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Modern Primary Breast Augmentation: Best Recommendations for Best Results

Bouwer, Lesley R. M.D.; van Dam, Daphne M.D.; van der Lei, Berend M.D., Ph.D.

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Plastic and Reconstructive Surgery: December 2019 - Volume 144 - Issue 6 - p 1109e-1110e
doi: 10.1097/PRS.0000000000006267
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With great interest, we have read the CME article by Wan and Rohrich entitled “Modern Primary Breast Augmentation: Best Recommendations for Best Results.”1 It really is a state-of-the-art article about modern breast augmentation and the use of implants with all of the recent developments, including breast implant-associated anaplastic large cell lymphoma.

This CME article, however, lacks the item of planning of the incision location in the neo–inframammary fold with its reconstruction in case of using the inframammary approach. Hidalgo and Spector2 already called incision placement in the inframammary approach “challenging” because the position of the inframammary fold changes with surgery.

Over the past 15 years, several methods have been published on incision-site positioning for inframammary augmentation mammaplasty. In our clinic, the unpublished Akademikliniken method and the Pythagorean theorem method.3 are most commonly used for incision-site positioning in the neo–infra mammary fold and result finally in a scar at or just above the reconstructed neo–inframammary fold. In 2016, Mallucci and Branford4 introduced a new method for determining the incision location: the ICE principle.

Very recently, we have performed a comparative study between the above-mentioned three different methods. After drawing of the location of the original inframammary fold, the three possible incision sites (according to the Akademikliniken method, the Pythagorean theorem, and the ICE principle) were drawn and documented photographically (Fig. 1). The values of the Akademikliniken method were obtained from the Allergan brochure (Allergan, Inc., Dublin, Ireland): the 55 percent lower ventral curvature value was drawn from the nipple downward without skin stretching. The ICE method4 was calculated for anatomical implants by adding half of the implant height to the projection and for round implants by adding 55 percent of the implant height to the projection (I). Then, the capacity of the breast (C) was measured from nipple to inframammary fold under stretch. By subtracting C from I, the excess (E) was calculated, which represents the distance the inframammary fold should be lowered: I − C = E. For the Pythagorean theorem method,3 half of the implant height (á) and the projection (â) is used to calculate the hypotenuse (ã) with the formula á2 + â2 = ã2: the calculated hypotenuse (ã) is then drawn from the lower border of the areola with stretching of the skin to determine the incision location in the neo–inframammary fold.

Fig. 1.
Fig. 1.:
Preoperative drawing on a patient, illustrating the significant differences in inframammary incision location using the three different measurement methods. The calculated incision sites according to the Akademikliniken method, the ICE principle, and the Pythagorean theorem were marked with H, ICE, and P, respectively.

Evaluating the above-mentioned measurements in 22 patients (six with anatomical and 16 with round implants), we found that the Akademikliniken method and the Pythagorean theorem method resulted in more or less comparable incision-site locations, whereas the ICE principle resulted in significantly lower incision-site locations. Based on years of experience, we know that both the Akademikliniken and Pythagorean theorem method3 result in a scar in or just above the reconstructed neo–inframammary fold. For the ICE method, we do not know but fear often either a scar that is too low or nipples that are too high (“star-gazing” nipples) (nipple − inframammary fold > 55 percent).

In our opinion, the key to successful inframammary breast augmentation is accurate planning of the incision location for a final scar in or just above the reconstructed neo–inframammary fold. To date, this item still is underexposed, and therefore we look forward to hearing experiences from other surgeons.


The authors have no financial interest to declare in relation to the content of this communication.

Lesley R. Bouwer, M.D.
Department of Plastic Surgery
Martini Hospital
Daphne van Dam, M.D.
Bergman Clinics
Berend van der Lei, M.D., Ph.D.
Bergman Clinics and Department of Plastic Surgery
University Medical Center Groningen
University of Groningen
Groningen, The Netherlands


1. Wan D, Rohrich RJ. Modern primary breast augmentation: Best recommendations for best results. Plast Reconstr Surg. 2018;142:933e–946e.
2. Hidalgo DA, Spector JA. Breast augmentation. Plast Reconstr Surg. 2014;133:567e–583e.
3. Bouwer LR, Tielemans HJ, van der Lei B. The Pythagorean theorem as a tool for preoperative planning of a concealed scar in augmentation mammaplasty with round implants. Plast Reconstr Surg. 2015;135:110–112.
4. Mallucci P, Branford OA. Design for natural breast augmentation: The ICE principle. Plast Reconstr Surg. 2016;137:1728–1737.
5. del Yerro JL, Vegas MR, Fernandez V, et al. Selecting the implant height in breast augmentation with anatomical prosthesis: The “number Y”. Plast Reconstr Surg. 2013;131:1404–1412.
6. Tebbetts JB, Adams WP. Five critical decisions in breast augmentation using five measurements in 5 minutes: The high five decision support process. Plast Reconstr Surg. 2005;116:2005–2016.


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