Keywords blunt injury - breast reconstruction - traffic accident - seat belts
Introduction
Blunt breast trauma is a rare entity and occurs in 2% of blunt chest injuries.[1 ] Seat belt use has significantly reduced the number of deaths associated with motor
vehicle accidents.[2 ] However, a new pattern of injuries has emerged called “seat belt syndrome,” which
encompasses a broad spectrum of injuries, including soft tissue injuries to the breast.
Traumatic breast injuries range from bruising to avulsion, caused by compression of
the breast between the bony rib cage and the seat belt.[3 ] Repairing cosmetic sequelae from severe breast trauma represents an unusual challenge
in breast reconstruction. The aim of this study was to present a systematic review
of the literature on breast reconstruction after blunt trauma associated with the
use of a seat belt. Also, we describe the first case of breast reconstruction using
the Ribeiro technique.
Case
A 58-year-old woman with a history of severe chest trauma in a car accident, during
which she was wearing a seat belt. She presented fractures of the right upper extremity,
nose, and multiple rib fractures, for which she required an anterolateral thoracotomy
approach and reduction and osteosynthesis of three right ribs, radius, and distal
ulna. The patient was consulted 7 months later in our Plastic Surgery Department due
to a deformity in the left breast. On physical examination, she presented third-degree
bilateral breast ptosis and an inframammary scar extending from the right midaxillary
line to the left sternal border. In addition, she had a marked asymmetry due to a
large soft tissue defect in the superomedial pole of the left breast. This defect
caused retraction of the breast tissue and medialization of nipple–areola complex
(NAC; [Fig. 1 ]). Breast deformity was classified as class 2b of the Teo and Song classification
([Table 1 ]).[4 ] Mammographic studies demonstrated a 7 × 5 cm cytosteatonecrosis cyst in the inferomedial
quadrant of the left breast ([Fig. 2 ]).
Fig. 1 Preoperative images showing the medial defect in the left breast. (A ) Front view. (B ) Oblique view.
Table 1
Teo and Song classification
Class
Presentation
1a
Immediate presentation with bruising and pain of the breast with or without minor
wounds
New breast asymmetry for patients with implants in situ
1b
Immediate presentation with expanding breast
2a
Late presentation with tender breasts, mild bruising, or palpable lump
2b
Late presentation with structural distortion (breast cleft or capsule contracture)
Fig. 2 Breast ultrasound showing a 7 cm × 5 cm cystic image with thin walls (red arrow).
Surgical Technique
The preoperative marking was based on the Pitanguy technique for breast reduction,[5 ] and the procedure was performed under general anesthesia. A solution with 2% xylocaine
and 1/100,000 dilution adrenaline was used to infiltrate the area. We performed epidermalization
of the left breast, including resection of the anterolateral thoracotomy scar. The
inferomedial quadrant was approached and a large cyst of cytosteatonecrosis was found
that was resected. In addition, a scar fibrosis area was identified that corresponded
to the soft tissue defect, which caused considerable loss of breast tissue. To cover
the medial breast defect and improve its shape, we designed a lower flap 4 to 5 cm
wide and 2 to 3 cm thick ([Fig. 3 ]), according to the Ribeiro technique.[6 ]
Fig. 3 Intraoperative images of the left breast. (A ) Preparation of the lower pedicle that should measure between 2 and 3 cm thick. (B ) Fixation of the pedicle in the superomedial sector of the fascia of the pectoralis
major muscle.
This flap was deepithelialized and an incision was made along its edges down to the
muscular fascia, from which it was detached. The lower pedicle was maintained through
which the fourth, fifth, and sixth intercostal perforators penetrated, thus ensuring
irrigation of the dermo-lipo glandular flap. After de-epidermizing the pedicle and
periareolar area previously designed to correct the location of the NAC, the dermoglandular
flap was fixed to the pectoralis major at the level of the second left intercostal
space in the superomedial pole. Finally, contralateral breast symmetrization was performed
by reduction and mastopexy with inverted T. No complications were reported and hospital
discharge was granted on the first postoperative day. The evolution was favorable
during the 12-month follow-up, with excellent cosmetic results and patient satisfaction
([Fig. 4 ]).
Fig. 4 Postoperative images. (A ) Front view. (B ) Oblique view.
Systematic Review of the Literature
This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses
(PRISMA) reporting guidelines.[7 ] We performed a literature search from inception until November 2022 in the following
databases: MEDLINE, EMBASE, and Google Scholar. For the initial search, the following
keywords and MeSH terms were used: “Breast” AND “Mammoplasty OR Breast reconstruction”
AND “Blunt injury OR Nonpenetrating Wound” AND “Traffic accident OR Seat Belts.”
Study Selection
Initial screening of articles by title and abstract was performed independently by
two reviewers, selecting relevant studies according to eligibility criteria. A third
author resolved any inclusion conflict using Rayyan software.[8 ] The inclusion of articles was limited to (1) articles published from inception up
to November 2022; (2) reports in English and French; (3) female patients over 18 years
old; (4) patients with blunt breast trauma; (5) seat belt use; and (6) patients with
cleft deformity or breast distortion in the line of the seat belt. Meanwhile, studies
were excluded if they met one or more of the following criteria: (1) language other
than English and French; (2) meta-analyses or systematic reviews; (3) male patients;
(4) patients with breast trauma as a result of a different mechanism of injury; and
(5) reports of conservative, minimally invasive treatment or studies that did not
report surgical reconstruction of breast deformity.
Data Extraction
The following information was extracted: first author's name, the publication year,
and the country, patients' age and sex, the presentation of breast deformity, intraoperative
findings, surgical reconstruction technique, complications, and follow-up results.
Statistical Analysis
Meta-analysis could not be performed because this systematic review includes an extremely
rare entity based on published cases. However, the extracted data from the cases were
put on a sheet and then quantitatively analyzed using descriptive statistics.
The search resulted in 120 records, of which 23 were duplicates. After title and abstract
screening, 91 articles were excluded. This systematic review included six published
articles[3 ]
[4 ]
[9 ]
[10 ]
[11 ]
[12 ] after full-text assessment. The PRISMA flow diagram presents the study selection
process ([Fig. 5 ]).
Fig. 5 Preferred Reporting Items for Systematic Reviews and Meta-analyses flowchart of the
study selection process.
Study Characteristics
This systematic review of published cases included six articles with seven patients
([Table 2 ]). The year of published case reports ranged from 2010 to 2021, of which 67% were
published in the past 10 years. Most of the published cases are from the United Kingdom
(three cases), followed by France (two cases). According to the Teo and Song classification,
seven class 2b cases were reported. The mean age of the patients was 57.6 years (range:
37–60). In all cases, the affected breast was on the right side and a diagonal cleft
predominated with NAC retraction. The most frequent intraoperative finding was fat
necrosis, which could be accompanied by fibrosis. Regarding surgical techniques, in
five cases a breast reduction was performed on the deformed breast with different
types of pedicles (three superomedial flaps, one lower flap, one superior flap), and
only in two cases was the breast reconstruction technique described in detail. One
case presented complications (delayed wound healing of the inferior incisions). Median
follow-up was 7.5 months (range: 3–12) with satisfactory cosmetic results.
Table 2
List of cases of women with breast reconstruction after blunt trauma with a seat belt
No.
Study (year)
Country
Age
Presentation
Intraoperative findings
Reconstruction technique
Complication
Follow-up (mo)
1
Paddle and Morrison (2010)[3 ]
Australia
37
Right diagonal cleft + NAC retraction
Fat necrosis
Right mastopexy + left reduction
No
6
2
Scevola et al(2011)[9 ]
France
60
Right diagonal cleft + NAC retraction
Fat necrosis
Mastopexy + bilateral
reduction (superomedial flap) + lipofilling
No
12
3
54
Right diagonal cleft
Fat necrosis
No
12
4
Teo et al (2014)[16 ]
The United Kingdom
67
Right diagonal cleft + NAC retraction
Fat necrosis
Resection + deepithelialization of the edges of the cleft
No
2
5
Petrie (2014)[10 ]
The United Kingdom
69
Right diagonal cleft + NAC retraction
Fat necrosis
Breast reduction (superomedial flap) + lipofilling
No
–
6
Noel et al (2020)[11 ]
The United States
53
Right diagonal cleft
Fat necrosis + fibrosis
Bilateral reduction (lower flap)
Delayed wound healing of inferior incisions
4
7
Lafford et al (2021)[12 ]
The United Kingdom
63
Right vertical cleft + NAC inversion
Fibrosis
Bilateral reduction (superior flap)
No
3
8
Our case
Argentina
58
Left soft tissue defect + NAC retraction
Fat necrosis +
fibrosis
Mastopexy + bilateral
reduction (lower flap type I Ribeiro)
No
12
Abbreviation: NAC, nipple–areola complex.
Discussion
Mechanisms of seat belt breast trauma include both shearing and crushing injuries
resulting from shoulder restraint. Most patients have associated injuries that, due
to their severity, require immediate treatment. The most common are long bone extremity
fractures (47%), rib fractures (15%), solid organ injury (11%), and pneumothorax or
hemothorax (10%).[1 ] This coincides with the associated lesions in our patient.
Two classification systems have been proposed for blunt breast trauma with the aim
of stratifying the injuries and establishing adequate treatment. In 2007, the first
classification of seat belt injuries in the female breast was described, categorized
according to the type and severity of the injury at the time of the traffic accident.[13 ] However, it did not include late presentations, pregnant patients, or patients with
breast prostheses. Subsequently, in a systematic review, a four-level classification
was presented that categorizes patients according to the time of presentation of symptoms
and their treatment, representing the most complete report that summarizes all published
literature on seat belt-associated breast injuries.[4 ]
Our case corresponds to class 2b, which includes severe aesthetic sequelae and a late
presentation with cleft deformity in the seat belt line or breast distortion, with
reconstruction being the main treatment. Class 2b breast deformity represents a significant
reconstructive challenge in restoring the natural contour of the breast, the inframammary
fold, and repositioning of the NAC.[12 ] So far, seven class 2b cases have been reported discussing different reconstruction
options in seat belt-associated breast trauma. In all cases, the affected breast was
on the right side and a diagonal cleft predominated with NAC retraction. In contrast,
our patient presented involvement of the left breast with medialization of the NAC.
This type of breast deformity was present late in breasts with certain anatomical
characteristics such as the presence of a greater volume in the lower pole with a
predominance of adipose tissue, lax skin, and third-degree ptosis. We estimate that
skin retraction and NAC occurred as a result of fat necrosis and fibrosis, which were
found to be the most frequent intraoperative findings. This presentation also coincides
with our case.
On the other hand, this breast morbidity has not been described in patients with breast
implants,[14 ]
[15 ] probably because implants interposed as a damping mechanism between the bony rib
cage and soft tissues when seat belts dynamically restrain people in their seats.
Regarding reconstruction techniques, they were individualized for each patient according
to the type of breast deformity. However, the surgical techniques used were described
in detail only in two cases. Paddle and Morrison[3 ] described a modified Hall–Findlay-type mastopexy with good cosmetic results. Similarly,
Teo et al[16 ] reported an approach in which they resected and deepithelialized the edges of the
cleft, with subsequent elevation of the NAC in a superolateral pedicle while creating
and mobilizing the superomedial and inferolateral crura to close the oblique breast
defect. Furthermore, Lafford et al[12 ] performed NAC retraction release with resection of the edges of the defect and subsequent
bilateral breast reduction with a superior flap. On the other hand, Petrie[10 ] resected the edges of the defect but limited the incision from the lower edge of
the cleft to a point on the upper edge of the NAC to avoid leaving a visible scar
in the cleavage area of the breast. Scevola et al[9 ] applied conventional breast reduction techniques and a posterior glandular flap
in gland reshaping and lipofilling to fill in substance loss and improve breast contour.
Noel et al[11 ] designed a modified inferior dermoglandular pedicle to correct the defect and standard
reduction in the contralateral breast. However, they do not describe the surgical
technique used.
Breast reduction techniques would appear to be the best indication to correct the
defect generated by blunt trauma in ptotic breasts. Therefore, the specific reduction
technique, as well as the different pedicle techniques selected, must consider the
physical characteristics of the patient and the surgeon's experience. On the other
hand, the inferior pedicle technique is currently a popular approach for breast reduction.
This technique is useful for the correction of breast asymmetries and ptosis and can
be used on virtually any breast size and shape with a high degree of patient satisfaction.[17 ]
In contrast to what has been reported so far, we describe reconstruction of the breast
defect using the Ribeiro inferior glandular dermo-lipo flap technique.[6 ] This flap was presented for the first time in Brazil at the Congress of the Brazilian
Society of Plastic Surgery in 1971. This technique, also known as the “first pedicle
or safety pedicle,” was designed to provide safety in terms of volume in the case
of reductions, greater projection of the upper pole, and more lasting results in the
cases of mastopexies.[18 ] During the past 30 years, the technique has been adapted to allow the development
of five different types of flaps with different indications.[6 ] Due to its versatility and use, not only in cosmetic surgery but also in reconstructive
surgery, we can consider it an extraordinary resource in breast plastic surgery.
In relation to breast deformities in blunt trauma, we can find a wide spectrum of
presentations; therefore, there is no adopted reconstruction standard. However, we
must consider surgical treatment individually for each patient.
Blunt mammary trauma associated with seat belt use is rare; therefore, reconstructive
treatment implies a challenge for the plastic surgeon, who must evaluate each case
individually and establish the most appropriate surgical strategy. This is the first
report to describe breast reconstruction with the Ribeiro inferior flap technique
in reconstruction after blunt breast trauma associated with the use of seat belts.
We believe that the Ribeiro technique is a feasible and safe alternative in the treatment
of posttraumatic breast deformities, offering very good long-term results.
