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Journal of Plastic, Reconstructive & Aesthetic Surgery (2014) xx, 1e2
CORRESPONDENCE AND COMMUNICATION Seat belt injury causing bisection of the breast: A case report* Dear Sir, Seat belt use has been mandatory in the United Kingdom since 1983 for front seat passengers, and since 1991 for rear seat users.1 This measure has hugely reduced the risk of serious injuries and death associated with road traffic accidents.2,3 However, this restraint system is associated with a particular pattern of injuries in the configuration of the seat belt, namely sternal fractures, bowel trauma or spinal injuries. There have been multiple publications on these injuries which have now been termed ‘seat belt syndrome’ or ‘seat belt injuries’. We report a case of breast bisection as a result of seat belt trauma with description of the reconstructive procedure. A 67 year old lady was involved in a road traffic accident resulting in severe bruising across her right breast from her seat belt. There were no open wounds and she did not require any medical treatment at this stage. Over the subsequent weeks, she noticed a worsening deformity of her right breast. Her past medical history included rheumatoid arthritis affecting her hips for which she took Naproxen 500 mg BD, and she was otherwise fit and well. She had attended regular mammograms that had been normal. She first attended the breast unit three months after her accident and was noted to have severe indentation of her right breast in line of her seat belt (Figure 1). A mammogram and ultra-sound scan was performed which revealed extensive fat necrosis. Core biopsies were performed despite a low index of suspicion by the radiologist. This showed fat necrosis with no suspicious features. Surgery was offered to correct the indentation of her breast. Ten months following the accident, she underwent a complex reconstructive procedure performed under general anesthetic. The edges of diagonal depression were incised and de-epithelised. The nipple areolar complex was
* Work attributable to: Plastic and Reconstructive Surgery Department, Royal Hallamshire Hospital, Sheffield, S10 2TB.
raised on a superiolateral pedicle. A superiomedial and inferiolateral pillar were created, mobilised to close the oblique defect in the breast. Figure 2 shows the intraoperative detail. There were no peri-operatively complications and she was discharged home one day postoperatively. At a followup appointment, she reported high levels of satisfaction. Whilst her right breast was smaller than her left, she felt symmetrical in a bra and declined any further procedures. Figure 3 demonstrates her postoperative result. The shoulder restraint portion of the three-point lapdiagonal belt is commonly positioned over or near the female breast. Injury to the breast tissue results from compressive forces between the seat belt and the boney ribcage during rapid deceleration. Breast deformity following seat belt restraint has been documented, but there is paucity in the literature regarding reconstructive options. The challenge for the plastic surgeon is that each case will be slightly different. Paddle et al.4 described a 37 year old with who similarly developed a diagonal cleft in
Figure 1 Oblique furrow demonstrated on right breast corresponding to the line of the seat belt.
1748-6815/$ - see front matter ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2014.01.024
Please cite this article in press as: Teo I, et al., Seat belt injury causing bisection of the breast: A case report, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/j.bjps.2014.01.024
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Figure 2 Intra-operative detail. The edges of the indentation were incised and de-epithelised. The nipple areolar complex was raised on a superiolateral pedicle. A superiomedial and inferiolateral pillar were created and mobilized to close the oblique defect in the breast.
Correspondence and communication Seat belt injuries to the breast will likely increase in incidence. The first priority in the assessment of such cases is to exclude breast cancer with the use of ‘triple assessment’ encompassing clinical examination, breast imaging and needle biopsy. There is a paucity of published data on reconstructive options. In this case we successfully recreated a convex mound by incising and de-epithelising the edges of the breast indentation and mobilizing breast pillars as necessary.
Conflicts of interest None.
Funding None.
Acknowledgements We would like to thank Evan H.T. Lim, medical illustrator for his help in illustration.
References
Figure 3 Two months following reconstruction of the right breast to correct the diagonal furrow.
her breast over the subsequent weeks following her road traffic accident. Her right breast had an invaginated nipple areolar complex. The authors performed a reconstructive procedure and raised the areolar as a 1 cm thick superomedially based flap. The edges of the medial and lateral segments were mobilized to fill the cavity. In this case, the contralateral left breast was reduced to match the right breast. The surgical management in our case is similar with incision of the edges of the diagonal furrows, and mobilization of breast pillars. The final reconstructed breast was subjectively and objectively cosmetically accepted, but smaller compared to the contralateral breast. It is reasonable to assume that any patient needing complex reconstruction for fat necrosis will result in some volume loss. Whilst this lady declined symmetrisation procedures, all patients should be counseled about the possible need to subsequent volume match surgeries.
1. Department for Transport. https://www.gov.uk/government/ organisations/department-for-transport. [accessibility verified 06.05.13]. 2. Crandall CS, Olson LM, Sklar DP. Mortality reduction with air bag and seat belt use in head-on passenger car collisions. Am J Epidemiol 2001;153:219e24. 3. Page Y, Cuny S, Hermitte T, et al. A comprehensive overview of the frequency and the severity of injuries sustained by car users and subsequent implications in terms of injury prevention. Ann Adv Automot Med 2012;56:165e74. 4. Paddle AM, Morrison WA. Seat belt injury to the female breast: review and discussion of its surgical management. ANZ J Surg 2010;80:71e4.
Isabel Teo Plastic and Reconstructive Surgery Department, Ninewells Hospital, Dundee DD19SY, UK E-mail address: [email protected] David Dujon Plastic and Reconstructive Surgery Department, Royal Hallamshire Hospital, Sheffield S10 2TB, UK Iman Azmy Breast Surgery Department, Chesterfield Royal Hospital, Calow, Derbyshire S445BL, UK 4 November 2013
Please cite this article in press as: Teo I, et al., Seat belt injury causing bisection of the breast: A case report, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/j.bjps.2014.01.024
MODEL
Journal of Plastic, Reconstructive & Aesthetic Surgery (2014) xx, 1e2
CORRESPONDENCE AND COMMUNICATION Seat belt injury causing bisection of the breast: A case report* Dear Sir, Seat belt use has been mandatory in the United Kingdom since 1983 for front seat passengers, and since 1991 for rear seat users.1 This measure has hugely reduced the risk of serious injuries and death associated with road traffic accidents.2,3 However, this restraint system is associated with a particular pattern of injuries in the configuration of the seat belt, namely sternal fractures, bowel trauma or spinal injuries. There have been multiple publications on these injuries which have now been termed ‘seat belt syndrome’ or ‘seat belt injuries’. We report a case of breast bisection as a result of seat belt trauma with description of the reconstructive procedure. A 67 year old lady was involved in a road traffic accident resulting in severe bruising across her right breast from her seat belt. There were no open wounds and she did not require any medical treatment at this stage. Over the subsequent weeks, she noticed a worsening deformity of her right breast. Her past medical history included rheumatoid arthritis affecting her hips for which she took Naproxen 500 mg BD, and she was otherwise fit and well. She had attended regular mammograms that had been normal. She first attended the breast unit three months after her accident and was noted to have severe indentation of her right breast in line of her seat belt (Figure 1). A mammogram and ultra-sound scan was performed which revealed extensive fat necrosis. Core biopsies were performed despite a low index of suspicion by the radiologist. This showed fat necrosis with no suspicious features. Surgery was offered to correct the indentation of her breast. Ten months following the accident, she underwent a complex reconstructive procedure performed under general anesthetic. The edges of diagonal depression were incised and de-epithelised. The nipple areolar complex was
* Work attributable to: Plastic and Reconstructive Surgery Department, Royal Hallamshire Hospital, Sheffield, S10 2TB.
raised on a superiolateral pedicle. A superiomedial and inferiolateral pillar were created, mobilised to close the oblique defect in the breast. Figure 2 shows the intraoperative detail. There were no peri-operatively complications and she was discharged home one day postoperatively. At a followup appointment, she reported high levels of satisfaction. Whilst her right breast was smaller than her left, she felt symmetrical in a bra and declined any further procedures. Figure 3 demonstrates her postoperative result. The shoulder restraint portion of the three-point lapdiagonal belt is commonly positioned over or near the female breast. Injury to the breast tissue results from compressive forces between the seat belt and the boney ribcage during rapid deceleration. Breast deformity following seat belt restraint has been documented, but there is paucity in the literature regarding reconstructive options. The challenge for the plastic surgeon is that each case will be slightly different. Paddle et al.4 described a 37 year old with who similarly developed a diagonal cleft in
Figure 1 Oblique furrow demonstrated on right breast corresponding to the line of the seat belt.
1748-6815/$ - see front matter ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2014.01.024
Please cite this article in press as: Teo I, et al., Seat belt injury causing bisection of the breast: A case report, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/j.bjps.2014.01.024
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MODEL
2
Figure 2 Intra-operative detail. The edges of the indentation were incised and de-epithelised. The nipple areolar complex was raised on a superiolateral pedicle. A superiomedial and inferiolateral pillar were created and mobilized to close the oblique defect in the breast.
Correspondence and communication Seat belt injuries to the breast will likely increase in incidence. The first priority in the assessment of such cases is to exclude breast cancer with the use of ‘triple assessment’ encompassing clinical examination, breast imaging and needle biopsy. There is a paucity of published data on reconstructive options. In this case we successfully recreated a convex mound by incising and de-epithelising the edges of the breast indentation and mobilizing breast pillars as necessary.
Conflicts of interest None.
Funding None.
Acknowledgements We would like to thank Evan H.T. Lim, medical illustrator for his help in illustration.
References
Figure 3 Two months following reconstruction of the right breast to correct the diagonal furrow.
her breast over the subsequent weeks following her road traffic accident. Her right breast had an invaginated nipple areolar complex. The authors performed a reconstructive procedure and raised the areolar as a 1 cm thick superomedially based flap. The edges of the medial and lateral segments were mobilized to fill the cavity. In this case, the contralateral left breast was reduced to match the right breast. The surgical management in our case is similar with incision of the edges of the diagonal furrows, and mobilization of breast pillars. The final reconstructed breast was subjectively and objectively cosmetically accepted, but smaller compared to the contralateral breast. It is reasonable to assume that any patient needing complex reconstruction for fat necrosis will result in some volume loss. Whilst this lady declined symmetrisation procedures, all patients should be counseled about the possible need to subsequent volume match surgeries.
1. Department for Transport. https://www.gov.uk/government/ organisations/department-for-transport. [accessibility verified 06.05.13]. 2. Crandall CS, Olson LM, Sklar DP. Mortality reduction with air bag and seat belt use in head-on passenger car collisions. Am J Epidemiol 2001;153:219e24. 3. Page Y, Cuny S, Hermitte T, et al. A comprehensive overview of the frequency and the severity of injuries sustained by car users and subsequent implications in terms of injury prevention. Ann Adv Automot Med 2012;56:165e74. 4. Paddle AM, Morrison WA. Seat belt injury to the female breast: review and discussion of its surgical management. ANZ J Surg 2010;80:71e4.
Isabel Teo Plastic and Reconstructive Surgery Department, Ninewells Hospital, Dundee DD19SY, UK E-mail address: [email protected] David Dujon Plastic and Reconstructive Surgery Department, Royal Hallamshire Hospital, Sheffield S10 2TB, UK Iman Azmy Breast Surgery Department, Chesterfield Royal Hospital, Calow, Derbyshire S445BL, UK 4 November 2013
Please cite this article in press as: Teo I, et al., Seat belt injury causing bisection of the breast: A case report, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/j.bjps.2014.01.024
