Public Perception of Ideal Areola Proportions.

BACKGROUND: In breast reconstruction, mastopexy, and breast reduction procedures, surgeons make decisions about the resulting areola size, and this significantly impacts the overall aesthetic result. Despite the importance of these decisions, little is known about the general population's preferences for areola size. The objective of this study was to survey the global population to better understand the public's perceptions of ideal areola dimensions. METHODS: A survey was developed with 9 different composite diagrams of a female torso (every combination of 3 breast widths and 3 waist widths). In each composite diagram, 6 different areola sizes were shown (areola-to-breast diameter ranging from 1:12 to 6:12). The survey was distributed via the Amazon Mechanical Turk digital platform, and respondents' demographics (sex, age, race/ethnicity, country, and state if located in the United States) and preferences for the most aesthetically pleasing size in each composite diagram were recorded. RESULTS: Among 2259 participants, with 1283 male (56.8%) and 976 female (43.2%), most participants were between 25 and 34 years old (1012, 44.8%), were from the United States (1669, 73.9%), and identified as White (1430, 63.3%). With 9 breast width and waist width combinations, the respondents were most likely to prefer the 2:12 (32.9%) areola-to-breast ratio ( P < 0.0001). The second most commonly preferred ratio was 3:12 (30.6%) ( P < 0.0001). Gender subgroup analysis showed that women preferred middle-range ratios, such as 2:12, 3:12, and 4:12 ( P < 0.0001). Meanwhile, men were more likely to prefer extreme ratios of 1:12 or 6:12 ( P < 0.0001). Across almost all races/ethnicities, 2:12 was significantly the most popular, except among American Indian/Alaskan Native and Middle Eastern where 3:12 was the most preferred ( P < 0.0001). Within the top 6 countries (United States, India, Brazil, Italy, Canada, United Kingdom), the United States, India, and Italy preferred 2:12, and Brazil, Canada, and the United Kingdom preferred 3:12 ( P < 0.0001). CONCLUSIONS: This study provides the first objective data on public impressions of the ideal areola proportions and can serve as a guide for surgical decision making in breast reconstruction and reshaping procedures.

Three-dimensional Evaluation of Results After Dual-Plane Breast Augmentation with and Without Internal Suture Mastopexy.

BACKGROUND: In patients with breast atrophy and ptosis, it is necessary to correct both problems simultaneously. This study aimed to analyze breast morphological changes with a three-dimensional (3D) scanning technique to demonstrate the improvement effect of dual-plane breast augmentation combined with internal suture mastopexy. METHODS: 3D breast surface scans were performed preoperatively and postoperatively in 24 patients (n = 35 breasts) undergoing internal suture mastopexy combined with prosthetic augmentation through the periareolar approach and 24 patients (48 breasts) undergoing simple dual-plane breast augmentation. Changes in linear distance, breast volume and volume distribution, breast projection, and nipple position were analyzed to assess the breast morphology. RESULTS: Compared with simple breast augmentation, augmentation combined with internal suture mastopexy was associated with a higher upper pole volume increase and greater medial and upward nipple displacement. After the surgery, the upper pole volume increased by an average of 10.6% in combined augmentation group and decreased by an average of 2.2% in the simple breast augmentation group. The measured breast projections were 24.8 ± 2.2% lower than expected in the combined group and 23.1 ± 4.1% lower than expected in the simple group, based on implant parameters recorded by the manufacturer. The nipple moved 0.2 ± 0.5 cm laterally, 1.6 ± 0.6 cm upward, and 2.8 ± 0.7 cm anteriorly in the combined group and 0.9 ± 0.5 cm laterally, 0.7 ± 0.6 cm upward, and 3.0 ± 0.6 cm anteriorly in the simple group. CONCLUSIONS: Dual-plane breast augmentation in addition to internal suture mastopexy appears to reposition breast tissue from the lower pole to fill in the deficient upper breast, pull the nipple medially and superiorly, and ultimately correct mild to moderate breast ptosis. LEVEL OF EVIDENCE III: 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 .

Long-Term Changes in Free Nipple Graft Morphology and Patient-Reported Outcomes in Gender-Affirming Mastectomies.

BACKGROUND: After gender-affirming mastectomies with free nipple grafts, satisfaction with nipples tends to fall short behind chest outcomes. This might be related to changes in nipple areolar complex (NAC) dimensions over time. Therefore, the aim of this study is to establish the long-term changes in NAC morphology and compare these to cisgender male NAC outcomes. MATERIALS: An observational, cross-sectional study was performed. Data from two prospective cohorts were collected: (1) transgender men after a mastectomy with free nipple grafts and (2) cisgender men (reference sample). Demographics and 3-D images were collected for both groups. NAC measurements were performed on the 3-D images at 4 time points (7-, 30-, 90- and 365-days postoperative) in transgender men and once in cisgender men. Furthermore, the BODY-Q (nipple module) was administered postoperatively at 30-, 90- and 365-days in transgender men. RESULTS: In total, 67 transgender and 150 cisgender men were included. NAC width and height in trans men changed from 21.5 mm (±2.7) to 23.8 mm (±3.9, p<0.001) and 16.2 mm (±2.5) to 14.7 mm (±3.0, p=0.01) within a year, respectively. On average, the NACs increasingly rotated 21 degrees in the latero-caudal direction (p<0.001). The mean NAC width and height in cisgender men were 28.1 mm (±5) and 20.7 mm (±4), being significantly larger than in transgender men. Satisfaction for size, shape and flatness decreased significantly after postoperative day 30 (p=<0.05) in transgender men. CONCLUSIONS: Morphology of and satisfaction with the NACs in transgender men significantly changed over time. Understanding and incorporating these differences into pre-operative counseling and surgical planning might help increase patient satisfaction. 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 .

Technical Refinement in Three-Dimensional Nipple-Areola Complex Tattooing of the Reconstructed Breast.

SUMMARY: Three-dimensional nipple-areola complex tattooing has previously been described as an alternative to surgical reconstruction using local flaps and grafts. This technique offers patients an option that can achieve aesthetically pleasing results without a donor site, changes in projection over time, or additional scarring. Plastic surgeons may be limited in their ability to create a realistic-appearing nipple-areola complex because of limited experience with basic tattooing techniques and unfamiliarity with the artistic principles of light and shadow required to create depth on a two-dimensional surface. Consistent results can be achieved with attention to the technical pearls discussed in this article.

Anthropometric breast measurements of young women with no history of pregnancy or surgery in Turkey.

Anthropometric measurements of the breast play a guiding role in surgical planning. In our study, it was aimed to determine the normal shape and size of the breast by taking measurements in young women who did not experience pregnancy or surgery and comparing them with the results of other studies. The breast parameters of 88 women aged between 18 to 30 years old, with a normal body mass index, with no history of previous pregnancy, surgery or rapid weight gain were measured. The measured parameters were age, body mass index, cup size, distance between nipple and suprasternal notch, distance between both nipples, distance between midclavicular point and nipple, distance between midclavicular point and upper border of the breast, the distance between the midaxillary line and nipple, the distance between the nipple and inframammarian fold, the projection of the breast, the projection of the nipple and the chest circumference under the breast. The mean values ​​were determined and the correlation between the parameters was evaluated statistically. A significant correlation was found between cup size and all parameters except for the chest circumference and nipple projection. The distance between the midclavicular point and upper border of the breast was found correlated with the cup size. In addition, a significant correlation was found between body mass index and all other parameters. This study revealed the average breast size and measurements of women in Turkey. It can be useful to guide for both reconstructive and aesthetic procedures of the breast.

Geometric Measurements of Nipple Position in Breasts Reconstructed with Transverse Rectus Abdominis Musculocutaneous Flap: A 5-Year Prospective Study.

BACKGROUND: After breast reconstruction, nipple position and other long-term changes in the reconstructed breast relative to the contralateral breast remain poorly understood. In this prospective cohort study, the authors performed serial nipple position measurements over 5 years in patients who had undergone breast reconstruction with a transverse rectus abdominis musculocutaneous (TRAM) flap. The effects of adjuvant radiotherapy on nipple position over time were also investigated. METHODS: The authors studied 150 patients who had undergone nipple-sparing mastectomy, using radial incision followed by immediate unilateral pedicled TRAM flap breast reconstruction. Measurements of sternal notch-to-nipple, midline-to-nipple, and inframammary fold-to-nipple distances were performed 1 day before reconstruction and 6, 12, 36, and 60 months after surgery, on patients' reconstructed and nonoperated breasts. RESULTS: The average sternal notch-to-nipple distance increased in both reconstructed and nonoperated breasts at every follow-up visit, with an average difference of 0.393 cm at the 60-month visit (p < 0.0001). Comparing the pattern of distance change, reconstructed breasts tend to change more slowly than nonoperated breasts until 36 months postoperatively. In irradiated breasts, the sternal notch-to-nipple distance was significantly smaller than in nonirradiated breasts, and nipple position changed minimally between 1 and 3 years after surgery. CONCLUSIONS: Nipple position in TRAM flap-reconstructed breasts changed over time compared with that in nonoperated breasts, especially along the vertical axis. The pattern of nipple position change in reconstructed breasts became similar to nonoperated breasts 3 years after surgery. In patients who had undergone adjuvant radiation therapy, nipple position remained consistent for 1 to 3 years. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Three-dimensional microanatomy of human nipple visualized by X-ray dark-field computed tomography.

PURPOSE: The three-dimensional (3D) structure of the human nipple has not been fully clarified. However, its importance has increased in recent years because it has become common practice to preoperatively explore the spread of breast cancer to the nipple with needle biopsy, ductoscopy, and/or ductal lavage for nipple-sparing mastectomy. Here, we demonstrated that X-ray dark-field computed tomography (XDFI-CT) is a powerful tool for reconstructing the 3D distribution pattern of human lactiferous ducts non-destructively, without contrast agent, and with high tissue contrast. METHODS: Nipples amputated from mastectomy specimens of 51 patients with breast cancer were visualized three-dimensionally by XDFI-CT. First, CT images and conventionally stained tissue sections were compared to demonstrate that XDFI-CT provides 3D anatomical information. Next, the number of ducts in the nipple and the number of ducts sharing an ostium near the tip of the nipple were measured from the volume set of XDFI-CT. Finally, the 3D distribution pattern of the ducts was determined. RESULTS: XDFI-CT can provide images almost equivalent to those of low-magnification light microscopy of conventional hematoxylin-eosin-stained histological sections. The mean number of ducts in all cases was 28.0. The total number of ducts sharing an ostium near the tip of the nipple was 525 of 1428. The 3D distribution patterns of the ducts were classified into three types that we defined as convergent (22%), straight (39%), or divergent (39%). CONCLUSIONS: XDFI-CT is useful for exploring the microanatomy of the human nipple and might be used for non-invasive nipple diagnosis in the future.

The sensory innervation of the human nipple.

Nipples represent a highly specialized skin with capital importance in mammals for breastfeeding and additionally in humans due to sexuality. The histological studies regarding this region are scarce, so 42 human nipples were studied to describe the morphology of the nipple innervation. Our results exclude the presence of a rich innervation on nipple's skin or superficial dermis, thus definitely excluding nipple skin from the concept glabrous skin. The presence of mechanoreceptors is limited to scarce Merkel cells on the epidermis and some corpuscular capsulated and non-capsulated structures in the dermis; Merkel cells progressively decrease with ageing. No Meissner corpuscles were found and the rare Pacinian corpuscles identified were close to vascular structures and embroidered in the mammary fatty tissue. The great sensitivity observed functionally on the breast and especially in the nipple can be morphologically explained by two elements; on the one hand there is a rich smooth muscle innervation present in the deep dermis; on the other hand the mammary gland demonstrate Piezo2 expression in many glandular cells, with two differentiated patterns in the ductal and in the acinar tissue of the breast. The role of Piezo2 in the normal mammary gland is discussed.

The Ideal Male Nipple-Areola Complex: A Critical Review of the Literature and Discussion of Surgical Techniques for Female-to-Male Gender-Confirming Surgery.

INTRODUCTION: Top surgery (mastectomy and masculinization of the chest) is a key gender affirming operation for many female-to-male transgender patients. Positioning of the nipple-areola complex (NAC) is a crucial part of this procedure. To date, there are no standards as to where to place the new NAC based on the patient's anatomy, to achieve the most aesthetically pleasing result. OBJECTIVE: The objectives of this study were to review the literature and analyze the anatomical averages for NAC shape, width, and height as well as vertical and horizontal placement and to compile the recommendations and proposed equations of NAC placement based on chest wall measurements, chest wall landmarks, and body habitus. METHODS: A systematic review of the literature was conducted in the spring of 2018. Eleven articles met the inclusion criteria, with objective measurements of, and guidelines for, positioning the male NAC in men that had not been preselected for being aesthetically perfect. RESULTS: The average diameter for a round NAC was 25.9 mm (SD, 2.5 mm), and the width and height of the oval-shaped NAC were found to be 25.3 mm (SD, 2.6 mm) and 20.1 mm (SD, 0.75 mm), respectively. The average sternal notch to nipple distance was found to be 19.3 cm (SD, 1.7 cm). The average internipple distance was 22.3 cm (SD, 1.6 cm). CONCLUSIONS: The data are inconclusive about the effects of anatomical measurements on NAC vertical and horizontal position, but areola diameter is reasonably consistent. There are a wide variety of guidelines and algorithms offered for determining these measurements.

Evaluación radiológica de la correspondencia entre los puntos antropomórficos de la mama y sus respectivos puntos antropométricos en el esqueleto torácico / Radiological evaluation of anthropomorphic points of the breast with their respective anthropometric points on the thoracic skeleton

Antecedentes y Objetivo. El éxito de una intervención de Cirugía Plástica está en su planificación. Las medidas antropométricas son importantes en la evaluación preoperatoria para mejorar los resultados quirúrgicos; sin embargo, las variantes anatómicas en cada paciente pueden alterar esta planificación. Nuestro objetivo es ubicar, mediante comprobación radiológica, las referencias anatómicas antropométricas del esqueleto torácico que permiten proyectar de manera más precisa en el tórax los puntos y líneas antropomórficos necesarios para planificar la cirugía mamaria, a saber: posición del complejo areola-pezón, surco submamario y meridiano de la mama. Material y método. Realizamos un estudio retrospectivo, descriptivo y transversal evaluando radiografías de tórax póstero-anteriores y laterales en una población general de mujeres para determinar los puntos precisos de referencia anatómica en el tórax de la ubicación del surco submamario (SS), del punto P (punto más alto de proyección mamaria, pezón) y del meridiano mamario (punto M). Resultados. Sobre un total de 61 radiografías en mujeres de entre 11 y 40 años de edad, el punto de máxima proyección del pezón estuvo ubicado en la cuarta costilla y el cuarto espacio intercostal en el 87% de los casos. En el 98% el surco submamario coincidió con la sexta costilla. Determinamos una diferencia de 1 a 2 cm entre el meridiano mamario escogido por la media entre la línea axilar anterior y la medioesternal y el que se ubica en la línea medioclavicular en el 88% de los casos. Conclusiones. Determinar estructuras fijas del esqueleto torácico que se relacionan de manera constante con estructuras y referencias de la mama (pezón, surco submamario y meridiano mamario), da al cirujano plástico criterios objetivos para la selección y proyección de puntos clave en la planificación de la cirugía mamaria, con proporción y armonía individualizadas en cada paciente, de cara a obtener resultados más estéticos y simétricos

Background and Objective. The success of a Plastic Surgery intervention is in its planning. Anthropometric measures are important in preoperative evaluation to improve surgical outcomes; however, anatomical variants in each patient can alter this planning. Our objective is to locate, through radiological verification, the anthropometric anatomical references of the thoracic skeleton that allow the anthropomorphic points and lines necessary to plan breast surgery to be projected more precisely in the chest, namely: position of the areola-nipple complex, submammary groove and meridian of the breast. Methods. We conduct a retrospective, descriptive and cross-sectional study evaluating postero-anterior and lateral chest radiographs in a general population of women, to determine the precise anatomical reference points in the thorax of the location of the submammary groove (SS), of point P (highest breast projection, nipple) and breast meridian (point M). Results. On a total of 61 radiographs in women between 11 and 40 years of age, the point of maximum projection of the nipple was located in the fourth rib and the fourth intercostal space in 87% of cases. In 98% the submammary groove coincided with the sixth rib. We determined a difference of 1 to 2 cm between the mammary meridian chosen by the mean between anterior and mid-sternal axillary line and that located in the midclavicular line in 88% of cases. Conclusions. Determining fixed structures of the thoracic skeleton that are constantly related to structures and references of the breast (nipple, submammary groove and breast meridian), gives the plastic surgeon objective criteria for the selection and projection of key points in the planning of breast surgery, with proportion and harmony individualized in each patient, in order to obtain more aesthetic and symmetrical results

Oncologic safety of nipple-sparing mastectomy in patients with short tumor-nipple distance.

BACKGROUND: There is a tendency to avoid nipple-sparing mastectomy (NSM) when a tumor-nipple distance (TND) is <2 cm due to the risk of occult nipple involvement. The purpose of the study was to determine whether the patients who undergo NSM with immediate reconstruction are oncologically safe when TND is <2 cm. METHODS: Patients who underwent NSM followed by immediate reconstruction for breast cancer were retrospectively analyzed. Patients who are negative for nipple-base in either frozen-section or paraffin histopathology were included. MRI was used to obtain TNDs to compare local-recurrence-free and disease-free survival in group I (TND <2 cm) and group II (TND ≥2 cm). Disease-free survival rates were determined to assess the outcome. RESULTS: Of the 214 cases with malignancy on MRI, 21 cases diagnosed with pure ductal carcinoma in situ were excluded. Among the 193 NSM cases diagnosed with invasive cancer, TND was <2.0 cm in 59 (30.56%) cases and ≥2.0 cm in 134 (69.43%) cases. No significant differences were found between groups in regards to ER, PR, HER2-neu status, and nodal involvement (P = 0.34, P = 0.41, P = 0.54, and P = 0.12 respectively). In a median follow-up time of 62 months (range; 13-114), patients in group I had four local recurrences, whereas group II was found to have five local and three distant metastases. No significant differences were observed between groups concerning disease-free survival (10-year DFS 93.2% vs 96.3%; P = 0.368 respectively). CONCLUSIONS: Patients who have invasive cancer diagnosis with a TND <2 cm are eligible to undergo therapeutic NSM with immediate reconstruction.

Nipple-Areolar Complex Position in Female-to-Male Transsexuals After Non-skin-excisional Mastectomy: A Case-Control Study in Japan.

BACKGROUND: Mastectomy is performed in female-to-male transsexual (FTM TS) patients as a surgical treatment to make a female thorax resemble a male thorax; however, no studies have examined the nipple-areolar complex (NAC) position in FTM TS patients after mastectomy. PATIENTS AND METHODS: The NAC position in 41 FTM TS patients before and after non-skin-excisional mastectomy was examined and compared with that in 50 age- and BMI-matched biologically male subjects as controls. The factors affecting the NAC position after the operation were also examined and verified by multiple regression analysis. RESULTS AND CONCLUSIONS: After non-skin-excisional mastectomy, the NAC in the FTM TS patients was positioned significantly more medially (horizontal NAC position ratio {('internipple distance'/'width of thorax') × 100} [HNPR]: preoperatively, 70.07% ± 4.19%; postoperatively, 63.28% ± 3.79%) and cranially (vertical NAC position ratio {('distance from sternal notch to nipple height'/'distance from sternal notch to umbilicus') × 100} [VNPR]: preoperatively, 43.87% ± 3.68%; postoperatively, 41.37% ± 3.15%). Postoperatively, the NAC in the FTM TS patients was located significantly more medially than that in the control subjects (HNPR: 63.28% ± 3.79% to 66.79% ± 4.82%), although the height of the NAC was the same. Multiple regression analysis revealed that the NAC position on breasts characterized by ptosis, a high projection, and lateral leaning (low skin elasticity and a substantial amount of skin between the nipples) tended to be positioned more medially after non-skin-excisional mastectomy. Laterally deviated eccentric circular type mastectomy may be a good option for FTM TS patients who have moderately sized breasts with such features. 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 .

Periareolar Augmentation-Mastopexy.

The authors describe their surgical technique for single-stage periareolar mastopexy with subglandular breast augmentation. They have performed this procedure in 85 patients since 2009 and found that this operative technique has allowed them to achieve reproducible outcomes in a single-stage procedure. Periareolar mastopexy with subglandular breast augmentation is an excellent procedure for patients who desire a larger breast size and who present with mild to moderate nipple ptosis with a paucity of excess skin in the lower pole of the breast. This article will review the perioperative management and detailed steps of the procedure and outline its indications for utilization and some of the common complications the authors have encountered.

Oncologic Trends, Outcomes, and Risk Factors for Locoregional Recurrence: An Analysis of Tumor-to-Nipple Distance and Critical Factors in Therapeutic Nipple-Sparing Mastectomy.

BACKGROUND: Oncologic outcomes with nipple-sparing mastectomy continue to be established. The authors examine oncologic trends, outcomes, and risk factors, including tumor-to-nipple distance, in therapeutic nipple-sparing mastectomies. METHODS: Demographics, outcomes, and overall trends for all nipple-sparing mastectomies performed for a therapeutic indication from 2006 to 2017 were analyzed. Oncologic outcomes were investigated with specific focus on recurrence and associated factors, including tumor-to-nipple distance. RESULTS: A total of 496 therapeutic nipple-sparing mastectomies were performed, with an average follow-up time of 48.25 months. The most common tumor types were invasive carcinoma (52.4 percent) and ductal carcinoma in situ (50.4 percent). Sentinel lymph node sampling was performed in 79.8 percent of nipple-sparing mastectomies; 4.1 percent had positive frozen sentinel lymph node biopsy results, whereas 15.7 percent had positive nodal status on permanent pathologic examination. The most common pathologic cancer stage was stage IA (42.5 percent) followed by stage 0 (31.3 percent). The rate of local recurrence was 1.6 percent (n = 8), and the rate of regional recurrence was 0.6 percent (n = 3). In all, 171 nipple-sparing mastectomies had magnetic resonance imaging available with which to assess tumor-to-nipple distance. Tumor-to-nipple distance of 1 cm or less (25.0 percent versus 2.4 percent; p = 0.0031/p = 0.1129) and of 2 cm or less (8.7 percent versus 2.0 percent; p = 0.0218/p = 0.1345) trended to higher rates of locoregional recurrence. In univariate analysis, tumor-to-nipple distance of 1 cm or less was the only significant risk factor for recurrence (OR, 13.5833; p = 0.0385). No factors were significant in regression analysis. CONCLUSIONS: In early stage and in situ breast carcinoma, therapeutic nipple-sparing mastectomy appears oncologically safe, with a locoregional recurrence rate of 2.0 percent. Tumor-to-nipple distances of 1 cm or less and 2 cm or less trended to higher recurrence rates. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

3D Mammometric Changes in the Treatment of Idiopathic Gynecomastia.

BACKGROUND: Three-dimensional surface imaging (3DSI) has shown promise for plastic surgeons to objectively assess changes in body contour and breast volume. OBJECTIVES: To assess the surgical outcome after bilateral subcutaneous mastectomy (BSM) and water jet-assisted liposuction (WAL) as treatment for idiopathic gynecomastia, using 3DSI to document changes regarding nipple-areolar complex (NAC) and breast volume. METHODS: Thirty male patients (Simon II A to B) receiving BSM and WAL were enrolled. Eight subjects received additional mastopexy and NAC reduction. Use of a Vectra 3D Imaging System® before and 6 months after surgery provided data regarding changes of NAC placement and NAC and breast dimensions. The sum volume of intraoperatively approximated lipoaspirate before and after centrifugation and mastectomy specimens quantified using water displacement were compared with 3D-assessed differences in volume. RESULTS: When compared to the NAC dimensions defined during surgery, patients receiving NAC reductions showed nonsignificant postoperative changes in NAC dimensions. Patients without additional mastopexy showed a significant (p < 0.001) vertical (15.7 ± 14.3%) and horizontal (17.1 ± 15.0%) reduction in NAC diameter. 3D volume changes (92.8 ± 26.4 mL) showed significant differences (p < 0.001) 6 months after surgery compared to the intraoperatively measured lipoaspirate before (182 ± 54.5 mL) and after (120 ± 34.6 mL) centrifugation. CONCLUSION: Although it is clear that patient satisfaction must remain the prime focus of surgical body contouring, 3DSI has proven valuable to objectively demonstrate both the anticipated outcome and further findings regarding treatment of idiopathic gynecomastia. 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 .

Validation of the ipsilateral nipple as the needle directional guide during right internal jugular vein catheterization: A prospective observational study.

BACKGROUND: The ipsilateral nipple has been used as a directional guide for needle advance during internal jugular vein (IJV) catheterization. We attempted to validate the utility of the ipsilateral nipple during IJV catheterization. METHODS: One hundred and two patients scheduled for elective surgery were enrolled. In the 15° Trendelenberg position with 30° head rotation, the apex of the triangle formed by the sternocleidomastoid muscle and the clavicle was identified. The angle formed by the line connecting the apex and the ipsilateral nipple and the actual course of the IJV was measured. The distance between the apex of the anatomical triangle and the IJV center identified were measured via ultrasound. RESULTS: The angle formed by the line connecting the apex and the ipsilateral nipple and the IJV was 16 ± 7.6° and was greater in females than males (14.8 ± 1.1 vs 17.4 ± 1.0°, P = 0.043). Regression analysis showed that height, weight, gender, and age did not affect the angle as an independent factor. The apex of the anatomical triangle was 0.5 cm medial to the IJV center and was shorter in females compared to males (0.33 ± 0.12 vs 0.6 ± 0.09 cm, P = 0.039). CONCLUSION: Our study shows that when the needle is inserted at the apex of the anatomical triangle directed towards the ipsilateral nipple, it crosses the IJV at 16°. Since the common carotid artery is usually medial to the IJV, directing the needle towards the ipsilateral nipple seems to be a safe way to avoid the common carotid artery and successfully puncture the IJV.

An Analysis of Nipple Enhancement at Breast MRI with Radiologic-Pathologic Correlation.

Breast MRI is the most sensitive imaging modality for assessment of the nipple-areola complex (NAC), which is important both in cancer staging and in high-risk screening. However, the normal appearance of the nipple at MRI is not well defined because of a paucity of scientific literature on this topic. Hence, there is a lack of descriptive terminology and diagnostic criteria, which may account for the wide variability in interpretation among radiologists when assessing the NAC on MR images. In light of the current shift toward possible expanded use of abbreviated (ie, fast) breast MRI for screening in women at average risk for cancer in particular, and because an increasing number of women now undergo nipple-sparing mastectomy for therapeutic and/or prophylactic indications, careful assessment of the NAC at MRI is essential. In this article, the normal pattern of nipple enhancement at MRI is defined on the basis of findings observed in healthy individuals, normal nipple enhancement at MRI is correlated with the structural anatomy of the nipple at histopathologic analysis, and artifacts and pitfalls related to MRI of the NAC are reviewed. Understanding the normal range of nipple morphology and enhancement at MRI is important, as it enables radiologists to better differentiate between normal and abnormal nipple findings with increased diagnostic confidence. ©RSNA, 2018 See discussion on this article by Cohen and Holbrook .

Metrics of the Aesthetically Perfect Breast.

Breast surgery has long been viewed as an art more than a science. However, defining and objectively measuring the ideal breast morphology and aesthetic proportions are fundamental for surgical planning and to setting the goals of surgery as well as to evaluate surgical outcomes. Despite the fact that much has been written about aesthetic and reconstructive breast surgery, there is still no real consensus about what the attributes are of an ideal breast. Moreover, there are in fact no objective standard measurement systems and guidelines to describe ideal or even normal breast shape. Though there is great variability in the perception of beauty among patients and surgeons alike due to many factors among which are age, sex, and sociocultural background, there is common agreement that beauty is a universal phenomenon that has a universal standard present across all civilizations and centuries, and that perceived beauty is enhanced and optimal aesthetics are achieved when proper measurements are made and anthropometric proportions as well as attractive harmonious ratios are respected. The current review is an attempt to summarize the most relevant information available trying to introduce some harmony in our perception of aesthetic ideals of breast surgery. Level of Evidence V 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 .