D-SUN Method to Prevent Double-Bubble Deformity in Broad Base Breasts with High-Rising Inframammary Fold

Dear editors, We read with great interest the article titled ‘‘D-SUN Method to Prevent Double-Bubble Deformity in Broad Base Breasts with High-Rising Inframammary Fold’’ by Fertsch S. et al., in which the authors clearly described their ‘‘D-SUN method’’ to guide surgeons to find the most appropriate implant volume for anatomical form-stable silicone implants and IMF incision placement to avoid complications in constricted short lower pole breasts. Finding the exact position of the surgical incision in the sulcus during augmentation mammoplasty in a broad breast with a high-rising inframammary fold is one of the most difficult items. We congratulate the authors for their innovative method and for their effort to amplify current literature with a new method to reduce complications in such difficult cases, but we have some elements to discuss. Double bubble is a common complication in patients with high inframammary folds, because the rigidity and morphological characteristic of the fascial framework are resistant to the stretching caused by the implant’s curvature. Double-bubble deformity occurs when the entire outer surface of the implant is not completely covered by the gland. When the lower edge of the implant must be located lower than the previous sulcus, a double fold aspect is revealed [1, 2]. The D-SUN method is a very useful procedure to calculate the exact position of the new fold, but it is not sufficient to avoid double-bubble deformity, because it may depend on other reasons. The correct choice of the implant is mandatory, but the clinical finding of this type of breast requires the correction of the rising inframammary fold and the gland should be processed to obtain complete coverage of the implant, including its distal edge [3]. Adipoglandular flaps or fat grafting help to lower the native sulcus, increase the vertical diameter of the breast and allows complete coverage of the breast implant [4]. The D-SUN method requires calculating the distance from the IMF to the nipple on stretch. This maneuver is strictly dependent on the surgeon’s personal sensibility and experience, because correct measurement could be difficult to obtain, especially in breast abnormalities such as tuberous breast, in which the lower pole can be concave or flat. Periareolar access permits to address and treat major problems in this type of breast and, avoids any scar misplacement, reduces scar visibility, by hiding it in a colortransition zone, and avoids, on the contrary of IMF access, accidental exposure during arm movement out of the bra