Anatomy of the superficial layer of superficial fascia around the nipple-areola complex

BACKGROUND

The periareolar incision is the preferred method for mammaplasty because of the minimal scarring, and suturing of the superficial fascial system (SFS) is useful for avoiding hypertrophic scarring. In this report, we describe the anatomical location of the SFS around the nipple-areolar complex (NAC) and its histological structure.

METHODS

To define the location of the SFS, 20 healthy women were assessed by ultrasonography, and sections of the NAC of 10 female cadavers were examined under a light microscope.

RESULTS

Ultrasonographic examination of sagittal sections of the breast revealed a hyperdense line immediately beneath the skin, which ran parallel with the skin and turned under the NAC. At the turning point, the line thickened to an average of 3.09 mm. The distance between the nipple and the thickest point of the hyperdense line was 10.14 mm on average. Histological structures of the line were collagen and elastic fibers containing smooth muscles that were connected to the dermis and adipose tissue. At the turning point, nerves, blood vessels, and mammary ducts were irregularly observed in the area of collagen and elastic fibers. These structures were intermingled, and the fiber bundle was very thick.

CONCLUSIONS

The thickest area of the turning point is an area of the superficial layer of superficial fascia, which is a key structure around the NAC. The detailed anatomical data shown in our study provide good morphological landmarks for the closure of periareolar incisions.

NO LEVEL ASSIGNED

This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266.

A Switched-Mode Breast Coil for 7 T MRI Using Forced-Current Excitation

In high-field magnetic resonance imaging, the radio frequency wavelength within the human body is comparable to anatomical dimensions, resulting in B1 inhomogeneity and nonuniform sensitivity patterns. Thus, this relatively short wavelength presents engineering challenges for RF coil design. In this study, a bilateral breast coil for (1)H imaging at 7 T was designed and constructed using forced-current excitation. By forcing equal current through the coil elements, we reduce the effects of coupling between the elements to simplify tuning and to ensure a uniform field across both breasts. To combine the benefits of the higher power efficiency of a unilateral coil with the bilateral coverage of a bilateral coil, a switching circuit was implemented to allow the coil to be reconfigured for imaging the left, right, or both breasts.

Average dielectric property analysis of complex breast tissue with microwave transmission measurements

Prior information about the average dielectric properties of breast tissue can be implemented in microwave breast imaging techniques to improve the results. Rapidly providing this information relies on acquiring a limited number of measurements and processing these measurement with efficient algorithms. Previously, systems were developed to measure the transmission of microwave signals through breast tissue, and simplifications were applied to estimate the average properties. These methods provided reasonable estimates, but they were sensitive to multipath. In this paper, a new technique to analyze the average properties of breast tissues while addressing multipath is presented. Three steps are used to process transmission measurements. First, the effects of multipath were removed. In cases where multipath is present, multiple peaks were observed in the time domain. A Tukey window was used to time-gate a single peak and, therefore, select a single path through the breast. Second, the antenna response was deconvolved from the transmission coefficient to isolate the response from the tissue in the breast interior. The antenna response was determined through simulations. Finally, the complex permittivity was estimated using an iterative approach. This technique was validated using simulated and physical homogeneous breast models and tested with results taken from a recent patient study.

Automatic landmarks detection in breast reconstruction aesthetic assessment

This paper addresses a fully automatic landmarks detection method for breast reconstruction aesthetic assessment. The set of landmarks detected are the supraesternal notch (SSN), armpits, nipples, and inframammary fold (IMF). These landmarks are commonly used in order to perform anthropometric measurements for aesthetic assessment. The methodological approach is based on both illumination and morphological analysis. The proposed method has been tested with 21 images. A good overall performance is observed, although several improvements must be achieved in order to refine the detection of nipples and SSNs.

Automated segmentation of breast in 3-D MR images using a robust atlas

This paper presents a robust atlas-based segmentation (ABS) algorithm for segmentation of the breast boundary in 3-D MR images. The proposed algorithm combines the well-known methodologies of ABS namely probabilistic atlas and atlas selection approaches into a single framework where two configurations are realized. The algorithm uses phase congruency maps to create an atlas which is robust to intensity variations. This allows an atlas derived from images acquired with one MR imaging sequence to be used to segment images acquired with a different MR imaging sequence and eliminates the need for intensity-based registration. Images acquired using a Dixon sequence were used to create an atlas which was used to segment both Dixon images (intra-sequence) and T1-weighted images (inter-sequence). In both cases, highly accurate results were achieved with the median Dice similarity coefficient values of 94% ±4% and 87 ±6.5%, respectively.

Health professionals' experiences providing breastfeeding-related care for obese women

BACKGROUND

Obese women are at high risk of early breastfeeding cessation, and health professionals (HPs) have a unique opportunity to provide them with breastfeeding support. Our objective was to describe HPs' experiences providing breastfeeding care for obese women during the prenatal, peripartum, and postpartum periods.

MATERIALS AND METHODS

In-depth, qualitative interviews were conducted with 34 HPs (including obstetricians, midwives, pediatricians, nurses, and lactation consultants) who care for pregnant or lactating women. They were recruited from a variety of settings in central New York. Interviews were audio-recorded, transcribed, verified for accuracy, and then analyzed qualitatively.

RESULTS

HPs identified obesity in multiple ways, some of which were consistent with standard cutoffs, whereas others implied extreme obesity. Nearly all HPs discussed ways they perceive obese women have challenges with breastfeeding. Some HPs described challenges as specific to obese women (e.g., limited mobility), whereas others described challenges as universal but more likely to occur among obese women (e.g., difficulties positioning the infant to breastfeed). Across professions, HPs described providing breastfeeding care for obese women as requiring more time and physical work and as being more challenging. HPs acknowledged stigma around obesity and discussed treating obese women with dignity and the same as other women. Strategies were suggested for improving breastfeeding support for obese women.

CONCLUSIONS

HPs identified multiple challenges that obese women encounter with breastfeeding, as well as their own challenges with providing care. Comprehensive strategies are needed to assist obese women with breastfeeding and to alleviate strain on HPs who provide their care.

A 16-channel receive, forced current excitation dual-transmit coil for breast imaging at 7T

Purpose

To enable high spatial and temporal breast imaging resolution via combined use of high field MRI, array coils, and forced current excitation (FCE) multi channel transmit.

Materials and Methods

A unilateral 16-channel receive array insert was designed for use in a transmit volume coil optimized for quadrature operation with dual-transmit RF shimming at 7T. Signal-to-noise ratio (SNR) maps, g-factor maps, and high spatial and temporal resolution in vivo images were acquired to demonstrate the utility of the coil architecture.

Results

The dual-transmit FCE coil provided homogeneous excitation and the array provided an increase in average SNR of 3.3 times (max 10.8, min 1.5) compared to the volume coil in transmit/receive mode. High resolution accelerated in vivo breast imaging demonstrated the ability to achieve isotropic spatial resolution of 0.5 mm within clinically relevant 90 s scan times, as well as the ability to perform 1.0 mm isotropic resolution imaging, 7 s per dynamics, with the use of bidirectional SENSE acceleration of up to R = 9.

Conclusion

The FCE design of the transmit coil easily accommodates the addition of a sixteen channel array coil. The improved spatial and temporal resolution provided by the high-field array coil with FCE dual-channel transmit will ultimately be beneficial in lesion detection and characterization.

A dielectric model of human breast tissue in terahertz regime

The double Debye model has been used to understand the dielectric response of different types of biological tissues at terahertz (THz) frequencies but fails in accurately simulating human breast tissue. This leads to limited knowledge about the structure, dynamics, and macroscopic behavior of breast tissue, and hence, constrains the potential of THz imaging in breast cancer detection. The first goal of this paper is to propose a new dielectric model capable of mimicking the spectra of human breast tissue's complex permittivity in THz regime. Namely, a non-Debye relaxation model is combined with a single Debye model to produce a mixture model of human breast tissue. A sampling gradient algorithm of nonsmooth optimization is applied to locate the optimal fitting solution. Samples of healthy breast tissue and breast tumor are used in the simulation to evaluate the effectiveness of the proposed model. Our simulation demonstrates exceptional fitting quality in all cases. The second goal is to confirm the potential of using the parameters of the proposed dielectric model to distinguish breast tumor from healthy breast tissue, especially fibrous tissue. Statistical measures are employed to analyze the discrimination capability of the model parameters while support vector machines are applied to assess the possibility of using the combinations of these parameters for higher classification accuracy. The obtained analysis confirms the classification potential of these features.

In-vivo quantification of human breast deformation associated with the position change from supine to upright

Stereophotographic imaging and digital image correlation are used to determine the variation of breast skin deformation as the subject orientation is altered from supine to upright. A change in subject's position from supine to upright can result in significant stretches in some parts of the breast skin. The maximum of the major principal stretch ratio of the skin is different in different subjects and varies in the range of 1.25-1.60. It is also found that the boundaries of the breast move significantly relative to the skeletal structure and other fixed points such as the sternal notch. Such measurements are crucial since they provide basic data for validation of biomechanical breast models based on finite element formulations.

Breast size and breast cancer: a systematic review

BACKGROUND

There are many known breast cancer risk factors, but traditionally the list has not included breast size. The aim of this study was to synthesize the literature on breast size as a risk factor for breast carcinoma by examining studies addressing this question both directly and indirectly.

METHODS

A systematic review was performed searching MEDLINE from 1950 to November 2010, and updated again in February 2014. Literature was sought to assess the relationship between the following variables and breast cancer: 1) breast size; 2) breast reduction; 3) breast augmentation; and 4) prophylactic subcutaneous mastectomy. Findings were summarized and the levels of evidence were assessed.

RESULTS

50 papers were included in the systematic review. Increasing breast size appears to be a risk factor for breast cancer, but studies are limited by their retrospective nature, imperfect size measurement techniques and confounding variables. The evidence is stronger for risk reduction with breast reduction, including prophylactic subcutaneous mastectomy at the extreme. Generally the breast augmentation population has a lower risk of breast cancer than the general population, but it is unclear whether or not this is related to the bias of small breasts in this patient population and the presence of other confounders.

CONCLUSIONS

There is direct and indirect evidence that breast size is an important factor in the risk of developing breast cancer. Plastic surgeons are in a unique position to observe this effect. Well-designed prospective studies are required to further assess this risk factor.

The DAMA trial: a diet and physical activity intervention trial to reduce mammographic breast density in postmenopausal women in Tuscany, Italy. Study protocol and baseline characteristics

Aims and background. High mammographic breast density (MBD) is an established risk factor for breast cancer (BC). The influence of diet and physical activity (PA) on MBD has long been investigated. In an observational study of a cohort in Florence, we observed inverse associations between consumption of vegetables and olive oil and moderate leisure-time PA and MBD, while high alcohol intake and high glycemic load diets were positively associated with MBD. We set out to investigate whether dietary and PA interventions were able to reduce MBD in postmenopausal women with high MBD (>50%). Methods and study design. The DAMA (Diet, physical Activity and MAmmography) trial, a factorial randomized trial involving healthy nonsmoking postmenopausal women not using hormone replacement therapy and having MBD >50%, is aimed at evaluating the ability of a 24-month intervention based on moderate-intensity PA and/or dietary modification focused on plant foods with a low glycemic load, low in saturated fats and alcohol, and rich in antioxidants and fiber, to reduce the percent MBD. Participants have been randomized to 1 of 4 study arms (diet, PA, diet + PA, control). Dietary and PA habits and anthropometry are collected at baseline and at the end of the intervention phase together with repeated blood and urine samples. The primary outcome of the study is the absolute change in percent MBD as assessed on baseline and follow-up digital mammograms performed in the framework of the local screening program. Results. Of 728 eligible women, 234 (32.1%) agreed to participate. We did not observe any difference across study arms in the baseline distribution of variables of interest related to diet and lifestyle. Conclusions. The DAMA trial may contribute to a better understanding of MBD determinants. This will provide insight into the pathogenesis of BC and may allow the development of strategies for primary prevention focused on high-MBD groups that are easily identifiable in large-scale BC screening programs.

TRIAL REGISTRATION NUMBER

ISRCTN28492718.

Automatic segmentation of breast MR images through a Markov random field statistical model

An algorithm dedicated to automatic segmentation of breast magnetic resonance images is presented in this paper. Our approach is based on a pipeline that includes a denoising step and statistical segmentation. The noise removal preprocessing relies on an anisotropic diffusion scheme, whereas the statistical segmentation is conducted through a Markov random field model. The continuous updating of all parameters governing the diffusion process enables automatic denoising, and the partial volume effect is also addressed during the labeling step. To assess the relevance, the Jaccard similarity coefficient was computed. Experiments were conducted on synthetic data and breast magnetic resonance images extracted from a high-risk population. The relevance of the approach for the dataset is highlighted, and we demonstrate accuracy superior to that of traditional clustering algorithms. The results emphasize the benefits of both denoising guided by input data and the inclusion of spatial dependency through a Markov random field. For example, the Jaccard coefficient for the clinical data was increased by 114%, 109%, and 140% with respect to a K-means algorithm and, respectively, for the adipose, glandular and muscle and skin components. Moreover, the agreement between the manual segmentations provided by an experienced radiologist and the automatic segmentations performed with this algorithm was good, with Jaccard coefficients equal to 0.769, 0.756, and 0.694 for the above-mentioned classes.

Age-related ultrasonic properties of breast tissue in vivo

The aim of the current work was to quantify the ultrasonic properties of the whole breast in vivo as a function of age. Forty-four women were scanned using a computerized ultrasonic scanner developed in our laboratory. Raster scans in two orthogonal views, mediolateral and craniocaudal, were obtained using the ultrasonic through-transmission method. By combining the information from the two views, we estimated two acoustic properties: speed of sound and attenuation coefficient. On the basis of the results, both the attenuation coefficient and the speed of sound follow a three-phase age-related pattern. During the first phase, which corresponds to ages 20 to 35 y, both properties decrease with time and then remain roughly unchanged until about 55 y. During the third phase corresponding to ages >55 y, values decrease again with time. The mean speed of sound decreases from 1504 ± 35 m/s at <30 y to 1452 ± 9 m/s at >60 y (p < 0.01), and the attenuation coefficient decreases from 1.27 ± 0.32 to 0.96 ± 0.13 dB/cm/MHz (p < 0.03), respectively. In conclusion, both the ultrasonic speed of sound and the attenuation coefficient of breast tissue are age related. Both parameters decrease during life, markedly during the first and third phases. These changes may be attributed to anatomic and physiologic changes associated with reproductivity and menopause.

The simulation of 3D mass models in 2D digital mammography and breast tomosynthesis

PURPOSE

This work proposes a new method of building 3D breast mass models with different morphological shapes and describes the validation of the realism of their appearance after simulation into 2D digital mammograms and breast tomosynthesis images.

METHODS

Twenty-five contrast enhanced MRI breast lesions were collected and each mass was manually segmented in the three orthogonal views: sagittal, coronal, and transversal. The segmented models were combined, resampled to have isotropic voxel sizes, triangularly meshed, and scaled to different sizes. These masses were referred to as nonspiculated masses and were then used as nuclei onto which spicules were grown with an iterative branching algorithm forming a total of 30 spiculated masses. These 55 mass models were projected into 2D projection images to obtain mammograms after image processing and into tomographic sequences of projection images, which were then reconstructed to form 3D tomosynthesis datasets. The realism of the appearance of these mass models was assessed by five radiologists via receiver operating characteristic (ROC) analysis when compared to 54 real masses. All lesions were also given a breast imaging reporting and data system (BIRADS) score. The data sets of 2D mammography and tomosynthesis were read separately. The Kendall's coefficient of concordance was used for the interrater observer agreement assessment for the BIRADS scores per modality. Further paired analysis, using the Wilcoxon signed rank test, of the BIRADS assessment between 2D and tomosynthesis was separately performed for the real masses and for the simulated masses.

RESULTS

The area under the ROC curves, averaged over all observers, was 0.54 (95% confidence interval [0.50, 0.66]) for the 2D study, and 0.67 (95% confidence interval [0.55, 0.79]) for the tomosynthesis study. According to the BIRADS scores, the nonspiculated and the spiculated masses varied in their degrees of malignancy from normal (BIRADS 1) to highly suggestive for malignancy (BIRADS 5) indicating the required variety of shapes and margins of these models. The assessment of the BIRADS scores for all observers indicated good agreement based on Kendall's coefficient for both the 2D and the tomosynthesis evaluations. The paired analysis of the BIRADS scores between 2D and tomosynthesis for each observer revealed consistent behavior for the real and simulated masses.

CONCLUSIONS

A database of 3D mass models, with variety of shapes and margins, was validated for the realism of their appearance for 2D digital mammography and for breast tomosynthesis. This database is suitable for use in future observer performance studies whether in virtual clinical trials or in patient images with simulated lesions.

Requirements for static and dynamic higher order B0 shimming of the human breast at 7 T

The increased magnetic susceptibility effects at higher magnetic fields increase the demands for shimming of the B0 field for in vivo MRI and MRS. Both static and dynamic techniques have been developed to compensate for susceptibility-induced field inhomogeneities. In this study, we investigate the impact of and need for both static and dynamic higher order B0 shimming of magnetic field homogeneities in clinical breast MRI at 7 T. Both global and local field variations at lipid-tissue interfaces were observed in the magnetic field using TE-optimized B0 mapping at 7 T. With static B0 shimming, a field homogeneity of 39 ± 11 Hz (n = 48) was reached in a single breast using second-order shimming. Further compensation of the residual local field inhomogeneities caused by lipid-tissue interfaces does not seem to be feasible with shallow spherical harmonic fields. For bilateral shimming, the shimming quality was significantly less at 62 ± 15 Hz (n = 22) over both breasts, even after (simulated) fourth-order shimming. In addition, a substantial time-dependent field instability of 30 Hz peak to peak, with significant higher order field contributions, was observed during regular breathing. In conclusion, TE-optimized B0 field mapping reveals substantial field variations in the lipid-rich environment of the human breast, in both space and time. The static field variations could be partially minimized by third-order B0 shimming, providing sufficient lipid suppression. However, in order to fully benefit from the increased spectral dispersion at high fields, the significant magnetic field variations during breathing need to be considered.

Do breast cups improve breast cancer dosimetry? A comparative study for patients with large or pendulous breasts

PURPOSE

Treating patients with large or pendulous breasts is challenging. Although brassiere cups are currently in use, no study has yet been carried out to assess their dosimetric impact. The aim of the present study was to evaluate the possible dosimetric advantages of the use of breast cups on patients with large or pendulous breasts.

MATERIALS AND METHODS

Two CT studies were carried out on 12 breast cancer patients with large or pendulous breasts, with one study involving the use of breast cups. Radiation plans were developed in accordance with each of the CT studies. The following were compared: planning target volume (PTV), volume irradiated by the 95% isodose, conformity index, homogeneity index, mean lung dose, and mean heart dose was also compared for left breast treatment. The plan involving the use of cups was found to be the best option, leading to all patients being treated with cups. The resulting acute toxicity and cosmesis were also recorded. Both scenarios involved the use of film dosimetry to evaluate the skin doses.

RESULTS

The use of breast cups resulted in a significant reduction of the PTV volume (from 1640 cm3 to 1283 cm3), of the irradiated volume (from 2154 cm3 to 1477 cm3) and of the conformity index (from 1383 to 1213). Despite slight improvements in the homogeneity index (from 0.12 to 0.10), statistical significance was not attained. The use of breast cups also led to significant dose reductions in V20 for lung (from 13.7% to 1.7%) and V5 for heart (from 9.8% to 2.7%). No differences in acute toxicity or cosmesis were observed compared to patients treated without cups.

CONCLUSIONS

Our results show that the use of brassiere cups during breast radiation therapy leads to improvements in the main dosimetric factors analyzed. Furthermore, modifications to standard irradiation protocols are not required. In summary, we consider the technique of using breast cups with radiation therapy highly appropriate when treating breast cancer patients with large or pendulous breasts.

Advancements in molecular breast imaging

Breast cancer is the most common cancer in women, but with early detection, it is a treatable disease. Mammography has long been the medical imaging standard for breast cancer screening, with other breast imaging modalities used as adjunct procedures to support diagnostic interpretation. Molecular breast imaging (MBI) was introduced in the past decade as a promising adjunct to mammography. Using a radiopharmaceutical and a dedicated imaging device, MBI technology helps physicians examine metabolic activity within the breast. This article provides a review of breast anatomy and composition, explores genetic factors related to breast cancer, and examines practice guidelines related to MBI.

Breast augmentation with anatomic implants: a method based on the breast implantation base

Currently, aesthetic and reconstructive surgery of the breast should be considered in terms of contouring, and hence in terms of dimensions. Based on experience performing more than 5,000 breast augmentations with highly cohesive anatomic implants, the authors explore the aesthetic anatomy of the (augmented) breast and explain the importance of the breast implantation base (BIB), the aesthetic proportions of the lower breast pole, and the patient's somatotype in the implant selection for a natural-appearing breast augmentation. A method is described for transferring all these concepts and proportions to the preoperative marking of the individual patient.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .