Endoscopic excision of breast fibroadenoma through inframammary fold: Feasibility, safety and medium-term outcomes.

INTRODUCTION: Endoscopic-assisted surgery for breast tumors has the advantage of inconspicuous scars, less breast volume loss, and nipple areolar distortion. A novel endoscopic-assisted technique through inframammary fold for excision of fibroadenomas is presented. MATERIALS AND SURGICAL TECHNIQUE: Endoscopic-assisted excision of fibroadenoma(s) through inframammary fold was performed in four patients after informed written consent via three ports (12, 5, and 5 mm). Breast Cancer Treatment Outcome Score-12 (BCTOS-12) was used to evaluate patient satisfaction after surgery. DISCUSSION: No intraoperative and wound complication was noted. On median follow-up of 26.5 months, patients reported satisfactory responses to aesthetic and functional outcomes. No scar related complications were noted. Endoscopic-assisted excision of fibroadenoma through inframammary fold can be a safe and feasible option with good aesthetic outcomes.

Four-Layer Wound Closure Technique with Barbed Sutures for Inframammary Fold in Mastopexy Augmentation.

BACKGROUND: The inframammary fold (IMF) is an important landmark in breast aesthetic surgery. In augmentation mastopexy procedures, secure and accurate placement of the IMF is essential to aesthetic outcomes and to allow the new IMF to heal in the correct position without displacement. The authors present a simple and efficient four-layer wound closure technique using barbed sutures for closure of the repositioned IMF in augmentation mastopexy procedures. This method was previously described by the first author for reset of the IMF in breast augmentation surgery and has been adapted to the longer IMF incision in augmentation mastopexy procedures. METHODS: A retrospective review was undertaken of 335 patients who underwent bilateral breast augmentation mastopexy procedures with a Wise pattern technique at a single unit. The newly reset IMF was closed using barbed sutures and a four-layer closure technique. RESULTS: There were no cases of complications related to wound healing or wound dehiscence. One patient required explantation for an infected implant. CONCLUSION: The four-layer wound closure technique with barbed sutures provides a quick and efficient method for accurate closure of the newly reset IMF, with positive outcomes related to wound healing. Secure and accurate placement of the inframammary fold is crucial in augmentation mastopexy procedures. The use of a four-layer wound closure technique with barbed sutures provides an efficient method for accurate closure of the newly reset inframammary fold. This method was previously described by the first author for reset of the IMF in breast augmentation surgery and has been adapted to the longer IMF incision in augmentation mastopexy procedures. LEVEL OF EVIDENCE V: 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 .

Primary management of the inframammary fold in breast reconstruction using the thoracoabdominal advancement flap: Surgical technique.

Our experience in breast reconstruction confirms the significant importance of reconstructing the inframammary fold in achieving overall aesthetic satisfaction. We describe our technique for primary fixation of the inframammary fold in breast reconstruction using a thoracoabdominal advancement flap. This technique is suitable for patients with a vertical skin laxity of at least 5cm in the future inframammary fold. Prior to the procedure, it requires preparation through physiotherapy, the use of adhesive external breast prosthesis, and skin expansion using an inflatable prosthesis in extreme cases. The surgical approach follows the existing mastectomy scar. After subfascial dissection of the thoracoabdominal advancement flap, the surgeon proceeds to create two separate rows of sutures. The first row mimics the deep attachment of the inframammary fold, fixing the superficial fascia of the flap to the rib periosteum. The second row mimics the superficial attachment of the inframammary fold, fixing the dermis of the flap to the rib periosteum. The main advantage of this technique is its applicability to all breast reconstruction programs.

The Role of the Inframammary Fold (IMF) in Aesthetic and Reconstructive Surgery: A Critical Analysis and Surgical Solution.

INTRODUCTION: The inframammary fold (IMF) is a critical structure in breast aesthetics and is affected by various types of breast surgery. The ideal IMF has a semi-elliptical shape, which may become attenuated with age and descends in macromastia. The aim of this study was to analyse the IMF and retain/restore its shape with sutures. METHODS: A retrospective study was conducted on breast surgeries performed over a four-year period (2019-2022). The morphometry of the IMF was evaluated preoperatively while the patients were standing. In cases where the IMF was symmetrical, sutures were used to reinforce it during surgery. When the loss of the semi-elliptical shape was clinically indicated, the IMF was mobilized, repositioned, and then sutured into place. RESULTS: The study included 56 patients: 43 undergoing immediate breast reconstruction, and 13 undergoing bilateral breast reductions. In over two thirds of the patients, the lateral IMF was inferiorly displaced compared to the medial IMF. CONCLUSION: It is recommended to reinforce the IMF in all patients undergoing breast surgery. Where the IMF has an elliptical shape preoperatively, it is reinforced. Where IMF is inferiorly displaced, mobilization and superior advancement of the IMF, followed by suture reinforcement, are necessary. This approach results in a well-defined IMF with improved breast aesthetics. 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 .

Quantitative assessment of inframammary fold in Asians: an MRI study.

Background: The inframammary fold (IMF) is a critical structure affecting the aesthetics of the breast, yet the anatomy and location of the IMF remain controversial. The purpose of this study was to quantitatively evaluate the thickness and location of IMF utilizing magnetic resonance imaging (MRI). Methods: The MRI images of 240 breasts from 120 Asian women were analyzed. The quantitative measurements consisted of breast width, breast projection, nipple to inframammary fold, breast volume, IMF tissue thickness, and IMF position. The IMF position was evaluated by referring to the ribs, as well as measuring the distance between IMF and the inferior of the fifth rib. Results: The mean values of central thickness, medial thickness, and lateral thickness were 1.50±0.59, 1.46±0.60, and 1.76±1.04 cm, respectively. IMF central thickness demonstrated a moderate positive correlation with breast projection (r=0.559, P<0.001) and breast volume (r=0.523, P<0.001). The proportions of IMF located at the fourth intercostal, the fifth rib, the fifth intercostal, the sixth rib and the sixth intercostal were 5.8%, 29.2%, 43.3%, 20.4% and 1.3%, respectively. The average distance between IMF and the inferior of the fifth rib was 0.69±1.40 cm. 60.0% of women had near-symmetrical IMF, while 17.5% had left higher IMF and 22.5% had right higher IMF. Conclusions: This study used MRI to quantitatively assess the anatomy of IMF. The detailed knowledge of IMF would facilitate the ideal aesthetic outcome of mammaplasty.

Definitions of Abnormal Breast Size and Asymmetry: A Cohort Study of 400 Women.

BACKGROUND: Macromastia, micromastia and breast asymmetry have an impact on health and quality of life. However, there is scarce information addressing breast size and asymmetry frequency distribution in reference populations. OBJECTIVE: The current study aims to identify factors that influence breast size and symmetry and classifies abnormal breast sizes and breast asymmetries in an adult German population. METHODS: Breast base dimensions, breast volume, symmetry, and other breast anthropometric parameters of 400 German female patients were determined in a retrospective review of the MRI archives at our institution. Professional medical MRI-segmentation software was used for volume measurement. RESULTS: A total of 400 Patients were retrospectively enrolled. The patients had a mean age of 50 ± 12 years (min: 24; max: 82), mean BMI of 25.0 ± 5.0 (min: 14.7, max: 45.6), and a mean total breast volume of 976 ml (right: 973 ml, min: 64, max: 4777; left: 979 ml, min: 55, max: 4670). The strongest correlation of breast volume was observed with BMI (r = 0.834, p < 0.001), followed by breast base width (r = 0.799, p < 0.001). Smaller breasts have higher breast volume asymmetry ratios (r = - 0.124, p < 0.014). For a BMI between 18.5 and 24.9 kg/m2, micromastia is defined by breast volumes below 250 ml (5th percentile) and macromastia by volumes above 1250 ml (95th percentile). Abnormal breast volume asymmetry (< 5th and > 95th percentile) is equivalent to an absolute difference of approximately 25% relative to the smallest side (bidirectional asymmetry ratio 5th percentile - 19%; 95th percentile 26%). CONCLUSION: This study provides normative data of German women, as well as selected size-for-BMI percentiles and asymmetry ratio percentiles. The normative data may help to establish transparent and objective coverage criteria for health insurances. 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 .

Double-bubble deformity in breast augmentation: correction with percutaneous barbed sutures.

The double-bubble deformity is a complication after breast augmentation that often requires additional treatment such as elevation and restoration of the inframammary fold (IMF), parenchymal scoring or fat grafting. We describe a percutaneous technique that combines dual plane pocket dissection, parenchymal scoring and placement of a percutaneous barbed suture to create a new IMF. This technique takes approximately 10 minutes per breast to complete, and the resulting breast has an immediately noticeable double-bubble free surface. This technique can both prevent and treat a double-bubble deformity after dual plane breast augmentation. LEVEL OF EVIDENCE V: 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 .

How Do Positions of Nipple and Inframammary Fold Change After Autologous Breast Augmentation with Fat Grafting?

BACKGROUND: Breast augmentation with autologous fat grafting was widely used. However, it is unclear how does this kind of surgery affect the morphologic change of breast. This study aimed to explore the change of nipple and inframammary fold (IMF) levels, which are important aesthetic landmarks of breast that further explore whether this kind of surgery could correct the asymmetry of nipple and IMF. METHODS: Preoperative and postoperative measurements were performed in the patients who received fat grafting with or without fasciotomy. The position levels of nipple and IMF were measured. The preoperative and postoperative discrepancies and the difference of these levels after surgery were also calculated. RESULTS: As for the IMF asymmetry, in the fasciotomy plus fat grafting group, the asymmetry was significantly reduced after surgery, while there was no significant difference in the fat grafting group. As for the nipple asymmetry, fat grafting could not correct the asymmetry in both fasciotomy plus fat grafting group and fat grafting group. As for the morphological change after surgery, both nipple and IMF were descended significantly after surgery. The descending range of IMF in the preoperative higher group was larger than the preoperative lower group. On the preoperative IMF higher side, descending degree of IMF was significantly larger in the fasciotomy plus fat grafting group than fat grafting group. CONCLUSIONS: Fat grafting with fasciotomy can improve IMF asymmetry but cannot improve nipple asymmetry. Both IMF and nipple were lowered somehow after surgery, which might be related to the breast enlargement. 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.

A Simple Preoperative Marking of Implant Augmentation Mammoplasty: The Semicircle Method.

BACKGROUND: The location of the inframammary fold is the most critical step in the preoperative marking of implant augmentation mammoplasty. At present, most of the calculation formulas for new inframammary fold location determination are complicated. OBJECTIVE: Based on the aesthetic standards of the breast, we proposed a simple and effective method, the Semicircle method, to determine the location of the new inframammary fold. METHODS: In this prospective study, 21 patients were enrolled to record the distance from the nipple to the new inframammary fold calculated by the Semicircle method, Tebbetts method, Randquist method, Mallucci's ICE method and compare the Semicircle method to the other three methods by using the intraclass correlation coefficient. RESULTS: According to the statistical results of the intraclass correlation coefficient, the Semicircle method had poor consistency with the Tebbetts and ICE methods, but good consistency with the Randquist method. CONCLUSION: The Semicircle method is a simple and aesthetically acceptable design method for breast augmentation mammoplasty, which can quickly and efficiently determine the position of the new inframammary fold. At the same time, this method has good consistency with the Randquist method and can obtain satisfactory breast morphology. 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 .

The fascial structure of the breast: New findings on the anatomy of the inframammary fold.

The inframammary fold defines the shape and structure of the breast, especially in women. As the inframammary fold is placed between the fifth and sixth ribs, the ligaments or fascia are thought to attach from these ribs. However, the previous literature on what structures constitute the inframammary fold does not provide sufficient knowledge for reconstructing the natural form of the fold. This study aimed to clarify the structure that involves the inframammary fold. Ten sides of five formalin-fixed, adult Asian cadaveric breasts were studied. Upon dissection of the breast, including the ribs, the fat lobules were removed while preserving the septal structures under the microscope. The fascial structures were observed grossly and radiographically. A multilayered fascial structure was noted from the dermis near the inframammary fold, anchored to the deep fascia of the pectoralis major muscle mainly at the height of the fourth rib and partially of the fifth rib, from the outside of the nipple to the linea axillaris media, where the fold could be clearly observed. Additionally, the fat lobules around the inframammary fold were subdivided by thin septa closer to the dermis, and they fused posteriorly and upward to form this fascial structure. The inframammary fold was not formed by an adhesion directly under the sixth rib, but by the skin "hanging" from the height of the fourth and fifth ribs due to the multilayered fascial structure that repeatedly fused and dissociated and the changes in the size of the fat lobules. This new anatomical finding may help in inframammary fold reconstruction.

Defining the Inframammary Fold by Liposuction: An Essential Tool in Aesthetic Shaping of the Reconstructed Breast. Technique and Long-term Results in a Series of Patients.

BACKGROUND: A good inframammary fold (IMF) definition and position is essential to achieve a satisfactory and natural result in breast surgery. This structure can be damaged, especially during mastectomies. Multiple methods are reported in the literature to restore IMF or improve its definition. In this study, we present the results achieved in a series of patients treated with subdermal liposuction. METHODS: We report on all our patients who underwent IMF liposuction between January 2016 and June 2020. Subdermal liposuction was performed with a blunt 3 mm cannula along the new IMF to promote skin retraction and adherence between skin and fascia. Results were evaluated subjectively by the patients and objectively by 8 individuals not involved with the treatment. RESULTS: We performed IMF liposuction in 88 breasts (69 patients), aged 21-74 (mean 52) years for 82 implant-based reconstructions, 2 tuberous breasts, and 4 contralateral breast augmentations. Mean follow-up was 28 months (6-64). Subjective results: the overall result evaluated with the VAS scale reached 86.6/100. All the 22 patients interviewed judged as well defined the new inframammary fold. Objective results: in 83% of cases the definition of the inframammary fold was judged as good or excellent, while symmetry with contralateral IMF, natural appearance, and overall aesthetic outcome were judged as good. CONCLUSION: Based on our long-term satisfactory results, we recommend the technique of subdermal liposuction to improve the definition of IMF in breast reconstruction after mastectomy and other breast procedures. It is effective, easy to perform, minimally invasive, and durable. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. 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 .

Dog-ear's prevention during Inverted-T breast lift and reduction.

There are several techniques for the prevention of dog-ear. All of the techniques have their own disadvantages, since mostly they lengthen the wound. The current technique prevents dog ear during inverted-T breast lift and reduction without lengthening the wound or creating tension while closing the wound.

Thorax anthropometric position index: a simple evaluation of the inframammary fold position in the thorax.

Appropriate positioning of the inframammary fold (IMF) is essential for breast reconstruction. The purpose of this study was to quantitatively measure and evaluate the anthropometric position of the IMF in the thorax. A total of 145 Japanese women with unilateral breast cancer were analyzed. To indicate the superior-inferior position of the IMF on the non-diseased side, the distances from the sternal notch (SN) to the IMF along the midline (SN-IMFM) and from the SN to the umbilicus (UB) (SN-UB) were measured. A new index, the thorax anthropometric position (TAP) index for the IMF, was then defined as the ratio of SN-IMFM to SN-UB. The TAP index was calculated for each patient, and its correlations with demographic parameters, including age, body height, and body mass index, were statistically assessed. The TAP index was normally distributed and ranged from 0.500 to 0.704, with a mean of 0.590. Multivariate analysis revealed that age was an independent factor associated with a higher TAP index (p < .01). In addition, the paired t-test showed that the TAP index was significantly greater in the standing position than in the supine position (p < .001). The position of the IMF in the thorax could be objectively described by the TAP index, and it was suggested to become inferior with age and the standing position. The index, along with these findings, will provide useful information for the evaluation of the breast contour in an objective and simple manner.

D-SUN Method to Prevent Double-Bubble Deformity in Broad Base Breasts with High-Rising Inframammary Fold.

Breast augmentation is the most commonly performed plastic surgery among women worldwide. With time, implant selection shifted from arbitrary implantation to precise planning. Different methods address the dimensional planning process. Many of them are complex to put into practice, focusing mainly on the breast base. Constricted, short lower pole breasts are morphologically predisposed to complication such as double-bubble deformity. Yet, by focusing on the distance between the nipple on stretch and the inframammary fold, the D-SUN method guides the surgeon to find the most appropriate implant volume for anatomical form-stable silicon implants and IMF incision to avoid complications.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.

The island-type pedicled TRAM flap: Improvement of the aesthetic outcomes of breast reconstruction.

BACKGROUND: The pedicled transverse rectus abdominis myocutaneous flap (TRAM) remains an effective and widely-used method for breast reconstruction despite well-documented donor-site morbidity. We present the island-type pedicled TRAM flap as a way to obtain better and more reliable outcomes in breast reconstruction. METHODS: A retrospective chart review of patients who underwent breast reconstruction with an island-type pedicled TRAM flap was performed. Patient demographics and complications were reviewed. In the island-type pedicled TRAM flap, we transversely resected the upper ipsilateral rectus muscle surrounding the origin of the superior epigastric vessels, preserving only a 1-cm muscle strip including the vascular pedicle to prevent epigastric bulging and inframammary fold (IMF) disruption. The flap was turned over into the ipsilateral breast pocket. The IMF was repaired except for the portion where the pedicle was placed. RESULTS: From January 2013 to November 2017, 88 patients underwent surgery using the island-type pedicled TRAM flap. The etiology of the defect was breast cancer with mastectomy in 86 cases, and paraffinoma in two cases. Seventy-seven patients underwent unilateral reconstruction, and 11 patients underwent bilateral reconstruction. Minor fat necrosis occurred in eight cases. Mild inframammary or epigastric bulging was observed in five cases, and neither partial nor total flap necrosis was observed. The aesthetic outcome of the IMF was evaluated in 55 cases, and 53 cases received good overall scores. CONCLUSION: Although the island-type pedicled TRAM flap is technically challenging because careful dissection and pedicle identification is required, it can provide more reliable and better aesthetic results without an increased risk of vascular compromise.

Inframammary fold subcutaneous cushion assessment using MRI (magnetic resonance imaging).

BACKGROUND: The inframammary fold (IMF) is one of the most important elements in the determination of the aesthetic of the female breast. During mastectomies, it is important to preserve the subcutaneous portion nearby the IMF, attempting that, this preservation will greatly facilitate reconstruction allowing more satisfying aesthetic results. The aim of the present study is to evaluate the thickness of the subcutaneous IMF cushion using magnetic resonance imaging (MRI) acquisition images. METHODS: We have gauged the right breast IMF subcutaneous cushion from patients (all the cases without previous surgery in this topography) who were submitted to MRI in a diagnosis radiology center, between January and February of 2017. MRI images were analyzed in T1 fat saturated sequences. The assessment of the fold cushion was realized in the projection of axial measurements in sagittal plane. RESULTS: Among the 50 evaluated patients, the median measure of breast base was 9.91 cm. The median measure of the subcutaneous IMF cushion assessment in the sagittal projection of the breast base meridian was 2.40 cm (varying from 1.34 to 4.05 cm, with percentile 5% of 1.51 cm and percentile 95% of 3.55 cm). CONCLUSIONS: Other studies indicate the negligible amount of breast tissue and the low incidence of neoplasia in this topography, the preservation of the IMF seems feasible. The measurements of the IMF thickness, evaluated by MRI in this study, provide reference values for maintaining a desirable inframammary crease.

Endoscopic Transaxillary Versus Inframammary Approaches for Breast Augmentation Using Shaped Implants: A Matched Case-Control Study.

PURPOSE: The incision for breast augmentation can be chosen from the transaxillary, inframammary fold, periareolar, or transumbilical approaches. While the inframammary fold approach is commonly used worldwide, the transaxillary approach is more popular in Asia due to the more conservative location of the scar. In this study, we performed augmentation mammoplasty using anatomically shaped implants via the endoscopic transaxillary and inframammary fold incisions and compared the outcomes. METHODS: Three hundred sixty-four patients who underwent breast augmentation with shaped implants were enrolled. All were primary and bilateral cases. In total, 728 shaped implants were used. Patients' demographics, incision type, and complications were documented. Complications such as capsular contracture, hematoma, infection, implant malposition, wound problem, and chronic seroma were observed during the average 27 months of follow-up period and analyzed. RESULTS: One hundred ninety-five patients underwent augmentation mammoplasty via the inframammary approach, whereas 169 patients underwent the endoscopic transaxillary approach. Implant type and size were matched between the two groups. Complication rates were 1.8% and 2.7% in the inframammary and transaxillary approach, respectively. There was no significant difference between the two approaches in terms of surgical complications (p = 0.593). CONCLUSION: This study demonstrates that the endoscopic transaxillary approach is not inferior to the inframammary approach when shaped implants are used for augmentation mammoplasty. Therefore, the transaxillary approach may be an alternative method when using shaped implants for augmentation mammoplasty, especially for women who wish to avoid a visible scar on the inframammary fold. LEVEL OF EVIDENCE III: 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 .

[Breast reconstruction with temporary tissue expander]. / Reconstruction mammaire par prothèse d'expansion temporaire.

Tissue expansion in breast reconstruction is a technique based on a simple principle but subjected to numerous traps. Its success relies on the patient selection, a good preparation of the skin pocket, no rush during the inflating time, and a specific care during the definitive implant placement inside the skin pocket. This article aims to list and detail point-by-point the different surgical timings, their practical application, the pitfalls and the possible traps to avoid, in order to succeed in breast reconstruction using tissue expander.

Mammography image quality and evidence based practice: Analysis of the demonstration of the inframammary angle in the digital setting.

AIM: The aim of this study is to determine the clinical rates of the demonstration of the inframammary angle (IMA) on the mediolateral oblique (MLO) view of the breast on digital mammograms and to compare the outcomes with current accreditation standards for compliance. Relationships between the IMA, age, the posterior nipple line (PNL) and compressed breast thickness will be identified and the study outcomes validated using appropriate analyses of inter-reader and inter-rater reliability and variability. Differences in left versus right data were also investigated. METHOD: A quantitative retrospective study of 2270 randomly selected paired digital mammograms performed by BreastScreen NSW was undertaken. Data was collected by direct measurement and visual analysis. Intra-class correlation analyses were used to evaluate inter- and intra-rater reliability. RESULTS: The IMA was demonstrated on 52.4% of individual and 42.6% of paired mammograms. A linear relationship was found between the posterior nipple line (PNL) and age (p-value <0.001). The PNL was predicted to increase by 0.48 mm for every one year increment in age. The odds of demonstrating the IMA reduced by 2% for every one year increase in age (p-value = 0.001); are 0.4% higher for every 1 mm increase in PNL (p-value = 0.001) and 1.6% lower for every 1 mm increase in compressed breast thickness, (p-value<0.001). There was high inter- and intra-rater reliability for the PNL while there was 100% agreement for the demonstration of the IMA. CONCLUSION: Analysis of the demonstration of the IMA indicates clinically achievable rates (42.6%) well below that required for compliance (50%-75%) to known worldwide accreditation standards for screening mammography. These standards should be aligned to the reported evidence base. Visualisation of the IMA is impacted negatively by increasing age and compressed breast thickness but positively by breast size (PNL).