The Three Breast Dimensions: Analysis and Effecting Change

Sir

I read the article by Dr. Hall-Findlay, “The Three Breast Dimensions: Analysis and Effecting Change” (Plast Reconstr Surg. 2010; 125:1632-1642) and appreciate her documentation of changes to the breast following augmentation. Her review of 20 cases confirms that the distance from the sternal notch to the nipple increases by more than 2 cm even as early as 1 month postoperatively. This confirms my observations of over 25 years that subpectoral and subglandular placement of implants increases ptosis. This is very evident when an inframammary incision is used and the scar ends up superior to the fold. With a subglandular pocket, gravity is the deforming force. With a subpectoral pocket, the pectoralis major muscle contraction adds a deforming force of inferior and lateral displacement to gravity.

A submuscular pocket avoids this deforming force. Incorporating the serratus anterior with the pectoralis major helps prevent lateral and inferior migration of the implant. I have reviewed 20 of my own patients with a minimum of 4 months’ follow-up for measurements and have found an increase in the sternal notch-to-nipple distance on average of 0.4 cm. The average of the implants was 400 cc, larger than those used by Dr. Hall Findlay. When using smaller implants and when I did not lower the inframammary fold, there was no increase in the distance.

I agree with Dr. Hall-Findlay that we should measure our patients, which should make managing their expectations easier. Unfortunately, I rarely obtain records on patients seeking second opinions who have even had preoperative measurements and virtually never have had postoperative measurements. I often see patients who had ptosis and were talked into having large implants, which not surprisingly resulted in increased ptosis. DOI:10.1097/PRS.0b013e381fad608.

Lawrence Neal Gray, M.D.
Atlantic Plastic Surgery
100 Griffin Road
Portsmouth, NH 03801