Clinical Accuracy of Portrait 3D Surgical Simulation Platform in Breast Augmentation. Ryan K. Wong MD, David T Pointer BS, Kamran Khoobehi MD FACS

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1 Clinical Accuracy of Portrait 3D Surgical Simulation Platform in Breast Augmentation Ryan K. Wong MD, David T Pointer BS, Kamran Khoobehi MD FACS Division of Plastic, Reconstructive & Reconstructive Surgery, Louisiana State University Running Head: 3D Breast Imaging Address Correspondence: Kamran Khoobehi, MD FACS 3901 Veterans Blvd Metairie, LA Phone:

2 FINANCIAL DISCLOSURE: None of the authors have a financial interest in any of the products, devices, or drugs mentioned in this manuscript.

3 Abstract Background: The modern technology age has merged the application of computers and digital photography with the medical practice. The Axis Three Surgical Simulation Platform (Axis Three, Boston, MA) uses integrated image capture technology and rendering software to recreate a three dimensional model of the patient. Through the software, volumetric and linear measurements can be made on the model as well as performing simulations for breast augmentation. Purpose: This study was conducted to evaluate the accuracy of the volumetric measurements of the Axis Three system. The future application would be in the measurement and evaluation of percentage of fat retention in fat grafting to the breast procedures. Methodology: A retrospective chart review was conducted on patients who underwent breast augmentation procedures and imaging with the Axis Three system between May and August of Patients with ptosis or who underwent concomitant breast procedures along with their augmentation were excluded from the study. Pre operative imaging using the Portrait 3D system is performed during their initial consultation. Patients who choose to undergo breast augmentation are routinely followed at 1 week and 6 weeks post operatively. Postoperative imaging with the Axis Three system is repeated at their 6-week postoperative visit. Volumetric analysis was performed and the estimated implant volume was derived by calculating the difference between the pre operative and postoperative breast volume. Charts were reviewed by an independent reviewer for the actual implant volume used in surgery and these were

4 compared to the Axis Three calculated volumes. Charts were also reviewed for the occurrence of complications and revisions. Results: A total of 30 consecutive patients underwent breast augmentation during the study period and of these, 21 patients (42 breasts) were followed up with postoperative imaging with the Axis Three system. Postoperative imaging was taken on average of 10.7 weeks post operatively. Of the patients who underwent imaging, 10 were silicone implants and 11 were saline implants with an average implant volume of 342 cc. All implants were placed in the subpectoral plane through an inframammary incision. The average percent difference between the actual implant volume and the Axis Three implant volume was 13.8%. The average length of follow up was 10.7 weeks with no occurrences of complications or revisions. Introduction and Summary The modern age of technology has brought many new innovations to aid the medical field and the specialty of plastic surgery. This specialty has actively benefited from the progression of standard photography to digital photography. 1 The most recent benefit to plastic surgery is the development of three dimensional imaging systems. 2 Current systems such as Axis Three Surgical Simulation Platform (Axis Three, Boston, MA), Vectra X3 (Canfield, Fairfield, NJ), and

5 3dMD (Atlanta, GA) offer three-dimensional imaging of almost any aspect of the body including the face and breast. Breast augmentation remains one of the most commonly performed aesthetic procedures and the application of a 3D system offers advantages to both the physician and the patient. For the physician, the 3D system offers the advantage of calculating measurements and volumes not easily obtained by conventional 2D photography or physical examination. It can calculate volumes of each breast and identify pre existing asymmetry. The system can also vastly improve the communication of the postoperative result to the patient by providing them with a 3D simulated representation. Research regarding the accuracy of 3D technology is just beginning to emerge in the literature. The system has applications in many aspects of breast surgery including breast augmentation, reduction mammoplasty, mastopexy, and breast reconstruction. 2 Much of the literature has been focused on various applications and the potential value of future studies on various measurements using 3D rather than 2D images is undisputable. However, few studies have addressed the actual accuracy of these systems. 4-6 The purpose of this study is to measure the accuracy of the volumetric analysis of the Portrait 3D system. Materials and Methods A retrospective chart review was conducted on patients who underwent breast augmentation procedures and imaging with the Axis Three system between May and August of 2009.

6 Patients with ptosis, or patients who underwent concomitant breast procedures along with their augmentation, were excluded from the study. Because the software relies on accurate images of the entire breast surface, ptosis conceals the undersurface of the breast causing an overestimation of the volume. Charts were also reviewed for length of follow up and the emergence of complications and revisions. Pre operative imaging using the Axis Three system was performed during their initial consultation. Patients who chose to undergo breast augmentation were routinely followed at 1 week and 6 weeks post operatively. Postoperative imaging with the Axis Three system was repeated at their 6 week post operative visit or at a subsequent visit more than 6 weeks post operatively. Volumetric analysis was performed by a senior plastic surgery resident or the senior author using the Axis Three software. The required landmarks are placed on the lateral border of the breast, sterna notch, nipple, upper areola border, inframammary fold, and medial breast. The Axis Three software then extrapolates the breast volume from the data points. Fine adjustments to the points are made by the surgeon to ensure that the actual total breast is included to make it more accurate. The estimated implant volume was derived by calculating the difference between the pre operative and postoperative breast volume. Charts were reviewed by an independent reviewer for the actual implant volume used in surgery to avoid bias in the simulation measurements. These were then compared to the Axis Three calculated volumes. The difference between the simulated and actual implant volumes was calculated and the absolute value was used.

7 The percentage was deduced by dividing the difference by the actual implant volume. Results A total of 30 patients underwent breast augmentation between May and August of 2009 and of these, 21 patients (42 breasts) had adequate post operative imaging performed on the Axis Three system. The average implant size placed was 342 cc (range cc). Eleven of the implants were saline and 10 were silicone. All implants were placed through an inframammary incision in the subpectoral plane. Post operative imaging was performed on average of 10.7 weeks from their breast augmentation procedure. There were no complications or need for revisions with an average follow up of 10.7 weeks (range 6-21 weeks). When analyzing the data from the Axis Three system, the average simulated implant size was 333 cc (range cc). The average implant volume difference was calculated to be 48 cc with the percent difference calculated to be 13.8%. Discussion

8 The addition of 3D imaging to the arsenal of the plastic surgeon has numerous applications in the realm of aesthetic and reconstructive breast surgery. It is a visual tool, which can bring communication between the surgeon and the patient to a higher level. Plastic surgeons have longed for the ability to convey an accurate visual representation of a postoperative result to their patient and vice versa. The use of the simulation tools with 3D imaging brings this ability to a much higher level, with the ability to use the patient s own body as a model instead of relying on the previous adage of using before and after photographs of other patients, pictures from other sources, or placing implants into brassieres, among other methods. This modality of 3D imaging and computerized measurements also brings a new dimension in surgical planning in both aesthetic and reconstructive breast surgery. The volume measurements can better identify pre existing breast asymmetry, which may alter the plan for augmentation or reconstruction. In the realm of reconstruction, it may be possible to measure the volume of the intact breast in unilateral reconstruction patient. By knowing this measurement, we can better tailor our flaps to match the other side, ensuring better symmetry and possibly decreasing the need for subsequent revisions. With the evolution of fat grafting to the breast, the main issue of concern is fat survival and retention. The use of 3D imaging can be a valuable tool in calculating fat retention and determining preoperative and postoperative breast volumes. However, before using this data in common practice, it is important to validate the data the software provides. Losken et al studied 3dMD and compared software calculated volumes to volumes of mastectomy specimens determined by water displacement and found the

9 difference between the two volumes to be -2%. 4 In this study, we are evaluating the Portrait 3D system with known implant volumes as our controls. We attempted to eliminate bias by having the computer measurements made by an independent reviewer who had no prior knowledge of the implant volume placed at the time of surgery. Other limitations of this report include the small sample size and the necessity of manually defining the breast dimensions on the computer, which may affect the volume measurement depending on the operator. When not taking into account the absolute value, the average difference was found to be +9 cc with an average difference of 2.5%. However, we chose to use the absolute value of the difference in our calculations in order for the difference from the actual implant volume to be more accurate. Also, no correlation was found between the pre operative breast volume and the discrepancy in implant sizes (Figure 1). The study shows that the Portrait 3D platform produces accurate data when measuring breast volume. Its reliability can give confidence to the patient in better representing a simulated postoperative result. In addition, the data accuracy can enable to surgeon to better plan the surgery whether it be for aesthetic or reconstructive reasons. By establishing confidence in 3D imaging s accuracy, we can expand the possibilities provided by these systems to enhance the field of breast surgery.

10 1. DiSaia JP, Ptak JJ, Achauer BM. Digital photography for the plastic surgeon. Plast Reconstr Surg. 102: 569, Galdino GM, Nahabedian M, Chiaramonte M, Geng JZ, Klatsky S, Manson P. Clinical applications of three-dimensional photography in breast surgery. Plast Reconstr Surg. 110: 58, Isogai N, Sai K, Kamiishi H, et al. Quantitative analysis of the breast using a 3- dimensional laser light scanner. Ann Plast Surg. 56: 237, Losken A, Seify H, Denson DD, et al. Validating three-dimensional imaging of the breast. Ann Plast Surg. 54: 471, Tepper OM, Small K, Rudoph L, et al. Virtual 3-dimensional modeling as a valuable adjunct to aesthetic and reconstructive breast surgery. Am J Surg. 192: 548, Tepper OM, Small K, Unger JG, et al. 3D analysis of breast augmentation defines operative changes and their relationship to implant dimensions. Ann Plast Surg. 62: 570, Figure 1 Implant volume difference vs. pre operative breast volume.

11 Figure 2 Patient with pre op photographs, simulation with 300 cc implants, and post operative photographs after 300 cc implants. Figure 3 Patient with pre op photographs, simulation with 400 cc implants, and post operative photographs 11 weeks after 400 cc implants.

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