Title: Reply: The Three Breast Dimensions: Analysis and Effecting Change
Abstract: Sir: I appreciate Dr. Gray's comment on my article; however, it speaks to measurements using a procedure that is not common in the plastic surgery community. I believe that most plastic surgeons do not choose to place the implant in a completely submuscular plane in a primary breast augmentation because of the excessive muscle movement that occurs with contraction. I do not have much experience with a complete submuscular pocket for primary breast augmentation, but I have used it for augmentation after a previous reduction. I have not found that the inframammary fold goes up but that the opposite occurred. The weight of the implant still seems to be able to drop out of the inframammary fold, and I have found it better to create a limited subglandular pocket in the upper pole of the breast and keep the lower pole parenchyma undisturbed so that it can help support the implant in a higher position, but this approach can also fail. The complete submuscular plane is unfortunately only loosely adherent at its origin on the sixth rib inferiorly, and the implant seems to be able to “self-dissect” with its own weight. As far as the suprasternal notch–to-nipple distance stretching on average 2 cm after a breast augmentation, I only included a sample of 20 patients; however, I have performed the measurements on over 100 patients, with the same results. I suspect that a complete submuscular placement of the implant may not result in more than a 0.4-cm increase in suprasternal notch–to-nipple distance because the muscle compresses the implant and does not allow the skin and breast tissue to stretch. This clearly could be used to advantage when needed. I am glad to see that Dr. Gray has performed these measurements and I believe it is incumbent on all plastic surgeons who present a different or new approach to provide measurements to substantiate their claims. We practice an art, but we need to base our decisions on the results of science, which includes measurements and long-term observation. Many claims are made that are disproven with time, and long-term follow-up can be very humbling for the surgeon. Elizabeth J. Hall-Findlay, M.D. P.O. Box 2009 317 Banff Avenue, Suite 340 Banff, Alberta T1L 1B7, Canada