Patrick Mallucci

Population analysis of the perfect breast: a morphometric analysis.

Background: The authors previously identified key objective parameters that define the aesthetic ideal of the breast in a study of 100 models with natural breasts. In this follow-up article, the opinion of the general public on ideal breast proportions was surveyed. Methods: One thousand three hundred fifteen respondents were asked to rank the attractiveness of images of four women with varying breast sizes. Each of the women’s breasts were morphed into four different proportions. One of the key features was the upper pole–to–lower pole percentage proportion, corresponding to ratios of 35:65, 45:55, 50:50, and 55:45. Rankings were analyzed according to population demographics. Effects of age, sex, nationality, and ethnicity were evaluated. The responses of 53 plastic surgeons were included. Results: Breasts with an upper pole–to–lower pole ratio of 45:55 were universally scored highest, in particular, by 87 percent of women in their thirties (n = 190), 90 percent of men (n = 655), 94 percent of plastic surgeons (n = 53), 92 percent of North Americans (n = 89), 95 percent of South Americans (n = 23), 86 percent of Europeans (n = 982), 87 percent of Caucasians (n = 1016), and 87 percent of Asians (n = 209). Conclusions: This study reaffirms the authors’ previous findings that the 45:55 ratio has universal appeal in defining the ideal breast. The authors propose that this proportion should be used as a basis for design in aesthetic surgery.

Design for Natural Breast Augmentation: The ICE Principle.

Background: The authors’ published studies have helped define breast beauty in outlining key parameters that contribute to breast attractiveness. The “ICE” principle puts design into practice. It is a simplified formula for inframammary fold incision planning as part of the process for determining implant selection and placement to reproduce the 45:55 ratio previously described as fundamental to natural breast appearance. The formula is as follows: implant dimensions (I) − capacity of the breast (C) = excess tissue required (E). The aim of this study was to test the accuracy of the ICE principle for producing consistent natural beautiful results in breast augmentation. Methods: A prospective analysis of 50 consecutive women undergoing primary breast augmentation by means of an inframammary fold incision with anatomical or round implants was performed. The ICE principle was applied to all cases to determine implant selection, placement, and incision position. Changes in parameters between preoperative and postoperative digital clinical photographs were analyzed. Results: The mean upper pole–to–lower pole ratio changed from 52:48 preoperatively to 45:55 postoperatively (p < 0.0001). Mean nipple angulation was also statistically significantly elevated from 11 degrees to 19 degrees skyward (p ⩽ 0.0005). Accuracy of incision placement in the fold was 99.7 percent on the right and 99.6 percent on the left, with a standard error of only 0.2 percent. There was a reduction in variability for all key parameters. Conclusion: The authors have shown using the simple ICE principle for surgical planning in breast augmentation that attractive natural breasts may be achieved consistently and with precision. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Plastic, reconstructive and aesthetic surgeon: impact of managing perceptions on aesthetic publications

Perceptions about plastic surgery are a topical source of discussion. As a group of reconstructive surgeons who also practice aesthetic surgery, we are entering a period where we are trying to change public and peer perceptions of aesthetic surgery. The accessibility of cosmetic surgery, the emergence of cosmetic ‘tourism’ and the decline of aesthetic procedures from the NHS have left us needing to define to those around us, peers, stakeholders and the public, what it is exactly that we do. The recent collaboration between BAPRAS and Forster highlights the significance we place on how we are perceived. Plastic surgery is fascinating for us as surgeons but equally it would appear fascinating to others for what we might consider to be the ‘wrong’ reasons. Cosmetic surgery and the world of ‘nip and tuck’ is an exaggerated aspect of the speciality but undisputedly is the side which most people are familiar and feel comfortable with. The reconstructive aspect, the side that gets most of us out of bed in the morning, it would appear, is easily forgotten or overlooked. For many patients reconstructive and aesthetic surgery go hand in hand, and we know that restoration of both form and function are usually the goals of our work. As Laing and Sachedina succinctly pointed out in a recent editorial

Corrigendum: Fat harvest using a closed-suction drain

[This corrects the article on p. 288 in vol. 43.].

Reply: Population Analysis of the Perfect Breast

643e Reply: Population Analysis of the Perfect Breast: A Morphometric Analysis Sir: We welcome Dr. Swanson’s comments regarding our recent publication. We have some reservations, however, with the title of his correspondence and the evidence presented within. His communication is entitled “Ideal Breast Shape: Women Prefer Convexity and Upper Pole Fullness.” This statement chooses to completely ignore the findings of the population study published in the peer-reviewed article in this Journal.1 It is a statement based on personal opinion backed by no evidence. It is stated in his correspondence that “Mallucci and Branford promote four critical ideals of breast beauty” and that “The authors prefer a linear or slightly concave upper pole.” The whole point of the population study was to ask a highly mixed population for their opinion—the results are not an expression of our (the authors’) opinions, they are those of the population questioned. The editor of this Journal has produced a 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. DOI: 10.1097/PRS.0000000000001085

The bootlace thighplasty technique: Making use of sutures and staples

The medial thigh lift was originally described by Lewis. Lockwood subsequently contributed advancements to the design using fascial anchoring to produce stable results. The non-compressible nature of the tissues in the thigh necessitates accurate planning of skin-fat envelope excision. If resection is excessive this may result in skin necrosis, wound dehiscence or stretched scars. Inadequate resection leads to residual skin redundancy and recurrence of laxity. These complications are related to difficulties in setting the correct tension during preoperative marking and intraoperatively. Because of mobility of the tissues and distortion during surgery, indelible preoperative marking is essential to facilitate precise closure. Intraoperative oedema makes closure more difficult: Segmental resection and sequential closure techniques have facilitated this process, but may result in additional scars. We have addressed these issues using the “bootlace thighplasty” technique. We describe the use of skin staples and sutures to address three important aspects in thighplasty: Preincision “tailor tacking” with staples which takes tissue tension into account; Staples ensure that the position of skin markings and horizontal hash marks are clearly preserved during surgery ensuring accurate apposition of skin edges; Staple and suture pulley-assisted intraoperative approximation of skin edges during tissue resection facilitates tension free closure whilst simultaneously reducing intraoperative oedema. The patient is marked standing with knees apart with an indelible marker. The superior incision is marked in the perineal-thigh crease, stopping medial to the femoral triangle: Posteriorly, the incision continues into the medial buttock crease. A crescent of redundant skin is marked for resection. Medial thigh skin is retracted both medially and posteriorly, demonstrating the horizontal skin redundancy: Skin is marked and these initial lines are checked using the skin pinch technique. Horizontal hash marks are made approximately 5 cm apart.