Kevin Small

3D analysis of breast augmentation defines operative changes and their relationship to implant dimensions.

Breast augmentation is one of the most common plastic surgery procedures performed in the United States today. Evaluation of postoperative results lacks true objective measurements. The following study reports the application of 3-dimensional (3D) photography to document changes that occur in breast morphology after breast augmentation. Patients undergoing augmentation mammaplasty with a periareolar incision were offered pre- and postoperative 3D photographs. 3D models were constructed and the following parameters were assessed: maximum anterior-posterior projection from the chest wall, angle of breast projection, total breast volume, volumetric tissue distribution in the superior and inferior poles, and surface and vector distance measurements to key landmarks. A completed series of 3D images were obtained from 14 augmentation patients (28 breasts) at an average postoperative day of 143. Saline and silicone implants were used equally (n = 14 for each). Total volume of the breast changed in correlation with the implant size (1.9% difference, P = 0.83). There were no significant changes in the volumetric distribution within the upper and lower poles of the breasts noted between pre- and postoperative scans (P = 0.81). The internal angle of breast projection was found to increase (13.6 degrees, P < 0.01), as did the sternal notch to nipple distance (11 mm, P = 0.018). Anterior-posterior projection significantly increased by 23.3 mm. However, this increase in projection was 20.9% less than expected based on implant dimensions (72.7–58.7 mm, respectively, P < 0.01). This study documents objective changes in breast morphology after augmentation mammaplasty. 3D imaging scans were able to document true changes that occur with breast augmentation including breast volume, the increase in the internal angle of the breast projection, and the sternal notch to nipple distance. 3D photography further highlighted that breast augmentation results in less than expected anterior-posterior projection, possibly due to tissue attenuation occurring anterior to the implant.

An Innovative Three-dimensional Approach to Defining the Anatomical Changes Occurring after Short Scar-medial Pedicle Reduction Mammaplasty

Background: Three-dimensional photography of the breast offers new opportunities to advance the fields of aesthetic and reconstructive breast surgery. The following study investigates the use of three-dimensional imaging to assess changes in breast surface anatomy, volume, tissue distribution, and projection following medial pedicle reduction mammaplasty. Methods: Preoperative and postoperative three-dimensional scans were obtained from patients undergoing short-scar medial pedicle breast reduction. Three-dimensional models were analyzed by topographical color maps, changes in the lowest point of the breast, surface measurements, and the point of maximal projection. Total breast volume and percentage volumetric tissue distribution in the upper and lower poles were also determined. Results: Thirty patients underwent reduction mammaplasty (mean postoperative scan, 80 ± 5 days). Color maps highlighted the majority of spatial changes in the central, upper poles. Reduction mammaplasty resulted in a significant decrease in the anteroposterior projection of the breast (6.3 ± 0.2 postoperatively compared with 8.1 ± 0.2 cm preoperatively; p < 0.01). The point of maximal breast projection was elevated in the cranial-caudal direction (4.8 ± 0.4 cm; p < 0.01), with a corresponding elevation in the lowest point of the breast (4.8 ± 0.5 cm; p < 0.01). Volumetric three-dimensional measurements identified a significant change in percentage tissue distribution after reduction mammaplasty (45 ± 2 percent above the inframammary fold preoperatively versus 76 ± 2 percent postoperatively; p < 0.01). Conclusions: This study is the first to demonstrate the technical feasibility and clinical utility of three-dimensional geometric data in medial pedicle breast reduction surgery. This novel approach suggests new opportunities to define long-term operative changes following various breast procedures.

Three-Dimensional Imaging Provides Valuable Clinical Data to Aid in Unilateral Tissue Expander-Implant Breast Reconstruction

Abstract:  The current approach to breast reconstruction remains largely subjective and is based on physical examination and visual‐estimates of breast size. Thus, the overall success of breast reconstruction is limited by the inability of plastic surgeons to objectively assess breast volume and shape, which may result in suboptimal outcomes. A potential solution to this obstacle may be three‐dimensional (3D) imaging, which can provide unique clinical data that was previously unattainable to plastic surgeons. The following study represents a prospective analysis of patient volunteers undergoing unilateral tissue expander (TE)‐implant reconstruction by one of the two senior authors (MC, NSK). All patients underwent unilateral mastectomy with immediate or delayed insertion of a TE, followed by an exchange for a permanent silicone or saline implant. 3D scans were obtained during routine pre‐ and postoperative office visits. The 3D breast‐volume calculations served as a guide for surgical management. Twelve patients have completed 3D‐assisted unilateral breast reconstruction to date. These patients represent a wide range of body habitus and breast size/shape; 3D volume range from 136 to 518 cm3. The mean baseline breast asymmetry in this group was 12.0 ± 10.8%. Contralateral symmetry procedures were performed in eleven patients, consisting of the following: mastopexy (n = 6), augmentation (n = 1), mastopexy/augmentation (n = 2), and reduction mammoplasty (n = 2). Reconstruction was completed in a total number of 2 (n = 10) or 3 (n = 2) operations. Overall breast symmetry improved at the completion of reconstruction in the majority of patients, with an average postoperative symmetry of 95.1 ± 4.4% (relative to 88% preoperatively). 3D imaging serves a valuable adjunct to TE‐implant breast reconstruction. This technology provides volumetric data that can help guide breast reconstruction, such as in choosing the initial TE size, total volume of expansion, and final implant size/shape. 3D imaging technology also provides benefit as a method for assessing tissue expansion, the need for symmetry or revision procedures, and critically analyzing the final reconstructive outcome.

Mammometrics: The standardization of aesthetic and reconstructive breast surgery

The goal of cosmetic and reconstructive breast surgery is to create symmetric and aesthetically pleasing results in a reproducible manner. Although continued progress is dependent on the ability of plastic surgeons to accurately assess surgical outcomes, available methods to objectively evaluate aesthetic and reconstructive breast surgery are limited. This is quite different from other areas of plastic surgery, such as craniomaxillofacial surgery, that often use precise skeletal measurements to provide a platform for preoperative and postoperative analysis. In comparison, systematic evaluation of breast surgery has yet to be standardized. With the advent of three-dimensional photography, objective soft-tissue analysis of the breast is now possible. Recent work from our group and others has validated the use of three-dimensional breast photography in various clinical arenas, including autologous breast reconstruction, prosthetic breast reconstruction, reduction mammaplasty, and augmentation mammaplasty.1–7 Enthusiasm toward three-dimensional imaging technology has stemmed from the ability to not only obtain well-established breast measurements in an accurate manner, but also to generate measurements that were not previously possible with conventional tools, such as total breast volume, volumetric distribution, and breast projection. This article provides an overview of three-dimensional breast photography, with particular emphasis on its potential role to establish a standardized system for breast analysis. We introduce a new concept termed “mammometrics,” in which three-dimensional–based breast measurements can be used to help guide operative planning, objectively analyze surgical results, and document postoperative changes that occur over time.

Nipple-areolar complex ischemia after nipple-sparing mastectomy with immediate implant-based reconstruction: risk factors and the success of conservative treatment.

BACKGROUND Nipple-sparing mastectomy performed via an inframammary fold incision with implant-based reconstruction is an oncologically safe procedure that provides excellent cosmesis. OBJECTIVES The authors report their experience with conservative treatment of postoperative nipple-areolar complex (NAC) ischemia and an analysis of risk factors for NAC ischemia and conservative treatment failure. METHODS A retrospective chart review was conducted of 318 nipple-sparing mastectomies performed through inframammary fold incisions with implant-based reconstruction between July 2006 and October 2012. NAC dressings consisted of topical nitroglycerin, external warming for 24 hours, antibacterial petrolatum gauze, and a loose bra for 1 week. Patients were monitored for NAC ischemia as the primary endpoint. NAC ischemia was treated with bacitracin ointment. In cases of full-thickness ischemia, expanders were also partially deflated. RESULTS Partial- and full-thickness NAC ischemia occurred in 44 (13.8%) and 21 (6.6%) cases, respectively. All partial- and 17 full-thickness cases resolved with conservative treatment. Of these, 7 partial- and 2 full-thickness cases suffered residual depigmentation. Four full-thickness cases required operative debridement. Factors associated with NAC ischemia included increasing age (P = .035), higher body mass index (P = .0009), greater breast volume (P = .0023), and diabetes (P = .0046). Factors associated with conservative treatment failure included increasing age (P < .0001), higher body mass index (P = .014), greater breast volume (P = .020), smoking (P = .0449), acellular dermal matrix use (P < .0001), and single-stage reconstruction (P = .0090). CONCLUSIONS Postoperative NAC ischemia can be effectively managed conservatively to preserve cosmesis and implant viability. Knowledge of risk factors for NAC ischemia and conservative treatment failure may improve future patient counseling and outcomes.

Re-defining pseudoptosis from a 3D perspective after short scar-medial pedicle reduction mammaplasty

BACKGROUND Bottoming out is a well-known phenomenon described with reduction mammaplasty (RM). To date, the evaluation of post-operative bottoming out remains an imprecise science. The following study reports the application of three-dimensional (3D) photography to objectively investigate changes in breast morphology. METHODS Patients undergoing medial pedicle RM had 3D photographs (Konica Minolta V910) taken during the early and late post-operative period (early=60-120 days; late=400-500 days). 3D images were compared and bottoming out was assessed with 3D parameters and vectors including total breast volume, volumetric tissue distribution above and below the Central (C) plane, distance of the C-plane to the lowest point of the breast, and maximum anterior-posterior projection from the chest wall. RESULTS Post-operative images from 15 consecutive RM patients showed an average volume of 556+/-144 cm3 (early) and 441+/-183 cm3 (late). The percent of tissue in the upper pole of the breast changed from the early to late post-operative period (76% vs. 69%, respectively; p<0.01). The distance from a fixed C-plane to the inferior pole significantly increased (42+/-15 mm early vs. 51+/-18 mm late; p<0.01). AP projection decreased by an average of 6.23 mm (p<0.01). The lateral border of the IMF significantly dropped by 6.27 mm. CONCLUSIONS This study objectively describes both the occurrence of bottoming out and the quantitative amount in terms of changes in volumetric distribution, surface topography and breast projection. With 3D photography, plastic surgeons can perform objective evaluation of breast transformation over time, which ultimately will aid in planning to allow for better surgical outcomes.

Reply: Three-Dimensional Surface Imaging in Plastic Surgery: Foundation, Practical Applications, and Beyond.

Summary: Three-dimensional surface imaging has gained clinical acceptance in plastic and reconstructive surgery. In contrast to computed tomography/magnetic resonance imaging, three-dimensional surface imaging relies on triangulation in stereophotography to measure surface x, y, and z coordinates. This study reviews the past, present, and future directions of three-dimensional topographic imaging in plastic surgery. Historically, three-dimensional imaging technology was first used in a clinical setting in 1944 to diagnose orthodontologic conditions. Karlan established its use in the field of plastic surgery in 1979, analyzing contours and documenting facial asymmetries. Present use of three-dimensional surface imaging has focused on standardizing patient topographic measurements to enhance preoperative planning and to improve postoperative outcomes. Various measurements (e.g., volume, surface area, vector distance, curvature) have been applied to breast, body, and facial topography to augment patient analysis. Despite the rapid progression of the clinical applications of three-dimensional imaging, current use of this technology is focused on the surgeon’s perspective and secondarily the patient’s perspective. Advancements in patient simulation may improve patient-physician communication, education, and satisfaction. However, a communal database of three-dimensional surface images integrated with emerging three-dimensional printing and portable information technology will validate measurements and strengthen preoperative planning and postoperative outcomes. Three-dimensional surface imaging is a useful adjunct to plastic and reconstructive surgery practices and standardizes measurements to create objectivity in a subjective field. Key improvements in three-dimensional imaging technology may significantly enhance the quality of plastic and reconstructive surgery in the near future.

Surgical treatment of nipple malposition in nipple-sparing mastectomy device-based reconstruction.

Background: This article discusses the senior author’s (M.T.) experience with nipple-areola complex malposition following nipple-sparing mastectomy, surgical options for treatment, and an analysis of risk factors. Methods: A retrospective review was conducted on a prospectively collected institutional review board–approved database of nipple-sparing mastectomy cases with immediate device-based reconstruction performed between July of 2006 and October of 2012. Malposition was graded as mild (1 cm), moderate (2 cm), or severe (>3 cm) displacement. Results: Three hundred nineteen nipple-sparing mastectomies were reviewed. Malposition occurred in 44 (13.79 percent). Significant factors were age (p < 0.0001), diabetes mellitus (p = 0.0025), body mass index (p = 0.0093), preoperative sternal notch–to-nipple distance (p = 0.015), preoperative breast base width (p = 0.0001), periareolar mastectomy incision with lateral extension (p < 0.0001), prior radiation (p = 0.0004), prior lumpectomy (p = 0.0125), unilateral nipple-sparing mastectomy (p = 0.0004), and postoperative nipple-areola complex ischemia (p = 0.0174). Smoking status, breast volume resected, implant size, ablative surgeon, acellular dermal matrix, and single-stage reconstruction were not significant. Nineteen patients were satisfied. Eight were not offered surgical correction because of an inadequate skin envelope. Eight had crescent mastopexy, three had implant exchange and pocket revision, four had free nipple grafts, and two had pedicled nipple transposition. There were no incidences of necrosis or malposition after surgical correction. Conclusions: Nipple-sparing mastectomy followed by immediate device-based reconstruction has a risk of nipple malposition. Various surgical procedures are available to correct nipple malposition based on clinical presentation and are safe in certain populations. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Is There an Ideal Donor Site of Fat for Secondary Breast Reconstruction

BACKGROUND Loss of volume after autologous fat transfer to the breast is well documented, and various methods to improve long-term survival of fat grafts have been investigated (including both distant and neighboring harvest sites), but no optimal technique has been identified. OBJECTIVE The authors compare fat graft survival from 2 anatomical donor sites to determine whether there is an optimal site for fat graft harvesting in breast reconstruction. METHODS Seventy-three patients (109 breasts) who received fat grafting to reconstructed breasts from 2009 to 2012 were enrolled in this retrospective study and divided into 2 groups: group A had fat harvested from the abdomen and group B from the thighs. Fat grafting was performed using a modified Coleman technique for symmetry. For all patients, 3-dimensional scans were obtained and volumes were analyzed. RESULTS Forty-six patients (66 breasts) received an average of 101 mL of fat injected from the abdomen, and 27 (43 breasts) received an average of 102 mL from the thighs. Group A had 82% volume retention at 16 days, 63% at 49 days, and 45% at 140 days. Group B had 86% at 16 days, 63% at 49 days, and 46% at 140 days (P > .05). Patients were also stratified by radiation exposure and volume injected; neither affected donor site volume retention (P > .05). CONCLUSIONS Our data suggest that donor site, regardless of volume injected or tissue radiation, did not affect volume retention in fat grafting. Longer-term studies are needed to assess the stability of the breast after fat grafting.

Nipple-sparing mastectomy via an inframammary fold incision for patients with scarring from prior lumpectomy.

BackgroundNipple-sparing mastectomy (NSM) through an inframammary fold (IMF) incision can provide superior cosmesis and a high level of patient satisfaction. Because of concerns for nipple-areolar complex (NAC) viability using this incision, selection criteria may be limited. Here, we evaluate the impact of scarring from prior lumpectomy on NAC viability. MethodsA retrospective chart review was conducted on a prospectively collected database at a single institution between July 2006 and October 2012. A total of 318 NSMs through IMF incisions were performed. We compared the incidence of NAC ischemia in 122 NSM cases with prior lumpectomy with 196 NSM cases without prior lumpectomy. All 318 mastectomies were followed by implant-based reconstruction. Clinicopathologic factors analyzed included indications for surgery, technical details, patient demographics, comorbidities, and adjuvant therapy. ResultsThe overall incidence of NAC ischemia was 20.4% (65/318). Nipple-areolar complex ischemia occurred in 24.6% (30/122) of cases with prior lumpectomy and 17.9% (35/196) of cases without prior lumpectomy (P = 0.1477). Among the 30 ischemic events in the 122 cases with prior lumpectomy, epidermolysis occurred in 20 (16.4%) and necrosis occurred in 10 (8.2%). Two cases (1.6%) required operative debridement. Seven cases (5.7%) were left with areas of residual NAC depigmentation. All other cases completely resolved with conservative management. There was no significant correlation between the incidence of ischemia and surgical indication, tumor staging, age, body mass index, tissue resection volume, sternal notch to nipple distance, prior radiation, single-stage reconstruction, sentinel or axillary lymph node dissection, acellular dermal matrix use, presence of periareolar lumpectomy scars, diabetes, or smoking history. At a mean follow-up of 505 days (range, 7–1504 days), patient satisfaction was excellent. Local recurrence of breast cancer occurred in 3 cases (2.5%), and distant recurrence occurred in 2 cases (1.6%). ConclusionsPatients with scarring from prior lumpectomy do not have a higher rate of NAC ischemia and may be considered for NSM via an IMF incision.