Assessment of breast aesthetics

Novel Percutaneous Areola Reduction

We present a novel percutaneous areola reduction technique that, to our knowledge, has never been used or published in the past. This technique is a useful solution to the downsides of the current most commonly used technique for areola reductions that uses a circumareolar incision. Our current technique utilizes a percutaneous approach, which is a minimally invasive procedure, and produces a virtually scarless result.

The Influence of Scar Patterns After Reduction Mammoplasty on Eye Movement and Gaze Pattern: An Eye-Tracking Investigation

BACKGROUND

Given that scars are acknowledged as the primary cause of postoperative dissatisfaction following reduction mammoplasty, it is imperative to comprehend the patient's visual perception of different scar patterns in order to enhance patient satisfaction. To achieve this, eye-tracking technology provides an unbiased method of evaluating how observers assess breast scars.

METHODS

58 participants (32 females and 26 males) between the ages of 19 and 82 years (mean age of 29.47 ± 10.98 years) were shown 18 color photographs, taken at 3 viewing angles (right 45° oblique, frontal and frontal view with arms raised), from 6 patients undergone reduction mammoplasty with the inverted T-scar technique (3 patients) or no-vertical-scar technique (3 patients). The images were presented to every participant for a fixed duration of 5 s each. Eye-tracking device was used to collect and analyze the gaze data of viewers.

RESULTS

The nipple-areola complex (NAC) and the periareolar scar captured observers' gaze faster, had longer duration and more count of eye fixation than all other parts of breast scars, regardless of the viewing angle and scar pattern. Moreover, the scar region in the inverted T-scar pattern received greater and faster visual attraction of observer's gaze than the no-vertical-scar pattern.

CONCLUSION

The NAC and the periareolar scar seem to be perceived as the most important regions for breast aesthetics. The findings can be helpful to assist plastic surgeons in determining the most appropriate technique for reduction mammoplasty, meanwhile underlining the importance of a fine periareolar scar and symmetric NAC for excellent aesthetic outcomes. This is to our best knowledge the first study using eye-tracking technology in evaluating reduction mammoplasty outcomes. This study explored the influence of different scar patterns after reduction mammoplasty on eye movements and gaze patterns among observers. The study have validated the significance of the NAC and the periareolar scar for breast aesthetics and revealed that the scar region in the inverted T-scar pattern may be judged less visually attractive than the no-vertical-scar pattern.

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 .

An updated systematic review of esthetic grading tools in postmastectomy breast reconstruction

BACKGROUND AND OBJECTIVES

We ascertained whether a validated esthetic grading tool for breast reconstruction had been developed and widely adopted since the last published systematic review on the topic from 2015.

METHODS

We performed a systematic review identifying all studies using a grading tool to assess breast reconstruction, using search terms associated with all types of breast surgery and outcomes research. Articles were assessed for patient number, validated scale use, assessor type and training, assessor blinding, assessment method, scoring system type, type and timing of reconstruction, and usage of corroborating scales.

RESULTS

Of 2809 articles screened, 148 met the criteria. Only 3 used a validated tool, the Esthetic Items Scale. Most used study-only tools (n = 111) or unvalidated tools (n = 28). The most used unvalidated tool was the Garbay/Lowery 5-subscale rubric. Unanchored Likert scales were the most common subjective tool; two-dimensional images were the most used medium. Surgeons, patients, and nurses were the most common assessors. Twenty percent of studies used corroborating scales.

CONCLUSIONS

In the absence of a validated esthetic grading tool for breast reconstruction, researchers continue to rely on unvalidated scales. The only validated scale available is used infrequently and only validated among physicians. A validated, reliable, simple grading tool with clinical and scholastic relevance is needed.

Breast Decisions: Recommender System for Appearance Counseling about Breast Reconstruction

Appearance counseling is an important component of the consent process for breast reconstruction. The purpose of appearance counseling is to help the patient form realistic expectations of what she might look like after breast reconstruction. In this article, we introduce a recommender system, "BreastDecisions," for appearance counseling that suggests photographs of previous patients that are tailored to a specific patient to help her form realistic expectations of her own reconstruction.

Methods

We present user specifications and algorithm parameters needed to incorporate the recommender system into the appearance counseling workflow. We demonstrate the system for a common counseling scenario using a knowledgebase of previous breast reconstruction patients. The medical appropriateness of the recommended photographs for use in appearance counseling was evaluated by experts using a four-point rating system.

Results

The recommender system presents photographs that are medically appropriate for counseling a specific patient, depicts typical outcomes, and adapts to a variety of clinical workflows. For each of 33 patients taken as examples of breast reconstruction patients, we used the system to identify photographs for appearance counseling. The baseline average medical appropriateness of the recommended photographs was between mostly appropriate (some explanation needed) and medically appropriate (minimal explanation needed). We demonstrate filtering and ranking steps to reduce the number of recommended photographs and increase the average medical appropriateness.

Conclusions

Our recommender system automatically suggests photographs of previous breast reconstruction patients for use in counseling a patient about appearance outcomes. The system is patient-specific and customizable to a particular surgeon's practice.

Ultrasound Criteria and Baker Scale for Breast Implant Capsular Contracture Diagnosis

Due to the subjectivity of the Baker scale in grading capsular contracture (CC), an objective and reproducible measurement tool is necessary to estimate the presence and grade of CC in patients with breast implants. This study aimed to assess the capacity of breast ultrasonography to identify CCs using the Baker grading system.

Methods

This study included patients who underwent breast augmentation with implants or implant-based breast reconstruction. Patient demographics, surgical type, and ultrasonographic variables were analyzed. The Kruskal-Wallis test was used to determine differences between means, and the Fisher exact test was used for binary variables.

Results

A total of 21 patients (28 breasts) with smooth surface implants were included. In total, 39.2% of breasts had a score of Baker I, 25% had Baker II, 17.9% had Baker III, and 17.9% had Baker IV. When comparing breasts graded Baker I to IV, a mean capsule thickness of 0.6 ± 0.2, 1.0 ± 0.53, 1.68 ± 0.99, and 1.52 ± 0.46 mm, respectively, was shown (P = 0.0044). The breast implant deformity variable was significantly different between Baker grades I to IV (0.0218). Finally, Baker III and IV categories were five times more likely to have abnormal wrinkles than Baker I and II (odds ratio, 5.25; 95% confidence interval, 0.82-33.45; P = 0.0496).

Conclusion

Ultrasound is a useful tool for evaluating the presence of augmented thickness, implant shape deformity, and abnormal wrinkles of the implant shell in correlation with the severity of CC.

Symmetry of Nipple Position After Bilateral Nipple-Sparing Mastectomy and Implant-Based Reconstruction: The Impact of Reconstructive Method

PURPOSE

Asymmetry of nipple position is common in the female population. There are scant data on the impact of bilateral nipple-sparing mastectomy (NSM) and immediate implant-based reconstruction on nipple asymmetry.

METHODS

A retrospective review was performed of an institutional review board approved prospective database of NSM and immediate implant-based reconstruction was performed. BCCT.core software was used to examine preoperative and postoperative nipple asymmetry. It directly calculates the quantitative differences in nipple position between the breasts expressed as breast retraction assessment (BRA). Nipple to sternal notch (N-SN) asymmetry was calculated from the collected data.

RESULTS

Sixty-eight patients undergoing bilateral NSM and implant reconstruction were reviewed. Reconstructive methods were tissue expander (TE) 39 (57.4%) and direct to implant (DTI) (prepectoral 13, submuscular 16) 29 (42.6%). The TE group had greater body mass index (BMI) (23.5 vs 22.1, P = 0.02), mastectomy weight (390.7 vs 243.8, P = 0.001) and higher preoperative N-SN asymmetry (TE 0.89 vs DTI 0.59, P = 0.02). Ten patients received radiation (TE group 4, DTI group 6). The TE group had larger implant size (479.1 vs 375.0, P = 0.0001). Overall, TE reconstruction resulted in an increase in nipple asymmetry (mean BRA: preoperative, 1.50 vs postoperative, 1.65), which was not significant. Direct to implant reconstruction increased nipple asymmetry: mean N-SN asymmetry preoperative 0.59 versus postoperative 0.97 (P = 0.04) and mean BRA scores 1.40 and 1.82 (P = 0.06). Both implant locations in the DTI group resulted in an increase in postoperative asymmetry but was significant for the prepectoral group: mean BRA preoperative 1.19 versus postoperative 1.85, P = 0.02 and mean N-SN asymmetry preoperative 0.48 vs postoperative 0.94, P = 0.04. Radiation impacted the final mean BRA score: radiation 2.24 versus no radiation 1.63 (P = 0.05).

CONCLUSIONS

Patients who underwent TE reconstruction had significantly larger breasts and greater preoperative N-SN asymmetry than the DTI group. Despite this, the TE group resulted in mild increase in nipple asymmetry. Both implant locations in DTI reconstruction resulted in increased postoperative asymmetry but was significant for the prepectoral group. Radiation therapy has a significant impact of nipple asymmetry.

A Novel Validated Breast Aesthetic Scale

BACKGROUND

Breast aesthetics impacts patients' quality of life after breast reconstruction, but patients and surgeons frequently disagree on the final aesthetic evaluation. The need for a comprehensive, validated tool to evaluate breast aesthetics independently from the patient motivated this study.

METHODS

The 13-item Validated Breast Aesthetic Scale was developed after several internal meetings, and worded to be understood by a nonspecialist. Three items are common for both breasts, with the remaining being side-specific. To test the internal consistency of the scale subitems, postoperative photographs after different breast reconstruction techniques were graded by a six-member panel. To test interrater and intrarater correlation across time, four physicians evaluated the results of abdominally based breast reconstructions following nipple-sparing mastectomies.

RESULTS

Graded aesthetic outcomes of 53 patients showed that the Cronbach alpha of the subitems of the scale was 0.926, with no single item that, if excluded, would increase it. Twenty-two patients underwent aesthetic outcomes grading at four different time points. The mean overall appearance was 3.71 ± 0.62. The mean grade for overall nipple appearance was 4.0 ± 0.57. The coefficient alpha of the panel overall aesthetic grade across different time points was 0.957; whereas intragrader reliability for graders 1 through 4 individually showed alpha coefficients of 0.894, 0.9, 0.898, and 0.688, respectively. Similar results were found for the other items of the scale.

CONCLUSIONS

The proposed aesthetic scale evaluates different aspects of the breast reconstruction aesthetic result with excellent internal consistency among its subitems. Grading by a gender-balanced, diverse four-member panel using postoperative photographs showed higher reliability and reproducibility compared to single graders.

Breast Aesthetic Preferences: Analysis of 1294 Surveys

BACKGROUND

Aesthetic breast perceptions could be variable among cultures. Fullness, superior/inferior pole proportion and orientation and size of the nipple areolar complex are key elements in patient post-operative satisfaction and should be considered when planning breast aesthetic surgery.

METHODS

A descriptive study was designed, using an online survey, sent via social media. Standardized software modified images of breasts with different pole proportions, areolar nipple complex orientation and size were used.

RESULTS

From 1294 surveys collected, 1291 were analysed (969 women and 322 men). Significant differences in preferences of upper/lower pole breast proportions were found among groups of different age, gender, level of education and previous history of breast surgery.

CONCLUSIONS

In the studied population, we found several variations in aesthetic breast preferences related to their demographic characteristics and for this reason we believe that this research may serve as a "macro" guide for both patient and surgeon in primary and secondary breast surgery. To our knowledge, this is the largest survey study concerning breast aesthetic preferences done in Colombia and second largest in the world.

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.

Assessing Interobserver Variability of Cosmetic Outcome Assessment in Breast Cancer Patients Undergoing Breast-Conservation Surgery

BACKGROUND

Inter-rater reliability between breast surgical oncologists and reconstructive surgeons using cosmesis scales, and the correlation between their observations and patients' own subjective assessments, is poorly understood.

METHODS

Patients undergoing BCS in a prospective trial rated their cosmetic outcome on a Likert scale (poor/fair/good/excellent) at the postoperative and 1-year time points; photographs were also taken. Three breast surgical oncologists (not involved in these cases) and two reconstructive surgeons were asked to independently rate cosmesis using the Harvard/NSABP/RTOG scale.

RESULTS

Overall, 55 and 17 patients had photographs and Likert self-evaluations at the postoperative and 1-year time points, respectively. There was poor agreement between surgeon and patient ratings postoperatively [kappas - 0.042 (p = 0.659), 0.069 (p = 0.226), and 0.076 (p = 0.090) for the breast surgical oncologists; and 0.018 (p = 0.689) and 0.112 (p = 0.145) for the reconstructive surgeons], and poor interobserver agreement between surgeons of the same specialty (kappa - 0.087, 95% confidence interval [CI] - 0.091 to - 0.082, p = 0.223 for breast surgical oncologists; and kappa - 0.150, 95% CI - 0.157 to - 0.144, p = 0.150, for reconstructive surgeons). At 1 year, the interobserver agreement between breast surgical oncologists was better (kappa 0.507, 95% CI 0.501-0.512, p < 0.001); however, there was still poor correlation between the reconstructive surgeons (kappa - 0.040, 95% CI - 0.049 to - 0.031, p = 0.772). Agreement between surgeon and patient ratings remained poor at this time point [kappas - 0.115 (p = 0.477), 0.177 (p = 0.245), and 0.101 (p = 0.475) for breast surgical oncologists; and 0.335 (p = 0.037) and -0.118 (p = 0.221) for reconstructive surgeons].

CONCLUSION

Despite gradation scales for measuring cosmesis after BCS, high levels of agreement between surgeons is lacking and these do not always reflect patients' subjective assessments.

Review of Quantitative Imaging for Objective Assessment of Fat Grafting Outcomes in Breast Surgery

This article presents a comprehensive review of the use of quantitative measurements based on breast images to assess fat retention, breast aesthetics, and fat necrosis after autologous fat grafting. Breast volume measured from MRI and 3-dimensional surface images is widely used as a measure of fat retention. Breast aesthetics are assessed from a combination of anthropometric (distance and contour) measurements on breast surface images. Examination of radiologic images (ultrasonography, mammography, and MRI) is utilized to assess fat necrosis. The article discusses implementation guidelines for objective outcome assessment to support robust quantification and enable investigations of fat grafting efficacy. Level of Evidence: 4.

Cosmetic outcomes following wide local excision of impalpable breast cancer: is radioguided occult lesion localization using iodine-125 seeds better than hookwire localization?

BACKGROUND

Hookwire localization (HWL) is the gold standard for localizing impalpable tumours for breast conserving surgery. An alternative technique, radioguided occult lesion localization using iodine-125 seeds (ROLLIS), has been associated with lower re-excision rates. This paper investigates if cosmetic outcomes differ in women undergoing breast conserving surgery with HWL or ROLLIS.

METHODS

Women who had ROLLIS or HWL guided excision for impalpable breast cancer within a multicentre randomized controlled trial (RCT) (ANZCTR 12613000655741) were recruited. Exclusions were level 2 oncoplasty and mastectomy. Cosmetic outcome was calculated using BCCT.core, the Hopwood Body Image Scale and estimated percentage breast volume excised. Chi-squared analysis was used to determine the difference between the intervention groups.

RESULTS

Analysis was performed for 123 participants (66 ROLLIS and 57 HWL). The cosmetic outcome determined by BCCT.core for all participants was good with no significant difference between the ROLLIS and HWL groups. When reviewing the number of patients who experienced either a good or excellent result, there was a significantly higher number of patients in the ROLLIS group (n = 53, 82%) compared to the HWL group (n = 42, 74%, P = 0.02. There were no differences in Hopwood Body Image Scale or estimated percentage breast volume excised between groups. There was a reduction in the frequency of re-excision in the ROLLIS group (n = 3, 4.5%) versus HWL group (n = 8, 14%); however, this was not significant (P = 0.06).

CONCLUSION

Pre-operative localization of impalpable breast lesions using either ROLLIS or HWL resulted in a good cosmetic outcome with no significant difference between localization techniques.

Perception of the most perfect female breast shape among Malays, Chinese, and Indians community

Researchers have long tried to search for the 'perfect' aesthetic outcome of breast surgery. Although lots of anthropometric studies have been done, there is no consensus when dealing with harmony, abstract, and proportion that make up for its ideal shape. This study was convened via a survey to find the most perfect breast shape by assessing the upper pole contour and upper pole to lower pole ratio (UP:LP) preference among the Malays, Chinese, and Indians races. Hundred thirty-five individuals partook in this survey. Most of the participants generally preferred a more convex shape of upper pole contour with the Malay (50%) and Indian (35.7%) favored a more convex shape while the Chinese preferred it to be just slightly convex (42.8%). Single unmarried individuals (64.7%) significantly preferred a more convex upper pole contour (p = 0.018). The UP:LP ratio of 45:55 (p = 0.002) was the most significantly preferred proportion (37.8%) which largely comprised of the Chinese (51%), followed by Indian (21.6%) and Malay (19.6%). With these findings, using a controlled perception-preference method is a more preferred choice when describing an ideal breast shape as compare to an anthropometric measurement that might be less accurate. Therefore, breast and plastic surgeons alike need to look beyond the anthropometric numbers and should consider the other 'abstract' aesthetic shape which difficult to measure including the upper pole breast that has more convexity and the UP:LP ratio of 45:55 which showed to be the most aesthetically perfect form as agreed in the current works of literature.

Nipple-sparing mastectomy: A review of outcomes at a single institution

Nipple-sparing mastectomy (NSM) offers patients who are not candidates for breast-conserving treatment an aesthetically pleasing alternative to traditional mastectomy. Some studies have demonstrated its oncologic safety while others have demonstrated residual occult tumor cells at the nipple-areolar complex (NAC). These data prompt further review of oncologic outcomes after NSM.A single institution retrospective chart review was performed of all NSMs performed by 4 breast surgeons at Thomas Jefferson University Hospital over a span of 2012-2019. In this cohort, we review the reconstruction performed, axillary lymph node status, surgical margins, final pathology, loss of the NAC, recurrence rates, and follow-up. In our cohort, we reviewed 170 NSMs performed on 105 patients. All patients were female, and the average age was 46.9 years. Prophylactic procedures were performed on 43% of patients with 17.1% of patients being BRCA positive. Of those undergoing NSM for cancer (n = 94), the associated pathology was 28.8% DCIS, 32.9% IDC, and 3.5% ILC (this accounts for some patients with multiple diagnoses on final pathology). Sentinel lymph node biopsy (SLNB) was performed in 52.9% of cases with 10.6% of cases being positive for axillary disease. Margins were positive in 10.6% (n = 10) of cases performed for cancer with 8.5% (n = 8) of cases having positive margin at the NAC and the remainder being at the deep margin. Based on margin positivity, 2.4% (n = 4) of patients underwent redo surgery with 1 patient requiring re-resection at the NAC margin and 3 patients having total NAC resection. Total loss of NAC occurred in 5.9% (n = 10) of cases due to positive margins (n = 3) and necrosis (n = 7). Recurrence occurred in 7.2% (n = 7) of cases who underwent NSM for cancer. Locoregional recurrence in breast tissue, skin, or axilla occurred in 4.1% (n = 4) of cases with 0 recurrences at the NAC. Distant recurrence occurred in 4.1% (n = 4) of cases at both liver and bone. Average time to recurrence was 27.3 months. Of the 170 NSM performed, 98% had immediate tissue expander placement with 60% converting to permanent subpectoral implant reconstruction, 14% latissimus dorsi flap reconstruction, 0.6% delayed deep inferior epigastric artery perforator free-flap reconstruction, and 5.2% undergoing delayed free transversus abdominus muscle flap reconstruction. Of all the cases reviewed, there was only 1 death. Our average follow-up was 26.7 months. We demonstrate similar numbers in our analysis as other studies that have looked at oncologic outcomes after NSM. Although we demonstrate evidence of occult disease at the NAC margin when performing NSM, there was no evidence of recurrence at the NAC demonstrating its efficacy and safety. With proper patient selection, this procedure can be safely offered as an esthetically appealing alternative to traditional mastectomy.

Structured-light surface scanning system to evaluate breast morphology in standing and supine positions

Breast shapes are affected by gravitational loads and deformities. Measurements obtained in the standing position may not correlate well with measurements in the supine position, which is more representative of patient position during breast surgery. A dual color 3D surface imaging system capable of scanning patients in both supine and standing positions was developed to evaluate the effect of changes in body posture on breast morphology. The system was evaluated with  breast phantoms to assess accuracy, then tested on ten subjects in three body postures to assess its effectiveness as a clinical tool. The accuracy of the system was within 0.4 mm on average across the model. For the human study, there was no effect of body posture on breast volumes (p value > 0.05), but we observed an effect of completeness of breast scans on body posture (p value  < 0.05). Post-hoc tests showed that the supine position and the standing position with hands at the waist differed significantly (p value  < 0.05). This study shows that the system can quantitatively evaluate the effect of subject postures, and thereby has the potential to be used to investigate peri-operative changes in breast morphology.

Measuring Differential Volume Using the Subtraction Tool for Three-Dimensional Breast Volumetry: A Proof of Concept Study

Background. Three-dimensional (3D) photography provides a promising means of breast volumetry. Sources of error using a single-captured surface to calculate breast volume include inaccurate designation of breast boundaries and prediction of the invisible chest wall generated by computer software. An alternative approach is to measure differential volume using subtraction of 2 captured surfaces. Objectives. To explore 3D breast volumetry using the subtraction of superimposed images to calculate differential volume. To assess optimal patient positioning for accurate volumetric assessment. Methods. Known volumes of breast enhancers simulated volumetric changes to the breast (n = 12). 3D photographs were taken (3dMDtorso) with the subject positioned upright at 90° and posteriorly inclined at 30°. Patient position, breathing, distance and camera calibration were standardised. Volumetric analysis was performed using 3dMDvultus software. Results. A statistically significant difference was found between actual volume and measured volumes with subjects positioned at 90° (P < .05). No statistical difference was found at 30° (P = .078), but subsequent Bland–Altman analysis showed evidence of proportional bias (P < .05). There was good correlation between measured and actual volumes in both positions (r = .77 and r = .85, respectively). Univariate analyses showed breast enhancer volumes of 195 mL and 295 mL to incur bias. The coefficient of variation was 5.76% for single observer analysis. Conclusion. Positioning the subject at a 30° posterior incline provides more accurate results from better exposure of the inferior breast. The subtraction tool is a novel method of measuring differential volume. Future studies should explore methodology for application into the clinical setting.

The Aesthetically Ideal Position of the Nipple-Areola Complex on the Breast

BACKGROUND

Several studies have attempted to identify an objective description of the aesthetically ideal breast, but they have all suffered in their reliability because of having several intrinsic limitations. It is therefore essential to design a template of ideal breast features in order to predict and evaluate aesthetic outcomes in both reconstructive and cosmetic breast surgery. The aim of this study was to determine the aesthetically preferred position of the nipple- areola complex on the breast.

METHODS

A questionnaire was sent by regular mail to 1000 men and 1000 women aged between 16 and 74 years. They were asked to rank the attractiveness of a series of breasts of women in images with different NAC positions. The images showed breasts from two different angles: 12 frontal-view images with both breasts shown, and five sideview images with only one breast shown. All of the breasts had equal dimensions and proportions, with the same areola size but different NAC positions. Statistical analysis of data was carried out.

RESULTS

Eight hundred and thirteen of 2000 participants completed the questionnaire. The NAC placement preferred by both genders had a ratio of 40:60 x and 50:50 y, which means that it was best situated in the middle of the breast gland vertically and slightly lateral to the midpoint horizontally. Significant differences were found between the age and gender subgroup preferences.

CONCLUSIONS

This study identified the preferred position of the nipple-areola complex on the female breast in the general population. This is an important information when planning breast reconstructive and cosmetic surgery.

LEVEL OF EVIDENCE II

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 Impact of Mastectomy on Women's Visual Perception of Breast Aesthetics and Symmetry: A Pilot Eye-Tracking Study

BACKGROUND

Little is known about breast cancer survivors' perception of breast attractiveness. A better understanding of this subjective concept could contribute to the improvement of patient-reported outcomes after reconstructive surgeries and facilitate the development of new methods for assessing breast reconstruction outcomes.

OBJECTIVES

The aim of this eye-tracking (ET)-based study was to verify whether mastectomy altered women's visual perception of breast aesthetics and symmetry.

METHODS

A group of 30 women after unilateral mastectomy and 30 healthy controls evaluated the aesthetics and symmetry of various types of female breasts displayed as highly standardized digital images. Gaze patterns of women from the study groups were recorded using an ET system and subjected to a comparative analysis.

RESULTS

Regardless of the study group, the longest fixation duration and the highest fixation number were found in the nipple-areola complex. This area was also the most common region of the initial fixation. Several significant between-group differences were identified; the gaze patterns of women after mastectomy were generally characterized by longer fixation times for the inframammary fold, lower pole, and upper half of the breast.

CONCLUSIONS

Mastectomy might affect women's visual perception patterns during the evaluation of breast aesthetics and symmetry. ET data might improve our understanding of breast attractiveness and constitute the basis for a new reliable method for the evaluation of outcomes of reconstructive breast surgeries.

Breast Reconstruction with a Lateral Breast Free Flap: A New Application of Breast-sharing

Supplemental Digital Content is available in the text.

Breast reconstruction using contralateral autologous tissue, also known as breast sharing, is a viable option previously described in the literature, whereby flaps based on perforators of the internal mammary artery (internal mammary artery pedicle) are used. We report a postoncological breast reconstruction case using a microvascular flap taken from the lateral pole of the contralateral breast. We highlight the importance of preserving the medial pole of the donor breast for improving cosmesis, avoiding symmastia, and preserving the intermammary sulcus, as a difference with flaps based on the internal mammary artery pedicle flaps. Breast sensation could be recovered by neurotization of the lateral intercostal nerve, which may be included in the contralateral breast flap to be transferred. Contralateral breast free flaps could be an alternative to reconstruct the breast in selected patients. Oncological risk factors are discussed. Advances in genetic testing and tumor cell biology could help us to select the accurate candidates for this reconstructive technique.

Satisfaction with cosmetic outcomes of breast reconstruction: Investigations into the correlation between the patients' Breast-Q outcome and the judgment of panels

Objectives

We aimed to determine the relation between breast reconstruction method, patient satisfaction, and surgeon reported cosmetic outcome among women who underwent breast reconstruction after mastectomy.

Study Design

A cross-sectional study of patients treated between 2006 and 2010.

Main Outcome

Women's satisfaction with cosmetic outcomes after breast reconstruction.

Measures

Cosmetic outcomes were evaluated by (1) women using the Breast-Q to rate satisfaction with breasts outcomes, and (2) an independent panel using the Strasser score. The relationships between the Breast-Q rating, Strasser scores, and breast reconstruction methods, including laterality and timing, were evaluated by Mann–Whitney U tests, Spearman's rank correlations, and Wilcoxon signed-rank tests.

Results

Ninety-four women were included. Patients were more satisfied with their breasts if they had undergone autologous, unilateral, or secondary breast reconstruction compared with those who underwent alloplastic, bilateral, or primary breast reconstruction (p-values 0.008, 0.011, and 0.001, respectively). The Strasser system did not reveal significant cosmetic differences, with all breast reconstructions graded as mediocre or poor.

Conclusions

Patient satisfaction with breast outcomes, as measured by the Breast-Q, was described as mediocre or poorly reflected by the Strasser score. If doctors are to support patients to make informed decisions on the optimal method of breast reconstruction, we need a more sensitive, comprehensive tool reflecting patients’ cosmetic outcomes.

[Techniques enhancement for tissue expander/implant two-stage breast reconstruction]

OBJECTIVE

To investigate the outcomes of breast reconstruction with employing improved techniques throughout the tissue expander/implant two-stage breast reconstructed process, which involved the tissue expander placement, the saline filling intraoperatively and postoperatively, the implant selection, and the permanent implant replacement.

METHODS

In this study, 68 patients who had been provided immediate or delayed tissue expander/implant two-stage breast reconstruction with autologous fat injection post-mastectomy in Peking University Third Hospital from April 2014 to September 2018 were involved, and the relevant information was analyzed retrospectively. The enhancements of the techniques, involving the incision selection, the expander placement, the principle of expansion, the management of capsule, the prosthesis selection, and the assisted reconstruction method were summarized, and the reconstruction outcomes were evaluated objectively through three-dimensional surface imaging.

RESULTS

Among the 68 patients in this study, immediate reconstruction was conducted in 25 patients and 43 patients underwent delayed reconstruction. The median time of tissue expansion was 7.0 (3.0, 20.0) months, and the average volume of expansion was (372.8±87.2) mL. The median size of breast implant was 215 (100, 395) mL. The median number of injections for fat grafting was 1 (1, 3), and the average volume of fat grafting was (119.3±34.1) mL. The median follow-up time was 7.0 (4.0, 24.0) months. During the process of breast reconstruction, the tissue expander leakage was observed in two patients, and one of them underwent expander replacement due to the secondary infection. In the immediate reconstruction cases, the volume symmetry of bilateral breasts after reconstruction got even better than that before mastectomy (t=4.465, P<0.01). And in the delayed reconstruction cases, the volume between bilateral breasts also achieved good symmetry after reconstruction (t=0.867, P>0.1).

CONCLUSION

Good results of tissue expander/implant two-stage breast reconstruction could be achieved through the techniques enhancement, which involved the preferred transverse incision, the downward placement of expander, the rapid expansion of chest soft tissue, the release of capsule tension, the application of sizer in prosthesis selection, and the assisted autologous fat grafting.

Novel 3-Dimensional Imaging Analysis of the Ryan Procedure for Inframammary Fold Elevation in the Reconstruction of the Revised Breast

The inframammary fold (IMF) can be challenging to reconstruct after disruption during mastectomy or breast reconstruction. The Ryan procedure is a previously described technique with little long-term analysis. Our goal is to analyze the long-term results of the Ryan procedure using 3-dimensional (3D) technology, with the hypothesis that 3D measurements will provide quantitative outcomes that add to the qualitative assessment of the reconstruction. We retrospectively reviewed consecutive breast reconstruction patients by a single surgeon from January 1, 2012 to January 31, 2015 to identify patients who underwent the Ryan procedure. Previously obtained 3D photographs were then analyzed to compare breast base diameter, breast projection, and inter-IMF distance pre- and postoperatively. A survey was then given to 15 health professionals in our department to assess the IMF and symmetry pre- and postoperatively. Eight patients were eligible for inclusion. Four patients were unilateral reconstruction and 4 were bilateral. The Ryan procedure resulted in an inter-IMF discrepancy reduction of 39% and a breast projection increase of 18%. Average length of follow-up was 2.82 ± 0.75 years. One patient required a secondary IMF revision. The majority of survey respondents felt that the IMF and IMF symmetry were improved or stable postoperatively. The Ryan procedure seems to be a reliable and durable technique for IMF reconstruction with increased projection, decreased IMF discrepancy, and increased symmetry. Additionally, 3D imaging provides a useful approach in the assessment of breast reconstruction outcomes, adding quantitative outcomes measures to its evaluation.

Breast Anthropometry-Results of a Prospective Study Among Indian Breast Cancer Patients

Breast anthropometry plays an important role in surgical decision-making in the era of breast conservation therapy, oncoplasty and reconstruction. Majority of the currently available breast anthropometry data is from Western countries, and there is a need to evaluate anthropometric data among Indian women to tailor our surgical decision-making and achieve optimum surgical results. Two hundred and thirty-one breast cancer patients were included in this prospective study, and different anthropometric parameters were evaluated to assess and describe the nipple-areola complex, breast shape, size, volume and ptosis. Breast volume was calculated using formula developed by Qiao et al. Outcomes were compared with data available from different countries. Mean breast volume among Indian women was 515 ml. Nearly, 81% of patients had ptosis and up to 40% had grade 3 ptosis. Breast volume among Indian patients can be grouped into three categories based on quartiles (category I-≤ 220 ml, category II-> 220 to ≤ 730 ml, category III-> 730 ml). Overall breast anthropometry data among Indian women was different from the data reported from western studies. Breast anthropometry plays an important role in the surgical decision-making, and results of the study indicate that the anthropometry of Indian women is different from western counterparts.

Short-term Safety of Augmentation Mammaplasty Using the BellaGel Implants in Korean Women

Supplemental Digital Content is available in the text.

Asian women are stereotypically characterized by a slim body, smaller breasts and areolae, and larger nipples when compared with White women. They would therefore be vulnerable to displacement of a breast implant if they receive larger implants. They are also prone to hypertrophic and prolonged hyperemic scars. Surgeons should therefore be aware of Asian women’s breast anatomy, healing tendency, and preferences. We conducted this multicenter, retrospective study to assess the short-term safety of the BellaGel implants in Korean women.

The rule of thirds: Determining the ideal areolar proportions

Background

Breast surgery often requires changing the diameter of the areola. Recommended areolar size is commonly based on population averages, or surgical judgement. An ideal areola size has not been previously been described. We hypothesized that the ideal areolar diameter would be proportional to two breast measurements not commonly altered during breast surgery: the nipple diameter and breast base width.

Methods

'The Sun' newspaper (London, UK) publishes photographs of topless models which are selected based on the aesthetic appeal of their non-operated breasts. The publication's archive, from March 2014 to January 2017, was independently reviewed by three authors to identify photographs that presented a clear anterior view of the breast. The base width, nipple diameter and areolar diameter were measured independently by each reviewer. Measurements were pooled, and the mean was included for analysis. Ratios of the areolar diameter to the base width and the nipple diameter were calculated.

Results

The photographs of 58 models were eligible for inclusion. The average areolar diameter to base width was 0.29 (SD = 0.05). The average nipple to areolar diameter was 0.29 (SD = 0.06).

Conclusions

In aesthetically pleasing breasts, the areolar diameter is proportional to both the breast base width and nipple diameter. Breast base width is commonly measured preoperatively in aesthetic breast procedures, and is not typically modified. Breast base width can therefore be used to determine the ideal areolar size using the ratio of areola:base width ratio of 0.29 identified in this study.

A prospective comparison of subjective and objective assessments of cosmetic outcomes following breast brachytherapy

Purpose

We evaluated agreement between subjective and objective methods of cosmesis scoring in an accelerated partial breast irradiation (APBI) cohort.

Material and methods

Consecutive women treated with APBI using interstitial brachytherapy reported for clinical follow-up every 6 months. Single cross-sectional assessment of the breast cosmesis was done by a radiation oncologist (subjective method) using Harvard scale and by photographic assessment using BCCT.core (Breast Cancer Conservative Treatment. Cosmetic results, version 3.1) software (objective method) at 18-36 months post-APBI. The agreement between subjective and objective methods for the overall score as well as individual subjective/objective subdomains was computed using kappa statistics. ANOVA was used to test the correlation between objective indices and subjective subdomains.

Results

The agreement between the subjective (physician) and objective assessment was good with a kappa of 0.673. Overall, 77 (98.7%) patients were satisfied with the overall outcomes of breast conservation therapy. The kappa agreement between physician and patient scoring was 0.457 (95% CI: 0.240-0.674). Among the subjective subdomains, location of the nipple areola complex (NAC) had good agreement with both the overall subjective and objective score, with the kappa of 0.778 and 0.547, respectively. In the objective indices, BCE (breast compliance evaluation), LBC (lower breast contour), and UNR (unilateral nipple retraction) correlated significantly with the subjective subdomains: location of the NAC, breast size, and shape (p < 0.05 for all indices).

Conclusions

Good agreement exists for overall cosmetic outcomes measured by subjective and objective methods. Location of the NAC, breast size and shape are the most important parameters determining cosmetic outcomes irrespective of the method of assessment.

Improved patient-reported outcomes after autologous fat transplantation and corrective surgery after breast surgery

BACKGROUND

Autologous fat transplantation (AFT) is being increasingly used to improve the results after breast-conserving surgery and breast reconstruction. However, studies on patient-reported outcomes (PROs) and health-related quality of life (HRQoL) after AFT are scarce. The aim of this prospective longitudinal case-series study was to assess PRO in women who had undergone AFT after surgery for breast cancer or risk-reducing mastectomy.

METHODS

Fifty women, who had undergone breast-conserving surgery or breast reconstruction, needing corrective surgery, were consecutively included between 2008 and 2013. A 20-item study-specific questionnaire (SSQ) and the Short Form Health Survey (SF-36) were used pre-operatively and 6 months, 1 year and 2 years post-operatively, to evaluate PRO and HRQoL.

RESULTS

The patients underwent three (1-4) AFT procedures, with the injection of 164 ml (median) (range 40-516) fat. Thirty-eight and 34 patients completed the study-specific questionnaire and the SF-36, respectively, both pre-operatively and after 2 years. Sixteen of the 20 items in the SSQ were improved after 2 years, including breast size (p < 0.0001), shape (p < 0.0001), appearance (p < 0.0001), softness of the breast (p = 0.001), pain in the region (p = 0.005), scarring from previous breast surgery (p < 0.001) and willingness to participate in public physical activities (p < 0.001). HRQoL did not largely differ before and after AFT, or between the study group and a reference population.

CONCLUSIONS

AFT alone or in combination with other corrective surgical procedures, improved PRO after breast-conserving surgery and breast reconstruction in both irradiated and non-irradiated women.

Dual Coverage of the Inferior Pole with Conjoined Fascial Flap and Acellular Dermal Matrix for Immediate One-Stage Breast Reconstruction with a Prosthetic Implant

BACKGROUND

Elevation of a conjoined fascial flap composed of the pectoralis major, serratus anterior, and external oblique fascia is a type of surgical technique using autologous tissue to cover the lower pole after immediate one-stage direct-to-implant (DTI) breast reconstruction. However, volumetric breast implants hinder use of this technique alone. For better structural stability and more aesthetically favorable breast contour in large breasts, we have devised a technique involving dual coverage of the lower pole by a conjoined fascial flap and acellular dermal matrix (ADM).

METHODS

Twenty Asian patients underwent DTI breast reconstruction from March 2013 to May 2014. ADM was used to cover the inferomedial quadrant of the breast, and a conjoined fascial flap was elevated to cover the remaining inferolateral quadrant. Both patient- and plastic surgeon-reported outcome measures were assessed using questionnaires.

RESULT

For every domain of the patient- and plastic surgeon-reported questionnaires, the mean scores were between satisfied and very satisfied. Two patients developed a seroma and one patient developed partial skin flap necrosis. Both seromas resolved after a series of aspirations. The necrotic skin flap was revised under local anesthesia 3 weeks after the reconstructive surgery.

CONCLUSION

The use of dual coverage of the inferior pole with a conjoined fascial flap and ADM for immediate DTI among patients with large breasts is supported by high scores in both patient- and plastic surgeon-reported outcome measures, as well as low complication rates.

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 .

Objective evaluation of nipple position after 336 breast reductions

Throughout different eras and cultures what is considered the cosmetically ideal breast has varied greatly. There is no broadly accepted standardised method that objectively evaluates aesthetic outcome after breast reduction mammoplasty. The primary aim of this study was to evaluate the result of breast reduction regarding nipple position, comparing it to an objective previously described standard. Secondary aims were to determine symmetry and examine predictors for achieving an aesthetically pleasing breast. The position of the nipple was measured in postoperative pictures and compared to a previously described standard. Three-hundred and thirty-six breast were included in the study. Compared with the previously described standard, 26% (89/336) of the nipples were within the optimal position in mediolateral direction, and 44% (147/336) in craniocaudal direction. The majority of women had the nipple in the same position in the two breasts. Age at surgery seems to significantly influence the possibility of achieving an optimal nipple position. No other predictors were found. Improvements can be made in placement of the nipple during reduction mammoplasty. Further studies are needed on how knowledge of the ideal nipple position can be used to optimize surgical planning and technique, and reduce variability in outcomes, in breast reduction mammoplasties.

Body image dissatisfaction in patients undergoing breast reconstruction: Examining the roles of breast symmetry and appearance investment

OBJECTIVE

Reconstruction as part of treatment for breast cancer is aimed at mitigating body image concerns after mastectomy. Although algorithms have been developed to objectively assess breast reconstruction outcomes, associations between objectively quantified breast aesthetic appearance and patient-reported body image outcomes have not been examined. Further, the role of appearance investment in explaining a patient's body image is not well understood. We investigated the extent to which objectively quantified breast symmetry and patient-reported appearance investment were associated with body image dissatisfaction in patients undergoing cancer-related breast reconstruction.

METHODS

Breast cancer patients in different stages of reconstruction (n = 190) completed self-report measures of appearance investment and body image dissatisfaction. Vertical extent and horizontal extent symmetry values, which are indicators of breast symmetry, were calculated from clinical photographs. Associations among breast symmetry, appearance investment, body image dissatisfaction, and patient clinical factors were examined. Multi-variable regression was used to evaluate the extent to which symmetry and appearance investment were associated with body image dissatisfaction.

RESULTS

Vertical extent symmetry, but not horizontal extent symmetry, was associated with body image dissatisfaction. Decreased vertical extent symmetry (β = -.19, P < .05) and increased appearance investment (β = .45, P < .001) were significantly associated with greater body image dissatisfaction while controlling for clinical factors.

CONCLUSIONS

Breast symmetry and patient appearance investment both significantly contribute to an understanding of patient-reported body image satisfaction during breast reconstruction treatment.

Refinements in the Techniques of 2-Stage Breast Reconstruction

BACKGROUND

Two-stage breast reconstruction with tissue expanders is one of the most common plastic surgery procedures. Acellular dermal matrix (ADM) has become popular for its ability to improve expansion parameters and aesthetics, albeit with a higher complication profile. We present data that support redefining 2-stage reconstruction to include tissue expanders regardless of final reconstructive modality to act as a bridge. Furthermore, we show that cooperation with the ablative surgeon and technical refinements support ADM omission from the first stage of reconstruction.

METHODS

We retrospectively reviewed charts from the senior author's (D.A.J.) private practice over a 10-year follow-up period. Inclusion criteria included all women over 18 years who underwent mastectomy and had a tissue expander placed immediately or in a delayed fashion and successfully completed tissue expansion and are finished with the second stage of reconstruction or awaiting second stage of reconstruction. Demographic data, tissue expander filling data, final reconstruction, aesthetic outcome, and complications were tabulated.

RESULTS

A total of 118 women (165 breasts) met inclusion criteria. There were no statistically significant differences in initial fill volume (P = 0.094), number of visits until final expansion (P = 0.677), or final fill volume (P = 0.985) between the ADM and non-ADM cohorts. In addition, non-ADM patients had superior aesthetic scores with respect to defects other than scarring (P = 0.015), projection (P = 0.013), and inframammary fold quality (P = 0.009). Fifteen percent of women decided to change desired final reconstruction modality during the tissue expansion phase.

CONCLUSIONS

This reconstructive algorithm emphasizes surgical cooperation between the ablative and reconstructive surgeon, improved technique, and patient education. This focus translates into maintained tissue expansion, aesthetically pleasing results, and allows for the omission of ADM from reconstruction.

The Telemark Breast Score: A Reliable Method for the Evaluation of Results after Breast Surgery

BACKGROUND

Validated instruments for assessing results after breast surgery are sparse. The authors present here a method used for the past 10 years at their institution for evaluation of outcome after breast-conserving surgery and microsurgical breast reconstruction.

METHODS

The Telemark Breast Score is a method based on standard two-dimensional photographs assessing the outcome after breast surgery in terms of volume, shape, and symmetry. Three panels comprising two plastic surgeons, two breast surgeons, and two nurses tested the Telemark Breast Score on 346 patients who underwent breast-conserving surgery for cancer and 31 other patients who underwent deep inferior epigastric perforator flap reconstruction. All patients were assessed at least 1 year after their operation. Consistency of agreement between and within the panels was studied.

RESULTS

Interobserver and intraobserver reliability was good after consensus discussion. Good rating stability was shown using test-retest measurements.

CONCLUSION

The Telemark Breast Score is an inexpensive, statistically reliable method and can be applied for quality control after breast surgery.

CLINCAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Acellular Dermal Matrix Versus Inferior Deepithelialized Flap Breast Reconstruction: Equivalent Outcomes, with Increased Cost

BACKGROUND

Approximately 250,000 new cases of breast cancer are diagnosed yearly in the U.S. resulting in more postmastectomy breast reconstructions (PMBRs). The acellular dermal matrix (ADM) expander-implant method became popular in the mid-2000s, but newer techniques such as the inferior deepithelialized flap (IDF) has more recently been described. We hypothesize that ADMs and IDFs provide comparable aesthetic outcomes, with no difference in complication rates and operative characteristics.

METHODS

A retrospective, single-institution study was performed between July 1, 2012, and June 30, 2014, examining all PMBR's (ADM and IDF). Outcomes were categorized as clinical (e.g., complications requiring surgical intervention) or aesthetic.

RESULTS

A total of 65 patients (41 ADM; 24 IDF; mean age, 53.4 ± 10.7 years) were included, with 101 PMBR's evaluated (63 ADM and 38 IDF). Patients who underwent IDFs had higher body mass index (32 versus 25; P < 0.01) and higher grades of breast ptosis. Major complication rates were similar between ADM and IDF groups (22% versus 31.5%; P = 0.34). There were no differences in aesthetic outcomes between groups (rater intraclass correlation, 0.92). The average IDF breast reconstruction took nearly 30 minutes longer per reconstructed side (192 minutes versus 166 minutes; P = 0.02), but operative costs were more expensive for the ADM breast reconstruction.

CONCLUSIONS

The IDF procedure took 30 minutes longer for each reconstructed side, without significant differences in complications or aesthetic outcomes between the 2 PMBRs. IDF reconstructions may be more suitable for patients with grade 3 breast ptosis and higher body mass index. Further studies should focus on long-term outcomes and value-based approaches to PMBR.

Quantitative Assessment of Breast Cosmetic Outcome After Whole-Breast Irradiation

PURPOSE

To measure, by quantitative analysis of digital photographs, breast cosmetic outcome within the setting of a randomized trial of conventionally fractionated (CF) and hypofractionated (HF) whole-breast irradiation (WBI), to identify how quantitative cosmesis metrics were associated with patient- and physician-reported cosmesis and whether they differed by treatment arm.

METHODS AND MATERIALS

From 2011 to 2014, 287 women aged ≥40 with ductal carcinoma in situ or early invasive breast cancer were randomized to HF-WBI (42.56 Gy/16 fractions [fx] + 10-12.5 Gy/4-5 fx boost) or CF-WBI (50 Gy/25 fx + 10-14 Gy/5-7 fx). At 1 year after treatment we collected digital photographs, patient-reported cosmesis using the Breast Cancer Treatment and Outcomes Scale, and physician-reported cosmesis using the Radiation Therapy Oncology Group scale. Six quantitative measures of breast symmetry, labeled M1-M6, were calculated from anteroposterior digital photographs. For each measure, values closer to 1 imply greater symmetry, and values closer to 0 imply greater asymmetry. Associations between M1-M6 and patient- and physician-reported cosmesis and treatment arm were evaluated using the Kruskal-Wallis test.

RESULTS

Among 245 evaluable patients, patient-reported cosmesis was strongly associated with M1 (vertical symmetry measure) (P<.01). Physician-reported cosmesis was similarly correlated with M1 (P<.01) and also with M2 (vertical symmetry, P=.01) and M4 (horizontal symmetry, P=.03). At 1 year after treatment, HF-WBI resulted in better values of M2 (P=.02) and M3 (P<.01) than CF-WBI; treatment arm was not significantly associated with M1, M4, M5, or M6 (P≥.12).

CONCLUSIONS

Quantitative assessment of breast photographs reveals similar to improved cosmetic outcome with HF-WBI compared with CF-WBI 1 year after treatment. Assessing cosmetic outcome using these measures could be useful for future comparative effectiveness studies and outcome reporting.

Comparison of Aesthetic Outcomes Between Vertical and Horizontal Flap Insets in Breast Reconstruction with the TRAM or DIEP Flaps

BACKGROUND

Tissue transfer, such as use of the transverse rectus abdominis myocutaneous (TRAM) or deep inferior epigastric artery perforator (DIEP) free flaps, is considered a standard method. However, outcomes may vary among inset methods. Here we compared the aesthetic outcomes of breast reconstructions using vertical and horizontal flap inset methods.

METHODS

We, respectively, reviewed 274 patients who underwent unilateral post-mastectomy breast reconstruction using TRAM or DIEP free flaps between April 2006 and December 2013. Photographs (frontal and bilateral oblique views) obtained 6 months post-operatively were evaluated. Symmetry scores and regional volume discrepancy scores were compared between the vertical and horizontal inset groups. Symmetry scores were adjusted for 11 potential confounding factors on multivariate regression analysis.

RESULTS

The vertical inset method was associated with higher total symmetry scores, projection, and ptotic naturalness scores. On multivariate regression analysis, the inset method was an independent predictor of outcomes. Regional volume discrepancy score analysis showed a greater tendency for more symmetrical volumes in the upper, medial, and lateral poles with the vertical inset.

CONCLUSION

The flap inset method is one of the key determinants of aesthetic breast reconstruction outcomes. The vertical inset method was associated with superior aesthetic outcomes and enabled balanced distribution of flap volume to the four poles of the breast.

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 .

Objective decision making between conventional and oncoplastic breast-conserving surgery or mastectomy: An aesthetic and functional prospective cohort study

BACKGROUND

Breast-conserving surgery (BCS) is considered the standard treatment for early-stage breast cancer. However, fair to poor cosmetic outcomes following conventional BCS have been observed in as many as one-third of cases. The aim of this study was to determine the critical tumor-to-breast volume ratio for each quadrant of the breast beyond which conventional BCS would no longer offer acceptable cosmetic and functional results or satisfactory quality of life for the patient.

METHODS

A prospective cohort study was performed between December 2011 and December 2013 involving 350 patients younger than 70 years with early-stage unifocal (T ≤ 30 mm) breast cancer who underwent wide excision and axillary sentinel lymph node biopsy followed by whole-breast irradiation. Using validated panels and software (the Breast Cancer Treatment Outcome Scale [BCTOS], EORTC Cancer Quality of Life Questionnaire number C30-BR23, and Breast Cancer Conservative Treatment - cosmetic results [BCCT.core] software), quality of life and aesthetic and functional parameters and their changes in correlation to the percentage of breast volume excised were statistically analyzed.

RESULTS

The maximum percentages of breast volume that were resectable by conventional BCS without resulting in unacceptable aesthetic and functional outcomes or decreased quality of life were 18-19% in the upper-outer quadrant (p < 0.0001), 14-15% in the lower-outer quadrant (p < 0.0001), 8-9% in the upper-inner quadrant (p < 0.0001), and 9-10% in the lower-inner quadrant (p < 0.0001).

CONCLUSION

Aided by the calculated cut-off values for each breast quadrant, breast surgeons might render more objective decisions regarding performing conventional BCS, using oncoplastic techniques or choosing mastectomy with immediate reconstruction.

[Shift the skin paddle in an additional incision improves the result: Study of a series of 82 breast reconstructions by latissimus dorsi flap and prosthesis implantation at 10 years]

The position of the skin paddle on the breast area is a fundamental element for the breast reconstructions by latissimus dorsi flap and prosthesis implantation. Should, as Millard advocated, to recreate the initial defect and include it in the mastectomy scar or is it better in an additional incision as have others authors. This study compares the long-term morphological results of these two attitudes, with or without additional incision.

PATIENTS AND METHODS

Eighty-two breast reconstructions by latissimus dorsi flap and prosthesis implantation, with a mean follow-up of 9.5 years were scored from 1 to 5 by a panel of expert and non-expert. The patients scored also their own reconstruction. Various parameters of the reconstructed breast were thus evaluated. We compared the results, according to the positioning of the skin paddle: with additional incision (50 cases); without additional incision (32 cases). The characteristics of the mastectomy scar on the breast area, high or low, horizontal or oblique, defined 6 groups where the results of the 2 surgical options were compared.

RESULTS

Only the reconstructions with additional incision get significantly higher results than those without additional incision (P<0.05). This involves the two panels, in the case of high mastectomy scars. In the others cases the additional incision is not essential.

CONCLUSIONS

If the realization of an additional incision can be perceived like misfit on an area already "mutilated", we plead for this solution in selected cases. This provides a benefit stable in time, in terms of overall results, shape and even rendering scar.

The Aesthetically Ideal Position of the Nipple-Areola Complex on the Breast

Background

Several studies have attempted to identify an objective description of the aesthetically ideal breast, but they have all suffered in their reliability because of having several intrinsic limitations. It is therefore essential to design a template of ideal breast features in order to predict and evaluate aesthetic outcomes in both reconstructive and cosmetic breast surgery. The aim of this study was to determine the aesthetically preferred position of the nipple–areola complex on the breast.

Methods

A questionnaire was sent by regular mail to 1000 men and 1000 women aged between 16 and 74 years. They were asked to rank the attractiveness of a series of breasts of women in images with different NAC positions. The images showed breasts from two different angles: 12 frontal-view images with both breasts shown, and five side-view images with only one breast shown. All of the breasts had equal dimensions and proportions, with the same areola size but different NAC positions. Statistical analysis of data was carried out.

Results

Eight hundred and thirteen of 2000 participants completed the questionnaire. The NAC placement preferred by both genders had a ratio of 40:60 x and 50:50 y, which means that it was best situated in the middle of the breast gland vertically and slightly lateral to the midpoint horizontally. Significant differences were found between the age and gender subgroup preferences.

Conclusions

This study identified the preferred position of the nipple–areola complex on the female breast in the general population. This is an important information when planning breast reconstructive and cosmetic surgery.

Level of Evidence II

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.

Repeated measures analyses of dermatitis symptom evolution in breast cancer patients receiving radiotherapy in a phase 3 randomized trial of mometasone furoate vs placebo (N06C4 [alliance])

PURPOSE

Radiotherapy-related dermatological toxicities over time have not been well quantified. We examined during and immediately following radiation therapy skin toxicities over time in a randomized study of mometasone furoate vs placebo during breast radiotherapy.

MATERIAL AND METHODS

Patients with breast cancer undergoing radiotherapy to the breast or chest wall were randomized. Symptoms related to skin toxicity were addressed weekly using provider-reported Common Terminology Criteria for Adverse Events (CTCAE v3.0) and 4 patient-reported outcomes (PRO) surveys. We applied repeated measures and risk analysis methodologies.

RESULTS

One hundred seventy-six patients were enrolled. By CTCAE, significant differences favoring mometasone were detected over time in all toxicities except skin striae, atrophy, and infection. Statistically significant differences between arms at baseline but not over time occurred for all Linear Analog Self-Assessment. Statistically significant differences occurred for all symptoms in the temporal profile of symptoms as measured by PRO surveys (all P < .001).

CONCLUSIONS

The use of longitudinal methods enhanced the ability of PRO tools to detect differences between study arms. Our results strengthened the conclusions of the original report that mometasone reduced acute skin toxicities. PRO surveys can accurately assess patients' experiences of symptom type and intensity over time and should be included in future clinical trials. For radiotherapy-related dermatological toxicity, we hypothesized that clinically significant differences over time, if any, can be found by repeated measures. We examined the acute skin toxicities in a randomized study of mometasone vs placebo during breast radiotherapy. For secondary end points, we showed that longitudinal methods enhanced the detection of differences between study arms and strengthened the conclusions from the original report. Frequent patient-reported outcome surveys over time should be included in future clinical trials.

Long-term results of oncoplastic breast surgery with latissimus dorsi flap reconstruction: a pilot study of the objective cosmetic results and patient reported outcome

Purpose

The goal of oncoplastic breast surgery is to restore the appearance of the breast and improve patient satisfaction. Thus, the assessment of cosmetic results and patient-reported outcomes (PROs) using appropriately constructed and validated instruments is essential. The aim of the present study was to assess the long-term objective cosmetic results and corresponding PROs after oncoplastic breast surgery.

Methods

Cosmetic results were assessed by the patients, a medical panel, and a computer program (BCCT.core). PROs were assessed using BREAST-Q, a questionnaire that measures the perception of patients having breast surgery. The cosmetic results and PROs were analyzed in patients who underwent quadrantectomy and partial breast reconstruction utilizing the latissimus dorsi flap.

Results

The mean duration of the follow-up period was 91.6 months (range, 33.3–171.0 months), and mean age of the patients was 51 years old (range, 33–72 years). The mean tumor size was 2.1 cm (range, 0.9–5.5 cm). There was fair agreement between the medical panel and BCCT.core score (K = 0.32, P < 0.001), and a statistically significant correlation between the BCCT.core score and medical panel cosmetic results was identified (r = 0.606, P < 0.001). A better BCCT.core result was related to a higher PRO of each BREAST-Q domain—satisfaction with breasts (R² = 0.070, P = 0.039), satisfaction with outcome (R² = 0.087, P = 0.021), psychosocial well-being (R² = 0.085, P = 0.023), sexual well-being (R² = 0.082, P = 0.029), and satisfaction with information (R² = 0.064, P = 0.049).

Conclusion

Our long-term results of oncoplastic surgery achieved a high level of patient satisfaction with good cosmetic results. The medical panel and BCCT.core results correlated well with the PROs of the patients using valid, reliable, and procedure-specific measures.

Long-term objective esthetic outcome after breast-conserving therapy

The prediction of unfavorable long-term esthetic outcome (AO) is important for patient consultation. We aimed to analyze variables characterizing the improvement and impairment of AO over time after breast-conserving surgery. A subgroup of a prospective, monocenter cohort study was analyzed to evaluate the results of the BCCT.core software (Breast Cancer Conservative Treatment.cosmetic results) which was used to objectively assess the AO before (n = 356), shortly after (n = 294) and in median 3 years after surgery (n = 356). We analyzed potential influencing factors (such as body mass index, (y)pT-stage, weight of resected specimen, etc.) on the AO using logistic regression analyses (n = 256). Finally, we tried to characterize groups of patients with improving or impaired AO over time (n = 294). Predictors for an unfavorable AO were an axillary lymphadenectomy (OR = 4.05), a tumor in the 12 o'clock position (OR = 2.22), a tumor stage larger or equal to (y)pT2 stage (OR = 2.11), and a surgical specimen weight >75 g (OR = 2.71). Patients with lower specimen weight were more likely to improve in the long-term follow-up (p = 0.018), whereas patients with a higher (y)pT-stage tended to become impaired with time. Although overall AO decreased over time, nearly half of the patients with an unfavorable AO shortly after surgery improved in the long-term follow-up. Predictors of unfavorable AO can be used in patient consultation preoperatively to prepare them for the postsurgical period and/or to recommend surgical alternatives (e.g., more complex oncoplastic techniques). Knowledge of improvement and impairment may help patients and physicians in the postsurgical consultation setting.