Preoperative Breast Size Research Articles

A Machine Learning Approach to Identify Previously Unconsidered Causes for Complications in Aesthetic Breast Augmentation.

Primary breast augmentation is one of the most commonly requested aesthetic procedures. Considering the large number of procedures performed in connection with a high demand, it is crucial to prevent complications. For this reason, finding and avoiding possible sources of complications is decisive. Between January 2010 and December 2021, 1625 female patients underwent an aesthetic breast augmentation performed by a single surgeon. The data collected were analyzed through a machine learning technique for binary recursive partitioning. This made it possible to detect unknown sources of a complication and determine a vertex for the various features. When analyzing the data, for most features a high importance score with low entropy was achieved, concluding a high significance. In addition, reproducibility was demonstrated through detailed testing and training accuracies in the algorithm. With this procedure, in addition to known risks such as a high BMI and round implant shape, a larger than A preoperative bra-cup size (OR: 2.7) and a taller body could also be identified as most significant influencing factors for complications. Preoperative breast size plays an exceptionally important role in the occurrence of complications and should be a factor held in a surgeon's considerations. In addition, this study shows ways to transfer artificial intelligence into plastic surgery to increase medical quality. 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 .

Predicting adherence of dose–volume constraints for personalized partial-breast irradiation technique

PurposeMulticatheter interstitial brachytherapy (MIB) and external-beam (EB) radiotherapy are established partial-breast irradiation (PBI) techniques. Although EB-PBI is widely available, it requires extra irradiated margins for target uncertainties. We examined the impact of EB-PBI on dose–volume constraints as compared to MIB-PBI. Methods and MaterialsAmong 653 patients receiving MIB-PBI between October 2008 and April 2020, consequent 159 patients after September 2018 were examined. Clinical target volume (CTV) included the lumpectomy cavity plus 1.0 cm. Planning target volume (PTV) for EB-PBI was defined as CTV with 1.0-cm expansion. Because the ratio of PTV to breast volume (RPB) was related to cosmesis, <25% of RPB was defined as suitable for the ipsilateral breast constraints. Preoperative breast size was classified as very small (<350 cm3), small (350–699 cm3), and medium or large (≥700 cm3). According to each category, the dose–volume constraints of the organs at risk were compared between the two PBI techniques. ResultsPatients including 84 very small, 59 small, and 16 moderate to large breasts were examined. Although RPB was suitable in all patients receiving MIB-PBI, it was achieved in 74 patients (46.5%) receiving EB-PBI (p < 0.0001). The suitable RPB in patients with very small, small, and moderate to large breast was 32.1%, 55.9%, and 100%, respectively (p < 0.0001). Normal-tissue constraints for the other organs could be satisfied in patients with moderate to large breasts. ConclusionAlthough EB-PBI may be an appropriate option for patients with moderate to large breasts, MIB-PBI could still be a crucial technique, especially for patients with small breasts.

Technical considerations in nonreconstructive mastectomy patients.

Not all women undergo post-mastectomy breast reconstruction due to medical comorbidities or personal preference. An aesthetically pleasing closure and contour of the chest wall is still desired, though may be technically difficult to achieve in some patients. By combining techniques and lessons learned from breast reductions and female-to-male mastectomies (FTTM), we present a technical approach to aesthetic primary closure post-mastectomy that can be utilized in patients regardless of preoperative breast size. After mastectomy, excess cranial/caudal tissue is determined and the lower flap is de-epithelialized to allow for bulk in the reconstructed breast. Excess tissue in the horizontal plane is assessed, and axillary, nonbreast tissue is medialized. Excess skin in the horizontal plane is removed with a small lateral incision similar to a wise-pattern closure. We have performed this technique with good aesthetic results and satisfied patients postoperatively. When performing post-mastectomy closure without reconstruction, attention to tissue excess, medialization of axillary tissue and providing bulk with lateral and caudal tissue allows for an easy, reproducible, and aesthetic closure.

Is the Right Research Being Conducted to Advance Knowledge about Breast Reconstruction? An Analysis of the Research Pipeline

It has been estimated that up to 85 percent of research is of limited value or wasted, in part because of the wrong research questions being addressed. In this study, the authors identified research gaps for breast reconstruction using guideline recommendations based on low-quality or no evidence. The authors then evaluated whether research was currently being conducted to fill these gaps. The authors extracted grade C and D options, which are based on limited evidence, from the American Society of Plastic Surgeon's clinical practice guideline for breast reconstruction. For each option, the authors created Participants, Intervention, Comparator, Outcome questions and search strings using a systematic process. Searches were conducted of ClinicalTrials.gov and the World Health Organization's International Clinical Trials Registry Platform to locate new and ongoing studies. The authors also catalogued studies on breast reconstruction funded by the Plastic Surgery Foundation. Of the 10 research gaps, only six were being addressed by new and ongoing research. Timing of reconstruction (immediate or delayed) and use of acellular dermal matrix were most frequently studied. Preoperative referral of a plastic surgeon before mastectomy, complications associated with preoperative breast size, effects of hormone therapy on postoperative outcomes, and methods for detecting local recurrence after mastectomy were not being addressed by new research. Studies funded by the Plastic Surgery Foundation showed a similar pattern. Of the areas identified, some have received more attention than others. Gaps remain. The authors' results should spark interest in conducting research on these topics and, by so doing, strengthen the clinical practice guideline recommendations.

Preoperative breast size affects reconstruction status following mastectomy.

Much research has been devoted to why women choose not to be reconstructed following mastectomy. The effect of breast size has not been well explored. The authors aimed to assess the relationship between breast size and reconstructive choices. A single-center retrospective review of women undergoing mastectomy between 2011 and 2014 was performed. Demographics, surgical variables, and reconstruction decisions were analyzed using t tests, Mann-Whitney U tests, and chi-squared tests. Significant (P<.05) variables were included in a multivariable logistic regression model. About 610 patients were analyzed. The median mastectomy specimen weight was 572g (62-5230g), which did not correlate with BMI (P=.44). Women who underwent reconstruction had lighter mastectomy specimens, averaging 643 vs 848g (P<.0001). A regression controlling for ethnicity, insurance status, number of comorbidities, age at mastectomy, cancer stage, BMI, specimen weight, and mastectomy laterality was constructed. Lower specimen weight (P=.005), lower cancer stage (P=.008), bilateral mastectomy (P=.042), and younger age at mastectomy (P<.0001) were significantly associated with reconstruction. Women with larger breasts were less likely to be reconstructed regardless of their BMI and comorbidities. Larger breasted women may be considered worse prosthetic reconstruction candidates due to increased complications and suboptimal aesthetic outcomes but may find the increased invasiveness and recovery of autologous reconstruction an unattractive alternative. Furthermore, it is possible that surgeons may be less supportive of breast reconstruction for larger breasted women if there are concerns about safety or the aesthetic quality of the result. In the future, qualitative research must be done to determine why more larger breasted women choose not to be reconstructed as well as develop better ways to increase their reconstructive options.

Breast Reconstruction with Tissue Expanders

Periprosthetic infection remains a frustrating and costly complication of breast reconstruction with tissue expanders. Although some specific steps have been previously shown to reduce periprosthetic infections, no comprehensive protocol addressing all aspects of preoperative, intraoperative, and postoperative patient management has been evaluated in the literature. The authors' goal was to evaluate the effectiveness of their protocol at reducing periprosthetic infections. A comprehensive, best-practices protocol was introduced and implemented in November of 2010. All patients undergoing breast reconstruction using tissue expanders at the authors' institution in the 5 years before the protocol, and in the 2 years after, were analyzed. Three hundred five patients underwent 456 tissue expander reconstructions in the 5 years before the protocol, and 198 patients underwent 313 reconstructions in the 2 years after. Significantly fewer patients developed periprosthetic infection after protocol (11.6 percent versus 18.4 percent; p=0.042), and the number of infected tissue expanders trended toward a decrease (9.3 percent versus 13.2 percent; p=0.097). On multivariate analysis, the protocol significantly reduced the odds of periprosthetic infection (OR, 0.45; p=0.022). Predictors of infection included obesity (OR, 2.01; p=0.045) and preoperative breast size larger than C cup (OR, 2.83; p=0.006). The authors' comprehensive, best-practices protocol allowed them to reduce the odds of tissue expander infections by 55 percent (OR, 0.45; p=0.022). The authors were able to identify several potential areas of improvement that may help them lower the rate of infection further in the future. Therapeutic, III.

Cup size and nipple-sparing mastectomy.

e12021 Background: We performed a preliminary analysis of the American Society of Breast Surgeons (ASBS) Nipple Sparing Mastectomy Registry (NSMR) to assess preoperative breast size, as measured by...

The Effects of Breast Size in Unilateral Postmastectomy Breast Reconstruction

Postmastectomy breast reconstruction is offered to women with breast cancer regardless of body habitus and breast size. The decision regarding technique for breast reconstruction includes patient preference, risk factors, and physical characteristics. The purpose of this study was to determine whether there is a relationship between preoperative breast size and choice of reconstruction, choice of contralateral breast symmetry procedure, and incidence of complications. A retrospective review of 355 patients who underwent unilateral breast reconstruction at Emory University from 2005 to 2009 was performed. Patients were stratified into 3 groups based on mastectomy specimen weight with small breasts defined as less than 500 g, medium breasts as 500 to 1000 g, and large breasts as more than 1000 g. Patient demographics were queried including age and risk factors. Additional data points included type of reconstruction, contralateral procedure, and complications. There were 144 patients with small breasts (40.5%), 150 with medium breasts (42.1%), and 62 with large breasts (17.4%). Women with small breasts were equally likely to undergo tissue expander (34%), latissimus dorsi flap (32%), or TRAM/DIEP flap (34%) reconstruction. Women with medium breasts were most likely to undergo TRAM/DIEP reconstruction (47%), whereas women with large breasts were most likely to undergo latissimus dorsi reconstruction (37%; P = 0.134). Small-breasted women were more likely to undergo contralateral augmentation (P < 0.0001), which varied based on the type of reconstruction. Women with medium-sized breasts were more likely to undergo mastopexy (P = 0.033), and large-breasted women were more likely to undergo reduction (P < 0.0001). Women with complications had a greater mean mastectomy weight than women without complications (744 g compared with 620 g, P = 0.0062), and there was an increasing incidence of postoperative wound infections with increasing breast size (18% of large breasts, 7% of medium breasts, and 3% of small breasts; P = 0.0003). Preoperative breast size does play a role when choosing the most appropriate reconstructive option and symmetry procedure. Being able to adjust the contralateral breast, however, brings the extremes of breast size toward the middle, making most options available regardless of initial size and shape. There are noticeable trends in technique and outcome when stratified by breast size.

Simultaneous mastopexy in patients undergoing prophylactic nipple-sparing mastectomies and immediate reconstruction

In some patients, a satisfactory aesthetic result of reconstruction following a nipple-sparing mastectomy (NSM) is limited by breast ptosis that goes uncorrected in the early phase of reconstruction. Most plastic surgeons remain hesitant to perform a mastopexy at the time of NSM due to concerns with nipple and/or skin flap loss. From 1990 to 1995, 33 female patients underwent NSM with simultaneous mastopexy and immediate implant-based reconstruction by a single surgeon at our institution. On chart review, the following data were extracted: age, co-morbidity, indication, breast size, initial/final implant volumes, type of implant, mastopexy technique, mastectomy flap/nipple necrosis, other complications, revision surgery and follow-up. An unpaired, two-tailed t-test was performed where indicated. P-value<0.05 was considered significant. Wound complications occurred in 18.2% patients (10.9% breasts) without delaying tissue expansion. As many as 3% patients developed unilateral, isolated partial ischaemia of the mastectomy flap and 8% patients developed unilateral, superficial areolar loss. All resolved with conservative treatment. Only one patient developed bilateral total nipple loss. There was no correlation between preoperative breast size and postoperative complications. None of the patients developed breast cancer. Average follow-up was 11.6 years. With proper technique, simultaneous mastopexy is a safe procedure in highly selected patients undergoing NSM with reconstruction.

One-Stage Immediate Breast Reconstruction With Implants

The current standard of care for breast implant reconstruction after mastectomy is 2-stage reconstruction with placement of tissue expanders followed by implants. The immediate use of implants at the time of mastectomy, which eliminates the need for a second operative procedure, has been sparsely reported and is not yet accepted as the standard of care. This study describes a 1-stage immediate implant reconstruction technique and evaluates its risks. Between 2005 and 2010, immediate implant reconstruction was performed in 43 sequential patients on a total of 78 breasts. Permanent silicone implants were placed at the time of mastectomy with the assistance of acellular dermal matrix (ADM). Follow-up was for an average of 575 days. Implant sizes varied widely from 175 to 800 mL. In order to create the correct breast shape and implant placement, specific techniques of acellular dermal matrix placement in the reconstruction were critically important. Aesthetic evaluation of the patients was performed, evaluating pre- and postoperative photos by 20 evaluators. Pictures were rated according to a 4-point Harris breast scale. A 2-sided paired t test was then used to compare the rating scores. Complication rates were as follows: seroma occurred in 6.4% of breasts; infection resolving with antibiotics occurred in 2.6%; infection requiring implant removal occurred in 3.8%; and hematoma occurred in 1.3%. Neither preoperative breast size nor implant size correlated to an increased risk of complications (P>0.05). Complication rate increased with age (P=0.02). The average score for the preoperative images was 2.1, whereas the postoperative average was 2.4. This represented a statistically significant improvement above the baseline (preoperative) breasts with a P<0.001, according to a 2-sided paired t test. With complication rates similar to previously reported tissue expander reconstructions, immediate implant reconstruction is a viable alternative to 2-stage expander reconstruction, presenting many advantages over expander reconstruction while offering the same risk profile and eliminating the additional risks, costs, and discomfort of a second procedure. Additionally, aesthetic results were highly satisfactory according to patients themselves and based on evaluation by independent observers.

Peri-areolar marking in Lejour's mammoplasty—a simple device to aid trainee learning: the flexible curve

We propose the use of a simple device—the flexible curve—to aid trainees with the peri-areolar markings of Lejour's mammoplasty. This cheap and simple, commercially available, wipe clean device can be purchased in any art store and easily adapted for purpose. It assists beginners in the marking of the areola site in vertical mammoplasty and speeds the learning curve needed to make the marks accurately despite great variation in pre-operative breast size and contour. Both authors have found the device incredibly useful in the peri-areolar marking of Lejour's mammoplasty technique. We hope that publication and awareness of the device may assist others to achieve accurate peri-areolar markings with ease.

A Single Surgeon??s 12-Year Experience with Tissue Expander/Implant Breast Reconstruction: Part II. An Analysis of Long-Term Complications, Aesthetic Outcomes, and Patient Satisfaction

Few reports have critically evaluated long-term outcomes following two-stage implant reconstruction. The objective of this study was to evaluate long-term aesthetic results, late complications, and patient satisfaction following tissue expander/implant breast reconstruction. A single surgeon's extensive experience with implant-based reconstruction provides an opportunity to evaluate these results in a uniformly treated patient population. A total of 1522 tissue expander/implant reconstructions were initiated in 1221 patients from July of 1992 to June of 2004. Data on a cohort of 315 patients (410 reconstructions) with a minimum of 1 year of follow-up were entered into a prospectively maintained outcomes database. Overall aesthetic grade, capsular contracture grade, patient satisfaction, and late complications were prospectively evaluated, and outcome data were recorded on an ongoing basis. Mean follow-up was 36.7 months. Eighty-eight percent of patients had a good to excellent aesthetic result. Laterality of reconstruction (bilateral versus unilateral) and radiation history were significant predictors of overall cosmesis. Aesthetic results were not related to preoperative breast size, implant volume, or body mass index. Pathologic capsular contractures (grade III/IV) developed in 10.4 percent of patients. Four percent of all permanent implants were exchanged for a second prosthesis. Ninety-five percent of patients were satisfied with their reconstruction. Tissue expander/implant reconstruction yields good to excellent long-term aesthetic results in the majority of patients, and overall patient satisfaction remains high. Bilateral reconstructions have higher overall aesthetic grades. Reconstruction may be performed in patients with larger-volume breasts with satisfactory cosmesis. Successful outcomes are possible in patients who receive chest wall irradiation.

Factors Affecting Mammographic Visualization of the Breast After Augmentation Mammaplasty

To measure the effect of various parameters on mammographic visualization of the breast after augmentation mammaplasty. Preoperative and postoperative mammography was performed in patients undergoing augmentation mammaplasty. The area of breast tissue visualized on each film was measured. Changes in the area visualized were correlated with a variety of different parameters. The Breast Center, Van Nuys, Calif, a free-standing multidisciplinary breast diagnostic and treatment facility. The 68 women (126 breasts) represent a consecutive sample of patients undergoing augmentation mammaplasty for whom preoperative and postoperative mammograms were available. Area visualized was correlated with degree of capsular contracture, implant position, type of mammography, preoperative breast size, implant size, and implant type. The major factor affecting mammography is capsular contracture. Little or no capsular contracture results in a 30% reduction in the area visualized; moderate or severe contracture results in a 50% reduction. Other important factors include implant position (improved visualization with implant beneath pectoral muscle) and type of mammography performed (slightly more tissue seen with displacement technique). Very small preoperative breast size yields increased visualization. Implant size and type have little or no effect. In most women with breast implants, there is a decrease in measurable breast tissue on the postaugmentation mammogram. Capsular contracture and implant position exert a profound effect; type of mammography performed and preoperative breast size are also significant.