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

Swanson, Eric M.D.

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Plastic and Reconstructive Surgery: March 2017 - Volume 139 - Issue 3 - p 799e-801e
doi: 10.1097/PRS.0000000000003116
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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.:
This patient’s before (left) and after (right) photographs appear in the authors’ Figures 6 and 7. The age of the patient, implant size, and postoperative period are not provided. The original published postoperative photograph had been tilted 5.5 degrees backward, so as to give the appearance of an upturned nipple. The Canfield 7.4.1 Mirror Imaging software (Canfield Scientific, Inc., Fairfield, N.J.) is used to correct this discrepancy and a difference in magnification. The nipple position and inclination are unchanged after surgery. MPost, plane of maximum postoperative breast projection. (Adapted with permission from Figures 6 and 7 in Mallucci P, Branford OA. Design for natural breast augmentation: The ICE principle. Plast Reconstr Surg. 2016;137:1728–1737, with permission of the publisher. Adaptations are themselves works protected by copyright. So in order to publish this adaptation, authorization must be obtained both from the owner of the copyright in the original work and from the owner of copyright in the translation or adaptation.)

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


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 Center
11413 Ash Street
Leawood, Kan. 66211


1. Mallucci P, Branford OADesign for natural breast augmentation: The ICE principle.Plast Reconstr Surg201613717281737
2. Mallucci P, Branford OAConcepts in aesthetic breast dimensions: Analysis of the ideal breast.J Plast Reconstr Aesthet Surg201265816
3. Mallucci P, Branford OAPopulation analysis of the perfect breast: A morphometric analysis.Plast Reconstr Surg2014134436447
4. Swanson EPhotometric evaluation of inframammary crease level after cosmetic breast surgery.Aesthet Surg J201030832837
5. Swanson ECan we really control the inframammary fold (IMF) in breast augmentation?Aesthet Surg J201636NP313NP314
6. Matousek SA, Corlett RJ, Ashton MWUnderstanding the fascial supporting network of the breast: Key ligamentous structures in breast augmentation and a proposed system of nomenclature.Plast Reconstr Surg2014133273281
7. Swanson EProspective photographic measurement study of 196 cases of breast augmentation, mastopexy, augmentation/mastopexy, and breast reduction.Plast Reconstr Surg2013131802e819e
8. Hsia HC, Thomson JGDifferences in breast shape preferences between plastic surgeons and patients seeking breast augmentation.Plast Reconstr Surg2003112312320; discussion 321
9. Tebbetts JB, Adams WPFive critical decisions in breast augmentation using five measurements in 5 minutes: The high five decision support process.Plast Reconstr Surg200511620052016
10. Adams WP JrThe process of breast augmentation: Four sequential steps for optimizing outcomes for patients.Plast Reconstr Surg200812218921900
11. Swanson EProspective outcome study of 225 cases of breast augmentation.Plast Reconstr Surg201313111581166; discussion 1167–1168
12. Hidalgo DA, Sinno SCurrent trends and controversies in breast augmentation.Plast Reconstr Surg201613711421150
13. Hall-Findlay EJBreast implant complication review: Double capsules and late seromas.Plast Reconstr Surg20111275666
14. Brody GS, Deapen D, Taylor CR, et al.Anaplastic large cell lymphoma occurring in women with breast implants: Analysis of 173 cases.Plast Reconstr Surg2015135695705
15. Swanson ETextured breast implants, anaplastic large-cell lymphoma (ALCL), and conflict of interest.Plast Reconstr Surg2017139000e000e


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