Pectoralis Major Median Myotomy: The Median Cut.

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Sir: With great interest, we read the article by Borenstein and Abrahami entitled “Pectoralis Major Median Myotomy: The Median Cut.”1 We truly appreciate the presented insights on the correction of the “waterfall deformity” in breast augmentation. The authors describe a novel technique, incorporated within a dual-plane breast augmentation, to avoid a type I double-bubble deformity or waterfall deformity by cutting the caudal edge of the pectoralis major muscle. Women who desire a correction of their breast after pregnancy and lactation period commonly suffer from upper pole atrophy and ptosis or pseudoptosis. These cases can be quite challenging regarding the decision-making for or against simultaneous mastopexy.2,3 According to many authors, avoiding the mastopexy whenever possible is advantageous for the patient and the surgeon. We agree that this particular collective with mild ptosis can benefit from the maneuver described by Borenstein and Abrahami and should generally receive the “the median cut.” However, if the ptosis is not corrected sufficiently and a necessary mastopexy is not performed, these patients are prone to revision surgery.4 Although we agree with the authors that the median cut is helpful in waterfall deformity prevention in certain cases, we see an additional benefit in this maneuver. To prevent an animation deformity, we have been using a virtually equal technique since 2015 in breast augmentation procedures. We cut the caudal margin of the pectoralis major muscle for 3 to 4 cm as described by Borenstein and Abrahami. Therefore, we apply this technique in every dual-plane augmentation and also in young female patients with small breasts who seek aesthetic breast enlargement and are not in danger of any waterfall deformity. This technical advancement was mentioned in our previous work “Motiva Ergonomix Round SilkSurface Silicone Breast Implants: Outcome Analysis of 100 Primary Breast Augmentations over 3 Years and Technical Considerations.”5 Although the prevalence and clinical significance of animation deformities remain unclear, the incidence of some degree of an animation deformity has been reported to be as high as 77.5 percent when implants are placed in a subpectoral plane, with a moderate or severe deformity seen in up to 15 percent of cases.6 In our experience, even though revision surgery is rarely indicated in animation deformity, patients can be bothered by this condition. We congratulate Borenstein and Abrahami for raising awareness for this simple and elegant technique, which can be an excellent technique for breast surgeons. Not only is the lifting effect on borderline ptotic breasts improved but it also diminishes the bothersome condition of animation deformity in dual-plane or submuscular breast augmentation. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. Raphael Wenny, M.D.Manfred Schmidt, M.D.Section of Plastic and Reconstructive SurgeryDepartment of General SurgeryKepler Uniklinikum LinzLinz, Austria Dominik Duscher, M.D.Section of Plastic and Reconstructive SurgeryDepartment of General SurgeryKepler Uniklinikum LinzLinz, AustriaDepartment for Plastic and Hand SurgeryKlinikum rechts der IsarTechnical University of MunichMunich, Germany Georg M. Huemer, M.D., M.Sc., M.B.A.Section of Plastic and Reconstructive SurgeryDepartment of General SurgertKepler Uniklinikum LinzLinz, Austria