Staying Out of Double-Bubble and Bottoming-Out Deformities in Dual-Plane Breast Augmentation: Anatomical and Clinical Study.
BACKGROUND
Double-bubble and bottoming-out deformities represent the second most common reason for revision surgery in breast augmentation. Etiopathogenesis of these complications is still unclear. The aim of this paper is to report our findings in breast cadaver dissections focusing on the inframammary fold (IMF) applied anatomy and to critically review our ten-year experience in breast augmentation.


METHODS
A cadaveric study has been performed on four consecutive embalmed cadavers. A retrospective review of 207 consecutive women who underwent breast augmentation, using the submuscular dual-plane technique with a periareolar approach, between January 2003 and January 2013, was performed.


RESULTS
According to our dissections, the IMF is a complex osseo-fascio-cutaneous structure in which the superficial pectoralis fascia represents a key structure in breast augmentation surgery. Hence, a critical analysis of the IMF relationship with surrounding breast structures helps to understand the etiology of double-bubble and bottoming-out deformities and gives the anatomical basis to prevent them. In our early clinical experience, we experienced 3% of double-bubble and 6% of bottoming-out deformities. Those complications were avoided later by dissection in the inferior pole according to the anatomical findings.


CONCLUSIONS
Bottoming-out and double-bubble deformities can be avoided if an anatomical approach is used during pocket dissection at the level of the IMF, paying attention to avoid disrupting the superficial and deep attachments of the superficial pectoralis fascia at the IMF. A comprehensive understanding of IMF anatomy and the key surgical maneuvers to avoid these complications must be taken into account for each route of dissection.


LEVEL OF EVIDENCE IV
This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
['Salgarello|Marzia|M|', 'Visconti|Giuseppe|G|']
D000328:Adult D000368:Aged D001940:Breast D018427:Breast Implants D002102:Cadaver D015331:Cohort Studies D004210:Dissection D004954:Esthetics D005260:Female D006801:Humans D057910:Implant Capsular Contracture D016462:Mammaplasty D008875:Middle Aged D011183:Postoperative Complications D011379:Prognosis D012086:Reoperation D012189:Retrospective Studies D018570:Risk Assessment D014945:Wound Healing D055815:Young Adult
Breast augmentation Augmentation mammaplasty Breast implant Implant malposition Inframammary fold breast augmentation Periareolar breast augmentation