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Kotti. Plast Aesthet Res 2018;5:16 I http://dx.doi.org/10.20517/2347-9264.2018.11 Page 7 of 9

Figure 10. Example of an asymmetry with an offset definition of the Inframammary fold: The stars show different positions of the
inframammary folds reaching the midline; the BK point in this case will be the upper one and the ptosis treatment will aim to horizontalize
the BK line and make it crossing the BK point

Even if we totally adhere to Regnault to individualize “parenchymal maldistribution” that we also excluded
[6]
from our classification, we do not agree with the definitions of “normal breast”, “true” or “pseudo-ptosis”.
In fact, what is “normal” for Regnault is a “perfect breast” for us, as we consider that a normal breast may
[6]
also have a small ptosis regressing with a “hands up test” positive. Conversely, this small ptosis may express
desirable femininity in some cultures; many Asian women, in order to prove their mature femininity, waged
a hashtag campaign called #carrypenunderbreast that went viral on social media, demonstrating that a
glandular parenchymal distribution under the IMF is, for the majority of people, a desired target in the
Eastern hemisphere and also a normal shape in Western countries.

“Pseudo-ptosis” considers the sagging of the parenchyma despite the nipple position remaining above the
IMF without taking regard to the high or low position of the IMF. Indeed, this crease is a curved line, usually
starting from the anterior axillary line to the sternal area with a different attachment and a different direction
from one patient to another, and sometimes from one breast to another for the same woman [Figure 10].
Using it as a landmark is a shortcoming of the Regnault classification, as well as the one proposed a year
[6]
later by Vandenbussche and even later reconfirmed in the literature by including a physiological approach
[7,8]
to each of the four new grades described by the same author.

Robert Brink confirmed this physiological necessity to explain ptosis one year after Vandenbussche’s
paper by proposing a different classification in his work, and a variation of the “Round Block” periareolar
[7,8]
mastopexy approach to the “true ptosis concept” .
[9]
In our approach, we always analyze the physiology of breast sagging for each patient but never nest it within
a treatment diagram. We believe that defining a true and a pseudo-ptosis is unfit for a decision-making
process as confirmed by Kirwan’s vision .
[10]
Nevertheless, despite the detailed and pragmatic algorithm proposed by this author, we do not agree with
the use of centimeters as a way of measurement to differentiate one proposed alphabetic grade from another.
In fact, we believe that “1 cm” on the breast is different from one woman to another according to the skeleton
and to the phenotype of each body, and that the classification of the breast and the diagnosis of the ptosis
have to be defined in an overview and designed in a frontal view (never on a lateral view).

In Figure 5 we elaborated an algorithm that respects the surgeon’s training and preferred technique in order
to globalize the clinical and surgical approach to the primary task of breast ptosis treatment. Even if we