Comment on Balancing Nipple and Inframammary Fold in Transaxillary Augmentation Mammaplasty with Anatomical Implant: The ‘NIMF’ Classification and Surgical Algorithm

Abstract

Addressing frequent breast asymmetry while performing augmentation mammoplasty is a key factor for securing patients’ satisfaction particularly since 93% of them are unaware of their asymmetry prior to being indicated by plastic surgeons as well stated by Li et al. [1]. Asymmetry may be subtle concerning nipples and/or inframammary folds (IMF) positions only; it may also be more substantial involving breast volume and breast mound profile almost always associated with nipples and/or IMF asymmetry. Li et al. [1] are describing 4 categories of breast asymmetry based on nipples and IMF positions and are proposing a rather detailed and elaborate algorithm for correction; however they have overlooked the more important and troublesome breast mound asymmetry that impacts considerably surgical outcome and may require further correction much more than what has been described by the authors. Nevertheless, the authors must be commended for shedding light on a rarely discussed aspect of augmentation mammoplasty. We agree with the authors that the nipples and IMF are pivotal landmarks in breast aesthetics and that proper preoperative planning of the new IMF position is crucial to achieve optimal outcome for augmentation mammoplasty. We strongly disagree however with their assertion that the new IMF should be maintained at the same preoperative level. Lengthening of the lower pole skin is invariably required for augmentation mammoplasty by either compliance-dependent lower pole expansion or more often by recruitment of submammary upper abdominal skin necessitating lowering of the IMF in a large number of patients, particularly when implantation of a large prosthesis is being contemplated [2]. The authors calculate the nipple-to-new-IMF distance under maximal skin stretch by an empirical formula as 1/2 (implant width ? implant projection). Claiming that this formula has been working well for 10 years in over 1500 cases of augmentation mammaplasty does not make it correct. Putting aside the difficulty in accurately measuring projection and the inherent variability in measurements with skin under maximal stretch, the proposed formula is conceptually incorrect specifically because the authors report using anatomical implants in all their patients. An aesthetically pleasing outcome is achieved only when optimal relationship of nipple to implant is respected preserving desirable upper to lower poles proportions. Thus estimating new nipple position is the most critical step in preoperative planning of augmentation mammoplasty. Thus, new nipple position, not IMF position, should be the guide in relation to which proper implant placement over the chest wall is determined. Subsequently, determining the lower border level of the implant footprint and secondarily determining IMF position, should be based by necessity on implant height in relation to nipple position, certainly not & Fadl Chahine [email protected]