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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.  Body Image Screening for Cancer Patients Undergoing Reconstructive Surgery 
Psycho-oncology  2014;23(8):898-905.
Objectives
Body image is a critical issue for cancer patients undergoing reconstructive surgery, as they can experience disfigurement and functional impairment. Distress related to appearance changes can lead to various psychosocial difficulties, and patients are often reluctant to discuss these issues with their healthcare team. Our goals were to design and evaluate a screening tool to aid providers in identifying patients who may benefit from referral for specialized psychosocial care to treat body image concerns.
Methods
We designed a brief 4-item instrument and administered it at a single time point to cancer patients who were undergoing reconstructive treatment. We used simple and multinomial regression models to evaluate whether survey responses, demographic, or clinical variables predicted interest and enrollment in counseling.
Results
Over 95% of the sample (n = 248) endorsed some concerns, preoccupation, or avoidance due to appearance changes. Approximately one-third of patients were interested in obtaining counseling or additional information to assist with body image distress. Each survey item significantly predicted interest and enrollment in counseling. Concern about future appearance changes was the single best predictor of counseling enrollment. Sex, age, and cancer type were not predictive of counseling interest or enrollment.
Conclusions
We present initial data supporting use of the Body Image Screener for Cancer Reconstruction. Our findings suggest benefits of administering this tool to patients presenting for reconstructive surgery. It is argued that screening and treatment for body image distress should be provided to this patient population at the earliest possible time point.
doi:10.1002/pon.3491
PMCID: PMC4116641  PMID: 25066586
body image; distress screening; breast cancer; head and neck cancer; reconstructive surgery
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.  Impact of Surgical Techniques, Biomaterials, and Patient Variables on Rate of Nipple Necrosis after Nipple-Sparing Mastectomy 
Plastic and reconstructive surgery  2013;132(3):330e-338e.
Background
Nipple-sparing mastectomy (NSM) is appropriate for selected patients with early-stage breast cancer or high breast cancer risk. However, the rate of nipple necrosis after NSM is relatively high (10% to 30%). No study has specifically evaluated whether clinical and technical factors contribute to nipple necrosis after NSM. The objectives of this study were to determine the impact of clinicopathologic and surgical variables on rates of partial and total nipple necrosis after NSM and to compare overall complication rates between NSM and skin-sparing mastectomy (SSM).
Methods
The study included 233 cases, 113 had NSM and immediate breast reconstruction and 120 matched (for disease stage, comorbidities, and age) cases of SSM and immediate reconstruction performed at our institution from September 2003 through May 2011. Complications were analyzed using the Fisher’s exact test, and in the NSM group, clinicopathologic and surgical variables were analyzed using Rao-Scott chi-squared tests for relationship with partial or total nipple necrosis.
Results
The overall complication rate was 28% for NSM and 27% for SSM (p>0.99). In patients who did not have axillary surgery (those undergoing risk-reducing mastectomy), the overall rate of complications was significantly higher in the NSM group than in the SSM group (26% versus 9%; p=0.06). However, in patients who had axillary surgery (either sentinel lymph node biopsy or axillary lymphadenectomy), the overall complication rate did not differ between the two groups. For NSM, the overall incidence of any (partial or total) nipple necrosis was 20%. There were only 2 cases (2%) with total necrosis. Larger breasts (C cup or larger) were associated with a higher rate of nipple necrosis (34% for C cup; 6% for A and B cup; p=0.003). Smoking (p=0.08) and vascular comorbidities (p=0.09) did not reach statistical significance as predictors of nipple necrosis. The other factors analyzed were not predictors of nipple necrosis.
Conclusions
We found no significant difference in the overall incidence of complications in patients who have NSM compared to those who have SSM. Interestingly, the exclusion of axillary lymphatic surgery in patients undergoing risk-reducing NSM for high breast cancer risk did not decrease the incidence of complications, probably because of the inherent technical complexity of performing NSM in and of itself. Although partial nipple necrosis did occur quite frequently (19%), total nipple necrosis after NSM occurred infrequently (2%). Importantly, patients with breast size of C cup or larger had an increased risk for nipple necrosis after NSM and immediate breast reconstruction.
Clinical Level of Evidence
Therapeutic, III.
doi:10.1097/PRS.0b013e31829ace49
PMCID: PMC3935717  PMID: 23985644
6.  Prospective Evaluation of the Nipple Areola Complex Sparing Mastectomy for Risk Reduction and for Early-Stage Breast Cancer 
Annals of surgical oncology  2011;19(4):10.1245/s10434-011-2099-z.
Background
Psychological effects of mastectomy for women with breast cancer have driven treatments that optimize cosmesis while strictly adhering to oncologic principles. Although skin-sparing mastectomy is oncologically safe, questions remain regarding the use of nipple–areola complex (NAC)-sparing mastectomy (NSM). We prospectively evaluated NSM for patients undergoing mastectomy for early-stage breast cancer or risk reduction.
Methods
We enrolled 33 early-stage breast cancer and high-risk patient; 54 NSMs were performed. NAC viability and surgical complications were evaluated. Intraoperative and postoperative pathologic assessments of the NAC base tissue were performed. NAC sensory, cosmetic and quality of life (QOL) outcomes were also assessed.
Results
Twenty-one bilateral and 12 unilateral NSMs were performed in 33 patients, 37 (68.5%) for prophylaxis and 17 (31.5%) for malignancy. Mean age was 45.4 years. Complications occurred in 16 NACs (29.6%) and 6 skin flaps (11.1%). Operative intervention for necrosis resulted in 4 NAC removals (7.4%). Two (11.8%) of the 17 breasts with cancer had ductal carcinoma-in-situ at the NAC margin, necessitating removal at mastectomy. All evaluable patients had nipple erection at 6 and 12 months postoperatively. Cosmetic outcome, evaluated by two plastic surgeons, was acceptable in 73.0% of breasts and 55.8% of NACs, but lateral displacement occurred in most cases. QOL assessment indicated patient satisfaction.
Conclusions
NSM is technically feasible in select patients, with a low risk for NAC removal resulting from necrosis or intraoperative detection of cancer, and preserves sensation and QOL. Thorough pathologic assessment of the NAC base is critical to ensure disease eradication.
doi:10.1245/s10434-011-2099-z
PMCID: PMC3854933  PMID: 21979111
7.  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
8.  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
9.  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
10.  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
11.  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
12.  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
13.  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
14.  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
15.  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

Results 1-15 (15)