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Patient satisfaction in breast surgery is dependent on achieving a balance among all aesthetic subunits. The purpose of this study is to identify which subunit of the breast women consider important and correlate this clinically to improve patient satisfaction following breast surgery. A total of 313 subjects (ages, 20-80) were surveyed using a 25-point survey instrument collected via a telemedicine form. The data was analyzed to determine clinical significance. Of the subjects, 63% selected the upper inner quadrant as the most important subunit. Furthermore, 66% of the subjects indicated defects located in this region would lead them to seek operative intervention and this was consistent for all subgroups. Based on these results, defects in the upper inner quadrant of the breast are more likely to cause patient dissatisfaction. Patient outcomes following surgery can be enhanced by restoring volume and minimizing scars in this upper medial subunit of the breast.

BACKGROUND Techniques in breast reconstruction have vastly improved with natural feeling, aesthetically pleasing breasts created through transfer of free or pedicled tissue. Traditional flap designs incorporate a skin paddle that leaves a "patch," which can be fairly large on the nouveau breast, clearly delineating the boundaries between the reconstruction and the native skin. In this article, the authors discuss the operative technique and present a clinical series of patients undergoing the periareolar advancement flap procedure. This technique reduces the skin paddle either to a circumferential areola-size area onto which the nipple can be simultaneously reconstructed (type I) or a single linear scar (type II) across the breast mound, thus enhancing the aesthetic appearance of the reconstructed breast. METHODS A retrospective review of all patients between 2007 and 2009 undergoing periareolar advancement flaps under the care of the senior author (M.S.C.) was performed. Type of reconstruction, staging of procedures, additional operations, and complications were recorded. RESULTS Fifteen patients had a type I procedure and six patients had a type II procedure. There were no major complications. One patient had minor nipple scabbing that resolved. All type I patients had concomitant nipple reconstructions at the time of their periareolar advancement flap. CONCLUSIONS The periareolar advancement flap is a useful technique to include in the range of secondary revision procedures for further refinement of autologous breast reconstruction. It results in a sensate, more aesthetically pleasing breast. It has low complication rates and can be performed at the same time as a nipple reconstruction in type I patients. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.

Despite many modifications to the extended latissimus dorsi flap, its use in autologous breast reconstruction remains limited because of insufficient volume and donor-site morbidity. Through a detailed analysis of the deposition of back fat, this study describes a low transverse extended latissimus dorsi flap harvest technique that increases flap volumes and improves donor-site aesthetics.Eight fresh cadaver hemibacks were used to identify the anatomical location of the fat compartments. Correlation between the fat compartments and the fat folds was made using photographic analysis of 216 patients. Retrospective case note review was conducted of all patients who had a low transverse extended latissimus dorsi flap performed by the senior author (M.S.-C.).Cadaveric dissection and photographic analysis confirmed the presence of the four distinct fat compartments in the back. The lower compartments 3 and 4 were the most frequently identified and the largest, with mean values of 367 cm and 271 cm, respectively. The clinical series comprised eight high-body mass index patients who underwent 12 pure autologous breast reconstructions using the low transverse skin paddle harvest technique. Donor-site complications included partial dehiscence (n=2) and minor infection (n=3). There were no instances of seroma, and fat necrosis (5 percent) occurred in one breast.The low transverse skin paddle extended latissimus dorsi flap is reliable and provides sufficient volume for purely autologous breast reconstruction with low donor-site morbidity and improved body contouring for a select group of patients. The authors' initial experience with high-body mass index patients shows promising results with this flap in a challenging group.

Breast reconstruction using the deep inferior epigastric perforator (DIEP) flap is becoming more common and can help reduce donor site morbidity. The authors proposed that dissection of the deep inferior epigastric artery (DIEA) and vein (DIEV) to their external iliac source may not be required for safe flap transfer.Sixteen whole fresh cadaveric hemiabdomens were used to dissect transverse abdominal-based flaps. Latex injection of the DIEA system was carried out, and the diameters of the DIEA/DIEV vessels were assessed at various points along the course of the pedicle from the origin to the perforator. A clinical study of 26 patients who underwent a short and ultrashort pedicle DIEP flaps was carried out.The average DIEA and DIEV vessel diameters were relatively similar from the external iliac origin to a point just caudal to the bifurcation. At the lateral rectus edge, the average DIEA diameter was 3.2 mm, and the DIEV diameter was 3.1 mm. The average pedicle length obtained with classic DIEP dissection was 16.9 cm, short-pedicle DIEP dissection 10.4 cm, ultrashort technique 8.1 cm, and free TRAM technique 6.5 cm. Venous injection study demonstrated rich venous interconnections between both venae comitantes. In their clinical study, the authors were able to achieve average pedicle lengths of 11.0 cm when transecting cranial to the lateral edge of the rectus, with average diameters of 2.5 mm (artery) and 2.9 mm (vein).Transection of the DIEA/DIEV pedicle at the lateral rectus edge or more proximally is safe and can help reduce operative time and donor-site morbidity.Therapeutic, IV.

The transverse myocutaneous gracilis flap has traditionally been used to reconstruct smaller breasts. The authors have been performing autologous breast reconstruction utilizing the flap with two types of modifications to increase flap volume: an extended and a vertical extended flap. In this article, they discuss the different operative techniques and present a clinical series of both flap types.A retrospective review of all patients undergoing either flap modification under the senior author (M.S.-C.) was performed. Data collated included pedicle artery and vein diameters, flap weight, and patient complications.Twenty-four transverse myocutaneous gracilis flaps were performed: 12 extended (seven patients) and 12 vertical flaps (six patients). The vertical group trended to have greater flap weights than the extended group. Mean flap weight was 385.75 g (range, 181 to 750 g) for the extended group and 469.75 g (range, 380 to 605 g) for the vertical group (p = 0.06). Mean arterial diameter of the medial circumflex artery was 1.9 mm (range, 1.5 to 2.0 mm), mean venous diameter was 2.4 mm (range, 2.0 to 3.5 mm), and mean pedicle length was 6.8 cm (range, 6.0 to 7.0 cm). All donor sites were closed primarily. Complications included seroma (n = 1), wound dehiscence (n = 2), and partial flap loss (n = 2).Modifications of the transverse myocutaneous gracilis flap increase flap volume and can be useful in patients who do not wish to have abdomen, buttock, or back scars. Donor-site scars can be concealed, and patients have the added benefit of a thigh lift. Complications are comparable to those found with other reconstructive options.Therapeutic, III.

Summary Fullness in the lateral thoracic area following breast reconstruction can be a source of concern for patients. This redundant tissue creates disharmony between the newly reconstructed breast, the lateral mammary fold, and the lateral thoracic compartment. In this article we present the results of our anatomical/histological study, discuss the operative technique and present a clinical series of patients who underwent this procedure. Methods Cadaveric Anatomical study: Dye injection studies on 4 hemi-chests to determine if the lateral thoracic fold is a separate anatomic fat compartment. Tissue from the boundaries between identified compartments was also submitted for routine H&E histological analysis. Clinical study: Retrospective case note analysis of all patients undergoing dermolipectomy performed by the senior author. Results In the analyzed cadavers, a clear line of delineation was found separating the lateral thoracic fold from the breast and adjacent structures, this was confirmed histologically. Forty patients underwent 64 dermolipectomy procedures. The average dimension of the resected specimen was 13.37 cm (range 3.0–25.0 cm) × 5.44 cm (range 1.0–12.0 cm). The mean time of dermolipectomy following initial reconstruction was 15.4 months. As the BMI increased the average resection size increased both in length ( p = 0.002) and width ( p = 0.006). There were no postoperative complications. Conclusion The lateral thoracic fold is a distinct fat compartment. Dermolipectomy following breast reconstruction is a useful adjunct and should be considered in any patient with excess skin/subcutaneous tissue in the lateral thoracic region. The procedure has a low complication rate and can be performed in conjunction with other post reconstruction refinement procedures.

Refinements made in latissimus dorsi breast reconstruction have improved the aesthetic appearance of the breast without changing the donor-site location. The optimal location for donor-site placement, from a patient's perspective, is still unknown. The purpose of this study was to assess women's preference for the latissimus dorsi donor-site location; the reasons for donor-site choice; and the correlation between donor-site location preference and factors such as, age, body mass index, body image, and clothing options.Two hundred fifty women between the ages of 20 and 80 years were surveyed. Participants analyzed patients' pictures and ranked the scar locations from most desirable to least desirable. The reason for preference and additional factors were assessed. The data were then collected and analyzed using contingency tables with p0.005.The low and middle transverse donor sites were the most preferred sites, 54 percent and 22 percent, respectively. The most common reasons for choosing a donors site were ability to conceal the scar in a low-back top and contour improvement. Women younger than 50 years were more concerned about the ability to conceal the scar (64 percent). Women older than 50 years were focused on contour improvement (40 percent) and concealing the scar while clothed (42 percent) (p0.05). No direct correlation with age, body mass index, body image, or clothing options was seen.Women overwhelmingly prefer the low and middle transverse scar locations. Physicians should consider using these locations primarily in suitable patients, as this may improve overall patient satisfaction following breast reconstruction.