The accuracy of breast volume measurement methods: A systematic review

Breast volume in non-obese females is related to breast adipose cell hypertrophy, inflammation, and COX2 expression

BACKGROUND

Breast hypertrophy seems to be a risk factor for breast cancer and the amount and characteristics of breast adipose tissue may play important roles. The main aim of this study was to investigate associations between breast volume in normal weight women and hypertrophic adipose tissue and inflammation.

METHODS

Fifteen non-obese women undergoing breast reduction surgery were examined. Breast volume was measured with plastic cups and surgery was indicated if the breast was 800 ml or larger according to Swedish guidelines. We isolated adipose cells from the breasts and ambient subcutaneous tissue to measure cell size, cell inflammation and other known markers of risk of developing breast cancer including COX2 gene activation and MAPK, a cell proliferation regulator.

RESULTS

Breast adipose cell size was characterized by cell hypertrophy and closely related to breast volume. The breast adipose cells were also characterized by being pro-inflammatory with increased IL-6, IL-8, IL-1β, CCL-2, TNF-a and an increased marker of cell senescence GLB1/β-galactosidase, commonly increased in hypertrophic adipose tissue. The prostaglandin synthetic marker COX2 was also increased in the hypertrophic cells and COX2 has previously been shown to be an important marker of risk of developing breast cancer. Interestingly, the phosphorylation of the proliferation marker MAPK was also increased in the hypertrophic adipose cells.

CONCLUSION

Taken together, these findings show that increased breast volume in non-obese women is associated with adipose cell hypertrophy and dysfunction and characterized by increased inflammation and other markers of increased risk for developing breast cancer.

TRIAL REGISTRATION

Projektdatabasen FoU i VGR, project number: 249191 (https://www.researchweb.org/is/vgr/project/249191).

"Normal" breast dimensions in obese women-reference values and the effect of weight loss

BACKGROUND

Breast hypertrophy may cause significant suffering, such as back- and breast pain, painful shoulder groves, and eczemas. Furthermore, women with breast hypertrophy may have lower quality of life than women without breast hypertrophy. Although 50% of the women undergoing breast reduction in the US have body mass index (BMI) >30 kg/m2, the current standard of normality is based on studies focusing on women <40 years of age and BMIs <25 kg/m2. This study aimed to present reference values for breast measurements for women with obesity and to investigate the relationship between BMI loss and each breast measurement.

MATERIALS AND METHODS

One hundred and six women underwent laparoscopic Roux-en-Y gastric bypass in Gothenburg, Sweden. The participants' breast anthropometrics were measured before and after bariatric surgery and their perception of the skin on their breasts was measured using the Sahlgrenska Excess Skin Questionnaire.

RESULTS

Breast volume, sternal notch to nipple (SNN) distance, and ptosis increased significantly with increasing BMI. For instance, women with BMIs between 30-34.9 kg/m2 have a mean breast volume of approximately 770 ml, those with BMIs of 40-44.9 kg/m2 have approximately 1150 ml, and those with BMIs above 50 kg/m2 have approximately 1400 ml. Furthermore, the percent change in the respective breast measurements relative to percent BMI change can be predicted, for instance, with a 20% reduction in BMI, the breast volume, SNN-distance, and ptosis decrease by 25%, 4%, and 20% respectively.

CONCLUSIONS

This article presents the first standard of normality for breast anthropometrics in women with obesity and a model for predicting the change in breast anthropometrics relative to BMI.

CLINICAL TRIAL REGISTRATION

This is a longitudinal observation study, registered https://fou.nu/is/gsb/ansokan/49651, No: VGFOUGSB-49651. Trial registry name: "Överskottshud efter överviktskirurgi - dess utveckling samt behov och effekt av plastikkirurgi" ("Excess skin after bariatric surgery - its development and the need and effect of plastic surgery").

A comparative study of 3D measuring methods for monitoring breast volume changes

Three-dimensional (3D) imaging techniques are promising new tools for measuring breast volume, for example in gender-affirming therapy. Transgender individuals can be treated with gender-affirming hormone therapy (GAHT). A robust method for monitoring breast volume changes is critical to be able to study the effects of feminizing GAHT. The primary aim of this study was to compare the accuracy of three 3D devices (Vectra XT, Artec LEO and iPhone XR) for measuring modest breast volume differences using a mannequin. The secondary aim of this study was to evaluate these methods in several performance domains. We used reference prostheses of increasing volumes and compared the volumes using GOM-inspect software. For Vectra XT 3D images, manufacturer-provided software was used to calculate volumes as well. The scanning methods were ranked based on their performance in a total of five categories: volume estimations, costs, user-friendliness, test subject-friendliness and technical aspects. The 3D models analyzed with GOM-inspect showed relative mean estimate differences from the actual volumes of 9.1% for the Vectra XT, 7.3% for the Artec LEO and 14% for the iPhone XR. For the Vectra XT models analyzed with the built-in software this was 6.2%. Root mean squared errors (RMSE) calculated based on the GOM-inspect volume analyses showed mean RMSEs of 2.27, 2.54 and 8.93 for the Vectra XT, Artec LEO and iPhone XR, respectively. The Vectra software had a mean RMSE of 3.00. In the combined performance ranking, the Vectra XT had the most favorable ranking, followed by the Artec LEO and the iPhone XR. The Vectra XT and Artec LEO are the preferred scanners to monitor breast development due to the combination of higher accuracy and overall performance. The current study shows that 3D techniques can be used to adequately measure modest breast volume differences and therefore will be useful to study for example breast changes in transgender individuals using feminizing GAHT. These observations may also be relevant in other fields of 3D imaging research.

Automatic segmentation of MRI in prospective breast volume evaluation: Comparison of different assessments for immediate breast reconstruction

BACKGROUND

Assessment of breast volume is essential in preoperative planning of immediate breast reconstruction (IBR) surgery to achieve satisfactory cosmetic outcome. This study introduced a breast volume measurement tool that can be used to perform automatic segmentation of magnetic resonance images (MRI) and calculation of breast volume. We compared the accuracy and reliability of this measurement method with four other conventional modalities.

METHODS

Patients who were scheduled to undergo mastectomy with IBR between 2016 and 2021 were enrolled in the study. Five different breast volume assessments, including automatic segmentation of MRI, manual segmentation of MRI, 3D surface imaging, mammography, and the BREAST-V formula, were used to evaluate different breast volumes. The results were validated using water displacement volumes of the mastectomy specimens.

RESULTS

In this pilot study, a total of 50 female patients met the inclusion criteria and contributed 54 breast specimens to the volumetric analysis. There was a strong linear association between the MRI and water displacement methods (automatic segmentation: r = 0.911, p < 0.001; manual segmentation: r = 0.924, p < 0.001), followed by 3D surface imaging (r = 0.858, p < 0.001), mammography (r = 0.841, p < 0.001), and Breast-V formula (r = 0.838, p < 0.001). Breast volumes measured using automatic and manual segmentation of MRI had lower mean relative errors (30.3% ± 22.0% and 28.9% ± 19.8, respectively) than 3D surface imaging (38.9% ± 31.2), Breast-V formula (44.8% ± 25.8), and mammography (60.3% ± 37.6).

CONCLUSION

Breast volume assessment using the MRI methods had better accuracy and reliability than the other methods used in our study. Breast volume measurement using automatic segmentation of MRI could be more efficient compared to the conventional methods.

Priorities for efficacy trials of gender-affirming hormone therapy with estrogen: collaborative design and results of a community survey

PURPOSE

Treatment guidelines for gender-affirming hormone therapy with estrogen (GAHT-E) recommend specific dosing regimens based on limited data. Well-controlled efficacy trials are essential to tailoring treatment to patient goals as the guidelines recommend. The goal of this study was to take a foundational step toward designing community-centered effectiveness trials for gender-diverse individuals seeking GAHT-E.

METHODS

Our team developed a cross-sectional survey based on broad clinical experience and consultation with our community advisory board. The survey included 60 items covering demographics, transition history, goals and priorities for treatment, indicators of treatment success, sexual function goals, and future research priorities. The survey was distributed during the summer of 2021, primarily through social networks designed for gender-expansive individuals seeking treatment with estrogen.

RESULTS

A total of 1270 individuals completed the survey. Overall treatment goals most frequently rated "extremely important" or "very important" were the following: (1) improved satisfaction with life (81%), (2) appearing more feminine (80%), (3) appearing less masculine (77%), (4) improved mental health (76%), and (5) being seen as your true gender by others (75%). The three body characteristics most frequently rated "highest priority" or "high priority" among changes were the following: (1) facial hair (85%), (2) breast shape or size (84%), and (3) body shape (80%). The highest-rated research priority was comparing feminization with different routes of estrogen administration.

CONCLUSION

The goals and experiences of individuals seeking GAHT-E are diverse. Future clinical trials of GAHT-E should be grounded in the needs and priorities of community stakeholders.

A Machine Learning-Based Model for Breast Volume Prediction Using Preoperative Anthropometric Measurements

BACKGROUND

Accurate assessment of breast volume is helpful in preoperative planning and intraoperative judgment in both cosmetic and reconstructive breast surgery. In this prospective study, a formula was derived using machine learning algorithm (Gradient Boosted Model).

METHOD

A prospective study was performed on 39 female-to-male transgender patients. Bilateral mastectomy was done for all patients. Preoperative anthropometric measurements were performed on 78 breasts of these patients. Weight of breasts was calculated postoperatively with digital scale (weight), and then volume of breasts was calculated with the calibrated container (water displacement technique). Authors built a model based on Python CatBoostClassifier. Finally, an android application was built for ease of real-time utilization.

RESULTS

Eight anthropometric measurements were collected preoperatively as independent variables. Breast vertical perimeter at lower half, upper pole, sternal notch to nipple and nipple to IMF had most correlation with volume and weight. Based on machine learning model, the following formula established: Breast volume = (breast width) × 24.69 + (nipple to IMF) × 49.03 - (sternal notch to nipple) × 1.34 + (anterior axillary line to medial border) × 6.57 - (upper pole) × 1.27 - (chest perimeter IMF) × 5.63 + (chest perimeter nipple) × 10.40 + (breast vertical perimeter at lower half) × 9.20 - 1133.74. The R2 of the model is 0.93, and RMSE is 62.4.

CONCLUSION

Our formula is an accurate method for preoperative breast volume assessment. We built an android App (Breast Volume Predictor) for the real-time utilization of resulting formula. It is available at Google Play Store for free download.

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 .

Quantification of Breast Volume According to age and BMI: A Three-Dimensional MRI Analysis of 400 Women

OBJECTIVE

Breast size alteration is the most common aesthetic surgical procedure worldwide. This study aimed to assess the correlation between breast volume and BMI or age.

MATERIALS AND METHODS

The analyses were conducted utilizing 400 patients selected by a retrospective review of the archives at our institution. Epidemiological data and medical history were assessed. Adjusting for the age and BMI of patient from previously described cohorts, we calculated mean breast volumes per side and differences from the upper and lower percentiles to the mean volumes.

RESULTS

The patients had a median BMI of 23.5 (range: 14.7-45.6) and a median age of 51 (range: 24-82). The average total breast volume increased strongly with BMI (r=0.834, p<0.01) and moderately with age (r=0.305, p<0.01). Within a BMI range of 18-24, breast volumes in the 8th and 18th percentile differ on average by about 50 ml. One BMI unit increase in women with breast sizes in the 10th percentile accounts for a breast volume difference of about 30 ml.

CONCLUSION

BMI strongly correlates with breast size. To achieve natural results, preoperative consultation and planning of aesthetic and reconstructive breast surgery must recognize BMI as a major determinant of average breast size.

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 .

Total Breast Reconstruction with Lipofilling after Traditional Mastectomy without the Use of Tissue Expanders

BACKGROUND

Lipofilling can be used to reconstruct a breast without additional implants or autologous composite grafts. However, methods to maximize retention of the transferred fat remain under debate. Here, the authors present their experience of breast reconstruction with lipofilling without concomitant use of tissue expanders.

METHODS

Patients who had completed breast reconstruction with lipofilling between June of 2010 and June of 2016 were reviewed. Those with obtainable follow-up magnetic resonance imaging scans were included in this cross-sectional study. The hospital records were reviewed for details of the lipofilling operations. Magnetic resonance imaging scans were evaluated for the volume retention and quality of the transferred fat. The patients were asked to assess the appearance and sensitivity of the reconstructed breast, the recovery time, and any adverse effects at the fat donor area.

RESULTS

Thirty-eight women with 41 reconstructed breasts were included in the study. The median age at follow-up was 62 years (range, 48 to 78 years). They had undergone a median of four (range, two to six) lipofilling procedures with a median total volume 690 mL (range, 369 to 1350 mL). After a median follow-up of 2.1 years (range, 0.4 to 6.8 years), the median proportion of transferred fat retained was 58% (range, 14% to 119%), representing a reconstructed breast volume of 76% (range, 17% to 100%) of the contralateral breast. Oil cysts larger than 10 mm were detected in 7%. Most patients reported being satisfied with the reconstructed breast and experienced few side effects.

CONCLUSIONS

Breast reconstruction with lipofilling can be performed with an acceptable number of procedures and no preoperative skin expansion. It extends the option of autologous breast reconstruction to women unsuited for major reconstructive procedures.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Estimation of Mastectomy Volume Using Preoperative Mastectomy Simulation Images Acquired by the Vectra H2 System

Preoperative prediction of breast volume is very important in planning breast reconstruction. In this study, we assessed the usefulness of a novel method for preoperative estimation of mastectomy volume by comparing the weight of actual mastectomy specimens with the values predicted by the developed method using the Vectra H2.

Methods

All patients underwent skin-sparing mastectomy and immediate autologous breast reconstruction. Preoperatively, the patient's breast was scanned using the Vectra H2 and a postmastectomy simulation image was constructed on a personal computer. The estimated mastectomy volume was calculated by comparing the preoperative and postmastectomy three-dimensional simulation images. Correlation coefficients with the estimated mastectomy volume were calculated for the actual mastectomy weight and the transplanted flap weight.

Results

Forty-five breasts of 42 patients were prospectively analyzed. The correlations with the estimated mastectomy volume were r = 0.95 (P < 0.0001) for actual mastectomy weight and r = 0.84 (P < 0.0001) for transplanted free-flap weight. The mastectomy weight estimation formula obtained by linear regression analysis using the estimated mastectomy volume was 0.98 × estimated mastectomy volume + 5.4 (coefficient of determination R2 = 0.90, P < 0.0001). The root-mean-square error for the mastectomy weight estimation formula was 38 g.

Conclusions

We used the Vectra H2 system to predict mastectomy volume. The predictions provided by this method were highly accurate. Three-dimensional imaging is a noncontact, noninvasive measurement method that is both accurate and simple to perform. Use of this effective tool for volume prediction is expected to increase in the future.

How Useful Is the SSN–Nipple Distance? An Analytical Questionnaire Survey on Anthropometric Measurements for the Aesthetically Ideal Positioning of the Nipple–Areolar Complex

Several studies have attempted to identify the optimal anthropometric measurement for the aesthetically ideal positioning of the nipple–areolar complex. However, no standardised solutions and measurements for planning surgical procedures have been reached. The aim of this study is to identify the optimal anthropometric measurement between the suprasternal notch (SSN)–nipple distance and mid-clavicle (MC)–nipple distance for the aesthetic position of the nipple–areola complex (NAC) on the breast. A detailed online survey was sent to 300 board-certified plastic surgeons and residents of plastic surgery departments of hospitals in German, Austrian, and Swiss. A similar survey was also provided to 100 patients who had planned or had already undergone breast surgery. All participants were asked to rank the attractiveness of a series of women’s breasts in images with different NAC position measurements. The images showed breasts from two different measurements and distances: all the breasts had equal dimensions and proportions and the same areola size. Complete datasets were obtained from 203 of the 300 board-certified plastic surgeons and residents of plastic surgery departments in German-speaking countries (recall 68%) and from 100 patients. The majority of doctors and patients find a symmetrical breast with a mirrored position of the nipple–areola complex more attractive than a non-symmetrical breast. In cases with minor measurement differences, such as 0.5 cm (SSN vs. MC), there is no relevant difference in the breast symmetry. However, at larger distances, the MC-to-nipple distance is superior for achieving aesthetically appealing symmetry compared with the SSN-to-nipple distance. Using the MC-to-nipple distance seems to be superior for correct nipple positioning than the SSN-to-nipple distance and is a valuable preoperative measurement option for breast symmetry with correct nipple height. Further studies on this topic involving a more general population should be conducted to confirm the improvements in perception with the preoperative measurements using the anatomical landmarks.

Is Preoperative Asymmetry a Predictor of Postoperative Asymmetry in Patients Undergoing Breast Reduction?

Plastic surgeons aim to achieve symmetry in breast surgeries, which is the main determinant of chest aesthetics. The aim of this study was to verify if preoperative breast asymmetry is a predictor of postoperative asymmetry in women undergoing breast reduction. In this prospective study, we enrolled 71 women (the mean age 37 years, SD 10 years) with breast hypertrophy who underwent reduction mammaplasty. We collected clinical data including age, height, weight, weight of the resected tissues, and performed pre and postoperative photographic documentation. The following measurements of both breasts were analyzed: volumes (vol), nipple-sternal notch distance (A-sn), difference between nipples' levels (A-A'), nipple-midline distance (A-ml), difference between inframammary folds levels (IF-IF'), distance between inframammary fold and nipple (IF-A), distance between inframammary fold apex and midline (IF-ml). All measurements were performed preoperatively and 6 months after the surgery and asymmetries of all variables were calculated (asy-vol, A-A', asyA-sn, asyA-ml, IF-IF', asyIF-A, asyIF-ml). Postoperative asymmetry of breast volumes and nipples position was not associated with any of the analyzed clinical variables. Postoperative asymmetry of nipples' level was associated with preoperative asymmetry of IF-ml; however, logistic regression did not detect any preoperative measurement influencing postoperative volume and nipples' level asymmetry. Moreover, we found that preoperative asyIF-ml increased the risk of postoperative volume asymmetry, which is above the average (52 cc) (OR = 2.04). Postoperative breast asymmetry after breast reduction is not related neither to preoperative asymmetries nor clinical variables; however, asymmetry of inframammary fold apex to the midline may be the factor affecting postoperative volumetric asymmetry.

Challenges in developing a quantitative method of measuring breast development using 3D imaging: An example of a novel method for use in induced breast development with exogenous oestrogen

OBJECTIVE

Optimal breast development is an essential part of exogenous oestrogen treatment in females undergoing pubertal induction. We set out to develop a novel technique using three-dimensional (3D) imaging to determine change in breast volume that is applicable when no pre-existing breast contours are present.

DESIGN

A prospective observational study.

PATIENTS

The imaging methodology was developed using a single male subject to assess reproducibility and validity. The technique was then applied to 29 participants undergoing pubertal induction with exogenous oestradiol who were recruited from Paediatric Gynaecology and Reproductive Endocrinology clinics at University College London Hospital.

MEASUREMENTS

Breast images were taken using a 3D photographic system. Two images, taken at different times, were manually superimposed to produce a differential breast volume. The initial step of method development set out to show that volume change was not secondary to positioning artefact or image manipulation. This was established by using images of a male participant taken on different occasions. The technique was then used to assess reproducibility in participants undergoing pubertal induction treatment.

RESULTS

Good intraobserver reproducibility (intraclass correlation (ICC) 0.77) was demonstrated with static image manipulation. Validity of the imaging technique was established as there was no significant difference between the known reference volume produced by computer generated warping and that calculated by manual image manipulation. There was excellent intraobserver reproducibility for breast volume calculation in participants undergoing induced breast development (ICC 0.99).

CONCLUSIONS

3D imaging is a promising novel tool to provide quantitative breast volume assessment in individuals undergoing breast induction with exogenous oestradiol treatment.

Comparison of analog and digitally evaluated volume of the female breast in reconstructive breast surgery. Validation of a noninvasive measurement method with 3D camera1

BACKGROUND

Reconstructive surgery is established as a standard treatment option after mastectomy due to cancer. It is crucial to patients to achieve a natural and symmetric looking breast through reconstruction. Anthropometric measurements are used to assess the objective symmetry of the breast, which are prone to errors and difficult to reproduce.

OBJECTIVE

The aim of this work is to validate breast volumetry using three-dimensional surface imaging.

METHODS

We compared preoperatively analog and digitally evaluated volume of the breast with our gold standard, direct water displacement measurement of the mastectomy specimen. We examined 34 breast specimens in total.

RESULTS

Each measurement method (Breast Sculptor, VAM, Breast-V) for breast volume/mass determination demonstrates acceptable agreement ranges when compared with resected volumes and masses. The strongest volumetry instrument is Breast Sculptor (digital), the weakest is Breast-V (analog).

CONCLUSIONS

3D surface imaging is a quick, effective, and convenient method to evaluate breast shape and volume. The accuracy, reproducibility, and reliability of 3D surface imaging were comparable with MRI in our study.This takes us a step closer to the long-term goal of establishing robust instruments to plan breast reconstructive surgery, achieve better surgical results, and contribute to quality assurance in breast surgery.

Reliability and Measurement Error of Breast Volume Calculation Using Three-Dimensional Surface Imaging

Background: Breast lymphedema after breast cancer is challenging to quantify. Three-dimensional (3D) surface imaging is one available technique to measure breast volume, however, the measurement properties of available software programs have not been fully determined. The aim of this study was to determine equivalency of measurements with two software programs as well as reliability, standard error of measurement (SEM), and smallest detectable change (SDC). Methods and Results: Retrospective three-dimensional surface imaging (3D-SI) of 100 breasts taken before or after breast conserving surgery for breast cancer were retrieved for reliability analysis. Three assessors followed a standardized measurement technique using two software programs, Vectra^® 3D Analysis Module (VAM) and Breast Sculptor^®. Mean breast volume was 489.9 ± 206 cc using VAM and 480.1 ± 229.1 cc using Breast Sculptor. Lin's concordance showed poor agreement between programs (0.81-0.88). Measurements using VAM had excellent intra- and inter-rater reliability with SEM = 4.1% for one assessor and 8.7% for multiple assessors. Breast Sculptor also had excellent intra-rater and substantial inter-rater reliability but the SEM was much larger at 14.5% (intra-rater) and 19.1% (inter-rater). The SDC value was lowest for VAM and a single rater with 56 cc indicating a meaningful change beyond measurement error. Conclusion: Breast volume measurements captured with 3D-SI using VECTRA-XT are highly reliable, but the volumes, SEM, and SDC varied between the two software programs. Measurement error was lowest with VAM software. Although the usefulness of VECTRA-XT and VAM software to detect change in breast volume is promising, further solutions to reduce measurement error are required to improve clinical utility to measure breast lymphedema.

Morphometric study of post menarcheal nulliparous breasts, their clinical relevance and relationship with body size indicators in a Nigerian population

Background

The female breast is a symbol of femininity and aesthetics having a great psychosocial impact on the woman's sense of wellbeing and self-esteem. To optimize satisfaction of patients in cosmetic and reconstructive breast surgeries, there is a need to define the dominant breast size and shape that connotes feminine attractiveness. This necessitates the knowledge of ideal data for normal nulliparous female breast parameters and volume for various body sizes in the particular population, nationality, and race.

Aim

To establish reference data for normal breast parameters and volumes for the various body sizes amongst the Nigerian population and to determine their relationships with other body parameters.

Patients and Methods

A total of 528 breasts from 264 Nigerian undergraduate post-menarcheal nulliparous students of the University of Nigeria Enugu Campus aged between 17 and 29 years were measured. Thirty-one (31) anthropomorphic parameters and five body size anthropometric indicators were measured. Data obtained were analyzed using Statistical Package for Social Sciences (SPSS) version 21(IBM) and were summarized using various descriptive statistics tools.

Results

The mean nipple-nipple distance is 23.37 ± 3.10. The mean left Midclavicle-nipple Length (22.17 ± 3.5 cm) is significantly (P = 0.04) higher than the right (21.79 ± 3.3 cm) just as the mean left (12.60 ± 2.5) medial radius is significantly (P = 0.0001) longer than the right (12.45 ± 2.4 cm). The mean left nipple projection (0.37 ±0.2 cm) and left vertical surface dimension (32.27 ± 5.7 cm) are significantly (P > 0.05) longer than the right (0.33 ±0.2) and (31.76 ± 5.2 cm). Also the mean volume for the left breast (605.26 ± 280.52 cm) is significantly (0.0001) higher than that of the right breast (592.53 ± 278.69). Breast volume correlated well with most of the breast parameters, BMI, and other anthropometric variables. Most breasts were ptotic (51%, 55%), especially the left breasts. Breast dimensions were asymmetrical in >50% of subjects, where the left breasts were seen to have slightly greater breast dimensions than right.

Conclusion

Breast values and related body size parameters were noted to be comparatively higher than earlier reported values mostly for the Asian population.

Volumetry in Breast Reconstruction: Always New, Always Better?

Although breast surgeries for aesthetic or reconstructive purposes are regularly performed, no focus has been laid on establishing an adequate and reliable volumetry method. While CT and MRI scan represent methods that are already in clinical use, the 3D scan  is a novel and promising tool, easy to use with the possibility to measure the anatomic breast volume in an upright position. Nevertheless, its reliability is broadly underinvestigated. 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 .

Predictive value of 3D imaging to guide implant selection in immediate breast reconstruction

Background

Pre-operative estimation of breast mound volume for immediate breast reconstruction is necessary for operative planning, especially in direct-to-implant reconstruction. Our purpose was to investigate the relationship between pre-operative predictions of breast mound weight from 3D imaging and actual mastectomy weight and implant size.

Methods

A retrospective chart review of all patients who had previously undergone nipple-sparing mastectomy (NSM) by a single surgeon was performed. Pre-operative 3D images were reviewed and calculations of breast mound weight were performed by three independent reviewers. Intra-operative mastectomy weight and final implant weight were collected from patient charts. A regression analysis between calculated and actual values was performed.

Results

There were 59 reconstructed breasts included. Pre-operative 3D imaging-guided breast weight calculations were similar across reviewers (R=0.96). Pre-operative calculations of breast weight were 49.4g (SD=134.0) smaller than actual mastectomy specimens. Mastectomy specimens were 41.0g (SD=130.2) smaller than final implant sizes. Thereby, the relationship was as follows: Pre-operative calculated breast weight < actual Mastectomy weight < implant weight. Mastectomy weight and final implant size had linear relationships with pre-operative calculations of breast weight. Formulas for predicting mastectomy weight [mastectomy weight = 63.2 + 0.95 (pre-operative calculated weight)] and implant size [Implant weight = 209.7+ 0.56 (pre-operative calculated weight)] from pre-operative calculations of breast weight were generated.

Conclusions

Three-dimensional scanning technologies may be a useful tool to predict implant sizes for direct-to-implant breast reconstruction. Final implant size was heavier than intra-operative mastectomy weight and pre-operative calculated breast mound weight.

Automated Breast Volume Assessment Derived From Digital Breast Tomosynthesis Images Compared to Mastectomy Specimen Weight and Its Applications in Cosmetic Optimisation

Background: Estimating the size and volume of the breast preoperatively is an important step in surgical planning for many breast procedures such as immediate implant-based breast reconstructions and reduction mammoplasties. Breast volume estimation helps in appropriate implant selection preoperatively.

Objectives: The aim of this study was to objectively evaluate the estimation of breast weight by automatic volumetric breast assessment in digital breast tomosynthesis (DBT) using Quantra™ 2.2 Breast Density Assessment Software (Hologic Inc., Marlborough, Massachusetts, United States). Methods: Breast specimen weight after mastectomy and volume estimated by Quantra software were recorded.

Results: Volume assessment obtained from Quantra software showed a high correlation with actual mastectomy specimen weight, with Pearson’s correlation coefficients of 0.952.

Conclusions: The automated DBT-derived breast volume using the Quantra software is a simple and practical method to assess breast size and weight preoperatively. 

Vectra 3D Simulation in Lower Eyelid Blepharoplasty: How Accurate is it?

BACKGROUND

Estimating the volume of fat to be resected during lower lid blepharoplasty can be challenging. While the excess fat is clearly visible in the upright position, it retracts into the orbital cavity when the patient is in decubitus. Several tools have been developed to predict the volume required for adequate outcomes and to reduce the risk of complications. Among these, 3D photography, in addition to being noninvasive, radiation-free, portable and relatively inexpensive, can be used to make simulations.

OBJECTIVE

To assess the level of agreement between Vectra H1 camera simulations and the outcome of lower eyelid blepharoplasties with volume removal based on these simulations.

METHODS

Preoperatively, a 3D camera and simulation software (Vectra H1, Canfield Imaging Systems) was used to estimate the fat pad volume to be resected from the lower eyelids in a sample of 35 patients (female n = 34) aged 55 years on average. Following the procedure, the patients were photographed at 1, 3 and 6 months and the outcome was compared to the simulation.

RESULTS

The agreement between the simulated volume and the intraoperative volume was high. While the difference between the postoperative volume and the simulated volume decreased over time, at 6 months the actual volume was still 0.30 mL (right eye) and 0.24 mL (left eye) larger than the simulated volume.

CONCLUSIONS

A systematic and significant difference was found between the simulation volume and the postoperative volume. The low level of agreement observed suggests that the accuracy of the tested software is insufficient for reliable simulations.

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 .

A Prospective Investigation of Predictive Parameters for Preoperative Volume Assessment in Breast Reconstruction

Preoperative breast volume estimation is very important for the success of the breast surgery. In this study four different breast volume determination methods were compared. The end-point of this prospective study was to evaluate the concordance between different modalities of breast volume assessment (MRI, BREAST-V, mastectomy specimen weight, conversion from weight to volume of mastectomy specimen) and the breast prosthetic volume implanted. The study enrolled 64 patients between 2017 and 2019, who had all been treated by the same surgeons for monolateral nipple–areola complex-sparing mastectomy and implant breast reconstruction. Only patients who had a breast reconstruction classified as “excellent” from an objective (BCCT.core software) and subjective (questionnaire) point of view at the 6-month interval after the operation were included in the study. Data analysis highlighted a strong correlation between the volumes of the chosen prostheses and the weights of mastectomy converted into volume, especially for patients with grades B and C parenchymal density. The values of the agreement between the volumes of the chosen prostheses and the assessments from MRI and BREAST -V proved to be lower than expected from the literature. None of the four studied methods presented any strong correlation with the initial breast width. Our results suggest that conversion from weight to volume of mastectomy specimen should be used to assist in determining the volume of the breast implant to be implanted. This method would help the reconstructive surgeon guide the choice of the most appropriate implant preoperatively.

Bigger Bust No Longer on Trend: Malaysians Prefer Moderation in Ideal Female Breast Augmentation

Background It is important to correctly determine the ideal female breast anatomy and aesthetic proportions in order to prepare for surgery and establish its goals. Leaving the preference to the operating surgeons alone might leave unsatisfactory results, which especially leads to reoperation, quite often in the aspect of breast dimension.

Methods This study was conducted using an online graphic questionnaire. We attempted to seek male and female perspectives toward their preferred ideal female breast size for breast augmentation, in order to provide up-to-date data to assist breast surgeons in attaining satisfactory surgical results.

Results Sixty males and 67 females participated in the study comprising Asian major ethnicities of Malay, Chinese, and Indian. Universally, 46.6% of men and 53.5% of women preferred 30 mm diameter for the most ideal nipple-areola complex (NAC) size. For the perfect bust, they generally favored size C and D cup (37.8% and 38.5%, respectively).

Conclusion The majority of women seek natural breast beauty and the longing for an oversized look appears to have infiltrated practice but these assumptions have finally been challenged by these findings.

A systematic review and meta-analysis of risks and benefits with breast reduction in the public healthcare system: priorities for further research

Background

There is no consensus for when publicly funded breast reduction is indicated and recommendations in guidelines vary greatly, indicating a lack of evidence and unequal access. The primary aim of this review was to examine risks and benefits of breast reduction to treat breast hypertrophy. Secondary aims were to examine how the studies defined breast hypertrophy and indications for a breast reduction.

Methods

A systematic literature search was conducted in PubMed, MEDLINE All, Embase, the Cochrane Library, and PsycInfo. The included articles were critically appraised, and certainty of evidence was assessed using the GRADE approach. Meta-analyses were performed when possible.

Results

Fifteen articles were included; eight reporting findings from four randomised controlled trials, three non-randomised controlled studies, three case series, and one qualitative study. Most studies had serious study limitations and problems with directness. Few of the studies defined breast hypertrophy. The studies showed significantly improved health-related quality of life and sexuality-related outcomes in patients who had undergone breast reduction compared with controls, as well as reduced depressive symptoms, levels of anxiety and pain. Most effect sizes exceeded the reported minimal important difference for the scale. Certainty of evidence for the outcomes above is low (GRADE ⊕ ⊕). Although four studies reported significantly improved physical function, the effect is uncertain (very low certainty of evidence, GRADE ⊕). None of the included studies reported data regarding work ability or sick leave. Three case series reported a 30-day mortality of zero. Reported major complications after breast reduction ranged from 2.4 to 14% and minor complications from 2.4 to 69%.

Conclusion

There is a lack of high-quality studies evaluating the results of breast reduction. A breast reduction may have positive psychological and physical effects for women, but it is unclear which women benefit the most and which women should be offered a breast reduction in the public healthcare system. Several priorities for further research have been identified.

Pre-registration

The study is based on a Health Technology Assessment report, pre-registered and then published on the website of The Regional HTA Centre of Region Västra Götaland, Sweden.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-021-01336-7.

Mammography with a fully automated breast volumetric software as a novel method for estimating the preoperative breast volume prior to mastectomy

Purpose

Increasing interest in maintaining a positive body image following breast cancer surgery has become an important aspect of reconstruction surgery. Volume matching of the reconstructed breast to natural breasts is the most important consideration. This study aimed to explore the feasibility of using mammography with a fully automated breast volumetric software to measure the preoperative breast volume in patients with breast cancer.

Methods

We evaluated patients who underwent a total mastectomy between July 2016 and February 2021. The specimen volume following total mastectomy was compared with breast volume estimates using a fully automated volumetric software (Quantra ver. 2.1.1) and 4 other previously described mammography-based prediction methods. The association between the estimates and mastectomy specimen volume was assessed using Pearson correlation and Bland-Altman analysis.

Results

Sixty-six patients were included. Compared with previously described mammography-based methods, Quantra estimates were more strongly correlated with mastectomy specimen volume in the entire, fatty, and dense breast groups (r = 0.920, 0.921, and 0.915, respectively; P < 0.001). In applying Quantra estimates for measuring preoperative breast volume, we adjusted a simple equation: mastectomy specimen volume = Quantra estimate × 0.8.

Conclusion

Mammography with a fully automated breast volumetric software can be useful for measuring preoperative breast volume in patients with breast cancer who undergo reconstruction surgery.

Innovations for the future of breast surgery

BACKGROUND

Future innovations in science and technology with an impact on multimodal breast cancer management from a surgical perspective are discussed in this narrative review. The work was undertaken in response to the Commission on the Future of Surgery project initiated by the Royal College of Surgeons of England.

METHODS

Expert opinion was sought around themes of surgical de-escalation, reduction in treatment morbidities, and improving the accuracy of breast-conserving surgery in terms of margin status. There was emphasis on how the primacy of surgical excision in an era of oncoplastic and reconstructive surgery is increasingly being challenged, with more effective systemic therapies that target residual disease burden, and permit response-adapted approaches to both breast and axillary surgery.

RESULTS

Technologies for intraoperative margin assessment can potentially half re-excision rates after breast-conserving surgery, and sentinel lymph node biopsy will become a therapeutic procedure for many patients with node-positive disease treated either with surgery or chemotherapy as the primary modality. Genomic profiling of tumours can aid in the selection of patients for neoadjuvant and adjuvant therapies as well as prevention strategies. Molecular subtypes are predictive of response to induction therapies and reductive approaches to surgery in the breast or axilla.

CONCLUSION

Treatments are increasingly being tailored and based on improved understanding of tumour biology and relevant biomarkers to determine absolute benefit and permit delivery of cost-effective healthcare. Patient involvement is crucial for breast cancer studies to ensure relevance and outcome measures that are objective, meaningful, and patient-centred.

Review of Quantitative Imaging for Objective Assessment of Fat Grafting Outcomes in Breast Surgery

This article presents a comprehensive review of the use of quantitative measurements based on breast images to assess fat retention, breast aesthetics, and fat necrosis after autologous fat grafting. Breast volume measured from MRI and 3-dimensional surface images is widely used as a measure of fat retention. Breast aesthetics are assessed from a combination of anthropometric (distance and contour) measurements on breast surface images. Examination of radiologic images (ultrasonography, mammography, and MRI) is utilized to assess fat necrosis. The article discusses implementation guidelines for objective outcome assessment to support robust quantification and enable investigations of fat grafting efficacy. Level of Evidence: 4.

The current progress and critical analysis of three-dimensional scanning and three-dimensional printing applications in breast surgery

Background

Several attempts have been made to develop a tool capable of evaluating breast shape and volume to aid surgical planning and outcome assessment. More recently, newer technologies such as three-dimensional (3D) scanning and 3D printing have been applied in breast assessment. The aim of this study was to review the literature to assess the applicability of 3D scanning and 3D printing in breast surgery.

Methods

A literature search was carried on PubMed, Google Scholar and OVID from January 2000 to December 2019 using the keywords ‘3D’, ‘Three-dimensional’, ‘Three/four dimensions’ and ‘Breast’.

Results

A total of 6564 articles were identified initially; the abstracts of 1846 articles were scanned, and 81 articles met the inclusion criteria and were included in this review. Articles were reviewed and classified according to their aims, study subjects, the software and hardware used, main outcomes and major limitations.

Conclusions

These technologies are fast and easy to use, however, high costs, long processing times and the need for training might limit their application. To incorporate these technologies into standard healthcare, their efficacy and effectiveness must be demonstrated through multiple and rigorous clinical trials.

Perception of the most perfect female breast shape among Malays, Chinese, and Indians community

Researchers have long tried to search for the 'perfect' aesthetic outcome of breast surgery. Although lots of anthropometric studies have been done, there is no consensus when dealing with harmony, abstract, and proportion that make up for its ideal shape. This study was convened via a survey to find the most perfect breast shape by assessing the upper pole contour and upper pole to lower pole ratio (UP:LP) preference among the Malays, Chinese, and Indians races. Hundred thirty-five individuals partook in this survey. Most of the participants generally preferred a more convex shape of upper pole contour with the Malay (50%) and Indian (35.7%) favored a more convex shape while the Chinese preferred it to be just slightly convex (42.8%). Single unmarried individuals (64.7%) significantly preferred a more convex upper pole contour (p = 0.018). The UP:LP ratio of 45:55 (p = 0.002) was the most significantly preferred proportion (37.8%) which largely comprised of the Chinese (51%), followed by Indian (21.6%) and Malay (19.6%). With these findings, using a controlled perception-preference method is a more preferred choice when describing an ideal breast shape as compare to an anthropometric measurement that might be less accurate. Therefore, breast and plastic surgeons alike need to look beyond the anthropometric numbers and should consider the other 'abstract' aesthetic shape which difficult to measure including the upper pole breast that has more convexity and the UP:LP ratio of 45:55 which showed to be the most aesthetically perfect form as agreed in the current works of literature.

Breast Biomechanics: What Do We Really Know?

Although half the world's population will develop breasts, there is limited research documenting breast structure or motion. Understanding breast structure and motion, however, is imperative for numerous applications, such as breast reconstruction, breast modeling to better diagnose and treat breast pathologies, and designing effective sports bras. To be impactful, future breast biomechanics research needs to fill gaps in our knowledge, particularly related to breast composition and density, and to improve methods to accurately measure the complexities of three-dimensional breast motion. These methods should then be used to investigate breast biomechanics while individuals, who represent the full spectrum of women in the population, participate in a broad range of activities of daily living and recreation.

Sustained Breast Development and Breast Anthropometric Changes in 3 Years of Gender-Affirming Hormone Treatment

CONTEXT

Breast development is important for most trans women. An important limitation of current breast development measurement methods is that these do not allow for 3D volume analyses.

OBJECTIVES

To examine breast development and change in anthropometry during the first 3 years of gender-affirming hormone treatment using 3D imaging. Associations with clinical or laboratory parameters and satisfaction with the gained breast development were also studied.

DESIGN

Prospective cohort study.

SETTING

Specialized tertiary gender identity clinic in Amsterdam, the Netherlands.

PARTICIPANTS

Participants were 69 adult trans women with a median age of 26 years (interquartile range, 21-38).

INTERVENTIONS

Gender-affirming hormone treatment.

MAIN OUTCOME MEASURES

Volumetric and anthropometric breast development and satisfaction.

RESULTS

Breast volume increased by 72 cc (95% confidence interval [CI], 48-97) to 100 cc (standard deviation 48). This resulted in a cup-size <A-cup in 71% of the participants. Although the change in breast-chest difference plateaued after approximately 9 months, sustained increase in breast volume was observed during the 3-year observation period. Sternal notch to nipple distance increased by 1.3 cm (95% CI, 0.9-1.7) and internipple distance increased by 1.0 cm (95% CI, 0.4-1.5). At least 58% of trans women were satisfied with the gained breast size.

CONCLUSIONS

Sustained breast growth and development during hormone treatment was observed during the full 3-year observation period. The breasts of trans women are positioned more laterally and caudally on the chest compared with cis women. Although modest breast volumes were observed, breast development was satisfactory to most trans women.

Clinical Assessment of Breast Volume: Can 3D Imaging Be the Gold Standard?

Background:

Three-dimensional (3D) camera systems are increasingly used for computerized volume calculations. In this study we investigate whether the Vectra XT 3D imaging system is a reliable tool for determination of breast volume in clinical practice. It is compared with the current gold standard in literature, magnetic resonance imaging (MRI), and current clinical practice (plastic surgeon’s clinical estimation).

Methods:

Breast volumes of 29 patients (53 breasts) were evaluated. 3D images were acquired by Vectra XT 3D imaging system. Pre-existing breast MRI images were collected. Both imaging techniques were used for volume analyses, calculated by two independent investigators. Breast volume estimations were done by plastic surgeons during outpatient consultations. All volume measurements were compared using paired samples t-test, intra-class correlation coefficient, Pearson’s correlation, and Bland–Altman analysis.

Results:

Two 3D breast volume measurements showed an excellent reliability (intra-class correlation coefficient: 0.991), which was comparable to the reliability of MRI measurements (intra-class correlation coefficient: 0.990). Mean (SD) breast volume measured with 3D breast volume was 454 cm³ (157) and with MRI was 687 cm³ (312). These volumes were significantly different, but a linear association could be found: y(MRI) = 1.58 × (3D) – 40. Three-dimensional breast volume was not significantly different from volume estimation made by plastic surgeons (472 cm³ (69), P = 0.323).

Conclusions:

The 3D imaging system measures lower volumes for breasts than MRI. However, 3D measurements show a linear association with MRI and have excellent reliability, making them an objective and reproducible measuring method suitable for clinical practice.

3-Dimensional objective aesthetic evaluation to replace panel assessment after breast-conserving treatment

BACKGROUND

Two-thirds of patients with early breast cancer undergo breast-conserving treatment (BCT). Aesthetic outcome is important and has long term implications for psychosocial wellbeing. The aesthetic goal of BCT is symmetry for which there is no gold-standard measure. Panel scoring is the most widely adopted assessment but has well-described limitations. This paper describes a model to objectively report aesthetic outcome using measures derived from 3-dimensional surface images (3D-SI).

METHOD

Objective measures and panel assessment were undertaken independently for 3D-SI of women who underwent BCT 1-5 years previously. Univariate analysis was used to test for association between measures and panel score. A forward stepwise multiple linear regression model was fitted to identify 3D measurements that jointly predicted the mean panel score. The fitted model coefficients were used to predict mean panel scores for an independent validation set then compared to the mean observed panel score.

RESULTS

Very good intra-panel reliability was observed for the training and validation sets (wκ = 0.87, wκ = 0.84). Six 3D-measures were used in the multivariate model. There was a good correlation between the predicted and mean observed panel score in the training (n = 190) and validation (n = 100) sets (r = 0.68, r = 0.65). The 3D model tended to predict scores towards the median. The model was calibrated which improved the distribution of predicted scores.

CONCLUSION

A six-variable objective aesthetic outcome model for BCT has been described and validated. This can predict and could replace panel assessment, facilitating the independent and unbiased evaluation of aesthetic outcome to communicate and compare results, benchmark practice, and raise standards.

Relationship between formulaic breast volume and risk of breast cancer based on linear measurements

BACKGROUND

Whether breast volume is a risk factor for breast cancer is controversial. This study aimed to evaluate whether a significant association between breast volume and risk of breast cancer, based on linear measurements, was present by applying propensity score matching (PSM).

METHODS

The study was designed as a hospital-based case-control study. Between March 2018 and May 2019, 208 cases and 340 controls were retrospectively reviewed. Information on menarche, smoking, feeding mode, oral contraceptives, reproductive history and family history was obtained through a structured questionnaire. Breast volume was calculated using a formula based on linear measurements of breast parameters. Cox regression and PSM were used to estimate odds ratios and 95% confidence intervals for breast cancer using risk factors adjusted for potential confounders.

RESULTS

There was a significant difference in breast volume between the two groups before propensity score matching (P = 0.014). Binary logistic regression showed that the risk of breast cancer was slightly higher in the case group with larger breast volumes than in the control group(P = 0.009, OR = 1.002, 95%CI:1.000 ~ 1.003). However, there was no significant statistical difference between the two groups using an independent sample Mann-Whitney U test (P = 0.438) or conditional logistic regression (P = 0.446).

CONCLUSIONS

After PSM for potential confounding factors, there is no significant difference in breast volume estimated by BREAST-V formula between the case group and the control group. The risk of breast cancer may not be related to breast volume in Chinese women.

Measuring Differential Volume Using the Subtraction Tool for Three-Dimensional Breast Volumetry: A Proof of Concept Study

Background. Three-dimensional (3D) photography provides a promising means of breast volumetry. Sources of error using a single-captured surface to calculate breast volume include inaccurate designation of breast boundaries and prediction of the invisible chest wall generated by computer software. An alternative approach is to measure differential volume using subtraction of 2 captured surfaces. Objectives. To explore 3D breast volumetry using the subtraction of superimposed images to calculate differential volume. To assess optimal patient positioning for accurate volumetric assessment. Methods. Known volumes of breast enhancers simulated volumetric changes to the breast (n = 12). 3D photographs were taken (3dMDtorso) with the subject positioned upright at 90° and posteriorly inclined at 30°. Patient position, breathing, distance and camera calibration were standardised. Volumetric analysis was performed using 3dMDvultus software. Results. A statistically significant difference was found between actual volume and measured volumes with subjects positioned at 90° (P < .05). No statistical difference was found at 30° (P = .078), but subsequent Bland–Altman analysis showed evidence of proportional bias (P < .05). There was good correlation between measured and actual volumes in both positions (r = .77 and r = .85, respectively). Univariate analyses showed breast enhancer volumes of 195 mL and 295 mL to incur bias. The coefficient of variation was 5.76% for single observer analysis. Conclusion. Positioning the subject at a 30° posterior incline provides more accurate results from better exposure of the inferior breast. The subtraction tool is a novel method of measuring differential volume. Future studies should explore methodology for application into the clinical setting.

Three-dimensional surface imaging in breast cancer: a new tool for clinical studies?

Background

Three-dimensional Surface Imaging (3DSI) is a well-established method to objectively monitor morphological changes in the female breast in the field of plastic surgery. In contrast, in radiation oncology we are still missing effective tools, which can objectively and reproducibly assess and document adverse events in breast cancer radiotherapy within the framework of clinical studies. The aim of the present study was to apply structured-light technology as a non-invasive and objective approach for the documentation of cosmetic outcome and early effects of breast radiotherapy as a proof of principle.

Methods

Weekly 3DSI images of patients receiving either conventionally fractionated radiation treatment (CF-RT) or hypofractionated radiation treatment (HF-RT) were acquired during the radiotherapy treatment and clinical follow-up. The portable Artec Eva scanner (Artec 3D Inc., Luxembourg) recorded 3D surface images for the analysis of breast volumes and changes in skin appearance. Statistical analysis compared the impact of the two different fractionation regimens and the differences between the treated and the contralateral healthy breast.

Results

Overall, 38 patients and a total of 214 breast imaging sessions were analysed. Patients receiving CF-RT showed a significantly higher frequency of breast erythema compared to HF-RT (93.3% versus 34.8%, p = 0.003) during all observed imaging sessions. Moreover, we found a statistically significant (p < 0.05) volumetric increase of the treated breast of the entire cohort between baseline (379 ± 196 mL) and follow-up imaging at 3 months (437 ± 224 mL), as well as from week 3 of radiotherapy (391 ± 198 mL) to follow-up imaging. In both subgroups of patients undergoing either CF-RT or HF-RT, there was a statistically significant increase (p < 0.05) in breast volumes between baseline and 3 months follow-up. There were no statistically significant skin or volumetric changes of the untreated healthy breasts.

Conclusions

This is the first study utilizing 3D structured-light technology as a non-invasive and objective approach for the documentation of patients receiving breast radiotherapy. 3DSI offers potential as a non-invasive tool to objectively and precisely monitor the female breast in a radiooncological setting, allowing clinicians to objectively distinguish outcomes of different therapy modalities.

Wavelia Breast Imaging: The Optical Breast Contour Detection Subsystem

Wavelia is a low-power electromagnetic wave breast imaging device for breast cancer diagnosis, which consists of two subsystems, both performing non-invasive examinations: the Microwave Breast Imaging (MBI) subsystem and the Optical Breast Contour Detection (OBCD) subsystem. The Wavelia OBCD subsystem is a 3D scanning device using an infrared 3D stereoscopic camera, which performs an azimuthal scan to acquire 3D point clouds of the external surface of the breast. The OBCD subsystem aims at reconstructing fully the external envelope of the breast, with high precision, to provide the total volume of the breast and morphological data as a priori information to the MBI subsystem. This paper presents a new shape-based calibration procedure for turntable-based 3D scanning devices, a new 3D breast surface reconstruction method based on a linear stretching function, as well as the breast volume computation method that have been developed and integrated with the Wavelia OBCD subsystem, before its installation at the Clinical Research Facility of Galway (CRFG), in Ireland, for first-in-human clinical testing. Indicative results of the Wavelia OBCD subsystem both from scans of experimental breast phantoms and from patient scans are thoroughly presented and discussed in the paper.

Unilateral Tissue Expander/Implant Two-Stage Breast Reconstruction with the Assistance of Three-Dimensional Surface Imaging

BACKGROUND

In China, traditional preoperative planning of unilateral breast reconstruction mainly depends on anthropometric measurement and visual assessment. Thus, the lack of objective assessment of breast volume and shape would likely result in suboptimal reconstruction outcomes. Three-dimensional surface imaging (3D-SI), which could provide objective measurement data of the breast, may be a promising solution to this problem.

METHODS

A retrospective review of patients undergoing tissue expander (TE)/implant breast reconstruction without any mammoplasty surgery on the contralateral sides in our hospital from August 2013 to May 2018 was performed. All the patients underwent unilateral mastectomy with immediate or delayed insertion of TE, followed by an exchange of a silicone gel implant without contralateral procedures. 3D images were obtained at the time of preoperation, the routine expansion visit, and post-exchange of implant. The breast volume measured by 3D-SI served as a guide to conduct the surgery management, such as in deciding the total volume of expansion and guiding the final implant size selection. 3D-SI also provided objective data to evaluate the final outcomes of the reconstruction.

RESULTS

Fifty-one patients were included in this study, in which eighteen patients underwent immediate TE insertion and thirty-three patients underwent delayed TE insertion. The ptosis degree of contralateral breasts was assessed as follows: forty-four were normal, and seven showed mild ptosis. The average expansion degree was controlled at 161.6% ± 14.1% compared to the contralateral breasts. The volume of implants exchanged had a strong linear correlation with the 3D volume of the contralateral breasts at the end of expansion (P < 0.01). The mean time of follow-up was 9.1 ± 6.6 months. There was only one patient who experienced TE leakage with secondary infection and received TE exchange. For the immediate reconstruction group, the overall breast symmetry improved at the completion of implant exchange (P < 0.01), with an average asymmetry of 5.3% ± 4.0% compared with 10.6% ± 6.1% initially. For the delayed reconstruction group, the reconstructed side achieved good volume symmetry to the contralateral side (P > 0.05). There was no significant difference in breast basal width between bilateral breasts post-reconstruction (P > 0.05).

CONCLUSION

3D-SI serves as a valuable adjunct by providing accurate 3D volume of breasts within TE/implant breast reconstruction in Chinese patients without obvious breast ptosis, which could facilitate surgeons to achieve good reconstructive outcomes.

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.

Breast Asymmetry, Classification, and Algorithm of Treatment: Our Experience

BACKGROUND

In the literature, several classifications of breast asymmetries and treatment protocols have been proposed over time, which are mainly based on etiological or morphological characteristics of the deformity. The aim of this study was to present our new classification, based on patient's self-consciousness of breast asymmetry, a simple and reliable treatment algorithm is also presented.

METHODS

The case series included 343 patients treated between January 2006 and January 2015. Only patients presenting with developmental breast asymmetries were included in the study. All patients underwent prior classification in three groups based on the patient's degree of awareness of their asymmetry. A specific treatment algorithm was associated with each group according to breast size, grade of ptosis, and patient's desire. At the 48-month follow-up appointment, patients completed an anonymous questionnaire that addressed satisfaction with breast shape, size, and symmetry, scar appearance, body perception, self-esteem, perceived attractiveness, intimate life, and overall feelings about their breasts.

RESULTS

Mean patient age was 24.6 years (range 18-57 years). Mean follow-up was 54.4 months (6 months to 9 years). At the 48-month follow-up, 66.7% of the patients completed a visual analog scale (VAS) satisfaction questionnaire. An overall satisfaction rate of 77.0% was reported, and a statistically significant difference in the distribution of the overall satisfaction between groups was found. No patient expressed complete dissatisfaction.

CONCLUSIONS

The proposed classification and the surgical algorithm is a simple, applicable, and reliable method to assess and treat breast asymmetries with a high satisfaction rate as confirmed from our results.

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 Table of Contents or the online Instructions to Authors www.springer.com/00266.

A New Tool for Breast Anthropometric Measurements: Presentation and Validation for Women and Men

Introduction

Anthropometric measurements of breasts are crucial for planning surgical procedures; however, there are no practical solutions for their quick, digital performance. The aim of the study was to present and validate a self-designed web application BreastIdea (BI) designed for indirect breast anthropometry.

Methods

Ten male and 10 female volunteers had their chests measured directly according to the routine clinical practice. Then their chests were photographed in non-standardised conditions. Corresponding measurements were performed using BI. Accuracy and both relative and absolute reliability of BI measurements were investigated.

Results

Breast assessments using BI yielded highly accurate results and presented near-perfect precision when compared to direct anthropometric measurements of the breast. Indirect anthropometry eliminates the necessity to trace the body’s curves, which usually introduces a bias to linear measurements.

Conclusion

BI web application is a reliable tool for indirect breast measurements in a clinical setting, providing accurate results regardless of chest pathology and photograph standardisation.

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.

Preoperative breast volume evaluation of one-stage immediate breast reconstruction using three-dimensional surface imaging and a printed mold

BACKGROUND

Accurate assessment of breast volume is an essential component of preoperative planning in one-stage immediate breast reconstruction (IBR) for achieving breast symmetry and a satisfactory cosmetic outcome. In this study, we compared breast volume estimation using three-dimensional (3D) surface imaging with magnetic resonance imaging (MRI) to determine the accuracy of breast volume measurements. Further, a 3D printing mold for facilitating autologous breast reconstruction intraoperatively is described.

METHODS

Patients scheduled to therapeutic or prophylactic mastectomy with one-stage IBR, either by autologous tissue transfer or direct implant, from 2016 to 2019, were enrolled in this study. 3D surface image and MRI were performed to evaluate breast volume and shape. The results were validated by the water displacement volume of the mastectomy specimen. Finally, a 3D printing mold was designed for breast reconstruction with autologous tissue.

RESULTS

Nineteen women who were scheduled to have 20 mastectomies (18 unilateral and one bilateral) were included. There was a strong linear association between breast volume measured using the two different methods and water displacement of mastectomy specimens when a Pearson correlation was used (3D surface image: r = 0.925, p < 0.001; MRI: r = 0.915, p < 0.001). Bland-Altman plots demonstrated no proportional bias between the assessment methods. The coefficient of variation was 52.7% for 3D surface imaging and 59.9% for MRI. The volume of six breasts was evaluated by both measurements and the intraclass correlation coefficient was 0.689 for 3D surface image (p = 0.043) and 0.743 for MRI (p = 0.028).

CONCLUSION

Using 3D surface image to evaluate breast shape and volume is a quick, effective, and convenient method. The accuracy, reproducibility, and reliability of 3D surface imaging were comparable with MRI in our study. In addition, 3D-printed molds can achieve better symmetry and aesthetic outcomes in immediate autologous breast reconstructions.

Does 2-Stage Implant-Based Breast Reconstruction Allow for a Larger Volume of the Definite Implant Compared With 1-Stage Reconstruction?

INTRODUCTION

Breast reconstruction using implants is still the main breast reconstruction technique worldwide. Current debate within implant-based breast reconstruction is whether to perform a 1-stage (direct implant) or 2-stage (tissue expander/implant) reconstruction. Volume differences between a woman's native breast and changes in volume after breast reconstruction might be an important factor for a patient's choice between these types of reconstruction. Three-dimensional imaging facilitates objective breast volume estimates. The goal of this study was to investigate differences between the patient's natural breast and the volume after completed breast reconstruction. One- and two-stage implant-based breast reconstruction techniques were compared. Finally, it was assessed whether patient satisfaction is causally related with the final breast volume after reconstruction.

METHODS AND RESULTS

A total of 38 patients were included in the study, including 35 two-stage breast reconstructions and 27 one-stage reconstructions. Preoperative and postoperative 3-dimensional images of the breast with the Vectra XT Imaging system were taken. Volume analysis was performed to estimate the patient's native breast volume. Implant size were derived from the operation report. A mean volume reduction for the 1-stage reconstruction group was found -1 mL, whereas an increase of +80 mL was found in the 2-stage reconstruction group (P < 0.005). Patient satisfaction related to volume outcome was not significantly different between both groups, using the Breast-Q questionnaire.

CONCLUSIONS

This study shows that a 2-stage breast reconstruction has the potential of an increased breast volume compared with a similar breast volume in 1-stage reconstruction.

Enabling older adults to carry out paperless falls-risk self-assessments using guidetomeasure-3D: A mixed methods study

BACKGROUND

The home environment falls-risk assessment process (HEFAP) is a widely used falls prevention intervention strategy which involves a clinician using paper-based measurement guidance to ensure that appropriate information and measurements are taken and recorded accurately. Despite the current use of paper-based guidance, over 30% of all assistive devices installed within the home are abandoned by patients. This is in part due to poor fit between the device, the patient, and the environment in which it is installed. Currently HEFAP is a clinician-led process, however, older adult patients are increasingly being expected to collect HEFAP measurements themselves as part of the personalisation agenda. Without appropriate patient-centred guidance, levels of device abandonment to are likely to rise to unprecedented levels. This study presents guidetomeasure-3D, a mobile 3D measurement guidance application designed to support patients in carrying out HEFAP self-assessments.

AIM

The aim of this study is to present guidetomeasure-3D, a web-enabled 3D mobile application that enables older-adult patients to carry out self-assessment measurement tasks, and to carry out a mixed-methods evaluation of its performance, and associated user perceptions of the application, compared with a 2D paper-based equivalent.

METHODS

Thirty-four older adult participants took part in a mixed-methods within-subjects repeated measures study set within a living lab. A series of HEFAP self-assessment tasks were carried out according to two treatment conditions: (1) using the 3D guidetomeasure-3D application; (2) using a 2D paper-based guide. SUS questionnaires and semi-structured interviews were completed at the end of the task. A comparative statistical analysis explored performance with regards to measurement accuracy, accuracy consistency, task efficiency, and system usability. Interview transcripts were analysed using inductive and deductive thematic analysis (informed by UTAUT).

RESULTS

The guidetomeasure-3D application outperformed the 2D paper-based guidance in terms of accuracy (smaller mean error difference in 11 out of 12 items), accuracy consistency (p < 0.05, for 6 out of 12 items), task efficiency (p = 0.003), system usability (p < 0.00625, for two out of 10 SUS items), and clarity of guidance (p < 0.0125, for three out of four items). Three high-level themes emerged from interviews: Performance Expectancy, Effort Expectancy, and Social Influence. Participants reported that guidetomeasure-3D provided improved visual quality, clarity, and more precise guidance overall. Real-time audio instruction was reported as being particularly useful, as was the use of the object rotation and zoom functions which were associated with improving user confidence particularly when carrying out more challenging tasks.

CONCLUSIONS

This study reveals that older adults using guidetomeasure-3D achieved improved levels of accuracy and efficiency along with improved satisfaction and increased levels of confidence compared with the 2D paper-based equivalent. These results are significant and promising for overcoming HEFAP equipment abandonment issue. Furthermore they constitute an important step towards overcoming challenges associated with older adult patients, the digitisation of healthcare, and realising the enablement of patient self-care and management via the innovative use of mobile technologies. Numerous opportunities for the generalisability and transferability of the findings of this research are also proposed. Future research will explore the extent to which mobile 3D visualisation technologies may be utilised to optimise the clinical utility of HEFAP when deployed by clinicians.

Menstrual Cycle-Related Fluctuations in Breast Volume Measured Using Three-Dimensional Imaging: Implications for Volumetric Evaluation in Breast Augmentation

BACKGROUND

Breast volume is a key parameter of breast measurement in breast augmentation. However, the correlation between menstrual cycle phases and variation in breast volume has not been well studied.

METHODS

Young female patients with regular menstrual cycles underwent eight three-dimensional imaging scans during a single menstrual cycle from November 2017 to January 2018. Breast volumetric difference at each timepoint and basic breast volume were measured for each subject. Preovulatory phase and postovulatory phase values were compared using an unpaired t test. A Pearson's linear correlated analysis was performed to identify the correlation between the basic breast volume and maximum range of breast volumetric difference during the menstrual cycle.

RESULTS

Thirteen patients (26 breasts) met the inclusion criteria. During the menstrual cycle, the breast volumetric difference showed first a rising trend followed by a fall. A significant difference in the breast volumetric difference between the preovulatory phase and postovulatory phase (- 19.6 ± 2.1 ml pre-ovulation vs. - 6.9 ± 3.3 ml post-ovulation, p = 0.002) was noted. There was a positive linear association between breast volume and maximum range of breast volumetric difference when a Pearson correlation was used (r = 0.45, p = 0.021).

CONCLUSIONS

The breast volume fluctuates during the menstrual cycle, and there is a significant difference between the preovulatory phase and postovulatory phase for breast volumetric change. The influence of the menstrual cycle on breast volume should be taken into consideration by plastic surgeons performing breast augmentation.

LEVEL OF EVIDENCE IV

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Nonrigid reconstruction of 3D breast surfaces with a low-cost RGBD camera for surgical planning and aesthetic evaluation

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A nonrigid 3D breast surface reconstruction pipeline running on a standard PC taking a noisy RGBD input video from a Kinect-style camera is proposed.

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Pairwise nonrigid ICP is extended to the multi-view case incorporating soft mobility constraints in areas of non-overlap.

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Shortest distance correspondences as a new technique for data association are shown to lead to consistently better alignment.

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The method is able to reconstruct clinical-quality surface models in spite of varying degrees of postural sway during data capture.

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Landmark and volumetric quantitative validation in metric units demonstrate improved reconstruction quality on par with the gold standard and superior to a competing method.

Accounting for 26% of all new cancer cases worldwide, breast cancer remains the most common form of cancer in women. Although early breast cancer has a favourable long-term prognosis, roughly a third of patients suffer from a suboptimal aesthetic outcome despite breast conserving cancer treatment. Clinical-quality 3D modelling of the breast surface therefore assumes an increasingly important role in advancing treatment planning, prediction and evaluation of breast cosmesis. Yet, existing 3D torso scanners are expensive and either infrastructure-heavy or subject to motion artefacts. In this paper we employ a single consumer-grade RGBD camera with an ICP-based registration approach to jointly align all points from a sequence of depth images non-rigidly. Subtle body deformation due to postural sway and respiration is successfully mitigated leading to a higher geometric accuracy through regularised locally affine transformations. We present results from 6 clinical cases where our method compares well with the gold standard and outperforms a previous approach. We show that our method produces better reconstructions qualitatively by visual assessment and quantitatively by consistently obtaining lower landmark error scores and yielding more accurate breast volume estimates.