A cognitive behavioral therapy-based intervention to address body image in patients with facial cancers: Results from a randomized controlled trial.

OBJECTIVES: Body image adjustment is a crucial issue for patients with facial cancer, but body image-specific interventions are scarce. We report results of a novel psychotherapeutic intervention to address body image concerns during acute postoperative recovery following facial reconstructive surgery. Our primary aims were to evaluate the intervention's feasibility, acceptability, and efficacy on body image concerns, psychological distress, and quality of life (QOL). METHODS: Adults with facial cancers who endorsed body image concerns were recruited to participate in a randomized controlled trial. The intervention group participated in 4 in-person counseling sessions. The control group received an educational booklet and a brief phone call. Participants completed measures of body image, distress, and QOL at baseline and at the 4-week follow-up to assess the impact of the intervention. Intervention outcomes were assessed with 2 sample t-tests or Mann-Whitney U tests as appropriate. RESULTS: Twenty-nine participants completed both the baseline and follow-up assessments. The intervention demonstrated good feasibility with a high retention rate (79%), visit completion rate (81%), and high satisfaction scores (75% reported mean satisfaction score of >3). Intervention did not result in an observed statistically significant difference in reduction in body image dissatisfaction and disturbance, psychological distress, or improvement in QOL compared with the control group. However, intervention resulted in statistically significant difference in perceived social impact (-1 vs. -8.3, p = 0.033) compared to control group. SIGNIFICANCE OF RESULTS: Our study highlights the potential clinical benefits of a novel psychotherapeutic intervention that targets body image concerns and suggests the need for further evaluation.

A qualitative assessment of body image in adolescents and young adults (AYAs) with cancer.

CONTEXT: Among adolescents and young adults (AYAs), cancer and its treatment can disturb body image in distinct ways compared to younger or older individuals. OBJECTIVE: Since AYA body image is not well understood, this study was designed to develop a conceptual framework for body image in AYAs with cancer. METHODS: Concept elicitation interviews were conducted with 36 AYA patients [10 adolescents (15-17 years), 12 emerging adults (18-25 years), 14 young adults (26-39 years)] and health care providers (n = 36). The constant comparative method was used to analyze for themes and properties, with themes considered saturated if they were present and salient across participant sets. RESULTS: Twenty themes emerged from participant data. Three themes illustrate a shared understanding of patients' experience of body image: (1) physical changes produce shifts in identity and experience of self; (2) precancer body image shapes how the AYA experiences cancer-related physical changes, and (3) changes to the body are upsetting. Nine themes were unique to patients while eight themes were unique to providers. Patient body image experiences were found to evolve over time, largely affected by concerns about how others view them. Providers appeared attuned to AYA patient body image but recognized that it is not systematically addressed with patients. CONCLUSION: More striking than differences between patient groups is the consistency of themes that emerged. The conceptual framework of body image developed from these data offers an important step toward addressing body image concerns for AYA patients.

Longitudinal analysis of patient-reported outcomes and cosmesis in a randomized trial of conventionally fractionated versus hypofractionated whole-breast irradiation.

BACKGROUND: The authors compared longitudinal patient-reported outcomes and physician-rated cosmesis with conventionally fractionated whole-breast irradiation (CF-WBI) versus hypofractionated whole-breast irradiation (HF-WBI) within the context of a randomized trial. METHODS: From 2011 to 2014, a total of 287 women with American Joint Committee on Cancer stage 0 to stage II breast cancer were randomized to receive CF-WBI (at a dose of 50 grays in 25 fractions plus a tumor bed boost) or HF-WBI (at a dose of 42.56 grays in 16 fractions plus a tumor bed boost) after breast-conserving surgery. Patient-reported outcomes were assessed using the Breast Cancer Treatment Outcome Scale (BCTOS), the Functional Assessment of Cancer Therapy-Breast, and the Body Image Scale and were recorded at baseline and 0.5, 1, 2, and 3 years after radiotherapy. Physician-rated cosmesis was assessed at the same time points. Outcomes by treatment arm were compared at each time point using a 2-sided Student t test. Multivariable mixed effects growth curve models assessed the effects of treatment arm and time on longitudinal outcomes. RESULTS: Of the 287 patients enrolled, 149 were randomized to CF-WBI and 138 were randomized to HF-WBI. At 2 years, the Functional Assessment of Cancer Therapy-Breast Trial Outcome Index score was found to be modestly better in the HF-WBI arm (mean 79.6 vs 75.9 for CF-WBI; P = .02). In multivariable mixed effects models, treatment arm was not found to be associated with longitudinal outcomes after adjusting for time and baseline outcome measures (P≥.14). The linear effect of time was significant for BCTOS measures of functional status (P = .001, improved with time) and breast pain (P = .002, improved with time). CONCLUSIONS: In this randomized trial, longitudinal outcomes did not appear to differ by treatment arm. Patient-reported functional and pain outcomes improved over time. These findings are relevant when counseling patients regarding decisions concerning radiotherapy. Cancer 2016. © 2016 American Cancer Society. Cancer 2016;122:2886-2894. © 2016 American Cancer Society.

Eigen-disfigurement model for simulating plausible facial disfigurement after reconstructive surgery.

BACKGROUND: Patients with facial cancers can experience disfigurement as they may undergo considerable appearance changes from their illness and its treatment. Individuals with difficulties adjusting to facial cancer are concerned about how others perceive and evaluate their appearance. Therefore, it is important to understand how humans perceive disfigured faces. We describe a new strategy that allows simulation of surgically plausible facial disfigurement on a novel face for elucidating the human perception on facial disfigurement. METHOD: Longitudinal 3D facial images of patients (N = 17) with facial disfigurement due to cancer treatment were replicated using a facial mannequin model, by applying Thin-Plate Spline (TPS) warping and linear interpolation on the facial mannequin model in polar coordinates. Principal Component Analysis (PCA) was used to capture longitudinal structural and textural variations found within each patient with facial disfigurement arising from the treatment. We treated such variations as disfigurement. Each disfigurement was smoothly stitched on a healthy face by seeking a Poisson solution to guided interpolation using the gradient of the learned disfigurement as the guidance field vector. The modeling technique was quantitatively evaluated. In addition, panel ratings of experienced medical professionals on the plausibility of simulation were used to evaluate the proposed disfigurement model. RESULTS: The algorithm reproduced the given face effectively using a facial mannequin model with less than 4.4 mm maximum error for the validation fiducial points that were not used for the processing. Panel ratings of experienced medical professionals on the plausibility of simulation showed that the disfigurement model (especially for peripheral disfigurement) yielded predictions comparable to the real disfigurements. CONCLUSIONS: The modeling technique of this study is able to capture facial disfigurements and its simulation represents plausible outcomes of reconstructive surgery for facial cancers. Thus, our technique can be used to study human perception on facial disfigurement.

Social challenges of cancer patients with orbitofacial disfigurement.

PURPOSE: Patients who undergo orbital exenteration often experience social problems because of their facial disfigurement. The authors studied the interaction of cancer patients who had undergone orbital exenteration with family members and friends (primary groups) and with acquaintances and strangers (secondary groups) in small and large groups. METHODS: In-depth telephone interviews were conducted with 12 patients treated at a cancer center (7 men and 5 women aged 51-81 years) and 12 family members (8 spouses and 4 children or siblings). Three patients had adenoid cystic carcinoma of lacrimal gland, 3 had squamous cell carcinoma of conjunctiva/eyelid, and 1 each had conjunctival melanoma, eyelid sebaceous gland carcinoma, transitional cell carcinoma of lacrimal sac, adenocarcinoma of orbit, neuroendocrine carcinoma of orbit, and basal cell carcinoma of eyelid. Time from orbital exenteration to interview ranged from 8 months to 36 years (median, 44 months). RESULTS: Two patient groups were identified according to comfort in interactions with acquaintances and strangers. Always comfortable patients were always at ease. Occasionally comfortable patients were at ease in large groups in situations of "benign neglect" and in small groups when they received "sympathy"; were uncomfortable in large and small groups when episodes of "intrusion" occurred; and had mixed responses to benign neglect in small groups and sympathy in large groups. Both patient groups felt comfortable with family members and friends. CONCLUSIONS: Patients who will undergo orbital exenteration should be warned about possible difficulties with social interactions. Healthcare personnel should be trained to help patients and family members prepare for such difficulties.

Characterization of human female breast and abdominal skin elasticity using a bulge test.

Characterization of material properties of human skin is required to develop a physics-based biomechanical model that can predict deformation of female breast after cosmetic and reconstructive surgery. In this paper, we have adopted an experimental approach to characterize the biaxial response of human skin using bulge tests. Skin specimens were harvested from breast and abdominal skin of female subjects who underwent mastectomy and/or reconstruction at The University of Texas MD Anderson Cancer Center and who provided informed consent. The specimens were tested within 2 h of harvest, and after freezing for different time periods but not exceeding 6 months. Our experimental results show that storage in a freezer at -20 °C for up to about 40 days does not lead to changes in the mechanical response of the skin beyond statistical variation. Moreover, displacement at the apex of the bulged specimen versus applied pressure varies significantly between different specimens from the same subject and from different subjects. The bulge test results were used in an inverse optimization procedure in order to calibrate two different constitutive material models - the angular integration model proposed by Lanir (1983) and the generalized structure tensor formulation of Gasser et al. (2006). The material parameters were estimated through a cost function that penalized deviations of the displacement and principal curvatures at the apex. Generally, acceptable fits were obtained with both models, although the angular integration model was able to fit the curvatures slightly better than the Gasser et al. model. The range of the model parameters has been extracted for use in physics-based biomechanical models of the breast.

Considering Breast Reconstruction after Mastectomy: A Patient Decision Aid Video and Workbook.

Women report difficulty understanding and personalizing breast reconstruction information during the complex and time-limited period of cancer treatment planning. Patient decision aids can help patients become well informed, form realistic expectations, prepare to communicate with the surgical team, and be more satisfied with their decision-making process. METHODS: We engaged patients, providers, and stakeholders in a user-centered design process to develop an online patient decision aid video and interactive workbook for breast reconstruction after mastectomy. The video and workbook introduce breast reconstruction and compare the risks and benefits of 3 key decisions: reconstruction versus no reconstruction, immediate versus delayed, and tissue- versus implant based. Pilot testing using cognitive interviews and pre-/postdecision aid questionnaires assessed acceptability, knowledge, and decision-making values. RESULTS: After viewing the decision aid, patients (n = 20) scored 97.5% correct on a knowledge test; however, the factors driving their decisions were varied. All (n = 40) patients and providers/stakeholders provided over 80% positive acceptability ratings. 97.5% said they would recommend the video and workbook to other women with breast cancer. CONCLUSIONS: The Considering Breast Reconstruction after Mastectomy patient decision aid video and workbook show potential for improving informed decision-making. Delivery before the initial plastic surgery consultation was well supported as a way to give women time to process the information and prepare to talk with the surgical team about their options. The Personal Decision Worksheet shows potential for assessing patients' knowledge and the factors driving their personal decision-making process.

Mechanical response of human female breast skin under uniaxial stretching.

Skin is a complex material covering the entire surface of the human body. Studying the mechanical properties of skin to calibrate a constitutive model is of great importance to many applications such as plastic or cosmetic surgery and treatment of skin-based diseases like decubitus ulcers. The main objective of the present study was to identify and calibrate an appropriate material constitutive model for skin and establish certain universal properties that are independent of patient-specific variability. We performed uniaxial tests performed on breast skin specimens freshly harvested during mastectomy. Two different constitutive models - one phenomenological and another microstructurally inspired - were used to interpret the mechanical responses observed in the experiments. Remarkably, we found that the model parameters that characterize dependence on previous maximum stretch (or preconditioning) exhibited specimen-independent universal behavior.

Quantitative Assessment of Breast Cosmetic Outcome After Whole-Breast Irradiation.

PURPOSE: To measure, by quantitative analysis of digital photographs, breast cosmetic outcome within the setting of a randomized trial of conventionally fractionated (CF) and hypofractionated (HF) whole-breast irradiation (WBI), to identify how quantitative cosmesis metrics were associated with patient- and physician-reported cosmesis and whether they differed by treatment arm. METHODS AND MATERIALS: From 2011 to 2014, 287 women aged ≥40 with ductal carcinoma in situ or early invasive breast cancer were randomized to HF-WBI (42.56 Gy/16 fractions [fx] + 10-12.5 Gy/4-5 fx boost) or CF-WBI (50 Gy/25 fx + 10-14 Gy/5-7 fx). At 1 year after treatment we collected digital photographs, patient-reported cosmesis using the Breast Cancer Treatment and Outcomes Scale, and physician-reported cosmesis using the Radiation Therapy Oncology Group scale. Six quantitative measures of breast symmetry, labeled M1-M6, were calculated from anteroposterior digital photographs. For each measure, values closer to 1 imply greater symmetry, and values closer to 0 imply greater asymmetry. Associations between M1-M6 and patient- and physician-reported cosmesis and treatment arm were evaluated using the Kruskal-Wallis test. RESULTS: Among 245 evaluable patients, patient-reported cosmesis was strongly associated with M1 (vertical symmetry measure) (P<.01). Physician-reported cosmesis was similarly correlated with M1 (P<.01) and also with M2 (vertical symmetry, P=.01) and M4 (horizontal symmetry, P=.03). At 1 year after treatment, HF-WBI resulted in better values of M2 (P=.02) and M3 (P<.01) than CF-WBI; treatment arm was not significantly associated with M1, M4, M5, or M6 (P≥.12). CONCLUSIONS: Quantitative assessment of breast photographs reveals similar to improved cosmetic outcome with HF-WBI compared with CF-WBI 1 year after treatment. Assessing cosmetic outcome using these measures could be useful for future comparative effectiveness studies and outcome reporting.

Computation of breast ptosis from 3D surface scans of the female torso.

Stereophotography is now finding a niche in clinical breast surgery, and several methods for quantitatively measuring breast morphology from 3D surface images have been developed. Breast ptosis (sagging of the breast), which refers to the extent by which the nipple is lower than the inframammary fold (the contour along which the inferior part of the breast attaches to the chest wall), is an important morphological parameter that is frequently used for assessing the outcome of breast surgery. This study presents a novel algorithm that utilizes three-dimensional (3D) features such as surface curvature and orientation for the assessment of breast ptosis from 3D scans of the female torso. The performance of the computational approach proposed was compared against the consensus of manual ptosis ratings by nine plastic surgeons, and that of current 2D photogrammetric methods. Compared to the 2D methods, the average accuracy for 3D features was ~13% higher, with an increase in precision, recall, and F-score of 37%, 29%, and 33%, respectively. The computational approach proposed provides an improved and unbiased objective method for rating ptosis when compared to qualitative visualization by observers, and distance based 2D photogrammetry approaches.

Inferior Breast-Chest Contour Detection in 3-D Images of the Female Torso.

Stereophotogrammetry is finding increased use in clinical breast surgery, both for breast reconstruction after oncological procedures and cosmetic augmentation and reduction. The ability to visualize and quantify morphological features of the breast facilitates pre-operative planning and post-operative outcome assessment. The contour outlining the lower half of the breast is important for the quantitative assessment of breast aesthetics. Based on this inferior breast contour, relevant morphological measures, such as breast symmetry, volume, and ptosis, can be determined. In this paper, we present an approach for automatically detecting the inferior contour of the breast in 3D images. Our approach employs surface curvature analysis and is able to detect the breast contour with high accuracy, achieving an average error of 1.64 mm and a dice coefficient in the range of 0.72-0.87 when compared with the manually annotated contour (ground truth). In addition, the detected contour is used to facilitate the detection of the lowest visible point on the breast, which is an important landmark for breast morphometric analysis.

In-vivo quantification of human breast deformation associated with the position change from supine to upright.

Stereophotographic imaging and digital image correlation are used to determine the variation of breast skin deformation as the subject orientation is altered from supine to upright. A change in subject's position from supine to upright can result in significant stretches in some parts of the breast skin. The maximum of the major principal stretch ratio of the skin is different in different subjects and varies in the range of 1.25-1.60. It is also found that the boundaries of the breast move significantly relative to the skeletal structure and other fixed points such as the sternal notch. Such measurements are crucial since they provide basic data for validation of biomechanical breast models based on finite element formulations.

3D surface imaging of the human female torso in upright to supine positions.

Three-dimensional (3D) surface imaging of breasts is usually done with the patient in an upright position, which does not permit comparison of changes in breast morphology with changes in position of the torso. In theory, these limitations may be eliminated if the 3D camera system could remain fixed relative to the woman's torso as she is tilted from 0 to 90°. We mounted a 3dMDtorso imaging system onto a bariatric tilt table to image breasts at different tilt angles. The images were validated using a rigid plastic mannequin and the metrics compared to breast metrics obtained from five subjects with diverse morphology. The differences between distances between the same fiducial marks differed between the supine and upright positions by less than 1% for the mannequin, whereas the differences for distances between the same fiducial marks on the breasts of the five subjects differed significantly and could be correlated with body mass index and brassiere cup size for each position change. We show that a tilt table-3D imaging system can be used to determine quantitative changes in the morphology of ptotic breasts when the subject is tilted to various angles.

Helping patients make choices about breast reconstruction: a decision analysis approach.

Decision analysis can help breast reconstruction patients and their surgeons to methodically evaluate clinical alternatives and make hard decisions. The purpose of this article is to help plastic surgeons guide patients in making decisions though a case study in breast reconstruction. By making good decisions, patient outcomes may be improved. This article aims to illustrate decision analysis techniques from the patient perspective, with an emphasis on her values and preferences. The authors introduce normative decision-making through a fictional breast reconstruction patient and systematically build the decision basis to help her make a good decision. The authors broadly identify alternatives of breast reconstruction, propose types of outcomes that the patient should consider, discuss sources of probabilistic information and outcome values, and demonstrate how to make a good decision. The concepts presented here may be extended to other shared decision-making problems in plastic and reconstructive surgery. In addition, the authors discuss how sensitivity analysis may test the robustness of the decision and how to evaluate the quality of decisions. The authors also present tools to help implement these concepts in practice. Finally, the authors examine limitations that hamper adoption of patient decision analysis in reconstructive surgery and health care in general. In particular, the authors emphasize the need for routine collection of quality-of-life information, out-of-pocket expense, and recovery time.

Assessing Women's Preferences and Preference Modeling for Breast Reconstruction Decision-Making.

BACKGROUND: Women considering breast reconstruction must make challenging trade-offs amongst 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 nine 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 wellbeing 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 nine 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 seven 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.

Quantitative measures of facial expression for patients with head and neck cancer.

In addition to changes in facial morphology, head and neck cancer treatment can impact the facial expression. Quantification of changes in facial expression, particularly of smiling, would enable a deeper understanding of the relationship between physical changes and psychosocial adjustment in patients being treated for facial cancer. This study proposes 48 quantitative facial expression measures, which consist of the length normalized distances and slopes between 27 manually annotated fiducial points on standard 2D clinical photographs of patients with head and neck cancer. Using the proposed measures, the maximum intensity of smiling for patients with head and neck cancer prior to their treatments was compared to that of a sample from a healthy population. A total of 7 facial expression measures captured statistically significant differences between patients with head and neck cancer and healthy individuals. These measures suggest that patients with head and neck cancer are less expressive than people without head and neck cancer. This study is the first attempt to quantify the facial expression of patients with head and neck cancer and to build a foundation for studying how surgical interventions may affect their facial expressions. Moreover, this study lays the groundwork for future investigation of the relationship between facial expression and psychosocial adjustment in cancer patients.

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.

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.

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.

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.