Vertical Breast Research Articles

Association of Dosimetric Parameters and Boost Volume with Quantitative Cosmetic Outcomes in a Randomized Trial of Conventionally Fractionated vs. Hypofractionated Whole Breast Irradiation

<h3>Purpose/Objective(s)</h3> Whole breast irradiation (WBI) is the most common treatment in radiation oncology, yet there is a relative paucity of evidence delineating the relationship between dosimetric parameters and long-term outcomes. We conducted a prospective randomized trial with longitudinal follow up to compare two different WBI dosing schedules and sought to evaluate the association of dosimetric parameters and boost volume with long term cosmetic outcomes using novel, previously validated, quantitative metrics of breast cosmesis derived from 2-dimensional photographs. <h3>Materials/Methods</h3> A prospective randomized trial of patients with early breast cancer who were randomly assigned to conventionally fractionated or hypofractionated WBI plus boost was conducted from 2011-14. Anteroposterior photographs from the low-neck to umbilicus were obtained at baseline, 6 months, and yearly through 5 years. Fiducial points marking each nipple and inframammary fold were delineated on each photograph and used to calculate a measure of nipple symmetry (M1) and breast vertical symmetry (M2), as previously described (PMID 28333010). These values range from 0 to 1 with values closer to 1 indicating better symmetry. Multivariable logistic regression longitudinal models with M1 and M2 as outcomes, dichotomized at the median, evaluated associations of dosimetric parameters and boost volume with M1 and M2 adjusting for relevant clinical, demographic and treatment variables. Candidate dosimetric variables included volume of tissue encompassed by the 90% isodose line (PTV), tumor bed volume, volume encompassed by the 105% isodose line, maximum point dose in the breast (Dmax), central axis separation, percent dose delivered with 18 MV photons, boost energy, boost position, boost modality, and cross-sectional area of the boost field. <h3>Results</h3> Of the 287 patients included in this trial, 149 patients received CF-WBI and 138 received HF-WBI, with median follow up 48 months. Median age was 60 years. Median PTV was 1340cc (IQR 904-1760), median tumor bed volume was 23cc (IQR 13-43), and median boost field size was 64cm² (IQR 54-80). 50% of patients had a Dmax of ≥107% of the prescription dose. A total of 1600 photographs were annotated to calculate M1 and M2. In multivariable analysis, highest quartile of PTV (OR 0.40, P=0.002) and boost field size (OR 0.50, P=0.02) were associated with worse M1 outcome compared to the lowest quartile. Highest quartile of tumor bed volume was associated with worse M2 compared to the lowest quartile (OR 0.52, P=0.03). <h3>Conclusion</h3> Utilizing previously validated quantitative measures of cosmetic outcome derived from 2D photographs, we found that boost fields with cross-sectional area <54 cm² and PTV <1760cc were associated with better nipple symmetry, and tumor bed volume >43cc was associated with worse vertical breast symmetry. Understanding how dosimetric parameters and boost volume affect long-term cosmetic outcomes can facilitate optimization of breast radiation treatment plans.

Association of Treatment Arm with Quantitative Cosmetic Outcome in a Randomized Trial Comparing Whole Breast Irradiation Dosing Schedules

<h3>Purpose/Objective(s)</h3> We have previously validated that two measures of breast symmetry derived from an anteroposterior photograph, termed M1 and M2, correlate with patient- and physician-reported cosmetic outcome and offer an opportunity to quantitate breast cosmesis without relying on subjective human assessment. Within the context of a prospective randomized trial comparing two dosing schedules for whole breast irradiation (WBI) (50 Gy/25fx+10-14 Gy/5-7fx boost [CF-WBI] versus 42.56 Gy/16fx+10-12.5 Gy/4-5fx boost [HF-WBI]), we evaluated the impact of treatment arm on M1 and M2 through five years follow up. <h3>Materials/Methods</h3> 2D AP photographs framed from the mid-neck to umbilicus were obtained at baseline, 6 months, and yearly through 5 years on a prospective randomized trial of 287 patients with early breast cancer who were randomly assigned to CF-WBI+boost or HF-WBI+boost. For each photograph, we marked the coordinates of each nipple and inframammary fold and used these values to calculate M1 and M2 as per prior methods (PMID 28333010). M1 and M2 range from 0 to 1 with higher values indicating better nipple symmetry (M1) or vertical breast symmetry (M2). Multivariable logistic regression longitudinal models were created with M1 and M2 as outcomes, dichotomized at the median, to evaluate associations of treatment arm with M1 and M2 adjusting for relevant clinical, demographic, and treatment variables. <h3>Results</h3> A total of 287 patients were enrolled on this trial (n=149 allocated to CF-WBI; n=138 to HF-WBI) with median follow up 48 months. Median age was 60 years with 11% Black and 13% Hispanic and 44% obese. A total of 1600 photographs were acquired and marked to calculate M1 and M2. At five-years follow up, M1 was 0.92 for CF-WBI and 0.91 for HF-WBI (P=0.55) and M2 was 0.63 for CF-WBI and 0.66 for HF-WBI (P=0.40). In multivariable longitudinal analysis, treatment arm was not correlated with either M1 (OR 0.76; P=0.16) or M2 (OR 1.19; P=0.39). In contrast, obesity was associated with worse M1 (OR 0.50; P=0.003) and worse M2 (OR 0.58; P=0.03) and age≥70 years was associated with worse M2 (OR 0.39; P=0.02). <h3>Conclusion</h3> This is one of the first randomized trials to use an objective, quantitative approach to measure breast cosmesis and compare outcomes by treatment arm. We found that cosmesis as assessed via M1 and M2 was similar by treatment arm, providing high quality evidence supporting cosmetic equivalence of CF-WBI and HF-WBI. Future breast cancer radiation trials could adopt this approach to compare different radiation regimens.

A Comparison of Complication Rates in Wise Pattern Versus Vertical Breast Reduction.

Breast reduction has a well-chronicled history and remains a common reason for patients to seek plastic surgery consultation. The Wise pattern is the most common skin reduction pattern in the United States. Vertical pattern reduction is also widely used and offers the potential for decreased scar burden. Both patterns have been used with a variety of pedicles for preservation of the nipple areolar complex, which may also impact complication rate and patient satisfaction. There is a preponderance of literature on breast reduction surgery but limited comparative data on the safety profile of these patterns. The purpose of this article is to review the comparative literature, with emphasis on the overall risk of complications. OVID and PubMed were used to query the literature for articles comparing complication rates in both Wise pattern and vertical breast reduction. Inclusion criteria were case series that encompassed both vertical and Wise pattern reductions and cited the rate of complications. Complications included in our analysis of total complication rate were as follows: hematoma, seroma, infection, dehiscence, fat necrosis, skin necrosis, and nipple areolar complex necrosis. We excluded standing cutaneous deformity as a complication. Articles that included oncoplastic breast reductions were also excluded. The primary analysis was an inverse variance-weighted random-effect meta-analysis of overall complication rate, with the association between the technique and overall complication rate quantified using odds ratios. Eight articles were identified that met inclusion criteria, representing 963 patients (525 Wise pattern and 438 vertical pattern). The overall complication rate pooled across the studies favored vertical pattern reduction, but the result was not definitive. Vertical pattern breast reduction can be done safely. Our statistical analysis found a trend toward decreased complications with vertical reductions, but did not reach statistical significance. Patients seeking breast reduction are a heterogeneous population with respect to breast size, degree of ptosis, body habitus, body mass index, comorbidities, and acceptance of scars. It remains important to individualize the approach to the patient and their needs. More quantitative, comparative data, especially from randomized controlled trials, would be useful to further evaluate the relative safety profiles of the 2 patterns.

Greater Breast Support Alters Trunk and Knee Joint Biomechanics Commonly Associated With Anterior Cruciate Ligament Injury.

ObjectiveThe female breast is a passive tissue with little intrinsic support. Therefore, women rely on external breast support (sports bras) to control breast motion during athletic tasks. Research has demonstrated that lower levels of breast support are associated with altered trunk and pelvis movement patterns during running, a common athletic task. However, no previous study has identified the effect of sports bra support on movement patterns during other athletic tasks including landing. Therefore, the purpose of this study was to examine the effects of breast support on trunk and knee joint biomechanics in female collegiate athletes during a double-leg landing task.MethodsFourteen female collegiate athletes completed five double-leg landing trials in each of three different sports bra conditions: no support, low support, and high support. A 10-camera motion capture system (250 Hz, Qualisys, Goteburg, Sweden) and two force platforms (1,250 Hz, AMTI, Watertown, MA, USA) were used to collect three-dimensional kinematics and ground reaction forces simultaneously. Visual 3D was used to calculate trunk segment and knee joint angles and moments. Custom software (MATLAB 2021a) was used to determine discrete values of dependent variables including vertical breast displacement, knee joint and trunk segment angles at initial contact and 100 ms post-initial contact, and peak knee joint moments. A repeated measures analysis of covariance with post-hoc paired samples t-tests were used to evaluate the effect of breast support on landing biomechanics.ResultsIncreasing levels of breast support were associated with reductions in peak knee flexion (Right: p = 0.008; Left: p = 0.029) and peak knee valgus angles (Right: p = 0.011; Left: p = 0.003) as well as reductions in peak knee valgus moments (Right: p = 0.033; Left: p = 0.013). There were no changes in peak knee extension moments (Right: p = 0.216; Left: p = 0.261). Increasing levels of breast support were associated with greater trunk flexion angles at initial contact (p = 0.024) and greater peak trunk flexion angles (p = 0.002).ConclusionsLower levels of breast support are associated with knee joint and trunk biomechanical profiles suggested to increase ACL injury risk.

Vertical Breast Displacement in Asian Women During Exercise: influence of Bra Type, Size and Different Parts of the Breast

Abstract Asian women have smaller breast sizes and greater breast density, which suggests specific research on their breast kinematics and biomechanics. To investigate vertical breast displacement of Asian women among exercise modalities (rope skipping, walking, jogging, running) in different support conditions (wearing everyday bra or sports bra), and assess the motion between different parts of the breast, seven participants were selected to participate in this study. Five infrared markers were placed on each of their left breasts, and a three-dimensional motion capture system (NDI Optotrak Investigator) was used to collect the data on vertical breast displacement during walking (5 km/h), jogging (7.5 km/h), running (10 km/h) and rope skipping (2 Hz). No significant difference was found in the vertical displacement of different parts of the breast in the two bra conditions. Also, there was significant difference in vertical breast displacement among rope skipping, jogging and running. Breast size did not significantly affect its vertical displacement. The smaller, denser breast appears to reach a threshold of vertical displacement that is similar at high severities of dynamic exercises (jogging, running and rope skipping). The results might be useful for designing special sports bras for Asian women with small breasts or rope skipping participants to improve the shock absorption function.

Breast biomechanics, exercise induced breast pain (mastalgia), breast support condition and its impact on riding position in female equestrians

Breast biomechanics, exercise-induced breast pain (EIBP) and performance effects in female athletes are established. Wearing sports bras during exercise reduces breast movement and EIBP. Despite the prevalence of female equestrians, little investigation of breast movement during horse riding exists, yet excessive breast movement, embarrassment and EIBP are reported. Breast movement relative to the torso is linked to EIBP, associated with magnitude and direction of forces generated. Equestrians may experience novel breast and upper-body movement patterns in response to large vertical excursions of the horse. This study aimed to establish relative vertical breast displacement (RVBD), EIBP and positional changes in three support conditions: ‘no support’, ‘low support’ and ‘high support’. Thirty-eight female equestrians rode a Racewood™ Equine Simulator in each breast support condition in medium walk, medium trot (sitting) and medium canter. Trials were filmed and analysed using Quintic® Biomechanics V29. Significant reductions in RVBD (P&lt;0.001) and EIBP (P&lt;0.001) were identified with increased breast support in all gaits. In medium trot (sitting) a significant reduction in range of movement (ROM) of shoulder-elbow-wrist (P&lt;0.001) was seen from low to high support. ROM of torso-vertical angles were reduced from no support to low support (P&lt;0.001) and further by high support (P&lt;0.001). This reduction in ROM was significantly greater in large breasted riders (cup size DD-FF) (n=21) (P&lt;0.001) compared to small breasted (cup size AA-D) (n=17). These results suggest that appropriate breast support positively impacts EIBP and riding position in female riders possibly enhancing performance. As RVBD and reported EIBP were not wholly comparative with results in female runners, further research is warranted to establish breast movement in equestrianism in three dimensions.

A Review and Measurement Study of the Central Mound Pedicle for Breast Reduction.

Background:The central mound approach to breast reduction has been the subject of recent interest in the literature. However, quantitative evaluation using measurements is lacking. This review was undertaken to objectively evaluate changes in breast dimensions, and to compare the results to a popular alternative method, vertical mammaplasty.Methods:An electronic search was performed using PubMed to identify all publications endorsing the central mound technique. Published lateral photographs were matched for size and orientation, with computer assistance. Measurements included breast projection, upper pole projection, lower pole level, breast mound elevation, nipple level, and breast parenchymal ratio. Results were compared with published measurement data for the vertical technique.Results:Twenty-three manuscripts were identified. Ten included photographs suitable for analysis. On average, breast projection decreased 1.1 cm after central mound breast reduction (P < 0.05). Upper pole projection dropped 0.4 cm (not significant). The lower pole level was raised 2.6 cm (P < 0.05). The nipple level was over-elevated 0.6 cm, on average. The breast parenchymal ratio increased by 0.54. A central mound dissection decreased breast projection. In contrast, publications using a vertical breast reduction demonstrated maintenance of upper pole and breast projection and a modest (<1 cm) increase.Conclusions:For each measurement comparison, the vertical method outperforms the central mound. Because of its anatomy and geometry, measurements show that the vertical method for breast reduction is more favorable than a central mound dissection. This method can also be used safely for secondary breast reductions.

Effects of Breast Support and Gait Speed on Three-Dimensional Breast Displacement for Women with Small Breasts

This paper investigated three-dimensional breast displacement under different breast support conditions and gait speeds for women with small breasts. The breast coordinates of fifteen female participants with small breasts (sizes ranging from A to C) were recorded during treadmill walking and running tests under two different sports bra conditions and a no bra condition. The results showed that although vertical breast displacement was always the greatest in each condition, mediolateral breast displacement was significantly greater than anteroposterior breast displacement. Mediolateral breast displacement was not effectively reduced in the two sports bra conditions compared to the no bra condition. It is recommended that sports bra designed for women with small breasts should aim to limit mediolateral breast displacement instead of anteroposterior breast displacement, on the premise of controlling vertical breast displacement. The findings also suggest that the effectiveness of sports bras at reducing side-to-side breast movement requires further optimisation.

Analysis of dynamic vertical breast displacement for the design of seamless moulded bras

Traditional breast displacement studies included human subjects and maintaining result consistency is restricted by biomechanical limitations. This study proposes an objective approach that investigates the effects of various bra features on breast support during movement by conducting a wear trial with the VICON motion capture system. The vertical breast displacement in five different bra conditions is assessed and compared. Results indicate that the effectiveness of bras depends on the cup material used and design. The foam cups which are low in density and fabricated from soft polyurethane induces less overall breast displacement during movement. Bras of full-cup style also offer better breast movement control with significant vertical breast displacement reduction as compared with the half-cup style. These findings enhance current breast displacement analysis and understanding of bra features associated with changes in the biomechanics of breasts, thereby providing objective methods for bra evaluation and a design basis for breast protection.

Adding an underwire in bras decreases breast motion and discomfort during locomotion

The aim of this study was to determine whether exercise-induced vertical breast motion and discomfort in women with large breasts decrease when an underwired bra is used compared with when an underwire-free bra is worn. Vertical breast displacement was assessed in nine women (C cup size) who exercised on a treadmill in two bra conditions: underwired bra and underwire-free bra. Perceived breast motion and discomfort were reported by each participant using the visual analogue scale after each bra condition trial. Vertical breast displacement and perceived breast motion and discomfort were compared between the two bra conditions. Vertical breast displacement (p < 0.05) and perceived breast motion (p = 0.007) and discomfort (p = 0.025) were significantly lower in the underwired bra condition than in the underwire-free bra condition. The bra design feature of containing an underwire was effective in decreasing exercise-induced vertical breast motion and discomfort among the women with large breasts. The current research is the first study to explore the effects of including a bra underwire on the change in breast motion and discomfort.

Control Performance of Different Bra Designs and Materials during Physical Activity

Bras give support to the breasts and prevent damage to their different components during daily activities. Previous studies have however merely focused on specific types of bras and/or shoulder straps but failed to provide specific guidelines on bra features and materials that can be used to improve the support different functions of bras. The purpose of this study is to evaluate the breast control performance of various types and designs of bra under the conditions of walking and running. Two younger women and 1 older woman (all with a bra size of 36C/80C) have participated in a wear trial to don a total of 12 different commercial bras with different design features, and a changeable bra in which 12 different variables are examined, including the materials, strap width and type of underwire. The 3D movement of the breasts in the various bra conditions during walking at a speed of 4 km/h and running at 6 km/h is recorded and then compared with the braless condition by using an 11-camera motion capture system. The percentage of change in the nipple displacement in the vertical direction relative to the clavicle displacement is used to quantify and compare the breast control performance of the bras. A significant difference (p&lt;0.01) in the ability of the bras to control movement is observed between the group of younger subjects and the mature subject (left breast: 11.49% vs. 35.42%, and right breast: 18% vs. 32.47%, respectively). The control performance of the bras is significantly different (p&lt;0.01) during running and walking (left breast: 26.39% vs. 12.54%, and right breast: 30.04% vs. 15.61%, respectively). The correlation analysis showed that a small bra cup volume (length across the bra cup), taller gore, elongation of the bra strap and bra band, and rigid bra cup fabric allow good control of vertical breast displacement.

Comparison of Vertical Breast Displacement during Rope Skipping, Walking, Jogging and Running

In order to investigate the effect of exercise modality and bra type on vertical breast displacement, seven participants with similar ages and body types were selected to take part in this study. Three-dimensional motion capture system (NDI Optotrak Certus) was used to collect the data of vertical breast displacement when participants were walking at the speed of 5 km/h, jogging at the speed of 7.5 km/h, running at the speed of 10 km/h on a treadmill, and rope skipping at the frequency of twice per second. It was found that there was no significant difference in vertical breast displacement between rope skipping, jogging and running. And the vertical breast displacement when wearing sports bra is significantly less than everyday bra in four exercise modalities. The results of this study might be useful for designing special sports bra for rope skipping modality.

Lower Pole Mastopexy-Augmentation: Indications and Applications.

Breast augmentation in primary or secondary patients with long lower pole lengths but appropriately sited nipples is at high risk of "bottoming out" following surgery. The lower pole mastopexy-augmentation (LPMA) was developed to correct long lower pole lengths or preempt bottoming out in breasts deemed at risk, avoiding the requirement for periareolar and vertical breast scar as well as minimizing the requirement for the utilization of synthetic mesh. The goal of this short report was to analyze outcomes in patients who underwent the LPMA to determine its application and limitations. The author reviewed 12 consecutive cases of both primary and secondary situations over a 6-year period. Cases were objectively assessed according to the relationship of the nipple to the point of maximal breast projection on lateral view as well as the upper to lower pole breast proportions. All cases provided good outcomes, with improvements in both the position of the nipple in relation to the point of maximal breast projection and with respect to the upper to lower pole breast ratios. LPMA is a useful addition to the armamentarium in dealing with complex situations in breast augmentation.

Both Bilateral Breast Volume Discrepancy and Asymmetric Anterior Chest Wall Shape Contribute to the Unsightly Breast Contour in Female Right Thoracic Idiopathic Scoliosis.

A retrospective radiographic study. To evaluate the asymmetry of breast volume (BV) and shape in female adolescent idiopathic scoliosis (AIS) patients and to define their relationship with deformed components of the anterior chest wall and curved spine. The higher incidence of asymmetric breast development in AIS was described by prior studies. However, the interplay between scoliosis curve magnitude and severity of breast asymmetry (BA) are unknown. A total of 73 surgically treated female right thoracic AIS patients classified as Lenke type I were enrolled in this study, with the average Cobb angle being 52.08±11.68 degrees. The Image J software was utilized to calculate BV. Both concave and convex radiographic parameters of breast shape were measured including the extraversion angle (EA), the coverage angle (CA), the axial breast height, the vertical breast height (VBH), and the nipple-to-sternum distance. The inclination angles of the concave and convex anterior chest wall were also assessed. BA was calculated according to the formula as follows: BA=(concave-convex)×BV/[(concave+convex)×BV]/2. The measurements of spinal deformity parameters included the Cobb angle, the RAsag angle, and the RAml angle. Paired t test was performed to analyze the asymmetry of breast shape, and Pearson correlation analysis was utilized to define the correlation between the breast shape, spinal deformity, and the inclination of anterior chest wall. The concave BV, EA, axial breast height, and vertical breast height were significantly larger than those of the convex side (P<0.05), whereas the concave CA and the inclination angle of the anterior chest wall were significantly smaller than those of the convex side (P<0.05). No difference was detected between the concave and the convex nipple-to-sternum distance (P>0.05). The averaged BA was 11.4%, with the ratio of asymmetry beyond 10% being 52.1%. No statistically significant relationships between BA and Cobb angle, RAsag angle, RAml angle were detected (P>0.05). The inclination angle of the anterior chest wall demonstrated significant correlation with EA (P<0.001) and CA (P<0.001), respectively. The incidence of BA in AIS is notable, with the concave breast being larger, more extroversive, and more concentrated than the convex breast. The discrepancy between concave and convex anterior chest wall inclination bound to scoliosis could have a major influence on breast orientation and profile, suggesting a synergistic role of anterior chest wall deformity and bilateral BV discrepancy in the formation of BA.

Bipedicle Vertical Mammoplasty Associated with Liposuction/Lipotunnelization.

Vertical techniques have become more popular and versatile in breast reduction and mastopexy procedures. The authors introduce a combination of vertical mammoplasty with vertical bipedicle technique, presenting some innovations concerning pedicle design, glandular dissection pattern, and the role of liposuction. In this article, we describe a personal surgical technique and analyze the results on 73 mastopexy and breast reduction patients, operated on between 2012 and 2014 by the senior author. The most important aspects of this technique are as follows: 1. the concept of lipotunnelization, where parenchymal tunnels are made with cannulas without suction; 2. the systematic use of liposuction/lipotunnelization to recreate the inframammary fold and decrease pillars height; 3. the use of a thick and narrow vertical pedicle (bipedicled); 4. no skin undermining. Twenty-five patients underwent mastopexy and 48 breast reduction. Results were evaluated by clinical examination and patient photographs. Good shape and projection of the breast and correct nipple elevation were achieved, correlating with a high level of patient satisfaction. No major complications occurred. This lipomammoplasty technique is a reliable and effective option, suitable for a wide range of symptomatic macromastia/ptosis. Adjunctive use of liposuction/lipotunnelization in vertical breast reduction accomplishes effective contouring of the breast with low associated complications and significantly reduces the revision rates. 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 .

Vertical breast measurement in East Asian women: A guide for mastopexy and reduction to form nonptotic breasts in unilateral prosthetic breast reconstruction

Following unilateral breast cancer surgery, mastopexy and reduction of the unaffected breast are often performed to obtain symmetrical breasts. The use of implants in breast reconstruction results in a nonptotic breast. To achieve symmetry following the procedure, the unaffected side should be nonptotic too. However, no study has yet reported any indices for the design of mastopexy and reduction in this direction. We present a new method of preoperative design that uses vertical breast measurements to form nonptotic breasts according to individual breast shapes. We performed vertical breast measurements of the unaffected breasts of 193 patients scheduled to undergo surgery for unilateral breast cancer. The vertical base dimension (VBD) and vertical surface dimension (VSD) of the ptotic and nonptotic breasts and the height of the nipple in the nonptotic breast were measured in centimeters. The borderline between ptotic and nonptotic breasts was expressed using the formula VSD=1.13×VBD+1.86. The height of the nipple in nonptotic breasts was 0.8 times the distance between the sternal notch and lowest point of the inframammary fold on the midline. From these findings, we formulated a new method for forming a nonptotic breast from a ptotic breast using an inverted T design. These results can be used for the design of mastopexy and reduction when forming a nonptotic breast on the unaffected side. These procedures can be performed without significantly lifting the nipple-areolar complex if required during unilateral prosthetic breast reconstruction.

The effect of breast support on vertical breast displacement and breast pain in female riders across equine simulator gaits

The effect of breast support on vertical breast displacement and breast pain in female riders across equine simulator gaits

Influence of the Pectoralis Major Muscle Sling in Chest Wall-Based Flap Suspension After Vertical Mammaplasty: Ten-Year Follow-Up.

The pectoralis muscle sling has proven to be a suitable alternative technique for long-term results in breast parenchyma suspension. Although the pectoralis muscle sling has been subjectively observed to reduce the bottoming-out effect with a bipedicled muscle flap (muscular loop), there has not been a study to objectively or numerically prove it. This study aimed to radiologically evaluate the influence of a pectoralis muscle sling in supporting the chest wall-based flap after a vertical breast-reduction technique. Twenty-one female patients underwent a vertical breast reduction with the chest wall-based flap and were randomly divided into two subgroups. Ten patients were in subgroup (S), which consisted of patients with a muscle sling. Eleven patients without the muscle sling technique were assigned as a control group (C). Periodic radiological examinations were performed at 1, 3, 6, and 12 months and then at 10 years postoperatively to analyze the breast flap and any migration with respect to three titanium clips placed intraoperatively on the chest wall parenchyma flap. Patients in subgroup S had a significantly higher difference in migration of the chest wall-based flaps between the first day and 10 years postoperatively when compared with patients in subgroup C (P < .001), as shown by the distances measured between titanium clip locations. After 10 years of follow-up, there were changes in chest wall-based flap bottoming-out in patients in whom a pectoralis major muscle sling was utilized compared with those patients without it. Thus, a pectoralis major muscle sling seems to provide greater and longer-lasting support to the flap position on the patient's chest. 2 Therapeutic.

Vertical Scar Breast Reduction: Does Gathering the Incision Matter?

The vertical scar bilateral breast reduction is a highly effective technique to reduce breast volume and create long-lasting aesthetic improvements. A cited disadvantage is the inability to adequately shorten the vertical scar, leading to chest wall scars or inframammary puckers. Gathering or cinching sutures have been described as a strategy to confront this issue. This article aims to determine if suture gathering is an effective methods to (1) reduce the incision length, (2) shorten the areola-to-inframammary fold (IMF) distance, and (3) reduce the pucker revision rate. All patients undergoing vertical breast reduction performed by the senior author (E.H.F.) from 2001 to 2007 were included. The patient population was divided into "gather" and "no gather" groups depending on how the vertical incision was closed. There were 203 patients in the "no gather" group and 193 in the "gather" group. Age, body mass index, and resection weight were statistically but not clinically different. The percent reduction in vertical incision length was significantly greater in the "gather" group (34.2 ± 9.9% vs. 12.2 ± 5.9%). Both groups showed a gradual lengthening of areola-to-IMF distance postoperatively. Suture gathering had no impact on the pucker revision rate but increased healing complications. Gathering sutures significantly reduce the incision length in the operating room but do not change the areola-to-IMF distance or pucker revision rate. Gathering negatively influences skin vascularity and wound healing. It is acceptable and necessary to have a longer areola-to-IMF distance in a vertical reduction to accommodate increased projection.

An Oncoplastic Approach to Reconstruct Upper Pole Partial Mastectomy Defects in Minimally Ptotic and Average Size Breasts.

Sir: Breast conservation of upper pole breast cancers without oncoplastic reconstruction can lead to contour deformities and translocation of the nipple-areola complex after radiation therapy.1–3 Traditional methods to reconstruct upper pole partial mastectomy defects involve a Wise pattern skin incision with rotation of adjacent tissue.4 This technique is best suited for ptotic and large breasts, but is difficult to use in minimally ptotic or average sized breasts. The circumvertical pattern may be more suitable for these patients. Benefits include fewer incisions and no concern for T-junction skin necrosis.5 The authors translate these benefits to oncoplastic surgery through a novel rotation of breast tissue from the 6-o’clock position into the superior pole partial mastectomy defect, based on either a medial or lateral pedicle, all through a circumvertical skin incision. The patient’s breasts are marked preoperatively. The vertical limb is not drawn, as this is created with a tailor-tacking method after the partial mastectomy is completed. The location of the tumor guides the marking of either a lateral or medial pedicle. The breast surgeon performs intraoperative ultrasound to mark the skin margin directly anterior to the biopsy marker. If a close or positive anterior margin exists on the final pathologic examination, the marked skin can be excised 2 to 3 weeks after surgery. The plastic surgeon then makes the outer periareolar and areolar incision, and deepithelializes the intervening skin. The oncologic breast surgeon then performs the needle-localized partial mastectomy through the outer border of the deepithelialized area, leaving the pedicle to the nipple-areola complex based either laterally or medially. The base of the partial mastectomy defect is marked with clips to guide radiation therapy. The areolar and periareolar incisions are then made on the contralateral breast, and the intervening skin is deepithelialized. The areolas are stapled into the 12-o’clock position and the patient is sat up to tailor-tack the vertical limb. The vertical limbs are marked and incised, and the skin on the cancer side is deepithelialized. The 6-o’clock tissue that is normally discarded during a vertical breast reduction is incised in a V shape and elevated as an extension of the pedicle (Fig. 1). The flap is elevated, with care taken to avoid dividing any deep perforators into the pedicle. Before rotation, the distal flap dermis is checked for punctate bleeding. The rotated flap stays in place with closure of the vertical pillars (Fig. 2). The contralateral reduction is then performed with excision of the 6-o’clock breast tissue. The contralateral breast is made 5 to 10 percent smaller, to account for volume loss caused by radiation therapy on the cancer side.Fig. 1: Lateral pedicle with extension. Lateral pedicle with inferior extension that would be thrown away in a traditional circumvertical breast reduction.Fig. 2: Rotation of tissue. Rotation of inferior extension into the superior mastectomy defect.The proposed technique uses a circumvertical skin incision and rotation of the tissue from the 6-o’clock position into the defect, based on either a medial or lateral pedicle. The authors believe that this technique is suited for minimally ptotic or average sized breasts, and allows for improved cosmesis of the reconstructed breast compared with traditional techniques. DISCLOSURE All authors have no commercial associations or information that might pose or create a conflict of interest with the information presented within this article. Ajul Shah, M.D. Anup Patel, M.D. Section of Plastic Surgery Andrew Kenler, M.D. Department of Surgery Yale University School of Medicine New Haven, Conn. Shareef Jandali, M.D. Plastic and Reconstructive Surgery Bridgeport Hospital Bridgeport, Conn.