title: Should We Excise Native Breast Skin Envelope to Achieve Symmetric Scars in Bilateral Autologous Breast Reconstruction?--A Survey of Surgeon and Patient Preference.
abstract: BACKGROUND
  Given the multiple possible scar patterns in autologous breast reconstruction and combinations of such patterns in bilateral reconstruction, the present study aimed to determine the importance of scar symmetry in achieving aesthetically pleasing results.
  
  
  METHODS
  A survey was administered to 128 participants including plastic surgeons and female breast reconstruction patients. In part A of the survey, participants were provided with photos of bilateral autologous breast reconstructions, and scar placement was varied to represent bilateral (1) immediate, (2) delayed symmetric, (3) delayed asymmetric, and (4) a mixture of immediate and delayed free flap reconstructions. Participants were asked to rank the photos in order of best to worst aesthetic outcome. In part B, pairs of the same reconstruction before and after nipple-areolar complex (NAC) reconstruction were presented, and participants were asked to assign a score to each photo according to aesthetic outcome.
  
  
  RESULTS
  In part A, immediate reconstructions that included the smallest flap skin paddles ranked best among 52.5% ± 30% of participants, followed by delayed symmetric reconstructions that ranked best in 46.7% ± 29.6%. Mixed reconstructions ranked worst among 53.6% ± 37.6% of participants, followed by delayed asymmetric reconstructions (42.5% ± 37.9%). When NAC reconstruction was added to 1 set of the photos in part A, the same immediate reconstruction was ranked best, a significantly higher proportion of the time (36.3% increase, P < 0.001). This was accompanied by a significant decrease in top ranking for the delayed symmetric reconstruction (37.9% decrease, P < 0.001). In part B, addition of NAC increased each reconstruction's score by an average of 1.36 points on a 5-point scale with patients citing less improvement between the conditions (0.93 ± 0.03) than plastic surgeons (1.13 ± 0.49) (P = 0.03).
  
  
  CONCLUSIONS
  More symmetric breast scars led to higher aesthetic ranking of bilateral autologous breast reconstructions. Participants in our survey preferred symmetric scars, even if achieving such a scar pattern would require excision of native breast skin and inclusion of more flap skin. Furthermore, NAC reconstruction alone improves aesthetic outcome, and improvement was most notable among immediate reconstructions.
authors.affiliation: From the *Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University, and †Stanford University, School of Medicine, Stanford, CA.
authors.forename: Rebecca M
authors.initials: RM
authors.lastname: Garza
authors.forename: Tiffany A
authors.initials: TA
authors.lastname: Chen
authors.forename: Gordon K
authors.initials: GK
authors.lastname: Lee
mesh_terms: D000328:Adult; D000368:Aged; D001291:Attitude of Health Personnel; D002921:Cicatrix / Q000209:etiology* / Q000523:psychology*; D004954:Esthetics; D005260:Female; D006801:Humans; D008297:Male; D016462:Mammaplasty / Q000379:methods* / Q000523:psychology; D008875:Middle Aged; D057240:Patient Preference / Q000523:psychology / Q000706:statistics & numerical data*; D010781:Photography; D011183:Postoperative Complications / Q000523:psychology*; D066231:Surgeons / Q000523:psychology*; D013524:Surgical Flaps