The use of inverted-L posteromedial thigh (L-PMT) flap for autologous breast reconstruction: A case report.

The posteromedial thigh (PMT) flap has been described for breast reconstruction in vertical fashion (vPMT). However, it might not incorporate enough soft tissue for reconstruction of a medium size breast. Here, we present a case utilizing the free inverted-L posteromedial thigh (L-PMT) flap for autologous reconstruction of the breast. A 65-year-old woman with a body max index (BMI) of 24.5 kg/m2 underwent nipple sparring mastectomy and received immediate unilateral breast reconstruction. The flap was raised based on the first medial perforator of the profunda femoris artery (PFA). The internal mammary artery and vein were dissected as recipient vessels. The flap size was 25 cm × 25 cm. The mastectomy specimen and weight of the flap was 260 g and 310 g, respectively. The flap survived completely after surgery. The donor site was primarily closed with minimal morbidities. Follow-up observations were conducted from 1 to 6 months. The patient was satisfied with the reconstruction. The free L-PMT flap may be suitable for breast reconstruction in women with moderate breast size. The inverted-L pattern of the PMT flap allows the surgeon to include a bigger quantity of flap soft tissue enabling a more anatomical shape of the breast and represents an alternative design that may be used for autologous breast reconstruction in selected patients.

Computer assisted evaluation of plate osteosynthesis of diaphyseal femur fracture considering interfragmentary movement: a finite element study.

A semi-automated workflow for evaluation of diaphyseal fracture treatment of the femur has been developed and implemented. The aim was to investigate the influence of locking compression plating with diverse fracture-specific screw configurations on interfragmentary movements (IFMs) with the use of finite element (FE) analysis. Computed tomography (CT) data of a 22-year-old non-osteoporotic female were used for patient specific modeling of the inhomogeneous material properties of bone. Hounsfield units (HU) were exported and assigned to elements of a FE mesh and converted to mechanical properties such as the Young's modulus followed by a linear FE analysis performed in a semi-automated fashion. IFM on the near and far cortex was evaluated. A positive correlation between bridging length and IFM was observed. Optimal healing conditions with IFMs between 0.5 mm and 1 mm were found in a constellation with a medium bridging length of 80 mm with three unoccupied screw holes around the fracture gap. Usage of monocortical screws instead of bicortical ones had negligible influence on the evaluated parameters when modeling non-osteoporotic bone. Minimal user input, automation of the procedure and an efficient computation time ensured quick delivery of results which will be essential in a future clinical application.

[Father-Child-Contact and Well-being of the Children in Separated and Non-Separated Families]. / Vater-Kind-Kontakt und kindliches Wohlbefinden in getrennten und nicht-getrennten Familien.

Father-Child-Contact and Well-being of the Children in Separated and Non-Separated Families This study investigated determinants of the contact between children and fathers after parental separation and the interplay of family status (non-separated vs. separated families), father-child relationship-quality and child's well-being. We compared 254 adolescents aged 15 to 19 years, from non-separated and separated families, by administering an adaptation of the "Inventory of Life Quality in Children and Adolescents" (Mattejat u. Remschmidt, 1998) and the scale emotionality of the FPI-R (Fahrenberg, Hampel, Selg, 2000). Contact between fathers and children after parental separation was mainly associated with parental conflict and contact during and after the separation. No significant associations were found with age and gender of the child, maternal remarriage or paternal education. The relationship to the father mediated the effects of family arrangement on different measures of child well-being. In separated families children with little contact to their fathers showed worse relationships to them compared to children in intact families. Good father-child relationships were positively associated with different measures of children's well-being. A central conclusion of this study is, that the father-child relationship is an important source for child's well-being.

Three-dimensional prediction of free-flap volume in autologous breast reconstruction by CT angiography imaging.

PURPOSE: The diagnostic use of computer tomography angiography (CTA) to identify perforating blood vessels for abdominal free-flap breast reconstruction was extended to estimate the three-dimensional (3D) preoperative flap volume and to compare it with the real intraoperative flap weights in order to (1) evaluate the accuracy of CTA-based 3D flap volume prediction, and (2) to analyze abdominal tissue estimation for required breast volume reconstruction. METHODS: Preoperative CTA was performed in 54 patients undergoing unilateral breast reconstruction with a free, deep, inferior epigastric artery perforator flap. 3D flap volumes ([Formula: see text]) based on CTA data were calculated and compared with the actual intraoperative flap weight (g). In addition, a breast volume to flap volume ratio was calculated to analyze whether the estimated 3D abdominal flap volume would match that of the breast to be removed. RESULTS: 40 CTA data sets (74.1 %) fulfilled the technical requirements for a reliable determination of flap volume. 3D CTA flap volume prediction showed no relevant differences to the actual flap weight (p = 0.44) and high correlations (r = 0.998, [Formula: see text]), allowing a prediction accuracy within 0.29 [Formula: see text] 3.0 % (range: from [Formula: see text]8.77 to 5.67 %) of the real flap weight. Significantly larger flap volumes were harvested compared with the actually required breast volumes ([Formula: see text]), leading to an average of 21 % of the remnant flap tissue potentially being discarded. CONCLUSIONS: CTA-based 3D flap volume prediction provides accurate preoperative guidelines concerning the needed amount of abdominal tissue that can be harvested to achieve acceptable symmetry.

A computational tool for preoperative breast augmentation planning in aesthetic plastic surgery.

Breast augmentation was the most commonly performed cosmetic surgery procedure in 2011 in the United States. Although aesthetically pleasing surgical results can only be achieved if the correct breast implant is selected from a large variety of different prosthesis sizes and shapes available on the market, surgeons still rely on visual assessment and other subjective approaches for operative planning because of lacking objective evaluation tools. In this paper, we present the development of a software prototype for augmentation mammaplasty simulation solely based on 3-D surface scans, from which patient-specific finite-element models are generated in a semiautomatic process. The finite-element model is used to preoperatively simulate the expected breast shapes using physical soft-tissue mechanics. Our approach uses a novel mechanism based on so-called displacement templates, which, for a specific implant shape and position, describe the respective internal body forces. Due to a highly efficient numerical solver we can provide immediate visual feedback of the simulation results, and thus, the software prototype can be integrated smoothly into the medical workflow. The clinical value of the developed 3-D computational tool for aesthetic breast augmentation surgery planning is demonstrated in patient-specific use cases.

Comparison of different material models to simulate 3-d breast deformations using finite element analysis.

Biomechanical breast modeling using finite element (FE) analysis to predict 3-D breast deformations is of interest for various biomedical applications. Currently no consensus of reliable magnitudes of mechanical breast tissue properties exists. We therefore applied 12 material properties proposed in the literature to FE simulation models derived from prone MRI breast datasets of 18 female volunteers. A gravity free starting position is computed with an iterative FE algorithm followed by the calculation of the upright position of the breast and then compared to the real breast geometry in standing position using corresponding 3-D surface scans to determine the accuracy of the simulation. Hyper-elastic constitutive models showed superior performance than linear elastic models which cannot exceed the linear Hookean domain. Within the group of applied hyper-elastic material models those proposed by Tanner et al. (Med Phys 33:1758-1769, 2006) and Rajagopal et al. (Acad Radiol 15:1425-1436, 2008) performed significantly (p < 0.01) better than other material models. The advantage of the method presented is its non-invasive character by combining 3-D volume and surface imaging with automated FE analysis. Thus, reliable biomechanical breast models based on the presented methods can be applied in future to derive patient-specific material parameter sets to improve a wide range of healthcare applications.

Multiaxial mechanical properties and constitutive modeling of human adipose tissue: a basis for preoperative simulations in plastic and reconstructive surgery.

A preoperative simulation of soft tissue deformations during plastic and reconstructive surgery is desirable to support the surgeon's planning and to improve surgical outcomes. The current development of constitutive adipose tissue models, for the implementation in multilayer computational frameworks for the simulation of human soft tissue deformations, has proved difficult because knowledge of the required mechanical parameters of fat tissue is limited. Therefore, for the first time, human abdominal adipose tissues were mechanically investigated by biaxial tensile and triaxial shear tests. The results of this study suggest that human abdominal adipose tissues under quasi-static and dynamic multiaxial loadings can be characterized as a nonlinear, anisotropic and viscoelastic soft biological material. The nonlinear and anisotropic features are consequences of the material's collagenous microstructure. The aligned collagenous septa observed in histological investigations causes the anisotropy of the tissue. A hyperelastic model used in this study was appropriate to represent the quasi-static multiaxial mechanical behavior of fat tissue. The constitutive parameters are intended to serve as a basis for soft tissue simulations using the finite element method, which is an apparent method for obtaining promising results in the field of plastic and reconstructive surgery.

3-D analysis of breast morphology changes after inverted T-scar and vertical-scar reduction mammaplasty over 12 months.

One major objective of all types of breast reduction procedures is to achieve a long-lasting, stable and aesthetically pleasing three-dimensional (3-D) breast shape, but current surgical outcome evaluation is limited. This study compares the extent of soft-tissue oedema and breast tissue migration related to 3-D breast morphology changes after inverted T-scar and vertical-scar breast reduction over 12 months. 3-D breast surface scans of patients undergoing inverted T-scar (n=52 breasts) and vertical-scar (n=44 breasts) reduction mammaplasty were obtained preoperatively and 2-3 days, 1 week, 1 month, 3 months, 6 months, 9 months and 12 months postoperatively. 3-D images were analysed at each time point comparing distances, 3-D breast contour deviations (%), breast surface (cm2) and volume (cc) measurements including volumetric distribution between the upper portion (UP) and the lower portion (LP) of the breast (%). Total postoperative breast volume decreased by 11.7% (T-scar) and by 7.8% (vertical-scar) during the first 3 months (both p<0.001) without relevant changes in the following months, indicating that soft-tissue oedema is resolved after 3 months. The T-scar (vertical-scar) group showed a preoperative UP to LP volumetric distribution of 43:57% (45:55%) versus 86:14% (91:9%) immediately after surgery. Breast tissue significantly redistributes (both p=0.001) from the UP to the LP during the first postoperative year by 16.5% (T-scar) and 21% (vertical-scar), resulting in a final UP to LP ratio of 70:30% for both techniques, without further breast contour deviations (both p>0.05) after 6 months (T-scar) and 9 months (vertical-scar). Breast morphological changes after reduction mammaplasty are completed after a period of 3-6 months in the T-scar group and 6-9 months in the vertical-scar group.

Evaluation of precision and accuracy assessment of different 3-D surface imaging systems for biomedical purposes.

Three-dimensional (3-D) surface imaging has gained clinical acceptance, especially in the field of cranio-maxillo-facial and plastic, reconstructive, and aesthetic surgery. Six scanners based on different scanning principles (Minolta Vivid 910®, Polhemus FastSCAN™, GFM PRIMOS®, GFM TopoCAM®, Steinbichler Comet® Vario Zoom 250, 3dMD DSP 400®) were used to measure five sheep skulls of different sizes. In three areas with varying anatomical complexity (areas, 1 = high; 2 = moderate; 3 = low), 56 distances between 20 landmarks are defined on each skull. Manual measurement (MM), coordinate machine measurements (CMM) and computer tomography (CT) measurements were used to define a reference method for further precision and accuracy evaluation of different 3-D scanning systems. MM showed high correlation to CMM and CT measurements (both r = 0.987; p < 0.001) and served as the reference method. TopoCAM®, Comet® and Vivid 910® showed highest measurement precision over all areas of complexity; Vivid 910®, the Comet® and the DSP 400® demonstrated highest accuracy over all areas with Vivid 910® being most accurate in areas 1 and 3, and the DSP 400® most accurate in area 2. In accordance to the measured distance length, most 3-D devices present higher measurement precision and accuracy for large distances and lower degrees of precision and accuracy for short distances. In general, higher degrees of complexity are associated with lower 3-D assessment accuracy, suggesting that for optimal results, different types of scanners should be applied to specific clinical applications and medical problems according to their special construction designs and characteristics.

Comparative assessment of 3D surface scanning systems in breast plastic and reconstructive surgery.

In this work, we compared accuracy, repeatability, and usability in breast surface imaging of 2 commercial surface scanning systems and a hand-held laser surface scanner prototype coupled with a patient's motion acquisition and compensation methodology. The accuracy of the scanners was assessed on an anthropomorphic phantom, and to evaluate the usability of the scanners on humans, thorax surface images of 3 volunteers were acquired. Both the intrascanner repeatability and the interscanner comparative accuracy were assessed. The results showed surface-to-surface distance errors inferior to 1 mm and to 2 mm, respectively, for the 2 commercial scanners and for the prototypical one. Moreover, comparable performances of the 3 scanners were found when used for acquiring the breast surface. On the whole, this study demonstrated that handheld laser surface scanners coupled with subject motion compensation methods lend themselves as competitive technologies for human body surface modeling.

Prediction of breast resection weight in reduction mammaplasty based on 3-dimensional surface imaging.

Prediction of resection weight (RW) in reduction mammaplasty is helpful in achieving breast symmetry and in fulfilling the stringent reimbursement requirements of health insurance companies. Current breast volume estimations are largely based on surgeon's experience, which are partially unreliable and often cumbersome to obtain. Therefore, this study aims to develop a formula to predict RW based on 3D surface imaging. A total of 68 breasts were treated with bilateral T-scar, and 40 breasts were treated with bilateral or unilateral vertical-scar reduction mammaplasty. Linear distances and volume measurements were assessed 3-dimensionally preoperatively and 6 months postoperatively. Significant correlations between the RW and the calculated preoperative breast volume (ρ = 0.804) and the sternal notch to nipple distance (ρ = 0.839) were found in both techniques (P < .001). Regression equations with the RW were performed to derive prediction formulas. Surgeons may benefit from the formulas in terms of improvement in preoperative planning, dealing with insurance coverage questions, and optimizing patient consultation.

A review of 13 years of experience with endoscopic forehead-lift.

OBJECTIVE: To conduct objective quantitative and qualitative evaluations of the long-term result in endoscopic forehead-lift. METHODS: Medical charts of 143 patients who underwent endoscopic forehead-lift between 1994 and 2007 were reviewed for postoperative complications and the duration of complaints. Patients received a questionnaire to evaluate satisfaction and social restriction after surgery. Objective photographic preoperative and postoperative eyebrow-to-eye distances in a relaxed position and during muscle contractions were obtained. RESULTS: A total of 98 patients (69% response; mean follow-up, 38 months) showed high satisfaction (score, 7.1 of 10). In a relaxed position, mean midpupil-to-eyebrow elevation was 5.6 mm after surgery, with significant eyebrow symmetry between the left and right eyes (P < .05), and showed significant influence of time (P = .005) on persisting eyebrow elevation, with a decrease of almost 1 mm per year. Measurements during muscle contraction showed no relevant differences. CONCLUSION: Endoscopic forehead-lift enables long-lasting results with highly satisfied patients.

Three-dimensional evaluation of breast augmentation and the influence of anatomic and round implants on operative breast shape changes.

BACKGROUND: Currently, postoperative outcome analysis in breast augmentation is essentially subjective, and objective evaluation of treatment efficacy is lacking. This study evaluates the influence of anatomic and round implant parameters on breast contour changes after subpectoral breast augmentation using three-dimensional (3D) surface imaging. METHODS: 3D surface breast scans of 17 patients (34 breasts) undergoing subpectoral breast augmentation with round implants and of ten patients (20 breasts) receiving anatomic implants via an axillary approach under endoscopic assistance or a submammary fold incision were obtained before and 6 months postoperatively. 3D linear distance, breast volume, and surface measurement were correlated with the implanted round and anatomic implant parameters, and the resulting breast shape changes were evaluated. RESULTS: Total breast volume changed in correlation with the implant size (2.4% difference; r=0.894; p<0.001). Implant volume and type influence the nipple-to-inframammary fold distance (N-IMF). Every inserted 100 ml implant volume enlarges the N-IMF distance by 0.8 cm (anatomic>round; p=0.01). Postoperatively, the IMF dropped by an average of 1.3 cm for round implants and by 1.1 cm for anatomic implants, without relevant differences between the applied surgical incision and the selected implants (p>0.05). Breast projection increased significantly more with anatomic implants (2.4 cm) than with round implants (1.7 cm) (p=0.01). The breast projection increase was 22% less than expected for round implants and 25% less than expected for anatomic implants based on the manufacturer implant parameters (p<0.01), without essential differences regarding the surgical incision. CONCLUSIONS: 3D breast shape changes induced by round and anatomic implants after subpectoral augmentation mammaplasty are objectively documented including breast projection, volume, and N-IMF distance changes. 3D surface imaging may have a potential clinical contribution to objective surgical outcome research. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors at www.springer.com/00266.

Objective breast symmetry evaluation using 3-D surface imaging.

This study develops an objective breast symmetry evaluation using 3-D surface imaging (Konica-Minolta V910(®) scanner) by superimposing the mirrored left breast over the right and objectively determining the mean 3-D contour difference between the 2 breast surfaces. 3 observers analyzed the evaluation protocol precision using 2 dummy models (n = 60), 10 test subjects (n = 300), clinically tested it on 30 patients (n = 900) and compared it to established 2-D measurements on 23 breast reconstructive patients using the BCCT.core software (n = 690). Mean 3-D evaluation precision, expressed as the coefficient of variation (VC), was 3.54 ± 0.18 for all human subjects without significant intra- and inter-observer differences (p > 0.05). The 3-D breast symmetry evaluation is observer independent, significantly more precise (p < 0.001) than the BCCT.core software (VC = 6.92 ± 0.88) and may play a part in an objective surgical outcome analysis after incorporation into clinical practice.

Three-dimensional evaluation of breast contour and volume changes following subpectoral augmentation mammaplasty over 6 months.

BACKGROUND: Changes in breast-morphology occur after all types of breast surgery, but a systematic and objective surgical result assessment is currently lacking. Three-dimensional (3-D) surface imaging offers the ability to quantitatively evaluate breast contour, shape, surface and volume changes after surgery. This study evaluates 3-D breast contour and volume changes after breast augmentation over time. METHODS: 3-D surface imaging of 14 subpectoral breast-augmentation patients (n = 28 breasts) were accomplished over six time periods (preoperative (OP), post-OP 1: 2-3 days; post-OP 2: 1 week; post-OP 3: 1 month; post-OP 4: 3 months; and post-OP 5: 6 months after surgery) and linear-distance measurement, breast volume and surface changes were analysed. 3-D breast-contour- and volume variations are expressed in percentage changes over time. RESULTS: All breast measurements changed significantly between pre-OP and post-OP 1 (Friedmann test, p = 0.001-0.025). First significant postoperative changes over time compared with post-OP 1 for breast volume, surface, sternal notch to nipple and nipple to inframammary-fold-distance measurements are quantifiable after 1 month (post hoc Wilcoxon test, p = 0.001 for all) with further relevant breast volume (post hoc Wilcoxon test, p = 0.041) and surface changes (post hoc Wilcoxon test, p = 0.037) between months 1 and 3 after surgery. The inframammary fold dropped by 1.4 cm after 6 months and final breast volume ± 0.5% is reached between months 1 and 3 after surgery. Valuable reductions in breast contour and volume by nearly 85% are also reached after 1 month (Wilcoxon test, p = 0.001) and changed to 98% after 3 months and 100% after 6 months. CONCLUSIONS: Breast morphological changes following subpectoral breast augmentation are completed after 3 months. 3-D surface imaging may play a part in comparing different breast-augmentation techniques.

Women's quality of life and surgical long-term outcome after breast reconstruction in Poland syndrome patients.

BACKGROUND: In the last decades, several surgical approaches have been used to improve the appearance and quality of life of female Poland syndrome patients. The aim of this study was to analyze the women's quality of life and long-term outcome after breast reconstruction. METHODS: Forty-nine women with Poland syndrome who were treated surgically between 1974 and 2007 received standardized questionnaires to evaluate their quality of life and satisfaction after surgical treatment. RESULTS: Patient response was 65%, with 32 completed questionnaires by 16 women who had pedicled latissimus dorsi myocutaneous (LDM) flaps, 12 with tissue expander or silicone implants, and 4 who had free transverse rectus abdominis myocutaneous (TRAM) flaps. Of these patients, 16 were satisfied or highly satisfied with their postoperative appearance (13 with LDM, 2 with prosthesis, and 1 with TRAM), 16 patients would recommend the same surgery to others under similar circumstances (10 with LDM, 5 with prosthesis, and 1 with TRAM), and 18 patients would choose the same method again (14 with LDM, 3 with prosthesis, and 1 with TRAM). CONCLUSIONS: In our study, we found that satisfactory outcome in breast reconstruction was achieved particularly when using the LDM flap, which remains the only method that recreates the anterior axillary fold. Future studies on reconstruction methods with autogenous tissue (e.g., TRAM, deep inferior epigastric perforator [DIEP] flap) are needed, however, to analyze quality of life and long-term outcome in patients with Poland syndrome.

[Breast volume assessment based on 3D surface geometry: verification of the method using MR imaging]. / Brustvolumenbestimmung anhand der 3-D-Oberflächengeometrie: Verifizierung der Methode mit Hilfe der Kernspintomographie.

Differences in breast volume and contour are subjectively estimated by surgeons. 3D surface imaging using 3D scanners provides objective breast volume quantification, but precision and accuracy of the method requires verification. Breast volumes of five test individuals were assessed using a 3D surface scanner. Magnetic resonance imaging (MRI) reference volumes were obtained to verify and compare the 3D scan measurements. The anatomical thorax wall curvature was segmented using MRI data and compared to the interpolated curvature of the posterior breast volume delimitation of 3D scan data. MRI showed higher measurement precision, mean deviation (expressed as percentage of volume) of 1.10+/-0.34% compared to 1.63+/-0.53% for the 3D scanner. Mean MRI [right (left) breasts: 638 (629)+/-143 (138) cc] and 3D scan [right (left) breasts: 493 (497)+/-112 (116) cc] breast volumes significantly correlated [right (left) breasts: r=0.982 (0.977), p=0.003 (0.004)]. The posterior thorax wall of the 3D scan model showed high agreement with the MRI thorax wall curvature [mean positive (negative) deviation: 0.33 (-0.17)+/-0.37 cm]. High correspondence and correlation of 3D scan data with MRI-based verifications support 3D surface imaging as sufficiently precise and accurate for breast volume measurements.