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Prioritizing Native Breast Skin Preservation Or Scar Symmetry In Autologous Breast Reconstruction? Using Crowdsourcing To Assess Laypersonsí Preference
Ashraf A. Patel, BS1,2, Carol L. Feng, BS3, Alan Nguyen, BS4, John Spaw, BS3, Rebecca Garza, MD1, Gordon K. Lee, MD, FACS1, Rahim S. Nazerali, MD, MHS1.
1Stanford University, Palo Alto, CA, USA, 2SUNY Upstate Medical University, Syracuse, NY, USA, 3Rush Medical College, Chicago, IL, USA, 4Oakland University, Rochester, MI, USA.

PURPOSE
Bilateral autologous breast reconstruction has many approaches, resulting in many possible scar and flap patterns. Recent literature suggests that factors such as scar symmetry and skin paddle size impact patient preferences more than preservation of native breast skin, despite traditional reconstructive surgical principles. Since patient satisfaction with plastic surgery procedures is also largely influenced by conventional beauty standards set by the general public, we utilize a novel crowdsourcing method to evaluate laypeopleís aesthetic preferences for different bilateral autologous reconstructions to determine the relative importance of scar/skin paddle symmetry and preservation of native breast skin.
METHODS
Using Amazonís Mechanical Turk crowdsourcing marketplace, participants ranked images of bilateral autologous breast reconstructions based on overall aesthetic appearance. Images were digitally modified to reflect four types of reconstruction: immediate (IR), delayed symmetric (DS), delayed asymmetric (DA), or mixed (MR). Participants also compared IR and DA reconstructions before and after nipple areolar complex reconstruction (NACr) using a five-point Likert scale based on various aesthetic factors.
RESULTS
A total of 132 subjects were included in this study. DS was ranked most favorably (1.74), followed by IR (1.95), DA (2.93), and MR (3.34) (Figure 1). Friedman rank sum (X2(3) = 219.6, p < 0.001) and Pairwise tests (p < 0.001) showed statistical significance between all four reconstructions. Likert ratings were higher for IR when compared to DA reconstructions for skin quality (p = 0.002), scar visibility (p < 0.001), scar position (p < 0.001), and breast symmetry, shape, and position (p < 0.001). Ratings increased for all aesthetic factors when the same breast was shown after NACr (p < 0.001).
CONCLUSION
In bilateral autologous breast reconstruction, more symmetric breast scars are rated higher aesthetically than nonsymmetric scarring. Our findings also suggest that subjects preferred maintaining scar symmetry over preservation of native breast skin. Individual breast aesthetic factors were consistently rated higher after NACr than without NACr. These findings are consistent with previous studies utilizing non-crowdsourced participants, which demonstrates the potential for online crowdsourcing to be used as a powerful and reliable tool to assess the general publicís preference and subsequently improve patient satisfaction in plastic surgery.


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