Three-dimensional Imaging and Simulation in Breast Augmentation

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.

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.

Assessment of Patient Satisfaction Using a New Augmented Reality Simulation Software for Breast Augmentation: A Prospective Study

Background: Breast augmentation is one of the most frequently performed plastic surgery procedures. Providing patients with realistic 3D simulations of breast augmentation outcomes is becoming increasingly common. Until recently, such programs were expensive and required significant equipment, training, and office space. New simple user-friendly programs have been developed, but to date there remains a paucity of objective evidence comparing these 3D simulations with post-operative outcomes. The aim of this study is to assess the aesthetic similarity between a pre-operative 3D simulation generated using Arbrea breast simulation software and real post-operative outcomes, with a focus on patient satisfaction. Methods: The authors conducted a prospective study of patients requiring breast augmentation. Patients were asked to assess how realistic the simulation was compared to the one-year post-operative result using the authors’ grading scale for breast augmentation simulation assessment. Patient satisfaction with the simulations was assessed using a satisfaction visual analogue scale (VAS) ranging from 0 (not at all satisfied) to 10 (very satisfied). Patient satisfaction with the surgical outcome was assessed using the BREAST-Q Augmentation Module. Results: All patients were satisfied with the simulations and with the attained breast volume, with a mean VAS score of 8.2 ± 1.2. The mean simulation time took 90 s on average. The differences between the pre-operative and one-year post-operative values of the three BREAST-Q assessments were found to be statistically significant (p < 0.001). Conclusions: Three-dimensional simulation is becoming increasingly common in pre-operative planning for breast augmentation. The present study aimed to assess the degree of similarity of three-dimensional simulations generated using Arbrea Breast Software and found that the use of the software provided a very satisfying representation for patients undergoing breast augmentation. However, we recommend informing patients that only the volume simulation is extremely accurate. On the other hand, it is necessary to not guarantee an absolute correspondence regarding the breast shape between the simulation and the post-operative result.

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.

BreastGAN: Artificial Intelligence-Enabled Breast Augmentation Simulation

BACKGROUND

Managing patient expectations is important to ensuring patient satisfaction in aesthetic medicine. To this end, computer technology developed to photograph, digitize, and manipulate three-dimensional (3D) objects has been applied to the female breast. However, the systems remain complex, physically cumbersome, and extremely expensive.

OBJECTIVES

The authors of the current study wish to introduce the plastic surgery community to BreastGAN, a portable, artificial intelligence (AI)-equipped tool trained on real clinical images to simulate breast augmentation outcomes.

METHODS

Charts of all patients who underwent bilateral breast augmentation performed by the senior author were retrieved and analyzed. Frontal before and after images were collected from each patient's chart, cropped in a standardized fashion, and used to train a neural network designed to manipulate before images to simulate a surgical result. AI-generated frontal after images were then compared with the real surgical results.

RESULTS

Standardizing the evaluation of surgical results is a timeless challenge which persists in the context of AI-synthesized after images. In this study, AI-generated images were comparable to real surgical results.

CONCLUSIONS

This study features a portable, cost-effective neural network trained on real clinical images and designed to simulate surgical results following bilateral breast augmentation. Tools trained on a larger dataset of standardized surgical image pairs will be the subject of future studies.

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.

Three-dimensional Assessment of the Breast: Validation of a Novel, Simple and Inexpensive Scanning Process

BACKGROUND/AIM

Methods to assess three-dimensionally the breast surface are increasingly used in plastic and reconstructive surgery. The aim of this study was to validate the use of the Structure Sensor 3D scanner (Occipital, Inc., Boulder, CO, USA) connected to an iPad Pro (Apple, Inc., Cupertino, CA, USA) as a novel, inexpensive and handheld three-dimensional scanning process.

MATERIALS AND METHODS

Surface images of a medical human female anatomy torso model of rigid plastic were repeatedly acquired with Structure Sensor 3D scanner and compared with those obtained using two clinically established 3D imaging systems. Digital measurements of vector and surface breast distances were analyzed using Mimics® Innovation Suite 20 medical imaging software (Materialise, Leuven, Belgium).

RESULTS

The analysis of variance (ANOVA) revealed no statistically significant difference among measurements obtained using different scanning processes for all the variables examined (p>0.05).

CONCLUSION

The study demonstrates analogous practicability and reliability for surface image acquisition using the newly introduced Structure Sensor 3D scanner and other clinically established scanners.

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

Three-Dimensional Evaluation of Static and Dynamic Effects of Botulinum Toxin A on Glabellar Frown Lines

BACKGROUND

The use of injectable solutions for aesthetic purposes has increased tremendously, but lacks objective support. We aimed at assessing static and dynamic effects of botulinum toxin A (BoNTA) on glabellar lines by use of an objective three-dimensional methodology.

METHODS

We prospectively collected three-dimensional stereographic photographs of two different facial expressions (pretreatment, 30 and 90 days posttreatment) in 21 patients, receiving a total of 20 units of BoNTA in both corrugator supercilii muscles. The primary endpoint was the three-dimensional static and dynamic surface irregularity, and secondary endpoints were the glabellar line scale and overall patient satisfaction. Blinded retrospective data analysis and statistical evaluation were performed with p < 0.05 considered statistically significant.

RESULTS

Static glabellar lines (neutral facial expression) were significantly reduced by - 17% and - 24% on day 30 and 90 posttreatment, respectively (vs. pretreatment; both p < 0.0001). Dynamic glabellar frown lines (firmest possible bilateral eye closure) demonstrated a reduction of surface irregularity by - 26% and - 21% on day 30 and 90 posttreatment, respectively (vs. pretreatment; both p < 0.0001). The subjective dynamic glabellar line scale documented a statistically significant improvement on day 30 posttreatment (mean ± SD: 1.5 ± 0.8; p < 0.05) versus pretreatment (2.8 ± 1.0). Polled patients confirmed a subjective wrinkle improvement 90 days posttreatment.

CONCLUSION

The presented setup detected even subtle changes of BoNTA treatment for facial wrinkling and is a promising asset for scientific evaluations of clinical studies analyzing the outcome and duration of efficacy of injectable solutions on the face.

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 .

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

Comparison between different methods of breast implant volume choice and degree of postoperative satisfaction

OBJECTIVES

to assess the degree of patient satisfaction after undergoing breast augmentation and compare three different, easy, inexpensive and universal methods of preoperative choice of breast implant volume.

METHODS

a prospective study was carried out at University Hospital Pedro Ernesto of State University of Rio de Janeiro, in 94 women from Rio de Janeiro, aged 18 to 49 years, submitted to breast augmentation mammaplasty with breast implant due to hypomastia. All implants were textured, with a round base and high projection and were introduced into the retroglandular space through an inframammary access. The patients were divided into three groups: Control, Silicone and MamaSize®, with 44, 25 and 25 patients, respectively. Satisfaction questionnaires were applied in the pre and postoperative periods by the same evaluator, through the visual analogue scale, in which '0' meant very unsatisfied and '100' very satisfied for the four variables: shape, size, symmetry and consistency. The degree of satisfaction with the surgical scar was also assessed in the postoperative period.

RESULTS

when the preoperative and postoperative satisfaction levels were compared, there was a difference in all variables for the three groups, with statistical significance. However, when the postoperative data were compared with each other, there was no significant difference. The degree of satisfaction with the surgical scar was high.

CONCLUSION

the augmentation mammaplasty with breast implant had a high index of satisfaction among patients. However, there was no difference in the degree of satisfaction in the postoperative period between the three methodologies of breast volume measurement.