Animation Deformity in Breast Reconstruction Patients: A Quantitative Analysis of Nipple Displacement and Patient Reported Outcomes

PURPOSE

Animation deformity, characterized by superolateral displacement of the implant with contraction of the pectoralis major muscle, is a complication of reconstructive breast surgery with submuscular implants. Severe cases may warrant corrective surgery. While subjective classification systems have been proposed, there is a paucity of quantitative approaches for assessing animation deformity. We endeavored to develop a reproducible, clinically relevant, quantitative model for grading animation deformity.

 

METHODS

Patients of the senior author presenting for prosthetic breast reconstruction follow-up between April 2017 and February 2018 were recruited for this study. Patient videos and still images were taken at rest and with pectoralis contraction, and nipple position and skin puckering were quantitatively assessed using ImageJ. The degree of nipple displacement and skin puckering for each patient was correlated with perioperative variables. Becker grading of animation deformity was used as a legacy scale for comparison. The BREAST-Q survey was used as a validated measure of patient-reported outcomes.

 

RESULTS

A total 72 patients accounting for 127 reconstructed breasts were included in final analysis. These included 104 (81.9%) bilateral reconstructions, 61 (48.0%) prophylactic reconstructions, and 62 (48.8%) reconstructions in which the pectoralis major was cut inferiorly. Average patient age was 49.5 (SD 8.3) and BMI was 26.2 (SD 6.0) at the time of reconstruction. Median follow-up time to video capture and BREAST-Q administration was 13.2 months after permanent implant placement. Image-based measurements demonstrated mean nipple displacement of 1.99 cm (SD 1.10 cm) and mean breast area with skin puckering of 18.14% (SD 15.80%). Both nipple displacement and skin puckering measurements were moderately right-skewed (skewness 0.76 and 0.54, respectively). Partial inferior myotomy of the pectoralis major during tissue expander placement, which occurred in 84% of cases that used ADM, was associated with 0.64 cm more nipple displacement (p=0.001). A history of infection complicating reconstruction was also associated with increased nipple displacement (p=0.036). No other variables, such as age, BMI, handedness, adjunctive therapy, mastectomy specimen weight, or implant size correlated with measures of animation deformity. A novel classification system was created using convenience cut-points of 2cm nipple displacement and 25% skin puckering: Grade I (<2 cm displacement and <25% skin puckering), Grade II (>2 cm and <25%), Grade III (<2 cm and >25%) and Grade IV (>2cm and >25%). These grades comprised 59 (46.5%), 24 (18.9%), 12 (9.4%), and 32 (25.2%) breasts, respectively. Grades were significantly correlated with Becker grading (R=0.58, p<0.0001). Patient satisfaction with appearance and rippling were not associated with grades.

 

CONCLUSION

We performed the first quantitative analysis of animation deformity in breast reconstruction patients.  Partial myotomy of the pectoralis major resulted in greater degree of nipple displacement. Lack of association between animation deformity and patient satisfaction highlights the importance of non-aesthetic factors to patient satisfaction. The quantitative grading system presented here may facilitate future research in animation deformity.