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

Sensor technology and machine learning to guide clinical decision making in plastic surgery

Subjective clinical evaluations are deeply rooted in medical practice. Recent advances in sensor technology facilitate the acquisition of extensive amounts of objective physiological data that can serve as a surrogate for subjective assessments. Along with sensor technology, a branch of artificial intelligence, known as machine learning, has provided decisive advances in several areas of medicine due to its pattern recognition and outcome prediction abilities. The assimilation of machine learning algorithms into sensor technology can substantially improve our current diagnostic and treatment competencies. This review explores available data on the use of sensor technology and machine learning in areas of interest for plastic surgeons, updates current knowledge on the most recent technological advances, and provides a new perspective on the field.

Evaluating 3D Simulation Accuracy for Breast Augmentation Outcomes: A Volumetric and Surface Contour Analysis in Chinese Patients

BACKGROUND

The use of three-dimensional imaging in breast augmentation with silicone implants has revolutionized the surgery planning process by providing detailed visualizations of expected post-surgical outcomes. This technology enhances the decision-making process, enabling patients to choose their implants with greater confidence and ultimately leading to higher satisfaction with the postoperative outcome.

OBJECTIVE

This study aims to assess the accuracy of 3D imaging simulations using the Canfield Vectra XT 3D system in predicting breast augmentation outcomes in Chinese patients, focusing on volume, surface contour, breast anterior-posterior (AP) Projection, and breast internal angle.

METHODS

Our study analyzed female patients who received breast augmentation, documenting their preoperative and three-month postoperative conditions with 3D Vectra XT system images. Exclusions were made for patients undergoing concurrent breast surgeries or those with tuberous or ptotic breasts, due to limitations of the imaging system. Implants used were either round textured or anatomically shaped cohesive silicone gel, inserted subpectorally through trans-axillary or inframammary incisions, based on personalized evaluations. A detailed comparison between preoperative simulations and actual postoperative outcomes was conducted, focusing on volume, surface contour, AP projection, and internal angle variations. Statistical significance was determined through paired T tests, P < 0.05.

RESULTS

In the analysis of preoperative simulations for determining postoperative outcomes in breast surgery, our study involving 42 Chinese patients, a total of 84 breasts, was conducted. The results indicated a mean volumetric discrepancy of 21.5 ± 10.3 (SD) cubic centimeters between the simulated and actual postoperative outcomes, achieving an accuracy rate of 91.9%. The root mean square deviation for the breast surface geometry was calculated to be 4.5 ± 1.1 (SD) millimeters (mm), demonstrating a low variance between the predicted and observed outcomes. The investigation found no significant variations across any specific areas of the breast surface, highlighting the uniform accuracy of the simulations across the entire breast. Additionally, the mean differences in Anterior-Posterior (AP) projection and internal angle were determined to be 8.82 ± 5.64 mm and 0.48 ± 1.91 (SD) degrees, respectively. These findings collectively attest to the efficacy of preoperative simulations in accurately predicting the postoperative physical appearance of breasts, thereby providing a valuable tool for surgical planning and improving the consultation process for patients.

CONCLUSIONS

The Canfield Vectra XT 3D system has proven to be remarkably accurate in predicting the volumetric outcomes of breast augmentation surgery, with an accuracy rate exceeding 91.9%. It stands as a valuable tool for surgeons and patients alike, enhancing the preoperative planning process by offering a realistic preview of surgical results. This advancement not only facilitates a deeper understanding and setting of realistic expectations for patients but also strengthens the communication between patients and surgeons, ultimately leading to higher satisfaction rates with the surgical outcomes. It also emphasizes the significance of detailed documentation and consent processes in protecting against legal repercussions.

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 www.springer.com/00266 .

Optimizing Implant Width Selection in Breast Augmentation: Insights From On-Patient Landmark Positioning in 3-Dimensional Breast Simulation

BACKGROUND

The Vectra XT 3D simulation program is a valuable tool for implant selection during the decision-making process regarding breast augmentation. The software allows for the assignment of automatically or manually positioned anatomical landmarks and provides accompanying measurements.

OBJECTIVES

This study aimed to present a strategy for standardizing landmark placement on Vectra images during primary breast augmentations, optimizing implant selection and ensuring consistency in breast width data collection.

METHODS

The author performed a retrospective analysis of patient data in which breast width measurements were obtained through clinical assessment (CA) and the Vectra program with both automatically (VA) and manually (VM) placed landmarks. Consideration was also given to the thickness of medial and lateral breast tissues. The suggested implant base width from all groups was then compared to the actual implant placed during the surgical procedure.

RESULTS

Comparing the change rates with the actual implant width revealed that rates in CA measurements were significantly lower than those in VA (P < .05), and similarly lower than those in VM (P < .05). Furthermore, change rates in VM were significantly lower than in VA (P < .05). Each group showed a significant positive correlation with the actual implant width.

CONCLUSIONS

The Vectra XT 3D simulation program is a valuable adjunct in breast augmentation. However, relying on it solely may lead to inaccuracies in the assessment of breast dimensions due to automatic landmarking. To achieve standardized measurements, landmarks can be marked on the patient before creating the Vectra image. Our results underline the superiority of clinical judgment to simulation programs when establishing a reliable surgical plan.

LEVEL OF EVIDENCE: 3

Three-dimensional Simulation on Patient-reported Outcomes Following Oncoplastic and Reconstructive Surgery of the Breast: A Randomized Trial

Background

Three-dimensional (3D) imaging using computer simulations is an evolving technology. There is a lack of strong data on the use of this technology for oncoplastic (OP) and reconstructive surgery.

Methods

A prospective, randomized, single-center trial including breast cancer patients undergoing OP or mastectomy with immediate breast reconstruction with implant (IBR) enrolled from November 2019 to October 2021 at the Hospital Nossa Senhora das Graças, Breast Unit in Curitiba, Brazil. Both patients undergoing OP and those in the IBR group were randomized to undergo 3D imaging and simulation of postoperative results (intervention group) or 3D imaging without simulation (control group). All patients were invited to complete a patient-reported outcome (BREAST-Q) expectations module and breast reconstruction or reduction/mastopexy module before and 6 months after surgery.

Results

A total of 96 patients were enrolled. Sixty-nine patients (45 OP and 24 IBR) completed the pre- and postoperative questionnaires and were randomized for the simulation. Women in the OP group had higher expectations for breast appearance when clothed than those in the IBR implant group (93.4 ± 16.3 versus 82.9 ± 26.5; P = 0.03). The intervention group was more satisfied with information than the control group (P = 0.021). Both patients who underwent OP and IBR believed that the 3D simulation helped them understand the surgical process (86.6% and 75%, respectively).

Conclusions

Preoperative 3D simulation significantly improved patient's satisfaction with information and did not decrease postoperative satisfaction with the outcomes. The incorporation of preoperative 3D simulation may be a valuable tool in breast reconstruction.

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 .

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

CLINICAL QUESTION/LEVEL OF EVIDENCE

Diagnostic, I.

Coronal, Sagittal, and Horizontal Classification of the Chest Shape and Its Role in Selection of Proper Implants

Background

The number of female breast correction procedures has been steadily increasing. Despite extensive literature being available on these procedures, few authors have discussed the role of preoperative chest wall analysis in relation to postoperative outcomes. To date, no comprehensive classification of chest shape has been introduced in the literature. The aim of this study was to present a novel classification of chest shapes, based on three basic planes: coronal (C), sagittal (S), and horizontal (H), hence the proposed name "CSH classification."

Method

In this study, a retrospective analysis of 1000 randomly selected chest and breast images was conducted by three independent nonmedical evaluators, using standardized digital images captured with the Vectra 3D body scanner. All examined patients were qualified for breast augmentation surgery.

Results

Among 1000 randomly examined patients, 923 were classified in the coronal plane, 920 in the sagittal plane, and 627 in the horizontal plane. Other patients were excluded from the study due to insufficient quality of the images. A notable 43.2% of women have shoulder height asymmetries. A relationship between shoulder height asymmetry and chest width was confirmed by the chi-square Pearson test (P = 0.04), indicating that a higher shoulder is associated with a greater chest width on the same side. Furthermore, 84.7% of women displayed excessive upper chest projection, whereas 28.4% showed excessive lower chest projection. Additionally, 84.4% of women had chest projection asymmetries.

Conclusions

The vast majority of the women had natural asymmetries of the breast or and chest wall. The CSH classification allows systematizing the chest shape assessment. The chest shape has a significant impact on breast implant selection and the choice of the breast surgery technique.

Brassiere Cup Size Agreement between Patients and Plastic Surgeons: Do Surgeons and Patients Speak the Same Size Language?

Patients undergoing plastic surgery of the breasts often communicate their size expectations as a brassiere cup size. However, multiple factors may cause a miscommunication between the surgeon and patient when brassiere cup size is used as a measure of results. The aim of this study was to determine the degree of agreement between disclosed and estimated brassiere cup size and also interrater agreement.

Methods

Three-dimensional (3D) scans of 32 subjects were evaluated by 10 plastic surgeons estimating cup size using the American brassiere system. The surgeons were blinded to all parameters, including the 3D surface software-derived volume measures of the Vectra scan. The 3D scans of the anterior torsos were viewed. The plastic surgeons' estimations were compared with the cup sizes stated by the subjects (disclosed cup size), using simple and weighted Kappa statistics.

Results

Agreement between the estimated and disclosed brassiere sizes was only slight (0.1479 ± 0.0605) using a simple Kappa analysis. Even when a Fleiss-Cohen-weighted comparison was used, only moderate agreement (0.6231 ± 0.0589) was found. The interrater agreement intraclass correlation coefficient was 0.705. Rater accuracy varied. The percentage of time spent in cosmetic practice and gender were not significantly correlated with accuracy.

Conclusions

Agreement between cup size disclosed by subjects and estimates by plastic surgeons was low. A miscommunication between the surgeon and patient may occur when using brassiere sizes to communicate wishes and estimates in procedures that involve changes in breast volume.

Effect of Pre-Surgical Orthopedic Treatment on Hard and Soft Tissue Morphology in Infants with Cleft Lip and Palate

The frequency of cleft lip and palate births in Japan is approximately 0.146%. The study aimed to compare the effects of NAM on restoring nasal morphology and improving extraoral nasal morphology in children with cleft lip and palate in the first stage of treatment using 3D imaging and oral model analysis. The subjects were five infants (37.6 ± 14.4 days old) with unilateral cleft lip and palate. The images taken with the 3D analyzer and oral model used for constructing the NAM at the first examination (baseline) and at the completion of the pre-surgical orthodontic treatment (157.8 ± 37.8 days old) were analyzed. The cleft distance was measured at the upper, middle, and lower points on the 3D images. On the model, the cleft jaw width at the maximum protrusion of the healthy and affected sides of the alveolar bone was measured. After the pre-surgical orthopedic treatment, the measured value on the model decreased significantly by a mean of 8.3 mm from baseline, and the cleft lip width narrowed by an average of 2.8 ± 2.2, 4.3 ± 2.3, and 3.0 ± 2.8 mm at the upper, middle, and lower points of the cleft, respectively. Pre-surgical orthopedic treatment using NAM can help narrow the width of the cleft jaw and lip. The sample size is stated at the study limit in the paper.

Initial Assessment of VECTRA Three-Dimensional Imaging to Accurately Simulate Breast Volume Changes in Transfeminine Patients: A Mannequin Study

BACKGROUND

Methods that aim to accurately measure and predict breast development can be utilized in gender-affirming treatment planning, patient education, and research.

OBJECTIVES

The authors sought to evaluate whether three-dimensional (3D) stereophotogrammetry accurately measures transfeminine breast volume changes on a masculine frame when simulating anticipated changes in soft tissue after gender-affirming surgical therapy. Then, we describe the innovative application of this imaging modality in a transgender patient to illustrate the potential role of 3D imaging in gender-affirming surgical care.

METHODS

A 3D VECTRA scanner (Canfield, Fairfield, NJ) was used to measure anthropometric breast measurements. Postoperative changes in breast volume were simulated on a cardiopulmonary resuscitation mannequin using 450 cc MENTOR breast implants (Mentor Worldwide LLC, Irvine, CA). To demonstrate the ability of the VECTRA to accurately simulate transfeminizing augmentation in practice, we describe its use in a 30-year-old transgender female with a 2-year history of gender-affirming hormone therapy, presenting for gender-affirming surgical care.

RESULTS

In the mannequin, mean breast volumes were 382 cc on the right (range 375-388 cc), and 360 cc on the left (range 351-366 cc). The average calculated difference in volume between the 2 sides was 22 cc (range 17-31 cc). There were no instances where the left side was calculated to be larger than the right or where the calculated size was smaller than the actual implant size.

CONCLUSIONS

The VECTRA 3D camera is a reliable and reproducible tool for preoperative assessment, surgical planning, and simulating breast volume changes after gender-affirming surgery.

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.

Use of Three-Dimensional Imaging to Assess the Effectiveness of Volume as a Critical Variable in Breast Implant Selection

BACKGROUND

In breast augmentation, breast base diameter has been recognized as an important variable in implant selection. However, breast implant volume also has a tremendous impact on the final result. Previous methods of preoperative volume determination have been limited to external devices in a bra. Computer-based three-dimensional simulation technology now allows the physician to effectively communicate with the patient preoperatively regarding volume.

METHODS

A cohort of 40 consecutive patients underwent routine breast augmentation with either anatomically shaped or round implants. Five methods of preoperative volume determination including the Crisalix three-dimensional computer imaging system (Crisalix Virtual Aesthetics, Lausanne, Switzerland), along with an associated virtual reality tool, were used to assess the preoperative desires of the patients. A postoperative questionnaire was used to assess patient satisfaction with each volume determination method.

RESULTS

Of the 40 patients, 100 percent were satisfied with their result; however, given the opportunity, 12 percent would have chosen a larger implant. The virtual reality tool and external sizers were shown to be the most effective in choosing an implant. The virtual reality tool was judged to be very helpful (62 percent), very accurate (78 percent), and important (88 percent) in helping patients choose their desired implant size.

CONCLUSION

Prioritizing volume as an implant selection variable in breast augmentation results in a very high rate of patient satisfaction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Intraoperative 3D Comparison of Round and Anatomical Breast Implants: Dispelling a Myth

Background: Thanks to 3D imaging, it is possible to measure the influence of different parameters on breast augmentation. In this study, we compare the effect of different shapes and sizes of breast implants on the topography of the resulting breast. Furthermore, the impact of different breast implants on inter-landmark distances and on changes of the nipple position was assessed. Methods: This interventional prospective study was carried out on 10 female patients after collecting informed consent. 3D scans of the native and augmented breasts were performed intraoperatively with small, medium, and large sizes of both anatomical and round implants, resulting in a total of n = 130 single breast scans. These scans were analyzed for topographic shift quantification, nipple migration, and inter-landmark distances of the breast. Results: Implant size, but not implant shape leads to significant topographic shifts of the breast (p < 0.001 and p = 0.900, respectively). Both round and anatomical implants lead to a significantly higher volumetric increase in the upper quadrants compared to the lower quadrants (p < 0.001). Nipple migration into the superomedial quadrant was seen in about 90% of augmentations. No evident differences in inter-landmark distances were observed when round and anatomical implants of different sizes were compared. Conclusions: Implant size rather than shape influences the postoperative aesthetic results. No significant difference in topographic shift was found comparing round and anatomical implants, suggesting that both implant shapes result in comparable aesthetic outcomes.

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

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

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

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

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

Validating three-dimensional imaging for volumetric assessment of periorbital soft tissue

Purpose: To evaluate the accuracy and interobserver variability of three-dimensional (3D) stereophotogrammetric imaging for volumetric assessment in the periorbital region and to propose a protocol for measurement. Methods: A cross-sectional study was performed. Fifty-eight normal adult subjects had photographs taken using the VECTRA M3 imaging system on two separate occasions at a single center teaching hospital. The primary study outcome measurement was mean volume change in the periorbital region, using different methods of image analysis with the following variables: registration method, eyes open or closed, eyelids measured separately or together, extension of area measured to include mid-face. Accuracy was defined as the agreement between paired images with no measured change in volume (0 mL). The agreement between two independent observers was assessed using Bland-Altman plots. Results: There was a statistically significant difference (P < .0001) between the different methods of measurement, with registration of images having the most effect (partial eta squared 0.229). A mean change in volume of 0.11 ± 0.13 mL was reported for the most accurate method. Agreement between observers was confirmed (highest Intraclass Correlation Coefficient 0.63). Conclusions: Assessment of volumetric change in the periorbital region using 3D image reconstruction is accurate with good interobserver repeatability and is suitable for clinical use. A protocol for data acquisition using the VECTRA M3 is proposed. 3D image reconstruction holds promise to enable diagnosis, treatment monitoring, and surgical outcome evaluation in ocular adnexal disease.

Observations Concerning the Match between Breast Implant Dimensions, Breast Morphometry, and a Patient-reported Outcome

Background:

Outcome studies in breast augmentation do not assess how an implant has been matched to the soft tissue envelope. The study hypothesis is that there is a relationship between breast and implant dimensions and the subjective outcome of patient satisfaction.

Methods:

In a study of patients undergoing subfascial breast augmentation (n = 341), morphometric measurements and a postsurgical survey of satisfaction with breast size were performed 3 months postoperatively. A ratio empirically derived from breast width, implant width, and projection (Rib) was calculated in patients who wished to have smaller, bigger, or no change in their implant size.

Results:

76% were content with breast size, 16.7% wished to be larger, and 7.3% wished to be smaller. Rib differed between groups who did not want to change size (n = 259, mean = 5.8, SD = 0.9), those who wished to be bigger (n = 57, mean = 5.6, SD = 1.1), and those who wished to be smaller (n = 25, mean = 5.3, SD = 1.3, H(341) = 14.0, P < 0.01). Rib differed between groups whose result was as expected (mean = 5.6, SD = 0.9), compared with those who expected to be bigger (mean = 5.4, SD = 1.2) or who expected a smaller outcome (mean = 5.6 SD = 1.0, H(341) = 18.3, P < 0.01).

Conclusions:

These data provide an objective measurement by which studies concerning breast augmentation can be reported and compared. The method may guide standardization of clinical research regarding breast implant surgery.

A Pilot Study Evaluation of 3-Dimensional Imaging in Cosmetic Breast Augmentation: Results of a Single Surgeon 3.5-Year Retrospective Study Using the BREAST-Q Questionnaire

BACKGROUND

Traditional methods of breast implant size selection provide limited ability to demonstrate postoperative outcomes. Three-dimensional (3D) imaging provides an opportunity for improved patient evaluation, surgical planning, and evaluation of postoperative breast appearance.

OBJECTIVES

The authors hypothesized that preoperative 3D imaging for patients undergoing breast augmentation would improve patient satisfaction and understanding of expected surgical outcomes.

METHODS

A retrospective review of patients undergoing breast augmentation by a single surgeon over a 3.5-year period was performed. Patients presenting after the VECTRA was purchased had preoperative 3D imaging, while patients presenting before this did not. Eligible patients received a BREAST-Q questionnaire designed for postoperative evaluation of breast augmentation. They also received a second survey that evaluated expected vs actual breast outcomes.

RESULTS

In total, 120 surveys were mailed and 61 patients (50.8%) returned the survey. The 3D imaged group had improved BREAST-Q scores regarding satisfaction with outcome, surgeon, and physical well-being compared with the group that did not. The imaged group also had higher size, shape, and overall breast correlation scores, confidence in implant size selection scores, and communication with surgeon scores. The differences between the 2 groups were not statistically significant.

CONCLUSIONS

Three-dimensional imaging is a valuable tool in breast surgery. Although this study showed improvement in patient satisfaction and predicted outcome scores in the 3D imaged group, the results were not statistically significant. With the majority of patients reporting that they would choose 3D imaging, it appears to instill confidence in patients regarding both surgeon and implant selection.

LEVEL OF EVIDENCE 4

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

Background:

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

Methods:

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

Results:

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

Conclusions:

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

New aspects in digital breast assessment: further refinement of a method for automated digital anthropometry

Purpose

In this trial, we used a previously developed prototype software to assess aesthetic results after reconstructive surgery for congenital breast asymmetry using automated anthropometry. To prove the consensus between the manual and automatic digital measurements, we evaluated the software by comparing the manual and automatic measurements of 46 breasts.

Methods

Twenty-three patients who underwent reconstructive surgery for congenital breast asymmetry at our institution were examined and underwent 3D surface imaging. Per patient, 14 manual and 14 computer-based anthropometric measurements were obtained according to a standardized protocol. Manual and automatic measurements, as well as the previously proposed Symmetry Index (SI), were compared.

Results

The Wilcoxon signed-rank test revealed no significant differences in six of the seven measurements between the automatic and manual assessments. The SI showed robust agreement between the automatic and manual methods.

Conclusion

The present trial validates our method for digital anthropometry. Despite the discrepancy in one measurement, all remaining measurements, including the SI, showed high agreement between the manual and automatic methods. The proposed data bring us one step closer to the long-term goal of establishing robust instruments to evaluate the results of breast surgery.

Level of evidence: IV.

"Topographic Shift": a new digital approach to evaluating topographic changes of the female breast

PURPOSE

To assess precise topographic changes of the breast, objective documentation and evaluation of pre- and postoperative results are crucial. New technologies for mapping the body using digital, three-dimensional surface measurements have offered novel ways to numerically assess the female breast. Due to the lack of clear demarcation points of the breast contour, the selection of landmarks on the breast is highly dependent on the examiner, and, therefore, is prone to error when conducting before-after comparisons of the same breast. This study describes an alternative to volumetric measurements, focusing on topographic changes of the female breast, based on three-dimensional scans.

METHOD

The study was designed as an interventional prospective study of 10 female volunteers who had planned on having aesthetic breast augmentation with anatomical, textured implants. Three dimensional scans of the breasts were performed intraoperatively, first without and then with breast implants. The topographic change was determined as the mean distance between two three-dimensional layers before and after augmentation. This mean distance is defined as the Topographic Shift.

RESULTS

The mean implant volume was 283 cc (SD = 68.6 cc, range = 210-395 cc). The mean Topographic Shift was 7.4 mm (SD = 1.9 mm, range = 4.8-10.7 mm). The mean Topographic Shifts per quadrant were: I: 8.0 mm (SD = 3.3 mm); II: 9.2 mm (SD = 3.1 mm); III: 6.9 mm (SD = 3.5 mm); IV: 1.9 mm (SD = 4.3 mm).

CONCLUSION

The Topographic Shift, describing the mean distance between two three-dimensional layers (for example before and after a volume changing therapy), is a new approach that can be used for assessing topographic changes of a body area. It was found that anatomical, textured breast implants cause a topographic change, particularly on the upper breast, in quadrant II, the décolleté.

Prediction of the Ideal Implant Size Using 3-Dimensional Healthy Breast Volume in Unilateral Direct-to-Implant Breast Reconstruction

Background and objectives: There is no consensus regarding accurate methods for assessing the size of the implant required for achieving symmetry in direct-to-implant (DTI) breast reconstruction. The purpose of this study was to determine whether the ideal implant size could be estimated using 3D breast volume or mastectomy specimen weight, and to compare prediction performances between the two variables. Materials and Methods: Patients who underwent immediate DTI breast reconstruction from August 2017 to April 2020 were included in this study. Breast volumes were measured using 3D surface imaging preoperatively and at postoperative three months. Ideal implant size was calculated by correcting the used implant volume by the observed postoperative asymmetry in 3D surface imaging. Prediction models using mastectomy weight or 3D volume were made to predict the ideal implant volume. The prediction performance was compared between the models. Results: A total of 56 patients were included in the analysis. In correlation analysis, the volume of the implant used was significantly correlated with the mastectomy specimen weight (R2 = 0.810) and the healthy breast volume (R2 = 0.880). The mean ideal implant volume was 278 ± 123 cc. The prediction model was developed using the healthy breast volume: Implant volume (cc) = healthy breast volume × 0.78 + 26 cc (R2 = 0.900). The prediction model for the ideal implant size using the 3D volume showed better prediction performance than that of using the mastectomy specimen weight (R2 = 0.900 vs 0.759, p < 0.001). Conclusions: The 3D volume of the healthy breast is a more reliable predictor than mastectomy specimen weight to estimate the ideal implant size. The estimation formula obtained in this study may assist in the selection of the ideal implant size in unilateral DTI breast reconstruction.

Evaluation of capsular contracture following immediate prepectoral versus subpectoral direct-to-implant breast reconstruction

Capsular contracture is a common adverse outcome following implant breast reconstruction, often associated with radiation treatment. The authors hypothesize that muscle fibrosis is the main contributor of breast reconstruction contracture after radiation. Retrospective chart review identified patients that underwent DTI reconstruction with pre-or post-operative breast irradiation. Signs of capsular contracture were assessed using clinic notes and independent graders reviewing two-dimensional images and anatomic landmarks. Capsular contracture rate was greater in the subpectoral vs. prepectoral group (n = 28, 51.8% vs. n = 12, 30.0%, p = 0.02). When compared to prepectoral DTI reconstruction in irradiated patients, subpectoral implant placement was nearly 4 times as likely to result in capsular contracture (p < 0.01). Rates of explantation, infection, tissue necrosis, and hematoma were comparable between groups. We also found that when subpectoral patients present with breast contracture, chemoparalysis of the muscle alone can resolve breast asymmetry, corroborating that muscle is a key contributor to breast contracture. As prepectoral breast reconstruction is gaining popularity, there have been questions regarding outcome following radiation treatment. This study suggest that prepectoral breast reconstruction is safe in an irradiated patient population, and in fact compares favorably with regard to breast contracture.

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

INTRODUCTION

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

METHODS AND RESULTS

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

CONCLUSIONS

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

Three-Dimensional Simulation for Breast Augmentation of Female Asymmetric Pectus Excavatum: A Case Report

Breast augmentation for women with asymmetric pectus excavatum (PE) has a characteristic problem in that surgeons need to select implants while considering the left-right difference in breast volume, contour, and position. We herein report a 33-year-old woman with severe asymmetric PE who presented with residual breast asymmetry after chest wall correction using the Nuss procedure. Her right breast appeared hypoplastic and the right anterior chest wall remained depressed. Augmentation of the right breast with a silicone implant was performed, selecting the inserted implant preoperatively with the assistance of three-dimensional (3D) simulation. The breast asymmetry and anterior chest wall depression were improved to a natural appearance. Three-dimensional simulation represents an advantageous way to preoperatively select optimal implants for breast augmentation in asymmetric PE women with breast asymmetry.

Level of Evidence: 5

Modern Primary Breast Augmentation: Best Recommendations for Best Results

LEARNING OBJECTIVES

After reading this article, the participant should be able to: 1. Develop a practical method for preoperative implant size selection. 2. List characteristics and examples of fourth- and fifth-generation silicone implants. 3. Recognize the differences in "profile" designations across implant manufacturers. 4. Recall updated statistics on breast implant-associated anaplastic large cell lymphoma and describe current guidelines on disease diagnosis and treatment. 5. Apply atraumatic and aseptic surgical techniques in primary breast augmentation.

SUMMARY

Modern primary breast augmentation requires an intimate knowledge of the expanding breast implant market, including characteristics of current generation silicone implants and "profile" types. Optimal implant size selection requires balancing patient desires with tissue qualities. Evidence and awareness of breast implant-associated anaplastic large cell lymphoma continue to grow, and patients and surgeons alike should be informed on the most updated facts of the disease entity. Atraumatic surgical technique and aseptic adjuncts are critical in reducing periprosthetic inflammation and contamination, both of which are known instigators of capsular contracture and potentially breast implant-associated anaplastic large cell lymphoma.

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.

Chances and limitations of a low-cost mobile 3D scanner for breast imaging in comparison to an established 3D photogrammetric system

BACKGROUND

In search of new possibilities in 3D surface imaging, several nonmedical scanning systems have been assessed for their implementation in plastic surgery. The aim of this study was to compare a new affordable 3D imaging consumer product with an established medical 3D imaging system for objective 3D breast imaging.

METHOD

We compared a low-cost mobile, handheld scanner against an established medical 3D surface imaging system. Forty-two female patients who underwent different types of breast surgery were captured in a 3D view with both devices. Digital breast measurement, volume measurement, and breast surface-to-surface analysis were done using Mirror software. Repeatability was assessed by repeated 3D scans of the torso and surface-to-surface analysis.

RESULTS

Digital breast measurement showed low differences with good-to-excellent correlation between both devices. Mean breast volume difference was small (-5.11 ± 32.10 mL) within the 95% limits of agreement. Surface-to-surface analysis yielded a higher surface deviation in the lower breast quadrants (1.62 ± 0.80 mm root mean square [RMS] error and 1.81 ± 0.88 mm RMS error) than in the upper breast quadrants. Repeatability was satisfactory with a mean of 0.636 ± 0.279 mm RMS error.

CONCLUSION

Affordable mobile surface scanners may offer new perspectives in the future for 3D breast imaging. Although surface acquisition was sufficient for breast measurements in comparison to an established system, the lack of appropriate medical software for patient consultation next to moderate texture quality needs to be improved for wider acceptance in plastic surgery.

Three-Dimensional Imaging and Breast Measurements: How Predictable Are We?

BACKGROUND

Outcomes in aesthetic breast surgery are dependent on preoperative breast measurements. The accuracy of 3-dimensional (3D) imaging in measuring critical landmarks in augmentation mammaplasty surgery has not been described.

OBJECTIVES

We aimed to determine the predictability of 3D imaging compared to direct measurements.

METHODS

Two raters measured the breasts of 28 women using four anthropometric (direct) measurements: sternal notch to nipple distance (Sn-N), nipple to midline (N-M), nipple to inframammary-fold distance under maximal stretch (N-IMF), and base width (BW). Measurements (indirect) were also obtained using 3D imaging. Statistical analysis was completed with Bland-Altman plots.

RESULTS

Each rater collected 56 data points for each of the four measurements. This resulted in 224 data points per rater. The Sn-N measurement had a 0.05 cm (SD, 0.65) difference in the mean values obtained between direct and indirect measurements. N-M had a mean difference of 0.20 cm (SD, 0.62). The mean difference for BW was 1.26 cm (SD, 0.69 cm), and N-IMF showed a mean difference of 1.22 cm (SD, 0.74 cm). Three-dimensional imaging overestimated Sn-N, N-M, and BW, while it underestimated N-IMF.

CONCLUSIONS

Three-dimensional imaging has good utility and is most accurate for Sn-N and N-M measurements, which require frontal imaging of a standing patient. BW and N-IMF are less accurate due to obscured landmarks on frontal imaging. The medial and lateral aspects of the breast may be obscured when measuring BW on 3D imaging, which may explain this difference. N-IMF is a dynamic measurement, and as a result, 3D imaging has limited ability to measure this distance accurately.

LEVEL OF EVIDENCE 3

Current Trends in Breast Augmentation: An International Analysis

BACKGROUND

Breast augmentation surgery remains the most frequently performed aesthetic surgical procedure worldwide. However, many variations exist regarding preoperative planning, surgical management, and postoperative care.

OBJECTIVES

The goal was to evaluate current trends and practices in breast augmentation, with a focus on international variability.

METHODS

A questionnaire was sent to over 5000 active breast surgeons in 44 countries worldwide. The survey inquired about current controversies, new technologies, common practices, secondary procedures, and surgeon demographics. The findings and variations were evaluated and correlated to evidence-based literature.

RESULTS

There were a total 628 respondents equaling a response rate of approximately 18%. While certain approaches and common practices prevail also on an international basis, there exist several geographic controversies. For example, while almost fifty percent of surgeons in the United States and Latin America never use anatomically shaped implants, in Europe and Oceania most surgeons use them. Similarly, in Latin America, Europe, Asia, and Oceania, over 80% of surgeons use silicone implants only, whereas in the United States only 20% use them - meanwhile US surgeons use the largest implants (78% > 300 cc). Internationally dominant practice preferences include preoperative sizing with silicone implants, as well as the use of inframammary incisions and partial submuscular pockets.

CONCLUSIONS

Significant differences exist when comparing most common surgical breast augmentation approaches on an international basis. While certain techniques seem to be universal standards, there still remain several controversies. Further standardizing this most common aesthetic surgical procedure according to evidence-based guidelines will help to improve outcomes.

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.

Evidence-Based Medicine: Breast Augmentation

LEARNING OBJECTIVES

After reading this article, the participant should be able to: 1. Understand the key decisions in patient evaluation for cosmetic breast augmentation. 2. Cite key decisions in preoperative planning. 3. Discuss the risks and complications, and key patient education points in breast augmentation.

SUMMARY

Breast augmentation remains one of the most popular procedures in plastic surgery. The integral information necessary for proper patient selection, preoperative assessment, and surgical approaches are discussed. Current data regarding long term safety and complications are presented to guide the plastic surgeon to an evidence-based approach to the patient seeking breast enhancement to obtain optimal results.

Use of Poly-4-Hydroxybutyrate Mesh to Optimize Soft-Tissue Support in Mastopexy: A Single-Site Study

BACKGROUND

The ptotic breast is surgically rejuvenated through a mastopexy procedure. Recurrent ptosis or other negative changes to the breast shape are not uncommon following mastopexy, as the tissue laxity and skin quality that contributed to ptosis are not surgically corrected. The purpose of this study was to assess the postsurgical changes in the breasts of patients who underwent a primary mastopexy procedure with soft-tissue reinforcement using a long-term poly-4-hydroxybutyrate resorbable scaffold (i.e., GalaFLEX).

METHODS

From July of 2012 to January of 2014, 11 consecutive patients underwent a central mound mastopexy with soft-tissue reinforcement in the lower pole using a poly-4-hydroxybutyrate resorbable scaffold. Patients returned for postoperative follow-up visits that included three-dimensional scans of their breasts at months 1, 3, 6, and 12.

RESULTS

There were no major complications in the study. Changes in the breast shape defined by distances between predefined landmarks between months 1 and 12 ranged from 1.5 to 9.6 percent. Some postoperative breast settlement occurred between months 1 and 3. The mean change in the nipple-to-inframammary fold distance from months 1 to 12 was 8 mm. Lower pole stretch was 5 percent.

CONCLUSIONS

Initial findings suggest that central mound mastopexy with soft-tissue reinforcement in the lower pole performed on difficult larger breasts yields a relatively stable result for 1 year after surgery. There was no statistically significant change between months 3 and 12 from the sternal notch to lowest point on the breast as determined by established three-dimensional imaging techniques.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Matching the Implant to the Breast: A Systematic Review of Implant Size Selection Systems for Breast Augmentation

BACKGROUND

For primary breast augmentation, several implant selection systems have been described to guide the surgeon with choosing from a variety of manufactured implant dimensions and properties. Controversy exists regarding the most efficacious method of selecting an appropriate implant size that best matches the patient's breast.

METHODS

The goal of this systematic review was to provide a comprehensive list of documented implant size selection systems, and to critically evaluate them. Implant size selection systems were grouped into categories based on selection principles. Articles were evaluated based on reported outcome measures and methodologic quality.

RESULTS

Thirty-three implant size selection systems were included in the final analysis. Only 12 percent of articles (four of 33) reported clinical outcomes that could be compared to accepted literature values or industry standards. Articles that described tissue-based planning systems, which use clinical guidelines to determine the optimal patient-specific implant dimensions, were of highest methodologic quality using the Methodological Index for Non-Randomised Studies scale, when compared to systems that used breast "dimensional" analyses that stress tissues to the desire of the patient and/or surgeon, and compared to systems that did not use breast measurement (means ± SD, 6.0 ± 1.4, 1.4 ± 2.3, and 0.0 ± 0.0, respectively).

CONCLUSIONS

There is some evidence to support tissue-based planning as a superior approach to implant size selection planning; studies that used tissue-based planning reported lower reoperation rates compared with industry standards and accepted literature values. The authors offer several suggestions on how to improve the methodologic quality of future studies describing new implant selection systems.

The Effect of Nasal Tip Rotation on Upper Lip Length

Background

Increasing the nasolabial angle (NLA) with tip rotation generates the appearance of a lengthened lower facial third. In particular, the upper lip show seems increased following elevation of the nasal tip.

Objectives

The purpose of this study is to quantify the impact of tip rotation on upper lip length (ULL), and to establish a predictable correlation between the two.

Methods

A retrospective cohort study of rhinoplasty patients with increased tip rotation, using either caudal septal extension graft (CSEG) or columellar strut graft (CS), was performed. Three-dimensional photos were obtained and analyzed anthropometrically and used to measure the ULL and NLA. The deltas between NLA and ULL at the various time points, was then compared using linear regression with P < .05 recognized as statistically significant.

Results

One-hundred and fifty patients were identified and 88 patients met inclusion criteria. CS and CSEG were used in 40% (n = 36), and 60% (n = 52), respectively. Three-dimensional assessment showed that as the NLA positively correlated with the ULL in both cohorts. The CSEG group created a greater NLA and ULL compared to the CS cohort. Both NLA and ULL decreased over time, but remained statistically increased as compared with preoperative measurements. For every one degree of NLA increase, the ULL increases by 0.05 mm.

Conclusions

Increasing nasal tip rotation in rhinoplasty results in greater upper lip show. Both CS and CSEG can effectively increase tip rotation and ULL. A predictable correlation of nearly 0.05 mm of ULL for every 1 degree of tip rotation is shown.

Level of Evidence

4.

Preoperative implant selection for unilateral breast reconstruction using 3D imaging with the Microsoft Kinect sensor

AIMS

This study aimed to investigate whether breast volume measured preoperatively using a Kinect 3D sensor could be used to determine the most appropriate implant size for reconstruction.

METHODS

Ten patients underwent 3D imaging before and after unilateral implant-based reconstruction. Imaging used seven configurations, varying patient pose and Kinect location, which were compared regarding suitability for volume measurement. Four methods of defining the breast boundary for automated volume calculation were compared, and repeatability assessed over five repetitions.

RESULTS

The most repeatable breast boundary annotation used an ellipse to track the inframammary fold and a plane describing the chest wall (coefficient of repeatability: 70 ml). The most reproducible imaging position comparing pre- and postoperative volume measurement of the healthy breast was achieved for the sitting patient with elevated arms and Kinect centrally positioned (coefficient of repeatability: 141 ml). Optimal implant volume was calculated by correcting used implant volume by the observed postoperative asymmetry. It was possible to predict implant size using a linear model derived from preoperative volume measurement of the healthy breast (coefficient of determination R² = 0.78, standard error of prediction 120 ml). Mastectomy specimen weight and experienced surgeons' choice showed similar predictive ability (both: R² = 0.74, standard error: 141/142 ml). A leave one-out validation showed that in 61% of cases, 3D imaging could predict implant volume to within 10%; however for 17% of cases it was >30%.

CONCLUSION

This technology has the potential to facilitate reconstruction surgery planning and implant procurement to maximise symmetry after unilateral reconstruction.

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 Process of Breast Augmentation with Special Focus on Patient Education, Patient Selection and Implant Selection

Breast augmentation remains one of the most commonly performed plastic surgical procedures worldwide; however, Food and Drug Administration clinical trials have suggested that this procedure has a reoperation rate of 14% to 24% after 3 years. Recent literature has proposed that breast augmentation should not only be a surgical procedure but ultimately a surgical process to reduce postoperative complications and enhance patient satisfaction. The process of breast augmentation has been documented to optimize postsurgical outcomes and includes the following 4 steps: patient education, tissue-based planning, refined surgical techniques, and defined postoperative management.

The Etiologies of Chest Wall and Breast Asymmetry and Improvement in Breast Augmentation

Patients presenting for correction of breast and chest wall asymmetries may have undergone numerous thoracic procedures in early childhood and may have suffered profound psychosocial effects. Complex congenital syndromes as well as mild breast asymmetries should be carefully documented using objective measurements, photography, and 3-dimensional simulations when available. Shaped highly cohesive breast implants offer plastic surgeons more possibilities and precision by fine-tuning the gel distribution and specific volumes required to correct the hypoplastic elements. Long-lasting correction of asymmetry can be obtained when patients are not oversized, and care is taken to avoid visibility, palpability, and malposition problems.

Techniques used by United Kingdom consultant plastic surgeons to select implant size for primary breast augmentation

BACKGROUND

Techniques used to estimate implant size for primary breast augmentation have evolved since the 1970s. Currently no consensus exists on the optimal method to select implant size for primary breast augmentation.

METHODS

In 2013 we asked United Kingdom consultant plastic surgeons who were full members of BAPRAS or BAAPS what was their technique for implant size selection for primary aesthetic breast augmentation. We also asked what was the range of implant sizes they commonly used. The answers to question one were grouped into four categories: experience, measurements, pre-operative external sizers and intra-operative sizers.

RESULTS

The response rate was 46% (164/358). Overall, 95% (153/159) of all respondents performed some form of pre-operative assessment, the others relied on "experience" only. The most common technique for pre-operative assessment was by external sizers (74%). Measurements were used by 57% of respondents and 3% used intra-operative sizers only. A combination of measurements and sizers was used by 34% of respondents. The most common measurements were breast base (68%), breast tissue compliance (19%), breast height (15%), and chest diameter (9%). The median implant size commonly used in primary breast augmentation was 300cc.

SUMMARY

Pre-operative external sizers are the most common technique used by UK consultant plastic surgeons to select implant size for primary breast augmentation. We discuss the above findings in relation to the evolution of pre-operative planning techniques for breast augmentation.