Plastic and Reconstructive Surgery • July 2015 A major advantage of the Pythagorean theorem may be the more three-dimensional aspect of our formula, as it includes the implant radius and projection, whereas other techniques are based only on implant volume. Nevertheless, a comparative study to evaluate the results of the Pythagorean approach and the method described by Aboelatta et al.2 would be very interesting and more than useful. Evaluation of the results of an incision location using the High Five system in our opinion is less useful because the exact position of the incision is not obtained from the system and would be too dependent on interpretation of the individual surgeon. Finally, we realize that because of the very valuable comments of Jiuzuo Huang and Xiao Long, we have just adjusted the “Pythagorean theorem system” for round breast implants by clearly stating never to place the incision higher than the inframammary fold when calculated as such: in such a case, the implant is actually too small for the breast envelope and the incision should (1) be placed in the existing inframammary fold or (2) the procedure should be combined with a mastopexy procedure to shorten the distance from the areola to the neo–inframammary fold and lift the areola-nipple complex. Both of these procedures have been performed as such by us during the past 2 years in some cases. DOI: 10.1097/PRS.0000000000001347
Lesley R. Bouwer, M.D. Department of Plastic Surgery Medical Center Leeuwarden Leeuwarden, The Netherlands Department of Plastic Surgery University Medical Center Groningen University of Groningen Groningen, The Netherlands
Berend van der Lei, M.D., Ph.D. Department of Plastic Surgery University Medical Center Groningen Faculty of Medicine University of Groningen Groningen, The Netherlands Correspondence to B. van der Lei, M.D., Ph.D. University Medical Center Groningen University of Groningen Hanzeplein 1 Postbox 30001 9700 RB Groningen, The Netherlands [email protected]
DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. REFERENCES 1. Tebbetts JB, Adams WP. Five critical decisions in breast augmentation using five measurements in 5 minutes: The high five decision support process. Plast Reconstr Surg. 2005;116:2005–2016. 2. Aboelatta YA, Aboelatta H, Elgazzar K. A simple method for proper placement of the inframammary fold incision in pri-
mary breast augmentation. Ann Plast Surg. March 29, 2014; Epub ahead of print.
Forgotten Functionality Sir:
W
e read with interest the prospective cohort study by Nuzzi et al. designed to quantify the physical, social, and psychological impact of breast asymmetry. Their commendable study examined the impact of this condition on 59 patients and compared the results to groups of 142 normal breasted individuals and 160 patients with macromastia.1 Their findings showed that breast asymmetry scored significantly lower than controls in three Short Form-36 domains (general health, social functioning, and role-emotional, in addition to the Rosenberg Self-Esteem Scale). The authors mention that this is the first large study to look at the physical, social, and psychological impact of this condition; however, interestingly, the study does not mention the primary function of the breast: lactation. Congenital breast asymmetry has been classified numerous times and ways, most recently by Kolker and Collins.2 This in itself proves the difficult and variable nature of this condition, which can present as anything from a slight discrepancy in glandular volume to unilateral amastia and Poland syndrome variants. Breast asymmetry caused by a deficiency in glandular volume can have a marked effect on the lactation ability of the affected breast.3 As this condition is often bilateral yet asymmetrical, the impact of reduced lactation can cause an inability to breastfeed. We note that the patients in this study cohort are young, with an age range up to 21 years. This cohort of patients may not yet have reached the age of childbearing and lactation, but this is exactly the group in which the complete potential impact of all components to the condition should be counseled. Breastfeeding is recommended by the World Health Organization in exclusivity to 6 months,4 with continued breastfeeding up to the age of 2 years. The health benefits of breastfeeding are well established and recommended by the American Academy of Pediatrics. Mothers are increasingly encouraged and keen to establish this mode of infant feeding over artificial feeding. In addition to its renowned physical health benefits for mother and infant, breastfeeding is associated with reduced postpartum depression and increased neonatal psychological well-being.5 When lactation does not work out despite maternal effort, there can be a profound effect on psychological wellbeing, potentially leading to postpartum depression.6 As the authors correctly point out, breast asymmetry is about not only cosmesis but also psychological well-being. We would add that breast asymmetry is not just about cosmesis and psychological well-being but also functionality. Breasts, when not functioning correctly in lactation, can have a profound negative effect on the already delicate state of maternal well-being. DOI: 10.1097/PRS.0000000000001352
108e Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Volume 136, Number 1 • Letters Siún M. Murphy, M.B., B.Ch., M.D. Nicola O’Byrne, I.B.C.L.C. Department of Plastic Reconstructive and Aesthetic Surgery Blackrock Clinic Dublin, Ireland Correspondence to Dr. Murphy Blackrock Clinic Rock Road Blackrock Co Dublin, Ireland
DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. REFERENCES 1. Nuzzi LC, Cerrato FE, Webb ML, et al. Psychological impact of breast asymmetry on adolescents: A prospective cohort study. Plast Reconstr Surg. 2014;134:1116–1123. 2. Kolker AR, Collins MS. Tuberous breast deformity: Classification and treatment strategy for improving consistency in aesthetic correction. Plast Reconstr Surg. 2015;135:73–86. 3. Neifert MR. Prevention of breastfeeding tragedies. Pediatr Clin North Am. 2001;48:273–297. 4. Sharma AJ, Dee DL, Harden SM. Adherence to breastfeeding guidelines and maternal weight 6 years after delivery. Pediatrics 2014;134(Suppl 1):S42–S49. 5. Jones NA, McFall BA, Diego MA. Patterns of brain electrical activity in infants of depressed mothers who breastfeed and bottle feed: The mediating role of infant temperament. Biol Psychol. 2004;67:103–124. 6. McPeak KE, Sandrock D, Spector ND, Pattishall AE. Important determinants of newborn health: Postpartum depression, teen parenting, and breast-feeding. Curr Opin Pediatr. 2015;27:138–144.
Reply: Psychological Impact of Breast Asymmetry on Adolescents: A Prospective Cohort Sir:
We thank the authors for their thoughtful comments regarding our 2014 Plastic and Reconstructive Surgery article entitled “Psychological Impact of Breast Asymmetry on Adolescents: A Prospective Cohort.”1 We agree that the deformational nature of breast asymmetry—in particular, breast hypoplasia and tuberous breast deformity—may hinder a woman’s ability to breastfeed and is well documented in the literature.2,3 Breast asymmetry has been associated with minimal postnatal breast engorgement, insufficient milk production and, in extreme instances, a complete inability to breastfeed.2,3 In an age where “breast is best,” one can hypothesize that these negative sequelae may further diminish the psychological well-being of women with breast asymmetry, a group proven in our study to already suffer psychological deficits compared with their unaffected female peers. As our adolescent
sample was nulliparous, we were unable to quantify or comment on the negative effects of impaired lactation because of breast asymmetry. It must be noted that of the roughly 75 percent of American mothers who choose to breastfeed, nearly 77 percent discontinue breastfeeding before the Centers for Disease Control and Prevention–recommended 1-year mark because of physical and lifestyle constraints.4 Compared with these figures, a study of 34 women with breast asymmetry who had not undergone surgical treatment found that 85 percent of their sample could not produce at least half of the milk volume necessary to nourish their infant within the first postpartum week.3 Although many women face difficulties breastfeeding, certainly women with breast asymmetry are at an increased disadvantage. We suggest in our article that early intervention for adolescent breast asymmetry may help alleviate the negative psychosocial effects of the condition. We must, however, acknowledge that the effect of surgery in the developing breast on future lactation is the source of some debate. Despite conflicting data, a recent meta-analysis has found that women undergoing breast augmentation were more likely to experience lactation difficulties than unaffected women who had not undergone breast surgery.5 As such, we agree that breast functionality must not be forgotten when considering the negative effects of breast asymmetry. Adolescents and parents in particular must be counseled regarding the possibility of diminished future lactation as a result of surgical intervention. Pregnant and postpartum women with breast asymmetry should also be counseled with respect to their increased risk for breastfeeding difficulties and encouraged by their health care provider to seek lactation support services. It remains unknown to what extent a diminished capacity to lactate would offset the potential benefits of improved breast symmetry in this population. We aim to address this question as we follow our young patients through adulthood. DOI: 10.1097/PRS.0000000000001342
Laura C. Nuzzi, B.A. Felecia E. Cerrato, M.P.H. Michelle L. Webb, P.A.-C. Heather R. Faulkner, M.D., M.P.H. Erika M. Walsh, M.D. Adolescent Breast Clinic and Department of Plastic and Oral Surgery
Amy D. DiVasta, M.D., M.M.Sc. Adolescent Breast Clinic and Division of Adolescent/Young Adult Medicine
Arin K. Greene, M.D., M.M.Sc. Brian I. Labow, M.D. Adolescent Breast Clinic and Department of Plastic and Oral Surgery Boston Children’s Hospital and Harvard Medical School Boston, Mass.
109e Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Lesley R. Bouwer, M.D. Department of Plastic Surgery Medical Center Leeuwarden Leeuwarden, The Netherlands Department of Plastic Surgery University Medical Center Groningen University of Groningen Groningen, The Netherlands
Berend van der Lei, M.D., Ph.D. Department of Plastic Surgery University Medical Center Groningen Faculty of Medicine University of Groningen Groningen, The Netherlands Correspondence to B. van der Lei, M.D., Ph.D. University Medical Center Groningen University of Groningen Hanzeplein 1 Postbox 30001 9700 RB Groningen, The Netherlands [email protected]
DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. REFERENCES 1. Tebbetts JB, Adams WP. Five critical decisions in breast augmentation using five measurements in 5 minutes: The high five decision support process. Plast Reconstr Surg. 2005;116:2005–2016. 2. Aboelatta YA, Aboelatta H, Elgazzar K. A simple method for proper placement of the inframammary fold incision in pri-
mary breast augmentation. Ann Plast Surg. March 29, 2014; Epub ahead of print.
Forgotten Functionality Sir:
W
e read with interest the prospective cohort study by Nuzzi et al. designed to quantify the physical, social, and psychological impact of breast asymmetry. Their commendable study examined the impact of this condition on 59 patients and compared the results to groups of 142 normal breasted individuals and 160 patients with macromastia.1 Their findings showed that breast asymmetry scored significantly lower than controls in three Short Form-36 domains (general health, social functioning, and role-emotional, in addition to the Rosenberg Self-Esteem Scale). The authors mention that this is the first large study to look at the physical, social, and psychological impact of this condition; however, interestingly, the study does not mention the primary function of the breast: lactation. Congenital breast asymmetry has been classified numerous times and ways, most recently by Kolker and Collins.2 This in itself proves the difficult and variable nature of this condition, which can present as anything from a slight discrepancy in glandular volume to unilateral amastia and Poland syndrome variants. Breast asymmetry caused by a deficiency in glandular volume can have a marked effect on the lactation ability of the affected breast.3 As this condition is often bilateral yet asymmetrical, the impact of reduced lactation can cause an inability to breastfeed. We note that the patients in this study cohort are young, with an age range up to 21 years. This cohort of patients may not yet have reached the age of childbearing and lactation, but this is exactly the group in which the complete potential impact of all components to the condition should be counseled. Breastfeeding is recommended by the World Health Organization in exclusivity to 6 months,4 with continued breastfeeding up to the age of 2 years. The health benefits of breastfeeding are well established and recommended by the American Academy of Pediatrics. Mothers are increasingly encouraged and keen to establish this mode of infant feeding over artificial feeding. In addition to its renowned physical health benefits for mother and infant, breastfeeding is associated with reduced postpartum depression and increased neonatal psychological well-being.5 When lactation does not work out despite maternal effort, there can be a profound effect on psychological wellbeing, potentially leading to postpartum depression.6 As the authors correctly point out, breast asymmetry is about not only cosmesis but also psychological well-being. We would add that breast asymmetry is not just about cosmesis and psychological well-being but also functionality. Breasts, when not functioning correctly in lactation, can have a profound negative effect on the already delicate state of maternal well-being. DOI: 10.1097/PRS.0000000000001352
108e Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Volume 136, Number 1 • Letters Siún M. Murphy, M.B., B.Ch., M.D. Nicola O’Byrne, I.B.C.L.C. Department of Plastic Reconstructive and Aesthetic Surgery Blackrock Clinic Dublin, Ireland Correspondence to Dr. Murphy Blackrock Clinic Rock Road Blackrock Co Dublin, Ireland
DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. REFERENCES 1. Nuzzi LC, Cerrato FE, Webb ML, et al. Psychological impact of breast asymmetry on adolescents: A prospective cohort study. Plast Reconstr Surg. 2014;134:1116–1123. 2. Kolker AR, Collins MS. Tuberous breast deformity: Classification and treatment strategy for improving consistency in aesthetic correction. Plast Reconstr Surg. 2015;135:73–86. 3. Neifert MR. Prevention of breastfeeding tragedies. Pediatr Clin North Am. 2001;48:273–297. 4. Sharma AJ, Dee DL, Harden SM. Adherence to breastfeeding guidelines and maternal weight 6 years after delivery. Pediatrics 2014;134(Suppl 1):S42–S49. 5. Jones NA, McFall BA, Diego MA. Patterns of brain electrical activity in infants of depressed mothers who breastfeed and bottle feed: The mediating role of infant temperament. Biol Psychol. 2004;67:103–124. 6. McPeak KE, Sandrock D, Spector ND, Pattishall AE. Important determinants of newborn health: Postpartum depression, teen parenting, and breast-feeding. Curr Opin Pediatr. 2015;27:138–144.
Reply: Psychological Impact of Breast Asymmetry on Adolescents: A Prospective Cohort Sir:
We thank the authors for their thoughtful comments regarding our 2014 Plastic and Reconstructive Surgery article entitled “Psychological Impact of Breast Asymmetry on Adolescents: A Prospective Cohort.”1 We agree that the deformational nature of breast asymmetry—in particular, breast hypoplasia and tuberous breast deformity—may hinder a woman’s ability to breastfeed and is well documented in the literature.2,3 Breast asymmetry has been associated with minimal postnatal breast engorgement, insufficient milk production and, in extreme instances, a complete inability to breastfeed.2,3 In an age where “breast is best,” one can hypothesize that these negative sequelae may further diminish the psychological well-being of women with breast asymmetry, a group proven in our study to already suffer psychological deficits compared with their unaffected female peers. As our adolescent
sample was nulliparous, we were unable to quantify or comment on the negative effects of impaired lactation because of breast asymmetry. It must be noted that of the roughly 75 percent of American mothers who choose to breastfeed, nearly 77 percent discontinue breastfeeding before the Centers for Disease Control and Prevention–recommended 1-year mark because of physical and lifestyle constraints.4 Compared with these figures, a study of 34 women with breast asymmetry who had not undergone surgical treatment found that 85 percent of their sample could not produce at least half of the milk volume necessary to nourish their infant within the first postpartum week.3 Although many women face difficulties breastfeeding, certainly women with breast asymmetry are at an increased disadvantage. We suggest in our article that early intervention for adolescent breast asymmetry may help alleviate the negative psychosocial effects of the condition. We must, however, acknowledge that the effect of surgery in the developing breast on future lactation is the source of some debate. Despite conflicting data, a recent meta-analysis has found that women undergoing breast augmentation were more likely to experience lactation difficulties than unaffected women who had not undergone breast surgery.5 As such, we agree that breast functionality must not be forgotten when considering the negative effects of breast asymmetry. Adolescents and parents in particular must be counseled regarding the possibility of diminished future lactation as a result of surgical intervention. Pregnant and postpartum women with breast asymmetry should also be counseled with respect to their increased risk for breastfeeding difficulties and encouraged by their health care provider to seek lactation support services. It remains unknown to what extent a diminished capacity to lactate would offset the potential benefits of improved breast symmetry in this population. We aim to address this question as we follow our young patients through adulthood. DOI: 10.1097/PRS.0000000000001342
Laura C. Nuzzi, B.A. Felecia E. Cerrato, M.P.H. Michelle L. Webb, P.A.-C. Heather R. Faulkner, M.D., M.P.H. Erika M. Walsh, M.D. Adolescent Breast Clinic and Department of Plastic and Oral Surgery
Amy D. DiVasta, M.D., M.M.Sc. Adolescent Breast Clinic and Division of Adolescent/Young Adult Medicine
Arin K. Greene, M.D., M.M.Sc. Brian I. Labow, M.D. Adolescent Breast Clinic and Department of Plastic and Oral Surgery Boston Children’s Hospital and Harvard Medical School Boston, Mass.
109e Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
