An Objective Evaluation of Breast Symmetry and Shape Differences Using 3-Dimensional Images

Comparative assessment of 3D surface scanning systems in breast plastic and reconstructive surgery

In this work, we compared accuracy, repeatability, and usability in breast surface imaging of 2 commercial surface scanning systems and a hand-held laser surface scanner prototype coupled with a patient's motion acquisition and compensation methodology. The accuracy of the scanners was assessed on an anthropomorphic phantom, and to evaluate the usability of the scanners on humans, thorax surface images of 3 volunteers were acquired. Both the intrascanner repeatability and the interscanner comparative accuracy were assessed. The results showed surface-to-surface distance errors inferior to 1 mm and to 2 mm, respectively, for the 2 commercial scanners and for the prototypical one. Moreover, comparable performances of the 3 scanners were found when used for acquiring the breast surface. On the whole, this study demonstrated that handheld laser surface scanners coupled with subject motion compensation methods lend themselves as competitive technologies for human body surface modeling.

Looking ‘the same’: Experiences of women who have had corrective surgery for breast asymmetry

Qualitative interviews with ten women found that following corrective surgery for congenital breast asymmetry, women were still concerned with the symmetry of their breasts and expressed high ideals regarding symmetry. Although women found an improvement in body confidence, some felt their confidence and socializing would be further improved with time. Women were secretive about their breast asymmetry and their surgery, being fearful of negative reactions from other people. It is necessary to establish and improve patients’ expectations of the outcome of surgery particularly regarding symmetry, as well as providing psychological and social support to women after surgery.

Experiences of the Use of External Breast Prosthesis among Breast Cancer Survivors in Korea

PURPOSE

The purpose of this study was to examine the experiences of the use of external breast prostheses among breast cancer survivors in Korea.

METHODS

A qualitative descriptive study was conducted, using focus groups. Data were collected from breast cancer survivors who were patients of C women's hospital in Seoul, Korea. Data were analyzed using content analysis in order to identify significant themes.

RESULTS

Participants included forty breast cancer survivors who had mastectomy as a surgical treatment. Four themes emerged from the collected data were: 1) concern over the high price of external breast prosthesis, 2) irregular use of external breast prosthesis, 3) unsatisfied with mastectomy bra, and 4) wanting to hide or not to talk about using breast prosthesis openly.

CONCLUSION

Since most participants reported irregular use and negative experiences related to external breast prosthesis or mastectomy bra use, healthcare workers should allow more time for proper fitting and counseling and consulting with breast cancer survivors. In addition, health care providers as well as family and friends should keep in mind that cancer survivors need support that can help them cope by using positive reframing. Furthermore, improvements in the coverage of costs and services are needed for these women. This would be helpful for breast prosthesis users.

A novel quantitative measure of breast curvature based on catenary

Quantitative, objective measurements of breast curvature computed from clinical photographs could be used to investigate factors that impact reconstruction and facilitate surgical planning. This paper introduces a novel quantitative measure of breast curvature based on catenary. A catenary curve is used to approximate the overall curvature of the breast contour, and the curvature measure is extracted from the catenary curve. The catenary curve was verified by comparing its length, the area enclosed by the curve, and the curvature measure from the catenary curve to those from manual tracings of the breast contour. The evaluation of the proposed analysis employed untreated and postoperative clinical photographs of women who were undergoing tissue expander/implant (TE/Implant) reconstruction. Logistic regression models were developed to distinguish between the curvature of breasts undergoing TE/Implant reconstruction and that of untreated breasts based on the curvature measure and patient variables (age and body mass index). The relationships between the curvature measures of untreated breasts and patient variables were also investigated. The catenary curve approximates breast curvature reliably. The curvature measure contains useful information for quantifying the curvature differences between breasts undergoing TE/Implant reconstruction and untreated breasts, and identifying the effect of patient variables on the breast shape.

Weight versus volume in breast surgery: an observational study

Objectives

The study hypothesis is to assess correlation of breast specimen weight versus volume.

Design

Consecutive patients undergoing breast surgery at a single tertiary referral centre during a 6-month period were included. Specimen weight was measured in grams. Direct volume measurements were performed using water displacement. Data including side of the breast, age and menstrual status of the patient were noted.

Setting

Knowledge of breast volume provides an objective guide in facilitating the achievements of balance in reconstructive operations. Surgeons use intraoperative weight measurements from individual breasts to calculate the breast volume assuming that weight is equal to the volume of the specimen. However, it is unclear whether weight accurately reveals the true volume of resection.

Participants

Forty-one patients were included in the study with 28 having bilateral surgeries, 13 having unilateral procedures giving a total of 69 breast specimens.

Main outcome measures

Breast specimen weight correlation to breast specimen volume.

Results

The mean age of the group was 42.4 years. Fifty-two specimens were from premenopausal patients and 17 were of postmenopausal. Thirty-five were left-sided. Twenty-six patients had bilateral breast reduction, two had bilateral mastectomy, nine had a unilateral mastectomy and four patients had a unilateral breast reduction. The difference between weight and volume of these breasts was 36.4 units (6.6% difference). The difference in measurement of weight and volume in premenopausal was 37.6 units compared to 32.6 units in postmenopausal women. The density was 1.07 and 1.06, respectively. This was statistically not significant.

Conclusions

No significant difference between volume and weight was seen in this series. Furthermore, we are unable to support the notion that premenopausal patients have a significant difference in the proportion of fatty and glandular tissue as there was little difference between the weight and the volume. An easy, clinically proper formula for the quantification of actual breast volume has yet to be derived.

The use of 3D laser imaging and a new breast replica cast as a method to optimize autologous breast reconstruction after mastectomy

Aesthetically pleasing and symmetrical breasts are the goal of reconstructive breast surgery. Sometimes, however, multiple procedures are needed to improve a reconstructed breast's symmetry and appearance. In order to avoid additional corrective procedures, we have developed a new method that uses a reverse engineering technique to produce what we call a new breast replica cast (NBRC). The NBRC is a mould of the contralateral healthy breast, designed according to preoperative laser 3D images. During surgery, the mould is used to help shape the new breast. With this method, we are able to achieve breast symmetry in terms of volume, projection, contour, and position on the chest wall more accurately, more quickly, and more safely than before.

3-D breast anthropometry of plus-sized women in South Africa

Exploratory retail studies in South Africa indicate that plus-sized women experience problems and dissatisfaction with poorly fitting bras. The lack of 3-D anthropometric studies for the plus-size women's bra market initiated this research. 3-D body torso measurements were collected from a convenience sample of 176 plus-sized women in South Africa. 3-D breast measurements extracted from the TC(2) NX12-3-D body scanner 'breast module' software were compared with traditional tape measurements. Regression equations show that the two methods of measurement were highly correlated although, on average, the bra cup size determining factor 'bust minus underbust' obtained from the 3-D method is approximately 11% smaller than that of the manual method. It was concluded that the total bust volume correlated with the quadrant volume (r = 0.81), cup length, bust length and bust prominence, should be selected as the overall measure of bust size and not the traditional bust girth and the underbust measurement. STATEMENT OF RELEVANCE: This study contributes new data and adds to the knowledge base of anthropometry and consumer ergonomics on bra fit and support, published in this, the Ergonomics Journal, by Chen et al. (2010) on bra fit and White et al. (2009) on breast support during overground running.

Objective breast symmetry evaluation using 3-D surface imaging

This study develops an objective breast symmetry evaluation using 3-D surface imaging (Konica-Minolta V910(®) scanner) by superimposing the mirrored left breast over the right and objectively determining the mean 3-D contour difference between the 2 breast surfaces. 3 observers analyzed the evaluation protocol precision using 2 dummy models (n = 60), 10 test subjects (n = 300), clinically tested it on 30 patients (n = 900) and compared it to established 2-D measurements on 23 breast reconstructive patients using the BCCT.core software (n = 690). Mean 3-D evaluation precision, expressed as the coefficient of variation (VC), was 3.54 ± 0.18 for all human subjects without significant intra- and inter-observer differences (p > 0.05). The 3-D breast symmetry evaluation is observer independent, significantly more precise (p < 0.001) than the BCCT.core software (VC = 6.92 ± 0.88) and may play a part in an objective surgical outcome analysis after incorporation into clinical practice.

Three-dimensional photogrammetry for surgical planning of tissue expansion in hemifacial microsomia

BACKGROUND

We aim to illustrate the applications of 3-dimensional (3-D) photogrammetry for surgical planning and longitudinal assessment of the volumetric changes in hemifacial microsomia.

METHODS

A 3-D photogrammetric system was employed for planning soft tissue expansion and transplantation of a vascularized scapular flap for a patient with hemifacial microsomia. The facial deficiency was calculated by superimposing a mirror of the normal side on the preoperative image. Postsurgical volumetric changes were monitored by serial superimposition of 3-D images.

RESULTS

A total of 31 cm(3) of tissue expansion was achieved within a period of 4 weeks. A scapular free flap measuring 8 cm × 5 cm was transplanted to augment the facial deficiency. Postsurgical shrinkage of the flap was observed mainly in the first 3 months and it was minimal thereafter.

CONCLUSION

3-D photogrammetry can be used as a noninvasive objective tool for assessing facial deformity, planning, and postoperative follow-up of surgical correction of facial asymmetry.

Assessment of cosmesis after breast reconstruction surgery: a systematic review

BACKGROUND

Breast reconstruction (BR) is undertaken to improve cosmetic outcomes, but how this is optimally assessed is uncertain. This review summarises current methods for assessing cosmesis after reconstructive surgery and makes recommendations for future practice.

METHODS

A comprehensive systematic review identified all studies with 20 or more participants that evaluated the cosmetic outcome of BR. Four evaluation criteria (reporting of study inclusion criteria, type and timing of BR and timing of assessment) were used to assess study quality. Articles reporting at least three of the four criteria were considered robust and further summarised to report methods of cosmetic assessment, assessor details and the scoring systems used.

RESULTS

122 primary papers assessed cosmesis in 11,308 women with median follow-up of 28.8 months (range 18.0-42.9 months). Cosmesis was assessed by either healthcare professionals or patients in 33 (27.1%) and 37 studies (30.3%), respectively, and by both professionals and patients in 52 (42.6%). Professional assessments included 43 (40.2%) clinical, 49 (45.8%) photographic and 13 (12.1%) geometric assessments conducted by between 1 and 26 observers. Surgeons were most frequently involved in assessments (n = 71, 67.6%), but in 38 (36.1%) papers the assessor's profession was not reported. Twenty-seven (25.7%) papers used previously published assessment scale. Patients' views were assessed in 89 studies, using questionnaires (n = 63) or interviews (n = 12); 14 (15.7%) did not report how patients' views were obtained.

CONCLUSIONS

Current methods for assessing the cosmetic outcome of BR vary widely. A valid patient-centred assessment method is required to fully understand the outcomes of BR and to inform decision-making.

Validation of stereophotogrammetry of the human torso

The objective of this study was to determine if measurements of breast morphology computed from three-dimensional (3D) stereophotogrammetry are equivalent to traditional anthropometric measurements obtained directly on a subject using a tape measure. 3D torso images of 23 women ranged in age from 36 to 63 who underwent or were scheduled for breast reconstruction surgery were obtained using a 3dMD torso system (3Q Technologies Inc., Atlanta, GA). Two different types (contoured and line-of-sight distances) of a total of nine distances were computed from 3D images of each participant. Each participant was photographed twice, first without fiducial points marked (referred to as unmarked image) and second with fiducial points marked prior to imaging (referred to as marked image). Stereophotogrammetry was compared to traditional direct anthropometry, in which measurements were taken with a tape measure on participants. Three statistical analyses were used to evaluate the agreement between stereophotogrammetry and direct anthropometry. Seven out of nine distances showed excellent agreement between stereophotogrammetry and direct anthropometry (both marked and unmarked images). In addition, stereophotogrammetry from the unmarked image was equivalent to that of the marked image (both line-of-sight and contoured distances). A lower level of agreement was observed for some measures because of difficulty in localizing more vaguely defined fiducial points, such as lowest visible point of breast mound, and inability of the imaging system in capturing areas obscured by the breast, such as the inframammary fold. Stereophotogrammetry from 3D images obtained from the 3dMD torso system is effective for quantifying breast morphology. Tools for surgical planning and evaluation based on stereophotogrammetry have the potential to improve breast surgery outcomes.

MRI-based breast volumetry-evaluation of three different software solutions

As lipofilling of the female breast is becoming more popular in plastic surgery, the use of MRI to assess breast volume has been employed to control postoperative results. Therefore, we sought to evaluate the accuracy of magnetic resonance imaging (MRI)-based breast volumetry software tools by comparing the measurements of silicone implant augmented breasts with the actual implant volume specified by the manufacturer. MRI-based volume analysis was performed in eight bilaterally augmented patients (46 ± 9 years) with three different software programs (Brainlab© I plan 2.6 neuronavigation software; mass analysis, version 5.3, Medis©; and OsiriX© v.3.0.2. 32-bit). The implant volumes analysed by the BrainLab© software had a mean deviation of 2.2 ± 1.7% (r = 0.99) relative to the implanted prosthesis. OsiriX© software analysis resulted in a mean deviation of 2.8 ± 3.0% (r = 0.99) and the Medis© software had a mean deviation of 3.1 ± 3.0% (r = 0.99). Overall, the volumes of all analysed breast implants correlated very well with the real implant volumes. Processing time was 10 min per breast with each system and 30 s (OsiriX©) to 5 min (BrainLab© and Medis©) per silicone implant. MRI-based volumetry is a powerful tool to calculate both native breast and silicone implant volume in situ. All software solutions performed well and the measurements were close to the actual implant sizes. The use of MRI breast volumetry may be helpful in: (1) planning reconstructive and aesthetic surgery of asymmetric breasts, (2) calculating implant size in patients with missing documentation of a previously implanted device and (3) assessing post-operative results objectively.

Automated spatial alignment of 3D torso images

This paper describes an algorithm for automated spatial alignment of three-dimensional (3D) surface images in order to achieve a pre-defined orientation. Surface images of the torso are acquired from breast cancer patients undergoing reconstructive surgery to facilitate objective evaluation of breast morphology pre-operatively (for treatment planning) and/or post-operatively (for outcome assessment). Based on the viewing angle of the multiple cameras used for stereophotography, the orientation of the acquired torso in the images may vary from the normal upright position. Consequently, when translating this data into a standard 3D framework for visualization and analysis, the co-ordinate geometry differs from the upright position making robust and standardized comparison of images impractical. Moreover, manual manipulation and navigation of images to the desired upright position is subject to user bias. Automating the process of alignment and orientation removes operator bias and permits robust and repeatable adjustment of surface images to a pre-defined or desired spatial geometry.

Optimization of clinical breast examination

BACKGROUND

Breast examination is necessary for evaluation of the 8% to 17% of cancers missed by mammograms, but it is being done less often and less effectively. To improve the use of breast examination, we tested whether a technique to focus attention could improve the call rate (the percent of examinations leading to further evaluation), a measure of quality, without retraining in examination technique.

METHODS

Clinicians were randomized to complete 1 of 2 dedicated, de-identified forms after routine breast examination: a long form intended to focus attention by requesting general breast descriptors along with clinical information and breast examination findings (10 clinicians recorded 964 examinations) or a short form recording only clinical information and examination findings (11 clinicians recorded 558 examinations). There was no technique retraining. Study call rates were compared with historical controls (298 breast examinations by 16 clinicians).

RESULTS

The call rates by the study groups of clinicians were similar, but the call rate using either form (8.3%) was significantly higher than the call rate in the preceding year when no dedicated form was used (4.7%; P=.031), suggesting a Hawthorne effect in which altering conditions of data collection (using the dedicated forms) functioned as an independent variable. Surveillance, Epidemiology, and End Results data predicted 3.4 cancers in all 1822 patients; 4 cancers were found.

CONCLUSION

Breast examination call rate doubled when attention was focused on examination results using a dedicated form, and we found the anticipated cancers. Breast examination quality can be improved by focusing clinician attention without retraining in technique.

Effect of alveolar bone grafting on nasal morphology, symmetry, and nostril shape of patients with unilateral cleft lip and palate

OBJECTIVE

To evaluate nasal morphology, symmetry, and nostril shape in patients with unilateral cleft lip and palate following mixed-dentition alveolar bone grafting.

DESIGN

Prospective stereophotogrammetric study.

SETTING

Hospital-based.

PATIENTS

Thirty-nine patients with a history of repaired unilateral cleft lip and palate who received an iliac crest alveolar bone graft were recruited prospectively to participate in the study. Each patient served as his/her own control.

INTERVENTIONS

Partial facial impressions of all patients were acquired before and a minimum of 6 months after the alveolar bone grafting procedure. Image acquisition and analysis of the casts constructed from these models were carried out using three-dimensional stereophotogrammetry.

MAIN OUTCOME MEASURES

Surface-based registrations and linear measurements were performed to assess nasal morphology and nostril shape. A modified Procrustes technique was used to determine the change in nasal symmetry. A two-tailed, paired t test and an analysis of covariance were used to assess statistical significance.

RESULTS

Significant side-to-side asymmetry exists in the nasal region of patients with unilateral cleft lip and palate, both before and after alveolar bone grafting. No significant changes were observed between pre-alveolar bone graft and post-alveolar bone graft images based on linear measurements, asymmetry scores, and registrations. Gender and surgeon were not significant factors.

CONCLUSION

Under the conditions of this study, mixed-dentition alveolar bone grafting appears to have no significant long-term effect on nasal morphology, symmetry, or nostril shape.

Reliability, validity, and precision of an active stereophotogrammetry system for three-dimensional evaluation of the human torso

To determine the reliability, stability, validity and precision of a stereophotogrammetry (SP) system for use in quantifying the complex three-dimensional structure of the human torso, we performed assessments of the system using images of geometric solids and a human-form mannequin. Analysis of geometric solids revealed excellent intra- and interrater reliability of the system for linear, surface area and volume measurements (r>0.99, P<0.001). Overall, no significant difference was found between SP and manual measurements (F=4.23, P>0.06). The system exhibited excellent stability in images of the mannequin over time (r>0.99). The limit of precision (error>5%) of the system to detect objects on the surface of the mannequin was estimated at an object size of 23.5cm(2) for surface area and 32mL for volume. These results demonstrate the capability of SP of the torso to be used as a reliable, stable and valid measure of torso morphology to be applied as a clinical outcome tool in studies of bony and soft tissue pathologies such as scoliosis, rib deformities, obesity or edema.

Validation of a three-dimensional facial scanning system based on structured light techniques

The aim of this study was to validate a newly developed three-dimensional (3D) structured light scanning system in recording the facial morphology. The validation was performed in three aspects including accuracy, precision and reliability. The accuracy and precision were investigated using a plaster model with 19 marked landmarks. The accuracy was determined by comparing the coordinates from the 3D images and from the coordinates measure machine (CMM). The precision was quantified through the repeated landmarks location on 3D images. The reliability was investigated in 10 adult volunteers. Each was scanned five times in 3 weeks. The 3D images acquired at different times were compared with each other to measure the reliability. We found that the accuracy was 0.93 mm, the precision was 0.79 mm, the reliability was 0.2mm. These findings suggested that the structured light scanning system was accurate, precise and reliable to record the facial morphology for both clinic and research purposes.

Comparison of milk output from the right and left breasts during simultaneous pumping in mothers of very low birthweight infants

PURPOSE

Milk output from the right and left breasts was compared in mothers who were pumping exclusively and had not yet fed their infants at breast.

METHODS

Thirty-five mothers of very low birthweight infants established lactation with a hospital grade, electric, dual pump, and recorded milk output separately for each breast during every pumping session from enrollment until completion of the study (mean = 19.8 days) using a standardized milk log. Milk output from each breast was also weighed during six observed milk expressions over a 2-week period during the study.

RESULTS

For the observed pumping sessions (n = 210), milk output was greater from the right breast in 65.7% of the sessions. For the milk log data (n = 3099 pumping sessions) milk output was greater from the right breast in 47.6% of the sessions, greater from the left breast in 28.0%, and equal from both breasts in 24.4% of the sessions. The mean difference in milk output between the right and left breasts was 6.6 mL (SD = 12.1) for the observed sessions, and 5.0 mL for the milk log data (SD = 10.9). The mean right-to-left breastmilk output ratio was 1.20 for the observed sessions and 1.17 for the milk log data. The right-to-left breastmilk ratios were not associated with time of day, day of pumping, total milk output, maternal handedness or the breast pump suction pattern. The right-to-left breast differences were associated with parity and breastfeeding experience, with primiparous women and first-time breastfeeders demonstrating the greatest differences.

CONCLUSIONS

These findings suggest that differences in the milk output from the right and left breasts are common, and that milk output is often greater from the right breast. The differences appear early in lactation, are not related to total milk output, and are relatively consistent throughout the day and over the first weeks of lactation.

Comparison between breast volume measurement using 3D surface imaging and classical techniques

Quantification of the complex breast region can be helpful in breast surgery, which is shaped by subjective influences. However, there is no generally recognized method for breast volume calculation. Three-dimensional (3D) body surface imaging represents a new alternative for breast volume computation. The aim of this work was to compare breast volume calculation with 3D scanning and three classic methods, focusing on relative advantages, disadvantages, and reproducibility. Repeated breast volume calculations of both breasts in six patients (n=12) were performed using a 3D laser scanner, nuclear magnetic resonance imaging (MRI), thermoplastic castings, and anthropomorphic measurements. Mean volumes (cc) and mean measurement deviations were calculated, and regression analyses were performed. MRI showed the highest measurement precision, with a mean deviation (expressed as a percentage of mean breast volume) of 1.56+/-0.52% compared with 2.27+/-0.99% for the 3D scanner, 7.97+/-3.53% for thermoplastic castings, and 6.26+/-1.56% for the anthropomorphic measurements. Breast volume calculations using MRI showed the best agreement with 3D scanning measurement (r=0.990), followed by anthropomorphic measurement (r=0.947), and thermoplastic castings (r=0.727). Compared with three classical methods of breast volume calculation, 3D scanning provides acceptable accuracy for breast volume measurements, better spatial interpretation of the anatomical area to be operated on (due to lack of chest deformation), non-invasiveness, and good patient tolerance. After this preliminary study and further development, we believe that 3D body surface scanning could provide better preoperative planning and postoperative control in everyday clinical practice.

Objective outcome evaluation of breast surgery

A new method is proposed to unambiguously define a geometric partitioning of 3D models of female thorax. A breast partitioning scheme is derived from simple geometric primitives and well-defined anatomical points. Relevant measurements can be extrapolated from breast partition. Our method has been tested on a number of breast 3D models acquired by means of a commercial scanner on real clinical cases.