Invited Discussion on: Myo-Glandular Flap Breast Reduction: Preventing the Bottoming Out Deformity—A Novel Technique

Abstract

The number of large and heavy breasts is a common challenge for plastic surgeons. In this study, the author sought to broaden the pros and cons of tissue repositioning in a breast lift setting [1]. The author’s move toward developing maneuvers so the bottoming out phenomena, lack of nipple–areola complex sensitivity as well as lack of upper pole fullness and low setting breasts are explored well in their article. The placement of the horizontal part of the inverted T that the author describes points to the modification of technique admittedly used early on but well corrected with the increasing number of cases performed. Similar thoughts in improving the lower pole mastopexy–augmentation have been shown by others [2]. With the alterations in more traditional inframammary fold changes begins a movement to attempt to limit the older problems of bottoming out and displacing the lower pole of tissue a desired choice. It is well described that the creating of this fold change intraoperatively gives the surgeon a degree of variability which plays well in this scenario. The ability to diminish tension on that part of the breast tissue assists in decreasing flattening out of the lower pole encountered by plastic surgeons. The author’s choice of no internal sutures of the inframammary crease is unique and effective in an appropriate shape. Once seen after more cases, the confidence of this technique will likely grow. I agree with the choice of a glandular fixation to the chest wall to maintain improved breast shape despite the lack of the normal suture placement at the bottom of the breast. The author thoroughly discusses the planning of the placement of the upper pole and allows the choice of performing a placement of the lower pole in an untethered fashion to give a new method to avoid the bottoming out seen in other cases. Over-dissection of breast tissue can be problematic, but in this case, when dealing with the potential loss of any areola was assisted using the central, superior, and medial pedicles to the tissues’ preservation. The author’s choice of upper pole focus is also helpful by the avoidance of a dissection of the upper pole along with maintaining the breast tissues attached to the pectoralis muscle. The author’s use of releasing the pectoral major muscle was helpful in moving the myo-glandular flap in a position of higher elevation, which likely resulted in less bottoming out of the breast tissue. This choice should be recognized for its thorough and subsequent results. This is contrary to the technique performed by others that use the release of the tissue from the muscle and reposition it to attempt to achieve upper pole fullness. The author brings to the front other techniques of upper pole fullness and undermining that may lead to flattening of the tissue and is appropriate to avoid. Although the involvement of the pectoralis muscle appears to be increasing in physicians using those techniques, more extensive & Julio Garcia [email protected]