Commentary on “The springback phenomenon:
does the final position of the nipple/areolar complex
correspond to the preoperative markings in reduction
mammaplasty?” by Y. Godwin et al.
G. L. Gunnarsson
Published online: 21 March 2007
The reduction mammaplasty is probably the most routinely
performed operation by any plastic surgeon. We are constantly
trying to improve our patient’s safety by searching for a safer
and simpler technique. Much has been added to the great in-
ventions of pioneers in the field, and the search for improve-
ment is still ongoing. The goal is to make it absolutely safe.
The authors seek an understanding of tissue elasticity
and want to see if tissue spring back affects the end result.
They also evaluate body morphology as a predictive tool
for postoperative outcome and conclude that there is a
greater spring back of breasts if they are big and pendulous.
There is otherwise no relation to the postoperative outcome.
They come to the conclusion that the surgeon has a tendency
to place the nipple–areolar complex (NAC) mark too high,
and the end results are consistently higher than expected by
a median of 0.6 cm.
The measured spring back of the preoperative nipple
marking and postoperative NAC location are relatively the
same. I would consider the difference to be within the limits
of normal measurement error.
The measurement of pre- and postoperative jugular node
to nipple distance is interesting and correlates to similar
measurements done by other researchers. However, I do not
think that it is safe to make any assumptions on the median
values stated by the authors because individuality is highly
variable, ranging up to 20 cm difference. The nipple mark is
placed higher than marked in 65% of patients and as
estimated in 27% or lower in 8%. I find it hard to understand
that the nipple can be placed lower than marked if operative
markings are strictly followed. If the reason is due to
postoperative tissue stretch, it should be apparent in more
patients than the 3 patients of the 37. In addition, the dif-
ference is only half a centimeter, and I personally would
consider that as a measurement error. I have noticed that there
is a measurement difference of up to 1 cm by an individual
measurer marking the nipple/areola distance. Because there
is only one researcher doing the measurement, it might be
less of a difference but still I doubt the conclusion.
The most important conclusion in my opinion is that the
spring-back phenomenon is not due to tissue recoil and
does not explain the higher placement of the NAC observed
in 60% of patients in the study for it does not correlate
to the judgment error. Thus, it is not a useful tool in the
preoperative evaluation of mammaplasty patients.
They also show that the tissue spring back is greater
preoperatively than postoperatively. In my opinion, too
many good evaluations suffer from lack of volume
considerations. One can strictly follow the skin line incision
but the tissue resected and postoperative swelling and,
subsequently, tissue atrophy and scarring, are something
that is more difficult to comprehend.
It is also interesting to evaluate the results of this article
in the context of other studies. The hypertrophic breast is an
expanded tissue and needs to be considered as such. The
connective tissue of expanded skin is different from the
unexpanded one. It has an increased collagen strength and a
decreased elasticity. The fact that spring-back values are
greater for infraareolar than supraareolar skin is consistent
with the conclusion that greater stress is on the superior
skin; furthermore, as with the expanded skin, it does not
contract as much as the unexpanded skin.
Eur J Plast Surg (2007) 29:369–370
This commentary refers to the article http://dx.doi.org/10.1007/
G. L. Gunnarsson (*)
Department of Plastic Surgery, Odense University Hospital,
5000 Odense, Denmark