The potential role of three-dimensional surface imaging as a tool to evaluate aesthetic outcome after Breast Conserving Therapy (BCT)

Three-Dimensional Surface Analysis for Preoperative Prediction of Breast Volume: A Validation Study

BACKGROUND

Few studies have examined whether preoperative three-dimensional surface imaging can accurately predict breast volume. Reliably predicting breast volume preoperatively can assist with breast reconstruction planning, patient education, and perioperative risk stratification.

METHODS

The authors conducted a review of patients who underwent mastectomy from 2020 to 2021 and included all patients who had preoperative VECTRA XT three-dimensional imaging. VECTRA Analysis Module (VAM) and VECTRA Body Sculptor (VBS) were used for volumetric analysis using standard anatomical breast borders. Breast weights were obtained intraoperatively. Predictive accuracy was defined as VAM estimates ±10% of mastectomy specimen weight or ±100 g of mastectomy weight.

RESULTS

The study included 179 patients (266 breasts). There was no significant difference ( P = 0.22) between mean mastectomy weight of 620.8 ± 360.3 g and mean VAM estimate of 609.5 ± 361.9 g. Mean VBS estimate was 498.9 ± 337.6 g, which differed from mean mastectomy weight ( P < 0.001). When defining predictive accuracy as ±100 g, 58.7% of VAM and 44.4% of VBS estimates were accurate. Body mass index, body surface area, and ptosis grade significantly affected VAM and VBS breast volume predictions.

CONCLUSIONS

VAM is more accurate at predicting mastectomy weight than VBS, likely because of VAM's analysis of surface topography rather than discrete surface landmarks. Discrepancies between VECTRA estimates and mastectomy weight were likely attributable to differences between surgical mastectomy borders and breast borders used in volumetric analysis. Surgeons should consider the physical characteristics of patients when using three-dimensional imaging.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Diagnostic, I.

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.

Clinical assessment of breast symmetry and aesthetic outcome: can 3D imaging be the gold standard?

There is a lack of an accurate standardised objective method to assess aesthetic outcome after breast surgery. In this methodological study, we investigated the intra- and inter-observer reproducibility of breast symmetry and volume assessed using three-dimensional surface imaging (3D-SI), evaluated the reproducibility depending on imaging posture, and proposed a new combined volume-shape-symmetry (VSS) parameter. Images were acquired using the VECTRA XT 3D imaging system, and analysed by two observers using VECTRA Analysis Module. Breast symmetry was measured through the root mean square distance. All women had undergone bilateral risk-reducing mastectomy and immediate breast reconstruction. The reproducibility and correlations of breast symmetry and volume measurements were compared using Bland-Altman's plots and tested with Spearman's rank correlation coefficient. 3D surface images of 58 women were analysed (348 symmetry measurements, 696 volume measurements). The intra-observer reproducibility of breast symmetry measurements was substantial-excellent, the inter-observer reproducibility was substantial, and the inter-posture reproducibility was substantial. For measurements of breast volumes, the intra-observer reproducibility was excellent, the inter-observer reproducibility was moderate-substantial, and the inter-posture reproducibility was substantial-excellent. The intra-observer reproducibility of VSS was excellent while the inter-observer reproducibility was substantial for both observers, independent of posture. There were no statistically strong correlations between breast symmetry and volume differences. The intra-observer reproducibility was found to be substantial-excellent for several 3D-SI measurements independent of imaging posture. However, the inter-observer reproducibility was lower than the intra-observer reproducibility, indicating that 3D-SI in its present form is not a great assessment for symmetry.

Evaluation of Vectra® XT 3D Surface Imaging Technology in Measuring Breast Symmetry and Breast Volume

BACKGROUND

Breast symmetry is an essential component of breast cosmesis. The Harvard Cosmesis scale is the most widely adopted method of breast symmetry assessment. However, this scale lacks reproducibility and reliability, limiting its application in clinical practice. The VECTRA® XT 3D (VECTRA®) is a novel breast surface imaging system that, when combined with breast contour measuring software (Mirror®), aims to produce a more accurate and reproducible measurement of breast contour to aid operative planning in breast surgery.

OBJECTIVES

This study aims to compare the reliability and reproducibility of subjective (Harvard Cosmesis scale) with objective (VECTRA®) symmetry assessment on the same cohort of patients.

METHODS

Patients at a tertiary institution had 2D and 3D photographs of their breasts. Seven assessors scored the 2D photographs using the Harvard Cosmesis scale. Two independent assessors used Mirror® software to objectively calculate breast symmetry by analysing 3D images of the breasts.

RESULTS

Intra-observer agreement ranged from none to moderate (kappa - 0.005-0.7) amongst the assessors using the Harvard Cosmesis scale. Inter-observer agreement was weak (kappa 0.078-0.454) amongst Harvard scores compared to VECTRA® measurements. Kappa values ranged 0.537-0.674 for intra-observer agreement (p < 0.001) with Root Mean Square (RMS) scores. RMS had a moderate correlation with the Harvard Cosmesis scale (r_s = 0.613). Furthermore, absolute volume difference between breasts had poor correlation with RMS (R² = 0.133).

CONCLUSION

VECTRA® and Mirror® software have potential in clinical practice as objectifying breast symmetry, but in the current form, it is not an ideal test.

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.

Correction of breast asymmetry by autologous fat grafting with the aid of 3D laser-scanning technology

BACKGROUND

Currently, the lack of clinically accurate measurement and evaluation methods for breast asymmetry has considerably limited the use of autologous fat grafting in the correction of breast asymmetry.

OBJECTIVE

This study calculated the volume difference in the bilateral breasts by three-dimensional (3D) laser scanning technology, established a bridge between digitalization and surgery to guide the correction of breast asymmetry by autologous fat grafting, and evaluated the surgical effect.

METHODS

In the experimental group (3D group), the measurement range was defined by standardized methods, the algorithm to calculate the volume difference in the bilateral breasts was determined by the established software instructions, and the volume of intraoperative autologous fat grafting was guided by personalized data. In the control group, the volume of intraoperative autologous fat grafting was determined based on the surgeon's visual assessment and surgical experience.

RESULTS

The volume difference in the bilateral breasts was less at 12 months after surgery (P < 0.05), the satisfaction of patients was higher (P < 0.05), and the reoperation rate was lower (P < 0.05). The incidence of postoperative complications was low in both groups (P > 0.05).

CONCLUSIONS

3D laser scanning technology can be used as a bridge between digitalization and surgery to significantly improve the surgical effect of autologous fat grafting in the correction of breast asymmetry, with high patient satisfaction and high clinical application value.

Satisfaction survey on a preoperative explanation method using three-dimensional breast imaging for breast cancer patients considering breast-conserving surgery

PURPOSE

Although one of the essential factors in surgical shared decision-making is the body image, the breast morphology after breast-conserving surgery is particularly difficult to explain in a uniform manner due to large individual differences.

METHODS

Patients with breast cancer eligible for breast-conserving surgery (BCS) were recruited between June 2020 and October 2021. We surveyed the patients' satisfaction with our method of explaining the likely breast morphology after BCS using three-dimensional (3D) breast imaging in the form of a questionnaire.

RESULTS

A total of 162 patients were enrolled, and 137 (84.6%) answered the questionnaire. One hundred and sixteen patients (84.6%) answered that they were very satisfied or satisfied with our explanation method, and 100 (73.0%) patients were very satisfied or satisfied with the 3D breast imaging. Some patients answered that 3D breast imaging helped them prepare for BCS, or on the contrary, made them choose mastectomy with breast reconstruction because the deformation likely with BCS was considered unacceptable. Only a few patients who underwent BCS felt that their postoperative morphology was more deformed than the preoperatively imagined one.

CONCLUSION

Our results suggest that our preoperative explanation method using 3D breast imaging was useful for shared decision-making.

Outcome reporting in therapeutic mammaplasty: a systematic review

BACKGROUND

Therapeutic mammaplasty (TM) is an oncological procedure which combines tumour resection with breast reduction and mastopexy techniques. Previous systematic reviews have demonstrated the oncological safety of TM but reporting of critically important outcomes, such as quality of life, aesthetic and functional outcomes, are limited, piecemeal or inconsistent. This systematic review aimed to identify all outcomes reported in clinical studies of TM to facilitate development of a core outcome set.

METHODS

Medline, EMBASE, CINAHL and Web of Science were searched from inception to 5 August 2020. Included studies reported clinical outcomes following TM for adult women. Two authors screened articles independently for eligibility. Data were extracted regarding the outcome definition and classification type (for example, oncological, quality of life, etc.), time of outcome reporting and measurement tools.

RESULTS

Of 5709 de-duplicated records, 148 were included in the narrative synthesis. The majority of studies (n = 102, 68.9 per cent) reported measures of survival and/or recurrence; approximately three-quarters (n = 75, 73.5 per cent) had less than 5 years follow-up. Aesthetic outcome was reported in half of studies (n = 75, 50.7 per cent) using mainly subjective, non-validated measurement tools. The time point at which aesthetic assessment was conducted was highly variable, and only defined in 48 (64.0 per cent) studies and none included a preoperative baseline for comparison. Few studies reported quality of life (n = 30, 20.3 per cent), functional outcomes (n = 5, 3.4 per cent) or resource use (n = 28, 18.9 per cent).

CONCLUSION

Given the oncological equivalence of TM and mastectomy, treatment decisions are often driven by aesthetic and functional outcomes, which are infrequently and inconsistently reported with non-validated measurement tools.

Three-dimensional simulation of aesthetic outcome from breast-conserving surgery compared with viewing photographs or standard care: randomized clinical trial

INTRODUCTION

Over half of women with surgically managed breast cancer in the UK undergo breast-conserving treatment (BCT). While photographs are shown prior to reconstructive surgery or complex oncoplastic procedures, standard practice prior to breast conservation is to simply describe the likely aesthetic changes. Patients have expressed the desire for more personalized information about likely appearance after surgery. The hypothesis was that viewing a three-dimensional (3D) simulation improves patients' confidence in knowing their likely aesthetic outcome after surgery.

METHODS

A randomized, controlled trial of 117 women planning unilateral BCT was undertaken. The randomization was three-way: standard of care (verbal description alone, control group), viewing two-dimensional (2D) photographs, or viewing a 3D simulation before surgery. The primary endpoint was the comparison between groups' median answer on a visual analogue scale (VAS) for the question administered before surgery: 'How confident are you that you know how your breasts are likely to look after treatment?'

RESULTS

The median VAS in the control group was 5.2 (i.q.r. 2.6-7.8); 8.0 (i.q.r. 5.7-8.7) for 2D photography, and 8.9 (i.q.r. 8.2-9.5) for 3D simulation. There was a significant difference between groups (P < 0.010) with post-hoc pairwise comparisons demonstrating a statistically significant difference between 3D simulation and both standard care and viewing 2D photographs (P < 0.010 and P = 0.012, respectively).

CONCLUSION

This RCT has demonstrated that women who viewed an individualized 3D simulation of likely aesthetic outcome for BCT were more confident going into surgery than those who received standard care or who were shown 2D photographs of other women. The impact on longer-term satisfaction with outcome remains to be determined.Registration number: NCT03250260 (http://www.clinicaltrials.gov).

Use of Symmetry Assessment Methods in the Context of Breast Surgery

BACKGROUND

Different procedures are available to help clinicians evaluate symmetry and cosmetic results in an objective manner after conservative breast cancer surgery. However, there are no similar methods in esthetic breast surgery, where the subjective assessment of the surgeon or the patient is usually considered the gold standard. The aim of this study is to evaluate the application of four software programs in the context of esthetic breast surgery and contrast their results with those of the subjective evaluation by a series of healthcare professionals.

MATERIALS AND METHODS

Sixty cosmetic breast surgery images were studied using four software programs considered appropriate for the objective evaluation (BCCT3.core^®, Breast Analyzing Tool^®, Objective Breast Cosmesis Scale^® and GBAI-Global Breast Asymmetry Index^®). The same cases were assessed by a group of 100 health professionals through an online survey as a subjective evaluation method.

RESULTS

Concordance among participants was high (κ = 0.753) as well as between three of the objective methods (BSI, OBCS, GBAI), but not with the BCCT parameter. There was no association between objective and subjective methods studied by the survey, according to the logistic regression model. The "symmetry" and "asymmetry" categories were accurately distinguished by the objective methods.

CONCLUSIONS

Objective evaluation in esthetic breast surgery has less variability than subjective assessment, and the estimation is possible through certain software previously restricted to conservative breast cancer surgery.

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 .

Structured-light surface scanning system to evaluate breast morphology in standing and supine positions

Breast shapes are affected by gravitational loads and deformities. Measurements obtained in the standing position may not correlate well with measurements in the supine position, which is more representative of patient position during breast surgery. A dual color 3D surface imaging system capable of scanning patients in both supine and standing positions was developed to evaluate the effect of changes in body posture on breast morphology. The system was evaluated with  breast phantoms to assess accuracy, then tested on ten subjects in three body postures to assess its effectiveness as a clinical tool. The accuracy of the system was within 0.4 mm on average across the model. For the human study, there was no effect of body posture on breast volumes (p value > 0.05), but we observed an effect of completeness of breast scans on body posture (p value  < 0.05). Post-hoc tests showed that the supine position and the standing position with hands at the waist differed significantly (p value  < 0.05). This study shows that the system can quantitatively evaluate the effect of subject postures, and thereby has the potential to be used to investigate peri-operative changes in breast morphology.

[Techniques enhancement for tissue expander/implant two-stage breast reconstruction]

OBJECTIVE

To investigate the outcomes of breast reconstruction with employing improved techniques throughout the tissue expander/implant two-stage breast reconstructed process, which involved the tissue expander placement, the saline filling intraoperatively and postoperatively, the implant selection, and the permanent implant replacement.

METHODS

In this study, 68 patients who had been provided immediate or delayed tissue expander/implant two-stage breast reconstruction with autologous fat injection post-mastectomy in Peking University Third Hospital from April 2014 to September 2018 were involved, and the relevant information was analyzed retrospectively. The enhancements of the techniques, involving the incision selection, the expander placement, the principle of expansion, the management of capsule, the prosthesis selection, and the assisted reconstruction method were summarized, and the reconstruction outcomes were evaluated objectively through three-dimensional surface imaging.

RESULTS

Among the 68 patients in this study, immediate reconstruction was conducted in 25 patients and 43 patients underwent delayed reconstruction. The median time of tissue expansion was 7.0 (3.0, 20.0) months, and the average volume of expansion was (372.8±87.2) mL. The median size of breast implant was 215 (100, 395) mL. The median number of injections for fat grafting was 1 (1, 3), and the average volume of fat grafting was (119.3±34.1) mL. The median follow-up time was 7.0 (4.0, 24.0) months. During the process of breast reconstruction, the tissue expander leakage was observed in two patients, and one of them underwent expander replacement due to the secondary infection. In the immediate reconstruction cases, the volume symmetry of bilateral breasts after reconstruction got even better than that before mastectomy (t=4.465, P<0.01). And in the delayed reconstruction cases, the volume between bilateral breasts also achieved good symmetry after reconstruction (t=0.867, P>0.1).

CONCLUSION

Good results of tissue expander/implant two-stage breast reconstruction could be achieved through the techniques enhancement, which involved the preferred transverse incision, the downward placement of expander, the rapid expansion of chest soft tissue, the release of capsule tension, the application of sizer in prosthesis selection, and the assisted autologous fat grafting.

Breast Shape Analysis With Curvature Estimates and Principal Component Analysis for Cosmetic and Reconstructive Breast Surgery

Background

Breast shape is defined utilizing mainly qualitative assessment (full, flat, ptotic) or estimates, such as volume or distances between reference points, that cannot describe it reliably.

Objectives

The authors quantitatively described breast shape with two parameters derived from a statistical methodology denominated by principal component analysis (PCA).

Methods

The authors created a heterogeneous dataset of breast shapes acquired with a commercial infrared 3-dimensional scanner on which PCA was performed. The authors plotted on a Cartesian plane the two highest values of PCA for each breast (principal components 1 and 2). Testing of the methodology on a preoperative and posttreatment surgical case and test-retest was performed by two operators.

Results

The first two principal components derived from PCA characterize the shape of the breast included in the dataset. The test-retest demonstrated that different operators obtain very similar values of PCA. The system is also able to identify major changes in the preoperative and posttreatment stages of a two-stage reconstruction. Even minor changes were correctly detected by the system.

Conclusions

This methodology can reliably describe the shape of a breast. An expert operator and a newly trained operator can reach similar results in a test/re-testing validation. Once developed and after further validation, this methodology could be employed as a good tool for outcome evaluation, auditing, and benchmarking.

Level of Evidence 4

Validation of the Vectra XT three-dimensional imaging system for measuring breast volume and symmetry following oncological reconstruction

PURPOSE

Three-dimensional surface imaging (3D-SI) of the breasts enables the measurement of breast volume and shape symmetry. If these measurements were sufficiently accurate and repeatable, they could be used in planning oncological breast surgery and as an objective measure of aesthetic outcome. The aim of this study was to validate the measurements of breast volume and symmetry provided by the Vectra XT imaging system.

METHODS

To validate measurements, breast phantom models of true volume between 100 and 1000 cm3 were constructed and varying amounts removed to mimic breast tissue 'resections'. The volumes of the phantoms were measured using 3D-SI by two observers and compared to a gold standard. For intra-observer repeatability and inter-observer reproducibility in vivo, 16 patients who had undergone oncological breast surgery had breast volume and symmetry measured three times by two observers.

RESULTS

A mean relative difference of 2.17 and 2.28% for observer 1 and 2 respectively was seen in the phantom measurements compared to the gold standard (n = 45, Bland Altman agreement). Intra-observer variation over ten repeated measurements demonstrated mean coefficients of variation (CV) of 0.58 and 0.49%, respectively. The inter-observer variation demonstrated a mean relative difference of 0.11% between the two observers. In patients, intra-observer variation over three repeated volume measurements for each observer was 3.9 and 3.8% (mean CV); the mean relative difference between observers was 5.78%. For three repeated shape symmetry measurements using RMS projection difference between the two breasts, the intra-observer variations were 8 and 14% (mean CV), the mean relative difference between observers was 0.43 mm for average symmetry values that ranged from about 3.5 to 15.5 mm.

CONCLUSION

This first validation of breast volume and shape symmetry measurements using the Vectra XT 3D-SI system suggests that these measurements have the potential to assist in pre-operative planning and also as a measure of aesthetic outcome.