Influence of Flap Thickness on Nipple Projection After Nipple Reconstruction Using a Modified Star Flap.

BACKGROUND: In nipple reconstruction, the width, length, and thickness of modified star flaps are concerns for long-term reconstructed nipple projection. However, the flap's projection has not been analyzed, based on its thickness. The aim of the present study was to investigate how flap thickness in a modified star flap influences the resulting reconstructed nipple and achieves an appropriate flap width in design. METHODS: Sixty-three patients who underwent nipple reconstruction using a modified star flap following implant-based breast reconstruction between August 2014 and July 2016 were included in this case-controlled study. The length of laterally diverging flaps was 1.5 times their width. The thickness of each flap was measured using ultrasonography, and the average thickness was defined as the flap thickness. We investigated the correlation between the resulting reconstructed nipple and flap thickness, and the difference of the change in the reconstructed nipple projection after using a thin or thick flap. RESULTS: The average flap thickness was 3.8 ± 1.7 (range 2.5-6.0) mm. There was a significant, linear correlation between the flap thickness and resulting reconstructed nipple projection (ß = 0.853, p < 0.01). Furthermore, the difference between the thin and thick flaps in the resulting reconstructed nipple projection was significant (p < 0.01). CONCLUSION: Measuring the flap thickness preoperatively may allow surgeons to achieve an appropriate flap width; otherwise, alternative methods for higher projection might be used. 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 .

Individual difference in pectoralis major muscle thickness and its effect on single-stage breast reconstruction using a tissue expander.

BACKGROUND: In breast reconstruction using a tissue expander (TE), sufficient coverage of the TE with the pectoralis major (PM) muscle, particularly with a musculofascial flap, is highly important for avoiding postoperative complications. In patients in whom the PM is thin, intraoperative trauma often occurs, leading to troublesome repair. The present study aimed to investigate the usefulness of preoperative measurement of PM thickness in planning of breast reconstruction using a TE. METHODS: In this case-control study, we identified 68 patients (70 breasts) with mammary carcinoma treated with simple mastectomy and TE insertion from April 2014 to December 2016. We measured average PM thickness at two specific points, sternocostal PM distance on the long axis and sternocostal PM area preoperatively using magnetic resonance imaging. Then, we analyzed the difference in PM thickness among individuals and its relationship to intraoperative trauma to the PM or surgical difficulty creating a muscular pocket (delicate PM). RESULTS: Average PM thickness was significantly larger in younger patients (p = 0.046) and those with larger breasts (p < 0.01). In addition, average PM thickness on the affected side was significantly smaller in patients with delicate PM (12 breasts) (p < 0.01). PM thickness had a significant influence on delicate or firm PM (odds ratio 27.40; 95% confidence interval 2.01-372.00; p = 0.013). CONCLUSION: These findings demonstrate the usefulness of preoperative measurement of PM thickness in planning of breast reconstruction using a TE. Dissection should be performed more carefully in patients with average PM thickness less than 2.9 mm.

A Simple and Practical Method for Setting Up a Criterion of Projection of Silicone Breast Implant After Simple Mastectomy.

Objective: In breast reconstruction, decision of projection of silicone breast implant in tissue expander replacement is difficult because of the need to consider several parameters that cannot be expressed in accurate numerical form. The present study aimed at a quantitative analysis based on decreased projection of the reconstructed side compared with silicone breast implant projection and to develop a new method for simple and practical decision of silicone breast implant projection. Methods: Thirty-five patients who had mammary carcinoma and were treated with simple mastectomy, tissue expander insertion, and replacement with anatomical silicone breast implant from April 2013 to March 2016 were retrospectively identified. We recorded the projection of used silicone breast implant (Pi). The projections of reconstructed breast 6 months after silicone breast implant insertion (Pr) and that of the unaffected breast during silicone breast implant selection (Pu) were measured. The difference between Pi and Pr was defined as the revised numerical value (Rev). We investigated whether Rev significantly differed according to age, body mass index, or Pu and analyzed correlations between Rev and age, Pu, and body mass index. Results: Mean Rev in all patients was 1.2 ± 0.3 cm. Rev was significantly higher in patients with higher body mass index than in those with lower body mass index (P < .01) and in patients with higher Pu than in those with lower Pu (P < .01). Significant positive correlations of Rev with body mass index and Pu were found (ß = .63, P < .01 and ß = .67, P < .01, respectively). Conclusions: Rev was a simple, practical, and cost-effective concept. We believe that it is a useful indicator for deciding silicone breast implant projection.

A New Criterion for the Application of 2-Stage Implant-Only Breast Reconstruction Using a Classification Based on the Rostrocaudal Distance Along the Chest Wall Between the Lowest Point of the Breast and Inframammary Fold.

Objective: It is generally difficult to achieve symmetry in implant-only breast reconstruction with ptosis, and it remains unclear what quantitative criterion may be applied in cases of breast ptosis regarding the application of this modality. Our study aimed to suggest a criterion for obtaining good aesthetic outcomes and a symmetrical inframammary fold that is well-fitting for the brassiere in implant-only breast reconstruction after simple mastectomy. Methods: We classified into 3 groups 50 consecutive patients who underwent implant-only breast reconstruction that created an inframammary fold using a modified internal method after simple mastectomy. The classification was based on the rostrocaudal distance along the chest wall between the lowest point of the breast the and the inframammary fold on the contralateral side (Dc, in millimeters). Thereafter, we compared this distance on the reconstructed side (Dr, in millimeters), Dc-Dr, and projection of the implant (Pi, in centimeters) between the groups and investigated the correlation between Dr and lower (Pi < 5.0 cm) and higher Pi (Pi ≥ 5.0 cm). Results: Dr was similar to Dc in groups 1 and 2 (0 ≤ Dc < 10 mm, 40/50 [80%]); however, Dr was significantly lesser than Dc in group 3 (Dc ≥ 10 mm, 10/50 [20%]). In addition, we found significant positive correlations between Dr and lower Pi and between Dr and higher Pi. Conclusions: A Dc below 10 mm may be a good indication for implant-only breast reconstruction. Furthermore, the modality may be applied where Dc is 7 mm or less in cases with lower Pi and where Dc is 13 mm or less in cases with higher Pi.

Decreased contralateral breast volume after mastectomy, adjuvant chemotherapy, and anti-estrogen therapy, in particular in breasts with high density.

Adjuvant chemotherapy and anti-estrogenic therapy can result in decreased volume of the contralateral breast, following mastectomy for the treatment of breast cancer. However, no data on the effect of adjuvant therapy on contralateral breast volume have previously been reported. We aimed to evaluate the extent to which adjuvant therapy and differences in breast density contribute to decreased breast volume. We conducted a prospective cohort study, selecting 40 nonconsecutive patients who underwent immediate breast reconstruction with mastectomy and expander insertion followed by expander replacement. We measured the contralateral breast volume before each procedure. The extent of the change was analyzed with respect to adjuvant therapy and breast density measured by preoperative mammography. The greatest decrease in breast volume was 135.1 cm3. The decrease in breast volume was significantly larger in the adjuvant therapy (+) group, particularly in patients with high breast density, than in the adjuvant therapy (-) group. Significant differences between the chemotherapy (+), tamoxifen (+) group and the chemotherapy (-), tamoxifen (+) group were not found. Breast density scores had a range of 2.0-3.3 (mean: 2.8). In breast reconstruction, particularly when performed in one stage, preoperative mammography findings are valuable to plastic surgeons, and possible decreases in the contralateral breast volume due to adjuvant therapy, particularly in patients with high breast density, should be considered carefully.

Breast reconstruction of an unusual configuration using two paranemic implants.

Implant-based breast reconstruction can be performed using a choice of various types of breast implants. However, cases where the breast shapes are unsuitable for implant-based reconstruction method are occasionally encountered. We present two patients with wide trunks who underwent breast reconstruction using an unusual configuration that involved a latissimus dorsi myocutaneous flap combined with two paranemic implants.