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1.  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
2.  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
3.  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
4.  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
5.  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
6.  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
7.  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
8.  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
9.  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 1-9 (9)