Reply to Comment on “Four-step Augmentation Mastopexy: Lift and Augmentation at Single Time (LAST)”

Sir:

We thank the authors for their comments¹ on our article “Four-step Augmentation Mastopexy.”²

We surely agree about the aesthetic benefits of combining breast tissue resection with implants—we observed that this combination resulted in higher and longer patient satisfaction rates. We would like to point out that the final breast volume will not necessarily be lesser than the preoperative one. The resulting implant/breast tissue ratio is always higher after surgery, and aesthetic benefits of less “saggy components” will occur even with true volume augmentation.

However, we do believe that adequate implant lower pole support is of utmost importance. On observing long-term breast surgery patients, in several cases, the implant descends past the inframammary fold and/or previous augmentation/mastopexy transverse scar—which would literally be the definition of an implant bottoming-out. On secondary surgery, intraoperative findings include large pockets (surely larger than the original surgical dissection), demonstrating that the implant weight acts itself on stretching the lower pole soft tissues; in many instances, the inframammary fold needs to be surgically redefined. These findings reinforce our understanding that the implant support should be as reliable as possible. To prevent the Snoopy nose deformity it is also imperative to sufficiently remove lower pole tissue, for it will hold back or at least delay the descent of this tissue, which is most often lax.³

We place the implants and seal the pockets before tissue resection because this placing and sealing allows us to strictly apply the 14-point plan⁴ while dealing with the implants. We prefer not to use an implant sizer to avoid pocket enlargement—tight and supported pockets will contribute to implant stability. Also, the premature submuscular pocket sealing will keep the implants protected under 2 independent tissue layers. The remaining breast parenchyma thickness will be 2 cm, so it is possible to estimate the final soft tissue volume around the implant and, therefore, the final breast volume, with sufficient accuracy.

Despite some slight technical differences between our procedures, we share the same idea about the fact that there is a place for this type of surgery. It is important to understand that some patients’ expectations may be better fulfilled—they are all properly clarified about the shortcomings and benefits, and many of them make a choice for longer lasting results.