Beauty Is in the Eye of the Beholder: Factors Influencing Disparity in Perceptions of Breast Reconstruction Aesthetic Outcomes

 

by Wu, Shannon S.; Duraes, Eliana F. R.; Scomacao, Isis; Morisada, Megan; Djohan, Risal S.; Bernard, Steven L.; Moreira, Andrea; Schwarz, Graham S.

 

Plastic and Reconstructive Surgery: July 2022 - Volume 150 - Issue 1 - p 42e-50e

 

Background:

Patient-reported outcomes are the primary measurement of breast reconstruction success, but results may be affected by nontechnical factors such as socioemotional determinants. Third-party observers provide an independent assessment of aesthetic outcomes. Factors associated with disparity between patient and observer perceptions of outcomes are not well understood.

Methods:

One hundred forty-seven patients underwent breast reconstruction at the authors’ institution between 2009 and 2011, completed the BREAST-Q, and had photographs graded by a diverse panel using the Validated Breast Aesthetic Scale. Patient satisfaction with breasts scores that aligned with observer scores were categorized as group 2; patient satisfaction that exceeded observer scores were group 1; and those lower than observer scores were group 3. Statistical analysis was performed using SPSS, with values of p < 0.05 considered statistically significant.

Results:

Twenty-eight patients (19 percent) were categorized as group 1, 93 (63 percent) in group 2, and 26 (18 percent) in group 3. Median overall appearance was highest in group 3 (median, 4.0; interquartile range, 4 to 4) and lowest in group 1 (median, 3.0; interquartile range, 2 to 3) (p < 0.001). Psychosocial, sexual, and physical well-being were significantly associated with disparity (group 1 or 3 status) (p < 0.01). Satisfaction with outcomes, nipples, abdomen, and breasts were significantly associated with disparity. Factors not significantly associated with disparity include age, body mass index, autologous or implant-based, adjuvant therapies, and timing of reconstruction.

Conclusions:

Incongruously high patient satisfaction with breast reconstruction aesthetics relative to third-party perception of aesthetic outcomes is associated with high quality-of-life scores. Incongruously low patient satisfaction with breast cosmesis compared with higher third-party perceptions was associated with low quality-of-life scores. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

 

Aesthetic Limitations in Direct-to-Implant Prepectoral Breast Reconstruction

 

By: Safran, Tyler; Al-Badarin, Faris; Al-Halabi, Becher; Viezel-Mathieu, Alex; Dionisopoulos, Tassos 

 

Plastic and Reconstructive Surgery: July 2022 - Volume 150 - Issue 1 - p 22e-31e

 

Background:

Prepectoral direct-to-implant reconstruction has become an alternative to staged subpectoral expander-based reconstruction. Although the surgical safety of this technique has been shown, aesthetic limitations have not been well-described. This article reports aesthetic limitations and elucidates risk factors that may predispose patients toward developing unfavorable outcomes following direct-to-implant prepectoral breast reconstruction.

Methods:

A retrospective chart review was performed, identifying patients who underwent prepectoral, direct-to-implant breast reconstruction from June of 2016 to June of 2019. Aesthetic limitations assessed included capsular contracture, rippling, implant malposition, and implant flipping.

Results:

Two hundred twenty-four consecutive women representing 334 breasts underwent immediate reconstruction performed by a single plastic surgeon. A midlateral incision was used in 185 breasts (55.4 percent) and the Wise pattern in 95 breasts (28.8 percent). The mean follow-up time was 30.5 months (45.3 to 18.3 months). Significant capsular contracture (grade 3 to 4) was noted in 27 breasts (8.1 percent), implant flipping in four breasts (1.2 percent), implant displacement in five breasts (1.5 percent), major rippling in nine breasts (2.7 percent), and minor rippling in 17 breasts (5.1 percent). The use of acellular dermal matrix had no significant effect on the aesthetic outcomes. In comparing breasts with postmastectomy radiation, there was a significant difference in the presence of minor rippling and capsular contracture (p < 0.05).

Conclusions:

This cohort represents the largest, single-surgeon, direct-to-implant prepectoral database in the literature. This report shows that aesthetic limitations were comparable to those seen with other forms of reconstruction. Complications did not differ in terms of acellular dermal matrix use. Certain factors can predispose patients to developing unfavorable aesthetic outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

 

A Novel Validated Breast Aesthetic Scale

by Duraes, Eliana F. R.; Durand, Paul; Morisada, Megan; Scomacao, Isis; Duraes, Leonardo C.; de Sousa, Joao Batista; Abedi, Nasim; Djohan, Risal S.; Bernard, Steven; Moreira, Andrea; Schwarz, Graham S. 

Plastic and Reconstructive Surgery: June 2022 - Volume 149 - Issue 6 - p 1297-1308

 

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.

 

 

 

Invisible Surgery Concept and Scenario Strategy: How to Get the Best Aesthetic Results in Oncoplastic Breast-Conserving Surgery

 

by Zhygulin, Andrii; Fedosov, Artem; Palytsia, Valentyn 

 

Plastic and Reconstructive Surgery: December 2021 - Volume 148 - Issue 6 - p 1209-1213

 

The authors believe that oncoplastic breast surgery has to achieve the best possible aesthetic results. In this article, they propose the concept of “invisible surgery.” This is a combination of certain oncoplastic techniques that allows for restoration of the original appearance of the breast without obvious scars on the breast. Further, the authors classify the techniques as follows: the “level 1 technique,” with contour approach; the “from inside” technique; the lateral parenchymal flap; the axillary subcutaneous adipofascial flap; the rotational lateral thoracic flap; regional island perforator flaps (lateral intercostal artery perforator, lateral thoracic artery perforator, anterior intercostal artery perforator, and medial intercostal artery perforator flaps); and the nipple-sparing mastectomy with immediate expander reconstruction. These techniques were combined by internal logic—one can move from one to another according to the preoperative planning and margins status during the operation. They call their approach the “scenario strategy.” The authors have performed 138 operations in 137 patients using this approach. Most of them involved the “from inside” technique and perforator flaps. The average tumor size was 2.4 cm, and the average specimen weight was 43.2 g. The total rate of complications was 14.6 percent. According to this concept, the surgery should be performed in such way that breast appearance will not change. It should be planned as one would plan a staged procedure, taking into account possible changes in the scenario during the operation to achieve the best possible aesthetic result.

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Analysis of the Visual Perception of Female Breast Aesthetics and Symmetry: An Eye-Tracking Study

Analysis of the Visual Perception of Female Breast Aesthetics and Symmetry: An Eye-Tracking Study

by Pietruski, Piotr; Paskal, Wiktor; Paskal, Adriana M.; Jaworowski, Janusz; Paluch, Lukasz; Noszczyk, Bartlomiej

Plastic and Reconstructive Surgery: December 2019 - Volume 144 - Issue 6 - p 1257-1266

Background: Because of its subjective character, the term “breast attractiveness” is poorly defined and thus its reliable standardized assessment can be particularly challenging. Because of objective analysis of the observer’s gaze pattern, eye-tracking technology may provide a better insight into the visual perception of breast aesthetics and symmetry.

Methods: One hundred observers, 50 women and 50 men, assessed the aesthetics and symmetry of eight types of female breasts displayed as digital images on frontal, lateral, and oblique projections. The gaze pattern of each observer was recorded using eye-tracking technology, and gaze data were subsequently analyzed.

Results: Although sex and breast type exerted an effect on attention capturing by some areas of interest, key characteristics of gaze patterns in female and male observers were essentially the same. Irrespective of observers’ sex, the longest fixation duration and the highest fixation number were recorded for lower breast regions, in particular, for the nipple-areola complex. Mean fixation duration in this area corresponded to 58 and 57 percent of overall observation time for female and male observers, respectively, during the assessment of breast aesthetics; and to 56 and 52 percent of overall observation time for female and male observers, respectively, during the assessment of breast symmetry.

Conclusions: Nipple-areola complex and lower breast are key focus areas for the assessment of breast aesthetics and symmetry. Gaze data collected during this study may constitute a valuable source of reference values for future eye-tracking research on various patient groups’ visual perception of breast attractiveness and deformities.

Optimizing DIEP Flap Insetting for Immediate Unilateral Breast Reconstruction: A Prospective Cohort Study of Patient-Reported Aesthetic Outcomes

Optimizing DIEP Flap Insetting for Immediate Unilateral Breast Reconstruction: A Prospective Cohort Study of Patient-Reported Aesthetic Outcomes

 by Razzano, Sergio; Marongiu, Francesco; Wade, Ryckie; Figus, Andrea  

Plastic and Reconstructive Surgery: February 2019 - Volume 143 - Issue 2 - p 261e–270e

Background: To improve the aesthetic outcome of deep inferior epigastric perforator (DIEP) flap breast reconstruction, flaps should be tailored to the patient’s characteristics. A single method of DIEP flap insetting will not suffice for all women seeking breast reconstruction. The authors share the outcomes of a prospective longitudinal study on DIEP flap insetting and present an algorithm for reconstruction.

Methods: Over 4 years, 70 consecutive immediate unilateral DIEP flap breast reconstructions were prospectively evaluated. DIEP insetting was based on the characteristics of the donor site and contralateral breast, according to the authors’ algorithm. Baseline and outcome data were collected. Aesthetic outcomes were evaluated by a panel of three independent assessors, and patient-reported outcomes were quantified using the BREAST-Q at 1 year after reconstruction.

Results: Seventy women underwent reconstruction. There were no total or partial flap failures, four cases of fat necrosis, and 14 revision operations. Women reported a mean overall BREAST-Q score of 82 of 100, representing excellent satisfaction but poor satisfaction with sexual well-being. BREAST-Q scores were not associated with age or body mass index. Fat necrosis reduced satisfaction with the chest (absolute mean reduction, 13; 95 percent CI, 8 to 18; p = 0.002). Independent assessors scored the outcomes favorably, but there was no agreement between surgeons, nurses, and lay assessors. Conclusions: The authors’ algorithm can support surgeons in selecting individually tailored DIEP flap insetting to achieve excellent aesthetic outcomes. Further research is needed as to the relevance of scores from BREAST-Q in relation to interventions. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The Implications of Barbed Sutures on Scar Aesthetics: A Systematic Review

The Implications of Barbed Sutures on Scar Aesthetics: ASystematic Review

Authors: Motosko, Catherine C., B.S.; Zakhem, George A., B.S.; Saadeh, Pierre B., M.D.; Hazen, Alexes, M.D.

Journal: Plastic and Reconstructive Surgery: August 2018 - Volume 142 - Issue 2 - p 337–343

Background: Barbed sutures have become increasingly popular in the field of aesthetic plastic surgery, particularly in body contouring and breast operations, in which the use of barbed sutures may offer both time and cost savings. Scar aesthetics is an important outcome for both surgeons and patients in these procedures; however, there is a paucity of studies assessing the aesthetic outcome of barbed sutures with regard to scarring.

Methods: A systematic review of the PubMed, EMBASE, and Cochrane databases was performed from the date of their inception through July of 2017 using the search terms “barbed suture” combined with “scar” or “wound.” Studies were included if they were prospective, evaluator-blind, randomized, controlled trials; closed the dermal layer of incisions using barbed sutures; and included an evaluator-blind aesthetic assessment of scarring.

Results: Six prospective, randomized, controlled trials met inclusion criteria. The cosmetic result of scars in 926 patients was evaluated after an average of 8.1 months. Five of the six controlled trials found the aesthetic results of wounds closed with barbed sutures to be equivalent to those closed with traditional sutures, and one study showed significantly superior aesthetic results with barbed sutures. Use of barbed sutures resulted in shorter operating times in four of the five studies that timed incision closure. Similar complication rates were observed in all evaluated studies.

Conclusion: Based on this systematic review, the majority of studies concluded that there were no differences in scarring aesthetics when dermal layers were closed using barbed sutures compared with traditional suturing techniques.