Key points

Background

Since the 1989 publication by the Committee on Nomenclature of the American Society for Aesthetic Plastic Surgery, there have been no consolidated updates to the breast nomenclature or any attempts to help standardize terminology. The aim of this project was to investigate inconsistencies in the use of descriptors in breast surgery and to recommend a novel nomenclature that will be adopted and standardized among plastic surgeons. Breast surgery has been a focus of plastic surgery since the birth of the discipline, with advancements in this area being integral in the development of our specialty. From 1983 to 1989, the Committee on Nomenclature of the American Society for Aesthetic Plastic Surgery conducted a literature review and published 4 articles to suggest a nomenclature for the field. Since this series of publications, there have been no consolidated updates to the nomenclature or attempts to standardized technology. Secondary to this lack, there is a great deal of confusion and redundancy in trying to define specific types of deformities or complications in patient’s breasts.

Evolutions of understanding over the last 27 years and recent advancements in the field, such as dual-plane breast augmentation, were not captured by this previous work. Moreover, a recent review of the literature shows that some descriptors are being used interchangeably. One example is the term “bottoming out.” It has been used by some surgeons synonymously with pseudoptosis as well as to describe inferior implant migration or lower pole stretch deformity of the breast. Another example is the multiple descriptors available for breast base abnormalities, including tuberous breast deformity, lower pole hypoplasia, tubular breast, and narrow-based breast or breast constriction. These interchangeable descriptors were identified by authors as an issue in the literature, but this issue has not been addressed.

Given the observed differences in usage and the length of time that has elapsed since a nomenclature was put forward, we investigated whether inconsistencies existed in the use of descriptors in breast surgery by reviewing the literature and in discussions with many leaders in the field. We used a Delphi methodology to first identify descriptors with multiple interpretations or that are used interchangeably, and then achieved consensus on an appropriate nomenclature in breast surgery. Identifying and addressing inconsistencies in this field is worthwhile; for any clinical or scientific discussion to occur, participants must share an equal understanding of the terminology being used.

Approach: Delphi consensus

We used a modified Delphi methodology to identify redundant and ambiguous descriptors and then achieve a consensus on a novel, standardized nomenclature and terminology in breast surgery. The process involved initial identification of the terminology to be further defined, a thorough review by content experts, and finally a Delphi consensus analysis. Institutional review board approval was obtained through the University of Toronto Research Ethics Board.

The modified Delphi approach consisted of a 3-step process. First, the steering committee, composed of an expert breast surgeon (M.B.) and resident physicians (H.R. and S.H.), reviewed the literature to identify potential inconsistencies in the use of terms in breast surgery. Second, the steering committee developed a 118-question survey to explore the current uses of 33 inconsistently used breast terms. This survey was refined through pilot testing by 5 plastic surgeons with significant experience in breast surgery.

The questionnaire was distributed to 32 breast surgery experts through SurveyMonkey (SurveyMonkey Inc., San Mateo, CA, 2017). Experts in the field were selected by the principal investigator (M.B.). Criteria used for selection were (1) recognized clinical interest in plastic surgery of the breast, (2) practice in North America, and (3) be in practice for a minimum of 3 years.

The questionnaire presented participants with questions on their use of 33 selected breast surgery descriptors. Representative examples of questions included: “Q23. Which of the following is correct regarding the term ‘bottoming out’ (Select one): [A,B, or C],” “Q92. Glandular ptosis is synonymous with inferior malposition. [True or False],” and “Q116. Hypoplastic breast refers to a small but otherwise normal breast. [True or False].” These descriptors were categorized into ptosis (ptosis, pseudoptosis, glandular ptosis), medial malposition (synmastia, medial malposition, bread loafing, window shading), inferior malposition (double bubble, Snoopy deformity, bottoming out, inferior malposition, waterfall deformity), superior malposition, planes of dissection (subpectoral, submuscular, dual planes I, II, and III), constricted breast (tuberous breast, constricted breast, tubular breast, herniated areola, puffy nipple, areola hypertrophy, pseudoherniation), hypertrophy (breast hypertrophy, hypermastia, gigantomastia, macromastia, juvenile macromastia, virginal hypertrophy of the breast), and hypoplasia (breast hypoplasia, micromastia). Each descriptor was assessed multiple times ( Table 1 ) using up to 2 different question types (multiple choice and true or false). Summary statistics were generated by SurveyMonkey; descriptive statistics were generated, with frequencies and percent of responses calculated for each survey question. Responses from the survey achieved consensus if more than 60% of respondents agreed.

Questions that did not achieve consensus were then forwarded to the third step of the Delphi. During a teleconference, the group of experts who participated in the second phase discussed each term to achieve consensus. The teleconference was moderated by M.B., and recorded by S.H. and H.R. Because consensus was achieved during the teleconference, a second online survey (fourth step) was not necessary to complete the Delphi process.

Consensus recommendations

Of the 26 experts who agreed to participate in the Delphi, 22 completed the survey for a completion rate of 85%. Of the 118 survey questions, 99 achieved consensuses (>60% of respondents agreed) ( Table 2 ). There was a lack of consensus on 16% of the questions in the survey. When questions were grouped by subject, disagreement rates were as follows: ptosis (n = 4), planes of dissection (n = 4), and tuberous breast (n = 2). Certain terms were also associated with a lack of consensus: bread loafing (n = 3), virginal hypertrophy of the breast (n = 2), bottoming out (n = 2), window shading (n = 1), and inferior malposition (n = 1).

The results of the survey were disseminated to the participants for review before the third phase of the Delphi. Of the 22 experts who completed the survey, 9 participated in the conference call. All concepts and terms that did not reach consensus during the second phase of the Delphi were discussed during the 1 hour and 30 minute teleconference meeting. Disagreements were brought forward by the moderator (M.B.) and discussed with all attendees until consensus was achieved ( Table 3 ). The group of experts agreed that there was misuse of and lack of a clear definition for several terms, such as window shading, bottoming out, waterfall deformity, and double bubble. Furthermore, there was redundancy in the terms used to describe breast hypertrophy and tuberous breast. The group recommended the removal of misused terms and introduce more anatomically accurate nomenclature, such as stretch deformity or implant–gland mismatch. When redundancy was present, only 1 term was maintained, such as constricted breast or breast hypertrophy. The experts agreed on the definitions of each term (see Table 3 ).

Table 3

A new lexicon of breast nomenclature

Category	Terms	Updated Definition
Implant pocket and surgical plane	Subglandular	Implant is placed beneath the gland above the muscle
	Subfascial	Implant is placed beneath pectoralis fascia
	Dual plane I	Muscle division of inferior pectoralis major border without release of gland from the muscle
	Dual plane II	Dissection of the gland off of the muscle allowing muscle release to lower border of areola
	Dual plane III	Dissection of the gland off the muscle allowing muscle release to upper border areola
Implant malposition	Medial Lateral Inferior Superior	Implant displaced medial/lateral/inferior/superior to the intended medial/lateral/inferior/superior breast border
Implant–gland mismatch		A breast deformity caused by inadequate distribution of tissue or positioning of tissue over an implant
Stretch deformity		Nipple to IMF distance is increased AND where the IMF remains fixed
Pectoral banding		Muscle contracting across the anterior surface of a dual plane implant causing an abnormal contour
Ptosis		Stretch deformity of the upper pole of the breast with descent of the nipple at or below the transposed IMF
Synmastia		Congenital or developmental webbing of the tissue over the sternum
Constricted breast		Congenital breast abnormality characterized by: 1. A contracted skin envelope both horizontally and vertically, 2. A narrow breast base, 3. Breast hypoplasia, 4. Tight and high IMF, 5. Herniation of the breast parenchyma into the areola, and 6. Areola hypertrophy.
Breast hypoplasia		Breast undergrowth
Breast hypertrophy		Breast overgrowth
	Juvenile hypertrophy	Age related prepubertal or pubertal breast overgrowth

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