Invited Discussion on: Simultaneous Augmentation Mastopexy with an Inferiorly Based Fascioglandular Flap: A Modification
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EDITOR’S INVITED COMMENTARY
Invited Discussion on: Simultaneous Augmentation Mastopexy with an Inferiorly Based Fascioglandular Flap: A Modification of the Balcony Technique Chiara Botti1
Received: 5 June 2020 / Accepted: 8 June 2020 Ó Springer Science+Business Media, LLC, part of Springer Nature and International Society of Aesthetic Plastic Surgery 2020
Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266. Mastopexy with implants has always been considered a very challenging procedure. As stated in this well-written article, it is difficult to reconcile two opposite needs: that of tightening the skin envelope to correct breast ptosis and that of augmenting the breast volume and fullness. So much has been the fear of this procedure that many have recommended staging it. Obviously, that is a quite prudent approach, but rather difficult to be accepted by patients. Cosmetic surgery patients, indeed, are reluctant to undergo two separate procedures, if given the option of one. Most women, nowadays, are very active and not willing to have two downtimes. On top of it, two procedures would inevitably be more expensive, require undergoing general anesthesia/sedation as well as feeling pain and discomfort twice. The issues to be taken into consideration are both the safety of the procedure and the longevity of the results. The idea of providing coverage of the lower pole of the implant by using an inferiorly based fascioglandular flap is interesting. A valid alternative remains submuscular implant insertion, but the authors explained why that plane was not chosen. Since wound dehiscence, especially at the crossing of the vertical and horizontal and/or periareolar incisions,
& Chiara Botti [email protected] 1
can be an issue, having one more layer of tissue to prevent implant exposure can be of help. Fascia may have more strength than dermis, and this is the same concept on which the deep plane face lift is based. Rather than pulling on the skin, tension is placed on the SMAS, which is believed to be more robust and less likely to give in than the cutaneous tissue. In the same way, pectoralis fascia in the case of breasts will be more reliable than dermis, particularly considering that the skin of a ptotic breast has already lost most of its elasticity by definition. Another observation is that new generation implants are supposed to produce an extremely thin capsule and one can no longer count on the Velcro effect of the old macrotextured implants; therefore, any further inner support to prevent implant bottoming out is to be considered useful. At the same time, though, it must be highlighted that most of the breast support is still provided by joining the vertical pillars rather than relying on the internal brassiere created by either a fascial or a dermal flap. The main use of any of these flaps is that
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