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1.  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 six-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.
doi:10.1097/GOX.0000000000000010
PMCID: PMC4044723  PMID: 24910814
2.  Developing a Theoretical Framework to Illustrate Associations Among Patient Satisfaction, Body Image and Quality of Life for Women Undergoing Breast Reconstruction 
Cancer treatment reviews  2013;39(6):673-681.
Within the field of breast reconstruction there is increasing focus on patient-reported outcomes related to satisfaction, body image, and quality of life. These outcomes are deemed highly relevant because the primary goal of breast reconstruction is to recreate the appearance of a breast (or breasts) that is satisfying to the patient. Prominent researchers have suggested the need to develop improved standards for outcome evaluation which can ultimately benefit patients as well as physicians. The purpose of this article is to summarize key findings in the area of patient-reported outcomes for breast reconstruction and introduce a theoretical framework for advancing research in this field. We conducted an extensive literature review of outcome studies for breast reconstruction focusing on patient-reported results. We developed a theoretical framework illustrating core patient-reported outcomes related to breast reconstruction and factors associated with these outcomes. Our theoretical model highlights domains and distinguishing features of patient satisfaction, body image, and quality of life outcomes for women undergoing breast reconstruction. This model further identifies a broad range of variables (e.g., historical/premorbid influences, disease and treatment-related factors) that have been found to influence patient-reported outcomes and need to be taken into consideration when designing future research in this area. Additional attention is given to examining the relationship between patient reported outcomes and outside evaluation of breast reconstruction. Our proposed theoretical framework suggests key opportunities to expand research in this area with the goal of optimizing body image adjustment, satisfaction, and psychosocial outcomes for the individual patient.
doi:10.1016/j.ctrv.2012.12.010
PMCID: PMC3681916  PMID: 23380309
breast reconstruction; body image; patient satisfaction; quality of life
3.  TRACHEOSTOMAPLASTY: A SURGICAL METHOD FOR IMPROVING RETENTION OF AN INTRALUMINAL STOMA BUTTON FOR HANDS-FREE TRACHEOESOPHAGEAL SPEECH 
Head & neck  2010;32(12):1674-1680.
Background
We describe a minimally invasive surgical technique, tracheostomaplasty, to overcome anatomical deformities of the stoma that preclude successful retention of a stoma button for hands free tracheoesophageal (TE) speech.
Methods
We conducted a retrospective analysis of 21 patients who underwent tracheostomaplasty after laryngectomy to accommodate an intraluminal valve attachment for hands-free TE speech.
Results
Sixteen men and 5 women (median age, 65 years; median follow-up, 27.7 months) underwent tracheostomaplasty; 6 patients developed a mild cellulitis that required therapy and 5 patients required a minor revision surgery. At last follow-up, 15 (71%) patients successfully achieved hands-free TE speech using an intraluminal stoma button. Three patients only retained the intraluminal device to facilitate digital occlusion. Tracheostomaplasty failed in 3 patients because of granulation tissue formation or stomal stenosis.
Conclusions
Tracheostomaplasty is a successful technique to improve intraluminal retention of a stoma button for hands-free TE speech in laryngectomy patients.
doi:10.1002/hed.21379
PMCID: PMC4061978  PMID: 20848405
laryngectomy; Barton–Mayo button; hands-free tracheoesophageal speech; outcome; complications
4.  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.
doi:10.1097/GOX.0000000000000062
PMCID: PMC4120963  PMID: 25105083
5.  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.
doi:10.1097/GOX.0000000000000010
PMCID: PMC4044723  PMID: 24910814
6.  Skin Graft Vascular Maturation and Remodeling: A Multifractal Approach to Morphological Quantification 
Objective
One important contributor to tissue graft viability is angiogenic maturation of the graft tissue bed. This study uses scale-invariant microvascular morphological quantification to track vessel maturation and remodeling in a split-thickness skin grafting model over 21 days, comparing the results to classical techniques.
Methods
Images from a previous study of split-thickness skin grafting in rats were analyzed. Microvascular morphology (fractal and multifractal dimensions, lacunarity, and vessel density) within fibrin interfaces of samples over time was quantified using classical semi-automated methods and automated multifractal and lacunarity analyses.
Results
Microvessel morphology increased in density and complexity, from 3 to 7 days after engraftment and then regressed by 21 days. Vessel density increased from 0.07 on day 3 to 0.20 on day 7 and then decreased to 0.06 on day 21. A similar trend was seen for the fractal dimension which increased from 1.56 at 3 days to 1.77 at 7 days then decreased to 1.57 by 21 days. Vessel diameters did not change while complexity and density did, signaling remodeling.
Conclusions
This new automated analysis identified design parameters for tissue engraftment and could be used in other models of graft vessel biology to track proliferation and pruning of complex vessel beds.
doi:10.1111/j.1549-8719.2012.00200.x
PMCID: PMC3467318  PMID: 22672367
Microcirculation; Split Thickness Skin Graft; Microvascular Morphology; Multifractal Analysis
7.  Automated Identification of Fiducial Points on 3D Torso Images 
Breast reconstruction is an important part of the breast cancer treatment process for many women. Recently, 2D and 3D images have been used by plastic surgeons for evaluating surgical outcomes. Distances between different fiducial points are frequently used as quantitative measures for characterizing breast morphology. Fiducial points can be directly marked on subjects for direct anthropometry, or can be manually marked on images. This paper introduces novel algorithms to automate the identification of fiducial points in 3D images. Automating the process will make measurements of breast morphology more reliable, reducing the inter- and intra-observer bias. Algorithms to identify three fiducial points, the nipples, sternal notch, and umbilicus, are described. The algorithms used for localization of these fiducial points are formulated using a combination of surface curvature and 2D color information. Comparison of the 3D co-ordinates of automatically detected fiducial points and those identified manually, and geodesic distances between the fiducial points are used to validate algorithm performance. The algorithms reliably identified the location of all three of the fiducial points. We dedicate this article to our late colleague and friend, Dr. Elisabeth K. Beahm. Elisabeth was both a talented plastic surgeon and physician-scientist; we deeply miss her insight and her fellowship.
doi:10.4137/BECB.S11800
PMCID: PMC4147764  PMID: 25288903
3D surface mesh; breast reconstruction; curvature; breast morphology; landmark detection
8.  Automated calculation of symmetry measure on clinical photographs 
1 ABSTRACT
Breast cancer is one of the most prevalent forms of cancer in the world. More than 250,000 American women are diagnosed with breast cancer annually. Fortunately, the survival rate is relatively high and continually increasing due to improved detection techniques and treatment methods. The quality of life of breast cancer survivors is ameliorated by minimizing adverse effects on their physical appearance. Breast reconstruction is important for restoring the survivor’s appearance. In breast reconstructive surgery, there is a need to develop technologies for quantifying surgical outcomes and understanding women’s perceptions of changes in their appearance. Methods for objectively measuring breast anatomy are needed in order to help breast cancer survivors, radiation oncologists, and surgeons quantify changes in appearance that occur with different breast reconstructive surgical options. In this study, we present an automated method for computing a variant of the normalized Breast Retraction Assessment (pBRA), a common measure of symmetry, from routine clinical photographs taken to document breast cancer treatment procedures.
doi:10.1111/j.1365-2753.2010.01477.x
PMCID: PMC2958233  PMID: 20630015
BRA; pBRA; Automated Detection; Digital Photographs; Umbilicus; Nipple Complex; Breast Cancer
9.  Quantifying the Aesthetic Outcomes of Breast Cancer Treatment: Assessment of Surgical Scars from Clinical Photographs 
Accurate assessment of the degree of scaring that results from surgical intervention for breast cancer would enable more effective pre-operative counseling. The resultant scar that accompanies an open surgical intervention may be characterized by variance in thickness, color, and contour. These factors significantly impact the overall appearance of the breast. A number of studies have addressed the mechanical and pathologic aspects of scarring. The majority of these investigations have focused on the physiologic process of scar formation and means to improve the qualities of a scar. Few studies have focused on quantifying the visual impact of scars. This manuscript critically reviews current methods used to assess scars in terms of overall satisfaction after surgery. We introduce objective, quantitative measures for assessing linear breast surgical scars using digital photography. These new measurements of breast surgical scars are based on calculations of contrast and area. We demonstrate, using the intra-class correlation coefficient (ICC), that the new measures are robust to observer variability in annotating the scar region on clinical photographs. As an example of the utility of the new measures, we use them to quantify the aesthetic differences of reconstruction following skin-sparing mastectomy vs. conventional mastectomy.
doi:10.1111/j.1365-2753.2010.01476.x
PMCID: PMC2958242  PMID: 20630016
Aesthetics; Breast Neoplasm; Esthetics; Mastectomy; Outcomes; Prostheses and Implants; Reconstructive Surgical Procedures; Surgical Flaps; Surgical Scars; Treatment Outcome; Quality of Life; Breast Conservation Therapy
10.  A Pilot Study on Using Eye Tracking to Understand Assessment of Surgical Outcomes from Clinical Photography 
Journal of Digital Imaging  2010;24(5):778-786.
Appearance changes resulting from breast cancer treatment impact the quality of life of breast cancer survivors, but current approaches to evaluating breast characteristics are very limited. It is challenging, even for experienced plastic surgeons, to describe how different aspects of breast morphology impact overall assessment of esthetics. Moreover, it is difficult to describe what they are looking for in a manner that facilitates quantification. The goal of this study is to assess the potential of using eye-tracking technology to understand how plastic surgeons assess breast morphology by recording their gaze path while they rate physical characteristics of the breasts, e.g., symmetry, based on clinical photographs. In this study, dwell time, transition frequency, dwell sequence conditional probabilities, and dwell sequence joint probabilities were analyzed across photographic poses and three observers. Dwell-time analysis showed that all three surgeons spent the majority of their time on the anterior–posterior (AP) views. Similarly, transition frequency analysis between regions showed that there were substantially more transitions between the breast regions in the AP view, relative to the number of transitions between other views. The results of both the conditional and joint probability analyses between the breast regions showed that the highest probabilities of transitions were observed between the breast regions in the AP view (APRB, APLB) followed by the oblique views and the lateral views to complete evaluation of breast surgical outcomes.
doi:10.1007/s10278-010-9338-x
PMCID: PMC3180533  PMID: 20852914
Breast neoplasm; Eye movements; Biomedical image analysis; Decision support; Evaluation research
11.  A Novel Quantitative Measure of Breast Curvature Based on Catenary 
Quantitative, objective measurements of breast curvature computed from clinical photographs could be used to investigate factors that impact reconstruction and facilitate surgical planning. This paper introduces a novel quantitative measure of breast curvature based on catenary. A catenary curve is used to approximate the overall curvature of the breast contour, and the curvature measure is extracted from the catenary curve. The catenary curve was verified by comparing its length, the area enclosed by the curve, and the curvature measure from the catenary curve to those from manual tracings of the breast contour. The evaluation of the proposed analysis employed untreated and postoperative clinical photographs of women who were undergoing tissue expander/implant (TE/Implant) reconstruction. Logistic regression models were developed to distinguish between the curvature of breasts undergoing TE/Implant reconstruction and that of untreated breasts based on the curvature measure and patient variables (age and body mass index). The relationships between the curvature measures of untreated breasts and patient variables were also investigated. The catenary curve approximates breast curvature reliably. The curvature measure contains useful information for quantifying the curvature differences between breasts undergoing TE/Implant reconstruction and untreated breasts, and identifying the effect of patient variables on the breast shape.
doi:10.1109/TBME.2012.2184541
PMCID: PMC3334380  PMID: 22271826
Breast cancer; breast curvature; breast reconstruction; catenary; digital photographs
12.  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.
doi:10.4137/BCBCR.S7140
PMCID: PMC3140267  PMID: 21792310
three-dimensional; stereophotogrammetry; subject pose; validation; breast; symmetry; surgical planning; pBRA
13.  Assessment of Breast Aesthetics 
Plastic and reconstructive surgery  2008;121(4):186e-194e.
A good aesthetic outcome is an important endpoint of breast cancer treatment. Subjective ratings, direct physical measurements, measurements on photographs, and assessment by three-dimensional imaging are reviewed and future directions in aesthetic outcome measurements are discussed. Qualitative, subjective scales have frequently been used to assess aesthetic outcomes following breast cancer treatment. However, none of these scales has achieved widespread use because they are typically vague and have low intra- and inter- observer agreement. Anthropometry is not routinely performed because it is impractical to conduct the large studies needed to validate anthropometric measures, i.e., studies in which several observers measure the same subjects multiple times. Quantitative measures based on digital/digitized photographs have yielded acceptable results but have some limitations. Three-dimensional imaging has the potential to enable consistent, objective assessment of breast appearance, including properties, such as volume, that are not available from two-dimensional images. However, further work is needed to define 3D measures of aesthetic properties and how they should be interpreted.
doi:10.1097/01.prs.0000304593.74672.b8
PMCID: PMC3097998  PMID: 18349598
Aesthetics; Breast Neoplasm; Esthetics; Mastectomy; Outcomes; Prostheses and Implants; Reconstructive Surgical Procedures; Surgical Flaps; Treatment Outcome; Quality of Life; Breast Conservation Therapy
14.  Toward Quantifying the Aesthetic Outcomes of Breast Cancer Treatment: Comparison of Clinical Photography and Colorimetry 
Rationale, aims and objectives
Scarring is a significant cause of dissatisfaction for women who undergo breast surgery. Scar tissue may be clinically distinguished from normal skin by aberrant color, rough surface texture, increased thickness (hypertrophy), and firmness. Colorimeters or spectrophotometers can be used to quantitatively assess scar color, but they require direct patient interaction and can cost thousands of dollars By comparison, digital photography is already in widespread use to document clinical outcomes and requires less patient interaction. Thus, assessment of scar coloration by digital photography is an attractive alternative. The goal of this study was to compare color measurements obtained by digital photography and colorimetry.
Method
Agreement between photographic and colorimetric measurements of color were evaluated. Experimental conditions were controlled by performing measurements on artificial scars created by a makeup artist. The colorimetric measurements of the artificial scars were compared to those reported in the literature for real scars in order to confirm the validity of this approach. We assessed the agreement between the colorimetric and photographic measurements of color using a hypothesis test for equivalence, the intra-class correlation coefficient (ICC), and the Bland-Altman method.
Results
Overall, good agreement was obtained for three parameters (L*a*b*) measured by colorimetry and photography from the results of three statistical analyses.
Conclusion
Color measurements obtained by digital photography were equivalent to those obtained using colorimetry. Thus, digital photography is a reliable, cost-effective measurement method of skin color and should be further investigated for quantitative analysis of surgical outcomes.
doi:10.1111/j.1365-2753.2008.00945.x
PMCID: PMC3072466  PMID: 19239578
Aesthetics; Breast Neoplasm; Clinical Photography; Reconstructive Surgical Procedures; Surgical Scars; Treatment Outcome
15.  A Multidimensional Analysis of Body Image Concerns Among Newly Diagnosed Patients with Oral Cavity Cancer 
Head & neck  2010;32(3):301-309.
Background
Body image is a critical psychosocial issue for patients facing treatment for oral cancer yet there is limited research conducted in this area. This study utilizes a multidimensional approach to body image assessment and evaluates relationships between body image, demographic, health, and psychosocial variables.
Methods
Newly diagnosed patients with oral cancer completed self-report questionnaires and a structured clinical interview.
Results
Most participants identified current and/or future body image concerns primarily related to impending surgery. Adequate psychometric properties were demonstrated on a range of body image measures. Depression was the strongest and most consistent predictor of body image outcomes.
Conclusions
Preliminary evidence supports the importance of evaluating body image concerns in oral cancer patients prior to surgical intervention. Our findings have implications for developing validated body image tools and can be used to guide psychosocial interventions targeting body image disturbance.
doi:10.1002/hed.21181
PMCID: PMC2821979  PMID: 19626634
body image; facial disfigurement; oral cavity cancer; distress; quality of life
16.  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.
doi:10.4137/BCBCR.S6352
PMCID: PMC3076012  PMID: 21494398
three-dimensional; anthropometry; validation; breast; photogrammetry; stereophotogrammetry; surgical planning
17.  Analysis of Breast Contour using Rotated Catenary 
Surgical reconstruction of natural-appearing breasts is a challenging task. Currently, surgical planning is limited to the surgeon’s subjective assessment of breast morphology. Therefore, it is useful to develop objective measurements of breast contour. In this paper, a novel quantitative measure of the breast contour based on catenary theory is introduced. A catenary curve is fitted on the breast contour (lateral and inferior) and the key parameter determining the shape of the curve is extracted. The new catenary analysis was applied to pre- and post-operative clinical photographs of women who underwent tissue expander/implant (TE/Implant) reconstruction. A logistic regression model was developed to predict the probability that the observed contour is that of a TE/Implant reconstruction from the catenary parameter, patient age, and patient body mass index. It was demonstrated that the parameters contain useful information for distinguishing TE/Implant reconstructed breasts from pre-operative breasts.
PMCID: PMC3041438  PMID: 21347015
18.  A Research Agenda for Appearance Changes Due to Breast Cancer Treatment 
Breast cancer is one of the most prevalent forms of cancer in the US. It is estimated that more than 180,000 American women will be diagnosed with invasive breast cancer in 2008. Fortunately, the survival rate is relatively high and continually increasing due to improved detection techniques and treatment methods. However, maintaining quality of life is a factor often under emphasized for breast cancer survivors. Breast cancer treatments are invasive and can lead to deformation of the breast. Breast reconstruction is important for restoring the survivor’s appearance. However, more work is needed to develop technologies for quantifying surgical outcomes and understanding women’s perceptions of changes in their appearance. A method for objectively measuring breast anatomy is needed in order to help both the breast cancer survivors and their surgeons take expected changes to the survivor’s appearance into account when considering various treatment options. In the future, augmented reality tools could help surgeons reconstruct a survivor’s breasts to match her preferences as much as possible.
PMCID: PMC3085417  PMID: 21655363
breast cancer; 3D imaging of breast; computer-assisted image analysis; quality of life
19.  Towards Quantifying the Aesthetic Outcomes of Breast Cancer Treatment: Assessment of Surgical Scars 
Our long-term goal is to develop decision aids that will improve breast cancer treatment by explicitly taking aesthetics in the consideration. Essentially all breast cancer treatment involves surgery, which inevitably leaves scars. However, the extent and type of scarring is not the same for different surgeries (e.g., different forms of reconstruction.) We present our preliminary experiences in using image processing techniques to quantify scar characteristics in clinical photographs.
PMCID: PMC1560447  PMID: 16779296

Results 1-19 (19)