Greg P Reece

local Recurrence Risk after Skin-sparing and Conventional Mastectomy: A 6-year Follow-up

In this study, the records of all patients at the University of Texas M. D. Anderson Cancer Center with T1 or T2 breast cancer who were treated between March of 1986 and November of 1990 with mastectomy followed by immediate breast reconstruction were reviewed for the presence of recurrent disease. Patients with in situ disease were not included. Patients were included in the study if a local recurrence occurred (regardless of the length of follow-up) or if a follow-up of 6 years or longer could be obtained. Patients were grouped according to the use or nonuse of skin-sparing mastectomy, by tumor stage, and by nuclear grade of the tumor. The series included 154 patients, of whom 114 had skin-sparing mastectomies and 40 had nonskin-sparing mastectomies. The local recurrence rate in the skin-sparing mastectomy group was 7.0 percent, whereas in the nonskin-sparing mastectomy group it was 7.5 percent. The sample size in the nonskin-sparing mastectomy group was too small for meaningful statistical analysis, but the data suggest that there is no clinically important difference in recurrence rates between the two groups. We conclude that the use of skin-sparing technique for early breast cancer patients does not significantly increase the risk of tumor recurrence after mastectomy.

Validation of Stereophotogrammetry of the Human Torso

The objective of this study was to determine if measurements of breast morphology computed from three-dimensional (3D) stereophotogrammetry are equivalent to traditional anthropometric measurements obtained directly on a subject using a tape measure. 3D torso images of 23 women ranged in age from 36 to 63 who underwent or were scheduled for breast reconstruction surgery were obtained using a 3dMD torso system (3Q Technologies Inc., Atlanta, GA). Two different types (contoured and line-of-sight distances) of a total of nine distances were computed from 3D images of each participant. Each participant was photographed twice, first without fiducial points marked (referred to as unmarked image) and second with fiducial points marked prior to imaging (referred to as marked image). Stereophotogrammetry was compared to traditional direct anthropometry, in which measurements were taken with a tape measure on participants. Three statistical analyses were used to evaluate the agreement between stereophotogrammetry and direct anthropometry. Seven out of nine distances showed excellent agreement between stereophotogrammetry and direct anthropometry (both marked and unmarked images). In addition, stereophotogrammetry from the unmarked image was equivalent to that of the marked image (both line-of-sight and contoured distances). A lower level of agreement was observed for some measures because of difficulty in localizing more vaguely defined fiducial points, such as lowest visible point of breast mound, and inability of the imaging system in capturing areas obscured by the breast, such as the inframammary fold. Stereophotogrammetry from 3D images obtained from the 3dMD torso system is effective for quantifying breast morphology. Tools for surgical planning and evaluation based on stereophotogrammetry have the potential to improve breast surgery outcomes.

3D Symmetry Measure Invariant to Subject Pose During Image Acquisition.

In this study we evaluate the influence of subject pose during image acquisition on quantitative analysis of breast morphology. Three (3D) and two-dimensional (2D) images of the torso of 12 female subjects in two different poses; (1) hands-on-hip (HH) and (2) hands-down (HD) were obtained. In order to quantify the effect of pose, we introduce a new measure; the 3D pBRA (Percentage Breast Retraction Assessment) index, and validate its use against the 2D pBRA index. Our data suggests that the 3D pBRA index is linearly correlated with the 2D counterpart for both of the poses, and is independent of the localization of fiducial points within a tolerance limit of 7 mm. The quantitative assessment of 3D asymmetry was found to be invariant of subject pose. This study further corroborates the advantages of 3D stereophotogrammetry over 2D photography. Problems with pose that are inherent in 2D photographs are avoided and fiducial point identification is made easier by being able to panoramically rotate the 3D surface enabling views from any desired angle.

Body image and quality of life of breast cancer patients

The process of cancer‐related breast reconstruction is typically multi‐staged and can take months to years to complete, yet few studies have examined patient psychosocial well‐being during the reconstruction process. We investigated the effects of reconstruction timing and reconstruction stage on body image and quality of life at specific time points during the breast reconstruction process.

In-vivo quantification of human breast deformation associated with the position change from supine to upright

Stereophotographic imaging and digital image correlation are used to determine the variation of breast skin deformation as the subject orientation is altered from supine to upright. A change in subjects position from supine to upright can result in significant stretches in some parts of the breast skin. The maximum of the major principal stretch ratio of the skin is different in different subjects and varies in the range of 1.25-1.60. It is also found that the boundaries of the breast move significantly relative to the skeletal structure and other fixed points such as the sternal notch. Such measurements are crucial since they provide basic data for validation of biomechanical breast models based on finite element formulations.

Assessing women's preferences and preference modeling for breast reconstruction decision making

Background: Women considering breast reconstruction must make challenging trade-offs among issues that often conflict. It may be useful to quantify possible outcomes using a single summary measure to aid a breast cancer patient in choosing a form of breast reconstruction. Methods: In this study, we used multiattribute utility theory to combine multiple objectives to yield a summary value using 9 different preference models. We elicited the preferences of 36 women, aged 32 or older with no history of breast cancer, for the patient-reported outcome measures of breast satisfaction, psychosocial well-being, chest well-being, abdominal well-being, and sexual well-being as measured by the BREAST-Q in addition to time lost to reconstruction and out-of-pocket cost. Participants ranked hypothetical breast reconstruction outcomes. We examined each multiattribute utility preference model and assessed how often each model agreed with participants’ rankings. Results: The median amount of time required to assess preferences was 34 minutes. Agreement among the 9 preference models with the participants ranged from 75.9% to 78.9%. None of the preference models performed significantly worse than the best-performing risk-averse multiplicative model. We hypothesize an average theoretical agreement of 94.6% for this model if participant error is included. There was a statistically significant positive correlation with more unequal distribution of weight given to the 7 attributes. Conclusions: We recommend the risk-averse multiplicative model for modeling the preferences of patients considering different forms of breast reconstruction because it agreed most often with the participants in this study.

Plastic surgeon expertise in predicting breast reconstruction outcomes for patient decision analysis

Background: Decision analysis offers a framework that may help breast cancer patients make good breast reconstruction decisions. A requirement for this type of analysis is information about the possibility of outcomes occurring in the form of probabilities. The purpose of this study was to determine if plastic surgeons are good sources of probability information, both individually and as a group, when data are limited. Methods: Seven plastic surgeons were provided with pertinent medical information and preoperative photographs of patients and were asked to assign probabilities to predict number of revisions, complications, and final aesthetic outcome using a questionnaire designed for the study. Logarithmic strictly proper scoring was used to evaluate the surgeons’ abilities to predict breast reconstruction outcomes. Surgeons’ responses were analyzed for calibration and confidence in their answers. Results: As individuals, there was variation in surgeons’ ability to predict outcomes. For each prediction category, a different surgeon was more accurate. As a group, surgeons possessed knowledge of future events despite not being well calibrated in their probability assessments. Prediction accuracy for the group was up to 6-fold greater than that of the best individual. Conclusions: The use of individual plastic surgeon–elicited probability information is not encouraged unless the individual’s prediction skill has been evaluated. In the absence of this information, a group consensus on the probability of outcomes is preferred. Without a large evidence base for calculating probabilities, estimates assessed from a group of plastic surgeons may be acceptable for purposes of breast reconstruction decision analysis.

Using a second free fibula osteocutaneous flap after repeated mandibulectomy is associated with a low complication rate and acceptable functional outcomes

Background: A significant percentage of patients who undergo segmental mandibulectomy for head and neck cancer will develop a new or recurrent cancer or osteoradionecrosis, necessitating a second mandibulectomy and reconstruction. In this scenario, many surgeons are reluctant to perform a reconstruction with an osseous flap because of the presumed increased morbidity and complexity. The purpose of this study was to evaluate the safety and efficacy of performing a second free fibula flap reconstruction after repeated segmental mandibulectomy. Methods: The authors retrospectively reviewed their prospectively maintained departmental database for mandible reconstructions performed between 1991 and 2016, identifying patients who had two sequential free fibula flap reconstructions. Patient, disease, and treatment characteristics were recorded and analyzed. Results: Twenty patients underwent a second free fibula flap reconstruction after a second mandibulectomy. The median follow-up was 72.5 months (range, 16 to 243 months). Preoperative virtual planning was used more often for the second fibula flap compared with the first (50 percent versus 10 percent; p = 0.004). The mean operative times were statistically similar for the first versus second fibula flap (673 minutes versus 586 minutes, respectively; p = 0.13). The postoperative complication rates (50 percent versus 30 percent, respectively; p = 0.19) and functional outcomes were similar between the first and second fibula flap reconstructions. Conclusion: Despite the increased technical complexity, the use of a second free fibula flap after repeated segmental mandibulectomy appears to be safe and to confer no higher risk than that for the first fibula flap. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Correspondence of Breast Measurements for Bra Design After Reconstruction Surgery

Bra fit is a common quality of life problem for women with breast reconstruction. However, there is a lack of knowledge of how the changes in breast size and shape due to breast reconstruction surgery affect a woman’s bra comfortability. There exists a unique opportunity to capture surgeons’ knowledge of how breasts change after reconstruction and relay that information to clothing designers to aid designing bras for this patient population. Our goal is to investigate how to translate surgical knowledge about breast size, shape, and symmetry changes to quantitative data usable for bra design. We compared common measurements of the breast used by clothing designers to determine bra fit to standard clinical measurements used by surgeons for reconstruction planning. In consultation with a clothing designer and reconstructive surgeon, we determined 7 bra measurements and 8 associated fiducial points that can be localized on the type of clinical images that is widely used for documenting surgical outcomes. The measurements summarize the width, height, and projection of the breasts, as well as, the location of the breasts in reference to each other and to the torso. From our previously gathered database of 3D surface images of the torsos of 505 women who underwent breast reconstruction at The University of Texas MD Anderson Cancer Center, we selected a sample of 32 women who had implant-based reconstruction and had 3D images before breast surgery and images from at least three months after final implant placement. Using software developed by our team members at the University of Houston, a team member marked fiducial points, which were reviewed by an expert, on the pre-operative and post-operative images to calculate the bra measurements. Using these fiducial points, we measure the size, shape, and symmetry changes in a manner that is directly translatable to clothing design from the pre-operative image to the post-operative image for each patient to identify common changes for implant-based reconstruction. Future work will lend insight into how different types of reconstruction affect bra fit and how bra design can be adapted to improve quality of life after breast reconstruction.

Eigen-disfigurement model for simulating plausible facial disfigurement after reconstructive surgery.

BackgroundPatients with facial cancers can experience disfigurement as they may undergo considerable appearance changes from their illness and its treatment. Individuals with difficulties adjusting to facial cancer are concerned about how others perceive and evaluate their appearance. Therefore, it is important to understand how humans perceive disfigured faces. We describe a new strategy that allows simulation of surgically plausible facial disfigurement on a novel face for elucidating the human perception on facial disfigurement.MethodLongitudinal 3D facial images of patients (N = 17) with facial disfigurement due to cancer treatment were replicated using a facial mannequin model, by applying Thin-Plate Spline (TPS) warping and linear interpolation on the facial mannequin model in polar coordinates. Principal Component Analysis (PCA) was used to capture longitudinal structural and textural variations found within each patient with facial disfigurement arising from the treatment. We treated such variations as disfigurement. Each disfigurement was smoothly stitched on a healthy face by seeking a Poisson solution to guided interpolation using the gradient of the learned disfigurement as the guidance field vector. The modeling technique was quantitatively evaluated. In addition, panel ratings of experienced medical professionals on the plausibility of simulation were used to evaluate the proposed disfigurement model.ResultsThe algorithm reproduced the given face effectively using a facial mannequin model with less than 4.4 mm maximum error for the validation fiducial points that were not used for the processing. Panel ratings of experienced medical professionals on the plausibility of simulation showed that the disfigurement model (especially for peripheral disfigurement) yielded predictions comparable to the real disfigurements.ConclusionsThe modeling technique of this study is able to capture facial disfigurements and its simulation represents plausible outcomes of reconstructive surgery for facial cancers. Thus, our technique can be used to study human perception on facial disfigurement.