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We were surprised by the statement of Ricci and Driscoll1: “the snoopy nose deformity is a completely different entity that stems from a completely different mechanism and is solved by different surgical techniques compared with the classic double bubble.” To our knowledge, these 2 major aesthetic complications of the breast augmentation are of the same origin and can be explained by the same predisposing morphological features,2 pertaining to the inframammary fold (IMF). In a number of studies, dissections were performed to find out the internal structures responsible for the surface landmarks of the breast. No matter if these studies claimed the distinct IMF ligament,3 splitting of Scarpa’s fascia into the anterior and posterior lamellae of the breast capsule along the IMF,4 or just condensation of criss-crossing ligaments5, all these data prove the reality of the superficial fascial system framework, which shapes the lower pole and the IMF. “The amount and density of the criss-crossing insertions here create the degree of constriction of the lower pole, and also the degree of fold definition.”5 It seems proper to add to the quotation, the degree of IMF tightness, which is generally graded as tight, moderate, or loose IMF.6 The tight IMF is “morphologically predisposed”2 for double bubble formation because of the density and rigidity of its fascial framework, which is able to resist stretching over the implant’s lower ventral curvature or even may be able to resume its initial shape after surgical release. This memory of shape restores the original IMF after its seemingly successful effacement and lowering at augmentation mammoplasty in 2 ways: first, by restoration of the original inframammary groove above the new one formed by the implant’s lower edge—double bubble; second, by restoration of whole IMF and lower pole fascial framework at the original position, causing the upward shift of the implant—snoopy nose. Both variants have the same morphological scene (fascial framework rigidity) and the same solution—respect or efface the IMF memory of shape. Comparing Figures 1 and 2 from the study by Ricci and Driscoll1 reveals that the original IMF is pretty high (morphologically prone2) in both pictures. In Figure 1, the necessity to remove the IMF shape memory by radical scoring or even resection of the lower pole parenchyma is obvious. In Figure 2, we see the “high riding implant,” meaning either misjudgment in pocket dissection or, most probably, recurrence of preoperative IMF location with forced implant cranial shifting.
In Figure 2, the indentation of the initial IMF is actually clearly seen, no matter that the general breast contour differs drastically from that shown in Figure 1. Cause and cure are the same. Higher position and smaller implant in case 1 will most probably produce the contour as shown in Figure 2. Vice versa, placing the implant lower than shown in patient in Figure 2 will surely cause double bubble, as shown in Figure 1. Pertinent solutions include nipple elevation, implant size decrease, and IMF fascial framework release.
We are motivated with the same urge as the authors to clarify the anatomical underpinning of these complications to better avoid or treat them. For that very reason, we cannot help but draw attention to the mistakes, like the following: “snoopy nose deformity is not caused by issues with the inframammary fold, but rather by ptosis of the breast gland relative to the implant causing a superior implant-to-nipple malposition.”1 Imagine now a high-breasted patient in whom the nipple will always look “ptotic” relative to the implant positioned at the IMF level. Imagine the catastrophe that may follow after “mastopexy” with the nipple elevation even closer to the clavicle, instead of prudently considering lowering the IMF.
Both double bubble and snoopy deformities stem from the same morphological reason—tight IMF, with memory of shape and propensity to resume shape after release. Understanding and accepting that the shape memory is key, to our mind, is a sine qua non to standardize the terminology.
The authors have no financial interest to declare in relation to the content of this article. The Article Processing Charge was paid for by the authors.