Reply to: Comments on “Breast augmentation together with intraoperative glandular transposition flap for prevention and correction of lower pole deformities”
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We would also like to congratulate the authors for their great results in very complicated cases. The classification of the tuberous breast that they introduced is of great value. The point of the present discussion is the flap mentioned in our article, which authors think is the same they described earlier .
Indeed, there are some similarities between their work and our work. However, there are several important factors of difference that we would like to highlight in detail.
There are two different flaps mentioned in their article , namely the “adipo-glandular flap” or “distal flap” and the “second flap,” i.e., “retro-areola distally based flap.”
Please, note that the “second flap” is completely different from ours. We did not need it and did not use it in our series. They used the “second flap” due to the nature of the deformity and to fill the gap produced, if we are not mistaken, by the first flap—“adipo-glandular flap.” In fact, this “second flap” is exactly the flap they have named in the title of the article and the flap they have written about in the conclusion of the abstract section (“The authors propose the use of the retro-areola glandular flap to resolve the typical residual depression of the final mammary aspect thus to overcome the malformation completely”). Therefore, this flap seems to be the flap about which the article is written. In fact, it looks very much like the “Flap Type IV” described by E. Muti in 2010 .
Our experience is predominantly based (and authors are absolutely right) on the normally developed breast. On the careful exploration of our results, we realized that the deformity of the lower pole might develop and persist even without the lowering of the inframammary fold (IMF). We started to pay close attention to it during the operation. We did not plan any of the flaps on the patients before the operation. This decision was based on the intraoperative findings. If we planned considerable IMF lowering, especially in the presence of ptosis and malformations, we opted for different techniques from the very beginning as stated in our article;
- 2.Normally developed breast means that we have (as evident from our drawings, pictures, and video) performed the following:
moved our flap to the breast, IMF, but not lower, not to the abdomen;
moved a normal, not herniated breast tissue;
moved it from the lower pole, not from the subareolar tissue.
Our flap is never based at the base of the breast; instead, it is based on the lower pole. Furthermore, if one follows the dotted line on the figure 1c in their article, it is evident that the base of their flap should be somewhere in the abdomen, which differs from our concept and contradicts figure 1d;
They have utilized the “adipo-glandular” flap, and we have used a purely glandular flap. This is evident from our text, drawings, pictures, and video;
We have not fixated the flap, as we do not need it; and
There is no information in the text that indicates that they cut the gland like we did, splitting the gland thickness into two layers—superficial and deep. There is no division on the skin, subcutaneous and glandular tissues, in their drawings; therefore, it is unclear where the dotted line in figure 1c really goes (between the skin and the gland or in the gland). If one looks at figure 2b, the color and structure of the tissues above the pectoralis major muscle are the same as in the reconstructed lower pole in the same figure. Is it all fat, gland? Therefore, it is not easy to guess what was meant. The name “adipo-glandular” compels one to think that they may have included subcutaneous fat in the flap, indicating that they may have used the full thickness glandular flap. The necessity of the “second flap” that they fixate to “the base of the first flap subcutaneously…” becomes obvious in this case. This explanation continues logically into the discussion section where they point the “different thicknesses between the areola and its peripheral skin covering the pivot point of the flap…” But the base of our flap is 100% subglandular, and it is based on the gland and the pivot point of our flap is covered by the gland.
Another article they mentioned in the references  presents the same figures; however, the flap is called “inferior superficial pedicled flap.” Why is the name different? Is it another flap? Why is it called “superficial”? We cannot call our flap superficial. The supplementary video material partly clarifies the technique (although the video ends abruptly); however, the details are absent, and the abovementioned arguments are valid. The traction they apply on the gland while dissecting the flap makes the dissection plane and the tissue to be included (maybe that is why it is “superficial flap”) in the flap different from our technique.
We also doubt whether it is consistently possible “to cover entirely the prosthesis” with this kind of flap. This is supported by other authors  and the implementation of fat grafting in their series.
We are really sorry to engage in this kind of discussion, but our article  was accepted on 9th April 2017 and published online on 13th May 2017, whereas their article  which contains video was published on 6th September 2017.
The abovementioned are some of our thoughts based on their text. We have tried to make our article as easy as possible to understand. We are sorry if it has led to misconceptions. We highly appreciate the letter they submitted.
We have continued to use the flap in the way it is described in our article and have followed up the patients. The results are stable, and there are no secondary deformities. We consider one of the factors for the stability to be the choice of the polyurethane implants in 100% of the cases. Other kinds of implants, which are not fixed, exert pressure on the lower pole, which may lead to atrophy, secondary ptosis, and deformities.
Based on the points mentioned above, we believe that our article (i.e., the description of the procedure, flap, drawings, video) contains new and valuable information to the reader. In fact, the factors of importance should not be about “the first” or “technique.” Instead, it should be about delivering the best results to the patients. We are open to discussion and collaboration and would like to thank Dr. Innocenti and colleagues for starting the discussion. It was a valuable opportunity to explain the details.
Compliance with ethical standards
Conflict of interest
Dmitry Batiukov and Vladimir Podgaiski declare that they have no conflict of interest.
- 2.Alessandro Innocenti, Dario Melita, Francesco Ciancio, Marco Innocenti (2018) Comments on “Breast augmentation combined with a transposed glandular flap for prevention and correction of lower pole deformities”. Eur J Plast Surg. https://doi.org/10.1007/s00238-018-1391-6
- 3.Innocenti A, Innocenti M (2015) Retro-areola distally based flap in the management of the full expression of tuberous breast: a simple strategy to resolve a weak point of the deformity. Aesthetic Plast Surg 39(5):700–705Google Scholar
- 4.Innocenti A, Innocenti M, Mori F, Melita D, Ciancio F, Cordova A (2017) Tuberous breast: past, present, and future: personal classification, treatment, and surgical outcomes. Ann Plast Surg. https://doi.org/10.1097/SAP.0000000000001200
- 6.Muti E (2010) Tuberous breast. Acta Medica Edizioni — Adottati Fidenza, Parma, p53Google Scholar