Assessment of Breast Asymmetry in Adolescent Idiopathic Scoliosis Using an Automated 3D Body Surface Measurement Technique

Using Photogrammetry to Analyze Anatomical Changes in the Nipple in Juvenile and Adolescent Scoliosis Patients

BACKGROUND

The need for an objective set of anterior trunk measurements, such as nipple and clavicular shoulder joints, is essential to quantify the anterior asymmetry present in scoliosis. This study aims to characterize breast asymmetry (BA) in young individuals with scoliosis using photogrammetry.

METHODS

Digital photographs of the anterior trunk of the 51 scoliosis patients aged 4-20 years were taken from an anterior perspective. These images were then transferred to a computer. Ten parameters were measured using the ImageJ software. The positions of patients' nipples were classified into 6 types based on ratios on the x-axis.

RESULTS

The majority of patients had a right breast that was larger, intensifying the apparent BA due to trunk rotation. The apical vertebra level in patients was found at T8 in 23.6% and T9 in 45.1%. In 92.5% of the patients, the right breast was consistently larger. The lengths between the lateral boundaries and nipples of the right and left breasts and between the medial boundary and nipple of the right breast were statistically significantly higher in males than in females (p < 0.05). Significant differences were found when comparing the values of the lengths between the medial boundaries and nipples of the right and left breasts, the difference in length between the right and left acromioclavicular joint lines, and the angles of the nipple and acromioclavicular joint with the degrees of scoliosis in juvenile and adolescents (p < 0.05). Pearson regression analysis revealed a significant correlation between BA differences and the Cobb angle with a correlation coefficient of 0.901. Factors related to breast aesthetics, like differences in the height of nipples and the distance from the sternal notch to the nipple, represent 30% of the overall score.

CONCLUSION

The study concluded that there is a significant correlation between the severity of scoliosis and BA differences. Augmentation mammaplasty for BA not only decreased the breast difference but also leveled the nipple disparities. Photogrammetry is considered to be an alternative to other methods and is believed to contribute to the follow-up of BA.

LEVEL OF EVIDENCE IV

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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.

Understanding breast asymmetry and its relation to AIS

STUDY DESIGN

Literature Review.

OBJECTIVE

Review the pathophysiology, causes, and treatment of breast asymmetry in patients with adolescent idiopathic scoliosis (AIS), as well as postoperative patient assessment and health-related quality of life.

BACKGROUND DATA

Female breast development begins at 35-day gestation and continues 2-4-year post-thelarche to achieve final volume and shape. During the post-pubertal period, errors in growth and development may result in breast asymmetry. Breast asymmetry typically attenuates with time, but can be pronounced in individuals with AIS. During adolescence, there is rapid development and, thus AIS patients are increasingly sensitive, physically and emotionally, to breast changes. While breast asymmetry can be monitored through radiographic measures and surface topography, pre- and postoperative patient assessment is also critical in determination of optimal patient treatment.

METHODS

A comprehensive literature review was performed on the pathophysiology, causes, and treatment of breast asymmetry. The advantages and limitations of various treatment options based on patient satisfaction were also investigated.

RESULTS

Various treatment options exist for breast asymmetry correction in AIS patients. Surgical correction involves an aesthetic outcome, as well as social, physical, and psychological impact on the patient. Despite the benefit of correction surgery, in terms of function and self-image, patient-reported outcomes still appear lower postoperatively in the domains of pain and mental health.

CONCLUSION

Breast asymmetry is very common, especially among AIS patients, and is often corrected with surgical augmentation. AIS correction surgery has been shown to aggravate breast asymmetry and negatively affect patient-reported outcomes. Other treatment modalities should thus be considered when presented with an adolescent patient. Understanding patient concerns and their relation to quality of life will help guide surgical and medical interventions in correction of AIS deformities. Long-term follow-up studies are necessary to determine whether such interventions are successful and if patients remain healthy.

LEVEL OF EVIDENCE

N/A.

Surface topography assessment of body shape after surgical correction in adolescent idiopathic scoliosis

HYPOTHESIS

Body surface topography (ST) improvements are associated with surgical correction in adolescent idiopathic scoliosis (AIS) and correlate with radiographic imaging.

DESIGN

Prospective observational study.

INTRODUCTION

Patients undergoing correction of AIS are most affected by body image. Radiographs have been the standard assessment tool but do not assess body shape features. ST, a validated, radiation-free assessment tool, directly represents the patient's deformity. We set out to assess ST improvements associated with surgical correction in AIS.

METHODS

Twenty-three consecutive operative AIS patients were enrolled and had radiographs and posterior ST obtained pre- and postoperatively (PO). ST changes were compared using paired t test, and correlations of ST with radiograph measurements were evaluated by linear regression.

RESULTS

Mean age at surgery was 15.0 ± 2 years, 82.6% female with mean follow-up of 1.0 year. Major Cobb angle improved from 56.91° ± 15.57° to 13.70° ± 4.89°. ST scoliosis angle corrected from 41.43° ± 11.52° to 11.78° ± 7.84° (p < .0001). Trunk length increased from 401.22 ± 32.43 to 422.30 ± 25.77 mm (Δ21.08 mm; p = .0004). Pelvic obliquity (waist asymmetry) trended toward improvement (6.0 ± 4.3 vs. 5.3 ± 7.1 mm; p = .06). Surface rotation was corrected from 17.35 ± 6.73 to 11.8 ± 4.12 mm (p < .0001), highly correlated with clinical trunk rotation (T p = .002 and TL p = .02). ST highly correlated with radiographic parameters. Sagittal balance correlated with improved function (p = .02).

CONCLUSION

ST, a radiation-free body shape assessment tool, improved with surgical correction of AIS and was highly correlated with radiographic outcomes.

Can Breast Asymmetry Following the Treatment of Juvenile Idiopathic Scoliosis with Growing Rod Be Prevented? : A Preliminary Analysis

Objective

It can be assumed that the progression of scoliosis in the juvenile period will increase the asymmetry in the rib cage, and thus will contribute to an increase in the breast asymmetry (BA) in the future. We are looking for answers to the questions; “How will the breasts look with respect to each other and what is the possibility of developing BA in the early follow-up period following the early surgical treatment and final fusion surgery of juvenile idiopathic scoliosis (JIS)?” For this reason, in this study, we aimed to evaluate the breast asymmetries of patients in the period after the final fusion.

Methods

Following growing rod treatment, final fusion was achieved in 12 females with JIS. We used the anthropomorphic measurement of the modified BREAST-V formula to assess whether there was an asymmetry between the breasts after an average of 4.8 years (2–11) following final fusion.

Results

In comparison, the mean volume of the left breast (222.4 mL [range, 104.1–330.2]) was larger than the mean volume of the right breast volume (214.5 mL [range, 95.2–326.7]) (p=0.034). The left breast was larger in 75% of the patients. BA was observed in 50% of the patients. No correlation was detected between the Cobb angle of the patient after final fusion and BA (p=0.688).

Conclusion

In the late follow-up period, BA was detected in 50% of the patients with JIS who achieved final fusion after treatment with growing rod. In majority of the patients, left breast was larger. The patients with JIS and their families can be informed prior to the operation about the probability of BA seen in the follow-up period after fusion.

Patients' Perceptions of Breast Asymmetry Improve After Spinal Fusion for Adolescent Idiopathic Scoliosis

STUDY DESIGN

Adolescent idiopathic scoliosis (AIS) patients undergoing spine fusion (SF) had their data prospectively collected. The SRS Spine Appearance Questionnaire (SAQ) was the primary outcome measure. The data were reviewed in a retrospective manner.

OBJECTIVES

Patient concerns about breast/chest wall asymmetry in AIS is high. This study sought to determine the improvement after spinal fusion (SF).

SUMMARY

Breast/chest wall asymmetry is a significant physical deformity associated with AIS. No literature exists on patient satisfaction related to improved breast/chest wall appearance after SF surgery.

METHODS

474 patients undergoing SF for AIS from 2006 to 2014 completed the SRS SAQ preoperation and at two years postoperation. Data were prospectively collected and reviewed in a retrospective manner. The SAQ includes two statements regarding breast/chest wall asymmetry (19 and 20). Statistical analysis was performed to determine a relationship between improved SAQ responses and any clinical/radiographic or surgical parameters.

RESULTS

395 females and 79 males (14.4 ± 2.0 years) with preoperation and two-year postoperation Cobb angle 60.6 ± 11.5 and 26.6 ± 12.1 were reviewed. Before surgery, 68.0% of patients identified with the statement "I want to have more even breasts" compared with 37.0% at two years postoperation. In addition, 78.9% identified with the statement "I want to have a more even chest in the front" preoperatively compared with 34.0% at two years postoperation. Positive preoperative responses correlated with scoliometer (p = .029) (p = .044) and Cobb angle of the major curve (p = .048 and p = .006). At two years postoperation, there was a significant number of patients (76%) who had at least a two-point decrease in their response to either statement (p < .0001).

CONCLUSION

Breast asymmetry is a significant concern of many AIS patients, including males, and correlates with preoperative curve magnitude. SF results in significant improvement in patient perception of breast/chest wall asymmetry, with 76% of patients reporting good outcomes at two years postoperation.

LEVEL OF EVIDENCE

Level 2.

APSS-ASJ Best Clinical Research Award: Is There a Difference between Patients' and Parents' Perception of Physical Appearance in Adolescent Idiopathic Scoliosis?

Study Design

Prospective study.

Purpose

To compare patients’ and parents’ perceptions of physical attributes (PAs) of adolescent idiopathic scoliosis (AIS) patients and to report any correlations between their perceptions and Scoliosis Research Society-22r (SRS-22r) scores.

Overview of Literature

Few studies have looked into the differences between patients’ and parents’ perceptions of their appearance.

Methods

AIS patient–parent pairs (n=170) were recruited. The patients’ and parents’ perceptions of six PAs were evaluated: waist asymmetry (WA), rib hump (RH), shoulder asymmetry (SA), neck tilt, breast asymmetry (BrA), and chest prominence. These PAs were ranked, and an aggregate PA (Agg-PA) score was derived from a score assigned to the attribute (6 for the most important PA and 1 for the least important). The patients also completed the SRS-22r questionnaire.

Results

Ninety-nine patients (58.2%) and 71 patients (41.8%) had thoracic and lumbar major curves, respectively. WA was ranked first by 54 patients (31.8%) and 50 parents (29.4%), whereas RH was ranked first by 50 patients (29.4%) and 38 parents (22.4%). The overall Agg-PA scores were similar for patients and parents (p>0.05). However, for thoracic major curves (TMCs) >40°, a significant difference was noted between the Agg-PA scores of patients and parents for SA (3.5±1.6 vs. 4.2±1.6, p=0.041) and BrA (3.0±1.6 vs. 2.2±1.3, p=0.006). For TMCs <40°, a significant difference was found between the Agg-PA scores of patients and parents for WA (3.7±1.6 vs. 4.4±1.5, p=0.050). BrA was negatively correlated with total SRS-22r score.

Conclusions

There were no significant differences between patients and parents in their ranking of the most important PAs. For TMCs >40°, there were significant differences in the Agg-PA for SA and BrA. Pa¬tients were more concerned about BrA and parents were more concerned about SA. Patients’ perception of the six PAs had weak correlation with SRS-22r scores.

Hemidystrophic Thorax Mimicking Scoliosis

Background:

We regularly use Angle of Trunk Rotation (ATR) measurements for scoliosis screening and also for clinical follow-up of our scoliosis patients under treatment. In some patients, when ATR measurements exceed the screening threshold but without a significant degree of curvature on the X-ray (Cobb angle), a Hemidystrophic Thorax (HDT) is diagnosed. The purpose of this paper was to present a case series of patients with this kind of thoracic deformity because this may be mimicking scoliosis to a significant degree.

Materials and Methods:

This case series is a consecutive series of patients where the first author detected a hemidystrophic thorax instead of or in combination with scoliosis. A 3D scan of the trunk was made and adjusted to the coordinates in order to achieve an upright orientation of the upper trunk. The scan was scaled in order to determine certain anatomic landmarks, as performed in preparation for bracing. The scan was cut horizontally at the xiphoid level and the plane at this level was analysed visually in order to detect deformations that were different to the typical scoliotic deformations in the horizontal plane.

Results:

Seven cases were analysed and described in more detail.

Conclusion:

The condition of HDT may lead to significant rib humps that mimic scoliosis. According to our case series, mild scoliosis can also be associated with HDT. HDT, according to the cases presented in this study, seems to be a relatively benign deformity. Long-term observations are necessary before a final conclusion can be drawn with respect to prognosis.