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PURPOSE: Breast-conserving surgery is the preferred treatment for breast cancer; however, its associated risk of local recurrence is higher than that of mastectomy. We performed a comparative analysis of four patient-reported outcomes, psychosocial well-being, sexual well-being, breast satisfaction, and physical well-being of the chest, and quality of life after three surgical approaches, breast-conserving therapy (BCT), mastectomy alone, and mastectomy with breast reconstruction, for breast cancer treatment. METHODS: A cross-sectional survey using the BREAST-Q questionnaire and including patients who had undergone breast surgery at least 1 year prior to survey completion was performed. The analysis included 1035 patients (mean age, 55.0 ± 9.1 years) who underwent breast reconstruction, 116 patients (mean age, 63.6 ± 12.2 years) who underwent mastectomy, and 64 patients (mean age, 60.8 ± 12.2 years) who underwent BCT. RESULTS: Patients who underwent reconstruction had significantly higher psychosocial well-being scores (62.8 ± 18.4) than those who underwent BCT (57.0 ± 23.6) and mastectomy (50.8 ± 16.8) (p < 0.01). However, significant differences in self-acceptance scores among all patients were not observed. Regarding sexual well-being and breast satisfaction, patients who underwent mastectomy had significantly lower scores (29.9 ± 18.7 and 41.8 ± 17.7, respectively) than those who underwent BCT (45.8 ± 26.6 and 58.3 ± 17.5, respectively) and reconstruction (46.4 ± 20.3 and 58.8 ± 15.4, respectively) (p < 0.01). Physical well-being of the chest scores were not significantly different among all patients (p = 0.14). Symptoms after mastectomy included chest muscle pain and arm movement impairment. Breast pain was a notable symptom after BCT. CONCLUSION: The study findings provide valuable insights regarding patient-reported outcomes, highlight the potential benefits of breast reconstruction, and emphasize the importance of patients' preferences.

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BACKGROUND: Patient-reported outcomes have become as important as mortality and morbidity in the postoperative evaluation of breast reconstruction surgery. The BREAST-Q is one of the most widely used patient-reported outcomes for breast reconstruction. OBJECTIVES: A comparative analysis of the scores on each of the BREAST-Q modules could help analyze different reconstruction methods. However, few studies have utilized BREAST-Q for this purpose. The aim of this study was therefore to compare breast reconstruction methods in terms of BREAST-Q module ratings. METHODS: The authors retrospectively reviewed the data of 1001 patients who had been followed for more than 1 year after breast reconstruction. The 6 BREAST-Q modules were rated on a scale of 0 to 100 and statistically analyzed by multiple regression. In addition, Fisher's exact test was performed after dividing the responses to each question into high- and low-rating groups. RESULTS: Microvascular abdominal flap reconstruction scored significantly better than implant-based reconstruction on all modules, except psychosocial and sexual well-being. In terms of satisfaction with the breast, latissimus dorsi flap reconstruction was superior to implant-based reconstruction. However, in terms of the reconstruction method, there were no differences in patients' willingness to make the same choice again or whether they regretted having surgery. CONCLUSIONS: The results highlight the superiority of autologous breast reconstruction. Reconstruction methods should only be performed after a thorough explanation of their characteristics to achieve results that meet patient expectations. The findings are useful for facilitating patient decision-making in breast reconstruction.

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Silicone breast implants are popularly used for breast reconstruction. As more patients receive long-term silicone breast implants, the number of replacement operations will also increase, and some patients prefer to change from silicone breast implantation to tertiary autologous reconstruction. We evaluated the safety of tertiary reconstruction and assessed patient views regarding the two reconstruction methods. We retrospectively analyzed patient backgrounds, surgical characteristics, and silicone breast implantation retention periods until tertiary reconstruction. We designed an original questionnaire to assess patient opinion regarding silicone breast implantation and tertiary reconstruction. Twenty-three patients (24 breasts) with decisive factors of patient-initiated elective surgery (n = 16), contralateral breast cancer occurrence (n = 5), or late-onset infection (n = 2) underwent tertiary reconstruction. The median time from silicone breast implantation to tertiary reconstruction was significantly shorter in patients with metachronous cancer (47 months) than that in those undergoing elective surgery (92 months). Complications included partial flap loss (n = 1), seroma (n = 6), hematoma (n = 5), and infection (n = 1). Total necrosis did not occur. Twenty-one patients responded to the questionnaire. The satisfaction score was significantly higher for abdominal flaps than for silicone breast implants. When presented with the option to select the initial reconstruction method again, 13 of 21 respondents chose silicone breast implantation. Tertiary reconstruction is beneficial because it reduces clinical symptoms and cosmetic complaints and is recommended as a bilateral reconstruction method, especially for patients with metachronous breast cancer. However, silicone breast implants, which are minimally invasive and associated with shorter hospital stays, were simultaneously found to be sufficiently attractive to patients.

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BACKGROUND: While breast reconstruction often improves the quality of life of patients with locally advanced breast cancer, there is still no consensus on its safety. This retrospective report aimed to verify the safety of immediate breast reconstruction for locally advanced breast cancer. METHODS: We retrospectively analyzed 500 breast cancer surgeries performed between January 2005 and December 2019 at our hospital, including 120 immediate breast reconstructions. The following five items were analyzed: the patients' choice of reconstruction method, rate of chemotherapy and radiotherapy, surgical margin positivity rate, complications associated with surgery, overall survival rate, and breast cancer-free survival rate. RESULTS: Sixty-three of the 120 patients underwent autologous breast reconstruction. Of those who underwent reconstruction surgery, 95.8% received chemotherapy and 78.3% underwent post-mastectomy radiation therapy. Reconstruction failed in 8 cases with tissue expander and in 1 case with free TRAM flap. Breast reconstruction surgery was not a factor in delaying adjuvant therapy, but complications requiring intervention tended to increase the duration of adjuvant therapy. There was no statistically significant difference in the rate of surgical margin positivity, overall survival rate, or breast cancer-free survival rate. CONCLUSIONS: Although complications associated with reconstructive surgery occurred, appropriate intervention prevented delays in breast cancer treatment, and the complications did not negatively affect the overall or breast cancer-free survival rates. Our study found no evidence to avoid primary breast reconstruction in patients with locally advanced breast cancer.

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PURPOSE: Immediate breast reconstruction (IBR) is a standard option for breast cancer patients, although its utility in patients with advanced breast cancer requiring neoadjuvant chemotherapy (NAC) is debatable. We assessed the short-term complications and long-term prognosis of IBR after NAC. METHODS: We retrospectively analyzed 1135 patients with IBR and/or NAC between 2010 and 2018, 43 of whom underwent IBR after NAC. RESULTS: Twenty-five patients underwent reconstruction with a tissue expander (TE) followed by silicon breast implantation, 5 with a latissimus dorsi muscle transfer flap, and 13 with a deep inferior epigastric perforator flap. Complete surgical resection with a free margin confirmed by a pathological assessment was achieved in all patients. The evaluation of the short-term complications indicated no cases of total flap necrosis, two cases of partial flap necrosis, and one case of wound infection. Only one case required postponement of subsequent therapy due to partial flap necrosis. A long-term evaluation indicated no local recurrence, although distant metastasis was observed in 4 cases, 3 patients died, and TE removal after post-mastectomy radiotherapy (PMRT) was performed in 2 of 11 TE cases. CONCLUSION: IBR may be a viable option in patients with advanced breast cancer who achieve complete surgical resection after NAC.

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BACKGROUND/AIM: Areola-sparing mastectomy (ASM), a conservative mastectomy with nipple hollowing, can be applied to intraductal breast cancer with a tumour-nipple-areola complex (NAC) distance of ≤2 cm. Here, we evaluated the safety and effectiveness of ASM. PATIENTS AND METHODS: We retrospectively reviewed the surgical outcomes of 61 patients (64 breasts) who underwent ASM between 2016 and 2020. RESULTS: Of the 64 breasts, 33 (51.6%) underwent ASM because the tumour-NAC distance on preoperative magnetic resonance imaging was ≤2 cm. Two patients had positive excisional margins but these were at the posterior areola surface therefore additional resection was possible. Over a median postoperative observation period of 16 months (range=3-52 months), one patient developed chest wall recurrence that was resected and did not recur again. CONCLUSION: For breast cancer with an extensive intraductal component, ASM is a good alternative to nipple-sparing mastectomy because it allows safe resection while maintaining aesthetics.

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ABSTRACT: Japan is one of the few countries that consider the application of permanent makeup a medical procedure, and only doctors and nurses are allowed to perform this procedure. Studies on the safety and esthetic outcomes of permanent makeup procedures are not available, although there are studies that report allergies and other complications associated with permanent makeup. Thus, we aimed to study the complications and esthetic outcomes of permanent makeup.We surveyed clients who underwent permanent eyebrow or eyeline makeup procedures at the Shibuya Mori Clinic between November 2016 and March 2020 using a paper-based questionnaire. The permanent makeup procedures involved inorganic pigments, such as iron oxide and titanium dioxide. The questionnaire consisted of 2 parts: the first part asked whether the clients had experienced persistent redness, itching, swelling, infection, or any other complications (multiple answers possible). The second part used a 5-point Likert scale to rate the clients' satisfaction with the color, shape, and overall appearance of their permanent makeup. We retrospectively studied the clients' responses to survey items.A total of 1352 clients participated in the survey. The median period between the procedure and survey response was 15 days. Overall, complications were reported in 12.1% of cases. The most common complication for each type of procedure was itching for eyebrow procedures (8.2%) and swelling for eyeline procedures (13.2%). Infections were reported in 3 cases (0.2%). None of the post-procedure symptoms persisted until the time of this study. The Likert scale measurements revealed that 89.6% of subjects were satisfied with the aesthetic outcome of their permanent makeup procedure(s).We believe that all symptoms observed in this study were due to needle insertion. No allergies were observed, and the infection rate was quite low (0.2%). Thus, our results suggest that permanent makeup procedures are safe and are associated with high client satisfaction. We must note that the appropriate environment, equipment, and techniques are important prerequisites.

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BACKGROUND: Nipple-areolar tattooing is well accepted as part of breast reconstruction, but the clinical data on its safety and patient satisfaction after the procedure are insufficient. We aimed to evaluate the complications of and patient satisfaction after nipple-areola tattooing in Japanese post-mastectomy breast reconstruction patients. METHODS: Patients who visited our center after undergoing nipple-areola tattooing from January 2017 to March 2020 were given an unmarked questionnaire with questions about complications related to their nipple-areola tattoo. Patients' registered their subjective evaluation responses regarding nipple-areola appearance using visual analog scale and that regarding overall satisfaction using 5-point Likert scale and free-text responses. Patients who were followed up within 6 months after tattooing or those with incomplete data were excluded. RESULTS: Sixty-two patients (average age: 49.7 ± 9.8 years), with an average post-tattooing period of 21.2 ± 10.5 months, were included. No patient had infections or allergic reactions. The average VAS score for nipple-areola appearance was high (8.5), and 59 patients (95.3%) answered that they were satisfied. In the free-text patient responses, 25 patients answered that they now felt comfortable going to the hot spring or taking a bath with their children, and 19 patients reported improved mental health after the procedure. CONCLUSION: Post-breast reconstruction nipple-areola tattooing with sterilized inorganic pigments could achieve high esthetics and patient satisfaction, without serious complications. It is recommended for Japanese individuals with a culture of visiting hot springs and public baths. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each submission to which evidence-based medicine rankings are applicable. This excludes review articles, book reviews, and manuscripts that concern basic science, animal studies, cadaver studies, and experimental studies. For a full description of these evidence-based medicine ratings, please refer to the table of contents or the online instructions to authors www.springer.com/00266 .

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INTRODUCTION: Tattooing techniques for reconstruction and rectification of the sequelae of cancer treatments, surgery, and scarring have received attention in the medical field. There is concern that tattooed skin is at risk of being burned by magnetic resonance imaging (MRI) examination. However, a detailed evaluation of the impact of MRI imaging on medically tattooed skin has not yet been performed. This study aimed to clarify the changes in common inorganic tattoo pigments during MRI examinations in an animal model. METHODS: Tattooed hairless mice with eight typical pigments for tattoos were evaluated for changes in temperature, color tone, and histology of the tattoos during a 9.4-T MRI. RESULTS: None of specimens had signs of burns, such as redness or blisters. In terms of temperature changes, the black iron oxide and carbon black specimens had a maximum temperature increase of 0.4 degrees. In the Munsell color system, no specific color changes were observed before or after the MRI. Color changes, evaluated as the ΔE00 in the L*a*b* color space, were all below 3.0 and were thus regarded as being indistinguishable and within the color unevenness of the tattoo. Histologic analysis of the specimens showed no significant changes before and after the MRIs. CONCLUSIONS: The observed temperature changes, color tone changes, and histological changes in the tattooed areas in this animal model were not of a magnitude considered likely to adversely affect the human body.

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BACKGROUND: Reconstruction of the nipple-areola complex is the final process in breast reconstruction. Local flaps and paramedical pigmentation is one of the major procedures for this. However, fading after paramedical pigmentation leads to a color difference between the selected pigment and its color in the skin. The aim of this study is to make a proposition in color choice of paramedical pigmentation for nipple-areola complex. METHODS: Our research focused on investigating the color changes over time after unilateral nipple-areola complex reconstruction using paramedical pigmentation in 25 patients to propose suitable color selections. We measured the color by spectrometer and conducted comparisons using the hue, saturation, and value (HSV) color space and the color space defined by the Commission International de L'eclairage based on one channel for luminance (lightness) (L) and two color channels (a and b) (L*a*b*). RESULTS: A comparison of the hue, value, and saturation of the reconstructed areola compared to the normal areolae was conducted using HSV color space; the value and saturation were satisfactory after 3 months and beyond, but the reconstructed areola tended to have stronger red hues. The color difference (ΔE00) calculated in L*a*b* color space showed slow fading after the scab was peeled off. CONCLUSIONS: This result indicates that a color with less redness and more yellowness, particularly 4-5 degrees of yellowness on the color wheel, than the normal side is the most appropriate color selection for this technique. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

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There are many surgical techniques for craniosynostosis. However, the indications for and timing of surgery still remain unclarified. Most of the skull growth in craniosynostosis is completed in the first year, and the bone is strong enough to undergo distraction osteogenesis. However, previous reports showed that patients operated on before 1 year of age had better IQ than those operated later in life. This report aims to consider the best timing for cranial expansion and surgical strategy for Apert syndrome. From January 2002 to December 2011, 13 patients with Apert syndrome were operated on and were followed up for more than 5 years. Nine patients underwent operations before 1 year of age (early surgery group) and three patients underwent operations later in life (late surgery group). They underwent fronto-orbital advancement for primary surgery. We evaluated postoperative developmental quotient every year and cephalic index (CI) measured by three-dimensional computerized tomography (3D-CT) at the age over 5 years retrospectively. Eleven of 13 patients improved their developmental quotient scores, with no significant intergroup differences. The CI evaluation showed cases with remnant brachycephalic deformity in both groups. Two patients with remnant plagiocephalic deformities tend to have primary surgery early in life compared to the others. Thus the delay in primary surgery had little influence on psychological development. We conclude that the primary surgery can be delayed unless the intracranial pressure needs to be controlled. In addition, fronto-orbital advancement could not sufficiently improve the brachycephalic appearance, other procedures like posterior vault distraction might be better alternatives.

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BACKGROUND: There are inherent limitations with previously reported inframammary fold (IMF) recreation methods. The IMF is firmly fixed to the chest wall, but not physiologically, and it is difficult to determine the correct IMF position in the supine position and in the absence of an implant. METHODS: With our new IMF reconstruction method (i.e., drawstring method), the IMF is recreated by drawing a barbed suture, penetrating the dermis, along the IMF. The barbed suture is fixed to the costal cartilage at the medial IMF, and the head is drawn and cut externally at the lateral IMF. The IMF level and depth can be finely adjusted by the tension, in a seated position after implant insertion. Furthermore, the approach can be from a small incision, and a smooth IMF curve is reconstructed. RESULTS: Our drawstring method was performed in 102 patients who underwent reconstruction using a breast implant (n = 95) or flap (n = 7). The mean patient age was 52.0 years (range 33-77 years) and the follow-up period was 12 months (range 3-18 months). Suture or implant infection or exposure did not occur. Suture slack occurred in ten patients with implant-based reconstruction; their IMF became shallow. Insufficient skin expansion (P < 0.005) and strong traction of the barbed suture from the caudal side (P < 0.05) were related to IMF slack. The total revision rate was 2.9 %. CONCLUSIONS: With sufficient skin expansion, the drawstring method using a barbed suture enables smooth and symmetrical IMF reconstruction. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

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