Correlation Between Scoliosis and Breast Asymmetries in Women Undergoing Augmentation Mammaplasty

Article (PDF Available)inAesthetic Plastic Surgery 34(3):374-80 · April 2010with 1,584 Reads
DOI: 10.1007/s00266-010-9506-x · Source: PubMed
Abstract
Breast asymmetries and scoliosis influence the results of augmentation mammaplasty. Although a variety of methods have been proposed to resolve breast asymmetries, to date, no simple preoperative algorithm has been proposed for predicting the breast volume and decreasing breast asymmetries in the place of subjective or expensive evaluation. The relationship between the scoliosis and breast volume asymmetry was further analyzed statistically in this study. The study enrolled 60 scoliotic patients from 780 patients undergoing augmentation mammaplasty between January 2000 and March 2008. The average follow-up period was 2 years. The inclusion criteria required hypoplastic breasts, a difference in bilateral breast volumes greater than 20 ml, and scoliosis with a Cobb angle greater than 10 degrees . The authors' surgical algorithm demonstrated an anthropomorphic equation for predicting breast volume and selecting the correct implant size. Pearson regression analysis showed that the breast volume asymmetry difference was significantly correlated with the severity of scoliosis (Cobb angle) (correlation coefficient, 0.901). No correlation between the difference in pre- and postoperative nipple and inframammary levels and the severity of scoliosis was noted. Augmentation mammaplasty significantly decreased the breast asymmetry differences (volume and nipple level) (p < 0.001). The average preoperative estimated breast volume was 45.3 ml for the smaller breast and 88.4 ml for the larger breast. This study found that the severity of scoliosis showed significant correlation with the breast volume asymmetry differences. Augmentation mammaplasty for breast asymmetries decreased not only the volume difference but also the difference in nipple levels.
ORIGINAL ARTICLE
Correlation Between Scoliosis and Breast Asymmetries in Women
Undergoing Augmentation Mammaplasty
Feng-Chou Tsai Ming-Shium Hsieh
Chuh-Kai Liao Shu-Ting Wu
Received: 10 February 2010 / Accepted: 17 March 2010 / Published online: 10 April 2010
ÓSpringer Science+Business Media, LLC and International Society of Aesthetic Plastic Surgery 2010
Abstract
Background Breast asymmetries and scoliosis influence
the results of augmentation mammaplasty. Although a
variety of methods have been proposed to resolve breast
asymmetries, to date, no simple preoperative algorithm has
been proposed for predicting the breast volume and
decreasing breast asymmetries in the place of subjective or
expensive evaluation. The relationship between the scoli-
osis and breast volume asymmetry was further analyzed
statistically in this study.
Methods The study enrolled 60 scoliotic patients from
780 patients undergoing augmentation mammaplasty
between January 2000 and March 2008. The average fol-
low-up period was 2 years. The inclusion criteria required
hypoplastic breasts, a difference in bilateral breast volumes
greater than 20 ml, and scoliosis with a Cobb angle greater
than 10°. The authors’ surgical algorithm demonstrated an
anthropomorphic equation for predicting breast volume
and selecting the correct implant size.
Results Pearson regression analysis showed that the
breast volume asymmetry difference was significantly
correlated with the severity of scoliosis (Cobb angle)
(correlation coefficient, 0.901). No correlation between the
difference in pre- and postoperative nipple and inframam-
mary levels and the severity of scoliosis was noted. Aug-
mentation mammaplasty significantly decreased the breast
asymmetry differences (volume and nipple level)
(p\0.001). The average preoperative estimated breast
volume was 45.3 ml for the smaller breast and 88.4 ml for
the larger breast.
Conclusion This study found that the severity of scoliosis
showed significant correlation with the breast volume
asymmetry differences. Augmentation mammaplasty for
breast asymmetries decreased not only the volume differ-
ence but also the difference in nipple levels.
Keywords Augmentation mammaplasty
Breast asymmetries Implant Scoliosis
Augmentation mammaplasty is a popular aesthetic proce-
dure in Asia. Surgeons are always asked to select breast
implants of an appropriate size and type when performing
augmentation mammaplasty. It is difficult to achieve this
goal if the surgeon intends to attempt correction of the
hypoplastic breast based on a subjective judgment or cer-
tain guidelines without objective preoperative or at least
intraoperative evaluation [1]. Because the breast is a three-
dimensional structure, substantial data or customization is
needed for sculpting of the breast to the desired shape using
surgical techniques or materials.
Apart from these inherent limitations, Rohrich et al. [2]
have described how breast and chest wall asymmetries (i.e.,
breast mound volume, inframammary fold position,
F.-C. Tsai (&)S.-T. Wu
Division of Plastic Surgery, Department of Surgery, Center
for Mathematical Biology, Taipei Medical University Hospital,
Taipei Medical University, 252, Wu Hsing Street,
Taipei 110, Taiwan
e-mail: biopattern@gmail.com
M.-S. Hsieh
Department of Orthopedic Surgery, Taipei Medical University
Hospital, Taipei Medical University, Taipei, Taiwan
e-mail: mediplasty@gmail.com
C.-K. Liao
Department of Family and Community Medicine, Cardinal Tien
Hospital, College of Medicine, Fu Jen Catholic University,
Taipei, Taiwan
e-mail: m013089004@tmu.edu.tw
123
Aesth Plast Surg (2010) 34:374–380
DOI 10.1007/s00266-010-9506-x
nipple–areola complex size and position, scoliosis, pectus
excavatum/carinatum, rib flaring, and the like) make the
aforementioned problems even more complex. Of these,
scoliosis is the most frequently encountered congenital
deformity of the spine in Asia, the other two being ky-
phosis and lordosis [35]. Heavy schoolwork and school-
bags may contribute to the greater prevalence of scoliosis
in Asian children and adolescent girls.
In most cases, the exact diagnosis of scoliosis is inci-
dental to routine X-rays (e.g., chest X-rays) for other rea-
sons such as respiratory problems or abdominal pain. Due
to patient safety and medical law in many countries, chest
X-ray examination is routinely performed for preoperative
and anesthetic assessment. This has offered an optimal
opportunity for a preoperative evaluation of scoliosis in
this study without additional costs.
Although patients with breast asymmetries in Taiwan do
not necessarily experience scoliosis in our clinical practice,
patients with scoliosis are always afflicted to some degree by
breast asymmetries. In this study we aimed to determine the
interplay between scoliosis and the breasts to find an effi-
cient way to resolve breast differences in scoliotic patients.
Many surgical plans for breast asymmetries in the liter-
ature focus on image evaluation, incidence, case reports,
techniques, and guidelines [68]. However, estimation of
breast volume is the most important issue because the choice
of implants affects the outcome. It also affects cost control
by decreasing the chance that the wrong size implants will be
opened during the operation. Optimal results are difficult to
obtain if no objective methods are available.
Several objective solutions for pre- or intraoperative
breast volume estimation have been proposed. For instance,
intraoperative temporary breast implant sizers allow sur-
geons to make more accurate implant selections. Ideally,
the patient should be informed about breast asymmetries
preoperatively rather than intra- or postoperatively.
In a comparison of different preoperative breast volume
calculation techniques (three-dimensional [3D] laser scans,
nuclear magnetic resonance imaging [MRI], computed
tomography [CT], thermoplastic casting, and anthropo-
morphic method), MRI measurements showed the highest
level of precision [9,10]. Unfortunately, 3D laser scan, CT,
and MRI are too costly for routine assessments. We
therefore recommend an anthropomorphic method as a
simple way of assessing and predicting breast volume
because surgeons always measure different portions of
breast profiles preoperatively for aesthetic purposes [11].
The anthropomorphic equation provides a practical
estimation of breast volume with a deviation of about
6.26%. This falls within the suggested range for saline
filling volume in breast implants. In other words, we can
take advantage of the filling volume range to adjust for
breast volume prediction error from the anthropomorphic
equation. Additionally, breast volume asymmetry often is
accompanied by different degrees of nipple or inframam-
mary fold-level asymmetries. In uncorrected scoliotic
patients, uneven shoulder or thoracic cage levels worsen the
severity of nipple or inframammary fold level asymmetries.
In this study, the correlation between the pre- and
postoperative parameters of breasts and the severity of
scoliosis also was analyzed. We investigated whether
augmentation mammaplasty using our surgical algorithm
not only corrected breast volume asymmetry but also
adjusted the supra- or infrastructure of the breast mound
(nipple or inframammary fold level) at the same time.
Patients and Methods
The study enrolled 60 scoliotic patients (7.6%) from 780
patients undergoing augmentation mammaplasty between
January 2000 and March 2008. The average follow-up
period was 2 years. Inclusion and exclusion criteria were
introduced for patient screening and to decrease selection
bias. The inclusion criteria required hypoplastic breasts, a
difference in breast volume between sides greater than
20 ml, and scoliosis with a Cobb angle greater than 10°.
The exclusion criteria ruled out patients with secondary or
iatrogenic breast asymmetries, including those due to
tumor excision, augmentation or reduction mammaplasty,
or cardiac and chest surgery, as well as patients with sco-
liosis after treatment. Informed consent was obtained in
accordance with the guidelines set forth by the Taipei
Medical University Hospital Institutional Review Board.
The Cobb angle was used for evaluation of curves in
scoliosis on an anteroposterior radiographic projection of
the chest (spine) no matter what kind of KV value (KV
value indicates the X-ray energy dose) was provided pre-
operatively. Using this method, a line is drawn along the
superior end plate of the superior end vertebra, and a
second line is drawn along the inferior end plate of the
inferior end vertebra. The angle between the two lines (or
the lines drawn perpendicular to them) is measured as the
Cobb angle. As a general rule, a Cobb angle of 10°is
regarded as a minimum angulation for defining scoliosis.
The symptoms of scoliosis, including uneven shoulder or
hip levels, also were recorded.
The surgical algorithm we used in augmentation mam-
maplasty for scoliotic patients with breast asymmetries is
shown in Fig. 1. First, preoperative breast volume was
measured with the anthropomorphic method using the
formula published by Qiao et al. [11]:
1
3pMP2ðMR þLR þIR MPÞ;ð1Þ
Aesth Plast Surg (2010) 34:374–380 375
123
where MR is the distance between the nipple and medial
breast border following the breast skin, LR is the distance
between the nipple and lateral breast border following the
breast skin, IR is the distance between the nipple and
inframammary fold following the breast skin, and MP is the
mammary projection, measured from sternum to nipple
base in a view of the patient from the lateral aspect. In other
words, the nipple is defined as the center of the breast for
measuring the medial, lateral, and inferior lengths as well as
the breast projection (Fig. 2). The smaller and larger esti-
mated preoperative breast volumes and the difference
between them are denoted as V
s
,V
l
,DV
pre
respectively.
Two additional breast profile parameters were the dif-
ferences in inframammary fold levels (DIMF) and nipple
levels (Dn) between the sides. Next, the target breast cup
size was communicated to the patient. The breast cup size
was transformed into the expected breast volume (V
e
)
based on Table 1[12]. For this calculation, we subtract the
estimated breast volume from the expected breast volume
to obtain the predicted implant size for both sides (V
e
-V
s
and V
e
-V
l
).
Finally, all procedures were performed by the senior
author (F.C.T.) using a transaxillary approach via the
submuscular or subfascial plane. The implant (Natrelle;
Allergan, Inc., Irvine, CA, USA) was intraoperatively filled
or overfilled with normal saline to achieve equality or
symmetry of breast volume. The difference in the final
filling saline volumes between the two sides was denoted
as DV
f
. The same anthropomorphic method was used to
measure the postoperative estimated breast volume. The
difference in postoperative estimated breast volumes
between sides was denoted as DV
post
.
Statistical Analysis
All statistical calculations were performed using SPSS 15.0
statistical software (SPSS, Chicago, IL, USA). The dif-
ference in the pre- and postoperative estimated breast
volumes between the sides was compared using paired t
tests. The correlations among the difference in preoperative
estimated breast volume (DV
pre
), final filling saline volume
(DV
f
), nipple (Dn) and inframammary fold level (DIMF),
and Cobb angle were investigated using Pearson’s
Fig. 1 A surgical algorithm for augmentation mammaplasty for
patients with breast asymmetries
Fig. 2 Four parameters of breast profiles in an anthropomorphic
equation: MR (distance between the nipple and the lowest point of the
sternum), LR (distance between the nipple and the lateral breast
border where the point is parallel to the lowest point of the sternum),
IR (distance between the nipple and the inframammary fold), and MP
(mammary projection)
Table 1 Correlation between breast cup size and breast volume in
Asia
Breast cup size Breast volume (V
E
, ml)
C 280 ±10
C
?
320 ±10
D 362 ±15
D
?
400 ±20
E 474 ±10
Data: mean ±standard deviation
376 Aesth Plast Surg (2010) 34:374–380
123
correlation and the regression analysis method. The data
are presented as mean ±standard deviation. Statistical
significance was set at a pvalue less than 0.01.
Results
Pearson regression analysis showed that the difference in
breast volumes between the two sides (DV
pre
) correlated
significantly with the severity of scoliosis (Cobb angle)
(correlation coefficient r, 0.901) and resulted in the linear
regression equation DV
pre
=5.19 ?3.15 9Angle
(Fig. 3). However, the difference between the pre- and
postoperative nipple (Dn) and inframammary levels
(DIMF) and the severity of scoliosis had no significant
correlation. The difference between the pre- (DV
pre
) and
postoperative breast volumes (DV
post
) was 43.07 ±11.49
and 6.38 ±3.82 ml, respectively (Table 2).
In evaluating whether augmentation mammaplasty using
the surgical algorithm can decrease the difference in breast
asymmetries, statistical significance was established by
comparing DV
pre
with DV
post
(p\0.001; Fig. 4). The dif-
ference in preoperative estimated breast volumes (DV
pre
)
correlated significantly with the difference in intraoperative
filling volumes (DV
f
)(p\0.001). A significant correlation
existed in the difference between pre- and postoperative
nipple levels (Dn)(p\0.001), but no statistically signifi-
cant difference was noted between the pre- and postopera-
tive inframammary fold levels (DIMF)(p=0.06; Fig. 5).
The average age of the patients was 27.3 ±5.1 years.
All scolioses were located in the left side. The most
common target breast cup size for the patients in our study
was C
?
. The average preoperative estimated breast volume
was 45.3 ml for the smaller breast and 88.4 ml for the
larger breast. The average implant size was 250 ml for the
smaller side and 275 ml for the larger side. Only nine
patients had been pregnant previously. The postoperative
results showed no significant changes in breast size during
the follow-up period.
Fig. 3 The breast volume asymmetry difference (DV
pre
) showed a
significant correlation with the Cobb angle. A linear regression
equation, DV
pre
=5.19 ?3.15 9Angle, also was obtained
Table 2 Breast profiles before and after augmentation mammaplasty
Preoperative
difference
Postoperative
difference
p
Value
Breast volume (ml) 43.07 ±11.49 6.38 ±3.82 \0.001
Nipple level (cm) 0.77 ±1.01 0.52 ±0.81 \0.001
Inframammary fold
level (cm)
0.41 ±0.96 0.02 ±0.16 0.06
Fig. 4 Augmentation mammaplasty using the surgical algorithm
significantly decreased the breast volume asymmetry difference
(p\0.001). In other words, the preoperative estimated breast volume
(DV
pre
) was larger than the postoperative estimated breast volume
(DV
post
)
Fig. 5 The difference in preoperative nipple levels (Dn) was
significantly corrected (p\0.001)
Aesth Plast Surg (2010) 34:374–380 377
123
Complications included deflation (n=1, 1.7%) and
capsular contracture with Baker grade 2 (n=3, 5%) dur-
ing a 2-year follow-up. Two patients reported rippling
around the saline implant. The results from the two cases
(obvious and insidious breast asymmetries) are presented in
Figs. 6through 7.
Discussion
One of the surgical problems encountered during aug-
mentation mammaplasty that often results in a poor out-
come is insidious breast asymmetries misdiagnosed or
neglected preoperatively. Some candidates for augmenta-
tion mammaplasty did not know that they had breast
asymmetries, and almost all of them were not aware of
scoliosis. Surgeons should thoroughly evaluate breast
asymmetries (including volume as well as nipple and
inframammary fold levels) and skeletal deformities pre-
operatively. Then to prevent postoperative disputes, the
patient should be informed of the risks and predicted out-
come in advance.
Breast asymmetries can be classified roughly into con-
genital and acquired causes. They have been recognized as
an important disorder of the breast since 1968 [13].
From the embryologic point of view, breast develop-
ment emerges from the primordial cells between the ventral
limb buds as two ectodermal ridges known as mammary
ridges during week 4 of gestation [14]. The cells around the
level of the fourth intercostal space specialize to become
the future breasts, whereas the remaining cells disappear.
During this developmental process, multiple factors
influence the growth, lengthening, and branching of mam-
mary glands. It is not surprising that patients demonstrate
different degrees of breast asymmetry and abnormality of the
chest wall. In rare cases, patients have a congenital anomaly
(i.e., Poland’s syndrome: 1:30000 cases/year) [15]. Con-
versely, most patients encounter only simple breast asym-
metry without the involvement of other deformed tissues.
Edstrom et al. [16] recognized that breast asymmetries
include different morphologic alterations of the breast,
nipple–areola complex, or both in shape, volume, and
positioning. The general incidence of breast asymmetry is
quite high, reaching 81.1% [17]. To be more exact, the
varying degrees of breast asymmetry that occur include the
nipple–areola complex (24%), volume (44%), base con-
striction (29%), inframammary fold position (30%), and
grades 1–3 ptosis (29%) [2].
When patients with breast asymmetry request augmen-
tation mammaplasty, the goal is to create symmetric and
Fig. 6 Obvious breast asymmetries. aA 24-year-old woman
requested endoscopic transaxillary subpectoral augmentation mam-
maplasty. Her posture obviously showed uneven shoulders (left). The
estimated breast volumes measured by the anthropomorphic equation
were 41.6 ml (right) and 85.2 ml (left). The expected breast cup was
C
?
(320 ±10 ml). The preoperative differences in the inframam-
mary fold and nipple levels were 1.2 and 1.6 cm, respectively. The
DV
pre
was therefore 43.6 ml. The saline implant volumes were
275 ml for the smaller right breast and 225 ml for the larger left
breast. The saline filling amounts were 285 ml (right) and 235 ml
(left). The postoperative differences in the inframammary fold and
nipple levels were corrected to 0.1 and 0.4 cm, respectively. With
DV
post
improved to 2.4 ml, there was almost no postoperative breast
volume asymmetry (right). bRoutine chest X-ray with a high KV
value showed scoliosis with a Cobb angle of 18°
378 Aesth Plast Surg (2010) 34:374–380
123
aesthetically pleasing breasts. The selection of breast
implant size plays a key role in the successful adjustment
of breast asymmetries. Experienced surgeons may base
their choice of implant size on subjective perioperative
observation. Consistently satisfactory results are however
difficult to achieve if no objective pre- or intraoperative
breast volume measurement is performed. Examinations
such as MRI can accurately estimate the breast volume, but
their high cost makes them impractical for every patient.
In this study, we showed that the anthropomorphic equa-
tion of Qiao et al. [11] provides a precise breast volume
prediction at no cost. What plastic surgeons need is a simple,
low-cost method for evaluating breast asymmetry differences
preoperatively rather than intraoperatively using sizers.
Patients receiving gel implants need particularly precise
predictions of implant size because no intraoperative
adjustment of implant size can be performed. The current
study demonstrated how our surgical algorithm efficiently
predicts and reduces the discrepancies in breast volume
asymmetry. In other words, after augmentation mammaplasty
following this specific process, the breasts will appear similar.
Scoliosis can be easily diagnosed by routine chest X-
rays even if a low KV value cannot provide sufficiently
high-quality vertebral body images for calculation, as
shown in Fig. 7b. Examining the patient’s back and asking
her to bend forward also are useful.
In the literature, we found that a certain percentage of
scoliotic patients also experienced breast asymmetries, but
a definite correlation between the two was unknown.
Because the upper thoracic curves in scoliosis tend to
progress less than the thoracolumbar curves, the breasts of
scoliotic patients seem not to change significantly since
adulthood [18]. This concept was confirmed by our study.
No significant alterations in postoperative breast asymme-
tries were noted during the follow-up period. The results
indicate that the difference in breast volumes between sides
correlated significantly with the severity of scoliosis (the
square of the correlation coefficient was 0.813.), although
no correlation between the differences in pre- and post-
operative nipple and inframammary levels and the severity
of scoliosis was noted.
A linear regression equation, DV
pre
=5.19 ?3.15 9
Angle, indicated that each incremental Cobb angle created
almost 3 ml in breast volume discrepancy if scoliosis had
been untreated since childhood. Scoliosis is therefore
suggestive of breast asymmetries and vice versa, with a
clear chain of relation established between scoliosis and
breast asymmetry. Breast volume asymmetries should not
be misdiagnosed if preoperative scoliosis-related symp-
toms and signs are noted during the first visit. Most
importantly, some scoliotic females experience postnatal
breast atrophy, which may mask the severity of
Fig. 7 Insidious breast asymmetries due to postnatal breast atrophy.
aA 32-year-old woman with a history of pregnancy and reporting
hypoplastic breasts requested augmentation mammaplasty. The
expected breast cup size was D (362 ±15 ml). Preoperatively, her
breasts appeared symmetric and similar (left), and the nipple and
inframammary fold levels appeared almost equal (DIMF =0.2 cm;
Dn=0.1 cm). The estimated breast volumes were 69.7 ml (right)
and 90.3 ml (left) after calculation using the anthropomorphic
equation, so the DV
pre
was 32.6 ml. The saline implant volumes
were 300 ml for the smaller right and 275 ml for the larger left breast.
The final saline filling amounts were 310 ml (right) and 285 ml (left).
After the operation, DV
post
decreased to 8.9 ml (right). Unfortunately,
the postoperative Dnincreased to 1 cm when this patient shrugged her
left shoulder, but DIMF decreased to near zero. bRoutine chest X-ray
with a low KV value showed scoliosis with a Cobb angle of 14°
Aesth Plast Surg (2010) 34:374–380 379
123
asymmetries and mislead the surgeon’s decision, although
only nine patients in our study had a history of pregnancy,
as shown in Fig. 7. The asymmetric size of the postnatal
breast skin envelope can lead to breast asymmetries.
Scoliotic patients also experience different grades of
asymmetric inframammary fold level due to uneven
shoulders or posture. The difference in inframammary fold
levels decreases if patients adjust their posture to force an
even shoulder level. Nevertheless, surgeons and patients
often face the difficult decision whether to correct this
difference iatrogenically during surgery.
Our suggestion is that preoperative communication is
crucial. In fact, asymmetric inframammary fold levels
should be corrected because patients always care whether
the postoperative inframammary fold levels are even no
matter what their body posture is appears to be. We
therefore corrected the inframammary fold differences to
make the levels as even as possible in all cases.
Furthermore, because the nipple is located on the top of
the breast mound, a postoperative difference in nipple
levels correlates with whether the breast volume was cor-
rected precisely, as shown in Figs. 6and 7. The situation is
akin to that of a balloon being deflated or inflated. The
better correction of breast volume asymmetries (DV
post
) for
the case shown in Fig. 6compared with the case in Fig. 7
indirectly influenced the outcome of nipple level adjust-
ment. Our results verified that the surgical algorithm sig-
nificantly corrected breast volume and nipple asymmetry at
the same time.
Finally, the percentage of complications in our study
was no higher than that reported in the literature [1921].
Rippling and capsular contracture in particular were
encountered less frequently than in previous reports. When
the wrong implant size was selected, the result often was a
mismatch with the surgical space created by the surgeon.
Although no statistical analysis was performed, it appeared
that the incidence of mismatch was reduced due to
appropriate sizing of the implant and saline overfilling.
In summary, we identified a significant correlation
between the severity of scoliosis and breast volume
asymmetry differences. Our simple surgical algorithm
helped surgeons accurately select the correct implant size
and decreased the breast asymmetry differences (volume
and nipple level) without resort to costly examinations or
facilities. The breast asymmetries were in fact correctable.
Acknowledgment This study was supported by Taipei Medical
University (TMU) grant TMU98-AE1-B10.
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380 Aesth Plast Surg (2010) 34:374–380
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  • ... Therefore, a clear understanding of back muscle activity in AIS is needed and may help to explain the mechanism of the initiation and progression of the deformity. There are some limitations on previous studies because of their insufficient number of subjects, lack of a control group (Bylund et al., 1987), inadequate description of the materials and methods (Bassani et al., 2008; Chan et al., 1999), lack of quantitative results (Perret and Robert, 2004), being limited to isometric contractions (Bylund et al., 1987; Dobosiewicz, 1997; McIntire et al., 2007), while subjects were fixed to an apparatus (de Oliveira et al., 2011; McIntire et al., 2007; Tsai et al., 2010), while wearing a brace (Odermatt et al., 2003), during an unloading perturbation in the frontal plane (Perret and Robert, 2004), or while standing on a tilting platform (Kuo et al., 2011). Feipel et al. (Feipel et al., 2002) suggested that EMG analysis of back muscles activity during dynamic lateral bending task is appropriate to distinguish between scoliotic and normal subjects as well as for evaluation of functional improvements of orthopedic intervention. ...
  • Article
    Although much has been written about breast aesthetics, the literature lacks a simple yet systematic and comprehensive approach for preoperative breast assessment. With use of the mnemonic "BFACE," the breast surgeon will analyze the bony skeleton and the breast footprint, areola, conus, and envelope. The authors present a thorough review of the important parameters that define the ideal breast, and several techniques for perceiving asymmetries more clearly. Strategic surgical planning is enabled by accurate perception.
  • Article
    Objective: Mastectomy is known to effect body posture after a change in the center of gravity of women due to a missing breast. Although previous studies on short-term postural changes in mastectomy patients using photogrammetry or Moiré topography suggested ipsilateral inclination of the trunk, our clinical observations during breast reconstruction surgeries indicated a contralateral shoulder elevation in women with unilateral mastectomy. Because the change in body posture can affect spinal alignment, we aimed to evaluate the long-term physical effects of unilateral mastectomy on spine deformity by radiographic examination. Methods: Posteroanterior chest radiographs of 60 women (mean age 56.3 ± 8.5 years) taken before and 12 months after the mastectomy were evaluated for Cobb angle and the presence or absence of a tilt from the midline in the coronal plane of vertebral body alignment. Results: Cobb angle decreased in 14 and increased in 38 of 60 patients after unilateral mastectomy, and the angular change was found to be independent of the mastectomy side (P < .001). A shift in Cobb angle to the mastectomy side was observed in 11 of 53 patients (P > .05), whereas a statistically significant shift in Cobb angle to the opposite of the mastectomy side was observed in 33 of 53 patients (P < .001). The results of this observational retrospective study indicated long-term spinal deformation in women with unilateral mastectomy. Two patients with idiopathic scoliosis before mastectomy even developed scoliosis. Conclusion: We recommend informing the patients of the possible change in body posture in the long term, which should be supported or limited with physical therapy.
  • Article
    Purpose Spontaneous surgical alterations of the distorted surface shape of thoracic cage in adolescent idiopathic scoliosis (AIS) may relocate and remodel the bilateral breast mounds. The purpose of this study was to analyze the influence of scoliosis correction surgery on female breast morphology and to identify the risk factors for iatrogenic breast asymmetry secondary to operative breast shape changes in AIS. Methods Thoracic AIS girls undergoing correction surgery were reviewed. Ten parameters concerning morphometric and CT evaluations of breast profile and symmetry were measured. The degree of asymmetry was determined and comparisons were made for evaluation of operative breast shape changes. The morphologically aggravated breast asymmetry would be considered if the concave and convex difference of either sternal notch-nipple length or sternal notch-nipple tilt angle increased post-operatively. Potential risk factors for iatrogenic breast asymmetry were identified. Results Sixty-eight AIS girls were reviewed. The concave breasts showed significantly more linear and less angular changes in morphological parameters post-operatively (p < 0.05). The concave and convex difference was significantly increased in morphological parameters and yet decreased in radiographic parameters. Ratio of aggravated morphological breast asymmetry was 61.2 %, and this patient group trended to have a minor pre-operative breast asymmetry though the difference was not statistically significant (p > 0.05). Moreover, patients with apex located at or above T7 showed greater changes in both morphological and radiographic dimensions as compared with those with apex beneath T7 (p < 0.05). Conclusion The incidence of aggravated post-operative breast asymmetry is notable. Those with higher thoracic apex level, combined with minor pre-operative breast asymmetry, were at relatively higher risk of iatrogenic breast asymmetry aggravation post-operatively. Moreover, discrepancy existed between the morphometric and radiographic parameters concerning the surgical influence on breast asymmetry.
  • Article
    Full-text available
    Background: Achieving satisfactory results may be difficult in augmentation mammaplasty patients in the presence of breast, chest wall, or vertebral deformities. These deformities have not been classified previously, and the impact of each deformity or combination of deformities has not been defined. Objectives: The aims of this study are to determine the complicating factors in augmentation mammaplasty, to classify these factors according to their influence on surgical outcome, and to develop an identification system for simplifying the recognition of challenging cases. Methods: We retrospectively analyzed photographs and records of 100 consecutive patients who underwent augmentation mammaplasty. We observed suboptimal results in 18 cases. Preoperative deformities of the breast, chest wall, and vertebra were recorded in order to determine which factor or factors had complicated the surgeries. Eventually, the relationship between suboptimal surgical results and complicating factors was evaluated. Results: We observed that some deformities alone caused suboptimal results, whereas others did not. Deformities that caused suboptimal results alone were called major complicating factors, and any others were called minor complicating factors. We observed that suboptimal results were also obtained in patients who had four minor complicating factors. Patients who had suboptimal results because of major or minor complicating factors were considered challenging cases. Conclusions: In this study, complicating factors for augmentation mammaplasty were defined and classified as major or minor depending on their effect on the surgical outcome. We suggest an identification system that simplifies the recognition of challenging cases in breast augmentation. Level of evidence: 4 Therapeutic.
  • Article
    Background: Variation in the anatomical position of the inframammary fold (IMF) in women remains poorly studied. Objectives: The purpose of this study was to evaluate the incidence of asymmetry between IMF locations on the chest wall of women undergoing breast augmentation and to determine breast measurements associated with IMF asymmetry. Methods: Three-dimensional imaging analysis of the breasts was performed in 111 women with micromastia, using the Vectra Imaging System(TM). The following measurements were recorded: vertical distance between right and left IMF (inter-fold distance), vertical distance between nipples (inter-nipple distance), and difference between projection of right and left breasts in anterior-posterior direction. Results: Asymmetry between the right and left IMF positions was found in the majority of patients (95.4%), with symmetry only found in 5 patients (4.6%). In the majority of patients (60.3%), the right IMF was located inferior to the left IMF with median inter-fold distance 0.4 cm (range, 0.1, 2.1 cm). In 39 patients (35.1%), the left IMF was located inferior to the right with median inter-fold distance 0.4 cm (range, 0.1, 1.7 cm). There was strong correlation between the degree of asymmetry of IMF and asymmetry of nipple areola complex (NAC) positions (r = 0.687, P < .01). Conclusions: The majority of women with micromastia demonstrate asymmetry of the IMF, which correlates with asymmetry of NAC location. The authors propose a classification system based on most commonly observed IMF locations as types I (right IMF inferior to left), type II (left IMF inferior to right) and type III (both IMF located on the same level). Level of evidence: 4 Diagnostic.
  • Article
    Full-text available
    Surface topography (ST) is a tool used to assess adolescent idiopathic scoliosis (AIS), which affects females more severely than males. However, current ST techniques fail to measure breast asymmetry related to torso deformity. Cosmetic deformity is important to patients because poor body appearance can cause psychological distress. Breast asymmetry is especially important to adolescent females. This study develops a method for assessing breast asymmetry using ST in patients with AIS, and proposes a reliable breast asymmetry classification for such patients. To achieve this, ST torso scans of 25 females (age: 15.4 ± 1.3 years; range: 13.5-17.5 years) with AIS were obtained. Scans were analyzed using a method that finds a rotoinversion matrix to minimize the distance between the torso scan and its reflected image about the sagittal plane. The mirrored torso was then fitted to the original torso using an iterative least- squares method, such that the average deviation between the observed and reflected torsos was minimized. The relative deviation between the two torsos was measured and displayed as a deviation colour map (DCM). Each patient's DCM was visually appraised by two of the authors and a breast asymmetry classification system was created based on this appraisal. Good intra- and inter-rater reliability was found for the classification decisions by five observers. All of the patients presented breast asymmetry that could be reliably categorized into the proposed five-group classification with all patients exhibiting deviations exceeding the threshold of 3 mm between sides routinely observed in healthy teenagers without scoliosis.
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    Background: The aim of this study was to analyze electrical activity of trunk muscles in adolescent idiopathic scoliosis patients and healthy subjects during trunk lateral bending and rotation movements. Methods: Ten patients with right thoracic scoliosis [Cobb angle: 29.1° (10.4°)] and 10 control adolescents were studied. Electrical activities of erector spinae muscle at 6th and 10th thoracic and 3rd lumbar vertebral level, and external oblique muscles were measured bilaterally during the right and left bending from standing and prone positions, and trunk rotation in sitting position. Findings: In trunk rotation to the right, the right-side external oblique (antagonist) muscle in scoliosis group was greater than that in control group (p b 0.05). In left bending fromstanding position, in scoliosis group, the antagonistic activity of EST6muscle was greater than its agonistic activity (p b 0.05). Also, in the right bending motion, the agonistic activity of external oblique of scoliosis group was higher than that of control group (p = 0.02). During the left bending from prone position, right-side EST6 and right-side ESL3 muscles of scoliosis group were greater than that of control group (p b 0.05). Interpretation: In left bending from standing position, in scoliosis group, the greater antagonistic activity of erector spinaemuscle at 6th thoracic vertebral level than its agonistic activity, indicates that scoliosis is associated with asymmetrical muscle activity. Lateral bending from standing position is appropriate test to distinguish between scoliosis and control subjects. In scoliosis, the asymmetrical muscle activity is not an inherent characteristic since it was not displayed in all back motions.
  • Article
    ... doi: 10.1097 / 01 . prs . 0000189206.94466 . a9 . Original Articles: Breast. The Incidence of Tuberous Breast Deformity in Asymmetric and Symmetric Mammaplasty Patients. DeLuca-Pytell, Danielle MMD; Piazza, Rocco CBA; Holding ...
  • Article
    Background: Breast asymmetry is commonly accompanied by tuberous deformity. To date, no study has reported the incidence of this breast deformity in the presence of asymmetry. A retrospective analysis of standard preoperative photographs was performed on 375 consecutive female patients presenting for mammaplasty over a 10-year span. Methods: Women were examined for symmetry, asymmetry, and the presence of tuberous deformity. Patients were graded by the Grolleau Classification System. Patients having congenital anomalies, tumors, infection, radiation, chest wall deformities, previous breast surgery history, and incomplete chart data were excluded. Results: Of the 375 patients studied, 81.1 percent (n = 304) presented with asymmetry. Of these asymmetric women, 88.8 percent (n = 270) were found to have tuberous deformity. Of the 71 patients who were symmetric, 7 percent (n = 5) were tuberous. Concurrent nipple-areola complex involvement in the tuberous asymmetric patient population was present in 50 percent of the women (n = 116). Of the tuberous deformities with nipple-areola complex, 87.9 percent (n = 116) were Grolleau type III. Nipple-areola complex involvement was not found in any of the symmetric patients. Of the 275 women with tuberous deformity, 531 breasts were tuberous and 60.3 percent (n = 320) were Grolleau’s type III. In total, 57.1 percent of all reduction mammaplasties (n = 92) and 83.2 percent of all augmentation mammaplasties (n = 178) had asymmetry with tuberous deformity. Conclusions: This is the first published study to demonstrate that tuberous deformity is strongly associated with asymmetry in women presenting for mammaplasty. This should be evaluated in preoperative planning to ensure optimal outcome. Patients with this deformity should be educated preoperatively so their expectations of postoperative results are realistic.
  • Article
    Prospective long-term data on the occurrence of complications following breast augmentation are sparse and the reported frequencies differ substantially. The Danish Registry for Plastic Surgery of the Breast has prospectively registered preoperative, perioperative, and postoperative data for women undergoing breast augmentation in Denmark since 1999. From the Registry, the authors identified 5373 women with a primary cosmetic breast augmentation between 1999 and 2007. The authors calculated incidence proportions of adverse clinical outcomes within three time intervals (0 to 30 days, 0 to 3 years, and 0 to 5 years) after primary implantation. Outcomes of primary interest were capsular contracture, asymmetry/ displacement of the implant, hematoma, and infection. During the entire follow-up period (mean, 3.8 years; range, 0.1 to 8.7 years), 16.7 percent of the women were registered with an adverse event and 4.8 percent of the women were registered with a surgery-requiring complication. The most common adverse events within 30 days were hematoma (1.1 percent) and infections (1.2 percent), whereas the most common adverse events within 5 years were change of tactile sense (8.7 percent) and asymmetry/ displacement of implant (5.2 percent). Within 5 years, 1.7 percent of the women had a record of severe capsular contracture. Displacement/asymmetry and capsular contracture were the most frequent indications for reoperation with removal or exchange of the implant. Population-based complication frequencies among women with cosmetic breast augmentation in a Danish nationwide implant registry were generally lower than those reported in other studies, although frequencies of complications increased with length of follow-up.
  • Article
    A 15-year-old girl was referred to our Department by the orthopedic surgeons, showing a massive unilateral gigantomastia of her right breast and a progressive idiopathic thoracic scoliosis. Ventral positioning of the patient for the planned scoliosis correction was impossible without prior treatment of the hypertrophic breast. In the first operation the fibroadenoma with a total weight of 3020 g was resected and histological examination revealed diagnosis of a juvenile giant fibroadenoma, which is a rare tumor of the stromal breast tissue. Tumor resection was followed by anterior thoracic release and posterior scoliosis correction.
  • Article
    The purpose of this study is to establish an optimal module of breast configuration, under normal seating state, for postoperative evaluation of a female breast implant surgery. The analytical parameters of breast configuration, such as the breast position, size and shape, can be derived from a three-dimensional (3D), full-sized image process under non-radiation condition. This optimal module converts the breast position, size and shape to the breast configuration indicator consisting of three components or indices-the breast position, volume and breast congruence rate. In conjunction with the continuity analysis, the breast configuration indicator would allow a surgeon to practically grasp the progress during the postsurgery revisits. In addition, the module derived from the proposed computer-aided breast configuration indicator could be of great use as a tool of communication between patients and surgeons.
  • Article
    The aim of this study is to describe the semiology for the assessment of breast asymmetry in the presence of scoliosis. Twenty-four women with right idiopathic scoliosis treated with bracing alone (23 out of 24) or with bracing and spine surgery (1 out of 24) were evaluated by physical and morphological examinations and three-dimensional (3D) surface scan. Physical examination revealed a smaller right breast in 20 women. A left costal protrusion was observed in 18 patients. Anthropomorphic analysis revealed that the right breast was higher in 19 cases, and smaller in 18 cases. The calculations from 3D scan showed the right breast to be smaller in 19 women. A strong correlation is found between clinical parameters, anthropomorphic measurements and 3D scan analysis, suggesting that a meticulous clinical examination is sufficient to evaluate breast asymmetry in patients with idiopathic scoliosis. A patient who is properly diagnosed and informed of her skeletal deformity and breast asymmetry is more likely to have realistic expectations from breast surgery.
  • Article
    We have found the study of split-and-reversed photographs useful in the preoperative evaluation of patients presenting for corrective surgery of the breasts. It puts double emphasis on minor asymmetries, and can be used as an objective tool in planning procedures to correct these, and in evaluating the results. Asymmetry in volume is, however, less readily demonstrated by this technique than is asymmetry of shape.