal, not filling the lower pole.7 Mastopexy unloads the lower pole.7

The authors1–3 advocate a linear upper pole, which they achieved bilaterally in 90 percent of their patients.1 However, women prefer convex upper poles8; they desire an ideal appearance, not necessarily a natural one—there being nothing more natural than a sagging breast. The example of a breast augmentation provided by the authors (Fig. 1) would be unsatisfactory for many women seeking a breast augmentation. The authors1 reference Tebbetts and Adams’ preoperative measurements9 as crucial, but Adams concedes that 20 percent of his patients voice postoperative concerns about their (small) size.10 Mallucci and Branford1 report that the negative consequences of oversized implants—higher complication rates and more reoperations—are well documented. However, the cited article making this claim references a “manuscript in preparation”; data are not provided.10 On the contrary, outcome studies reveal that patients with larger breast implants tend to report higher levels of satisfaction, with no increase in the complication rate.11 Women seeking a large implant size need not be “talked down.”1 Indeed, such discussions can be patronizing.11 There is no evidence that large implants cause a “destructive effect to the local breast environment,” or that a full cleavage “is attractive to very few in the naked breast.”

Fig. 1.

Fig. 1.

Mallucci and Branford1 claim that their method elevates the nipple position on the breast mound, and nipple angulation is increased from 11 degrees skyward to 19 degrees (which is not really a natural appearance). In their example, however, this “highly significant” increased inclination disappears once the backward tilt of the postoperative photograph is corrected (Fig. 1). Measurements on standardized photographs show that the nipple position is unchanged after a breast augmentation.7

The authors favor shaped implants.1 However, no outcome study or measurement study has documented their superiority over round implants.12 A strong link exists between textured implants and double capsules,13 late seromas,13 and anaplastic large cell lymphoma.14 With this knowledge, recommending shaped (and therefore textured) implants to patients is becoming increasingly difficult to justify.15

Using the word “beautiful” to describe one’s results1 is risky unless data exist to support such a statement. Similarly, “natural” or “tight” have little meaning from a scientific perspective. Reporting no complications1 among a sizable patient population is an anachronism. Photographs that are not standardized can be misleading (Fig. 1). Unfortunately, the authors are coming to the wrong conclusions because they do not have adequate measurement tools and the benefit of outcome studies from their patients. If they did, they would likely find that their patients desire upper pole fullness,8 convexity of the upper pole is preferred over linearity,8 larger implants (e.g., mean volume, 390 cc) are safe,11 the inframammary fold is not fixed at surgery but descends over time,4 and the nipple is not elevated by a breast implant.7

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The author declared no potential conflicts of interest with respect to the research, authorship, and publication of this communication. The author received no financial support for the research, authorship, and publication of this communication.

Eric Swanson, M.D.Swanson Center11413 Ash StreetLeawood, Kan.

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1. Mallucci P, Branford OADesign for natural breast augmentation: The ICE principle.Plast Reconstr Surg201613717281737
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