Algoritmo para la selección de colgajos perforantes perimamarios en reconstrucción inmediata poscirugía conservadora / Algorithm to select chest wall perforator flaps in immediate conservative breast surgery reconstruction

RESUMEN Antecedentes: los colgajos perforantes perimamarios son de gran utilidad en la reconstrucción mamaria inmediata en cirugía conservadora. Objetivo: describir los resultados del empleo de un algoritmo sobre colgajos perforantes perimamarios en la reconstrucción mamaria inmediata después de cirugía conservadora por cáncer de mama. Material y métodos: se llevó a cabo un estudio retrospectivo descriptivo. Se revisaron las historias clínicas de las pacientes operadas entre enero de 2020 y diciembre de 2022 por carcinoma de mama con cirugía conservadora y que requirieron reconstrucción con colgajos perimamarios. Las indicaciones incluyeron déficit de volumen, defecto de contorno y asimetría. Se evaluó el pedículo vascular del colgajo mediante Doppler color en todos los casos, lo que permitió seguir un algoritmo para la selección de la mejor opción de colgajo. Resultados: se realizaron 20 colgajos en 19 pacientes. Promedio de edad: 52 años ± 11 (rango 30-76). No existieron complicaciones intraoperatorias. Una paciente requirió reoperación por compresión del pedículo vascular del colgajo por hematoma, con la pérdida parcial, y otro colgajo sufrió epidermólisis superficial. No hubo pérdidas totales de ningún colgajo. Todas recibieron radioterapia posoperatoria y no experimentaron pérdida de volumen ni retracciones. Con un promedio de seguimiento de 15 meses, las pacientes valoraron los resultados a 6 meses como excelente en 7, bueno en 11 y regular en 2. Conclusión: la selección de colgajos perforantes locales para corregir defectos mamarios después de cirugía conservadora, mediante el examen con Doppler color preoperatorio para la identificación del pedículo vascular y un algoritmo específico, permitió obtener resultados estéticos satisfactorios sin requerir elementos aloplásticos ni revisiones posteriores.

ABSTRACT Background: Chest wall perforator flaps are a good option for immediate breast reconstruction after conservative surgery. Objective: The aim of this study was to describe the clinical results of an algorithm for using chest wall perforator flaps for breast reconstruction after breast-conserving surgery for breast cancer. Material and methods: We conducted a descriptive and retrospective study. The information was retrieved from the medical records of the patients diagnosed with breast cancer who underwent breast-conserving surgery and required reconstruction using chest wall perforator flaps between January 2020 and March 2022. The indications included volume deficit, contour defect and asymmetry. The vascular pedicle of the flap was evaluated by color Doppler ultrasound in all cases, which allowed us to follow an algorithm for selecting the best flap option. Results: Twenty flaps were made in 19 patients. Mean age: 52 years ± 11 (range 30-76). There were no intraoperative complications. One patient required reoperation due to a hematoma with compression of the vascular pedicle of the flap with partial flap loss, and another flap presented superficial epidermolysis. There were no cases of complete flap loss. All the patients underwent postoperative radiation therapy without loss of volume or retractions. Mean follow-up was 15 months. At 6 months, patients rated the results as excellent, good, and fair in 7, 11, and 2 cases, respectively. Conclusion: The selection of local perforator flaps to correct breast defects after conservative surgery, using preoperative color Doppler ultrasound to identify the vascular pedicle and a specific algorithm, allowed us to obtain satisfactory aesthetic results without the need for alloplastic elements or subsequent revisions.

Intraoperative Fluorescence Imaging to Identify and Preserve the Fifth Anterior Intercostal Sensory Nerves during Inferior Pedicle Reduction Mammoplasty.

Postoperative sensitivity of the nipple-areola complex (NAC) is an important concern for women after reduction mammoplasty. Previous studies have demonstrated that sensory branches of the fifth anterior intercostal nerve are important for innervating the NAC and that using an inferior pedicle technique is associated with improved sensory retention. The significance of this case report is that it demonstrates the importance of the fifth anterior intercostal sensory nerve branches using a prototype fluorescent imaging camera. The benefit of this device is that it can detect intraoperative auto-fluorescence of nerves and facilitate their identification and preservation, potentially facilitating the retention of sensation in the NAC and surrounding skin. The goals of this article are, therefore, to demonstrate the importance of this neurovascular pedicle when the inferior pedicle technique is used for breast reduction; and to provide demonstrative evidence of the nerve's presence within the fifth anterior intercostal artery perforator pedicle. The case involved a woman with mammary hypertrophy who underwent bilateral reduction mammoplasty using the inferior pedicle technique. Full NAC sensation was demonstrated on postoperative day 3 with complete sensory recovery at 1- and 3-month follow-up confirmed. To our knowledge, this is the first reported instance of the fifth intercostal nerve being visualized during aesthetic breast surgery, demonstrating the importance of this neurovascular bundle for sensory preservation when an inferior pedicle reduction mammaplasty technique is used.

Indocyanine green fluorescence versus blue dye, technetium-99M, and the dual-marker combination of technetium-99M + blue dye for sentinel lymph node detection in early breast cancer-meta-analysis including consistency analysis.

BACKGROUND: Axillary sentinel lymph node biopsies are standard of care in patients with breast cancer and no clinically apparent metastases. Traditionally, technetium-99m, blue dye, or both have been used to identify sentinel lymph nodes. However, blue dyes miss up to 40% of sentinel lymph nodes, while technetium-99m use is complex, costly, and exposes patients to radiation. Over the past decade, studies have consistently found the biologically inert fluorescent indocyanine green to be 95% to 100% sensitive in detecting breast cancer sentinel lymph nodes, yet indocyanine green remains infrequently used. METHODS: We conducted an extensive meta-analysis comparing indocyanine green against blue dye, technetium-99m, and the dual-marker combination of technetium-99m + BD. Unlike prior meta-analyses that only assessed either per-case or per-node sentinel lymph node detection, we analyzed the following 5 metrics: per-case and per-node sentinel lymph node detection and metastasis-positive sentinel lymph node sensitivity, and mean number of sentinel lymph nodes/case. We further examined the consistency and magnitude of between-study superiority and statistically significant within-study superiority of each marker against others. RESULTS: For every metric and analysis approach, indocyanine green was clearly superior to blue dye and at least non-inferior, if not superior, to technetium-99m and technetium-99m + blue dye. Assessing the consistency of superiority by at least 2.0%, indocyanine green was superior to blue dye 73 times versus 1, to technetium-99m 42 times versus 9, and to technetium-99m + blue dye 6 times versus 0. Within-study statistically significant differences favored indocyanine green over blue dye 29 times versus 0 and over technetium-99m 11 times versus 2. DISCUSSION: For sentinel lymph node detection in patients with breast cancer with no clinically apparent metastases, indocyanine green is clearly and consistently superior to blue dye and either non-inferior or superior to technetium-99m and technetium-99m + blue dye.

Resultados en reconstrucción mamaria inmediata prepectoral con implantes / Result of immediate prepectoral implant-based breast reconstruction

RESUMEN Antecedentes: la reconstrucción mamaria inmediata prepectoral con implantes es la incorporación técnica más reciente al arsenal de reconstrucción mamaria. Esta técnica proporciona un aspecto más natural a la reconstrucción, elimina complicaciones, como la deformidad por animación, y disminuye el dolor posoperatorio. Objetivo: describir los resultados quirúrgicos en una serie de pacientes con reconstrucción mamaria inmediata prepectoral con implantes de silicona. Material y métodos: se realizó un estudio retrospectivo descriptivo; fueron revisadas las historias clínicas y los informes de anatomía patológica de pacientes operadas con la técnica descripta entre marzo de 2018 y diciembre de 2021, por carcinoma invasor, no invasor y sarcoma de mama. Todas fueron evaluadas en el preoperatorio con mamografía digital y presentaban más de 2 cm de cobertura grasa en la mama intervenida. Resultados: se registraron 52 reconstrucciones en 40 pacientes. El promedio de edad fue de 52 años (rango 30-76). En todas se realizó mastectomía con preservación del complejo aréolapezón. Con un promedio de seguimiento de 40 meses, no se registraron complicaciones mayores. No se encontró animación, desplazamiento ni rotación del implante. Se observó contractura capsular grados III y IV después del año de seguimiento en 3 pacientes que realizaron radioterapia posoperatoria. Los resultados estéticos fueron excelentes y buenos en 40 mamas (80,0%), regulares en 8 mamas (12,0%) e insuficientes en 4 mamas (8,0%). Se necesitó revisión quirúrgica posoperatoria inmediata por hematoma en 4 mamas (7,7%). Conclusiones: la reconstrucción inmediata con implantes prepectorales posmastectomía fue una técnica segura y con alto porcentaje de satisfacción.

ABSTRACT Background: Prepectoral implant-based breast reconstruction has recently been added to the armamentarium for breast reconstruction. This technique provides natural-looking breasts, avoids complications, such as animation deformity, and reduces postoperative pain. Objective: The aim of this study was to describe the surgical outcomes in a series of patients undergoing immediate prepectoral breast reconstruction with silicone implants. Material and methods: A descriptive and retrospective study was carried out with review of the medical records and pathology reports of patients who underwent surgery using the described technique for invasive carcinoma, non-invasive carcinoma, and sarcoma of the breast from March 2018 to December 2021. All the patients were evaluated preoperatively with digital mammography and had fat coverage thickness in the operated breast > 2 cm. Results: A total of 52 reconstructions were performed on 40 patients. Mean age was 52 age (range 30- 76). The nipple sparing mastectomy was undertaken in all the cases. There were no major complications during the 40-month average follow-up. None of the patients experienced animation deformity, implant displacement, or rotation. After one year of follow-up, three patients who underwent postmastectomy radiotherapy showed grades III and IV capsular contracture. The aesthetic results were excellent and good in 40 breasts (80.0%), fair in 8 breasts (12.0%) and insufficient in 4 breasts (8.0%). Four breasts (7.7%) required surgical revision in the immediate postoperative period. Conclusions: Immediate prepectoral implant-based breast reconstruction is a feasible technique with enduring results and high level of satisfaction.

The Anatomy of the Frontalis Muscle Revisited: A Detailed Anatomic, Clinical, and Physiologic Study.

BACKGROUND: There are differing opinions with regard to the specific mechanical forces related to contraction of the frontalis muscle and how it exerts its effects on eyebrow motion. OBJECTIVES: To perform a detailed anatomic and clinical study of the frontalis muscle in cadavers and patients to better define the movement of the frontalis muscle. METHODS: This study consisted of four arms that included: 1) dynamic ecography to evaluate movement of the frontalis muscle, 2) anatomical study of the relationship between the frontalis muscle and the deep fascia, 3) histological study to define the frontalis muscle attachments and 4) clinical study to evaluate the action of the frontalis muscle in patients undergoing a temporal face lift. RESULTS: The frontalis muscle was attached, inserted, and adhered to the deep layer of the fascia in the superior cephalic and middle third of the forehead. In the superior cephalic third of the forehead, loose areolar tissue was observed deep to the frontalis muscle and the deep layer of the fascia. Within the middle third of the forehead, the deep layer of the galea was fused with the periosteum and firmly adhered. In the inferior caudal third of the forehead, the frontalis muscle was separated from the deep galeal aponeurosis and interdigitated with the orbicularis muscle. When the frontal muscle end was dissected free from the deep fascia by approximately 1 cm and pulled upward, no movement of the eyebrows was observed. Eyebrow elevation was only achieved by pulling on the inferior part of the muscle. CONCLUSIONS: Frontalis muscle movement occurs from the inferior caudal end towards the mid part of the muscle as it contracts centripetally on its superficial layer sliding over the deep part strongly attached to the deep fascia.

Sensory Evaluation of the Nipple-Areolar Complex Following Primary Breast Augmentation: A Comparison of Incision Approaches.

BACKGROUND: The central inframammary incisional approach for breast augmentation surgery disrupts the fifth anterior intercostal nerve-artery-vein-plexus. The authors hypothesized that preservation of the fifth anterior intercostal neurovascular pedicle might completely preserve nipple-areola complex (NAC) sensitivity after implant breast augmentation. OBJECTIVES: The aim of the study was to analyze if the use of a laterally displaced incision achieves better sensitivity results than the conventional median submammary incision in females who underwent primary breast augmentation surgery. METHODS: A group of 25 female patients (50 breasts) underwent a surgical protocol for primary prepectoral implant breast augmentation with a laterally displaced submammary incision. This group was compared to a similar group of 25 patients (50 breasts) who underwent breast augmentation through a conventional submammary central approach. Sensitivity testing with Semmes-Weinstein monofilaments was performed in both groups preoperatively and on postoperative days 2, 14, and 30, and after 6 months. RESULTS: Both groups were similar in age, BMI, comorbidities, and implant volumes. Preoperatively, all patients reported normal sensory function in both breasts. Postoperatively, in the laterally displaced incision group, sensory function remained normal in NAC areas, whereas in the conventional incision group, all cases presented the same degree of sensitivity diminution at Days 2, 14, and 30 (P = .000). At 6 months, all values were the same as at Day 30. CONCLUSIONS: Preservation of the fifth AIC pedicle resulted in complete preservation of preoperative NAC sensitivity. The laterally placed inframammary incision should be considered for patients undergoing primary prepectoral implant breast augmentation.

Fluorescence Imaging to Identify and Preserve Fifth Intercostal Sensory Nerves during Bilateral Nipple-sparing Mastectomies.

The use of nipple-sparing mastectomies has increased steadily over the past 10-15 years. However, one major source of patient dissatisfaction with both skin- and nipple-sparing mastectomies is lost skin and/or nipple sensation postoperatively due to intraoperative, iatrogenic sensory nerve injury. We summarize the case of a 41-year-old woman with BRCA(+) breast cancer who underwent bilateral, risk-reducing nipple-sparing mastectomies, immediately followed by bilateral, direct-to-implant breast reconstruction, in whom a prototype fluorescent imaging camera was used to facilitate sensory nerve identification and preservation. Preoperatively, tactile and thermal quantitative sensory testing were performed using a 30-gauge needle to determine baseline sensory function over both breasts. Then, nipple-sparing mastectomies and direct-to-implant reconstruction were performed. Using a laterally-displaced submammary approach, the anterior intercostal artery perforator neurovascular pedicle was preserved. Then a prototype camera, which emits near-ultraviolet light, was used to detect nerve autofluorescence. Intraoperatively under near-ultraviolet light, both the fifth intercostal nerve and its sensory branches auto-fluoresced clearly, so that surgery was completed without apparent injury to the fifth intercostal nerve or any of its branches. Postoperatively, the patient reported full sensory function throughout both breasts and both nipple-areolar complexes, which was confirmed on both tactile and thermal sensory testing at 3-month follow-up. The patient experienced no complications and rated her overall satisfaction with surgery on both breasts as 10 out of 10. To our knowledge, this is the first time sensory nerve auto-fluorescence has been reported to reduce the likelihood of intraoperative, iatrogenic nerve injury and preserve sensory function.

The reverse LICAP flap: A laterally based submammary perforator flap for breast reconstruction.

INTRODUCTION: The traditional donor sites for autologous breast reconstruction include the abdomen, thigh, buttock, and posterior thorax. Herein, we describe the use of the reverse lateral intercostal perforator (LICAP) flap originating from the submammary region as an option for breast reconstruction. METHODS: Fifteen patients (30 breasts) were included in this retrospective review. The procedure was performed for immediate reconstruction following a nipple sparing mastectomy utilizing an inframammary incision or an inverted T pattern with preservation of the fifth anterior intercostal perforator (n = 8), volume replacement after implant explantation (n = 5), and partial lower pole resurfacing with exteriorization of a portion of the LICAP skin paddle (n = 2). RESULTS: Flap survival was achieved in all patients. Three flaps (10%) had 1-2 cm of intraoperative distal tip ischemia, which was managed by excision prior to inset and closure. At the 12-month postoperative follow-up, stable results with good nipple position, breast shape, and projection were achieved in all patients. CONCLUSIONS: The reverse LICAP flap is a safe, effective, and reliable option for breast reconstruction following mastectomy.

Perforator-Based Cross-Midline Flaps of the Trunk: A Paradigm Shift in Flap Design.

BACKGROUND: The traditional design for truncal perforator flaps is ipsilateral without midline decussation. The presumed rationale is to minimize the risk of distal flap necrosis. In this article, the authors present their experience and results with contralateral truncal perforator flaps designed and raised crossing the midline. METHODS: This retrospective analysis included 43 patients (25 men and 18 women) who underwent reconstructive surgery from 1984 to 2021 using a contralateral flap design crossing the midline in the anterior trunk and upper back. Considerations included pathology, location, and the dimensions of the defect and flap. Arithmetic and weighted means with their 95% confidence intervals were estimated to compare ipsilateral and contralateral techniques. RESULTS: Contralateral flaps used included the internal mammary perforator flap ( n = 28) superficial superior epigastric artery flap ( n = 8), superior epigastric perforator flap ( n = 2), and the second or ninth dorsal intercostal artery perforator flap ( n = 5). All of these flaps, excluding the superficial superior epigastric artery flap, demonstrated length and coverage surface averages that were significantly greater than those of traditional ipsilateral flaps. However, with the contralateral superficial superior epigastric artery, both measures were statistically similar to those of traditional ipsilateral flaps. CONCLUSION: The anatomical variation design suggests that the trunk midline is not a barrier and that perforator flaps in these two regions may be raised on different longitudinal axes without compromising vitality. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Revascularization of the Nipple-Areola Complex following Nipple-Sparing Mastectomy.

BACKGROUND: Preoperative vascular mapping has been demonstrated to be an excellent adjunct to perforator flap surgery by reducing operative times and enhancing surgical precision. This study evaluated the benefit of preoperative vascular mapping using magnetic resonance imaging and Doppler ultrasonography to identify the different perforators to the breast and compared it to postoperative mapping. The authors' intent was to determine whether preoperative knowledge of the various vascular sources to the nipple-areola complex affected the outcome and vitality of the nipple-areola complex. METHODS: A prospective study was performed on 15 patients undergoing 25 nipple-sparing mastectomies for breast cancer or genetic predisposition. Ten patients underwent bilateral mastectomy, and five underwent unilateral mastectomy. Mean age was 52 years (range, 30 to 76 years). The mean patient body mass index was 22.4 kg/m2 (range, 20 to 35 kg/m2). Inclusion criteria consisted of breast cancer or genetic predisposition and grade 1 or 2 breast ptosis. Exclusion criteria included prior breast surgery, grade 3 ptosis, and gigantomastia. All patients underwent immediate direct-to-implant reconstruction. RESULTS: Preoperative vascular mapping by magnetic resonance imaging and external Doppler ultrasonography was performed in all 15 patients. In all 25 breasts, the fifth anterior intercostal artery perforator was identified preoperatively and preserved intraoperatively. Postoperative imaging demonstrated patency of the fifth anterior intercostal artery perforator vessels in all patients. Nipple-areola viability was demonstrated in all breasts. CONCLUSIONS: This study demonstrates that preoperative magnetic resonance imaging and Doppler ultrasonography for mapping breast perforator vessels is a useful strategy and should be considered for select patients undergoing nipple-sparing mastectomy. Identification of dominant perforators to the breast allowed mastectomy planning with preservation of the important perforator to the mastectomy skin flaps and nipple-areola complex. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Symmetry following unilateral two-stage prosthetic breast reconstruction: Is there an optimal time for managing the contralateral breast?

INTRODUCTION: Achieving breast symmetry following unilateral mastectomy remains a challenge. Contralateral procedures are usually necessary to achieve breast symmetry. Controversy exists regarding whether these symmetry procedures should be performed at the time of the initial reconstruction or on a delayed basis. MATERIALS AND METHODS: The study included 105 patients who had unilateral mastectomy, of which 55 had a simultaneous (immediate) contralateral symmetry procedure and 50 had a delayed contralateral symmetry procedure. Outcomes were compared and assessed for each cohort based on demographics, complications, and patient satisfaction. RESULTS: The delayed cohort required more procedures (3.4 vs. 1.8, p < 0.0001) but shorter overall hospitalization length (2.8 vs. 4.1 days, p < 0.0001). The two cohorts experienced a similar rate of revision (38.3% vs. 49.3%, p = 0.17) The delayed cohort required a contralateral balancing procedure after completion of reconstruction more often than the immediate cohort (p = 0.021). Overall reconstruction-specific complication rates were similar in both cohorts. The 36-Item Short-Form Health Survey (SF-36), a validated questionnaire for quality-of-life assessment, was administered 3 months after surgery and demonstrated that both cohorts reported similar outcomes when comparing their satisfaction with treatment. CONCLUSIONS: The results of this study demonstrate that immediate contralateral symmetry operations can be performed safely without increased morbidity. A new algorithm is presented.

The Importance of Fifth Anterior Intercostal Vessels following Nipple-Sparing Mastectomy.

BACKGROUND: The authors describe the vascular anatomy of the fifth anterior intercostal artery perforator and its role for perfusion of the nipple-areola complex following nipple-sparing mastectomy. METHODS: Twenty fresh cadavers were injected with 20 cc of colored latex through the internal mammary artery. The catheter was placed at the level of the second intercostal space after removal of the rib. The fifth intercostal space was dissected under magnification to observe the origin and trajectory of the fifth anterior intercostal artery perforator. Six selective computed tomographic angiograms of the fifth intercostal artery perforator were performed. A clinical case of nipple-sparing mastectomy in a woman with mammary hypertrophy is provided to demonstrate the utility of preserving the fifth anterior intercostal artery perforator. RESULTS: The fifth anterior intercostal artery perforator was consistently observed in all the cases and confirmed by angiography. The perforator gives rise to several branches that traverse in all directions. The ascending branches of the fifth anterior intercostal artery perforator are directed toward the nipple-areola complex and course within the subcutaneous layer between the skin and the parenchyma. The fourth and fifth anterior intercostal artery perforators are independent of one another. CONCLUSION: The main ascending branch of the fifth anterior intercostal artery perforator reaches the nipple-areola complex by the subcutaneous tissue independently of the Würinger fascia.

The Deltopectoral/Internal Mammary Artery Perforator Flap Revisited: Design Variations Based on Cadaveric and Clinical Investigation.

ABSTRACT: Current understanding of the vascular anatomy of the anterior chest wall suggests that perfusion of the deltopectoral flap may be compromised when crossing the midline at the anterior thoracic wall. The traditional deltopectoral flap is designed longitudinally over the ipsilateral side to avoid the risk of distal flap necrosis. The purpose of this article is to present our experience and results with 26 deltopectoral flaps that were designed and raised with the perforating vessels on the ipsilateral side with the majority of the flap crossing the midline extending to the contralateral side. This anatomic variation in flap design indicates that the sternal midline is not a barrier and that the internal mammary perforator flap may be raised on different longitudinal axes.

Thoracodorsal artery flaps for breast reconstruction-the variants and its approach.

Thoracodorsal artery (TDA) flaps, ranging from the vascular-pedicled thoracodorsal artery perforator (TDAP) flap, the propeller TDAP flap, and the muscle-sparing latissimus dorsi (MSLD) flap to the conventional latissimus dorsi (LD) flap and the extended LD flap, can all be used for breast reconstruction. The aim of this paper and review is to share our experiences and recommendations for procedure selection when applying TDA-based flaps for breast reconstruction. We describe the different surgical techniques and our thoughts and experience regarding indications and selection between these procedures for individual patients who opt for breast reconstruction. We have performed 574 TDA flaps in 491 patients: 60 extended LD flaps, 122 conventional LD flaps, two MSLD flaps, 233 propeller TDAP flaps, 122 TDAP flaps, and 35 free contralateral TDAP flaps for stacked TDAP breast reconstruction. All the TDA flaps are important flaps for reconstruction of the breast. The LD flap is still an option, although we prefer flaps without muscle when possible. The vascular-pedicled TDAP flap is an option for experienced surgeons, and the propeller TDAP flap can be used in most reconstructive cases of the breast, although a secondary procedure is often necessary for correction of the pedicle bulk. The extended LD flap is an option for women with a substantial body mass index, although it is associated with the highest morbidity of all the TDA flaps. The MSLD flap can be used if the perforators are small or if dissection of the perforators is assessed to be hazardous.

Should breast reconstruction and breast oncoplastic procedures be performed during the coronavirus pandemic?

The onset of the COVID-19 pandemic has changed the face of the treatment of breast cancer and breast reconstruction globally. Mastectomy with immediate implant-based breast reconstruction was on the rise due to advances in meshes and implants. However, due to the prioritisation of the critically ill and diversion of the work force, breast cancer treatment has drastically changed. This is an opinion paper written by the authors with experience and importance in the scenario of breast reconstructive surgery. The authors are from different countries with the COVID-19 pandemic in different stages.

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

Breast augmentation is the most commonly performed plastic surgery among women worldwide. With time, implant selection shifted from arbitrary implantation to precise planning. Different methods address the dimensional planning process. Many of them are complex to put into practice, focusing mainly on the breast base. Constricted, short lower pole breasts are morphologically predisposed to complication such as double-bubble deformity. Yet, by focusing on the distance between the nipple on stretch and the inframammary fold, the D-SUN method guides the surgeon to find the most appropriate implant volume for anatomical form-stable silicon implants and IMF incision to avoid complications.Level of evidence IV 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.