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    Dear Editor,

    I read with interest the recent original article published in your journal titled “Combined Breast Reduction Augmentation,” by Manero and Rodriguez-Vega []. I want to congratulate the authors both for the excellent results depicted and for the low complication rate they have achieved using their combined breast reduction acugmentation (CBRA) technique. The procedure is similar to the “reductive augmentation” technique that I published in your journal in June 2018 [], in that both techniques address the shortcomings of conventional breast reduction (i.e., lack of superior pole fullness and bottoming out) by combining reduction with simultaneous placement of submuscular silicone gel prostheses.

    There are a few substantive differences in our respective approaches upon which I wish to comment. First, the authors employ a premarked Weiss pattern in performing their reduction, whereas in all but the largest resections, we perform a circumvertical mastopexy. I find that tailor-tacking the breast envelope on the table as part of my circumvertical mastopexy allows for a shorter horizontal excision, whereas the Weiss pattern commits the patient to a full anchor-shaped scar at the inframammary fold. Second, in CBRA the resection is completed prior to placement of the implant into the pocket, whereas I place the implant before resection. I find that placing the implant in the pocket after the resection makes it more difficult to place the implant, and oftentimes, there are small tears or thinness at the inferior pole of the pocket.

    Finally, low capsular contracture rates were reported with both procedures. Since both approaches involve large open resections of breast tissue with endless possibilities for microbial contamination, this may be of particular interest in the current debate over the role of biofilm in the development of capsular contracture.

    In conclusion, I believe these two slightly different techniques, developed independently, approach both the best solution to achieving upper pole fullness and improvement in the appearance of breasts for those patients who would otherwise be candidates for breast reduction.