Comments on “Breast augmentation combined with a transposed glandular flap for prevention and correction of lower pole deformities”

Sir, We read with great interest the article entitled BBreast augmentation combined with a transposed glandular flap for prevention and correction of lower pole deformities^ by Dmitry Batiukov and Vladimir Podgaiski in which the authors reported their experience in refining lower pole contouring in a 30 series of cases during breast augmentation [1]. Since it is a very sensitive issue for the breast surgeon community, we really appreciate their effort in preventing lower pole deformity but we have some elements to discuss. Contouring a natural convexity with a pleasant and regular curve of the inferior quadrants is not always simple during breast surgery, and a meticulous preoperative planning, both in implant and surgical technique selection, is mandatory. In 2015, we published a paper reporting our experiences in preventing lower pole deformities in 71 patients who underwent tuberous breast correction, and later on, in 2017, we reconsidered our technique basing on a larger series of cases with an average follow-up of 25.9 months ranging from 6 to 60 months [2, 3]. In 2015, we described exactly the same adipo-glandular flap proposed in 2017 by the two authors. Furthermore, comparing the drawings explaining their surgical techniques, I found evident analogies with those available in our previous article. As discussed by the two authors, breast lower pole deformities after breast augmentation may occur, and double bubble deformity represents one of the worst side effects. It may occur more frequently in tuberous breast correction but, as reported by the authors, also in the presence of high inframammary fold, especially in the presence of inelastic tissues and wide implant. However, whenever part of the breast implant is located below the native inframammary fold or when the outer surface of the prosthesis is not homogeneously covered by the parenchyma, either for the implant size or congenital disorder, it may lead to unsatisfactory outcomes [4].We fully agree with the authors that the flap we proposed firstly works very efficiently to prevent lower pole deformities also in case of volume deficiency after implant placement, and we are very happy that our study has suggested a further publication by Batiukov and Podgaiski but we have further elements to discuss. The authors present an impressive series of postoperative outcomes, but the preoperative images, as far as it is possible to appreciate from the pictures, do not seem to reveal a real risk of postopertive lower pole deformities. The quality, the quantity and the consistency of native breast tissue show a normal and good appearance especially those reported in Figs. 5 and 6. In addition, the increment in breast size seems to be moderate. Furthermore, 15 months follow-up may result a very short time to evaluate the stability of surgical outcomes especially in cases of glandular tissue atrophy. I would like to encourage the authors to verify the efficacy of our technique in more difficult cases that show real risk of lower pole deformity during breast augmentation procedures.