Magnetic resonance images and linear measurements in the surgical treatment of breast asymmetry

Evaluation of Intraoperative Volumetric Assessment of Breast Volume Using 3D Handheld Stereo Photogrammetric Device

Methods for assessing three-dimensional (3D) breast volume are becoming increasingly popular in breast surgery. However, the precision of intraoperative volumetric assessment is still unclear. Until now, only non-validated scanning systems have been used for intraoperative volumetric analyses. This study aimed to assess the feasibility, handling, and accuracy of a commercially available, validated, and portable device for intraoperative 3D volumetric evaluation. All patients who underwent breast surgery from 2020 to 2022 were identified from our institutional database. Intraoperative 3D volumetric assessments of 103 patients were included in this study. Standardized 3D volumetric measurements were obtained 3 months postoperatively to compare the intraoperatively generated volumetric assessment. All of the study participants were women with a mean age of 48.3 ± 14.7 years (range: 20-89). The mean time for intraoperative volumetric assessment was 8.7 ± 2.6 min. The postoperative 3D volumetric assessment, with a mean volume of 507.11 ± 206.29 cc, showed no significant difference from the intraoperative volumetric measurements of 504.24 ± 276.61 cc (p = 0.68). The mean absolute volume difference between the intraoperative simulations and postoperative results was 27.1 cc. Intraoperative 3D volumetric assessment using the VECTRA H2 imaging system seems to be a feasible, reliable, and accurate method for measuring breast volume. Based on this finding, we plan to investigate whether volumetric objective evaluations will help to improve breast symmetry in the future.

New criteria for breast symmetry evaluation after breast conserving surgery for cancer

OBJECTIVE

to evaluate symmetry after breast-conserving surgery (BCS) for cancer.

METHODS

a prospective study of patients undergoing BCS. These patients were photographed using the same criteria of evaluation. The references points used were the nipple height difference (NH), the nipple-manubrium distances (NM), nipple-sternum distances (NS) and the angle between the intramammary fold and the nipple (nipple angle; NA). ImageJ software was used. Three breast symmetry models were evaluated: excellent/others (model 1), excellent-good/others (model 2) and others/poor (model 3). The ROC curve was used to select acceptable criteria for the evaluation of symmetry. Decision tree model analysis was performed.

RESULTS

a total of 274 women were evaluated. The BCCT.core result was excellent in 5.8% (16), good in 24.1% (66), fair in 46.4% (127) and poor in 23.7% (65). The difference in NH was associated with good breast area (0.837-0.846); acceptable differences were below 3.1 cm, while unacceptable values were greater than 6.4 cm. Differences in the NM were associated with average breast area (0.709-0.789); a difference in value of less than 4.5 cm was acceptable, while values greater than 6.3 cm were unacceptable. In the decision tree combined model, a good-excellent outcome for patients with differential (d) dNH = 1 (0 to 5.30 cm) and dNM ≠ 3 (<6.28 cm); and for a poor/poor result, values dNM = 3 (> 6.35).

CONCLUSIONS

the results presented here are simple tools that can assist the surgeon for breast symmetry evaluation.

JPEG and raw image files compared to direct measurement of the breast region

Purpose:

To compare JPEG and RAW image file extensions to direct measurement of the breast region.

Methods:

Points were marked on the breasts and arms of 40 female volunteers. The joining of these points in each hemibody formed seven linear segments, one angular segment and one median segment common to both hemibodies. Volunteers were photographed in a standardized fashion and evaluated by three raters using the software Adobe Photoshop CS6^® and three image file extensions (RAW, high resolution JPEG and low resolution JPEG); values were compared to direct anthropometry.

Results:

All variables had interclass correlation coefficient higher than 0.8 (ICC>0.8). On average, all variables in all methods showed differences (p<0.05) when compared to direct measurement. A formula was created for each segment and each image file extension in comparison with the direct measurement.

Conclusion:

Measurements were similar among the correlated JPEG and RAW image file extensions but differed from the actual breast measurement obtained with a caliper.

Preoperative estimation of breast resection weight in patients undergoing inferior pedicle reduction mammoplasty: the Bilgen formula

Background/aim

Symptomatic breast hypertrophy has a significant impact on the quality of life of women. The amount of tissue to be excised may be preoperatively estimated by an experienced surgeon. However, this remains a subjective assessment. Accurate quantification of the amount of breast tissue to be resected in the preoperative period will be a guide for both patient information and the surgeon during the operation. The aim of this study is to develop a new method based on simple measurements that can accurately estimate the resection weight in the preoperative period in a wide range of patients undergoing reduction mammoplasty.

Materials and methods

The study was carried out between December 2016 and September 2018. With the determined drawing and measurement methods, a triangle was obtained by measuring the distances among the sternal notch (A) - right nipple areola midpoint (B), sternal notch (A) - left nipple areola midpoint (C) and both internipple areola (B-C). The height of this triangle (h) was found by measuring the distance between the sternal notch and the midpoint of both nipple areola levels. The amount of breast tissue to be resected for each breast was calculated by multiplying the distance between the sternal notch–nipple areola and the height of the large triangle. The formula may be expressed as AB × h for the right breast and AC × h for left breast.

Results

When the t values ​​and significance levels of the beta coefficients of the independent variables were examined, the preoperative values ​​were determined to be in accordance with the actual values ​​after surgery (P < 0.05). The values ​​calculated before were calculated as the percentage of the actual values (91%). In other words, the R2 value showed that the calculated values were compatible with the actual values (R2 = 0.910).

Conclusions

With the formula described herein, one may accurately estimate the amount of tissue to be resected in a wide range of patients undergoing reduction mammoplasty whose sternal notch–nipple distances are between 28–42 cm. Additionally, because measurements for each breast are performed separately, breast asymmetry does not affect the results. In conclusion, the formula we devised is simple, applicable, and has a high accuracy rate.

An analysis of pose in 3D stereophotogrammetry of the breast

BACKGROUND

Volume of the breast can be objectively measured by three-dimensional (3D) photographs. This study describes the analysis of three different positions of the patient in image acquisition, in order to find the best pose for reproducible 3D photographs of the breasts.

METHOD

Twenty-four patients were included between February and September 2014 in a consecutive way. Data were collected prospectively. 3D photographs were acquired using a stereophotogrammetry system. Images were taken twice in three different positions (arms behind the back, arms placed on the hips and arms horizontally placed). Surface based matching was applied and the absolute mean distance between the surfaces of both 3D models of the same position was calculated. This difference measure represents the similarity of the photographs.

RESULTS

Univariate ANOVA showed a significant difference in distance between the three positions (sum of squares 1.12, p < 0.001). The horizontal position presented the lowest absolute mean distance (0.45 mm). Additional post hoc multiple comparisons analysis revealed a statistically significant difference between the distances of horizontal and back position (-0.22 mm, p < 0.001) and of back and hip position (0.13 mm, p = 0.009), with better results of the horizontal and hip positions, respectively.

CONCLUSION

Standardization of 3D acquisition in pre- and postoperative breast imaging could improve imaging reproducibility. Based on the results of this study, we recommend a pose with the arms in a horizontal position.

Breast volumetric analysis for aesthetic planning in breast reconstruction: a literature review of techniques

BACKGROUND

Accurate volumetric analysis is an essential component of preoperative planning in both reconstructive and aesthetic breast procedures towards achieving symmetrization and patient-satisfactory outcome. Numerous comparative studies and reviews of individual techniques have been reported. However, a unifying review of all techniques comparing their accuracy, reliability, and practicality has been lacking.

METHODS

A review of the published English literature dating from 1950 to 2015 using databases, such as PubMed, Medline, Web of Science, and EMBASE, was undertaken.

RESULTS

Since Bouman's first description of water displacement method, a range of volumetric assessment techniques have been described: thermoplastic casting, direct anthropomorphic measurement, two-dimensional (2D) imaging, and computed tomography (CT)/magnetic resonance imaging (MRI) scans. However, most have been unreliable, difficult to execute and demonstrate limited practicability. Introduction of 3D surface imaging has revolutionized the field due to its ease of use, fast speed, accuracy, and reliability. However, its widespread use has been limited by its high cost and lack of high level of evidence. Recent developments have unveiled the first web-based 3D surface imaging program, 4D imaging, and 3D printing.

CONCLUSIONS

Despite its importance, an accurate, reliable, and simple breast volumetric analysis tool has been elusive until the introduction of 3D surface imaging technology. However, its high cost has limited its wide usage. Novel adjunct technologies, such as web-based 3D surface imaging program, 4D imaging, and 3D printing, appear promising.

Photographs for anthropometric measurements of the breast region. Are there limitations?

PURPOSE

To determine the limitations of the photographs used to obtain the anthropometric measurements of the breast region.

METHODS

Five women, between the ages of 18 to 60 years, were evaluated. Photographs of the frontal and left and right profile views of their breasts were taken. Based on the current literature, the most commonly used anthropometric and anatomic landmarks for breast measurement were marked in their different positions. The different points were used to evaluate if the direct anthropometry was possible in a standardized way and determine how the points and the positions can to be used in any breast measurements.

RESULTS

There were some limitations to the use of defining points of the breast fold, as well as of its lower portion and lateral extension positions in both profiles.

CONCLUSION

The defining points of the breast fold and the profile photographs have some limitations and we suggested how the points and positions can be used for breasts measurements.

Image analysis software versus direct anthropometry for breast measurements

PURPOSE

To compare breast measurements performed using the software packages ImageTool(r), AutoCAD(r) and Adobe Photoshop(r) with direct anthropometric measurements.

METHODS

Points were marked on the breasts and arms of 40 volunteer women aged between 18 and 60 years. When connecting the points, seven linear segments and one angular measurement on each half of the body, and one medial segment common to both body halves were defined. The volunteers were photographed in a standardized manner. Photogrammetric measurements were performed by three independent observers using the three software packages and compared to direct anthropometric measurements made with calipers and a protractor.

RESULTS

Measurements obtained with AutoCAD(r) were the most reproducible and those made with ImageTool(r) were the most similar to direct anthropometry, while measurements with Adobe Photoshop(r) showed the largest differences. Except for angular measurements, significant differences were found between measurements of line segments made using the three software packages and those obtained by direct anthropometry.

CONCLUSION

AutoCAD(r) provided the highest precision and intermediate accuracy; ImageTool(r) had the highest accuracy and lowest precision; and Adobe Photoshop(r) showed intermediate precision and the worst accuracy among the three software packages.

Objective breast volume, shape and surface area assessment: a systematic review of breast measurement methods

BACKGROUND

There are many methods of measuring the breast and their clinical applications are well described in the literature. However, there has been no attempt to compare these various methods to allow the user to have a broad overview of the subject. The authors have attempted to summarise all the available methods to measure the breast in this article to provide a useful reference for all.

METHODS

A comprehensive literature search of PubMed was performed, and the resulting articles were screened and reviewed. The data regarding the methods' mechanism, reliability, time and cost were evaluated and compared.

RESULTS

A total of 74 articles dating from 1970 to 2013 were included in this study. All of the methods can be classified into those that measure (1) volume, (2) shape and (3) surface area. Each category consists of several methods that work through different mechanisms and they vary in their reliability and feasibility. Based on their mechanism, the volume measurement methods were further grouped into the natural shape methods, the stereological method, the geometrical methods and the mathematical modelling method.

CONCLUSIONS

More objective breast evaluation can be achieved if all three dimensions (volume, shape and surface area) are considered. In the volume measurements, 3D modelling and the MRI are the most reliable tools. Linear measurement (geometry) and mathematical modelling are less accurate but are more economical. In the shape measurements, besides the traditional linear measurement, 3D methods that can deliver colour-coded maps and Swanson's 2D photographic measurement system are capable of depicting and tracking breast shape changes after surgery. Although the surface area metric has not been used extensively, it has potential in clinical and research applications.

LEVEL OF EVIDENCE IV

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.

Prediction of resection weight in reduction mammaplasty based on anthropometric measurements

BACKGROUND

The aim of this study was to develop a simple, clinically useful method to accurately predict resection weight in women undergoing reduction mammaplasty.

PATIENTS AND METHODS

39 women undergoing breast reduction participated in the study. Sternal notch to nipple distance, nipple to inframammary fold distance (NIMF), medial end point to nipple distance (MN), lateral endpoint to nipple distance (LN), superior border of the breast to nipple distance (SN), breast circumference (BC), and chest circumference (CC) were measured. 5 other predicting variables were also derived; horizontal breast measurement (H) by adding MN to LN, vertical breast measurement (V) by adding NIMF to SN, the product of H and V (H*V), the product of H and NIMF (H*NIMF), and the difference between BC and CC (D). Regression analysis was used to compose a formula for predicting resection weight.

RESULTS

Among the predicting variables, H*NIMF measurements had the highest correlation coefficient value (Pearson correlation = 0.809) with the resection weight. The following formula was obtained with regression analysis: Predicted resection weight = (1.45 × H*NIMF) + (31.5 × D) - 576.

CONCLUSION

Breast resection weights can be accurately predicted by the presented method based on anthropomorphic measurements.

Anthropometry of the breast region: how to measure?

BACKGROUND

Breast region measurements are important for research, but they may also become significant in the legal field as a quantitative tool for preoperative and postoperative evaluation. Direct anthropometric measurements can be taken in clinical practice. The aim of this study was to compare direct breast anthropometric measurements taken with a tape measure and a compass.

METHODS

Forty women, aged 18-60 years, were evaluated. They had 14 anatomical landmarks marked on the breast region and arms. The union of these points formed eight linear segments and one angle for each side of the body. The volunteers were evaluated by direct anthropometry in a standardized way, using a tape measure and a compass.

RESULTS

Differences were found between the tape measure and the compass measurements for all segments analyzed (p>0.05).

CONCLUSION

Measurements obtained by tape measure and compass are not identical. Therefore, once the measurement tool is chosen, it should be used for the pre- and postoperative measurements in a standardized way.

LEVEL OF EVIDENCE IV

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 .

Prediction of breast resection weight in reduction mammaplasty based on 3-dimensional surface imaging

Prediction of resection weight (RW) in reduction mammaplasty is helpful in achieving breast symmetry and in fulfilling the stringent reimbursement requirements of health insurance companies. Current breast volume estimations are largely based on surgeon's experience, which are partially unreliable and often cumbersome to obtain. Therefore, this study aims to develop a formula to predict RW based on 3D surface imaging. A total of 68 breasts were treated with bilateral T-scar, and 40 breasts were treated with bilateral or unilateral vertical-scar reduction mammaplasty. Linear distances and volume measurements were assessed 3-dimensionally preoperatively and 6 months postoperatively. Significant correlations between the RW and the calculated preoperative breast volume (ρ = 0.804) and the sternal notch to nipple distance (ρ = 0.839) were found in both techniques (P < .001). Regression equations with the RW were performed to derive prediction formulas. Surgeons may benefit from the formulas in terms of improvement in preoperative planning, dealing with insurance coverage questions, and optimizing patient consultation.

Three-dimensional evaluation of breast augmentation and the influence of anatomic and round implants on operative breast shape changes

BACKGROUND

Currently, postoperative outcome analysis in breast augmentation is essentially subjective, and objective evaluation of treatment efficacy is lacking. This study evaluates the influence of anatomic and round implant parameters on breast contour changes after subpectoral breast augmentation using three-dimensional (3D) surface imaging.

METHODS

3D surface breast scans of 17 patients (34 breasts) undergoing subpectoral breast augmentation with round implants and of ten patients (20 breasts) receiving anatomic implants via an axillary approach under endoscopic assistance or a submammary fold incision were obtained before and 6 months postoperatively. 3D linear distance, breast volume, and surface measurement were correlated with the implanted round and anatomic implant parameters, and the resulting breast shape changes were evaluated.

RESULTS

Total breast volume changed in correlation with the implant size (2.4% difference; r=0.894; p<0.001). Implant volume and type influence the nipple-to-inframammary fold distance (N-IMF). Every inserted 100 ml implant volume enlarges the N-IMF distance by 0.8 cm (anatomic>round; p=0.01). Postoperatively, the IMF dropped by an average of 1.3 cm for round implants and by 1.1 cm for anatomic implants, without relevant differences between the applied surgical incision and the selected implants (p>0.05). Breast projection increased significantly more with anatomic implants (2.4 cm) than with round implants (1.7 cm) (p=0.01). The breast projection increase was 22% less than expected for round implants and 25% less than expected for anatomic implants based on the manufacturer implant parameters (p<0.01), without essential differences regarding the surgical incision.

CONCLUSIONS

3D breast shape changes induced by round and anatomic implants after subpectoral augmentation mammaplasty are objectively documented including breast projection, volume, and N-IMF distance changes. 3D surface imaging may have a potential clinical contribution to objective surgical outcome research.

LEVEL OF EVIDENCE III

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 at www.springer.com/00266.

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.