Nipple-areolar complex malposition in breast reconstruction after nipple-sparing mastectomy: a multi-institutional retrospective observational study in Japan

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The purpose of this study was to evaluate the degree of NAC malposition depending on several factors using data quantified with the Mamma Balance application (Medic Engineering K.K., Kyoto, Japan). Methods Patients who underwent unilateral breast reconstruction after NSM at 8 hospitals in Japan between 2007 and 2020 were retrospectively investigated. Using Mamma Balance, NAC malposition was quantified separately in horizontal and vertical directions using patient photographs from pre-operatively and 6–24 months post-operatively. The degree of malpositioning was then statistically compared using various factors. Results The NAC deviated more cranially and medially with implants than with flaps. Cases with latissimus dorsi flap showed lateral malposition more often than cases with deep inferior epigastric artery perforator flap. With flaps, lateral incisions showed more lateral malposition and peri-areolar incisions tended to show more medial NAC malposition. In cases with severe post-operative infection of the implant, the NAC tended to deviate cranially. In radiation cases, the NAC deviated cranially. No significant difference was observed according to degree of breast ptosis or use of the pull-down operation. Only a very weak correlation was observed between a larger amount of mastectomy and more cranial NAC malposition with both flaps and implants. Conclusions This study provides insights into the tendencies and characteristics of NAC malposition. breast reconstruction NSM nipple-areolar complex NAC malposition Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Nipple-sparing mastectomy (NSM) is an oncological surgical procedure that has been accepted for certain patient populations. This procedure allows patients to preserve the native nipple-areolar complex (NAC) and facilitates immediate, oncologically safe breast reconstruction [ 1 ]. However, cranial and lateral NAC malposition is often reported as an issue with breast reconstruction after NSM [ 2 – 4 ]. The position of the NAC represents an important factor in the aesthetic impression of the breast. The presence of the NAC is known to be associated with improved self-satisfaction and post-operative satisfaction in cases with serial mastectomy and breast reconstruction [ 5 , 6 ]. Many reports have described NAC malposition after NSM. While some reports have mentioned revision surgery for a malpositioned NAC, few have investigated the causes or risk factors. In addition, few reports have utilized quantitative, objective, unbiased measures to analyze NAC malposition in NSM [ 4 , 7 ]. Almost all of those few studies have included relatively small cohorts [ 3 , 8 , 9 ] and many reports have used photographs to assess NAC malposition. The recently developed Mamma Balance application (Medic Engineering K.K., Kyoto, Japan) allows the position of the NAC to be quantitatively evaluated [ 10 ]. We designed the present multi-institutional retrospective observational study of NAC position with breast reconstruction after NSM with photographs and the Mamma Balance application. The purpose of this study was to evaluate the degree of NAC malposition depending on the following factors: use of implants or flaps; degree of ptosis; flap type; incision line; post-operative complications; use of the pull-down procedure; breast size; and post-operative radiation therapy. Patients and Methods We undertook a retrospective study of patients who had undergone unilateral breast reconstruction after NSM at the following facilities from 2007 to 2020: Tokyo Medical and Dental University Hospital, Okayama University Hospital, Hiroshima University Hospital, The Cancer Institute Hospital of JFCR, Yokohama City University Hospital, Japan Community Health Care Organization Saitama Medical Center, St. Luke’s International Hospital and Mie University Hospital. Subjects in this study were patients with photographs from pre-operatively and 6–24 months post-operatively. Patients who had undergone contralateral revision, insertion of tissue expander before implant replacement on the affected side, or absence of the NAC on post-operative photographs were excluded. With Mamma Balance, two triangles are automatically created with vertices of the sternal notch, the nipple on either side and a point on a vertical line from the sternal notch to the umbilicus or xiphoid process. Mamma Balance provides information on the area of the resulting triangle in pixel values (S) and the angle between the midline and the line between the sternal notch and nipple (θ). We defined the following three lengths: from sternal notch to nipple (O); vertical line of the triangle (V); and horizontal line of the triangle (H). These values were calculated using the following formulas (Fig. 1 ): O 2 = 2S/cosθ × sinθ V=√(2S/cosθ × sinθ)×cosθ H=√(2S/cosθ × sinθ)×sinθ We assumed that lengths V and H on the unaffected side would not be changed post-operatively. We then calculated the post/pre-operative ratio of lengths V and H on the reconstructed side, corresponding to the degrees of post-operative craniocaudal and mediolateral malposition of the NAC. A post/pre-operative ratio for V less than 1 indicates cranial NAC malposition, while a ratio for H less than 1 reflects medial NAC malposition (Fig. 2 ). Differences in malpositioning due to the method of breast reconstruction, breast ptosis, flap type, incision type, breast amount, post-operative complications (hematoma, skin envelope necrosis, flap necrosis, circulation disorder of the NAC, and infection), pull-down fixation of the NAC, post-operative radiation therapy and the correlation between transition of NAC position and amount of mastectomy (in grams) were evaluated statistically. Surgical complications were classified using the Clavien–Dindo classification. Statistical analysis was carried out using Prism 9 software (GraphPad Software, San Diego, CA). Values of p < 0.05 were considered significant. The Mann–Whitney U test, Kruskal–Wallis test and Dunn's test with Bonferroni correction were applied for group comparisons. Spearman’s rank correlation coefficient was used to examine correlations. Results A total of 360 unilateral breast reconstructions were included in this study. Mean age was 46.0 years (range, 23–77 years), mean body mass index (BMI) was 21.6 kg/m 2 (standard deviation [SD] 3.08 kg/m 2 ) and mean follow-up period was 15.2 months (SD 10.37 months). The reconstructive methods involved submuscular implants in 196 cases, free deep inferior epigastric artery perforator (DIEP) flaps in 84 cases, latissimus dorsi (LD) flaps in 62 cases, profunda artery perforator (PAP) flaps in 9 cases, gluteal artery perforator (GAP) flaps in 4 cases, lumbar artery perforator (LAP) flap in 1 case, and other in 4 cases (fat graft: 3 cases; latissimus flap + implant: 1). Incision type for implant-based reconstruction was as follows: lateral, 100 cases; inframammary fold (IMF), 26 cases; radial-lateral, 22 cases; radial-oblique, 18 cases; peri-areolar, 20 cases; and unknown, 10 cases. Incision type for flap reconstruction was lateral, 121 cases (59 DIEP, 48 LD, 9 PAP, 4 GAP, 1 LAP), IMF, 1 case (DIEP); radial-lateral, 2 cases (1 DIEP, 1 LD); peri-areolar, 32 cases (21 DIEP, 11 LD); and unknown, 4 cases. Twenty-eight patients needed post-operative radiation therapy (Table 1 ). Table 1 Patient overview Patients Reconstruction method Incision line Radiation therapy Number 360 submuscular implant 196 implant lateral 100 yes 28 Age (years) 46.0 (23–77) flap IMF 26 no 332 BMI (kg/m 2 ) 21.6 (3.08) DIEP 84 radial-lateral 22 Follow-up (months) 15.2 (10.37) LD 62 radial-oblique 18 PAP 9 peri-areolar 20 GAP 4 unknown 10 LAP 1 flap lateral 121 DIEP 59, LD 48, PAP9, GAP 4, LAP 1 other IMF 1 DIEP 1 fat graft 3 radial-lateral 2 DIEP 1, LD 1 LD + implant 1 radial-oblique 0 peri-areolar 32 DIEP 21, DD 11 unknown 4 DIEP 2, LD 2 Patient data are given as the average (range for age, standard deviation for BMI and follow-up). DIEP: deep inferior epigastric artery perforator flap LD, latissimus dorsi flap; PAP, profunda artery perforator flap; GAP, gluteal artery perforator flap; LAP, lumbar artery perforator flap. Comparing between implant reconstruction (n = 196) and flap reconstruction (n = 160) showed that post/pre-operative ratio of horizontal position (H) was significantly smaller with implants than with flaps (p = 0.0209, implant: 0.98, flap: 1.01). Moreover, the post/pre-operative ratio of vertical position (V) was significantly smaller with implants than with flaps (p < 0.0001, implant: 0.91, flap: 0.98). Regarding flap type, lateral malposition was significantly more frequent with LD flap than with DIEP flap (p = 0.0344) (Fig. 3 ). No significant difference was observed according to the degree of breast ptosis (Fig. 4 ). Comparing by incision line, a significant difference in the frequency of lateral malposition was seen with flaps (p = 0.0005), but not with implants (Fig. 5 ). No significant difference was observed according to the presence or absence of the pull-down operation (Fig. 6). Comparing the absence of post-operative complications and varying degrees of complications (hematoma, skin envelope necrosis, flap necrosis, infection, circulatory disorder of NAC), post/pre-operative ratio of V differed significantly between no infection and grade 3 infection (Table 2 ). Table 2 Correlations between amount of mastectomy, post-operative complications and radiation therapy Flap (n) V:flap (ratio) H:flap (ratio) Implant (n) V:implant (ratio) H:implant (ratio) Hematoma n 155 0.96 1.02 187 0.89 0.97 Grade ≤2 4 0.95 0.96 5 0.91 1.04 Grade ≥3 1 0.93 0.86 4 0.86 0.92 Skin envelope necrosis n 151 0.97 0.99 186 0.89 0.97 Grade ≤2 7 1.00 1.02 9 0.91 1.00 Grade ≥3 2 0.92 1.09 1 0.86 1.01 Flap necrosis n 158 0.98 1.00 - - - Grade ≤2 2 1.00 1.08 - - - Grade ≥3 0 - - - - - Circulation disorder of NAC n 137 0.97 1.02 168 0.97 0.89 Grade ≤2 21 0.97 0.97 27 0.97 0.89 Grade ≥3 2 0.98 0.99 1 0.89 0.89 Infection n 157 0.97 1.00 189 0.91 0.98 Grade ≤2 3 0.99 1.04 2 0.93 0.93 Grade ≥3 0 - - 5 0.72* 0.93 Radiation No 102 0.98 1.01 141 0.91 0.97 Yes 13 0.93† 0.95 15 0.85‡ 0.97 Correlation with mastectomy amount (r) 119 -0.15 (0.111) -0.21 (0.019) 117 -0.20 (0.034) -0.12 (0.199) Comparisons were made between patients without complications and with varying degrees of complications. Regarding post-operative complications, the more severe the grade of infection (*p = 0.0009, compared with no infection). The Mann–Whitney U test, Kruskal–Wallis test and Dunn's test with Bonferroni correction were applied. Post/pre-operative ratio of V was significantly smaller with radiation therapy than without radiation therapy for both autologous and implant reconstruction (flap †p = 0.022, implant ‡p = 0.014). The correlation between amount of mastectomy (in grams) and NAC position transition is shown in the bottom row of the table as r (p-value). Spearman’s rank correlation coefficient was applied. In cases with flap reconstruction, a very weak negative correlation was identified between lateral transition and amount of mastectomy (r=-0.214, p = 0.019). In cases with implant reconstruction, a very weak negative correlation existed between vertical transition and amount of mastectomy (r=-0.200, p = 0.034). We sorted the degree of post-operative complications according to the Clavien–Dindo classification. Grade 2: Requiring pharmacological treatment with drugs other than those allowed for grade 1 complications. Blood transfusions, antibiotics and total parenteral nutrition are also included. Grade 3: Requiring surgical, endoscopic or radiological intervention. With the use of radiation therapy, post/pre-operative ratio of V was significantly smaller than that in radiation-free cases with both autologous and implant reconstruction (flap: 0.93, p = 0.022; implant: 0.87, p = 0.014) (Table 2 ). In terms of the correlation between transition of NAC position and amount of mastectomy (grams), in flap reconstruction cases, correlation coefficients were − 0.21 for lateral transition (p = 0.019) and − 0.15 for vertical transition (p = 0.111). In cases with implant reconstruction, correlation coefficients were − 0.12 for lateral transition (p = 0.199) and − 0.20 for vertical transition (p = 0.034) (Table 2 ). Discussion This study revealed the following results: ・The NAC was deviated more cranially and medially with implant reconstruction than with flap reconstruction; ・LD flap cases showed lateral deviation more often than DIEP flap cases; ・With flap reconstruction, lateral incisions were associated with lateral malposition and peri-areolar incisions were associated with medial NAC malposition; ・The NAC tended to be deviated cranially more often with severe post-operative implant infection than with no infection; ・The NAC deviated cranially with radiation in both implant and flap groups; ・A very weak correlation was apparent between larger mastectomy volume and greater cranial malposition of the NAC in both flap and implant cases. Various studies have examined NAC malposition in terms of grades [ 11 ], angles [ 9 ], subjective evaluations [ 12 ], vertical and horizontal balance [ 4 ], and more. Mamma Balance is original software that expresses NAC malposition in terms of area ratio. At this time, by replacing date from Mamma Balance with length, we were able to compare pre- and post-operative values in both vertical and Horizontal directions as continuous variables. This report is the first to quantify the degree of NAC malposition and compare risk factors in detail for a large number of cases. Previous studies have shown that both autologous and implant reconstructions carry a risk of NAC malposition (implant [ 3 , 13 ]; autologous [ 14 , 11 ]). In this study, implant reconstruction was seen to result in a significant risk of NAC cranial medial malposition. In contrast, the NAC tended to move more laterally with autologous reconstruction. These issues have been described in previous reports [ 7 , 10 ]. With autologous reconstruction, LD flaps tended to show more lateral deviation compared to DIEP flaps. This may be because the origin of the LD muscle is in the upper arm, and contraction pulls the NAC laterally. The use of LD flaps may have affected the difference in lateral malposition between autologous and implant cases. The procedure for dealing with LD muscle insertion (whether to cut the insertion or not) and thoracodorsal nerve differ depending on the facility, so one possibility is that NAC malposition occurred due to the outward pulling force of the musculature, particularly in facilities without disconnection of the LD muscle insertion. These findings are valuable because differences in NAC malposition among types of autologous flap have not previously been reported. Past studies have identified severe breast ptosis and breast size as risk factors for NAC asymmetry [ 8 , 16 ]. Many reports have stated that NSM is unsuitable for severely ptotic breasts [ 9 , 17 ], but no studies have examined associations between the degree of breast ptosis and NAC malposition. This study found no significant associations between the degree of breast ptosis according to the Regnault classification and either implant reconstruction or autologous tissue reconstruction. However, the number of cases with severe ptosis was small, which may have been why no significant differences were identified. In addition, only very weak correlations were observed between the amount of mastectomy and NAC malposition with both flap and implant reconstructions. One possibility that cannot be excluded is that some degree of selection bias may have existed in cases for which the weight of resected breast tissue was recorded, so the results of this retrospective study should be considered only as a reference. According to a past report, a vertical or Wise pattern incision is a risk factor for NAC malposition [ 9 ]. In our study, a significant difference was observed depending on the incision line used with flap reconstruction, but not with implant reconstruction. The NAC was thought to be pulled laterally by contraction of scar tissue forming at the incision line, but LD flaps tended to result in lateral deviation that might have affected this result for incision lines in flap reconstruction. Secondary healing after necrosis of the NAC or skin envelope is a risk factor of NAC malposition [ 17 ]. However, Choi et al. reported that necrosis of the NAC is not an obvious risk factor for malposition [ 9 ]. In this study, skin envelope necrosis and circulatory disorder of the NAC were not found to cause significant malpositioning of the NAC. This may have been a result of the small number of cases with these complications, but was still a new finding worth further investigation. The association between post-operative infection and NAC malposition has not yet been reported. Radiation therapy has been reported to cause NAC malposition [ 8 ], but some studies have found no association between radiation therapy and severe NAC malposition warranting resection [ 17 , 18 ]. In our study, both autologous and implant reconstructions caused significant NAC malposition in irradiated patients, supporting the finding that radiation therapy caused NAC malposition. NAC fixation by suture or the pull-down procedure using tape have been reported to prevent NAC malposition [ 19 – 21 ]. In our cases, no significant difference was observed according to the presence or absence of the pull-down operation. However, particularly with implants, some cases show severe cranial NAC malposition without the pull-down operation. Many reports have described revision operations for NAC malposition, but NAC fixation or pull-down measures for breast mount reconstruction appear effective and should be actively adopted to reduce patient burdens, both physically and mentally. Although there was no statistically significant difference in this study, this does not mean that the pull-down operation is unnecessary. Further case collection and study are required. These results should be considered when providing full information to patients making decisions on reconstructive methods. Patients who choose implant-based breast reconstruction should be aware of the risk of cranial malposition of the NAC during the post-operative course. The same applies for lateral malposition with LD flap reconstruction. Obviously, surgeons act to reduce post-operative complications and optimize the results of breast reconstruction. Moreover, we should consider adopting maneuvers like the pull-down method concurrently with formation of the breast mount. Various limitations of this study need to be kept in mind. First, almost all patients were Asian and we were unable to consider individuals from other ethnic backgrounds. Second, we assumed that the position of the NAC on the unaffected side before and after surgery would not change, and that imaging conditions would not be perfectly constant. Third, subcutaneous implant-based reconstruction was not considered because subpectoral implants are recommended by the guidelines used in Japan. Moreover, we could not consider the expansion speed of tissue expander cases, although early expansion reportedly reduces the risk of NAC malposition [ 10 ]. Finally, we could not completely remove the possibility of selection bias. Since this study was conducted as a retrospective analysis of cases from multiple institutions, surgical techniques could not be standardized. Conclusion We investigated NAC malposition following breast reconstruction after NSM in a large number of cases. Implant cases were more prone to cranial deviation than flap cases. In addition, we were able to obtain some insights into the tendencies and characteristics of NAC malposition. We should properly assess risks and proactively apply countermeasures to achieve the optimal results from NSM. Declarations Acknowledgments We are grateful to Dr. Masako Akiyama, Research Administration Division of Tokyo Medical and Dental University, for reviewing the analytical methods used in this study. This work was supported by Dr. Naoto Kondo, Dr. Chikako Yamauchi, Dr. Hiroko Nogi, Dr. Ayaka Shimo, and Dr. Teruhisa Sakurai, members of the Collaborative Study Group of Scientific Research of the Japanese Breast Cancer Society. Funding This research was supported by the 26 th Grant-in-Aid for Scientific Research from the Japanese Breast Cancer Society. Ethical approval and consent to participation All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The protocol was approved by the Institutional Ethics Committee of Okayama University as the lead investigator of the group study (2103-055), and by all collaborating institutions. For this type of study, formal consent is not required. Author contributions Conceptualization: HM. Methodology: SK, HM and SW. Data collection and investigation: All. Writing—analysis and original draft preparation: SK. Writing—review: HM, MS, SS, MI. Supervision: HM. Conflict of interest All authors have no conflict of interest. References Ogiya A, Nagura N, Shimo A, Nogi H, et al. 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Komiya T, Ojima Y, Ishikawa T, Matsumura H. Surgical techniques to prevent nipple-areola complex malposition in two-stage implant-based breast reconstruction. Arch Plast Surg. 2022;49(5):580–6. Sowa Y, Kodama T, Fuchinoue Y, Inafuku M, Terao M. Breast splint for prevention of nipple-areolar complex malposition after direct-to-implant breast reconstruction. Plast Reconstr Surg Glob Open. 2022;10(1):e3965. Cite Share Download PDF Status: Published Journal Publication published 08 Apr, 2024 Read the published version in Breast Cancer → Version 1 posted Editorial decision: Major Revision 25 Feb, 2024 Reviewers agreed at journal 12 Feb, 2024 Reviewers invited by journal 05 Feb, 2024 Editor assigned by journal 31 Jan, 2024 First submitted to journal 30 Jan, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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JFCR","correspondingAuthor":false,"prefix":"","firstName":"Mao","middleName":"","lastName":"Yamamoto","suffix":""},{"id":271426116,"identity":"13731b94-56b0-47fd-aa9a-0ec2a0fa1180","order_by":8,"name":"Kazutaka Narui","email":"","orcid":"","institution":"Yokohama City University Medical Center: Yokohama Shiritsu Daigaku Fuzoku Shimin Sogo Iryo Center","correspondingAuthor":false,"prefix":"","firstName":"Kazutaka","middleName":"","lastName":"Narui","suffix":""},{"id":271426117,"identity":"291a4b48-3637-4879-81eb-004a24bfff97","order_by":9,"name":"Junji Takano","email":"","orcid":"","institution":"Saitama Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Junji","middleName":"","lastName":"Takano","suffix":""},{"id":271426118,"identity":"f15fb0b2-89f3-4343-ac6a-52c4aed37555","order_by":10,"name":"Hirohito Seki","email":"","orcid":"","institution":"Saitama Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Hirohito","middleName":"","lastName":"Seki","suffix":""},{"id":271426119,"identity":"fe185f33-9e51-4ea3-ac3a-62a710fdf8af","order_by":11,"name":"Naomi Nagura","email":"","orcid":"","institution":"St Luke's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Naomi","middleName":"","lastName":"Nagura","suffix":""},{"id":271426120,"identity":"571a6087-38c5-4384-b28a-927bfaed487d","order_by":12,"name":"Makoto Ishitobi","email":"","orcid":"","institution":"Mie University: Mie Daigaku","correspondingAuthor":false,"prefix":"","firstName":"Makoto","middleName":"","lastName":"Ishitobi","suffix":""},{"id":271426121,"identity":"3df65485-0c4a-4734-834a-8f49c11e1b55","order_by":13,"name":"Tadahiko Shien","email":"","orcid":"","institution":"Okayama University: Okayama Daigaku","correspondingAuthor":false,"prefix":"","firstName":"Tadahiko","middleName":"","lastName":"Shien","suffix":""}],"badges":[],"createdAt":"2024-02-01 18:03:36","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3918288/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3918288/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s12282-024-01578-2","type":"published","date":"2024-04-08T15:00:34+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":50927167,"identity":"b0b81173-71f4-4878-b37e-b8024701a52e","added_by":"auto","created_at":"2024-02-09 17:15:02","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":129206,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eProcedure for using Mamma Balance and classifying NAC malposition\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eUpper\u003c/u\u003e:\u003c/p\u003e\n\u003cp\u003ea: A clinical photograph is taken\u003c/p\u003e\n\u003cp\u003eb: The photograph is uploaded into Mamma Balance and the midlines of the clavicles, both nipples and the navel or xiphoid process are marked.\u003c/p\u003e\n\u003cp\u003ec: The application makes two triangles: formed by midline of the clavicle, midline of the body and both nipples. The blue dashed line triangle represents the unaffected side, the red triangle represents the affected side.\u003c/p\u003e\n\u003cp\u003ed: The application calculates four numbers: the angle formed by the nipple, midline of the clavicle and midline of the body; the areas of the triangle formed by these points; the common area of these triangles; and the common area of these triangles as a percentage of the total area within each triangle. In this picture, the blue line is a part of mirror-reversed dashed triangle of Figure 1-c. The red line is a part of red triangle of Figure1-c. The green triangle represents the common area.\u003c/p\u003e\n\u003cp\u003ee: Values of V and H are determined from θ and area S (pixel value) using the below formulae:\u003c/p\u003e\n\u003cp\u003eO\u003csup\u003e2\u003c/sup\u003e=2S/cosθ×sinθ\u003c/p\u003e\n\u003cp\u003eV=√(2S/cosθ×sinθ)×cosθ\u003c/p\u003e\n\u003cp\u003eH=√(2S/cosθ×sinθ)×sinθ\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eLower\u003c/u\u003e:\u003c/p\u003e\n\u003cp\u003eAssuming that V and H on the unaffected side are constant pre- and post-operatively, we calculated the pre-operation/post-operation(pre/post-op) rate for V and H on the affected side:\u003c/p\u003e\n\u003cp\u003ef: V ratio \u0026lt;1; g: V ratio \u0026gt;1; h: H ratio \u0026lt;1; i: H ratio \u0026gt;1. “1” represents the same position as the unaffected side.\u003c/p\u003e","description":"","filename":"Slide1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3918288/v1/246b2488cc5d40aeb3eee6ed.jpg"},{"id":50925405,"identity":"6825d1cc-6d07-4c6e-83cb-1d1b3b4f0522","added_by":"auto","created_at":"2024-02-09 17:07:02","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":103084,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFlap vs implant, and flap types\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNumbers for each item indicate mean and standard deviation. We applied the Mann–Whitney U test for the post/pre-operative ratio of flap reconstruction (n=160) and implant reconstruction (n=196). Three fat graft and 1 latissimus flap + implant cases were excluded. The post/pre-operative ratio of vertical position (V) was significantly smaller with implants than with flaps (p\u0026lt;0.0001, implant: 0.91, flap: 0.98). Moreover, post/pre-operative ratio for Horizontal position (H) was significantly smaller with implants than with flaps (p=0.0209, implant: 0.98, flap: 1.01).\u003c/p\u003e\n\u003cp\u003eRegarding the type of flap, the Kruskal–Wallis test and Dunn's test with Bonferroni correction were used. A significant difference was found for lateral malposition DIEP flap vs LD flap (p=0.0344).\u003c/p\u003e\n\u003cp\u003eP-values are not shown for groups with no significant difference. Dashed lines indicate median and interquartile range in the violin plot.\u003c/p\u003e","description":"","filename":"Slide2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3918288/v1/39fed8bb82b3a8ed8b26b38b.jpg"},{"id":50925406,"identity":"428ca6ee-8b9d-4784-bd67-fcb26f30ef14","added_by":"auto","created_at":"2024-02-09 17:07:02","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":126136,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eBreast ptosis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNumbers for each item indicate mean and standard deviation, with comparisons by the degree of breast ptosis. The Kruskal–Wallis test and Dunn's test with Bonferroni correction were used. No significant difference was observed according to the degree of breast ptosis. Dashed lines indicate median and interquartile range in the violin plot.\u003c/p\u003e\n\u003cp\u003eRegnault 0: Nipple above the inframammary fold\u003c/p\u003e\n\u003cp\u003eRegnault 1: Nipple at the level of the\u003cstrong\u003e \u003c/strong\u003einframammary fold\u003c/p\u003e\n\u003cp\u003eRegnault 2: Nipple below the inframammary fold, but above the lower breast contour\u003c/p\u003e\n\u003cp\u003eRegnault 3: Nipple below the inframammary fold, and at the level of the lower breast contour\u003c/p\u003e","description":"","filename":"Slide3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3918288/v1/8d6cb5d560d2d8270d33fd89.jpg"},{"id":50925408,"identity":"76293bef-c691-4ac3-a23a-337fc2cf2561","added_by":"auto","created_at":"2024-02-09 17:07:02","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":150841,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eIncision line\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNumbers for each item indicate mean and standard deviation, with comparisons by incision line. Flaps showed significant differences in lateral malposition (p=0.0005), but implants showed no significant difference. The Mann–Whitney U test, Kruskal–Wallis test and Dunn's test with Bonferroni correction were applied. P-values are not shown for groups with no significant difference. Dashed lines indicate median and interquartile range in the violin plot.\u003c/p\u003e","description":"","filename":"Slide4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3918288/v1/f142240fa1765c1ca471be24.jpg"},{"id":50925409,"identity":"752a04ac-6690-448e-98f8-fd7b6243d3f4","added_by":"auto","created_at":"2024-02-09 17:07:02","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":84946,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePull-down procedure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNumbers for each item indicate mean and standard deviation, with comparisons by pull-down procedure. The Mann–Whitney U test was applied. No significant differences according to presence or absence of the pull-down operation were observed. Dashed lines indicate median and interquartile range in the violin plot.\u003c/p\u003e","description":"","filename":"Slide5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3918288/v1/fc2b88d5edb85f8c8037d342.jpg"},{"id":54712523,"identity":"c9f891e4-0cc9-41b0-88c6-43e4d3ccfd2d","added_by":"auto","created_at":"2024-04-15 15:08:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":727880,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3918288/v1/a12aed73-da6c-4e6f-a931-bb7a22bf860c.pdf"}],"financialInterests":"","formattedTitle":"Nipple-areolar complex malposition in breast reconstruction after nipple-sparing mastectomy: a multi-institutional retrospective observational study in Japan","fulltext":[{"header":"Introduction","content":"\u003cp\u003eNipple-sparing mastectomy (NSM) is an oncological surgical procedure that has been accepted for certain patient populations. This procedure allows patients to preserve the native nipple-areolar complex (NAC) and facilitates immediate, oncologically safe breast reconstruction [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. However, cranial and lateral NAC malposition is often reported as an issue with breast reconstruction after NSM [\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The position of the NAC represents an important factor in the aesthetic impression of the breast. The presence of the NAC is known to be associated with improved self-satisfaction and post-operative satisfaction in cases with serial mastectomy and breast reconstruction [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMany reports have described NAC malposition after NSM. While some reports have mentioned revision surgery for a malpositioned NAC, few have investigated the causes or risk factors. In addition, few reports have utilized quantitative, objective, unbiased measures to analyze NAC malposition in NSM [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Almost all of those few studies have included relatively small cohorts [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] and many reports have used photographs to assess NAC malposition. The recently developed Mamma Balance application (Medic Engineering K.K., Kyoto, Japan) allows the position of the NAC to be quantitatively evaluated [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. We designed the present multi-institutional retrospective observational study of NAC position with breast reconstruction after NSM with photographs and the Mamma Balance application. The purpose of this study was to evaluate the degree of NAC malposition depending on the following factors: use of implants or flaps; degree of ptosis; flap type; incision line; post-operative complications; use of the pull-down procedure; breast size; and post-operative radiation therapy.\u003c/p\u003e"},{"header":"Patients and Methods","content":"\u003cp\u003e We undertook a retrospective study of patients who had undergone unilateral breast reconstruction after NSM at the following facilities from 2007 to 2020: Tokyo Medical and Dental University Hospital, Okayama University Hospital, Hiroshima University Hospital, The Cancer Institute Hospital of JFCR, Yokohama City University Hospital, Japan Community Health Care Organization Saitama Medical Center, St. Luke\u0026rsquo;s International Hospital and Mie University Hospital. Subjects in this study were patients with photographs from pre-operatively and 6\u0026ndash;24 months post-operatively. Patients who had undergone contralateral revision, insertion of tissue expander before implant replacement on the affected side, or absence of the NAC on post-operative photographs were excluded.\u003c/p\u003e \u003cp\u003eWith Mamma Balance, two triangles are automatically created with vertices of the sternal notch, the nipple on either side and a point on a vertical line from the sternal notch to the umbilicus or xiphoid process. Mamma Balance provides information on the area of the resulting triangle in pixel values (S) and the angle between the midline and the line between the sternal notch and nipple (θ). We defined the following three lengths: from sternal notch to nipple (O); vertical line of the triangle (V); and horizontal line of the triangle (H). These values were calculated using the following formulas (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e):\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eO\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;2S/cosθ\u0026thinsp;\u0026times;\u0026thinsp;sinθ\u003c/p\u003e \u003cp\u003eV=\u0026radic;(2S/cosθ\u0026thinsp;\u0026times;\u0026thinsp;sinθ)\u0026times;cosθ\u003c/p\u003e \u003cp\u003eH=\u0026radic;(2S/cosθ\u0026thinsp;\u0026times;\u0026thinsp;sinθ)\u0026times;sinθ\u003c/p\u003e \u003cp\u003eWe assumed that lengths V and H on the unaffected side would not be changed post-operatively. We then calculated the post/pre-operative ratio of lengths V and H on the reconstructed side, corresponding to the degrees of post-operative craniocaudal and mediolateral malposition of the NAC. A post/pre-operative ratio for V less than 1 indicates cranial NAC malposition, while a ratio for H less than 1 reflects medial NAC malposition (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Differences in malpositioning due to the method of breast reconstruction, breast ptosis, flap type, incision type, breast amount, post-operative complications (hematoma, skin envelope necrosis, flap necrosis, circulation disorder of the NAC, and infection), pull-down fixation of the NAC, post-operative radiation therapy and the correlation between transition of NAC position and amount of mastectomy (in grams) were evaluated statistically. Surgical complications were classified using the Clavien\u0026ndash;Dindo classification.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eStatistical analysis was carried out using Prism 9 software (GraphPad Software, San Diego, CA). Values of p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 were considered significant. The Mann\u0026ndash;Whitney U test, Kruskal\u0026ndash;Wallis test and Dunn's test with Bonferroni correction were applied for group comparisons. Spearman\u0026rsquo;s rank correlation coefficient was used to examine correlations.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 360 unilateral breast reconstructions were included in this study. Mean age was 46.0 years (range, 23\u0026ndash;77 years), mean body mass index (BMI) was 21.6 kg/m\u003csup\u003e2\u003c/sup\u003e (standard deviation [SD] 3.08 kg/m\u003csup\u003e2\u003c/sup\u003e) and mean follow-up period was 15.2 months (SD 10.37 months). The reconstructive methods involved submuscular implants in 196 cases, free deep inferior epigastric artery perforator (DIEP) flaps in 84 cases, latissimus dorsi (LD) flaps in 62 cases, profunda artery perforator (PAP) flaps in 9 cases, gluteal artery perforator (GAP) flaps in 4 cases, lumbar artery perforator (LAP) flap in 1 case, and other in 4 cases (fat graft: 3 cases; latissimus flap\u0026thinsp;+\u0026thinsp;implant: 1). Incision type for implant-based reconstruction was as follows: lateral, 100 cases; inframammary fold (IMF), 26 cases; radial-lateral, 22 cases; radial-oblique, 18 cases; peri-areolar, 20 cases; and unknown, 10 cases. Incision type for flap reconstruction was lateral, 121 cases (59 DIEP, 48 LD, 9 PAP, 4 GAP, 1 LAP), IMF, 1 case (DIEP); radial-lateral, 2 cases (1 DIEP, 1 LD); peri-areolar, 32 cases (21 DIEP, 11 LD); and unknown, 4 cases. Twenty-eight patients needed post-operative radiation therapy (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient overview\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"11\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatients\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eReconstruction\u003c/p\u003e \u003cp\u003emethod\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eIncision\u003c/p\u003e \u003cp\u003eline\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eRadiation\u003c/p\u003e \u003cp\u003etherapy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e360\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003esubmuscular implant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e196\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eimplant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003elateral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46.0 (23\u0026ndash;77)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eflap\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eIMF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e332\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21.6 (3.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDIEP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eradial-lateral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFollow-up (months)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15.2 (10.37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eradial-oblique\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePAP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eperi-areolar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGAP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eunknown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLAP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eflap\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003elateral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e121\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDIEP 59, LD 48, PAP9, GAP 4, LAP 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eother\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eIMF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDIEP 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003efat graft\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eradial-lateral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDIEP 1, LD 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLD\u0026thinsp;+\u0026thinsp;implant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eradial-oblique\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eperi-areolar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDIEP 21, DD 11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eunknown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDIEP 2, LD 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"11\"\u003ePatient data are given as the average (range for age, standard deviation for BMI and follow-up).\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"11\"\u003eDIEP: deep inferior epigastric artery perforator flap\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"11\"\u003eLD, latissimus dorsi flap; PAP, profunda artery perforator flap; GAP, gluteal artery perforator flap; LAP, lumbar artery perforator flap.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eComparing between implant reconstruction (n\u0026thinsp;=\u0026thinsp;196) and flap reconstruction (n\u0026thinsp;=\u0026thinsp;160) showed that post/pre-operative ratio of horizontal position (H) was significantly smaller with implants than with flaps (p\u0026thinsp;=\u0026thinsp;0.0209, implant: 0.98, flap: 1.01). Moreover, the post/pre-operative ratio of vertical position (V) was significantly smaller with implants than with flaps (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001, implant: 0.91, flap: 0.98). Regarding flap type, lateral malposition was significantly more frequent with LD flap than with DIEP flap (p\u0026thinsp;=\u0026thinsp;0.0344) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eNo significant difference was observed according to the degree of breast ptosis (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eComparing by incision line, a significant difference in the frequency of lateral malposition was seen with flaps (p\u0026thinsp;=\u0026thinsp;0.0005), but not with implants (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eNo significant difference was observed according to the presence or absence of the pull-down operation (Fig.\u0026nbsp;6).\u003c/p\u003e \u003cp\u003eComparing the absence of post-operative complications and varying degrees of complications (hematoma, skin envelope necrosis, flap necrosis, infection, circulatory disorder of NAC), post/pre-operative ratio of V differed significantly between no infection and grade 3 infection (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCorrelations between amount of mastectomy, post-operative complications and radiation therapy\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFlap\u003c/p\u003e \u003cp\u003e(n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eV:flap\u003c/p\u003e \u003cp\u003e(ratio)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eH:flap\u003c/p\u003e \u003cp\u003e(ratio)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eImplant\u003c/p\u003e \u003cp\u003e(n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eV:implant\u003c/p\u003e \u003cp\u003e(ratio)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eH:implant\u003c/p\u003e \u003cp\u003e(ratio)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHematoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e155\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e187\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.97\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGrade \u0026le;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.04\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGrade \u0026ge;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.92\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSkin envelope necrosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e151\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e186\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.97\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGrade \u0026le;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGrade \u0026ge;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFlap necrosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e158\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGrade \u0026le;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGrade \u0026ge;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCirculation disorder of NAC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e137\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e168\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.89\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGrade \u0026le;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.89\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGrade \u0026ge;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.89\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInfection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e157\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e189\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.98\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGrade \u0026le;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.93\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGrade \u0026ge;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.72*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.93\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRadiation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e102\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e141\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.97\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.93\u0026dagger;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.85\u0026Dagger;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.97\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCorrelation with mastectomy amount (r)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e119\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.15 (0.111)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.21 (0.019)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e117\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-0.20 (0.034)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-0.12 (0.199)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003eComparisons were made between patients without complications and with varying degrees of complications. Regarding post-operative complications, the more severe the grade of infection (*p\u0026thinsp;=\u0026thinsp;0.0009, compared with no infection). The Mann\u0026ndash;Whitney U test, Kruskal\u0026ndash;Wallis test and Dunn's test with Bonferroni correction were applied.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003ePost/pre-operative ratio of V was significantly smaller with radiation therapy than without radiation therapy for both autologous and implant reconstruction (flap \u0026dagger;p\u0026thinsp;=\u0026thinsp;0.022, implant \u0026Dagger;p\u0026thinsp;=\u0026thinsp;0.014).\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003eThe correlation between amount of mastectomy (in grams) and NAC position transition is shown in the bottom row of the table as r (p-value). Spearman\u0026rsquo;s rank correlation coefficient was applied. In cases with flap reconstruction, a very weak negative correlation was identified between lateral transition and amount of mastectomy (r=-0.214, p\u0026thinsp;=\u0026thinsp;0.019). In cases with implant reconstruction, a very weak negative correlation existed between vertical transition and amount of mastectomy (r=-0.200, p\u0026thinsp;=\u0026thinsp;0.034).\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003eWe sorted the degree of post-operative complications according to the Clavien\u0026ndash;Dindo classification.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003eGrade 2: Requiring pharmacological treatment with drugs other than those allowed for grade 1 complications. Blood transfusions, antibiotics and total parenteral nutrition are also included.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003eGrade 3: Requiring surgical, endoscopic or radiological intervention.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eWith the use of radiation therapy, post/pre-operative ratio of V was significantly smaller than that in radiation-free cases with both autologous and implant reconstruction (flap: 0.93, p\u0026thinsp;=\u0026thinsp;0.022; implant: 0.87, p\u0026thinsp;=\u0026thinsp;0.014) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn terms of the correlation between transition of NAC position and amount of mastectomy (grams), in flap reconstruction cases, correlation coefficients were \u0026minus;\u0026thinsp;0.21 for lateral transition (p\u0026thinsp;=\u0026thinsp;0.019) and \u0026minus;\u0026thinsp;0.15 for vertical transition (p\u0026thinsp;=\u0026thinsp;0.111). In cases with implant reconstruction, correlation coefficients were \u0026minus;\u0026thinsp;0.12 for lateral transition (p\u0026thinsp;=\u0026thinsp;0.199) and \u0026minus;\u0026thinsp;0.20 for vertical transition (p\u0026thinsp;=\u0026thinsp;0.034) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study revealed the following results:\u003c/p\u003e \u003cp\u003e・The NAC was deviated more cranially and medially with implant reconstruction than with flap reconstruction;\u003c/p\u003e \u003cp\u003e・LD flap cases showed lateral deviation more often than DIEP flap cases;\u003c/p\u003e \u003cp\u003e・With flap reconstruction, lateral incisions were associated with lateral malposition and peri-areolar incisions were associated with medial NAC malposition;\u003c/p\u003e \u003cp\u003e・The NAC tended to be deviated cranially more often with severe post-operative implant infection than with no infection;\u003c/p\u003e \u003cp\u003e・The NAC deviated cranially with radiation in both implant and flap groups;\u003c/p\u003e \u003cp\u003e・A very weak correlation was apparent between larger mastectomy volume and greater cranial malposition of the NAC in both flap and implant cases.\u003c/p\u003e \u003cp\u003eVarious studies have examined NAC malposition in terms of grades [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], angles [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], subjective evaluations [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], vertical and horizontal balance [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], and more. Mamma Balance is original software that expresses NAC malposition in terms of area ratio. At this time, by replacing date from Mamma Balance with length, we were able to compare pre- and post-operative values in both vertical and Horizontal directions as continuous variables. This report is the first to quantify the degree of NAC malposition and compare risk factors in detail for a large number of cases.\u003c/p\u003e \u003cp\u003ePrevious studies have shown that both autologous and implant reconstructions carry a risk of NAC malposition (implant [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]; autologous [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]). In this study, implant reconstruction was seen to result in a significant risk of NAC cranial medial malposition. In contrast, the NAC tended to move more laterally with autologous reconstruction. These issues have been described in previous reports [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. With autologous reconstruction, LD flaps tended to show more lateral deviation compared to DIEP flaps. This may be because the origin of the LD muscle is in the upper arm, and contraction pulls the NAC laterally. The use of LD flaps may have affected the difference in lateral malposition between autologous and implant cases. The procedure for dealing with LD muscle insertion (whether to cut the insertion or not) and thoracodorsal nerve differ depending on the facility, so one possibility is that NAC malposition occurred due to the outward pulling force of the musculature, particularly in facilities without disconnection of the LD muscle insertion. These findings are valuable because differences in NAC malposition among types of autologous flap have not previously been reported.\u003c/p\u003e \u003cp\u003ePast studies have identified severe breast ptosis and breast size as risk factors for NAC asymmetry [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Many reports have stated that NSM is unsuitable for severely ptotic breasts [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], but no studies have examined associations between the degree of breast ptosis and NAC malposition.\u003c/p\u003e \u003cp\u003eThis study found no significant associations between the degree of breast ptosis according to the Regnault classification and either implant reconstruction or autologous tissue reconstruction. However, the number of cases with severe ptosis was small, which may have been why no significant differences were identified. In addition, only very weak correlations were observed between the amount of mastectomy and NAC malposition with both flap and implant reconstructions. One possibility that cannot be excluded is that some degree of selection bias may have existed in cases for which the weight of resected breast tissue was recorded, so the results of this retrospective study should be considered only as a reference.\u003c/p\u003e \u003cp\u003eAccording to a past report, a vertical or Wise pattern incision is a risk factor for NAC malposition [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In our study, a significant difference was observed depending on the incision line used with flap reconstruction, but not with implant reconstruction. The NAC was thought to be pulled laterally by contraction of scar tissue forming at the incision line, but LD flaps tended to result in lateral deviation that might have affected this result for incision lines in flap reconstruction.\u003c/p\u003e \u003cp\u003eSecondary healing after necrosis of the NAC or skin envelope is a risk factor of NAC malposition [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. However, Choi et al. reported that necrosis of the NAC is not an obvious risk factor for malposition [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In this study, skin envelope necrosis and circulatory disorder of the NAC were not found to cause significant malpositioning of the NAC. This may have been a result of the small number of cases with these complications, but was still a new finding worth further investigation. The association between post-operative infection and NAC malposition has not yet been reported.\u003c/p\u003e \u003cp\u003eRadiation therapy has been reported to cause NAC malposition [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], but some studies have found no association between radiation therapy and severe NAC malposition warranting resection [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. In our study, both autologous and implant reconstructions caused significant NAC malposition in irradiated patients, supporting the finding that radiation therapy caused NAC malposition.\u003c/p\u003e \u003cp\u003eNAC fixation by suture or the pull-down procedure using tape have been reported to prevent NAC malposition [\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. In our cases, no significant difference was observed according to the presence or absence of the pull-down operation. However, particularly with implants, some cases show severe cranial NAC malposition without the pull-down operation. Many reports have described revision operations for NAC malposition, but NAC fixation or pull-down measures for breast mount reconstruction appear effective and should be actively adopted to reduce patient burdens, both physically and mentally. Although there was no statistically significant difference in this study, this does not mean that the pull-down operation is unnecessary. Further case collection and study are required.\u003c/p\u003e \u003cp\u003eThese results should be considered when providing full information to patients making decisions on reconstructive methods. Patients who choose implant-based breast reconstruction should be aware of the risk of cranial malposition of the NAC during the post-operative course. The same applies for lateral malposition with LD flap reconstruction. Obviously, surgeons act to reduce post-operative complications and optimize the results of breast reconstruction. Moreover, we should consider adopting maneuvers like the pull-down method concurrently with formation of the breast mount.\u003c/p\u003e \u003cp\u003eVarious limitations of this study need to be kept in mind. First, almost all patients were Asian and we were unable to consider individuals from other ethnic backgrounds. Second, we assumed that the position of the NAC on the unaffected side before and after surgery would not change, and that imaging conditions would not be perfectly constant. Third, subcutaneous implant-based reconstruction was not considered because subpectoral implants are recommended by the guidelines used in Japan. Moreover, we could not consider the expansion speed of tissue expander cases, although early expansion reportedly reduces the risk of NAC malposition [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Finally, we could not completely remove the possibility of selection bias. Since this study was conducted as a retrospective analysis of cases from multiple institutions, surgical techniques could not be standardized.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWe investigated NAC malposition following breast reconstruction after NSM in a large number of cases.\u003c/p\u003e \u003cp\u003eImplant cases were more prone to cranial deviation than flap cases. In addition, we were able to obtain some insights into the tendencies and characteristics of NAC malposition. We should properly assess risks and proactively apply countermeasures to achieve the optimal results from NSM.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cu\u003eAcknowledgments\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe are grateful to Dr. Masako Akiyama, Research Administration Division of Tokyo Medical and Dental University, for reviewing the analytical methods used in this study.\u003c/p\u003e\n\u003cp\u003eThis work was supported by Dr. Naoto Kondo, Dr. Chikako Yamauchi, Dr. Hiroko Nogi, Dr. Ayaka Shimo, and Dr. Teruhisa Sakurai, members of the Collaborative Study Group of Scientific Research of the Japanese Breast Cancer Society.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was supported by the 26\u003csup\u003eth\u003c/sup\u003e Grant-in-Aid for Scientific Research from the Japanese Breast Cancer Society.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.\u003c/p\u003e\n\u003cp\u003eThe protocol was approved by the Institutional Ethics Committee of Okayama University as the lead investigator of the group study (2103-055), and by all collaborating institutions.\u003c/p\u003e\n\u003cp\u003eFor this type of study, formal consent is not required.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization: HM. Methodology: SK, HM and SW. Data collection and investigation: All. Writing\u0026mdash;analysis and original draft preparation: SK. Writing\u0026mdash;review: HM, MS, SS, MI. Supervision: HM.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors have no conflict of interest.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eOgiya A, Nagura N, Shimo A, Nogi H, et al. Long-term outcomes of breast cancer patients with local recurrence after mastectomy undergoing immediate breast reconstruction: a retrospective multi-institutional study of 4153 cases. Ann Surg Oncol. 2023;30(11):6532\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSalgarello M, Visconti G, Barone-Adesi L. Nipple-sparing mastectomy with immediate implant reconstruction: cosmetic outcomes and technical refinements. Plast Reconstr Surg. 2010;126(5):1460\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSmall K, Kelly MK, Swistel A, Dent LB, Taylor ME, Talmor M. Surgical treatment of nipple malposition in nipple-sparing mastectomy device-based reconstruction. Plast Reconstr Surg. 2014;133(5):1053\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHart A, Doyle K, Losken A, Carlson G, et al. Nipple malposition after bilateral nipple-sparing mastectomy with implant-based reconstruction: Objective postoperative analysis utilizing BCCT.core computer software. Breast J. 2020;26(7):1270\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMetcalfe KA, Semple LJ, Li DXL, Bagher S, Zhong T, et al. Long-Term Psychosocial Functioning in Women with Bilateral Prophylactic Mastectomy: Does Preservation of the Nipple-Areolar Complex Make a Difference? Ann Surg Oncol. 2015;22(10):3324\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWellisch DK, Schain WS, Noone RB, Little JW, et al. The psychological contribution of nipple addition in breast reconstruction. Plast Reconstr Surg. 1987;80(5):699\u0026ndash;704.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMori H, Umeda T, Osanai T, Hata Y. Esthetic evaluation of immediate breast reconstruction after nipple- sparing or skin-sparing mastectomy. Breast Cancer. 2005;12(4):299\u0026ndash;303.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSpear SL, Albino FP, Al-Attar A. Classification and management of the postoperative, high-riding nipple. Plast Reconstr Surg. 2013;131(6):1413\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChoi M, Frey JD, Salibian AA, Karo NS. Nipple-areola complex malposition in nipple-sparing mastectomy: a review of risk factors and corrective techniques from greater than 1000 reconstructions. Plast Reconstr Surg. 2017;140(2):247e\u0026ndash;57.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMakiguchi T, Nakamura H, Fujii T, Yokoo S. Quantitative assessment and risk factors for nipple-areolar complex malposition after nipple-sparing mastectomy. Breast Cancer. 2019;26(1):58\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMukai Y, Watanabe S, Matsumoto M, Saiga M, Kimata Y. Reliability and validity of Mamma Balance((R)): novel software to assess the symmetry of the nipple-areola-complex position. J Plast Reconstr Aesthet Surg. 2017;70(8):1147\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim H, Park SJ, Woo KJ, Bang SI. 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Techniques and outcomes of nipple sparing mastectomy in the surgical management of breast cancer. Curr Breast Cancer Rep. 2013;5(2):118\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChoi M, Frey JD. Optimizing aesthetic outcomes in breast reconstruction after nipple-sparing mastectomy. Aesthet Surg J. 2020;40(Suppl 2):S13\u0026ndash;S21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChu CK, Davis MJ, Abu-Ghname A, Winocour SJ, Losken A, Carlson GW. Implant reconstruction in nipple sparing mastectomy. Semin Plast Surg. 2019;33(4):247\u0026ndash;57.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReish RG, Lin A, Phillips NA, Winograd J, Liao EC, Cetrulo CL, et al. Breast reconstruction outcomes after nipple-sparing mastectomy and radiation therapy. Plast Reconstr Surg. 2015;135(4):959\u0026ndash;66.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMayer AP, Goodreau AM, Blanchet NP. \u003cem\u003eAccurate nipple areolar positioning in nipple-sparing mastectomy reconstruction.\u003c/em\u003e Plast Reconstr Surg Glob Open, 2019. 7(1): p. e2064.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKomiya T, Ojima Y, Ishikawa T, Matsumura H. Surgical techniques to prevent nipple-areola complex malposition in two-stage implant-based breast reconstruction. Arch Plast Surg. 2022;49(5):580\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSowa Y, Kodama T, Fuchinoue Y, Inafuku M, Terao M. Breast splint for prevention of nipple-areolar complex malposition after direct-to-implant breast reconstruction. Plast Reconstr Surg Glob Open. 2022;10(1):e3965.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"breast-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"brca","sideBox":"Learn more about [Breast Cancer](http://link.springer.com/journal/12282)","snPcode":"12282","submissionUrl":"https://www.editorialmanager.com/brca/default2.aspx","title":"Breast Cancer","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"breast reconstruction, NSM, nipple-areolar complex, NAC, malposition","lastPublishedDoi":"10.21203/rs.3.rs-3918288/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3918288/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePosition of the nipple-areolar complex (NAC) is an important factor in the aesthetic impression of the breast, and NAC malposition is often an issue in breast reconstruction after nipple-sparing mastectomy (NSM). The purpose of this study was to evaluate the degree of NAC malposition depending on several factors using data quantified with the Mamma Balance application (Medic Engineering K.K., Kyoto, Japan).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003ePatients who underwent unilateral breast reconstruction after NSM at 8 hospitals in Japan between 2007 and 2020 were retrospectively investigated. Using Mamma Balance, NAC malposition was quantified separately in horizontal and vertical directions using patient photographs from pre-operatively and 6\u0026ndash;24 months post-operatively. The degree of malpositioning was then statistically compared using various factors.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe NAC deviated more cranially and medially with implants than with flaps. Cases with latissimus dorsi flap showed lateral malposition more often than cases with deep inferior epigastric artery perforator flap. With flaps, lateral incisions showed more lateral malposition and peri-areolar incisions tended to show more medial NAC malposition. In cases with severe post-operative infection of the implant, the NAC tended to deviate cranially. In radiation cases, the NAC deviated cranially. No significant difference was observed according to degree of breast ptosis or use of the pull-down operation. Only a very weak correlation was observed between a larger amount of mastectomy and more cranial NAC malposition with both flaps and implants.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThis study provides insights into the tendencies and characteristics of NAC malposition.\u003c/p\u003e","manuscriptTitle":"Nipple-areolar complex malposition in breast reconstruction after nipple-sparing mastectomy: a multi-institutional retrospective observational study in Japan","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-09 17:06:57","doi":"10.21203/rs.3.rs-3918288/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major Revision","date":"2024-02-25T17:33:27+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2024-02-12T10:40:24+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-02-05T22:56:40+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-01-31T14:47:54+00:00","index":"","fulltext":""},{"type":"submitted","content":"Breast Cancer","date":"2024-01-31T04:03:33+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"breast-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"brca","sideBox":"Learn more about [Breast Cancer](http://link.springer.com/journal/12282)","snPcode":"12282","submissionUrl":"https://www.editorialmanager.com/brca/default2.aspx","title":"Breast Cancer","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"4addf35b-8e85-42e6-aa62-9f72336b5365","owner":[],"postedDate":"February 9th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-04-15T15:02:55+00:00","versionOfRecord":{"articleIdentity":"rs-3918288","link":"https://doi.org/10.1007/s12282-024-01578-2","journal":{"identity":"breast-cancer","isVorOnly":false,"title":"Breast Cancer"},"publishedOn":"2024-04-08 15:00:34","publishedOnDateReadable":"April 8th, 2024"},"versionCreatedAt":"2024-02-09 17:06:57","video":"","vorDoi":"10.1007/s12282-024-01578-2","vorDoiUrl":"https://doi.org/10.1007/s12282-024-01578-2","workflowStages":[]},"version":"v1","identity":"rs-3918288","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3918288","identity":"rs-3918288","version":["v1"]},"buildId":"J0_U0BvcaRcwD8yVFaRlm","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}