Author’s reply to Dr. Gunnarsson’s discussion of “The spring back phenomenon: Does the final position of the nipple areola complex correspond to the pre-operative markings in reduction mammoplasty?” by Y. Godwin et al.

Abstract

We thank Dr. Gunnarsson for reviewing our work. Our study set out to try and see if the patient’s body morphology and tissue spring back could be used as effective pre-operative predictive tools to allow the surgeon to place the nipple areola complex at exactly the level from the manubruim selected by the pre-operative mark. This study was not designed to predict the possible long-term changes in position of the nipple areola complex. It was designed to see if there was error between what the surgeon marks and what the surgeon finally gets and could patient factors be applied when marking the patient to decrease that error. The study concluded that the patient’s intrinsic morphological factors do influence the surgeon’s decision of the level of the pre-operative nipple mark. The mark is placed lower on ptotic breasts and where a large excision is anticipated. As Doctor Gunnarsson points out, reduction mammoplasty is a procedure routinely performed by most plastic surgeons. However, experienced plastic surgeons rely on that very experience to get the mark at the right level. To date, anatomical landmarks, such as the level of the inframammary crease, have been used along with rather loose instructions such as “place the nipple 1 or 2 cm below the submammary fold”. The danger for the novice surgeon is that their estimated pre-operative mark may be too high to be adequate in the long-term. Recoil of their pre-operative marks may make this error worse. We therefore suggest to be cautious and place the nipple areola at least 0.6 cm lower than their estimate. This will help to compensate for variations between their intended nipple level and the actual resultant immediate postoperative level. It will not compensate for bottoming out. It will, however, help the surgeon get the nipple in at the level intended at pre-operative marking, and this chosen level should be selected bearing in mind that bottoming out may occur over the years. Although the pre-operative spring back values did reflect the patient’s intrinsic factors, they could not be applied to predict the error in the final nipple level that may result from tissue recoil. This study, therefore, reports a negative finding. We feel this research needed to be done to see if a simple patient measurement, like spring back, could increase the accuracy of nipple placement at the time of marking up. Doctor Gunnarsson questions how 8% of the final nipple positions could have been lower than the pre-operative marks. Our results have been recorded accurately. The cause of the nipples being lower than marked can only be the human error of the surgeon who took the measurements and did the surgery. Reduction mammoplasty was performed strictly following the pre-operative markings, so I think, the error is most likely at the time of measurement. At the time of measurement, a small dot is placed at the centre of the manubrial notch with the patient sittting up with the neck in neutral. However, if the patient extends or flexes the neck, the skin stretches or relaxes, and this small dot can be seen to ride up or descend. Patients have a natural tendency to look down at the markings when you are marking them. You may need to ask them to sit up straight and look ahead again. This is probably when errors of measurement occur. There is no way of making this Eur J Plast Surg (2007) 29:371–372 DOI 10.1007/s00238-007-0119-9