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

A Novel Artificial Intelligence Model for Symmetry Evaluation in Breast Cancer Patients

INTRODUCTION

Artificial intelligence (AI) is a milestone for human technology. In medicine, AI is set to play an important role as we progress into a new era. In plastic surgery, AI can participate in breast symmetry assessment, which until now has been mainly subjective, allowing for inconsistencies. This study aims to improve this evaluation process by integrating a novel trained neural network with the breast symmetry calculator, BAS-Calc.

MATERIALS AND METHODS

We combined the BAS-Calc tool with a custom-made neural network trained to automatically detect key features of the breast. This integrated system was tested on 81 images of patients who had undergone breast reconstruction post-breast cancer treatment. Its performance was evaluated against two human observers using statistical analysis.

RESULTS

Our model successfully detected 399/405 (98.51%) of landmarks. Spearman and Pearson correlation indicated a strong positive relationship while Cohen's kappa demonstrated moderate to strong agreement between human observers and AI model. Notably, the average calculation time for the AI was 0.92 seconds, 16 times faster than the 14.09 seconds for humans.

CONCLUSIONS

Our AI model successfully calculated breast symmetry from images of patients who had undergone reconstructive oncological breast surgery, demonstrating high correlation with human assessments and a markedly reduced processing time. As AI continues to evolve, it is poised to become a pivotal tool in Medicine. Therefore, it is crucial for medical professionals to proactively engage in implementing AI technologies safely and effectively. Further studies are required to broaden our understanding and maximize the potential benefits in this area. Takeaway bullet points Artificial intelligence (AI) is an upcoming force to be reckoned with. AI should find its way into practical applications in plastic surgery. AI can be applied to improve patient care and evaluate aesthetic results. In this work, we present a novel AI model that automatically evaluates breast symmetry.

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 .

Identification of Key Breast Features Using a Neural Network: Applications of Machine Learning in the Clinical Setting of Plastic Surgery

BACKGROUND

In plastic surgery, evaluation of breast symmetry is an important aspect of clinical practice. Computer programs have been developed for this purpose, but most of them require operator input. Artificial intelligence has been introduced into many aspects of medicine. In plastic surgery, automated neural networks for breast evaluation could improve quality of care. In this work, the authors evaluate the identification of breast features with an ad hoc trained neural network.

METHODS

An ad hoc convolutional neural network was developed on the YOLOV3 platform to detect key features of the breast that are commonly used in plastic surgery for symmetry evaluation. The program was trained with 200 frontal photographs of patients who underwent breast surgery and was tested on 47 frontal images of patients who underwent breast reconstruction after breast cancer surgery.

RESULTS

The program was able to detect key features in 97.74% of cases (boundaries of the breast in 94 of 94 cases, the nipple-areola complex in 94 of 94 cases, and the suprasternal notch in 41 of 47 cases). Mean time of detection was 0.52 seconds.

CONCLUSIONS

The ad hoc neural network was successful in localizing key breast features, with a total detection rate of 97.74%. Neural networks and machine learning have the potential to improve the evaluation of breast symmetry in plastic surgery by automated and quick detection of features used by surgeons in practice. More studies and development are needed to further knowledge in this area.

Morphological Aesthetics Assessment of the Predicted 3D Simulation Results and the Actual Results of Breast Augmentation

BACKGROUND

Although three-dimensional (3D) simulations are becoming more common in preoperative breast augmentation planning, this does not necessarily imply that the simulated results are highly accurate.

OBJECTIVES

We aimed to evaluate the accuracy of the 3D simulation technique by comparing the differences in breast morphology between the 3D prediction model and the actual results.

METHODS

The simulation and actual postoperative results of 103 patients who underwent breast augmentation were analyzed retrospectively. Therefore, a 3D model was created, and the parameters of line spacing, nipple position, breast projection, surface area, and volume were evaluated. Furthermore, consider the difference in chest circumferences and breast volume.

RESULTS

In comparison with the simulation results, the actual results had a mean increase in the nipple to the inframammary fold (N-IMF) of 0.3 cm (P < 0.05) and a mean increase in basal breast width (BW) of 0.3 cm (P < 0.001), a difference that was not statistically significant in patients with larger breast volumes. There was a significant difference in the mean upper and lower breast volume distribution between simulated and actual breasts (upper pole 52.9% vs. 49.2%, P < 0.05, and lower pole 47.1% vs. 50.8%, P < 0.001). However, it was not statistically significant in patients with larger chest circumferences.

CONCLUSIONS

Our study shows that 3D simulation has uncertainties related to the patient's chest circumference and breast volume. Therefore, these two critical factors must be considered when using simulation assessment in preoperative planning.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A Computerized Recognition System to Assess Breast Asymmetry after Augmentation Mammaplasty

BACKGROUND

Breast augmentation patients are often unaware of their preexisting breast asymmetry before surgery but discover it afterward, which leads to postoperative dissatisfaction and increases the reoperation rate. However, elaboration on how patients subjectively analyze breast asymmetry and the recognition thresholds were limited.

METHODS

Two hundred female participants, including 100 patients 6 months postoperatively for primary augmentation mammaplasty and 100 preoperative patients, were recruited as two study groups. Self-assessments of breast asymmetry and objective measurements were taken. A computerized recognition experiment was constructed based on standardized three-dimensional models with different nipple-areola complex (NAC) and inframammary fold (IMF) asymmetry combinations. One hundred twenty-one three-dimensional models were generated and shown in random sequence. Participants responded whether they discovered breast asymmetry in each model. The recognition rate and 50% recognition thresholds of the asymmetry in NAC, IMF, lower pole length, volume, and their interrelations were calculated.

RESULTS

Self-assessment of the postaugmentation group showed more precise distinguishing of NAC, IMF, and lower pole distance asymmetry than in the preaugmentation group. The 50% recognition thresholds of NAC and IMF level discrepancies were approximately 0.75 cm, with the IMF asymmetry identified with higher accuracy. When the NAC level discrepancy ranged from 0.0 to 1.25 cm, adjusting the IMF level discrepancy from 0.0 to 0.5 cm in the same direction lowered participants' recognition rates of breast asymmetry.

CONCLUSIONS

Patients recognize their breast asymmetry issue more accurately after augmentation operations, despite improved parameters. In addition, adjusting the new IMF level, aligning with NAC discrepancy within 0.5 cm when treating mild NAC asymmetry, improved symmetric outcomes.

A Comparison Study of Nipple-Areolar Complex Measurement: Light Detection and Ranging (LiDAR) Camera Versus Photometry

BACKGROUND

In breast surgery, achieving esthetic outcomes with symmetry is crucial. The nipple-areolar complex (NAC) plays a significant role in breast characteristic measurement. Various technologies have advanced measurement techniques, and light detection and ranging (LiDAR) technology using three-dimensional scanning has been introduced in engineering. Increasing effort has been exerted to integrate such technologies into the medical field. This study focused on measuring NAC using a LiDAR camera, comparing it with traditional methods, and aimed to establish the clinical utility of LiDAR for obtaining favorable esthetic results.

METHODS

A total of 44 patients, who underwent breast reconstruction surgery, and 65 NACs were enrolled. Measurements were taken (areolar width [AW], nipple width [NW] and nipple projection [NP]) using traditional methods (ruler and photometry) and LiDAR camera. To assess correlations and explore clinical implications, patient demographics and measurement values were collected.

RESULTS

NAC measurements using a periscope and LiDAR methods were compared and correlated. LiDAR measurement accuracy was found to be high, with values above 95% for AW, NW and NP. Significant positive correlations were observed between measurements obtained through both methods for all parameters. When comparing body mass index, breast volume with AW and NW with NP, significant correlations were observed. These findings demonstrate the reliability and utility of LiDAR-based measurements in NAC profile assessment and provide valuable insights into the relationship between patient demographics and NAC parameters.

CONCLUSIONS

LiDAR-based measurements are effective and can replace classical methods in NAC anthropometry, contributing to consistent and favorable esthetic outcomes in breast surgery.

LEVEL OF EVIDENCE II

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 https://www.springer.com/00266 .

Evaluation of patient dose during a digital breast tomosynthesis

INTRODUCTION

When the patient dose in mammography is assessed, it is important to evaluate both average glandular dose (AGD) and entrance surface dose (ESD). A dose survey on both AGD and ESD in mammography has never been studied in Sri Lanka. Therefore, the present study aimed to evaluate the patient dose received during a full-field digital breast tomosynthesis (DBT) examination by determining both AGD and ESD.

METHODS

The study was performed on 140 patients who underwent DBT examination. The AGD, ESD, compression breast thickness (CBT), half-value layer (HVL), target/filter combination, kVp, and mAs values were obtained from the machine, and AGD for each projection was calculated using the equation proposed by the Dance 2011.

RESULTS

The measured mean AGDs and ESDs of both the breasts were statistically significantly lower than the reference values given by European protocol (p < 0.05). There were no statistically significant differences in both AGDs and ESDs between the right and left breast, between right craniocauidal (RCC) and left craniocaudal (LCC), and between right mediolateral oblique (RMLO) and left mediolateral oblique (LMLO) examinations (p > 0.05). The measured median AGDs and ESDs received for MLO projections of both breasts were statistically significantly higher than that of CC projections (p < 0.05).

CONCLUSION

The patients receive a low radiation dose during their DBT examination with both lowered AGD and ESD than the recommended values.

IMPLICATIONS FOR PRACTICE

The results can be used as a baseline to optimize the radiation dose in mammography in Sri Lanka.

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.

Breast Morphological Comparison Between Anatomic and Round Implant Augmentation: A Prospective Study

BACKGROUND

The choice of implant shape (anatomic or round) is one of the most critical issues for breast augmentation. Determining whether there are differences in the postoperative breast morphology of the 2 implants is pivotal for surgical planning. This issue has been controversial and lacking in evidence. The aim of this study was to provide reference for implant selection by comparing breast morphology after dual-plane augmentation with anatomic and round implants using 3-dimensional scanning technology.

METHODS

Patients with implant volume less than 300 mL who underwent transaxillary dual-plane augmentation were included in this study and were grouped according to implant shape. Three-dimensional scans were performed preoperatively and 6 months postoperatively. Postoperative breast height (BH), breast width (BW), BH of upper pole (BHUP), BH of lower pole (BHLP), breast projection (BP), BP of upper pole (BPUP), and BP of lower pole (BPLP) were measured separately, resulting in corresponding ratios (BH/BW, BHUP/BHLP, BP/BH, BPUP/BPLP). Breast volume, and the volumes of each pole (breast volume of upper pole [BVUP], breast volume of lower pole [BVLP]) and its ratio (BVUP/BVLP) were calculated. Correlation and regression analysis on the influencing factors of breast volume were performed.

RESULTS

Thirty patients with anatomic implants and 26 with round implants were enrolled in this study. The mean volumes of anatomic and round implants were 260.5 ± 26.7 and 267.9 ± 21.7 mL (P = 0.192). The ratios of BH/BW in the 2 groups were 1.39 ± 0.12 and 1.37 ± 0.19, respectively (P = 0.582). The BHUP/BHLP values of 2 groups were 1.35 ± 0.22 and 1.41 ± 0.25 (P = 0.160). Two sets of BPUP/BPLP were 0.68 ± 0.19 and 0.73 ± 0.17 (P = 0.133). The ratios of BP/BH in the 2 groups were 0.39 ± 0.08 and 0.39 ± 0.06 (P = 0.830). The BVUP/BVLP ratios for both groups were 0.75 ± 0.11 and 0.77 ± 0.12 (P = 0.287). There was a volume loss rate of 13.3% ± 3.9% and 13.9% ± 5% (P = 0.489). The postoperative volume showed a positive correlation with both the preoperative volume and the implant volume.

CONCLUSIONS

For patients with breast dysplasia undergoing transaxillary dual-plane augmentation with anatomic or round implants less than 300 mL, the difference in postoperative breast morphology is not obvious. Using these 2 shapes of implants results in a similar degree of volume loss.

An original method of analysis of the breast contour curve with 3-dimensional imaging: Case series

INTRODUCTION

Postoperative assessment of breast reconstruction results has become increasingly important. In this paper, a unique analysis method with 3-dimensional surface images of patients who were treated with immediate breast reconstruction is presented.

PATIENT CONCERNS

Five Japanese women were suspected of having breast cancer and visited our hospital for treatment.

DIAGNOSIS

Breast cancer was diagnosed by biopsy, mammography, ultrasonography, computed tomography, and magnetic resonance imaging.

INTERVENTIONS

Five patients underwent nipple/skin-sparing mastectomy, concomitant sentinel lymph node biopsy, and immediate breast reconstruction in our hospital. Three cases were reconstructed by extended latissimus dorsi flaps, one was reconstructed by a pedicled transverse rectus abdominis myocutaneous flap, and one was reconstructed by a deep inferior epigastric artery perforator flap. Three-dimensional photographs were taken 1 year postoperatively. The similarity of the breast contours between the reconstructed breast and the nonaffected opposite breast obtained from 3-dimensional images was analyzed. The calculated value is called the breast contour score.

OUTCOMES

No recurrence was observed during the follow-up period in any cases. All cases could be analyzed by breast contour score to evaluate the breast shapes.

CONCLUSION

The scores become a relative value that ranges from 0 (completely different) to 100 (completely the same). By expressing the score as a relative value, the breast contour score could help us understand the degree of breast symmetry more intuitively.

Nonsubjective Assessment of Shape, Volume and Symmetry during Breast Augmentation with Handheld 3D Device

Three-dimensional Surface Imaging (3DSI) has become a valuable tool for planning and documenting surgical procedures. Although surface scanners have allowed for a better understanding of breast shape, size, and asymmetry during patient consultation, its use has not been included in intraoperative assessment so far. Validation of the reliability of the intraoperative use of a portable handheld 3DSI equipment as a tool to evaluate morphological changes during breast augmentation surgery. The patients who underwent bilateral subpectoral breast augmentation through an inframammary incision were included in this study. Intraoperative 3DSI was performed with the Artec Eva device, allowing for visualization of the surgical area before incision, after use of breast sizers and implant, and after wound closure. Intraoperatively manual measurements of breast distances and volume changes due to known sizer and implant volumes were in comparison with digital measurements calculated from 3DSI of the surgical area. Bilateral breasts of 40 patients were 3D photographed before incision and after suture successfully. A further 108 implant sizer uses were digitally documented. There was no significant difference between manual tape measurement and digital breast distance measurement. Pre- to postoperative 3D volume change showed no significant difference to the known sizer and implant volume.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

3D Breast Volume Estimation

INTRODUCTION

Breast volume estimation is considered crucial for breast cancer surgery planning. A single, easy, and reproducible method to estimate breast volume is not available. This study aims to evaluate, in patients proposed for mastectomy, the accuracy of the calculation of breast volume from a low-cost 3D surface scan (Microsoft Kinect) compared to the breast MRI and water displacement technique.

MATERIAL AND METHODS

Patients with a Tis/T1-T3 breast cancer proposed for mastectomy between July 2015 and March 2017 were assessed for inclusion in the study. Breast volume calculations were performed using a 3D surface scan and the breast MRI and water displacement technique. Agreement between volumes obtained with both methods was assessed with the Spearman and Pearson correlation coefficients.

RESULTS

Eighteen patients with invasive breast cancer were included in the study and submitted to mastectomy. The level of agreement of the 3D breast volume compared to surgical specimens and breast MRI volumes was evaluated. For mastectomy specimen volume, an average (standard deviation) of 0.823 (0.027) and 0.875 (0.026) was obtained for the Pearson and Spearman correlations, respectively. With respect to MRI annotation, we obtained 0.828 (0.038) and 0.715 (0.018).

DISCUSSION

Although values obtained by both methodologies still differ, the strong linear correlation coefficient suggests that 3D breast volume measurement using a low-cost surface scan device is feasible and can approximate both the MRI breast volume and mastectomy specimen with sufficient accuracy.

CONCLUSION

3D breast volume measurement using a depth-sensor low-cost surface scan device is feasible and can parallel MRI breast and mastectomy specimen volumes with enough accuracy. Differences between methods need further development to reach clinical applicability. A possible approach could be the fusion of breast MRI and the 3D surface scan to harmonize anatomic limits and improve volume delimitation.

Three-Dimensional Reproducibility of the Soft Tissue Landmarks Taken by Structured-Light Facial Scanner in Accordance with the Head Position Change

The aim of this study was to evaluate the three-dimensional reproducibility of the structured-light facial scanner according to the head position change. A mannequin head was used and angle of the mannequin’s axis-orbital plane to the true horizontal plane was adjusted to +10, +5, 0, −5, and −10°. Facial scanning was conducted 30 times, respectively, and 150 3D images were obtained. Reoriented landmarks of each group were compared and analyzed. Reproducibility decreased as the distance from the facial center increased. Additionally, the landmarks below showed lower reproducibility and higher dispersion than landmarks above. These differences occurred mainly in the anteroposterior direction as opposed to other directions. Positive inclination of the head position showed superior reproducibility compared to a negative inclination. This study showed that reproducibility of a structured-light scanner could be varied depending on the head position. Inaccuracies of landmarks in the anteroposterior direction are greater than in other directions. This means that evaluations of the profile using a structured-light scanner should be made carefully. Therefore, the proper head position should be set to ensure the accuracy of the image.

Improved accuracy of breast volume calculation from 3D surface imaging data using statistical shape models

Background

Three-dimensional (3D) scanning is an established method of breast volume estimation. However, this method can never be entirely precise, since the thoracic wall cannot be imaged by the surface scanner. Current methods rely on interpolation of the posterior breast border from the surrounding thoracic wall. Here, we present a novel method to calculate the posterior border and increase the accuracy of the measurement.

Methods

Using principal component analysis, computed tomography images were used to build a statistical shape model (SSM) of the thoracic wall. The model was fitted to 3D images and the missing thoracic wall curvature interpolated (indirect volumetry). The calculations were evaluated by ordinary least squares regression between the preoperative and postoperative volume differences and the resection weights in breast reduction surgery (N = 36). Also, an SSM of the breast was developed, allowing direct volumetry. Magnetic-resonance images (MRI) and 3D scans were acquired from 5 patients in order to validate the direct 3D volumetry.

Results

Volumetry based on a SSM exhibited a higher determination coefficient (R² = 0,737) than the interpolation method (R² = 0,404). The methods were not equivalent (p = 0.75), suggesting that the methods significantly differ. There was no influence of BMI on the correlation in either method. The MRI volumetry had a strong correlation with the 3D volumetry (R² = 0,978).

Conclusion

The SSM-based method of posterior breast border calculation is reliable and superior to the currently used method of interpolation. It should serve as a basis of software applications aiming at calculation of breast volume from 3D surface scanning data.

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.

Ethnic and age differences in right-left breast asymmetry in a large population-based screening population

OBJECTIVE

Exposure to sex hormones is important in the pathogenesis of breast cancer and inability to tolerate such exposure may be reflected in increased asymmetrical growth of the breasts. This study aims to characterize, for the first time, asymmetry in breast volume (BV) and radiodense volume (DV) in a large ethnically diverse population.

METHODS

Automated measurements from digital raw mammographic images of 54,591 cancer-free participants (aged 47-73) in a UK breast screening programme were used to calculate absolute (cm³) and relative asymmetry in BV and DV. Logistic regression models were fitted to assess asymmetry associations with age and ethnicity.

RESULTS

BV and DV absolute asymmetry were positively correlated with the corresponding volumetric dimension (BV or DV). BV absolute asymmetry increased, whilst DV absolute asymmetry decreased, with increasing age (P-for-linear-trend <0.001 for both). Relative to Whites, Blacks had statistically significantly higher, and Chinese lower, BV and DV absolute asymmetries. However, after adjustment for the corresponding underlying volumetric dimension the age and ethnic differences were greatly attenuated. Median relative (fluctuating) BV and DV asymmetry were 2.34 and 3.28% respectively.

CONCLUSION

After adjusting for the relevant volumetric dimension (BV or DV), age and ethnic differences in absolute breast asymmetry were largely resolved.

ADVANCES IN KNOWLEDGE

Previous small studies have reported breast asymmetry-breast cancer associations. Automated measurements of asymmetry allow the conduct of large-scale studies to further investigate these associations.

Natural Breast Symmetry in Preoperative Breast Cancer Patients

Plastic surgeons aim to achieve breast symmetry during cosmetic and reconstructive breast surgery. They rely on measures of breast size, position, and projection to determine and achieve breast symmetry, but normative data on symmetry in preoperative breast reconstruction patients are scarce.

There are two sides to every story: implications of asymmetry on breast support requirements for sports bra manufacturers

This study aimed to investigate: (1) the prevalence and magnitude of breast movement asymmetry, (2) the interaction between static and dynamic breast asymmetry and (3) the influence of sports bras on breast asymmetry during running. Position data were collected from 167 females whilst treadmill running and then a sub-group of 12 participants in different bra conditions. Breast movement asymmetry existed in 89% of participants, with resultant static breast position asymmetry larger in participants displaying dynamic asymmetry. Asymmetry was most commonly caused (60% to 75%) by greater movement of the left breast. No significant relationships were found between asymmetry and bra size or breast pain. Sports bras reduced asymmetry prevalence from 75% to 33% of participants in the antero-posterior direction but only from 75% to 67% of participants in the infero-superior direction. The magnitude of range-of-motion asymmetry reduced from 67 mm with no bra to between 6 and 64 mm in-bra in the infero-superior direction, with the best performing bra incorporating encapsulating cups and adjustable straps and underband. It is recommended that sports bras allow underband and strap adjustment to facilitate individual breast support and that asymmetry is considered when designing and fitting bras, which could utilise resultant asymmetry measured statically.

Cosmetic assessment in brachytherapy (interventional radiotherapy) for breast cancer: A multidisciplinary review

PURPOSE

This review was to focus on breast brachytherapy cosmetic assessment methods state of the art and to define the advantages and disadvantages related to.

METHODS AND MATERIALS

We conducted a literature review of the major experience on breast brachytherapy cosmetic assessment methods in several databases (PubMed, Scopus, and Google Scholar databases). To identify the relevant works, a task force screened citations at title and abstract level to identify potentially relevant paper. An expert board reviewed and approved the text. The assessment systems were classified into three main groups: (1) the Oncological Toxicity Scales, (2) the Independent Patients Perspective Measures, (3) the Patient-Related Outcome Measures. Each cosmetic assessment method was evaluated following six parameters: (1) anatomical site, (2) advantages, (3) disadvantages, (4) subjective/objective, (5) quantitative/qualitative, (6) computers or pictures needs.

RESULTS

Eleven assessment methods were selected. Three methods were classified as Oncological Toxicity Scale, six in the Independent Patients Perspective Measures classification, and two as Patient-Related Outcome Measures. Six methods are subjective, while eight are objective. Four systems are classified as quantitative, four as qualitative while three both. Five systems need informatics support. Moreover, each method was discussed individually reporting the main characteristics and peculiarities.

CONCLUSIONS

Cosmesis is one major end point for the patient who has a malignancy of low lethal potential. In modern personalized medicine, there is a need for standardized cosmetic outcome assessments to analyze and compare the results of treatments. No gold standard methods currently exist. The result of this review is to summarize the various cosmesis methods, defining the strengths and weaknesses of each one and giving a line in research and clinical practice.

The Effect of Respiration on Breast Measurement Using Three-dimensional Breast Imaging

BACKGROUND

Three-dimensional (3D) imaging offers new opportunities to enable objective and quantitative analysis of the breast. Unlike scanning of rigid objects, respiration may be one of the factors that can influence the measurement of breast when using 3D imaging. In this study, we aimed to investigate how the different respiratory phases affect 3D morphologic and volumetric evaluations of the breast.

METHODS

We performed preoperative 3D breast imaging at the end of expiration (EE) and the end of inspiration (EI). We repeated scans on each respiratory phase, taking four scans in total (EE1, EE2 and EI1, EI2). Using Geomagic Studio 12 software, measurements from the different respiratory phases (EE1 and EI1) were compared for differences in the linear distances of breast. Breast volumetric change error (BVCE) was measured between EE1 and EE2 (R1) and between EI1 and EI2 (R2). A multilevel model was used to analyze the difference of linear-distances parameters between EE1 and EI1 and a paired sample t-test was used to analyze the difference between R1 and R2.

RESULTS

Our study included 13 Chinese women (26 breasts) with a mean age of 32.6 ± 6.3 years. Compared with EI, EE showed a longer sternal notch to the level of the inframammary fold and shorter nipple to midline (p < 0.05). During EI, breast projection increased by 0.23 cm (95% CI - 0.39, - 0.08) and breast base width increased by 0.27 cm (95% CI - 0.46, - 0.09). The position of the nipple moved by 0.18 cm (95% CI - 0.34, - 0.03) laterally, 0.41 cm (95% CI 0.18, 0.64) cranially, and 0.71 cm (95% CI - 0.92, - 0.51) anteriorly. Although there was no significant difference in BVCE between EE and EI, the result seen with EE appeared to be more consistent.

CONCLUSIONS

The results of this study demonstrate that there was no difference in breast volume results when patients are in the expiratory or inspiratory state during 3D breast imaging. This study, however, holds potential benefits to both surgical practice as well as the 3D imaging industry.

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 Evaluation of Three-Dimensional Image Simulation: Patient-Reported Outcomes and Mammometrics in Primary Breast Augmentation

BACKGROUND

Outcomes in primary breast augmentation depend on careful preoperative planning and clear communication between patient and surgeon. Three-dimensional imaging with computer simulation is an evolving technology with the potential to enhance the preoperative consultation for patients considering primary breast augmentation. The purpose of this study was to prospectively evaluate the impact of three-dimensional imaging with computer simulation on patient-reported and objective, mammometric outcomes in women undergoing primary breast augmentation.

METHODS

One hundred patients were enrolled in a prospective trial with randomized and nonrandomized arms. The randomized arm was composed of a control group consisting of patients who underwent tissue-based planning without simulation (n = 13) and an intervention group consisting of patients who were simulated (n = 10). The remainder constituted the nonrandomized group who specifically sought preoperative simulation. Patient-reported outcomes (BREAST-Q) and mammometric data were recorded and compared preoperatively and 6 months postoperatively.

RESULTS

Over time, significantly more patients refused randomization and chose simulation (p = 0.03). Breast augmentation led to substantial improvements in satisfaction with breasts, sexual well-being, and outcome. Simulation, however, did not significantly impact patient-reported outcomes or mammometric parameters. No strong correlations were identified between patient-reported outcomes and mammometrics.

CONCLUSIONS

Patients are likely to use novel technology such as three-dimensional photography with computer simulation if they perceive it to enhance their understanding of their final outcome. These patients may seek out practices specifically offering such technology. Incorporation of simulation into the preoperative consultation, however, did not lead to clinically meaningful changes in patient-reported outcomes.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Asymmetric development of the male mouse mammary gland and its response to a prenatal or postnatal estrogen challenge

The CD-1 mouse mammary gland is sexually dimorphic, with males lacking nipples. Recent studies have revealed that the underlying epithelium in the male mammary gland is sensitive to estrogenic environmental chemicals. In ongoing investigations, we observed asymmetric morphology in the left and right male mouse mammary glands. Here, we quantified these asymmetries in the embryonic, prepubertal, pubertal and adult male mammary gland. We found that the right gland was typically larger with more branching points compared to the left gland. We next evaluated the response of the left and right glands to 17α-ethinyl estradiol (EE2) after perinatal or peripubertal exposures. We found that the right gland was more responsive to EE2 than the left at both periods of exposure. These results reveal novel aspects of male mammary gland biology and suggest that future studies should control for laterality in the evaluation of hazards associated with exposures to estrogenic chemicals.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Applications and limitations of using patient-specific 3D printed molds in autologous breast reconstruction

Background

Over the last years, several techniques have been proposed to improve the outcome of autologous breast reconstruction procedures. One of these innovations describes patient-specific, three-dimensional (3D) printed breast molds for intraoperative use based on 3D stereophotogrammetry. In this article, we want to share our preliminary experiences with producing such templates, its clinical possibilities and limitations in practice.

Methods

Patient-specific templates were designed based on 3D stereophotogrammetry images. The 3D template was fabricated using a 3D printer. During breast reconstruction, the autologous flap was placed inside the printed template to aid the surgeon in determining the shape and volume of the autologous flap creating the desired breast dimensions. Patients were 3D-photographed 6 to 9 months post-operatively.

Results

Three patients with unilateral breast reconstructions showed a width difference of 0.5 cm and mean volume difference of 211 ml between the reconstructed and contralateral breasts. In the three bilateral reconstructed patients, a mean difference in breast width and volume of respectively 0.5 cm and 16 ml was found.

Conclusions

Patient-specific breast templates are inexpensive and relatively easy to design, while being practical and convenient to obtain insight in the dimensions of the desired breast during reconstruction, according to the operating surgeons. Patient selection is however critical, as patients must have sufficient donor volume and/or satisfying breast shape to be able to use the template to its full potential.

Level of evidence: Level IV, therapeutic study.

Batwing Mastopexy as Oncoplastic Surgical Approach to Periareolar Tumors in Upper Quadrants

Aims and background

Batwing mastopexy (BWM) is an oncoplastic technique most commonly used in the treatment of 12 o'clock periareolar tumors. The aim of this study was to assess the early cosmetic results of BWM performed for periareolar lesions located in the upper quadrants, i.e. from 10 to 2 o'clock position.

Methods and study design

A prospective analysis of a preliminary group of 35 women with periareolar intraductal or invasive breast cancer in the upper quadrants was done. All patients underwent wide lumpectomy with clear margins followed by BWM in order to obtain favorable cosmesis. For invasive cancers axillary biopsy or dissection was performed by separate incision. Cosmetic outcome was assessed 4 weeks after surgery by the patient with reference to breast shape, nipple-areola complex (NAC) position and scar arrangement. The result was rated as poor, medium or good for each parameter.

Results

There were no poor ratings of cosmetic outcome. The result was rated as medium by 5 women (14%) regarding breast shape and by 3 regarding NAC position (9%). The remaining women evaluated these parameters as good (86% and 91%, respectively). In contrast, scar arrangement was assessed as good by 26 patients (74%), medium by 8 (23%), and poor by 1 (3%). All women rating scar arrangement as other than good had a lesion located in the upper lateral quadrant. Considering the reasons for the relatively low scar acceptance by these women, the only important cause of disappointment was the placement of one of the radial parts of the scar in the area of decolletage in the upper medial quadrant.

Conclusions

BWM allows to achieve favorable breast shape and NAC position for lesions located in the upper quadrants regardless of the medial or lateral side. However, when performed in the lateral quadrant it produces a scar that can be hard to accept for some women.

Enhancing breast projection in autologous reconstruction using the St Andrew's coning technique and 3D volumetric analysis

Background

An increasing number of women undergo mastectomy for breast cancer and post-mastectomy autologous breast reconstruction has been shown to significantly improve the psychosexual wellbeing of the patients. A goal of treatment is to achieve symmetry and projection to match the native breast, and/or the contralateral breast in the case of a unilateral reconstruction. Autologous reconstruction, particularly with the deep inferior epigastric artery perforator (DIEP) flap, is particularly advantageous as it can be manipulated to mimic the shape and turgor of the native breast. However, very few techniques of shaping the breast conus when insetting the DIEP flap to enhance aesthetic outcome have been reported to date. With the aide of three-dimension (3D) photography and 3D-printed mirrored image of the contralateral breast as a guide intraoperatively, we describe our St Andrew's coning technique to create a personalized flap projection.

Method

We report a prospective case series of 3 delayed unilateral breast reconstructions where symmetrization procedure to the contralateral breast was not indicated. Using a commercial 3D scanner (VECTRA XR, Canfield Scientific), the breast region was imaged. The mirrored image was 3D-printed in-house using a desktop 3D printer.

Results

In all cases, projection of the breast mound was able to be safely achieved, with a demonstrated central volume (or 'cone') able to be highlighted on imaging and a 3D printed breast. A 3D print of the contralateral breast was able to be used intraoperatively to guide the operative approach.

Conclusions

The St Andrew's coning technique is a useful aesthetic maneuver for achieving breast projection during DIEP flap breast reconstruction, with 3D imaging techniques able to assist in perioperative assessment of breast volume.

Selection of Implants in Unilateral Prosthetic Breast Reconstruction and Contralateral Augmentation

BACKGROUND

In breast reconstruction using implants after unilateral mastectomy, it is challenging to create a natural, ptotic contour, and asymmetry is a potential drawback. To achieve breast symmetry and an ideal shape for both breasts, we performed contralateral augmentation in patients undergoing breast reconstruction with implants.

METHODS

Patients underwent unilateral mastectomy and 2-stage reconstruction. During the second stage of the procedure, contralateral augmentation mammoplasty was performed. Preoperatively, we obtained the patients' demographic information, and we then assessed breast volume, the volume and dimensions of the inserted implants, and complications. Breast symmetry was observed by the surgeon and was assessed by measuring the disparity between the final volume of each breast.

RESULTS

Contralateral augmentation was performed in 52 cases. When compared to patients who did not undergo a contralateral balancing procedure, patients who received contralateral augmentation were younger, thinner, and had smaller breasts. During implant selection for contralateral augmentation, we chose implants that were approximately 1 cm shorter in width, 1 level lower in height, and 1 or 2 levels lower in projection than the implants used for reconstruction. The postoperative breast contours were symmetric and the final volume discrepancy between each breast, which was measured by 3-dimensional scanning, was acceptable.

CONCLUSIONS

We demonstrate that contralateral augmentation can be recommended for patients who perceive their breasts to be small and not beautiful in order to achieve an ideal and beautiful shape for both breasts. Furthermore, this study offers guidelines for selecting the implant that will lead to the optimal aesthetic outcome.

Objective breast symmetry analysis with the breast analyzing tool (BAT): improved tool for clinical trials

PURPOSE

Objective cosmetic analysis is important to evaluate the cosmetic outcome after breast surgery or breast radiotherapy. For this purpose, we aimed to improve our recently developed objective scoring software, the Breast Analyzing Tool (BAT^®).

METHODS

A questionnaire about important factors for breast symmetry was handed out to ten experts (surgeons) and eight non-experts (students). Using these factors, the first-generation BAT^® software formula has been modified and the breast symmetry index (BSI) from 129 women after breast surgery has been calculated by the first author with this new BAT^® formula. The resulting BSI values of these 129 breast cancer patients were then correlated with subjective symmetry scores from the 18 observers using the Harris scale. The BSI of ten images was also calculated from five observers different from the first author to calculate inter-rater reliability. In a second phase, the new BAT^® formula was validated and correlated with subjective scores of additional 50 women after breast surgery.

RESULTS

The inter-rater reliability analysis of the objective evaluation by the BAT^® from five individuals showed an ICC of 0.992 with almost no difference between different observers. All subjective scores of 50 patients correlated with the modified BSI score with a high Pearson correlation coefficient of 0.909 (p < .001) which was better compared to the old software (r = 0.769; p < .001).

CONCLUSIONS

The modified BAT^® software improves the correlation between subjective and objective BSI values, and may be a new standard for trials evaluating breast symmetry.

Validity and intraobserver reliability of three-dimensional scanning compared with conventional anthropometry for children and adolescents from a population-based cohort study

BACKGROUND

Conventional anthropometric measurements are time consuming and require well trained medical staff. To use three-dimensional whole body laser scanning in daily clinical work, validity, and reliability have to be confirmed.

METHODS

We compared a whole body laser scanner with conventional anthropometry in a group of 473 children and adolescents from the Leipzig Research Centre for Civilization Diseases (LIFE-Child). Concordance correlation coefficients (CCC) were calculated separately for sex, weight, and age to assess validity. Overall CCC (OCCC) was used to analyze intraobserver reliability.

RESULTS

Body height and the circumferences of waist, hip, upper arm, and calf had an "excellent" (CCC ≥ 0.9); neck and thigh circumference, a "good" (CCC ≥ 0.7); and head circumference, a "low" (CCC < 0.5) degree of concordance over the complete study population. We observed dependencies of validity on sex, weight, and age. Intraobserver reliability of both techniques is "excellent" (OCCC ≥ 0.9).

CONCLUSION

Scanning is faster, requires less intensive staff training and provides more information. It can be used in an epidemiologic setting with children and adolescents but some measurements should be considered with caution due to reduced agreement with conventional anthropometry.

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

STUDY DESIGN

Cohort study.

OBJECTIVES

To assess breast asymmetry (BA) directly with 3D surface imaging and to validate it using MRI values from a cohort of 30 patients with significant adolescent idiopathic scoliosis (AIS). Also, to study the influence of posture (prone vs standing) on BA using the automated method on both modalities.

SUMMARY OF BACKGROUND DATA

BA is a common concern in young female patients with AIS. In a previous study using MRI, we found that the majority of patients with significant AIS experienced BA of up to 21% in addition to their chest wall deformity. MRI is costly and not always readily available. 3D surface topography, which offers fast and reliable breast acquisitions without radiation or distortion of the body surface, is an alternative method in the clinical setting.

METHODS

Thirty patients with AIS were enrolled in the study on the basis of their thoracic curvature, skeletal and breast maturity, without regard to their perception of their BA. Each patient underwent two imaging studies of their torso: a 3D trunk surface topography and a breast MRI. An automated breast volume measuring method was proposed using a program developed with Matlab programming.

RESULTS

Strong correlations were obtained when comparing the proposed method to the MRI on the left breast volumes (LBV) (r = 0.747), the right breast volumes (RBV) (r = 0.805) and the BA (r = 0.614). Using the same method on both imaging modalities also yielded strong correlation coefficients on the LBV (r = 0.896), the RBV (r = 0.939) and the BA (r = 0.709).

CONCLUSIONS

The proposed 3D body surface automated measurement technique is feasible clinically and correlates very well with breast volumes measured using MRI. Additionally, breast volumes remain comparable despite being measured in different body positions (standing and prone) in a young cohort of AIS patients.

LEVEL OF EVIDENCE

Level IV.

An analysis of pose in 3D stereophotogrammetry of the breast

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The 3D Facial Norms Database: Part 1. A Web-Based Craniofacial Anthropometric and Image Repository for the Clinical and Research Community

With the current widespread use of three-dimensional (3D) facial surface imaging in clinical and research environments, there is a growing demand for high-quality craniofacial norms based on 3D imaging technology. The principal goal of the 3D Facial Norms (3DFN) project was to create an interactive, Web-based repository of 3D facial images and measurements. Unlike other repositories, users can gain access to both summary-level statistics and individual-level data, including 3D facial landmark coordinates, 3D-derived anthropometric measurements, 3D facial surface images, and genotypes from every individual in the dataset. The 3DFN database currently consists of 2454 male and female participants ranging in age from 3 to 40 years. The subjects were recruited at four US sites and screened for a history of craniofacial conditions. The goal of this article is to introduce readers to the 3DFN repository by providing a general overview of the project, explaining the rationale behind the creation of the database, and describing the methods used to collect the data. Sex- and age-specific summary statistics (means and standard deviations) and growth curves for every anthropometric measurement in the 3DFN dataset are provided as a supplement available online. These summary statistics and growth curves can aid clinicians in the assessment of craniofacial dysmorphology.

Early frontofacial symmetry after correction of unilateral coronal synostosis: frontoorbital advancement vs endoscopic strip craniectomy and helmet therapy

Frontoorbital advancement (FOA) improves forehead and superior orbital asymmetry associated with unilateral coronal synostosis but has little effect on facial asymmetry. This study compares frontofacial symmetry after FOA and endoscopically assisted suturectomy (ESC) and postoperative helmet therapy.A retrospective review of 2 cohorts of patients with nonsyndromic unilateral coronal synostosis who had either FOA or ESC was undertaken. Choice of procedure was determined by age of patient at referral (younger than 4 months, FOA or ESC; older than 4 months, only FOA). Vectra 3D imaging system (Canfield Imaging Systems, Fairfield, NJ) was used to capture and analyze three-dimensional digital images. Comparative anthropometric measurements were made and statistically analyzed.Twenty-two patients met the inclusion criteria; 11 underwent ESC at mean age of 2 months (range, 1-4 months) and 11 underwent FOA at mean age of 12 months (range, 8-25 months). Mean age at three-dimensional digital imaging was 45.9 months (range, 18-64 months) for the FOA group and 34.5 months (range, 20-66 months) for the ESC group (P = 0.054).There was no difference between the 2 groups with regard to supraorbital symmetry (P = 0.54). The ESC group exhibited better facial symmetry in midline deviation (3.6° vs 1.4°; P = 0.018), nasal tip deviation (5.6° vs 2.3°; P = 0.006), and middle facial depth (6.9 vs 4.4 mm; P = 0.042). Lower facial depth was similar (3.8 vs 2.3 mm; P = 0.54).Early ESC and helmet therapy results in comparable brow symmetry and better overall facial symmetry than FOA done in late infancy.

Psychological impact of breast asymmetry on adolescents: a prospective cohort study

BACKGROUND

This study measures the impact of adolescent breast asymmetry compared with macromastia and female controls.

METHODS

The following surveys were given to patients with breast asymmetry, macromastia, and controls aged 12 to 21 years: Short Form Health Survey, Version 2 (Short Form-36), the Rosenberg Self-Esteem Scale, and the Eating Attitudes Test. Demographics were compared, and linear regression models, adjusted for body mass index category and age, were fit to determine the effect of case status on survey score.

RESULTS

Fifty-nine adolescents with asymmetry, 142 controls, and 160 macromastia patients participated. After controlling for differences in body mass index category, asymmetry patients scored lower on psychological Short Form-36 domains and the Rosenberg Self-Esteem Scale than controls (p < 0.05), but did not differ in physical health. When compared with macromastia adolescents, asymmetry patients scored significantly better on Short Form-36 physical health domains (p < 0.05), but had similar decrements in emotional functioning, mental health, self-esteem, and eating behaviors/attitudes, after accounting for differences in age. Age and asymmetry type and severity had no effect on survey scores, independent of body mass index category (p > 0.05). Asymmetry patients had a higher mean body mass index percentile than controls (83.36 versus 73.52) but did not differ from that of macromastia patients (83.39).

CONCLUSIONS

Breast asymmetry may negatively impact the psychological quality of life of adolescents similar to macromastia. Breast asymmetry is not just a cosmetic issue. Providers should be aware of the psychological impairments associated with asymmetry and provide proper support.

Reliability and validity of measurements of facial swelling with a stereophotogrammetry optical three-dimensional scanner

Volume changes in facial morphology can be assessed using the 3dMD DSP400 stereo-optical 3-dimensional scanner, which uses visible light and has a short scanning time. Its reliability and validity have not to our knowledge been investigated for the assessment of facial swelling. Our aim therefore was to assess them for measuring changes in facial contour, in vivo and in vitro. Twenty-four healthy volunteers with and without an artificial swelling of the cheek were scanned, twice in the morning and twice in the afternoon (in vivo measurements). A mannequin head was scanned 4 times with and without various externally applied artificial swellings (in vitro measurements). The changes in facial contour caused by the artificial swelling were measured as the change in volume of the cheek (with and without artificial swelling in place) using 3dMD Vultus software. In vivo and in vitro reliability expressed in intraclass correlations were 0.89 and 0.99, respectively. In vivo and in vitro repeatability coefficients were 5.9 and 1.3 ml, respectively. The scanner underestimated the volume by 1.2 ml (95% CI -0.9 to 3.4) in vivo and 0.2 ml (95% CI 0.02 to 0.4) in vitro. The 3dMD stereophotogrammetry scanner is a valid and reliable tool to measure volumetric changes in facial contour of more than 5.9 ml and for the assessment of facial swelling.

Is Breast Asymmetry Present in Girls with Adolescent Idiopathic Scoliosis?

STUDY DESIGN

Cross-sectional descriptive study.

OBJECTIVES

To characterize breast asymmetry (BA), as defined by breast volume difference, in girls with significant adolescent idiopathic scoliosis (AIS), using magnetic resonance imaging (MRI).

SUMMARY AND BACKGROUND

BA is a frequent concern among girls with AIS. It is commonly believed that this results from chest wall deformity. Although many women exhibit physiological BA, the prevalence is not known in adolescents and it remains unclear if it is more frequent in AIS. Breasts vary in shape and size and many ways of measuring them have been explored. MRI shows the highest precision at defining breast tissue.

METHODS

Thirty patients were enrolled on the basis of their thoracic curvature, skeletal and breast maturity, without regard to their perception on their BA. MRI acquisitions were performed in prone with a 1.5-Tesla system using a 16-channel breast coil. Segmentation was achieved using the ITK-SNAP 2.4.0 software and subsequently manually refined.

RESULTS

The mean left breast volume (528.32 ± 205.96 cc) was greater compared with the mean right breast volume (495.18 ± 170.16 cc) with a significant difference between them. The mean BA was found to be 8.32% ± 6.43% (p < .0001). A weak positive correlation was observed between BA and thoracic Cobb angle (0.177, p = .349) as well as thoracic gibbosity angle (0.289, p = .122). The left breast was consistently larger in 65.5% of the patients. Twenty patients (66.7%) displayed BA ≥5%.

CONCLUSIONS

We have described BA in patients with significant AIS using MRI. This method is feasible, objective, and very precise. The majority of patients had a larger left breast, which could compound the apparent BA secondary to trunk rotation. In many cases, BA is present independently of thoracic deformity. This knowledge will assist in counseling AIS patients in regards to their concerns with BA.

Three-Dimensional Imaging for Breast Augmentation: Is This Technology Providing Accurate Simulations?

BACKGROUND

For patients considering breast augmentation, 3-dimensional (3D) imaging provides a preoperative simulation of the postoperative result. However, the clinical accuracy of these simulations has not been assessed.

OBJECTIVE

The authors compared preoperative simulations with postoperative results of breast augmentation to permit more informed decisions about breast augmentation.

METHODS

To determine differences between simulations and actual results, volumetric and contour analyses were performed for patients who underwent 3D imaging both preoperatively and 3 months after breast augmentation. All patients received round smooth silicone implants or anatomically shaped cohesive silicone gel implants; the mean volume was 295 cc.

RESULTS

Twenty patients (40 breasts) underwent 3D imaging both pre- and postoperatively. There were no procedural complications or revisions. The mean difference between preoperative simulation and postoperative breast volume was 27.2 cc (range, 1.4-99.5 cc), representing a 9.2% mean difference in volume and an accuracy of 90.8%. The mean absolute difference (root mean square) of all surface points along the breast in aggregate was 4.0 mm (range, 1.8-8.3 mm). No specific location along the surface contour of the breast could be identified as having the greatest differences.

CONCLUSIONS

The preoperative simulation provided by 3D imaging is >90% accurate in predicting postoperative breast volume. The mean absolute differential for surface contour in this study was 4 mm, representing 98.4% accuracy based on average surface area.

LEVEL OF EVIDENCE

3.

Evidence-based recommendations for building better bras for women treated for breast cancer

Participating in exercise is beneficial for women who have been treated for breast cancer. However, not being able to find a comfortable exercise bra can be a barrier to exercise participation. This study aimed to systematically investigate what breast support women treated for breast cancer want when they exercise in order to provide evidence-based recommendations to improve exercise bra designs for these women. Based on 432 responses from a national online survey, frequency and relationship data were analysed (binary logistic regression) to understand exercise bra issues pertinent to this population. These issues included being able to control for asymmetrical cup sizes, managing heightened skin sensitivity, managing fluid (size) fluctuations, managing a prosthesis and restoring body image by restoring shape. This study provides evidence-based recommendations to inform an exercise bra design that will meet the unique needs of women treated for breast cancer. Rigorous, evidence-based evaluations of exercise bras for women treated for breast cancer may contribute to their well-being and quality of life through enhanced designs.

Does respiration influence breast volumetric change measurement with the three-dimensional scanning technique?

BACKGROUND

Measurement of volumetric change after aesthetic and reconstructive breast surgery is of great significance to plastic surgeons. This study aimed to investigate the influence of respiration on measurement of breast volumetric change via a three-dimensional (3D) scanning technique.

METHODS

In this study, ten augmentation mammaplasty patients received preoperative 3D scanning in different respiration states at three time points: the end of normal exhalation (ENE1), the end of normal inhalation (ENI), and the end of normal exhalation again (ENE2). Using Geomagic Studio 12 software, breast volumetric change error (BVCE) was measured between the ENE1 scan and the ENI scan (R1) and between the ENE1 scan and ENE2 scan (R2). Three-dimensional deviation, defined as the shortest distance from one scan to any point on the other scan, was measured in R1 and R2. A paired-sample t test was used to compare the means of BVCE and the 3D deviation between R1 and R2. Pearson's correlation coefficient was calculated between 3D deviation and BVCE. For the analysis, SPSS program version 16 was used. Differences were considered statistically significant at P values lower than 0.05.

RESULTS

The mean breast volume was 352.3 ± 52.7 ml, and BVCE was significantly lower in R1 than in R2 (9.7 vs. 21.3 ml; P = 0.000). The 3D deviation was significantly higher in R2 than in R1 (1.600 vs. 0.887; P = 0.000). In the analysis, BVCE was not correlated significantly with 3D deviation in R1 (P = 0.157) but was significantly correlated with 3D deviation in R2 (correlation coefficient = 0.766; P = 0.000).

CONCLUSIONS

Keeping patients in the same respiration state is crucial for accurate measurement of breast volumetric change via the 3D scanning technique.

LEVEL OF EVIDENCE I

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 .

Objective assessment of cosmetic outcome after targeted intraoperative radiotherapy in breast cancer: results from a randomised controlled trial

The international randomised targeted intraoperative radiotherapy (TARGIT) trial has demonstrated evidence of non-inferiority between the novel technique of TARGIT (intra-operative radiotherapy with Intrabeam(®)) and conventional external beam radiotherapy (EBRT) in women with early breast cancer in terms of the primary outcome measure of risk of local relapse within the treated breast. Cosmesis is an increasingly important outcome of breast conserving treatment with both surgery and radiotherapy contributing to this. It was unknown if the single high dose of TARGIT may lead to damaging fibrosis and thus impair cosmesis further, so we objectively evaluated the aesthetic outcome of patients within the TARGIT randomised controlled trial. We have used an objective assessment tool for evaluation of cosmetic outcome. Frontal digital photographs were taken at baseline (before TARGIT or EBRT) and yearly thereafter for up to 5 years. The photographs were analysed by BCCT.core, a validated software which produces a composite score based on symmetry, colour and scar. 342 patients were assessed, median age at baseline 64 years (IQR 59-68). The scores were dichotomised into Excellent and Good (EG), and Fair and Poor (FP). There were statistically significant increases in the odds of having an outcome of EG for patients in the TARGIT group relative to the EBRT group at year 1 (OR 2.07, 95 % CI 1.12-3.85, p = 0.021) and year 2 (OR 2.11, 95 % CI 1.0-4.45, p = 0.05). Following a totally objective assessment in a randomised setting, the aesthetic outcome of patients demonstrates that those treated with TARGIT have a superior cosmetic result to those patients who received conventional external beam radiotherapy.

Autologous fat transplantation: volumetric tools for estimation of volume survival. A systematic review

Autologous fat transplantation has gained great recognition in aesthetic and reconstructive surgery. Two main aspects are of predominant importance for progress control after autologous fat transplantation to the breast: quantitative information about the rate of fat survival in terms of effective volume persistence and qualitative information about the breast tissue to exclude potential complications of autologous fat transplantation. There are several tools available for use in evaluating the rate of volume survival. They are extensively compared in this review. The anthropometric method, thermoplastic casts, and Archimedes' principle of water displacement are not up to date anymore because of major drawbacks, first and foremost being reduced reproducibility and exactness. They have been replaced by more exact and reproducible tools such as MRI volumetry or 3D body surface scans. For qualitative and quantitative progress control, MRI volumetry offers all the necessary information: evaluation of fat survival and diagnostically valuable imaging to exclude possible complications of autologous fat transplantation. For frequent follow-up, e.g., monthly volume analysis, repeated MRI exams would not be good for the patient and are not cost effective. In these cases, 3D surface imaging is a good tool and especially helpful in a private practice setting where fast data acquisition is needed. This tool also offers the possibility of simulating the results of autologous fat transplantation.

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 .