Brassiere Cup Size Agreement between Patients and Plastic Surgeons: Do Surgeons and Patients Speak the Same Size Language?

Patients undergoing plastic surgery of the breasts often communicate their size expectations as a brassiere cup size. However, multiple factors may cause a miscommunication between the surgeon and patient when brassiere cup size is used as a measure of results. The aim of this study was to determine the degree of agreement between disclosed and estimated brassiere cup size and also interrater agreement. Methods: Three-dimensional (3D) scans of 32 subjects were evaluated by 10 plastic surgeons estimating cup size using the American brassiere system. The surgeons were blinded to all parameters, including the 3D surface software-derived volume measures of the Vectra scan. The 3D scans of the anterior torsos were viewed. The plastic surgeons' estimations were compared with the cup sizes stated by the subjects (disclosed cup size), using simple and weighted Kappa statistics. Results: Agreement between the estimated and disclosed brassiere sizes was only slight (0.1479 ± 0.0605) using a simple Kappa analysis. Even when a Fleiss-Cohen-weighted comparison was used, only moderate agreement (0.6231 ± 0.0589) was found. The interrater agreement intraclass correlation coefficient was 0.705. Rater accuracy varied. The percentage of time spent in cosmetic practice and gender were not significantly correlated with accuracy. Conclusions: Agreement between cup size disclosed by subjects and estimates by plastic surgeons was low. A miscommunication between the surgeon and patient may occur when using brassiere sizes to communicate wishes and estimates in procedures that involve changes in breast volume.

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.

Development of Machine Learning Algorithms for the Prediction of Financial Toxicity in Localized Breast Cancer Following Surgical Treatment.

PURPOSE: Financial burden caused by cancer treatment is associated with material loss, distress, and poorer outcomes. Financial resources exist to support patients but identification of need is difficult. We sought to develop and test a tool to accurately predict an individual's risk of financial toxicity based on clinical, demographic, and patient-reported data prior to initiation of breast cancer treatment. PATIENTS AND METHODS: We surveyed 611 patients undergoing breast cancer therapy at MD Anderson Cancer Center. We collected data using the validated COmprehensive Score for financial Toxicity (COST) patient-reported outcome measure alongside other financial indicators (credit score, income, and insurance status). We also collected clinical and perioperative data. We trained and tested an ensemble of machine learning (ML) algorithms (neural network, regularized linear model, support vector machines, and a classification tree) to predict financial toxicity. Data were randomly partitioned into training and test samples (2:1 ratio). Predictive performance was assessed using area-under-the-receiver-operating-characteristics-curve (AUROC), accuracy, sensitivity, and specificity. RESULTS: In our test sample (N = 203), 48 of 203 women (23.6%) reported significant financial burden. The algorithm ensemble performed well to predict financial burden with an AUROC of 0.85, accuracy of 0.82, sensitivity of 0.85, and specificity of 0.81. Key clinical predictors of financial burden from the linear model were neoadjuvant therapy (ßregularized, .11) and autologous, rather than implant-based, reconstruction (ßregularized, .06). Notably, radiation and clinical tumor stage had no effect on financial burden. CONCLUSION: ML models accurately predicted financial toxicity related to breast cancer treatment. These predictions may inform decision making and care planning to avoid financial distress during cancer treatment or enable targeted financial support. Further research is warranted to validate this tool and assess applicability for other types of cancer.

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.

Robotic harvest of the latissimus dorsi muscle: laboratory and clinical experience.

Minimally invasive harvest of the latissimus dorsi (LD) muscle is a desirable goal because of both the wide utility of this muscle and the length of incision required to harvest it. In this study, robotic harvest of the LD muscle was evaluated in a cadaver model and clinical series. Ten LD flaps were robotically harvested in eight cadavers. Positioning, port placement, procedural steps, instrumentation, and technical obstacles were all critically analyzed and reported. After modifying the technique based on experience gained in the cadaver study, eight LD muscles were robotically harvested and transferred in eight patients. Access included a short axillary incision and two additional port sites along the anterior border of the muscle. Insufflation was used to maintain the optical cavity. Indications included pedicled flaps for implant-based breast reconstruction and free flaps for scalp reconstruction. All flaps were successfully transferred without converting to open technique. In the clinical series, average time for setup and port placement was 23 minutes, and average robotic time was 1 hour and 51 minutes. There were no major complications. Robotic harvest of the LD is feasible and effective and permits full muscle harvest without a visible incision.

The survival curve: factors impacting the outcome of free flap take-backs.

BACKGROUND: When vascular compromise is detected, a free flap is immediately taken back to the operating room for attempted salvage. Which factors predict the success or failure of a take-back is currently unknown. METHODS: A review of free flaps performed at a single institution over the last 10 years was performed. A total of 4965 flaps were identified, and an analysis of factors predicting salvage or failure of first, second, and third take-backs for microvascular complications was performed. RESULTS: Of 4965 flaps, 517 (10.3 percent) required return to the operating room, 157 (3.34 percent) for vascular complications. There were 66 (1.41 percent) total flap failures. Of 157 take-backs, 102 required return once, 44 twice, and 11 three times, with salvage rates of 72, 34, and 27 percent, respectively (p < 0.01). Overall salvage rate was 58 percent. The probability of a flap going back for a second time was 35 percent. Risks for flap failure included thrombotic (35.1 percent) versus mechanical (8 percent) etiology (p = 0.01) and arterial (37.5 percent) or mixed (61.5 percent) versus venous only (25 percent) etiology (p = 0.06). Failure was more likely the greater number of days postoperatively the take-back occurred (p = 0.02). CONCLUSIONS: The number of returns to the operating room is inversely proportional to flap salvage. Mechanical and venous etiologies tend to result in salvage and arterial and thrombotic etiologies in failure. Earlier take-backs are more likely to be successful. Knowledge of these predictors of salvage should guide clinical decision making and informed consent. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Long-term results following fronto-orbital reconstruction in nonsyndromic unicoronal synostosis.

BACKGROUND: Fronto-orbital reconstruction is the standard of care for repair of unilateral coronal synostosis. This study examined the relationship between age at initial surgery and need for secondary surgery, to determine the optimal age for reconstruction. METHODS: The series comprised 81 patients with unicoronal synostosis who underwent reconstruction over a 30-year period by a single surgeon. Measured outcomes included reoperation rate, relapse/defect rate, relapse interval, and problem rate. RESULTS: Average age at surgery was 11.3 months (range, 1.5 to 71 months). The problem rate was 27.2 percent. Mean follow-up was 69 months (range, 6 to 234 months). The postoperative defect rate was 73 percent. Sixteen patients (20 percent) underwent reoperation to correct secondary deformities. Whitaker category I or II results were achieved in 90.1 percent. Problem rates for patients aged 0 to 6 months, 6 to 12 months, and older than 12 months were 13.3, 28, and 35, respectively. Secondary surgery was performed in 40 percent of patients whose first surgery was at 0 to 6 months, 7 percent aged 6 to 12 months, and 30.4 percent older than 12 months. After surgery, 87 percent of patients aged 0 to 6 months, 95 percent aged 6 to 12 months, and 87 percent older than 12 months had Whitaker category I or II results. CONCLUSIONS: Fronto-orbital advancement at younger than 6 months had the highest incidence of readvancement. Patients treated at 6 to 12 months had the least need for any secondary surgery; however, patients older than 12 months had the lowest incidence of readvancement. These results indicate that fronto-orbital advancement should be delayed until at least age 6 months to avoid relapse.

Aesthetics of facial skeletal surgery.

Orthognathic surgical planning should derive primarily from aesthetic considerations, and these should be based not on rigid cephalometric and anthropometric norms but on the surgeon's aesthetic sense. The historic goals of orthognathic surgery have addressed both stability and aesthetics. Stability relates to establishing a healthy, functional occlusion; aesthetic goals have focused on normalizing facial balance and proportions. With the advent of rigid fixation and bone graft substitutes, sacrificing facial aesthetics to attain stability and achieve a normal occlusion is no longer necessary. Orthognathic surgery now can be envisioned truly as aesthetic surgery.