Brown, Nicola

Loveridge, Amy

Mills, Chris

Scurr, Joanna

St Mary's University Open Research Archive

This is an open access article which appeared in a journal publishedby Elsevier. This article is free for everyone to access, download andread.Any restrictions on use, including any restrictions on furtherreproduction and distribution, selling or licensing copies, or postingto personal, institutional or third party websites are defined by theuser license specified on the article.For more information regarding Elsevier’s open access licensesplease visit:http://www.elsevier.com/openaccesslicensesAuthor's personal copyOriginal articleAcute changes in clinical breast measurements followingbra removal: Implications for surgical practiceJoanna Scurr a, *, Amy Loveridge a, Nicola Brown b, Chris Mills aa Research Group in Breast Health, University of Portsmouth, Cambridge Road, Portsmouth, Hampshire, UKb School of Sport, Health and Applied Science, St Mary's University, Waldegrave Road, Twickenham, Surrey, UKa r t i c l e i n f oArticle history:Received 9 January 2015Accepted 13 January 2015Available online 28 January 2015Keywords:BreastBiomechanicsDisplacementStraina b s t r a c tBackground: Stable measurement of breast position is crucial forobjective pre-operative planning and post-operative evaluation. Inclinical practice, breast measures are often taken immediatelyfollowing bra removal. However, research shows that restrictiveclothing (such as a bra) can cause acute anatomical changes,leading to the hypothesis that clinical breast measures may changeover time following bra removal. This cross-sectional observationalstudy aimed to provide simple clinical guidelines for the mea-surement of breast position which account for any acute changesin breast position following bra removal.Methods: Thirteen participants of varying breast sizes had markersattached to their thorax and nipples to determine clinical mea-sures of sternal notch to nipple distance, internipple distance,breast projection, and vertical nipple position. The positions ofthese landmarks were recorded using a motion capture systemduring 10 min of controlled sitting following bra removal.Results: Internipple distance and breast projection remained un-changed over 10 min, while the resultant sternal notch to nippledistance extended by 2.8 mm in 299 s (right) and 3.7 mm in 348 s(left). The greatest change occurred in the vertical nipple position,which migrated an average of 4.1 mm in 365 s (right) and 6.6 mmin 272 s (left), however, for one participant vertical migration wasup to 20 mm.* Corresponding author. Tel.: þ44 2392 845161; fax: þ44 2392 843680.E-mail address: Joanna.scurr@port.ac.uk (J. Scurr).Contents lists available at ScienceDirectJPRAS Openjournal homepage: ht tp: / /www. journals .e lsevier .com/jpras-openhttp://dx.doi.org/10.1016/j.jpra.2015.01.0022352-5878/© 2015 The Authors. Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive andAesthetic Surgeons. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).JPRAS Open 3 (2015) 22e25Author's personal copyConclusions: Internipple distance and breast projection can bemeasured ﬁrst following bra removal, followed by sternal notch tonipple distance, any measures associated with the vertical nippleposition should be made more than 6 min after bra removal. Theseguidelines have implications for breast surgery, particularly forunilateral reconstruction based on the residual breast position.© 2015 The Authors. Published by Elsevier Ltd on behalf of BritishAssociation of Plastic, Reconstructive and Aesthetic Surgeons. Thisis an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).IntroductionBreast surgery has been reported to lack accuracy and reproducibility,1 highlighting the need forobjective breast measurements that are accurate and repeatable. Breast measurement techniquesinclude manual positional measurement such as sternal notch to nipple distance, internipple distance,breast projection, and vertical nipple position.Whilst patient orientation during breast measurement has been investigated, no research hasconsidered the stability of clinical breast measures. Typically, these measurements occur shortly afterpatients remove their bra and it is assumed that these measures remain stable over time. Thisassumption has implications for unilateral breast surgery, when the residual breast position informsthe reconstructed breast position. The assumption that breast position remains stable is challenged byprevious literature which shows restrictive clothing causing acute anatomical changes. Previousresearch has reported bras causing chronic shoulder furrows of 3 cm2, decreased chest girth, decreasedvertical nipple position, increased breast circumference and increased internipple distance.3 Whileother research has reported that skin takes time to recover from compression.4 These studies suggestthat bras may cause acute changes in breast tissue position, which may affect clinical breast measures.Therefore, this study hypothesized that the following clinical breast measures would signiﬁcantlychange over 10 min after bra removal; sternal notch to nipple distance, internipple distance, nippleprojection, and inferior nipple migration.Materials/patients and methodsFollowing ethical approval, thirteen females (eligibility criteria: no surgical or clinical breasttreatment, nulligravida) provided informed consent and breast sizes were established (Table 1). In aprivate area, participants removed their upper body clothing and were seated in a control chair.Markers were attached to the sternal notch, left and right anteroinferior tenth rib and nipples.5 Par-ticipants remained as still as possible for 10 min as marker coordinates were recorded using motioncapture cameras (50 Hz, Qualisys, Sweden). Markers were identiﬁed with 0.6 mm accuracy. Coordinatesystems were established and multiplanar nipple coordinates, independent to thorax position, werecalculated every sample.5 Relative nipple position data were ﬁltered with 0.09 Hz cut-off frequency toeliminate breathing artefacts.The following clinical measures were calculated every sample; 1. resultant distance from sternalnotch to nipples, 2. internipple distance; resultant distance between left and right nipple, 3. nippleprojection; sagittal plane, perpendicular distance from thorax plane (deﬁned by sternal notch and ribmarkers) to nipple, 4. inferior or superior migration; vertical change in nipple position (in the localcoordinate system, relative to the sternal notch).To determine changes in measures across the trial, start and end nipple positions were statisticallycompared. Measures where signiﬁcant changes occurred (P < 0.05) demonstrated exponential change(supporting previous stress/strain literature for skin). Magnitude (c) and rate of change (b), and time (t)at which steady state occurred were investigated (Equation (1)).J. Scurr et al. / JPRAS Open 3 (2015) 22e25 23Author's personal copyf ðtÞ ¼ c1 ebt(1)ResultsResultant distance from sternal notch to right and left nipples showed signiﬁcant increases of2.7 mm and 3.9 mm from the ﬁrst to last 2 s of the trial (t = 4.803(12), P < 0.001; t ¼ 7.138(12), P < 0.001).Internipple distance and nipple projection remained unchanged over the trial (Table 1).Twelve of thirteen participants demonstrated inferior nipple migration over the trial (Table 1) from176 mm (right) and 179 mm (left) below the sternal notch to 180 mm (right; t ¼ 3.67(12),P ¼ 0.003) and 186 mm (left; t ¼ 4.44(12), P ¼ 0.001) 10 min later. The right and left nipples reachedsteady state at 365 s and 272 s after bra removal (Figure 1).DiscussionThis study found that resultant sternal notch to nipple distances increased by 2.7 mm (right) and3.9 mm (left) over 10 min, accepting the hypothesis. Although statistically signiﬁcant, this change issmall and unlike to affect clinical measurements. Internipple distance and nipple projection did notchange, rejecting the hypothesis. However, vertical nipple position demonstrated the greatest changefollowing bra removal, accepting the hypothesis for this measure. This change was ~20 mm in oneparticipant, averaging 7.4 mm across the group for the left nipple. These magnitudes of change arelikely to be clinically signiﬁcant. Modelling data established that the right and left nipples reachedsteady state within 365 s and 272 s following bra removal.From these results it is suggested that measures of vertical nipple position should be completed atleast 6 min after bra removal. This presents an easy to follow clinical recommendation that could beincorporated into existing practice without increasing consultation time, whilst ensuring a stablebreast position.Table 1Participant characteristics, direction of breast movement and change in vertical position of the right (R) and left (L) nipple overthe 10 min trial following bra removal.Breast size Age(yrs)Direction of change Vertical nippleposition (mm)Vertical (Inferiormigration)[ SuperiorY Inferiorx No changeMediolateral(Internipple distance)) R lateral/ R medial/L lateral)L medialx No changeAnteroposterior(Nipple projection)cAnteriorbPosteriorx No changeMagnitude ofchangeR L R L R L R L34C 20 Y Y ) x b c 0.8 2.034D 21 Y Y ) ) b b 0.8 2.432D 24 Y Y / / c b 3.9 2.834D 36 Y Y x ) b c 3.1 10.434D 25 [ Y ) ) c c 1.1 2.834D 25 Y Y / / c b 1.3 0.434D 21 Y Y ) / c c 4.5 5.734D 39 Y Y / ) c b 4.7 7.834DD 27 Y Y / ) b b 13.2 12.232DD 22 Y Y / ) b x 7.0 17.034DD 25 Y Y x ) x x 7.2 19.932DD 29 Y Y ) x c x 2.7 5.634E 28 Y x / ) c c 3.7 7.1Mean 26 4.0 7.4SD 5.7 3.7 6.0J. Scurr et al. / JPRAS Open 3 (2015) 22e2524Author's personal copyIn conclusion, this is the ﬁrst study to identify that clinical measures of breast position are inﬂu-enced by bra use prior to their assessment. To reduce this confounding variable clinicians are rec-ommended to measure vertical nipple position at least 6 min after bra removal. With one participantexperiencing ~20 mm inferior nipple migration, these results have implications for breast surgery,particularly when residual breast position informs reconstructed breast position.Ethical approvalThis study received Ethical Approval from the Science Faculty Ethics Committee at the University ofPortsmouth. Ethics Approval number: BSREC12/059.Conﬂicts of interest statementNone.AcknowledgementsNo external funding was received for this study.References1. Henseler H, Smith J, Bowman A, et al. Subjective versus objective assessment of breast reconstruction. J Plast Reconstr AesthetSurg. 2013;66:634e639.2. Mentz H, Ruiz-Razura A, Miniel L. Correction of the bra strap shoulder groove deformity in women. Plast Reconstr Surg. 2007;120:2122e2123.3. Ashizawa K, Sugana A, Gunji T. Breast form changes resulting from a certain brassiere. J Hum Ergol. 1999;19:53e62.4. Daly CH, Odland GF. Age-related changes in the mechanical properties of human skin. J Invest Dermatol. 1979;73:84e87.5. Scurr J, White J, Hedger W. The effect of breast support on the kinematics of the breast during the running gait cycle. J SportsSci. 2010;28:1103e1109.Figure 1. A) Mean (grey error bars display standard deviations) inferior migration (mm) of the left and right nipple over the10 min trial following bra removal. B) Optimized models of inferior migration extended to 20 min; grey panel shows ±5% steadystate boundaries (n ¼ 13).J. Scurr et al. / JPRAS Open 3 (2015) 22e25 25

Acute changes in clinical breast measurements following bra removal: Implications for surgical practice.

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