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• W2319466257 abstract "Sir: Mallucci and Branford1 promote four “critical ideals of breast beauty.”2 The first consideration in discussing an ideal breast is, whose definition of ideal should we use? So often, it has been the surgeon’s opinion. However, we know that the patient’s opinion is what matters most in terms of surgical success.3,4 The slope of the upper pole is a subjective assessment made by the authors. This determination may be made objectively by dividing the upper pole projection by the breast projection.5 This ratio is called breast convexity.5 Oblique views are prone to slight differences in rotation, making them difficult to standardize. Frontal and lateral images can be matched more easily and used to quantitate surgical changes (Fig. 1).5Fig. 1: This 30-year-old nulliparous woman is shown before (left) and 3 months after (right) a submuscular breast augmentation using smooth, round, Moderate Plus profile saline implants (Mentor Corp., Santa Barbara, Calif.) inflated to 450 cc. Upper and lower pole breast areas (shaded) are measured above and below the plane of maximum breast projection. Lower pole ratios less than 2.0 indicate a nonboxy shape. The total breast area is increased 79 percent. After surgery, the upper pole profile is convex. The postoperative breast parenchymal ratio is 1.84. Photographs are matched for size and orientation using the Mirror 7.1.1 imaging software (Canfield Scientific, Fairfield, N.J.). MPost, maximum postoperative breast projection; LPR, lower pole ratio; BPR, breast parenchymal ratio; BME, breast mound elevation.The authors prefer a linear or slightly concave upper pole.1,2 If concave upper poles were desirable, corsets and bras would not have been invented. One of the few studies to ask women for their opinion revealed that they (unlike their surgeons) prefer convex upper poles.6 Upper pole concavity may be the natural condition, but it is not the preferred one. The authors advocate a 45:55 ratio (0.82) using the upper pole takeoff, nipple level, and inframammary crease as landmarks.1,2 One practical limitation of this ratio is the fact that the upper breast margin is not well defined. There is a high degree of subjectivity in deciding where the chest ends and the breast starts. Different observers are likely to assign different ratios. The inframammary crease level is better defined than the upper pole takeoff, but it is still an unreliable surgical landmark because this level changes after surgery, lowering after a breast augmentation (Fig. 1) and rising after a vertical mastopexy.7 Also, the inframammary fold tends to be obscured in patients with ptosis. The lower pole level (the lowest point on the breast)5 is a more useful landmark. Importantly, the nipple may not align with the level of maximum breast projection, making it an unreliable marker for differentiating the upper and lower breast poles. The level of maximum postoperative breast projection serves as a useful reference plane for comparing upper and lower pole contributions (Fig. 1).5 The breast parenchymal ratio and nipple position are best considered separately.5 A vertical linear measurement1,2 does not reliably measure parenchymal contributions because the horizontal component is not measured. Two-dimensional measurements more accurately quantitate the parenchymal proportions.5 Two-dimensional analysis5 provides an ideal balance between one-dimensional analysis,1,2 which is too simple, and three-dimensional analysis, which is overly complicated.5 The authors’ panels of four images1 feature a variety of nipple positions. To properly compare breast shapes, the nipple position should be kept constant, at the apex of the breast. It is not surprising that few respondents chose the images with displaced nipples. This confounder undermines the authors’ conclusions. This is unfortunate because the authors expended a great deal of effort having the panels reviewed by different demographic groups,1 and the results would have been interesting if this confounder had been eliminated and the breast parenchymal ratio isolated as the variable of interest. There is a consensus that the nipple should sit at the point of maximum breast projection, with a neutral inclination.5 The authors promote an upward 20-degree tilt.1,2 A skyward tilt may sometimes occur naturally, but it may also be a telltale sign of implants that are displaced downward, causing bottoming out, or an unintended consequence of a Wise pattern breast reduction (pseudoptosis).8 With gradual inferior glandular displacement, this unnatural appearance is likely to become worse with time. What are the practical implications of such considerations? Physics and gravity dictate that the lower pole will assume a convex shape.5 Therefore, maintenance of lower pole convexity2 is unnecessary. Adequate resection of lower pole breast tissue during a mammaplasty (mastopexy, augmentation/mastopexy, or reduction) avoids a persistent lower pole bulge.9 When treating women with breast ptosis, the surgeon’s objective is to restore upper pole fullness and tighten the lower poles.9,10 If a patient lifts her breasts with the cups of her hands and says, “this is what I want,” she is likely to be best served with an augmentation/mastopexy.10 The preferred contour of the lower pole immediately after a properly performed vertical mammaplasty should be almost linear on a lateral view, not convex. It will always round out. Nipple overelevation should be avoided.8–10 Measurements reveal that after breast augmentation, the mean breast parenchymal ratio measures 1.61 on the right and 1.72 on the left.10 After augmentation/mastopexy, these ratios measure 1.68 and 1.78, respectively.10 Such ratios are approximately double the authors’ recommendation; however, these women consistently report high levels of satisfaction and improved quality of life.3,4 Notably, the mean preoperative breast parenchymal ratios for women with ptosis undergoing mastopexies are 0.76 and 0.89,10 very similar to the authors’ preferred ratio of 0.82. In summary, the plastic surgeon is best advised to aim for convex upper poles, tight lower poles, and a breast parenchymal ratio that favors upper pole fullness and convexity. These goals are the opposite of those advocated by the authors.1,2 Few patients complain of excessive perkiness more than a few months after a mammaplasty. The authors promote shaped implants.1 Interestingly, at a recent meeting,11 plastic surgeons in the audience were unable to discern from photographs which patients had shaped implants and which did not. Ironically, the ratio of correct to incorrect responses was 45:55. Shaped implants preferentially increase lower pole volume, accommodating the surgeon’s preference, but not the patient’s.6 Whether shaped implants offer advantages in cosmetic breast augmentation awaits evaluation by patients. DISCLOSURE The author has no financial interest to declare in relation to the content of this communication. The author has no conflicts of interest to disclose. There was no outside funding for this study. Eric Swanson, M.D. Swanson Center 11413 Ash Street Leawood, Kan. 66211 [email protected]" @default.
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• W2319466257 date "2015-03-01" @default.
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• W2319466257 title "Ideal Breast Shape" @default.
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