Color Differences of Skin Paddles Using the Free Flap for Autologous Breast Reconstruction in Asian Patients

Color Differences of Skin Paddles Using the Free Flap for Autologous Breast Reconstruction in Asian Patients | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Color Differences of Skin Paddles Using the Free Flap for Autologous Breast Reconstruction in Asian Patients Kengo Nakatsuka, Ryo Karakawa, Tomoyuki Yano This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4879228/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 25 Nov, 2024 Read the published version in Breast Cancer → Version 1 posted 5 You are reading this latest preprint version Abstract Background In this study, we aimed to evaluate color differences of the skin paddle in autologous breast reconstruction performed using the deep inferior epigastric artery perforator (DIEP) flap and the profunda artery perforator (PAP) flap. The primary focus was to compare the color match between the reconstructed breast skin and the donor-site skin, to achieve optimal esthetic results. Methods A retrospective analysis was performed on patients who had undergone unilateral breast reconstruction with a DIEP flap or a PAP flap between January 2020 and December 2022. Colors were captured using a digital camera and analyzed using Adobe Photoshop 2024 software. The L*, a*, and b* coordinates were used. The International Commission on Illumination Delta E 2000 (CIEDE2000) score was used to quantify color differences, comparing skin tones of the unaffected breast, DIEP flap, PAP flap, abdomen, and medial thigh. Results A total of 125 patients were analyzed. The DIEP flap demonstrated a closer color match to the native breast skin compared with the PAP flap (CIEDE2000 scores, 5.29 vs. 8.69, p < 0.01). No significant difference in color deformity with time was found between the DIEP flap and the PAP flap (CIEDE2000 scores, 5.61 vs. 8.25, p = 0.17). Conclusion Our findings suggest that the DIEP flap results in a more favorable color match for breast reconstruction than the PAP flap, enhancing esthetic outcomes. These results underscore the importance of considering skin color matching in flap selection for breast reconstruction surgery. Figures Figure 1 Figure 2 Figure 3 Introduction Autologous breast reconstruction is playing an increasingly important role in the comprehensive treatment of breast cancer, owing to its positive effects on the long-term psychosexual health of breast cancer survivors [ 1 , 2 ]. The deep inferior epigastric artery perforator (DIEP) flap is globally accepted as the first choice in autologous breast reconstruction, owing to its advantages in creating a natural breast mound with long-lasting esthetic results, a low rate of complications, and acceptable donor-site morbidity [ 3 , 4 ]. However, for some patients, the DIEP flap may not be the most favorable option, particularly when a patient has the preference to avoid abdominal scars, or for young women without redundant abdominal tissue or very thin abdominal tissue, women with the possibility of future pregnancy, and women with multiple abdominal scars [ 5 , 6 ]. The wide range of patients’ physical features and preferences has encouraged breast reconstructive surgeons to seek alternative flaps from different donor sites. As free flaps that do not require positional changes during the operation, thigh-based flaps such as the profunda artery perforator (PAP) flap and the transverse myocutaneous gracilis (TMG) flap, are considered a favorable choice for small to moderate-size autologous breast reconstructions [ 7 – 9 ]. They provide a relatively large amount of tissue that can be easily shaped to mimic a natural breast mound [ 10 , 11 ]. Breast reconstruction using the PAP flap has demonstrated constant vascular anatomy with enough length pedicle and adequate vessel diameter for sufficient microvascular anastomoses, which was associated with low donor-site morbidity and favorable cosmetic results [ 5 , 12 ]. In breast reconstruction using autologous tissue, a skin paddle is necessary for postoperative monitoring of the flap and for replenishing the missing skin of the patient by secondary reconstruction without using a tissue expander [ 13 ]. However, leaving the skin paddle in place after breast reconstruction results in a patchwork pattern on the breast [ 14 , 15 ]. The skin paddle after breast reconstruction with autologous tissue is handled differently in each case. In some facilities, the skin paddle is routinely excised at least three months after surgery, whereas in other facilities, the skin paddle is not always excised [ 16 – 18 ]. Especially in an irradiated breast, the breast envelope shows contracture, less vascular perfusion, and pigmentation. In some cases, the breast envelope should be replaced with a flap skin, resulting in relatively large exposure of the skin paddle [ 19 , 20 ]. When aiming for a more symmetrical breast, the color match between the skin paddle and the breast skin is important in terms of appearance, as well as form. There have been no papers describing color matching between the skin paddle and breast skin envelope after breast reconstruction using autologous tissue in Asian patients. Similarly, it has not been described whether skin paddle coloration changes postoperatively. In 2001, in an attempt to improve the CIELab formula, which quantifies the difference between two colors (ΔE*ab=[(ΔL*)2+(Δa*)2+(Δb*)2]1/2), the International Commission on Illumination developed a more sophisticated formula, namely, the International Commission on Illumination Delta E 2000 (CIEDE2000), to calculate color differences [ 21 ]. The CIEDE2000 formula reflects the color differences perceived by the human eye better than the CIELab formula [ 22 , 23 ]. Therefore, CIEDE2000 was used in the present study. The primary objective of this study is to compare the degree of color match achieved by using the DIEP flap and PAP flap. The secondary objective of this study is to compare the skin color of different parts of the body including the breast, abdominal, and lateral thigh. The tertiary objective of this study is to compare the skin paddle's color deformity of the DIEP flap and PAP flap. Patients and Methods Patients The study was approved by the Institutional Review Board of the Cancer Institute Hospital of the Japanese Foundation for Cancer Research (study approval no.: 2022-GB-171). Patients who had undergone unilateral breast reconstruction using a DIEP flap or a single PAP flap between January 2020 and December 2022 were included. Pictures of all patients taken at least one year postoperatively were used. Exclusion criteria included patients who had undergone radiation after breast reconstruction. Patient demographic data obtained from the medical records included age, sex, ethnicity, body mass index (BMI), history of smoking, flap type, and length of follow-up. In the outpatient clinic, pictures of the breast, abdomen, and medial thigh were taken using a digital camera with a ring flash, and a color marker (CasMatch; Bear Medic Corp., Tokyo, Japan) to adjust the color values of the images to compare them under the same conditions. Color Measurement The points of color measurement were as follows: (a) the skin color of the unaffected side of the breast was measured at a point 3-cm cephalic from the nipple of the unaffected breast (Fig. 1 ); (b) the skin color of the DIEP flap was measured at the midpoint of the DIEP flap (Fig. 1 ); (c) the skin color of the PAP flap was measured at the midpoint of the PAP flap (Fig. 2 ); (d) the skin color of the abdomen was measured at a point 3-cm cephalic from the midpoint of the postoperative abdominal wound (Fig. 1 ); and (e) the skin color of the medial thigh was measured at a point 3 cm horizontally anterior to the midpoint of the femoral wound (Fig. 3 ). After the skin color of the flap was calibrated in reference to CasMatch and using Adobe Photoshop 2024 software (Adobe Inc., San Jose, CA), the average values of the L* (lightness), a* (red/green), and b* (yellow/blue) color coordinates in five-pixel squares were measured. The procedure was performed five times, and the average values of the L*, a*, and b* color coordinates were measured. The CIEDE2000 scores were calculated to obtain the difference between the skin color of the unaffected side of the breast and the skin color of the DIEP flap (a–b); the color difference between the skin color of the unaffected side of the breast and the skin color of the PAP flap (a–c); the color difference between the skin color of the unaffected side of the breast and the skin color of the abdomen (a–d); the color difference between the skin color of the unaffected side of the breast and the skin color of the medial thigh (a–e), the skin color of the DIEP flap and the skin color of the abdomen (b–d); and the color difference between the skin color of the PAP flap and the skin color of the medial thigh (c–e). The CIEDE2000 score is an objective measure of difference between colors, which accounts for lightness, chroma, and hue weighting [ 24 ]. A CIEDE2000 value of 1.0 represents the smallest color difference that the human eye can detect. Higher values indicate more noticeable differences in color, which in this context means a less accurate color match. Color differences were calculated using a mathematical formula (Electronic supplementary material, Fig. 1 ). The average CIEDE2000 score between the skin color of the unaffected side of the breast and the skin color of the DIEP flap (a–b), and the average CIEDE2000 score between the skin color of the unaffected side of the breast and the skin color of the PAP flap (a–c) were used for colorimetric analysis of the color match by the DIEP flap and the PAP flap, respectively. The average CIEDE2000 score between the skin color of the unaffected side of the breast and the skin color of the abdomen (a–d), and the average CIEDE2000 score of the difference between the skin color of the unaffected side of the breast and the skin color of the medial thigh (a–e) were used for colorimetric analysis of the color match with the original color of the donor site. The average CIEDE2000 between the skin color of the DIEP flap and the skin color of the abdomen (b–d), and the color difference between the skin color of the PAP flap and the skin color of the medial thigh (c–e) were used for colorimetric analysis of the skin color changes over time after harvesting the flap. Statistical Analysis Statistical analyses were performed using IBM SPSS Statistics 29.0 software (IBM SPSS, Chicago, IL). A p -value of less than 0.05 was considered to indicate a statistically significant difference between groups. Data are presented as means and standard deviations. Demographic data were compared between the different reconstructive methods using the t -test. The mean color difference in each body part in this study was compared using the t -test. The chromaticity of three parts of the body and skin paddle was analyzed using analysis of variance (ANOVA). Results Patients Table 1 presents the demographic information of the patients. A total of 125 patients were identified as having undergone unilateral breast reconstruction using a DIEP flap or a PAP flap. Patient demographic data obtained from the medical records included age, BMI, history of smoking, flap type, and length of follow-up. All the patients were women, with a mean age of 51.56 (range: 29 to 67) years, and an average BMI of 22.51 kg/m 2 . The patients were all Japanese. Regarding Fitzpatrick skin type, all the patients were 3 or 4. The DIEP flap was used in 77 (62%) of the autologous tissue breast reconstructions. The PAP flap was used in 48 (38%) of the reconstructions. Five patients (4%) had a smoking history, and 120 patients (96%) were nonsmokers. The average length of follow-up was 15.27 months in DIEP flap patients and 14.25 months in PAP flap patients. All the PAP flaps were designed vertically. Table 1 Background characteristics of the patients All patients n = 125 DIEP flap PAP flap n = 77 n = 48 p -value Age, years (mean ± SD) 52.41 ± 6.71 50.21 ± 7.23 0.71 BMI,kg/m² (mean ± SD) 23.41 ± 3.01 21.06 ± 2.95 0.76 Smoking history (n) 3 (3.9%) 2 (4.2%) 0.81 Length of followup, month (mean ± SD) 15.27 ± 5.34 14.25 ± 4.68 0.62 DIEP, deep inferior epigastric artery perforator; PAP, profunda artery perforator; SD, standard deviation. Color Measurement Table 2 presents the skin colors by body parts, and the differences in the values for L*, a*, and b* among the body parts and flap types. Among the breast, abdomen, and medial thigh, the site with the lightest skin was the breast (L*: 74.32), whereas the darkest skin was the medial thigh (L*: 65.43). Redness and yellowness were highest in the medial thigh (a*: 12.35; b*: 18.81), and lowest in the breast (a*: 7.2; b*: 14.59). Comparing the two flap types, the DIEP flap was lighter in color (L*: 68.76). Redness and yellowness were higher in the PAP flap (a*: 9.33; b*: 21.37). Table 2 Chromaticity of 3 parts of the body and each flap Breast Abdomen Medial thigh DIEP flap PAP flap n = 125 n = 77 n = 48 n = 77 n = 48 F -value p -value L* (mean ± SD) 74.32 ± 4.67 66.08 ± 4.7 65.43 ± 6.4 68.76 ± 4.45 67.41 ± 5.23 3.02 < 0.01 a* (mean ± SD) 7.2 ± 2.08 8.59 ± 2.18 12.35 ± 2.37 7.7 ± 2.16 9.33 ± 2.85 3.05 < 0.01 b* (mean ± SD) 14.59 ± 3.4 15.22 ± 3.04 18.81 ± 3.44 18.4 ± 3.9 21.37 ± 3.65 3.01 < 0.01 DIEP, deep inferior epigastric artery perforator; PAP, profunda artery perforator; SD, standard deviation. The mean color difference between each body part is shown in Table 3 . There was less color difference between the unaffected side of the breast and the DIEP flap (a–b) than between the unaffected side of the breast and the PAP flap (a–c) (CIEDE2000 scores, 5.29 vs. 8.69, p < 0.01). Furthermore, there was less color difference between the unaffected side of the breast and the abdominal region (a–d) than between the unaffected side of the breast and the medial thigh (CIEDE2000 scores, 3.61 vs. 10.71, p < 0.01). There was no statistically significant difference between the skin paddle’s color deformity between the DIEP flap (b–d) and the PAP flap (c–e) (CIEDE2000 scores, 5.61 vs. 8.25, p = 0.17). Table 3 Mean color differences between various body parts DIEP flap PAP flap n = 77 n = 48 p - value Breast - Skin paddle a-b a-c (mean ± SD) 5.26 ± 2.6 8.69 ± 4.59 < 0.01 Breast - Donor site a-d a-e (mean ± SD) 3.61 ± 2.29 10.71 ± 4.8 < 0.01 Skin paddle - Donor site b-d c-e (mean ± SD) 5.61 ± 2.84 8.25 ± 4.2 0.17 DIEP, deep inferior epigastric artery perforator; PAP, profunda artery perforator; SD, standard deviation. a–b: difference between the skin color of the unaffected side of the breast and the skin color of the DIEP flap a–c: difference between the skin color of the unaffected side of the breast and the skin color of the PAP flap a–d: difference between the skin color of the unaffected side of the breast and the skin color of the abdomen a–e: difference between the skin color of the unaffected side of the breast and the skin color of the medial thigh b–d: difference between the skin color of the DIEP flap and the skin color of the abdomen c–e: difference between the skin color of the PAP flap and the medial thigh Discussion Breast reconstruction using autologous tissue enables the reconstruction of a breast that resembles the softness and temperature of a natural breast. In many cases, a skin paddle is used to monitor the condition of the flap after breast reconstruction [ 14 , 15 ]. In addition, skin paddles are required for immediate, delayed, and irradiated breast reconstruction when the skin envelope is not sufficiently expanded [ 13 ]. Revision surgery after breast reconstruction is partly at the patient's request. In examining the cosmetic aspects of the breast, the symmetry of the morphology is worked out at various facilities [ 25 , 26 ]. While symmetry of form is important in the consideration of the shape, the color match of the skin paddle is also an important factor. However, there are no reports focusing on the color matching of skin paddles in breast reconstruction with a large population of Asian patients. In this paper, we summarize the color difference between the skin paddle and the native skin, and the postoperative changes of the skin paddle in breast reconstruction using the DIEP flap and the PAP flap more than a year after the surgery. Several previous studies compared the degree of color match between the skin graft and the original skin in various head and neck reconstructive techniques, by analyzing digital photographs taken of patients, and calculating an objective biomedical measurement of color perception, namely, CIEDE2000 [ 27 , 28 ]. In the study by Knott et al., on average, split-thickness skin grafts over de-epithelialized myogenous and adipofascial free tissue transfers resulted in a closer color match than the skin paddles of donor sites, with the exception of the radial forearm donor site [ 27 ]. Dermody et al. performed an objective analysis of color match in patients who had undergone free tissue reconstruction following surgery for head and neck cancer [ 28 ]. When analyzing the absolute values of CIEDE2000 scores, there are no direct comparisons available for assessing human skin color. Nevertheless, other industries have created standards to ensure consistent color quality control across different materials. In previous studies comparing skin color differences, the American Society of Testing and Materials lightfastness scale was utilized to evaluate color differences based on CIEDE2000 scores [ 28 , 29 ]. Lightfastness I indicates excellent lightfastness, demonstrating a mean color change of less than four. Lightfastness II indicates very good lightfastness, with a mean color change of more than four but not more than eight. Lightfastness III indicates fair lightfastness, showing a mean color change of more than eight but not more than 16. Lightfastness Ⅳ indicates poor lightfastness, showing a mean color change of more than 16 but not more than 24. Lightfastness Ⅴ indicates very poor lightfastness, showing a mean color change of more than 24 (Table 4 ). Based on these standards, when evaluating the color match between the breast and the used flaps, the color difference between the DIEP flap and the breast was rated as very good, whereas the color difference between the PAP flap and the breast was rated as fair. From the perspective of color matching, it is advisable to use a tissue expander to stretch the breast skin when utilizing a PAP flap, to minimize the skin paddle. Furthermore, the PAP flap is not recommended for secondary reconstruction, in which a large amount of donor site skin is required. Table 4 The evaluation of the color differences based on CIEDE2000 scores Classification CIEDE2000 Perception Lightfastness I < 4 Excellent Lightfastness Ⅱ 4 to 7.9 Very good Lightfastness Ⅲ 8 to 15.9 Fair Lightfastness Ⅳ 16 to 23.9 Poor Lightfastness Ⅴ 24≦ Very poor Human skin varies in color tone from region to region [ 30 ]. Factors affecting color tone include melanocytes, blood vessels, telangiectasias, lentigines, hair follicles, ephelides, collagen density, and dermal thickness [ 31 ]. Optically, incident light on the skin is absorbed by pigments, such as melanin and hemoglobin in the skin, and diffuse reflected light enters the eye through scattering from the dermis and is recognized by the eye. Therefore, skin color is substantially affected by various factors, such as melanin, hemoglobin, and stratum corneum thickness [ 32 ]. Several studies have been published regarding standard CIELab values for various ethnic groups [ 33 , 34 ]. Han et al. measured the skin color of 600 Korean volunteers using the same chroma meter as used in this study, to investigate which free-flap donor sites were colorimetrically appropriate for facial cutaneous reconstruction [ 33 ]. The CIELab values, including those for the breast, abdomen, and thigh in Korean subjects demonstrated a similar pattern to the CIELab values shown in our results. The color difference between the skin paddle and its surroundings was larger for the PAP flap than for the DIEP flap in color matching after reconstruction using different free flaps. Using CIEDE2000, Mahrhofer et al. evaluated the skin color difference between the DIEP flap and the TMG flap in 60 Caucasian patients who had undergone unilateral secondary breast reconstruction [ 35 ]. A comparison between the DIEP flap and the TMG flap more than a year postoperatively demonstrated that the DIEP flap showed a preferable color match compared to the TMG flap (CIEDE2000 scores, 2.8 vs. 4.0, p = 0.009). In studies with different races, breast reconstruction using the DIEP flap showed a better color match, as in the present study. In addition, comparing the color match reconstructed by using the PAP flaps of Asian patients in our study and the TMG flaps of Caucasian patients in the previous research, there was a clear difference in coloration in the Asian patients (CIEDE2000 scores, 8.69 vs. 4.0). This result shows that color matching is significant in breast reconstruction using PAP flaps in Asian patients. An interesting finding of our present study was that skin paddle coloration changes postoperatively. Regardless of the type of flap, there was an increase in L* and decrease in a* in the skin paddle and donor site. Yamamoto et al. evaluated the skin color of the transferred flap and the donor region by means of a chroma meter in nine patients who underwent head and neck reconstruction, and three patients who underwent breast reconstruction [ 34 ]. A comparison between the transferred flaps and the donor sites demonstrated that the L* and a* values of the flaps used for facial reconstruction were noticeably different from those of the donor regions. In the three patients who underwent breast reconstruction using the transverse rectus abdominis myocutaneous (TRAM) flap, the color tone of the skin paddle was compared with that of the donor area. Although the number of cases was small, the study also showed an increase in L* and a decrease in a* in patients who underwent breast reconstruction using the TRAM flap. Reasons may include the breast region being strongly stretched by the surrounding skin. Our study has some limitations. First, the study was performed using a group of patients of a single race, and hence the possibility that the results may vary by race cannot be ruled out. Second, the color data of the donor area in this study were obtained at the time of the postoperative outpatient clinic appointment, and are not preoperative data. However, the abdomen and inner thighs are nonexposed areas and are considered to be minimally affected by ultraviolet light, so we believe that the use of this data as preoperative color of the donor area did not greatly affect our results. To summarize, our study's results demonstrated a clear difference in color matching when comparing the skin of the abdomen and thighs to the breast, and that the DIEP flap has a less noticeable postoperative color difference with the breast compared with the PAP flap. Declarations Conflicts of Interest None declared. Ethics This report was published with the consent and permission of the patients involved. Funding None. Acknowledgments None. References Costanzo D, Klinger M, Lisa A, Maione L, Battistini A, Vinci V. The evolution of autologous breast reconstruction. 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Colorimetric evaluation of skin color in the Japanese. Plast Reconstr Surg. 1995;96(1):139–45. Mahrhofer M, Reichert R, Fierdel F, Gu X, Grabenwöger J, Russe E, Schoeller T et al. Photometric Comparison of Skin Color Match between Abdominal- and Thigh-Based Free Flaps for Breast Reconstruction in Caucasian Patients. Plast Reconstr Surg. 2024 May 20. Supplementary Files Supplementalfigure1.pdf Electronic supplementary material Figure 1.CIEDE2000 was calculated by the following mathematical formula. Cite Share Download PDF Status: Published Journal Publication published 25 Nov, 2024 Read the published version in Breast Cancer → Version 1 posted Editorial decision: Minor Revision 29 Sep, 2024 Reviewers agreed at journal 31 Aug, 2024 Reviewers invited by journal 13 Aug, 2024 Editor assigned by journal 09 Aug, 2024 First submitted to journal 08 Aug, 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. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4879228","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":339690267,"identity":"11ea4015-3481-4549-b110-517de9673b77","order_by":0,"name":"Kengo Nakatsuka","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABG0lEQVRIie2QsWrDMBCGzwg8iXqVMdh9BBuBIUPdV4kRNIvTudCh2bKku0JKnsGP4CKoFyVePXQIGEoHD4Lspa4htAG5oVsh+qa74z7ulwAMhn8IOS4K8AHwYVacUlC/RP+upLNvRY87fxTvCl4Dd16JPZbJJC83zzsFiQ/WRnvGw9ubEYe3aIWZ7eGaTXN5yyIOrEu4HesUn2QxxSCsNTAbYYWmeZHFHoaiSyhDrRK0vXK9dhq0x+phElbt74pHMG06JV0R1qWsxTisT1xxF1lscRBsyZvYfZJltKxbGvGQUXvgLaSUVCkQV7xKG9W+3AcXVRbt1F3iO0T/Yx02sT5+tJf9Xvg1lwMGIHXUBrND5SyGFIPBYDgvPgHqpWLjzAFx6wAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0009-0009-0207-1009","institution":"Cancer Institute Hospital of the Japanese Foundation for Cancer Research","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Kengo","middleName":"","lastName":"Nakatsuka","suffix":""},{"id":339690268,"identity":"26145a2f-cacd-425f-bdb7-859e500012a0","order_by":1,"name":"Ryo Karakawa","email":"","orcid":"","institution":"Cancer Institute Hospital of the Japanese Foundation for Cancer Research","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ryo","middleName":"","lastName":"Karakawa","suffix":""},{"id":339690269,"identity":"0b12044a-ef43-4ce2-ba4b-d1d0fd4585f6","order_by":2,"name":"Tomoyuki Yano","email":"","orcid":"","institution":"Cancer Institute Hospital of the Japanese Foundation for Cancer Research","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Tomoyuki","middleName":"","lastName":"Yano","suffix":""}],"badges":[],"createdAt":"2024-08-08 08:05:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4879228/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4879228/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s12282-024-01655-6","type":"published","date":"2024-11-25T15:57:11+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":66370693,"identity":"aa276fec-50f3-40e3-8756-fed5e33280ab","added_by":"auto","created_at":"2024-10-11 04:35:48","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":441520,"visible":true,"origin":"","legend":"\u003cp\u003eThe points of color measurement were as follows. The skin color of the unaffected side of the breast was measured at the point 3-cm cephalic from the nipple on the unaffected side (yellow circle); the skin color of the DIEP flap was measured at the midpoint of the DIEP flap (red circle); and the skin color of the abdomen was measured at the point 3-cm cephalic from the midpoint of the postoperative abdominal wound (blue circle).\u003c/p\u003e","description":"","filename":"Fig1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4879228/v1/67121415178183395613fd99.jpg"},{"id":66371683,"identity":"9048da86-825d-4a85-9d98-b9088215a9d2","added_by":"auto","created_at":"2024-10-11 04:43:48","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":269736,"visible":true,"origin":"","legend":"\u003cp\u003eThe skin color of the PAP flap was measured at the midpoint of the PAP flap (green circle).\u003c/p\u003e","description":"","filename":"Fig2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4879228/v1/503b5c387746b5fdb9361f62.jpg"},{"id":66370689,"identity":"1a764c44-2145-4939-a608-0dadbe3fbf8f","added_by":"auto","created_at":"2024-10-11 04:35:48","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":144933,"visible":true,"origin":"","legend":"\u003cp\u003eThe skin color of the medial thigh was measured at the point 3-cm horizontally anterior to the midpoint of the wound on the thigh (black circle).\u003c/p\u003e","description":"","filename":"Fig3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4879228/v1/55fb1adb446aeb307ac7af1a.jpg"},{"id":70382104,"identity":"8b368884-5569-4b58-99b7-5e899b3fad25","added_by":"auto","created_at":"2024-12-02 16:23:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1265237,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4879228/v1/c3713c2e-15bc-4eae-92a2-4b027e4dca00.pdf"},{"id":66370691,"identity":"5feb8d44-917e-4459-baca-94f6f5fb05b6","added_by":"auto","created_at":"2024-10-11 04:35:48","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":153889,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eElectronic supplementary material\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 1.\u003c/strong\u003eCIEDE2000 was calculated by the following mathematical formula.\u003c/p\u003e","description":"","filename":"Supplementalfigure1.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4879228/v1/b1eb493aa051763429929f7b.pdf"}],"financialInterests":"","formattedTitle":"Color Differences of Skin Paddles Using the Free Flap for Autologous Breast Reconstruction in Asian Patients","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAutologous breast reconstruction is playing an increasingly important role in the comprehensive treatment of breast cancer, owing to its positive effects on the long-term psychosexual health of breast cancer survivors [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The deep inferior epigastric artery perforator (DIEP) flap is globally accepted as the first choice in autologous breast reconstruction, owing to its advantages in creating a natural breast mound with long-lasting esthetic results, a low rate of complications, and acceptable donor-site morbidity [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. However, for some patients, the DIEP flap may not be the most favorable option, particularly when a patient has the preference to avoid abdominal scars, or for young women without redundant abdominal tissue or very thin abdominal tissue, women with the possibility of future pregnancy, and women with multiple abdominal scars [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The wide range of patients\u0026rsquo; physical features and preferences has encouraged breast reconstructive surgeons to seek alternative flaps from different donor sites. As free flaps that do not require positional changes during the operation, thigh-based flaps such as the profunda artery perforator (PAP) flap and the transverse myocutaneous gracilis (TMG) flap, are considered a favorable choice for small to moderate-size autologous breast reconstructions [\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. They provide a relatively large amount of tissue that can be easily shaped to mimic a natural breast mound [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Breast reconstruction using the PAP flap has demonstrated constant vascular anatomy with enough length pedicle and adequate vessel diameter for sufficient microvascular anastomoses, which was associated with low donor-site morbidity and favorable cosmetic results [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn breast reconstruction using autologous tissue, a skin paddle is necessary for postoperative monitoring of the flap and for replenishing the missing skin of the patient by secondary reconstruction without using a tissue expander [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. However, leaving the skin paddle in place after breast reconstruction results in a patchwork pattern on the breast [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The skin paddle after breast reconstruction with autologous tissue is handled differently in each case. In some facilities, the skin paddle is routinely excised at least three months after surgery, whereas in other facilities, the skin paddle is not always excised [\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Especially in an irradiated breast, the breast envelope shows contracture, less vascular perfusion, and pigmentation. In some cases, the breast envelope should be replaced with a flap skin, resulting in relatively large exposure of the skin paddle [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. When aiming for a more symmetrical breast, the color match between the skin paddle and the breast skin is important in terms of appearance, as well as form. There have been no papers describing color matching between the skin paddle and breast skin envelope after breast reconstruction using autologous tissue in Asian patients. Similarly, it has not been described whether skin paddle coloration changes postoperatively.\u003c/p\u003e \u003cp\u003eIn 2001, in an attempt to improve the CIELab formula, which quantifies the difference between two colors (ΔE*ab=[(ΔL*)2+(Δa*)2+(Δb*)2]1/2), the International Commission on Illumination developed a more sophisticated formula, namely, the International Commission on Illumination Delta E 2000 (CIEDE2000), to calculate color differences [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The CIEDE2000 formula reflects the color differences perceived by the human eye better than the CIELab formula [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Therefore, CIEDE2000 was used in the present study.\u003c/p\u003e \u003cp\u003eThe primary objective of this study is to compare the degree of color match achieved by using the DIEP flap and PAP flap. The secondary objective of this study is to compare the skin color of different parts of the body including the breast, abdominal, and lateral thigh. The tertiary objective of this study is to compare the skin paddle's color deformity of the DIEP flap and PAP flap.\u003c/p\u003e"},{"header":"Patients and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u003c/h2\u003e \u003cp\u003e The study was approved by the Institutional Review Board of the Cancer Institute Hospital of the Japanese Foundation for Cancer Research (study approval no.: 2022-GB-171). Patients who had undergone unilateral breast reconstruction using a DIEP flap or a single PAP flap between January 2020 and December 2022 were included. Pictures of all patients taken at least one year postoperatively were used. Exclusion criteria included patients who had undergone radiation after breast reconstruction. Patient demographic data obtained from the medical records included age, sex, ethnicity, body mass index (BMI), history of smoking, flap type, and length of follow-up. In the outpatient clinic, pictures of the breast, abdomen, and medial thigh were taken using a digital camera with a ring flash, and a color marker (CasMatch; Bear Medic Corp., Tokyo, Japan) to adjust the color values of the images to compare them under the same conditions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eColor Measurement\u003c/h2\u003e \u003cp\u003eThe points of color measurement were as follows: (a) the skin color of the unaffected side of the breast was measured at a point 3-cm cephalic from the nipple of the unaffected breast (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e1\u003c/span\u003e); (b) the skin color of the DIEP flap was measured at the midpoint of the DIEP flap (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e1\u003c/span\u003e); (c) the skin color of the PAP flap was measured at the midpoint of the PAP flap (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e); (d) the skin color of the abdomen was measured at a point 3-cm cephalic from the midpoint of the postoperative abdominal wound (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e1\u003c/span\u003e); and (e) the skin color of the medial thigh was measured at a point 3 cm horizontally anterior to the midpoint of the femoral wound (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). After the skin color of the flap was calibrated in reference to CasMatch and using Adobe Photoshop 2024 software (Adobe Inc., San Jose, CA), the average values of the L* (lightness), a* (red/green), and b* (yellow/blue) color coordinates in five-pixel squares were measured. The procedure was performed five times, and the average values of the L*, a*, and b* color coordinates were measured.\u003c/p\u003e \u003cp\u003eThe CIEDE2000 scores were calculated to obtain the difference between the skin color of the unaffected side of the breast and the skin color of the DIEP flap (a\u0026ndash;b); the color difference between the skin color of the unaffected side of the breast and the skin color of the PAP flap (a\u0026ndash;c); the color difference between the skin color of the unaffected side of the breast and the skin color of the abdomen (a\u0026ndash;d); the color difference between the skin color of the unaffected side of the breast and the skin color of the medial thigh (a\u0026ndash;e), the skin color of the DIEP flap and the skin color of the abdomen (b\u0026ndash;d); and the color difference between the skin color of the PAP flap and the skin color of the medial thigh (c\u0026ndash;e). The CIEDE2000 score is an objective measure of difference between colors, which accounts for lightness, chroma, and hue weighting [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. A CIEDE2000 value of 1.0 represents the smallest color difference that the human eye can detect. Higher values indicate more noticeable differences in color, which in this context means a less accurate color match. Color differences were calculated using a mathematical formula (Electronic supplementary material, Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe average CIEDE2000 score between the skin color of the unaffected side of the breast and the skin color of the DIEP flap (a\u0026ndash;b), and the average CIEDE2000 score between the skin color of the unaffected side of the breast and the skin color of the PAP flap (a\u0026ndash;c) were used for colorimetric analysis of the color match by the DIEP flap and the PAP flap, respectively. The average CIEDE2000 score between the skin color of the unaffected side of the breast and the skin color of the abdomen (a\u0026ndash;d), and the average CIEDE2000 score of the difference between the skin color of the unaffected side of the breast and the skin color of the medial thigh (a\u0026ndash;e) were used for colorimetric analysis of the color match with the original color of the donor site. The average CIEDE2000 between the skin color of the DIEP flap and the skin color of the abdomen (b\u0026ndash;d), and the color difference between the skin color of the PAP flap and the skin color of the medial thigh (c\u0026ndash;e) were used for colorimetric analysis of the skin color changes over time after harvesting the flap.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eStatistical analyses were performed using IBM SPSS Statistics 29.0 software (IBM SPSS, Chicago, IL). A \u003cem\u003ep\u003c/em\u003e-value of less than 0.05 was considered to indicate a statistically significant difference between groups. Data are presented as means and standard deviations. Demographic data were compared between the different reconstructive methods using the \u003cem\u003et\u003c/em\u003e-test. The mean color difference in each body part in this study was compared using the \u003cem\u003et\u003c/em\u003e-test. The chromaticity of three parts of the body and skin paddle was analyzed using analysis of variance (ANOVA).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents the demographic information of the patients. A total of 125 patients were identified as having undergone unilateral breast reconstruction using a DIEP flap or a PAP flap. Patient demographic data obtained from the medical records included age, BMI, history of smoking, flap type, and length of follow-up. All the patients were women, with a mean age of 51.56 (range: 29 to 67) years, and an average BMI of 22.51 kg/m\u003csup\u003e2\u003c/sup\u003e. The patients were all Japanese. Regarding Fitzpatrick skin type, all the patients were 3 or 4. The DIEP flap was used in 77 (62%) of the autologous tissue breast reconstructions. The PAP flap was used in 48 (38%) of the reconstructions. Five patients (4%) had a smoking history, and 120 patients (96%) were nonsmokers. The average length of follow-up was 15.27 months in DIEP flap patients and 14.25 months in PAP flap patients. All the PAP flaps were designed vertically.\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\u003eBackground characteristics of the patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eAll patients\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;125\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\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 \u003cp\u003eDIEP flap\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePAP flap\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\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 \u003cp\u003en\u0026thinsp;=\u0026thinsp;77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, years (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52.41\u0026thinsp;\u0026plusmn;\u0026thinsp;6.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50.21\u0026thinsp;\u0026plusmn;\u0026thinsp;7.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.71\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI,kg/m\u0026sup2; (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.41\u0026thinsp;\u0026plusmn;\u0026thinsp;3.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.06\u0026thinsp;\u0026plusmn;\u0026thinsp;2.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.76\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSmoking history (n)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (3.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (4.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.81\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLength of followup, month (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15.27\u0026thinsp;\u0026plusmn;\u0026thinsp;5.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.25\u0026thinsp;\u0026plusmn;\u0026thinsp;4.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.62\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eDIEP, deep inferior epigastric artery perforator; PAP, profunda artery perforator; SD, standard deviation.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eColor Measurement\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e presents the skin colors by body parts, and the differences in the values for L*, a*, and b* among the body parts and flap types. Among the breast, abdomen, and medial thigh, the site with the lightest skin was the breast (L*: 74.32), whereas the darkest skin was the medial thigh (L*: 65.43). Redness and yellowness were highest in the medial thigh (a*: 12.35; b*: 18.81), and lowest in the breast (a*: 7.2; b*: 14.59). Comparing the two flap types, the DIEP flap was lighter in color (L*: 68.76). Redness and yellowness were higher in the PAP flap (a*: 9.33; b*: 21.37).\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\u003eChromaticity of 3 parts of the body and each flap\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=\"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=\"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 \u003cp\u003eBreast\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAbdomen\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMedial thigh\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDIEP flap\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePAP flap\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 \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;125\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003eF\u003c/em\u003e-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eL* (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e74.32\u0026thinsp;\u0026plusmn;\u0026thinsp;4.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e66.08\u0026thinsp;\u0026plusmn;\u0026thinsp;4.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e65.43\u0026thinsp;\u0026plusmn;\u0026thinsp;6.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e68.76\u0026thinsp;\u0026plusmn;\u0026thinsp;4.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e67.41\u0026thinsp;\u0026plusmn;\u0026thinsp;5.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ea* (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.2\u0026thinsp;\u0026plusmn;\u0026thinsp;2.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.59\u0026thinsp;\u0026plusmn;\u0026thinsp;2.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.35\u0026thinsp;\u0026plusmn;\u0026thinsp;2.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7.7\u0026thinsp;\u0026plusmn;\u0026thinsp;2.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e9.33\u0026thinsp;\u0026plusmn;\u0026thinsp;2.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eb* (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.59\u0026thinsp;\u0026plusmn;\u0026thinsp;3.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.22\u0026thinsp;\u0026plusmn;\u0026thinsp;3.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18.81\u0026thinsp;\u0026plusmn;\u0026thinsp;3.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18.4\u0026thinsp;\u0026plusmn;\u0026thinsp;3.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e21.37\u0026thinsp;\u0026plusmn;\u0026thinsp;3.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003eDIEP, deep inferior epigastric artery perforator; PAP, profunda artery perforator; SD, standard deviation.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe mean color difference between each body part is shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. There was less color difference between the unaffected side of the breast and the DIEP flap (a\u0026ndash;b) than between the unaffected side of the breast and the PAP flap (a\u0026ndash;c) (CIEDE2000 scores, 5.29 vs. 8.69, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Furthermore, there was less color difference between the unaffected side of the breast and the abdominal region (a\u0026ndash;d) than between the unaffected side of the breast and the medial thigh (CIEDE2000 scores, 3.61 vs. 10.71, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01). There was no statistically significant difference between the skin paddle\u0026rsquo;s color deformity between the DIEP flap (b\u0026ndash;d) and the PAP flap (c\u0026ndash;e) (CIEDE2000 scores, 5.61 vs. 8.25, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.17).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMean color differences between various body parts\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDIEP flap\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePAP flap\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e- value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBreast - Skin paddle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ea-b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ea-c\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.26\u0026thinsp;\u0026plusmn;\u0026thinsp;2.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.69\u0026thinsp;\u0026plusmn;\u0026thinsp;4.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBreast - Donor site\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ea-d\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ea-e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.61\u0026thinsp;\u0026plusmn;\u0026thinsp;2.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.71\u0026thinsp;\u0026plusmn;\u0026thinsp;4.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSkin paddle - Donor site\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eb-d\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ec-e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.61\u0026thinsp;\u0026plusmn;\u0026thinsp;2.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.25\u0026thinsp;\u0026plusmn;\u0026thinsp;4.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eDIEP, deep inferior epigastric artery perforator; PAP, profunda artery perforator; SD, standard deviation.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003ea\u0026ndash;b: difference between the skin color of the unaffected side of the breast and the skin color of the DIEP flap\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003ea\u0026ndash;c: difference between the skin color of the unaffected side of the breast and the skin color of the PAP flap\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003ea\u0026ndash;d: difference between the skin color of the unaffected side of the breast and the skin color of the abdomen\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003ea\u0026ndash;e: difference between the skin color of the unaffected side of the breast and the skin color of the medial thigh\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eb\u0026ndash;d: difference between the skin color of the DIEP flap and the skin color of the abdomen\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003ec\u0026ndash;e: difference between the skin color of the PAP flap and the medial thigh\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eBreast reconstruction using autologous tissue enables the reconstruction of a breast that resembles the softness and temperature of a natural breast. In many cases, a skin paddle is used to monitor the condition of the flap after breast reconstruction [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. In addition, skin paddles are required for immediate, delayed, and irradiated breast reconstruction when the skin envelope is not sufficiently expanded [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Revision surgery after breast reconstruction is partly at the patient's request. In examining the cosmetic aspects of the breast, the symmetry of the morphology is worked out at various facilities [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. While symmetry of form is important in the consideration of the shape, the color match of the skin paddle is also an important factor. However, there are no reports focusing on the color matching of skin paddles in breast reconstruction with a large population of Asian patients. In this paper, we summarize the color difference between the skin paddle and the native skin, and the postoperative changes of the skin paddle in breast reconstruction using the DIEP flap and the PAP flap more than a year after the surgery.\u003c/p\u003e \u003cp\u003eSeveral previous studies compared the degree of color match between the skin graft and the original skin in various head and neck reconstructive techniques, by analyzing digital photographs taken of patients, and calculating an objective biomedical measurement of color perception, namely, CIEDE2000 [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. In the study by Knott et al., on average, split-thickness skin grafts over de-epithelialized myogenous and adipofascial free tissue transfers resulted in a closer color match than the skin paddles of donor sites, with the exception of the radial forearm donor site [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Dermody et al. performed an objective analysis of color match in patients who had undergone free tissue reconstruction following surgery for head and neck cancer [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhen analyzing the absolute values of CIEDE2000 scores, there are no direct comparisons available for assessing human skin color. Nevertheless, other industries have created standards to ensure consistent color quality control across different materials. In previous studies comparing skin color differences, the American Society of Testing and Materials lightfastness scale was utilized to evaluate color differences based on CIEDE2000 scores [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Lightfastness I indicates excellent lightfastness, demonstrating a mean color change of less than four. Lightfastness II indicates very good lightfastness, with a mean color change of more than four but not more than eight. Lightfastness III indicates fair lightfastness, showing a mean color change of more than eight but not more than 16. Lightfastness Ⅳ indicates poor lightfastness, showing a mean color change of more than 16 but not more than 24. Lightfastness Ⅴ indicates very poor lightfastness, showing a mean color change of more than 24 (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Based on these standards, when evaluating the color match between the breast and the used flaps, the color difference between the DIEP flap and the breast was rated as very good, whereas the color difference between the PAP flap and the breast was rated as fair. From the perspective of color matching, it is advisable to use a tissue expander to stretch the breast skin when utilizing a PAP flap, to minimize the skin paddle. Furthermore, the PAP flap is not recommended for secondary reconstruction, in which a large amount of donor site skin is required.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe evaluation of the color differences based on CIEDE2000 scores\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClassification\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCIEDE2000\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePerception\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLightfastness I\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExcellent\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLightfastness Ⅱ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 to 7.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVery good\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLightfastness Ⅲ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 to 15.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLightfastness Ⅳ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 to 23.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePoor\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLightfastness Ⅴ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24≦\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVery poor\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eHuman skin varies in color tone from region to region [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Factors affecting color tone include melanocytes, blood vessels, telangiectasias, lentigines, hair follicles, ephelides, collagen density, and dermal thickness [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Optically, incident light on the skin is absorbed by pigments, such as melanin and hemoglobin in the skin, and diffuse reflected light enters the eye through scattering from the dermis and is recognized by the eye. Therefore, skin color is substantially affected by various factors, such as melanin, hemoglobin, and stratum corneum thickness [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Several studies have been published regarding standard CIELab values for various ethnic groups [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Han et al. measured the skin color of 600 Korean volunteers using the same chroma meter as used in this study, to investigate which free-flap donor sites were colorimetrically appropriate for facial cutaneous reconstruction [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. The CIELab values, including those for the breast, abdomen, and thigh in Korean subjects demonstrated a similar pattern to the CIELab values shown in our results.\u003c/p\u003e \u003cp\u003eThe color difference between the skin paddle and its surroundings was larger for the PAP flap than for the DIEP flap in color matching after reconstruction using different free flaps. Using CIEDE2000, Mahrhofer et al. evaluated the skin color difference between the DIEP flap and the TMG flap in 60 Caucasian patients who had undergone unilateral secondary breast reconstruction [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. A comparison between the DIEP flap and the TMG flap more than a year postoperatively demonstrated that the DIEP flap showed a preferable color match compared to the TMG flap (CIEDE2000 scores, 2.8 vs. 4.0, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.009). In studies with different races, breast reconstruction using the DIEP flap showed a better color match, as in the present study. In addition, comparing the color match reconstructed by using the PAP flaps of Asian patients in our study and the TMG flaps of Caucasian patients in the previous research, there was a clear difference in coloration in the Asian patients (CIEDE2000 scores, 8.69 vs. 4.0). This result shows that color matching is significant in breast reconstruction using PAP flaps in Asian patients.\u003c/p\u003e \u003cp\u003eAn interesting finding of our present study was that skin paddle coloration changes postoperatively. Regardless of the type of flap, there was an increase in L* and decrease in a* in the skin paddle and donor site. Yamamoto et al. evaluated the skin color of the transferred flap and the donor region by means of a chroma meter in nine patients who underwent head and neck reconstruction, and three patients who underwent breast reconstruction [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. A comparison between the transferred flaps and the donor sites demonstrated that the L* and a* values of the flaps used for facial reconstruction were noticeably different from those of the donor regions. In the three patients who underwent breast reconstruction using the transverse rectus abdominis myocutaneous (TRAM) flap, the color tone of the skin paddle was compared with that of the donor area. Although the number of cases was small, the study also showed an increase in L* and a decrease in a* in patients who underwent breast reconstruction using the TRAM flap. Reasons may include the breast region being strongly stretched by the surrounding skin.\u003c/p\u003e \u003cp\u003eOur study has some limitations. First, the study was performed using a group of patients of a single race, and hence the possibility that the results may vary by race cannot be ruled out. Second, the color data of the donor area in this study were obtained at the time of the postoperative outpatient clinic appointment, and are not preoperative data. However, the abdomen and inner thighs are nonexposed areas and are considered to be minimally affected by ultraviolet light, so we believe that the use of this data as preoperative color of the donor area did not greatly affect our results.\u003c/p\u003e \u003cp\u003eTo summarize, our study's results demonstrated a clear difference in color matching when comparing the skin of the abdomen and thighs to the breast, and that the DIEP flap has a less noticeable postoperative color difference with the breast compared with the PAP flap.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eConflicts of Interest\u003c/h2\u003e \u003cp\u003eNone declared.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eEthics\u003c/h2\u003e \u003cp\u003e This report was published with the consent and permission of the patients involved.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eNone.\u003c/p\u003e\u003ch2\u003eAcknowledgments\u003c/h2\u003e \u003cp\u003eNone.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCostanzo D, Klinger M, Lisa A, Maione L, Battistini A, Vinci V. The evolution of autologous breast reconstruction. Breast J. 2020;26(11):2223\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChang EI. Latest Advancements in Autologous Breast Reconstruction. Plast Reconstr Surg. 2021;147(1):e111\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKnox ADC, Ho AL, Leung L, Tashakkor AY, Lennox PA, Van Laeken N, et al. Comparison of Outcomes following Autologous Breast Reconstruction Using the DIEP and Pedicled TRAM Flaps: A 12-Year Clinical Retrospective Study and Literature Review. Plast Reconstr Surg. 2016;138(1):16\u0026ndash;28.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHunsinger V, Hivelin M, Derder M, Klein D, Velten M, Lantieri L. Long-Term Follow-Up of Quality of Life following DIEP Flap Breast Reconstruction. Plast Reconstr Surg. 2016;137(5):1361\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee ZH, Chu CK, Asaad M, Liu J, Selber JC, Butler CE, et al. Comparing Donor Site Morbidity for Autologous Breast Reconstruction: Thigh vs. Abdomen. Plast Reconstr Surg Glob Open. 2022;10(3):e4215.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOpsomer D, van Landuyt K. Indications and Controversies for Nonabdominally-Based Complete Autologous Tissue Breast Reconstruction. Clin Plast Surg. 2018;45(1):93\u0026ndash;100.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHaddock NT, Teotia SS. Consecutive 265 Profunda Artery Perforator Flaps: Refinements, Satisfaction, and Functional Outcomes. Plast Reconstr Surg Glob Open. 2020;8(4):e2682.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJo T, Jeon DN, Han HH. The PAP Flap Breast Reconstruction: A Practical Option for Slim Patients. J Reconstr Microsurg. 2022;38(1):27\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMyers PL, Nelson JA, Allen RJ Jr.. Alternative flaps in autologous breast reconstruction. Gland Surg. 2021;10(1):444\u0026ndash;59.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHunsinger V, Lhuaire M, Haddad K, Wirz FS, Abedalthaqafi S, Obadia D, et al. Medium- and Large-Sized Autologous Breast Reconstruction using a Fleur-de-lys Profunda Femoris Artery Perforator Flap Design: A Report Comparing Results with the Horizontal Profunda Femoris Artery Perforator Flap. J Reconstr Microsurg. 2019;35(1):8\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTielemans HJP, van Kuppenveld PIP, Winters H, Hupkens P, Ulrich DJO, Hummelink S. Breast reconstruction with the extended profunda artery perforator flap. J Plast Reconstr Aesthet Surg. 2021;74(2):300\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eQian B, Xiong L, Li J, Sun Y, Sun J, Guo N, et al. A Systematic Review and Meta-Analysis on Microsurgical Safety and Efficacy of Profunda Artery Perforator Flap in Breast Reconstruction. J Oncol. 2019;2019:9506720.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eToth BA, Lappert P. Modified skin incisions for mastectomy: the need for plastic surgical input in preoperative planning. Plast Reconstr Surg. 1991;87(6):1048\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChang EI, Ibrahim A, Zhang H, Liu J, Nguyen AT, Reece GP, et al. Deciphering the Sensitivity and Specificity of the Implantable Doppler Probe in Free Flap Monitoring. Plast Reconstr Surg. 2016;137(3):971\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFrey JD, Stranix JT, Chiodo MV, Alperovich M, Ahn CY, Allen RJ, et al. Evolution in Monitoring of Free Flap Autologous Breast Reconstruction after Nipple-Sparing Mastectomy: Is There a Best Way? Plast Reconstr Surg. 2018;141(5):1086\u0026ndash;93.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZafar SN. Ellsworth WA 4th. Reduction and Mastopexy of the Reconstructed Breast: Special Considerations in Free Flap Reconstruction. Semin Plast Surg. 2015;29(2):110\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTroy J, Little A, Kuykendall L, Dayicioglu D. Flap-Mastopexy in Autologous Breast Reconstruction: Timing and Technique. Ann Plast Surg. 2018;80(4):328\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSamaras S, Malata C. An Algorithm for Selecting Buoy Skin Paddle Design for Flap Monitoring in Total Autologous Breast Reconstruction After Nipple-Sparing Mastectomy. Cureus. 2023;15(1):e33443.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYoshida K, Yamazaki H, Takenaka T, Tanaka E, Kotsuma T, Fujita Y, et al. Objective assessment of dermatitis following post-operative radiotherapy in patients with breast cancer treated with breast-conserving treatment. Strahlenther Onkol. 2010;186(11):621\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSpear SL, Boehmler JH, Bogue DP, Mafi AA. Options in reconstructing the irradiated breast. Plast Reconstr Surg. 2008;122(2):379\u0026ndash;88.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWee AG, Lindsey DT, Shroyer KM, Johnston WM. Use of a porcelain color discrimination test to evaluate color difference formulas. J Prosthet Dent. 2007;98(2):101\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChu SJ, Trushkowsky RD, Paravina RD. Dental color matching instruments and systems. Review of clinical and research aspects. J Dent. 2010;38(Suppl 2):e2\u0026ndash;16.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSharma G, Wu W, Dalal EN. The CIEDE2000 color-difference formula: implementation notes, supplementary test data, and mathematical observations. Color Res App. 2005;30:21\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLuo MR, Cui G, Rigg B. The development of CIE 2000 colour-difference formula CIEDE 2000. Color Res App. 2001;26:340\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZucal I, De Pellegrin L, Parodi C, Harder Y, Schweizer R. The Influence of Inset and Shaping of Abdominal-Based Free Flap Breast Reconstruction on Patient-Reported Aesthetic Outcome Scores-A Systematic Review. J Clin Med. 2024;13(8):2395.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAtzeni M, Salzillo R, Haywood RM, Persichetti P, Ribuffo D, Figus A. Unilateral immediate deep inferior epigastric artery perforator flap breast reconstruction following skin sparing mastectomy: A comparative study on revision surgeries to improve breast symmetry. Microsurgery. 2022;42(8):766\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKnott PD, Alemi SA, Han M, Seth R, Park AM, Heaton CM, et al. Skin Color Match in Head and Neck Reconstructive Surgery. Laryngoscope. 2022;132(9):1753\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDermody SM, Kahng PW, Rao VM, Casper KA, Malloy KM, Rosko AJ, et al. Color Match following Free Flap Surgery in Head and Neck Reconstruction: A Colorimetric and Aesthetic Analysis. Plast Reconstr Surg. 2024;153(5):1142\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMaterials ASoTa. Materials Information and Technical Resources for Artists: ASTM and Lightfastness of Media.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYun IS, Lee WJ, Rah DK, Kim YO, Park BY. Skin color analysis using a spectrophotometer in Asians. Skin Res Technol. 2010;16(3):311\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLy BCK, Dyer EB, Feig JL, Chien AL, Del Bino S. Research Techniques Made Simple: Cutaneous Colorimetry: A Reliable Technique for Objective Skin Color Measurement. J Invest Dermatol. 2020;140(1):3\u0026ndash;e121.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJung G, Kim S, Lee J, Yoo S. Deep learning-based optical approach for skin analysis of melanin and hemoglobin distribution. J Biomed Opt. 2023;28(3):035001.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHan K, Choi T, Son D. Skin color of Koreans: statistical evaluation of affecting factors. Skin Res Technol. 2006;12(3):170\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYamamoto Y. Colorimetric evaluation of skin color in the Japanese. Plast Reconstr Surg. 1995;96(1):139\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMahrhofer M, Reichert R, Fierdel F, Gu X, Grabenw\u0026ouml;ger J, Russe E, Schoeller T et al. Photometric Comparison of Skin Color Match between Abdominal- and Thigh-Based Free Flaps for Breast Reconstruction in Caucasian Patients. Plast Reconstr Surg. 2024 May 20.\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":"","lastPublishedDoi":"10.21203/rs.3.rs-4879228/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4879228/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eIn this study, we aimed to evaluate color differences of the skin paddle in autologous breast reconstruction performed using the deep inferior epigastric artery perforator (DIEP) flap and the profunda artery perforator (PAP) flap. The primary focus was to compare the color match between the reconstructed breast skin and the donor-site skin, to achieve optimal esthetic results.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA retrospective analysis was performed on patients who had undergone unilateral breast reconstruction with a DIEP flap or a PAP flap between January 2020 and December 2022. Colors were captured using a digital camera and analyzed using Adobe Photoshop 2024 software. The L*, a*, and b* coordinates were used. The International Commission on Illumination Delta E 2000 (CIEDE2000) score was used to quantify color differences, comparing skin tones of the unaffected breast, DIEP flap, PAP flap, abdomen, and medial thigh.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 125 patients were analyzed. The DIEP flap demonstrated a closer color match to the native breast skin compared with the PAP flap (CIEDE2000 scores, 5.29 vs. 8.69, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01). No significant difference in color deformity with time was found between the DIEP flap and the PAP flap (CIEDE2000 scores, 5.61 vs. 8.25, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.17).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eOur findings suggest that the DIEP flap results in a more favorable color match for breast reconstruction than the PAP flap, enhancing esthetic outcomes. These results underscore the importance of considering skin color matching in flap selection for breast reconstruction surgery.\u003c/p\u003e","manuscriptTitle":"Color Differences of Skin Paddles Using the Free Flap for Autologous Breast Reconstruction in Asian Patients","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-11 04:35:43","doi":"10.21203/rs.3.rs-4879228/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Minor Revision","date":"2024-09-29T18:47:10+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2024-08-31T04:34:47+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-08-13T11:33:56+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-08-09T06:27:34+00:00","index":"","fulltext":""},{"type":"submitted","content":"Breast Cancer","date":"2024-08-08T04:03:54+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":"b5612629-d10c-4cc7-b178-bf83062f390b","owner":[],"postedDate":"October 11th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-12-02T16:00:36+00:00","versionOfRecord":{"articleIdentity":"rs-4879228","link":"https://doi.org/10.1007/s12282-024-01655-6","journal":{"identity":"breast-cancer","isVorOnly":false,"title":"Breast Cancer"},"publishedOn":"2024-11-25 15:57:11","publishedOnDateReadable":"November 25th, 2024"},"versionCreatedAt":"2024-10-11 04:35:43","video":"","vorDoi":"10.1007/s12282-024-01655-6","vorDoiUrl":"https://doi.org/10.1007/s12282-024-01655-6","workflowStages":[]},"version":"v1","identity":"rs-4879228","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4879228","identity":"rs-4879228","version":["v1"]},"buildId":"zQwnuV7TCBrMSSSToR1PI","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}