LAUSR

Disappointed with long-term results and high scar burden of early approaches of reduction mammaplasty and mastopexy relying on skin flaps to shape the breast mound, aesthetic surgery of the breast has evolved to short scar techniques with direct shaping of the gland without relying on skin excision for breast mound form. Mastopexy (breast lifting) techniques are continually evolving; it has been considered a challenging procedure when combined with auto-augmentation without the use of a breast implant [1]. Despite great advantages of breast lifting, consistent longterm lack of fullness in the upper pole and bottoming-out are a major deficiency of this procedure. Stability of the surgical result in terms of restoration and maintenance of the breast shape and nipple position has been and still is a major source of concern. Poor tissue quality that has resulted in breast ptosis persists after mastopexy has successfully rejuvenated the patient’s breast profile; it may fail again, resulting in recurrent ptosis [2]. Classically, lower pole ptotic breast tissue is lifted, basically as an inferiorly based deepithelialized dermoglandular flap, and secured to the pectoralis fascia in a subglandular pocket at a superior level. A medially based pedicle modification was described by Hall-Findlay [3]. What Yilmaz is describing, is a genuine attempt to improve upper pole fullness and overcome recurrent bottoming-out [4]. We agree with the author that in breasts with short nipple-to-areola complex (NAC) to infra-mammary fold (IMF) distance, an inferiorly based flap would not provide enough tissue to augment the breast upper pole and would not be easily mobilized to be advanced superiorly. What the author is describing is in fact a suspension technique of a laterally based triangular flap mobilized and rotated with advancement supero-medially. The flap is sutured to the pectoralis fascia above the NAC level with two or three absorbable sutures. The author has, however, underestimated the consistent problem with all described suspension techniques that is recurrent ptosis due to gravity. We do not see why the technique described by Yilmaz should differ in that regard. To minimize if not prevent bottoming-out of suspended lower pole tissues and to improve breast shape and maximize longevity of outcome, Graf et al. described passing the autologous tissue flap deep to a strip of pectoralis muscle [5]. Central mound mastopexy with soft tissue reinforcement using a long-term poly-4-hydroxybutyrate resorbable scaffold material (GalaFLEX; Galatea Corp., Lexington, Mass.) has also been reported with encouraging results [2]. On the other hand, with vertical mastopexy, midline suturing of medial and lateral pillars is believed to provide good hammock support maintaining breast projection and upper pole fullness. Though the author claims suturing pillars to benefit from this hammock effect, with close analysis of the described technique, it is obvious that suturing of medial and lateral skin flaps, 1–1.5 cm in thickness that do not qualify to be described as pillars, will certainly not provide adequate long term lower pole support. It must be mentioned that different authors have & Fadi Ghieh [email protected]