LETTER TO THE EDITOR Reverse Dual-Plane Mammaplasty—Revised G. Esposito Æ G. Gravante Received: 27 April 2007 / Accepted: 30 April 2007 Ó Springer Science+Business Media, LLC 2007 We appreciated the letter of Dr. Evangelos that allowed us to explain some issues that probably were not clear in our article. The subglandular positioning of prostheses is a world- wide accepted technique commonly considered "more aesthetic" than the submuscular. However, its weakness is mainly due to the tissue narrowing that usually occurs near prostheses margins, where there is not enough glandular tissue for coverage, more frequently inferiorly, superiorly and medially. Considering the medial and inferior nar- rowing, this usually takes a year and is particularly evident with very large prostheses. A correct choice of prostheses (regarding shapes, bases and perfectly fit for glands) is mandatory to prevent such inconvenience. Furthermore, in our experience, problems of superior pole narrowing could be avoided by selecting oval implants with a vertical dia- meter smaller than the horizontal (i.e., 9.6 vs. 11.5 cm). This, and not the pinch thickness test greater than 2 cm, ensured in our patients the most natural aspect of the su- perior pole even without using submuscular or subfascial positioning. Patients rarely asked for a complete fullness of the superior pole (most of the time they wanted the most naturally-looking appearance of it) and, in such cases, we agree that the subfascial approach would be the best choice. Finally, we believe that the efficacy of the sub- fascial approach in preventing rippling and capsular contractures still is not enough demonstrated as it was for the retromuscular approach. The fascia that Graf et al. [3] describe ("fascia tends to be thin and more fragile over the lower two-thirds of the muscle. The progressive thickening... along the upper third of the muscle constitutes the basis of the subfascial aug- mentation...") lies over the major pectoralis muscle. The pocket we describe begins inferiorly, where such fascia thickens and unifies with those of the serratus anterior and rectus abdominis muscles, in other words, our dissection begins where that of Graf et al. [3] ends (this is more clear comparing drawings published in our article and in the above mentioned reference). In our case, the inferior third of the prostheses lies on the intercostal fascia of the thoracic ribs, thus requiring that the medial fibers of the major pectoralis be incised where they insert on the sternum to secure a small muscular flap for coverage and protection of the prosthesis. Possibly, the inferior location is similar to that reported by Graf et al. [3], as suggested by Keramidas. However, this is not clear from the study reported, and should this be true, they do not describe any dissection of the medial muscular fibers of the pectoralis major [3]. We agree with Dr. Keramidas that sharp dissection is mandatory for the creation a subfascial pocket, but it is useless with the subglandular approach. Actually, in this case, once the correct plane is found, the finger dissection is completely bloodless (due to the absence of perforating vessels), more precise, and faster (1–2 min in our experi- ence). When dissection of the pocket’s superior part is terminated, sharp dissection is used to find the deep plane. Even in this case, once the correct plane is found (between the thoracic cage and the fascia), dissection is continued by finger dissection due to the absence of perforators (5–10 min). Sharp dissection is used again to join both parts of G. Esposito Burn Center S.Eugenio Hospital, Rome, Italy G. Gravante University of Tor Vergata in Rome, Rome, Italy G. Gravante (&) via U. Maddalena 40/a, 00043 Roma, Ciampino, Italy e-mail: ggravante@hotmail.com 123 Aesth Plast Surg (2007) 31:614–615 DOI 10.1007/s00266-007-0105-4