Evaluation of an assessment scale for aesthetic outcome in breast reconstructions based on digital photos in both 2D and 3D format

Figures & data

Figure 1. Examples of postoperative photographs evaluated in the study. (A) An expander prosthesis (EP) breast reconstruction in two-dimensional (2 D) format and in (B) three-dimensional (3 D) format. (C) A deep inferior epigastric perforator (DIEP) flap breast reconstruction in 2 D format and in (D) 3 D format.

Table 1. Frequency distribution of panels’ grading from the panels’ first assessments separated by photo format for size, shape, symmetry, scar appearance and nipple areolar complex.

Item	n	Likert scale grades n (%)					Total n (%)
		1	2	3	4	5
Size
2 D format
Expert	13	10 (4.3)	62 (27.0)	103 (44.8)	53 (23.0)	1 (0.4)	229 (99.6)
Layman	9	19 (9.2)	49 (23.7)	105 (50.7)	33 (15.9)	1 (0.5)	207 (100)
Patient	12	12 (8.3)	42 (29.2)	69 (47.9)	15 (10.4)	4 (2.8)	142 (98.6)
3 D format
Expert	13	12 (5.2)	66 (28.7)	96 (41.7)	55 (23.9)	1 (0.4)	230 (100)
Layman	9	28 (13.5)	51 (24.6)	92 (44.4)	35 (16.9)	206 (99.5)	207 (100)
Patient	12	14 (9.7)	46 (31.9)	73 (50.7)	9 (6.3)	2 (1.4)	144 (100)
Shape
2 D format
Expert	13	8 (3.5)	44 (19.1)	31 (13.5)	101 (43.9)	46 (20.0)	230 (100)
Layman	9	5 (2.4)	42 (20.3)	26 (12.6)	53 (25.6)	81 (39.1)	207 (100)
Patient	12	9 (6.3)	19 (13.2)	16 (11.1)	57 (39.6)	42 (29.2)	143 (99.3)
3 D format
Expert	13	15 (6.5)	50 (21.7)	42 (18.3)	92 (40.0)	31 (13.5)	230 (100)
Layman	9	18 (8.7)	45 (21.7)	25 (12.1)	56 (27.1)	63 (30.4)	207 (100)
Patient	12	12 (8.3)	26 (18.1)	16 (11.1)	45 (31.3)	43 (29.9)	142 (98.6)
Symmetry
2 D format
Expert	13	10 (4.3)	53 (23.0)	32 (13.9)	91 (39.6)	43 (18.7)	229 (99.6)
Layman	9	7 (3.4)	48 (23.2)	26 (12.6)	49 (23.7)	76 (36.7)	206 (99.5)
Patient	12	9 (6.3)	14 (9.7)	16 (11.1)	51 (35.4)	54 (37.5)	144 (100)
3 D format
Expert	13	16 (7.0)	59 (25.7)	34 (14.8)	89 (38.7)	30 (13.0)	228 (99.1)
Layman	9	20 (9.7)	56 (27.1)	30 (14.5)	50 (24.2)	51 (24.6)	207 (100)
Patient	12	7 (4.9)	34 (23.6)	13 (9.0)	41 (28.5)	49 (34.0)	144 (100)
Scar appearance
2 D format
Expert	13	0	22 (9.6)	45 (19.6)	130 (56.5)	31 (13.5)	228 (99.1)
Layman	9	1 (0.5)	27 (13.0)	46 (22.2)	77 (37.2)	54 (26.1)	205 (99.0)
Patient	12	6 (4.2)	19 (13.2)	16 (11.1)	42 (29.2)	60 (41.7)	143 (99.3)
3 D format
Expert	13	7 (3.0)	49 (21.3)	60 (26.1)	93 (40.4)	17 (7.4)	226 (98.3)
Layman	9	9 (4.3)	56 (27.1)	53 (25.6)	65 (31.4)	22 (10.6)	205 (99.0)
Patient	12	14 (9.7)	38 (26.4)	20 (13.9)	34 (23.6)	35 (24.3)	141 (97.9)
NAC
2 D format
Expert	13	9 (3.9)	40 (17.4)	58 (25.2)	72 (31.3)	20 (8.7)	199 (86.5)
Layman	9	11 (5.3)	38 (18.4)	35 (16.9)	56 (27.1)	35 (16.9)	175 (84.5)
Patient	12	7 (4.9)	24 (16.7)	18 (12.5)	42 (29.2)	35 (24.3)	126 (87.5)
3 D format
Expert	13	7 (3.0)	51 (22.2)	39 (17.0)	82 (35.7)	19 (8.3)	198 (86.1)
Layman	9	10 (4.8)	33 (15.9)	38 (18.4)	62 (30.0)	26 (12.6)	169 (81.6)
Patient	12	8 (5.6)	25 (17.4)	12 (8.3)	43 (29.9)	41 (28.5)	129 (89.6)

The expert and layman assessments are from the first phase of the study and the patient panel assessment from the second phase. The Likert scale grade with highest frequency per panel and item is in bold.

2 D: Two dimensional; 3 D: Three dimensional; NAC: Nipple areolar complex.

Table 2. Frequency distribution of panels’ grading from the panels’ first assessments separated by photo format for the overall aesthetic outcome.

Item	n	Likert scale grades n (%)										Total n (%)
		1	2	3	4	5	6	7	8	9	10
Overall aesthetic outcome
2 D format
Expert	13	0	6 (2.6)	16 (7.0)	13 (5.7)	18 (7.8)	23 (10.0)	41 (18.7)	57 (24.8)	41 (17.8)	15 (6.5)	230 (100)
Layman	9	0	4 (1.9)	14 (6.8)	11 (5.3)	18 (8.7)	25 (12.1)	36 (17.4)	42 (20.3)	39 (18.8)	18 (8.7)	207 (100)
Patient	12	5 (3.5)	5 (3.5)	9 (6.3)	7 (4.9)	9 (6.3)	13 (9.0)	18 (12.5)	23 (16.0)	30 (20.8)	25 (17.4)	144 (100)
3 D format
Expert	13	6 (2.6)	5 (2.2)	27 (11.7)	18 (7.8)	21 (9.1)	32 (13.9)	37 (16.1)	52 (22.6)	23 (10.0)	9 (3.9)	230 (100)
Layman	9	2 (1.0)	10 (4.8)	25 (21.1)	21 (10.1)	17 (8.2)	26 (12.6)	27 (13.0)	36 (17.4)	36 (17.4)	7 (3.4)	207 (100)
Patient	12	6 (4.2)	7 (4.9)	11 (7.6)	8 (5.6)	20 (13.9)	11 (7.6)	9 (6.3)	28 (19.4)	21 (14.6)	23 (16.0)	144 (100)

The expert and layman assessments are from the first phase of the study and the patient panel assessment from the second phase. The Likert scale grade with highest frequency per panel is in bold.

2 D: Two dimensional; 3 D: Three dimensional.

Table 3. Intrarater agreements with weighted kappa (κw) values.

Photo format	Expert panel	Layman panel	Patient panel
	n = 11	n = 7	n = 12
2 D	0.70 (0.62 − 0.75)	0.70 (0.58 − 0.74)	0.73 (0.50 − 0.89)
3 D	0.67 (0.54 − 0.80)	0.66 (0.60 − 0.69)	0.72 (0.29 − 0.83)

The patient panel's agreements were calculated based on ratings from the second phase of the study. Agreements are presented in median with minimum and maximum values in parenthesis.

Interpretations of wκ values: 0.00–0.20 slight, 0.21–0.40 fair, 0.41–0.60 moderate 0.61–0.80 substantial, >0.80 almost perfect [17].

2 D: Two dimensional; 3 D: Three dimensional.

Table 4. Interrater agreements with weighted kappa (κw) values.

Photo format	Expert panel	Layman panel	Patient panel
	n = 13	n = 9	n = 12
2 D	0.60 (0.36 − 0.74)	0.62 (0.44 − 0.73)	0.46 (0.19 − 0.73)
3 D	0.55 (0.35 − 0.77)	0.57 (0.38 − 0.67)	0.48 (0.04 − 0.73)

The patient panel agreements were calculated based on ratings from the second phase of the study. Agreements are presented in median with minimum and maximum values in parenthesis.

Interpretations of wκ values: 0.00-0.20 slight, 0.21-0.40 fair, 0.41-0.60 moderate 0.61-0.80 substantial, >0.80 almost perfect [17].

2 D: Two dimensional; 3 D: Three dimensional.

Table 5. Intrarater agreements with weighted kappa (κw) between assessments in 2 D format with the corresponding in 3 D format.

Reconstruction method	Expert panel	Layman panel	Patient panel
	n = 13	n = 9	n = 12
All	0.64 (0.33 − 0.78)	0.62 (0.46 − 0.73)	0.66 (0.25 − 0.77)
EP	0.55 (0.27 − 0.71)	0.56 (0.34 − 0.67)	0.57 (0.19 − 0.69)
DIEP flap	0.63 (0.32 − 0.83)	0.61 (0.43 − 0.80)	0.63 (0.13 − 0.86)

The patient panel's agreements were calculated based on ratings from the second phase of the study. Agreements are presented in median with minimum and maximum values in parenthesis.

Interpretations of wκ values: 0.00–0.20 slight, 0.21–0.40 fair, 0.41–0.60 moderate 0.61–0.80 substantial, >0.80 almost perfect [17].

EP: Expander prosthesis; DIEP: Deep inferior epigastric perforator; 2 D: Two dimensional; 3 D: Three dimensional.

Table 6. Aesthetic outcome scores per item and photo format assessed by three panels.

	Aesthetic outcome scores Median (range)
Panel	Size	Shape	Symmetry	Scar	NAC	Overall
Expert
2 D format	3 (2–5)	4 (1–5)	4 (1–5)	4 (2–5)	4 (1–5)	8 (2–10)
EP	3 (2–4)	3.5 (1–5)	3.5 (1–5)	4 (2–5)	3 (1–5)	7 (2–10)
DIEP flap	3 (2–5)	5 (4–5)	5 (4–5)	5 (2–5)	4 (2–5)	9 (7–10)
3 D format	3 (2–5)	4 (1–5)	4 (1–5)	4 (2–5)	4 (1–5)	7.5 (2–10)
EP	3 (2–4)	3.5 (1–5)	3.5 (1–5)	3 (2–5)	3 (1–5)	6 (2–10)
DIEP flap	3 (2–5)	5 (4–5)	5 (3–5)	4 (2–5)	4 (4–5)	9 (7–10)
Layman
2 D format	3 (1–4)	4 (1–5)	4 (1–5)	3 (1–5)	4 (1–5)	7 (1–10)
EP	2 (1–4)	4 (1–5)	4 (1–5)	3 (2–5)	3 (1–5)	6 (1–10)
DIEP flap	3 (2–4)	4.5 (3–5)	4 (3–5)	3 (1–5)	4 (3–5)	8 (6–10)
3 D format	3 (1–4)	4 (1–5)	4 (1–5)	3 (1–5)	4 (1–5)	7 (2–9)
EP	2 (1–4)	3 (1–5)	3 (1–5)	3 (1–5)	3 (1–5)	5 (2–9)
DIEP flap	3 (2–4)	5 (4–5)	5 (4–5)	3 (1–4)	4 (3–5)	8 (2–9)
Patient
2 D format	3 (1–5)	4 (1–5)	4 (1–5)	4 (1–5)	4 (1–5)	8 (1–10)
EP	2 (1–4)	4 (1–5)	4 (1–5)	4 (1–5)	3 (1–5)	7 (1–10)
DIEP flap	3 (2–5)	4 (2–5)	4 (2–5)	4 (1–5)	4 (1–5)	9 (2–10)
3 D format	3 (1–5)	4 (1–5)	4 (1–5)	3 (1–5)	4 (1–5)	7.5 (1–10)
EP	2 (1–4)	3 (1–5)	3 (1–5)	3 (1–5)	3 (1–5)	5 (1–10)
DIEP flap	3 (2–5)	5 (2–5)	5 (2–5)	4 (1–5)	4 (2–5)	8.5 (3–10)

On the 5-point rating scale, 1 equal very bad and 5 very good regarding items shape, symmetry, scar appearance and NAC. For the item size, 1 equal much smaller than the natural breast, 3 the same size as the natural breast and 5 much larger than the natural breast. Overall aesthetic outcome was rated on a 10-point scale on which 1 equal very bad and 10 very good.

EP: Expander prosthesis; DIEP: Deep inferior epigastric perforator; 2 D: Two dimensional; 3 D: Three dimensional; NAC: Nipple areolar complex.

Veiga DF, Neto MS, Garcia EB, et al. Evaluations of the aesthetic results and patient satisfaction with the late pedicled TRAM flap breast reconstruction. Ann Plast Surg. 2002;48(5):515–520.

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