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.

DIEAP Flap Patients Equally as Satisfied with the Abdomen as Abdominoplasty Patients.

BACKGROUND: The dermolipectomy of the deep inferior epigastric artery perforator (DIEAP) flap procedure is designed to give an end result as seen with abdominoplasty (AP). Several steps of an AP are, however, not routinely performed. This study compared the patient-reported outcomes between these 2 procedures with an emphasis on the abdomen. METHODS: Thirty-four patients reconstructed with a DIEAP flap (DIEAP group), and 30 patients with an AP (AP group) were asked to complete 2 study-specific questionnaires. The first questionnaire covered abdominal outcomes, whereas the second was concerned with general outcomes. RESULTS: The DIEAP group was significantly older compared with the AP group. Eighty-five percentage of the DIEAP group and 66 % of the AP group answered the questionnaires. Postoperatively, the DIEAP group was significantly more satisfied with their bodies when dressed (P = 0.009), and there was a trend of DIEAP patients being more satisfied with the appearance of the abdomen (P = 0.085). No significant difference was found comparing outcomes concerning umbilicus, muscle function, pain, scarring, and contour. The DIEAP group was more worried about their health than the AP group postoperatively (P = 0.044). AP patients had a significantly more altered body image (P = 0.016) and increased sexual desire (P = 0.003) than DIEAP patients. There was no significant difference regarding changes in self-image, social relationships, being naked with partner, and overall satisfaction. CONCLUSION: DIEAP flap patients were equally as satisfied with the abdomen as AP patients.

Donor-Site Morbidity After DIEAP Flap Breast Reconstruction-A 2-Year Postoperative Computed Tomography Comparison.

The study was undertaken to provide a more complete picture of donor-site morbidity following the deep inferior epigastric artery perforator (DIEAP) flap harvest in breast reconstruction. Most studies evaluating this subject have been performed using ultrasonography. Computed tomography (CT) might provide valuable information. METHODS: In 14 patients who were reconstructed with a DIEAP flap, donor-site morbidity was assessed by comparing routine preoperative CT abdomen with CT abdomen performed 2 years postoperatively. The anteroposterior diameter and transverse diameter (TD) of the rectus muscle were measured bilaterally within 4 standardized zones. Diastasis recti abdominis (DRA) was measured in the same zones. The abdominal wall was assessed for hernias, bulging, and seromas. RESULTS: The operated rectus muscle had a significantly increased anteroposterior diameter in 2 zones and decreased TD in 1 zone compared with preoperative measurements. Comparing the operated and nonoperated rectus muscles, the former had a significantly decreased TD in 1 zone. Supraumbilical DRA was significantly decreased with surgery, whereas infraumbilical DRA was significantly increased. No new hernias or bulging were found. Two patients had seroma formation in the abdominal wall. CONCLUSIONS: Symmetry of the 2 hemiabdomens is well preserved after DIEAP flap harvest; however, significant changes to the rectus muscles and DRA were observed. Hernia formation does not seem to be a postoperative complication of importance. The study indicates that DIEAP flaps result in limited donor-site morbidity, which for most patients does not outweigh the benefits of free perforator flap breast reconstruction.

Microcirculatory Evaluation of the Abdominal Skin in Breast Reconstruction with Deep Inferior Epigastric Artery Perforator Flap.

UNLABELLED: No studies have assessed the perfusion of the undermined abdominal skin in breast reconstruction with deep inferior epigastric artery perforator flap. A greater understanding of the procedure's impact on the perfusion of the abdominal skin can be valuable in predicting areas susceptible to necrosis. METHODS: Microcirculatory changes were monitored in the abdominal skin of 20 consecutive patients undergoing breast reconstruction with a deep inferior epigastric artery perforator flap. Quantitative mapping was performed with laser Doppler perfusion imaging at 7 set intervals. Measurements were taken and recorded within 4 standardized zones covering the skin between the xiphoid process and the upper incisional boundary of the flap (zones 1-4; cranial to caudal). RESULTS: Before commencing surgery, a significantly higher perfusion was registered in zones 3 and 4 when compared with zone 1. After undermining the abdominal skin, the perfusion in zones 1-3 increased significantly. After the abdominal closure, the perfusion dropped in all 4 zones and only the perfusion level in zone 1 remained significantly higher than preoperative mean. Postoperatively, the perfusion of each zone stabilized at a significantly higher level compared with preoperative values. No tissue necrosis was observed in any of the zones. CONCLUSIONS: Although perforators are divided during undermining of the abdominal skin, there seems to be a reactive hyperemia that exceeds the blood supply delivered by the perforators. Thus, due to microcirculatory mechanisms, the undermining of the abdomen during the procedure does not seem to present any great risk of tissue necrosis.

Extravasation injuries.

It is common for an intravascular catheter to be inserted to administer various types of therapy. Extravasation occurs frequently, and in the most severe cases plastic surgeons are often summoned to assess the extent of the injury and the possibility for reconstruction. The Department of Plastic and Reconstructive Surgery at Oslo University Hospital assesses approximately 15 severe cases of this type each year.

Monitoring microcirculatory changes in the deep inferior epigastric artery perforator flap with laser Doppler perfusion imaging.

Microcirculatory changes were monitored in 20 deep inferior epigastric artery perforator (DIEAP) flaps during unilateral breast reconstruction until the seventh postoperative day using laser Doppler perfusion imaging. Measurements were recorded according to the zonal classification by Scheflan and Dinner. The cutaneous territory zone IV was discarded during insetting due to marginal circulation. The highest perfusion levels were found the first postoperative day for both zones I and III. Postoperative perfusion values were significantly higher for these zones compared with zone II. Immediately after revascularization, zone I was significantly better perfused than both II and III. However, the perfusion in zone III stabilized at the level of zone I in the postoperative phase. Evaluating microcirculatory changes in the DIEAP flap with laser Doppler perfusion imaging showed that zones I and III have higher perfusion levels than zone II in the postoperative phase.

Donor site sensitivity after breast reconstruction with deep inferior epigastric artery perforator flap.

The aim of this study was to examine pressure sensitivity at the donor site after breast reconstruction with deep inferior epigastric artery perforator (DIEAP). In a cross-sectional survey, 2 groups of patients were analyzed. The DIEAP group consisted of 30 women who had previously had secondary breast reconstruction with DIEAP flap after mastectomy for breast cancer. The control group consisted of 7 women with no previous abdominal incisions planned for secondary breast reconstruction with DIEAP. Pressure thresholds were tested within the margins of the abdominal wall using Semmes-Weinstein monofilaments. In the DIEAP group a pattern of higher pressure thresholds was observed in the proximity of the scar. Comparing the 2 groups, significant higher pressure thresholds were found in the DIEAP group in the scar on both sides and in the midline from the scar to the umbilical level. Our data show that the abdominoplasty performed during breast reconstruction with DIEAP reduces cutaneous sensitivity in the donor site area.

[40 years of silicone breast implants]. / Silikonbrystimplantater gjennom 40 år.

BACKGROUND: It is estimated that approximately 50,000 Norwegian women have silicone breast implants following breast augmentation or breast reconstruction. Their numbers are growing and doctors will more often be confronted with the health problems related to these implants. MATERIAL AND METHODS: This review is based on information retrieved from Medline and our clinical experience. RESULTS AND INTERPRETATION: The modern silicone breast implant is the product of four decades of development. The ongoing debate on health problems associated with the implants has been a vibrant stimulator for research, but a causal relationship between implants and the development of breast cancer and autoimmune defects has not been found. The implants are not, however, without complications; more research is required in order to improve the implants and for quality assurance of treatment and follow up.

[Breast reconstruction following mastectomy]. / Brystrekonstruksjon etter mastektomi.

BACKGROUND: Breast cancer is the most common cancer in women, many of whom feel less feminine after the loss of a breast. Breast reconstruction can strengthen their self image, hence it is an excellent treatment option for those who have had a mastectomy. MATERIAL AND METHODS: This review is based on information retrieved from Medline and on clinical experience. We have also asked all departments of plastic surgery in Norway which methods of breast reconstruction they are using. RESULTS AND INTERPRETATION: Breast reconstruction following mastectomy is performed by plastic surgeons and if necessary in cooperation with breast surgeons. The missing breast can be reconstructed with an implant, autologous tissue or by combining the two methods. Many years of experience have resulted in high standards within reconstructive breast surgery. In Norway breast reconstruction is performed in every department of plastic surgery.

[Keloid and hypertrophic scars]. / Keloid og hypertrofisk arrdanning.

BACKGROUND: Keloid and hypertrophic scars develop most frequently in wounds with high skin tension and especially on the upper truncus. Both are characterized by an excessive dysfunctional collagen metabolism. MATERIAL AND METHODS: The article presents data from research in current literature and discuss the treatment of keloid and hypertrophic scars. RESULTS AND INTERPRETATION: Patients that are undergoing elective surgery should be handled with surgical techniques that reduce wound closing tension. Patients who are at high-risk or show excessive scar development should follow standard treatment. First-line therapy is silicone sheeting and/or pressure. In case of minimal response, steroid injections should be started after two months. The patient must be re-evaluated for a surgical approach combined with conservative treatment if the result is unsatisfactory after 12 months.