Total Breast Reconstruction with Lipofilling after Traditional Mastectomy without the Use of Tissue Expanders.

BACKGROUND: Lipofilling can be used to reconstruct a breast without additional implants or autologous composite grafts. However, methods to maximize retention of the transferred fat remain under debate. Here, the authors present their experience of breast reconstruction with lipofilling without concomitant use of tissue expanders. METHODS: Patients who had completed breast reconstruction with lipofilling between June of 2010 and June of 2016 were reviewed. Those with obtainable follow-up magnetic resonance imaging scans were included in this cross-sectional study. The hospital records were reviewed for details of the lipofilling operations. Magnetic resonance imaging scans were evaluated for the volume retention and quality of the transferred fat. The patients were asked to assess the appearance and sensitivity of the reconstructed breast, the recovery time, and any adverse effects at the fat donor area. RESULTS: Thirty-eight women with 41 reconstructed breasts were included in the study. The median age at follow-up was 62 years (range, 48 to 78 years). They had undergone a median of four (range, two to six) lipofilling procedures with a median total volume 690 mL (range, 369 to 1350 mL). After a median follow-up of 2.1 years (range, 0.4 to 6.8 years), the median proportion of transferred fat retained was 58% (range, 14% to 119%), representing a reconstructed breast volume of 76% (range, 17% to 100%) of the contralateral breast. Oil cysts larger than 10 mm were detected in 7%. Most patients reported being satisfied with the reconstructed breast and experienced few side effects. CONCLUSIONS: Breast reconstruction with lipofilling can be performed with an acceptable number of procedures and no preoperative skin expansion. It extends the option of autologous breast reconstruction to women unsuited for major reconstructive procedures. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Beyond the 21-cm Notch-to-nipple Myth: Golden Proportions in Breast Aesthetics.

BACKGROUND: The 21-cm notch-to-nipple distance has been accepted without academic scrutiny as a key measure in breast aesthetics. The Fibonacci sequence and phi ratio occur frequently in nature. They have previously been used to assess aesthetics of the face, but not the breast. This study aims to assess if the static 21-cm measure or the proportional phi ratio is associated with ideal breast aesthetics. METHOD: Subclavicular-breast height and breast width were used to calculate the aesthetic ratio. Subjects were subsequently aesthetically rated. A one-sample t-test was used to determine if the ratio for each breast differed from phi. Breast scores with one, both, or no breasts were compared with an optimal phi ratio. Analysis of variance was performed. Tukey-Kramer adjustment for multiple comparisons was used when pairwise comparisons were conducted. RESULTS: Five subjects (14%) had bilateral optimal phi ratio breasts. Four subjects (11%) had one breast with an optimal phi ratio. Subjects with bilateral optimal phi ratios had significantly higher overall breast scores than those with only one optimal breast (Δ = 0.86, P = 0.025) or no optimal breast (Δ = 0.73, P = 0.008). Distance from optimal Fibonacci nipple position was moderately to strongly correlated with aesthetic score (-0.630, P = 0.016). No correlation was found between 21-cm notch-to-nipple distance and aesthetic score. CONCLUSION: The bilateral optimal phi ratio is correlated with high overall aesthetic scores, as is the optimal Fibonacci nipple position. No correlation was found between 21-cm notch-to-nipple distance and overall aesthetic score.

An Aesthetic Factor Priority List of the Female Breast in Scandinavian Subjects.

Background: There is little consensus about the relative determinative value of each individual factor in female breast aesthetics. When performing breast surgery with an aesthetic goal, certain factors will be more important than others. The purpose of this study was to make an aesthetic factor rank list to determine the relative contributions to overall breast aesthetics. Method: Volunteers were scanned using the 3-dimensional Vectra system. Ten Scandinavian plastic surgeons rated 37 subjects, using a validated scoring system with 49 scoring items. The correlation between specific aesthetic factors and overall breast aesthetic scores of the subjects were calculated using Pearson's r, Spearman's ρ, and Kendall's τ. Results: A very strong correlation was found between overall breast aesthetic score and lower pole shape (0.876, P < 0.0001). This was also true for upper pole shape (0.826, P < 0.0001) and breast height (0.821, P < 0.0001). A strong correlation was found between overall breast aesthetic score and nipple position (0.733, P < 0.0001), breast size (0.644, P < 0.0001), and breast width (0.632, P < 0.0001). Factors that were only moderately correlated with aesthetic score were intermammary distance (0.496, P = 0.002), nipple size and projection (0.588, P < 0.0001), areolar diameter (0.484, P < 0.0001), and areolar shape (0.403, P < 0.0001). Perceived symmetry was a weak factor (0.363, P = 0.027). Conclusions: Aesthetic factors of the female breast can be ranked in a priority list. Shape of the lower pole and upper pole and breast height are primary factors of female breast aesthetics. These should be prioritized in any aesthetic breast surgery. Vertical dimensional factors seem to be more determinative than horizontal factors.

Full breast reconstruction with fat and how to recycle the "dog-ear".

Mastectomy without immediate reconstruction leaves us with a population of women who may need a new breast in a delayed fashion. These women are often elderly, not fit for major flap surgery or reluctant to have long scars or implants. Free fat grafting has mainly been used as an adjunct to other reconstructive methods. We present an option for delayed full breast reconstruction with free fat grafting alone. In some cases, we utilize the lateral excess as a flap in combination with fat grafting. Patient selection is crucial. A lady fitting this reconstruction method should have fat to donate, preferably in several different regions as well as redundant skin on the chest-wall and only minor radiation damage. Also, breast size requirements need to be sensible. The Fat is harvested in a closed system under general or local anesthesia. Following a few minutes decantation, the fat is put into syringes and injected from 4-6 entrance points into 3-4 layers with a blunt cannula. Depending on the width, height and thickness of the receiving chest wall, the transferred volume varies between 150-300 cc/operation. In general, 2-5 operations are needed to reconstruct a breast with fat alone. If the patient presents with lateral excess tissue, this can be utilized as a local, fasciocutaneous flap, de-epithelialized and rotated 180 degrees to support the inferior border of the new breast. This enables inferolateral definition and control of the breast footprint. The secret behind success in free fat grafting for full breast reconstruction lies in the small technical details and works safely and efficiently in a selected group of patients.

Estradiol fatty acid esterification is increased in high density lipoprotein subclass 3 isolated from hypertriglyceridemic subjects.

Estrogen fatty acid esters are potent lipophilic estrogens transported exclusively in lipoproteins. They are formed in HDL in a reaction catalyzed by LCAT which is considered a prerequisite for their antioxidative action. Our previous studies in normotriglyceridemic (NTG) individuals demonstrated that estradiol (E2) esterification occurred mainly in HDL3 causing accumulation of esterified, but not of unesterified E2 in the lipoprotein particles. Using HDL obtained from hypertriglyceridemic (HTG) patients, we now investigated the effect of altered HDL composition on E2 esterification. Ultracentrifugally isolated HDL2 and HDL3 from NTG- and HTG-males were incubated in an in vitro model system with radioactive and with supraphysiological concentrations of non-radioactive E2 with and without exogenous LCAT. After purification, copper-induced oxidation of HDL was measured by monitoring conjugated diene formation. The results demonstrated that (i) E2 esterification occurring mainly in HDL3 was significantly more efficient in HTG-HDL3 compared to NTG-HDL3, (ii) triglyceride content in HDL3 correlated positively with E2 esterification rate, and (iii) addition of both exogenous LCAT and E2 into the incubation prolonged lag time of HDL3 oxidation. Thus, HDL composition regulates LCAT-facilitated E2 esterification but the in vivo role of this finding can be verified only in experiments using physiological hormone concentrations.

Lecithin/cholesterol acyltransferase induces estradiol esterification in high-density lipoprotein, increasing its antioxidant potential.

Endogenous estrogens protect against atherosclerosis, but the exact mechanisms remain unclear. One possibility is inhibition of lipoprotein oxidation. To act as antioxidants, estrogens reportedly need to be converted to lipophilic estrogen fatty acyl esters in a reaction catalyzed by lecithin/cholesterol acyltransferase (LCAT). To demonstrate directly that estradiol (E2) esters formed by LCAT and incorporated in high-density lipoprotein (HDL) increase its antioxidant potential, we investigated the copper-induced oxidation of purified HDL after incubations of: 1) HDL alone; 2) HDL in the presence of exogenous E2; 3) HDL in the presence of exogenous LCAT; 4) HDL in the presence of both E2 and LCAT; and 5) HDL in the presence of E2, LCAT, and the LCAT inhibitor DTNB. We used this in vitro model system with supraphysiological concentrations of E2 and purified LCAT to produce E2 ester-containing HDL particles for studies of oxidation resistance. The lag time of HDL oxidation significantly increased with increasing contents of HDL-associated E2 esters. In conclusion, our results clearly demonstrated the role of LCAT in E2 esterification and its involvement in antioxidant protection of HDL. Elucidation of the possible in vivo role of HDL-associated estrogen esters requires further critical studies including experiments with physiological hormone concentrations.

Lipoprotein-associated estrogens.

The discovery of a family of hormonal steroids esterified with fatty acid has raised questions concerning their physiologic role. Because of their water-insolubility these compounds are present in the circulation only as components of lipoprotein particles. Current evidence supports the hypothesis that estrogen esterification is catalyzed by lecithin:cholesterol acyltransfearse associated with HDL. In addition, recent results indicate that estradiol esters are transferred from HDL to LDL particles in a cholesteryl ester transfer protein (CETP)-associated process. The studies now focus on the various possible physiologic roles proposed for these hormone derivatives, (1) functioning as fat-soluble antioxidants incorporated in lipoproteins rendering protection against oxidation of these particles, (2) providing a mechanism for hormonal storage in lipoproteins and fat tissues, (3) providing a novel hormone transport system using lipoprotein as carriers and lipoprotein receptors for entry into cells. Quantitative methods of determination of estradiol fatty acid esters in human body fluids have been developed. Preliminary studies suggest that diet-derived plant estrogens may also form fat-soluble derivatives which become incorporated in lipoproteins.

LCAT facilitates transacylation of 17 beta-estradiol in the presence of HDL3 subfraction.

It has been shown that estrogens need to be metabolized to their hydrophobic estrogen ester derivatives to act as antioxidants in lipoproteins. Data suggest that 17beta-estradiol (E(2)) becomes esterified in LCAT-induced reactions and the esters are transported from HDL particles to LDL and VLDL particles by a CETP-dependent mechanism. In the present study we have further investigated the regulation of E(2) esterification by LCAT and focused on the importance of HDL structure and composition in the esterification process. Isolated LDL, HDL(2), HDL(3), and reconstituted discoidal HDL (rHDL) were incubated with labeled E(2), with and without purified LCAT, at 37 degrees C for 24 h. After purification of the lipoprotein fractions, there was a significant peak of radioactivity representing esterified estradiol attached to HDL(3) and rHDL, but HDL(2) and LDL contained only trace amounts of labeled estradiol ester. TLC analysis confirmed that the radioactivity migrated in a position corresponding to that of 17beta-E(2) 17-monoester standard. The amount of radioactivity associated with HDL(3) and rHDL representing esterified E(2) was significantly increased by addition of purified LCAT. However, only limited increases of radioactivity were observed in HDL(2) and LDL. In conclusion, HDL subfractions differ in their potential to regulate estradiol esterification by LCAT.