- Email: [email protected]
Attaining symmetry in breast reconstruction
Correspondence and communications
1573
2. Donegan DJ, Kim TW, Lee G- C. Publication rates of presentations at an annual meeting of the American Academy of Orthopaedic Surgeons. Clin Orthop Relat Res; 2009 Nov 24; [Epub ahead of print]. 3. Li SF, Umemoto T, Crosley P, et al. SAEM abstracts to articles: 1997 and 1999e2001. Acad Emerg Med 2004;11:985e7. 4. Hamlet WP, Fletcher A, Meals RA. Publication patterns of papers presented at the annual meeting of the American Academy of Orthopaedic Surgeons. J Bone Joint Surg 1997;79:1138e43. 5. Peng PH, Wasserman JM, Rosenfeld RM. Factors influencing publication of abstracts presented at the AAO-HNS Annual Meeting. Otolaryngol Head Neck Surg 2006 Aug;135:197e203.
Nakul Kain Anuj Mishra Paul McArthur Warrington Road, Prescot Merseyside, Liverpool L355DR, United Kingdom E-mail address: [email protected] ª 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2010.02.024
Attaining symmetry in breast reconstruction* Sir, In breast reconstruction, attaining symmetry in size, shape, projection and position of both the breast and nipple-areolar complex is key to achieve an aesthetically pleasing outcome.1 Techniques have been described to help to achieve this symmetry.2 Often surgeons estimate symmetry or use complex measurements when marking a patient for the procedure. The footprint, conus and the envelope are the three components that need to be taken into consideration when reconstructing the breast.3 While the conus provides projection, the skin envelope is the major factor in establishing the shape of the breast.4 The envelope of the reconstructed breast depends on available native chest wall skin and the skin island of the flap used for reconstruction. Provided the scars on the chest wall are symmetrical, reconstruction involving mirror-image skin paddles helps attain symmetry of the skin envelope. In addition, final symmetry of the skin envelope is obtained by reconstructing identical nipple areolar complexes. While marking the skin paddles in bilateral breast reconstructions some surgeons try to eyeball symmetry while others use intricate measurements. The first *
This technique has been presented at the Irish Association of Plastic Surgeons Meeting, Galway, May 2009 XXXIVth Sir Peter Freyer Surgical Symposium meeting, Galway, Ireland, September 2009 International Plastic Reconstructive & Aesthetic Surgeons meeting, Delhi, November 2009.
Figure 1 (A) Flap outlined on one side and corresponding apical points marked on contra lateral side. (B) OpSite Flexigrid dressing applied to obtain an imprint (C). (D) Imprint transferred to contra lateral side, aligning the apical points. (E) Outline darkened to mark the skin paddle. (F) Breast reconstruction showing symmetrical envelopes.
1574
Correspondence and communications
Figure 2 (A) Unilateral breast and nipple reconstruction. (B) Application of the OpSite Flexigrid dressing to the normal side. The outline of the areola and centre of the nipple are marked. (C) The OpSite Flexigrid is then cut to the pattern and the central dot is used as a reference to place it on the other breast. (D) Marked areolar area is then tattooed.
approach does not necessarily produce a symmetrical skin paddle while the second approach is time consuming. We use the OpSite Flexigrid dressing to reproduce a mirror image of one side on the other, quickly and accurately. In bilateral latissimus dorsi flap breast reconstructions, we outline the desired flap size, shape and position on one side of the midline (Figure 1A). The apical points of the flap from the midline are measured and are marked equidistant on the opposite side of the midline. We then use the OpSite Flexigrid dressing to take an imprint of the marked flap (Figure 1B and C) and transfer it to the other side, aligning with the two apical points (Figure 1D). The transferred outline is then darkened with a marker pen (Figure 1E). This has helped us to harvest flaps with symmetrical skin paddles (Figure 1F) and also produce symmetrical scars on the back. Similarly, while tattooing the areola around the reconstructed nipple, the tattoo field needs to be symmetrical. The areola is not a perfect circle and has irregular borders. As a result, even if measurements are employed, precise symmetry is hard to achieve. In unilateral breast reconstructions (Figure 2A), we stick a OpSite Flexigrid dressing onto the existing areola, trace the borders onto it and mark the centre of the nipple(Figure 2B). We then cut out a template around the markings and use it to replicate the shape and size of the areola on the opposite side (Figure 2C). This helps us to achieve symmetry in the tattooed areola (Figure 2D). It is well established that a symmetrical outcome is an important parameter influencing patient satisfaction following surgery.1 Asymmetrical skin paddles will tend to give a visual illusion of asymmetry in the skin envelope even though the overall breast shape, size and volume may be
symmetrical. This described method is a simple, quick and accurate way of contributing to a symmetrical breast reconstruction.
Conflict of interest None.
References 1. Ramon Y, Ullmann Y, Moscona R, et al. Aesthetic results and patient satisfaction with immediate breast reconstruction using tissue expansion: a follow-up study. Plast Reconstr Surg 1997; 99:686e91. 2. Murray JD, Nahai F. Achieving symmetry of the reconstructed breast. Breast Dis 2002;16:107e16. 3. Blondeel PN, Hijjawi J, Depypere H, et al. Shaping the breast in aesthetic and reconstructive breast surgery: an easy three-step principle. Part IIeBreast reconstruction after total mastectomy. Plast Reconstr Surg 2009;123:794e805. 4. Hudson DA. Factors determining shape and symmetry in immediate breast reconstruction. Ann Plast Surg 2004;52:15e21.
John K. Dickson James M. Taylor Department of Plastic & Reconstructive Surgery, Royal Devon and Exeter Hospital, Barrack Road, Exeter, Devon EX2 5DW, UK Ruchika Rajan Department of Plastic & Reconstructive Surgery, Derriford Hospital, Plymouth, UK
Correspondence and communications
1575
Ajay L. Mahajan Department of Plastic & Reconstructive Surgery, Royal Devon and Exeter Hospital, Barrack Road, Exeter, Devon EX2 5DW, UK Department of Plastic & Reconstructive Surgery, Derriford Hospital, Plymouth, UK E-mail address: [email protected] ª 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2010.02.017
Correction of nipple hypertrophy: Nipple circumcision technique revisited Sir, Nipple hypertrophy can cause significant psychosocial problems and physical discomfort to the patient. Large nipples can affect a woman’s appearance. The patient may have problems with her choice of clothing, especially when wearing light clothes.1,2 The nipple-circumcision technique
Figure 1 Schematic drawing of the technique. First a circumferential incision is made approximately 5 mm above the nipple base; the second incision is made below the tip of the nipple at a level corresponding to the desired amount of reduction. The skin is deepitelized leaving the dermal layer intact. The incision is closed with 6-0 polypropylene, vertical mattress sutures.
Figure 2 Breast augmentation with implant and simultaneous nipple reduction was performed to the patient. (aeb) Preoperative views of the patient. (ced) Final results at the postoperative first year.
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2. Donegan DJ, Kim TW, Lee G- C. Publication rates of presentations at an annual meeting of the American Academy of Orthopaedic Surgeons. Clin Orthop Relat Res; 2009 Nov 24; [Epub ahead of print]. 3. Li SF, Umemoto T, Crosley P, et al. SAEM abstracts to articles: 1997 and 1999e2001. Acad Emerg Med 2004;11:985e7. 4. Hamlet WP, Fletcher A, Meals RA. Publication patterns of papers presented at the annual meeting of the American Academy of Orthopaedic Surgeons. J Bone Joint Surg 1997;79:1138e43. 5. Peng PH, Wasserman JM, Rosenfeld RM. Factors influencing publication of abstracts presented at the AAO-HNS Annual Meeting. Otolaryngol Head Neck Surg 2006 Aug;135:197e203.
Nakul Kain Anuj Mishra Paul McArthur Warrington Road, Prescot Merseyside, Liverpool L355DR, United Kingdom E-mail address: [email protected] ª 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2010.02.024
Attaining symmetry in breast reconstruction* Sir, In breast reconstruction, attaining symmetry in size, shape, projection and position of both the breast and nipple-areolar complex is key to achieve an aesthetically pleasing outcome.1 Techniques have been described to help to achieve this symmetry.2 Often surgeons estimate symmetry or use complex measurements when marking a patient for the procedure. The footprint, conus and the envelope are the three components that need to be taken into consideration when reconstructing the breast.3 While the conus provides projection, the skin envelope is the major factor in establishing the shape of the breast.4 The envelope of the reconstructed breast depends on available native chest wall skin and the skin island of the flap used for reconstruction. Provided the scars on the chest wall are symmetrical, reconstruction involving mirror-image skin paddles helps attain symmetry of the skin envelope. In addition, final symmetry of the skin envelope is obtained by reconstructing identical nipple areolar complexes. While marking the skin paddles in bilateral breast reconstructions some surgeons try to eyeball symmetry while others use intricate measurements. The first *
This technique has been presented at the Irish Association of Plastic Surgeons Meeting, Galway, May 2009 XXXIVth Sir Peter Freyer Surgical Symposium meeting, Galway, Ireland, September 2009 International Plastic Reconstructive & Aesthetic Surgeons meeting, Delhi, November 2009.
Figure 1 (A) Flap outlined on one side and corresponding apical points marked on contra lateral side. (B) OpSite Flexigrid dressing applied to obtain an imprint (C). (D) Imprint transferred to contra lateral side, aligning the apical points. (E) Outline darkened to mark the skin paddle. (F) Breast reconstruction showing symmetrical envelopes.
1574
Correspondence and communications
Figure 2 (A) Unilateral breast and nipple reconstruction. (B) Application of the OpSite Flexigrid dressing to the normal side. The outline of the areola and centre of the nipple are marked. (C) The OpSite Flexigrid is then cut to the pattern and the central dot is used as a reference to place it on the other breast. (D) Marked areolar area is then tattooed.
approach does not necessarily produce a symmetrical skin paddle while the second approach is time consuming. We use the OpSite Flexigrid dressing to reproduce a mirror image of one side on the other, quickly and accurately. In bilateral latissimus dorsi flap breast reconstructions, we outline the desired flap size, shape and position on one side of the midline (Figure 1A). The apical points of the flap from the midline are measured and are marked equidistant on the opposite side of the midline. We then use the OpSite Flexigrid dressing to take an imprint of the marked flap (Figure 1B and C) and transfer it to the other side, aligning with the two apical points (Figure 1D). The transferred outline is then darkened with a marker pen (Figure 1E). This has helped us to harvest flaps with symmetrical skin paddles (Figure 1F) and also produce symmetrical scars on the back. Similarly, while tattooing the areola around the reconstructed nipple, the tattoo field needs to be symmetrical. The areola is not a perfect circle and has irregular borders. As a result, even if measurements are employed, precise symmetry is hard to achieve. In unilateral breast reconstructions (Figure 2A), we stick a OpSite Flexigrid dressing onto the existing areola, trace the borders onto it and mark the centre of the nipple(Figure 2B). We then cut out a template around the markings and use it to replicate the shape and size of the areola on the opposite side (Figure 2C). This helps us to achieve symmetry in the tattooed areola (Figure 2D). It is well established that a symmetrical outcome is an important parameter influencing patient satisfaction following surgery.1 Asymmetrical skin paddles will tend to give a visual illusion of asymmetry in the skin envelope even though the overall breast shape, size and volume may be
symmetrical. This described method is a simple, quick and accurate way of contributing to a symmetrical breast reconstruction.
Conflict of interest None.
References 1. Ramon Y, Ullmann Y, Moscona R, et al. Aesthetic results and patient satisfaction with immediate breast reconstruction using tissue expansion: a follow-up study. Plast Reconstr Surg 1997; 99:686e91. 2. Murray JD, Nahai F. Achieving symmetry of the reconstructed breast. Breast Dis 2002;16:107e16. 3. Blondeel PN, Hijjawi J, Depypere H, et al. Shaping the breast in aesthetic and reconstructive breast surgery: an easy three-step principle. Part IIeBreast reconstruction after total mastectomy. Plast Reconstr Surg 2009;123:794e805. 4. Hudson DA. Factors determining shape and symmetry in immediate breast reconstruction. Ann Plast Surg 2004;52:15e21.
John K. Dickson James M. Taylor Department of Plastic & Reconstructive Surgery, Royal Devon and Exeter Hospital, Barrack Road, Exeter, Devon EX2 5DW, UK Ruchika Rajan Department of Plastic & Reconstructive Surgery, Derriford Hospital, Plymouth, UK
Correspondence and communications
1575
Ajay L. Mahajan Department of Plastic & Reconstructive Surgery, Royal Devon and Exeter Hospital, Barrack Road, Exeter, Devon EX2 5DW, UK Department of Plastic & Reconstructive Surgery, Derriford Hospital, Plymouth, UK E-mail address: [email protected] ª 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2010.02.017
Correction of nipple hypertrophy: Nipple circumcision technique revisited Sir, Nipple hypertrophy can cause significant psychosocial problems and physical discomfort to the patient. Large nipples can affect a woman’s appearance. The patient may have problems with her choice of clothing, especially when wearing light clothes.1,2 The nipple-circumcision technique
Figure 1 Schematic drawing of the technique. First a circumferential incision is made approximately 5 mm above the nipple base; the second incision is made below the tip of the nipple at a level corresponding to the desired amount of reduction. The skin is deepitelized leaving the dermal layer intact. The incision is closed with 6-0 polypropylene, vertical mattress sutures.
Figure 2 Breast augmentation with implant and simultaneous nipple reduction was performed to the patient. (aeb) Preoperative views of the patient. (ced) Final results at the postoperative first year.