Background: Aesthetic outcomes in breast surgery have historically been measured by ill-defined criteria and subjective surgeon assessment. Research efforts comparing different operative techniques have been limited by the absence of a standardized aesthetic assessment tool.
Purpose: The objective of this study was to develop a reliable computerized, image-based outcome assessment instrument for cosmetic and reconstructive breast surgery.
Methods: The elements of the aesthetically ideal breast were considered with respect to shape, symmetry and contour. Likert scale questions were then developed to assess these elements based on frontal, lateral and oblique patient photos. Pre and postoperative photos of both reconstructive and cosmetic patients were reviewed by 5 examiners (2 plastic surgeons, 3 medical students). Inter and intra-rater reliability was assessed using Kappa scores. Based on these scores, the questions were further modified and re-validated. The final Aesthetic Breast Score was composed of 10 questions. Using Microsoft AccessTM and PhotoshopTM programs, Aesthetic Breast Score software was then developed to allow for concurrent digital photo assessment and data entry.
Results: Five hundred photo assessments were performed. For each of the 10 Aesthetic Breast Score questions, inter-rater agreement was greater than 70% (range 71-82% agreement, p<0.005). For post-operative photos, greater than 75% inter-rater agreement was achieved (range 75-80%, p<0.001). Intra-rater reliability ranged from 69 to 78% (p<0.002). Inter and intra-rater reliability was higher for cosmetic patient photos than reconstructive patient photos. The Aesthetic Breast Score software permitted rapid photo scoring and data entry, with each patient assessment performed in less than 2 minutes.
Conclusion: The Aesthetic Breast Score is a reliable and rapid tool for assessment of patient photos. While photo evaluation is but one aspect of outcomes research, use of this instrument may facilitate future breast surgery studies by providing a more objective basis for patient review and by streamlining the process of photo evaluation and data entry.