Olivier A. Branford

Population analysis of the perfect breast: a morphometric analysis.

Background: The authors previously identified key objective parameters that define the aesthetic ideal of the breast in a study of 100 models with natural breasts. In this follow-up article, the opinion of the general public on ideal breast proportions was surveyed. Methods: One thousand three hundred fifteen respondents were asked to rank the attractiveness of images of four women with varying breast sizes. Each of the women’s breasts were morphed into four different proportions. One of the key features was the upper pole–to–lower pole percentage proportion, corresponding to ratios of 35:65, 45:55, 50:50, and 55:45. Rankings were analyzed according to population demographics. Effects of age, sex, nationality, and ethnicity were evaluated. The responses of 53 plastic surgeons were included. Results: Breasts with an upper pole–to–lower pole ratio of 45:55 were universally scored highest, in particular, by 87 percent of women in their thirties (n = 190), 90 percent of men (n = 655), 94 percent of plastic surgeons (n = 53), 92 percent of North Americans (n = 89), 95 percent of South Americans (n = 23), 86 percent of Europeans (n = 982), 87 percent of Caucasians (n = 1016), and 87 percent of Asians (n = 209). Conclusions: This study reaffirms the authors’ previous findings that the 45:55 ratio has universal appeal in defining the ideal breast. The authors propose that this proportion should be used as a basis for design in aesthetic surgery.

Design for Natural Breast Augmentation: The ICE Principle.

Background: The authors’ published studies have helped define breast beauty in outlining key parameters that contribute to breast attractiveness. The “ICE” principle puts design into practice. It is a simplified formula for inframammary fold incision planning as part of the process for determining implant selection and placement to reproduce the 45:55 ratio previously described as fundamental to natural breast appearance. The formula is as follows: implant dimensions (I) − capacity of the breast (C) = excess tissue required (E). The aim of this study was to test the accuracy of the ICE principle for producing consistent natural beautiful results in breast augmentation. Methods: A prospective analysis of 50 consecutive women undergoing primary breast augmentation by means of an inframammary fold incision with anatomical or round implants was performed. The ICE principle was applied to all cases to determine implant selection, placement, and incision position. Changes in parameters between preoperative and postoperative digital clinical photographs were analyzed. Results: The mean upper pole–to–lower pole ratio changed from 52:48 preoperatively to 45:55 postoperatively (p < 0.0001). Mean nipple angulation was also statistically significantly elevated from 11 degrees to 19 degrees skyward (p ⩽ 0.0005). Accuracy of incision placement in the fold was 99.7 percent on the right and 99.6 percent on the left, with a standard error of only 0.2 percent. There was a reduction in variability for all key parameters. Conclusion: The authors have shown using the simple ICE principle for surgical planning in breast augmentation that attractive natural breasts may be achieved consistently and with precision. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Role of reconstructive surgery in the management of head and neck cancer: A national outcomes analysis of 11,841 reconstructions

BACKGROUND The quality of head and neck cancer reconstruction in England is not known. Hospital administrative data provides details of treatment within the English National Health Service and may be used for national outcomes analysis. METHODS An algorithm for identifying head and neck surgery with flap-based reconstruction from administrative data was constructed and validated against information from three cancer units. The validated algorithm was applied to 2003-2013 national activity. RESULTS The algorithm was 91% sensitive and over 99% specific. Its application to administrative data identified 11,841 patients and demonstrated an increase of 52% in reconstruction-containing head and neck cancer surgery in the past decade. There were 7776 males and mean treatment age was 62 years. Oral cavity was the commonest primary site (n = 7567; 64%) and 7575 patients (64%) underwent primary surgery. The commonest procedure was floor-of-mouth excision (n = 3614) and 9749 patients had a neck dissection. The most commonly used flap was the radial forearm (n = 4429). Flap failure occurred in 496 (4.2%) patients. It increased the mean length of stay from 22 to 41 days (P < 0.00001), and the odds ratio of in-hospital death to 2.37 [95% confidence interval 1.66-3.38; P < 0.0001]. Lethality of reconstructive failure was not uniform and was highest when a pharyngolaryngeal flap failed. CONCLUSIONS Reconstructive surgery is central to the multidisciplinary management of head and neck cancer. Its quality directly influences patient morbidity and survival. We recommend that analysis of hospital administrative data should be periodically carried out as part of an over-arching quality assurance programme and, particularly for pharyngolaryngeal reconstructions, surgery should be undertaken in units with the best reconstructive outcomes.

Free flap survival after traumatic pedicle avulsion in an obese diabetic patient

wall reconstruction: a comparison of flap and mesh closure. Ann Surg 2000;232:586e96. 4. Bleichrodt RP, Simmermacher RK, van der Lei B, et al. Expanded polytetrafluoroethylene patch versus polypropylene mesh for the repair of contaminated defects of the abdominal wall. Surg Gynecol Obstet 1993;176:18e24. 5. Ramirez OM, Ruas E, Dellon AL. ‘‘Components separation’’ method for closure of abdominal-wall defects: an anatomic and clinical study. Plast Reconstr Surg 1990;86:519e26. 6. Maas SM, de Vries RS, van Goor H, et al. Endoscopically assisted ‘‘components separation technique’’ for the repair of complicated ventral hernias. J Am Coll Surg 2002;194:388e90. 7. Vargo D. Component separation in the management of the difficult abdominal wall. Am J Surg 2004;188:633e7. 8. Sukkar SM, Dumanian GA, Szczerba SM, et al. Challenging abdominal wall defects. Am J Surg 2001;181:115e21. 9. Ewart CJ, Lankford AB, Gamboa MG. Successful closure of abdominal wall hernias using the components separation technique. Ann Plast Surg 2003;50:269e73 [discussion 73e4]. 10. de Vries Reilingh TS, van Goor H, Rosman C, et al. ‘‘Components separation technique’’ for the repair of large abdominal wall hernias. J Am Coll Surg 2003;196:32e7. 11. Ramirez OM. Inception and evolution of the components separation technique: personal recollections. Clin Plast Surg 2006; 33:241e6. vi. 12. Thomas III WO, Parry SW, Rodning CB. Ventral/incisional abdominal herniorrhaphy by fascial partition/release. Plast Reconstr Surg 1993;91:1080e6. 13. Voigt M, Andree C, Galla TJ, et al. Reconstruction of abdominal-wall midline defects e the abdominal-wall components separation. Zentralbl Chir 2001;126:1000e4. 14. Reid RR, Dumanian GA. Panniculectomy and the separation-ofparts hernia repair: a solution for the large infraumbilical hernia in the obese patient. Plast Reconstr Surg 2005;116: 1006e12. 15. Dumanian GA, Denham W. Comparison of repair techniques for major incisional hernias. Am J Surg 2003;185:61e5. 16. Girotto JA, Ko MJ, Redett R, et al. Closure of chronic abdominal wall defects: a long-term evaluation of the components separation method. Ann Plast Surg 1999;42:385e94 [discussion: 94e95]. 17. Howdieshell TR, Proctor CD, Sternberg E, et al. Temporary abdominal closure followed by definitive abdominal wall reconstruction of the open abdomen. Am J Surg 2004;188:301e6. 18. Schecter WP, Ivatury RR, Rotondo MF, et al. Open abdomen after trauma and abdominal sepsis: a strategy for management. J Am Coll Surg 2006;203:390e6. 19. van Geffen HJ, Simmermacher RK, van Vroonhoven TJ, et al. Surgical treatment of large contaminated abdominal wall defects. J Am Coll Surg 2005;201:206e12.

PET-CT imaging in patients with chronic sternal wound infections prior to reconstructive surgery: A case series

Late presenting and recurrent sternal wound infections post-sternotomy are difficult to treat, with the clinical picture not necessarily reflecting the underlying problem. As a result of our experience, we suggest that these chronic cases should be managed using a different algorithm to acute sternal wound infection. Positron emission tomography combined with computerized tomography (PET-CT) imaging may be potentially useful in enabling accurate localization of disease sites, which guides adequate debridement prior to definitive reconstruction. It may also allow for disease surveillance and monitoring of the response to antimicrobial treatment. We present three cases which support the need for pre-operative imaging using PET-CT.

Subfascial harvest of the extended latissimus dorsi myocutaneous flap in breast reconstruction: a comparative analysis of two techniques.

Background: Widespread adoption of the extended latissimus dorsi myocutaneous flap in breast reconstruction has been limited by donor-site complications. The dissection plane may be either above or below the superficial layer of the thoracolumbar fascia, which may be transferred with the flap or retained on the back skin flaps. The aim of this study was to investigate whether varying the plane of dissection improves donor-site morbidity and complications. Methods: A comparative analysis of consecutive women treated with extended latissimus dorsi myocutaneous breast reconstruction by a single surgeon (D.F.) between 2006 and 2012 was performed. Results: Eighty patients were reviewed. Between 2006 and 2011, 47 patients were treated with traditional suprafascial harvest (group A); the subsequent 33 patients between 2011 and 2012 had subfascial harvest (group B), retaining the superficial fascia on the back skin flaps. When compared with group A, group B patients showed significant reduction in both mean number of seroma drainage events (p = 0.027) and mean total aspirated seroma volume, which was reduced by half (p = 0.006). Group B patients also reported significant reduction in donor-site pain (p = 0.041) and donor-site scar adherence to the chest wall (p = 0.026). No increases in flap or donor-site dehiscence, partial flap loss, or other minor or major complications were observed. Conclusion: The technique of subfascial harvest during autologous latissimus dorsi flap breast reconstruction significantly improves back donor-site morbidity without compromising flap survival. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Reply: Population Analysis of the Perfect Breast

643e Reply: Population Analysis of the Perfect Breast: A Morphometric Analysis Sir: We welcome Dr. Swanson’s comments regarding our recent publication. We have some reservations, however, with the title of his correspondence and the evidence presented within. His communication is entitled “Ideal Breast Shape: Women Prefer Convexity and Upper Pole Fullness.” This statement chooses to completely ignore the findings of the population study published in the peer-reviewed article in this Journal.1 It is a statement based on personal opinion backed by no evidence. It is stated in his correspondence that “Mallucci and Branford promote four critical ideals of breast beauty” and that “The authors prefer a linear or slightly concave upper pole.” The whole point of the population study was to ask a highly mixed population for their opinion—the results are not an expression of our (the authors’) opinions, they are those of the population questioned. The editor of this Journal has produced a breast reduction (pseudoptosis).8 With gradual inferior glandular displacement, this unnatural appearance is likely to become worse with time. What are the practical implications of such considerations? Physics and gravity dictate that the lower pole will assume a convex shape.5 Therefore, maintenance of lower pole convexity2 is unnecessary. Adequate resection of lower pole breast tissue during a mammaplasty (mastopexy, augmentation/mastopexy, or reduction) avoids a persistent lower pole bulge.9 When treating women with breast ptosis, the surgeon’s objective is to restore upper pole fullness and tighten the lower poles.9,10 If a patient lifts her breasts with the cups of her hands and says, “this is what I want,” she is likely to be best served with an augmentation/mastopexy.10 The preferred contour of the lower pole immediately after a properly performed vertical mammaplasty should be almost linear on a lateral view, not convex. It will always round out. Nipple overelevation should be avoided.8–10 Measurements reveal that after breast augmentation, the mean breast parenchymal ratio measures 1.61 on the right and 1.72 on the left.10 After augmentation/mastopexy, these ratios measure 1.68 and 1.78, respectively.10 Such ratios are approximately double the authors’ recommendation; however, these women consistently report high levels of satisfaction and improved quality of life.3,4 Notably, the mean preoperative breast parenchymal ratios for women with ptosis undergoing mastopexies are 0.76 and 0.89,10 very similar to the authors’ preferred ratio of 0.82. In summary, the plastic surgeon is best advised to aim for convex upper poles, tight lower poles, and a breast parenchymal ratio that favors upper pole fullness and convexity. These goals are the opposite of those advocated by the authors.1,2 Few patients complain of excessive perkiness more than a few months after a mammaplasty. The authors promote shaped implants.1 Interestingly, at a recent meeting,11 plastic surgeons in the audience were unable to discern from photographs which patients had shaped implants and which did not. Ironically, the ratio of correct to incorrect responses was 45:55. Shaped implants preferentially increase lower pole volume, accommodating the surgeon’s preference, but not the patient’s.6 Whether shaped implants offer advantages in cosmetic breast augmentation awaits evaluation by patients. DOI: 10.1097/PRS.0000000000001085