Aesth Plast Surg (2014) 38:344–349 DOI 10.1007/s00266-014-0291-9
ORIGINAL ARTICLE
BREAST
Anthropometry of the Breast Region: How to Measure? Paulo R. Quieregatto • Bernardo Hochman • Soraia F. Ferrara • Fabianne Furtado • Richard E. Liebano • Miguel Sabino Neto • Lydia M. Ferreira
Received: 27 August 2013 / Accepted: 31 January 2014 / Published online: 8 March 2014 Ó Springer Science+Business Media New York and International Society of Aesthetic Plastic Surgery 2014
Abstract Background Breast region measurements are important for research, but they may also become significant in the legal field as a quantitative tool for preoperative and postoperative evaluation. Direct anthropometric measurements can be taken in clinical practice. The aim of this study was to compare direct breast anthropometric measurements taken with a tape measure and a compass. Methods Forty women, aged 18–60 years, were evaluated. They had 14 anatomical landmarks marked on the breast region and arms. The union of these points formed eight linear segments and one angle for each side of the body. The volunteers were evaluated by direct anthropometry in a standardized way, using a tape measure and a compass. Results Differences were found between the tape measure and the compass measurements for all segments analyzed (p [ 0.05). Conclusion Measurements obtained by tape measure and compass are not identical. Therefore, once the measurement tool is chosen, it should be used for the pre- and postoperative measurements in a standardized way. Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings,
Study conducted at the Graduate Program in Plastic Surgery, Universidade Federal de Sa˜oPaulo (Unifesp), Sa˜o Paulo, SP, Brazil. P. R. Quieregatto B. Hochman (&) S. F. Ferrara F. Furtado R. E. Liebano M. Sabino Neto L. M. Ferreira Plastic Surgery Division, Universidade Federal de Sa˜o Paulo (UNIFESP), Rua Napolea˜o de Barros, 715, 4° andar, Vila Clementino, Sa˜o Paulo, SP 04023-002, Brazil e-mail: [email protected]; [email protected]
123
please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266. Keywords Anthropometry Breast Body weights and measures Mammaplasty Thorax
Introduction Measurements of the human body or its parts are an important chapter in any area of medicine. They are of particular relevance in plastic surgery as millimeters or centimeters can make a difference in getting a positive result. Nowadays, in addition to the clinical and research areas, measurements can also be taken into account in the legal field. In daily practice, plastic surgeons may use different anthropometric tools, sometimes without distinction, using, for instance, one for preoperative procedures, another during surgery, and a third postoperatively. For that reason it is important to emphasize that in the clinical practice of plastic surgeons, there is still no standard of measurements in general, including of the breast region. Direct anthropometry is performed directly on the individual using tools such as a tape measure, ruler, compass, protractor, calipers, and anthropometers [1]. The use of anthropometric or anatomical landmarks is recommended; it can reduce biases generated by absolute linear measurements when associated with angular measurements [2, 3]. Direct anthropometry has some measurement limitations such as difficulty in regions with protrusions and curvatures of the skin, inappropriate application of pressure on the skin by rigid instruments during the measurement, questionable reproducibility due to movements of the chest wall during breathing, loss of initial posture due to fatigue and discomfort
Aesth Plast Surg (2014) 38:344–349
345
Table 1 Search strategies a
‘‘Breast’’[Mesh] AND ‘‘Body Surface Area’’[Mesh] = 13 ‘‘Breast’’[Mesh] AND ‘‘Anthropometry’’[Majr] = 109a
(‘‘Breast’’[Mesh] AND ‘‘Anthropometry’’[Majr]) NOT ‘‘Breast Neoplasm’’[Mesh] = 109a ‘‘Breast’’[Mesh] AND (‘‘Body Weights and Measures’’[Mesh] OR ‘‘Body Weights and Measures/methods’’[Mesh]) = 782a (‘‘Photogrammetry’’[Mesh] OR ‘‘Photography’’[Mesh]) AND ‘‘Breast’’[Mesh] = 1,013a (‘‘Photogrammetry’’[Majr] AND ‘‘Breast’’[Majr]) OR (‘‘Anthropometry’’[Mesh] AND ‘‘Anthropometry/ methods’’[Mesh]) AND ‘‘Body Weights and Measures’’[Majr] = 1,280a (((‘‘Photogrammetry’’[Mesh] OR ‘‘Anthropometry’’[Mesh]) OR ‘‘Anthropometry/methods’’[Mesh]) AND ‘‘Breast’’[Mesh]) AND ‘‘Body Weights and Measures’’[Mesh] = 687a ‘‘Breast’’[Mesh] AND ‘‘Photogrammetry’’[Mesh] = 15a (‘‘Photogrammetry’’[Mesh Major Topic]) AND ‘‘Breast’’[Mesh] = 10a (‘‘Photogrammetry’’[Mesh] OR ‘‘Photogrammetry’’[All Fields]) AND (‘‘Breast’’[Mesh] OR ‘‘Breast’’[All Fields]) AND (‘‘Body Weights and Measures’’[Mesh] OR ‘‘Body Weights and Measures’’[All Fields]) OR (‘‘Anthropometry ‘‘[Mesh] OR ‘‘Anthropometry’’[All Fields]) = 355243a a
Number of articles retrieved
of the patient during relatively long evaluation periods, and even patient embarrassment due to the exposure of the naked body and application of measurement tools [2, 4]. Female breasts are difficult to measure accurately. In addition to the factors described above, other complicating factors arise from aspects inherent to breasts, such as volume and degree of sagging [4]. Using direct anthropometry, several authors [4–8] created primary reference parameters related to placement, shape, and volume. They also identified factors that influenced these measurements, i.e., weight, age, pregnancy, lactation, and biotype. The main tools used by plastic surgeons to measure the breast region are the tape measure and the compass. However, there is no consensus about a reference standard of landmarks and measurements. Thus, with respect to breasts and given the peculiar characteristics of this anatomical region, a standardized protocol is lacking, not only concerning the anatomical landmarks, but also the choice of the measuring tool. Therefore, the objective of this study was to compare direct breast anthropometric measurements taken with tape measure and compass.
of MEDLINE for articles from 1966 to December 2012. The search strategy used was formulated using the keywords shown in Table 1. Of the articles retrieved from the literature review, 16 authors have described anatomical or anthropometric landmarks for breast measurements, as shown in Table 2. Fourteen landmarks have been found with the patient in the anterior position and/or the profile. From these, it was verified in a preliminary study that four landmarks were not suitable for reproduction in photogrammetry: the inferior and midpoint of the mammary fold (SMMe), the point at the lateral mammary fold (SMLa), the navel point (Um), and the pubic point (Pu). After approval by the Research Ethics Committee (CEP No. 1054/10, Sa˜o Paulo, August 27, 2010), 40 volunteers, aged 18–60 years, from the Plastic Surgery Division Outpatient Service of the Universidade Federal de Sa˜o Paulo (UNIFESP) were included in the study. Each volunteer was instructed to remain in the anatomical position, with the head in the Frankfurt position, while being measured. Self-adhesive labels (0.6 cm in diameter and 0.3 mm in its internal part) were used to mark two landmarks on the midline and six landmarks on each side of the body to form linear segments. The connection of one point to another formed eight line segments on each side of the body, seven of which were formed bilaterally: IJ–PAP, XCL–PAP, PAP–Ac, Ac–EpL, Ax–PAP, PAP–LM, and the segment Ac–Yum (Fig. 1). The first measurement was done with a tape measure with the scale in millimeters. The tape measure was placed in the center of the label and pulled with uniform tension toward the center of the opposite label (Fig. 2a, c). The second measurement was conducted using a compass with a safety blunt tip. One tool arm was placed at the center of a label and the other arm at the center of the opposite label (Fig. 2b). The opening of the compass was transferred to a stainless steel ruler 30 cm long with a scale in millimeters (Fig. 2d). All measurements were compared using the Wilcoxon test (p \ 0.05).
Results Differences were found in all linear measurements when the results of the two measurement methods (p \ 0.001), tape measure and compass, were compared (Table 3). Statistical analysis was not performed on the angular measurement because only one measuring tool was used (protractor).
Methods
Discussion
To obtain the anatomical and anthropometric landmarks, a PubMed search was conducted in the electronic databases
According to Roebuck et al. [9], the origin of anthropometry reportedly was Marco Polo’s travels from 1273 to
123
123 38
–
1994
1986a 1997
2006
2009
2009
2009
2002
2007 2011
2011
Malata et al. [11]
Smith et al. [6] Quiao et al. [14]
Sigurson and Kirkland [15]
Denoel et al. [16]
Pozzobon et al. [17]
Odo [8]
Vandeput and Nelissen [18]
Kim et al. [19] Agbenorku et al. [20]
Liu and Thomson [21]
13 13
18
8
4
3
6
5
2
5
6 8
4
4
16
6
Measurements
5
x
x
x
x
x
IJ– Xi
14
x
(obl) x
x
x
x
x
x
x x
x
x
x
x
IJ– PAP
1
x
IJ– Pu
1
x
IJ– Umb
2
x
x
IJ– SMMe
5
x
x
x
x
(5 cm)
Cl– PAP
1
x
Ac– PAP
6
x
(perf)
x
x
x
x
Ax– PAP
11
x
x
x
x
x
x x
x
x
x
PAP– LM
6
x
x
x
x x
x
x
PAP– SMLa
13
x
x
x
(perf)
x
x
x
x x
(perf)
x
x
x
PAP– SMMe
5
x
x
x
x
x
PAP– PAP
6
x
x
x
x x
x
PAP– Dia
2
(olec)
Ac– EpL
1
x
Ac– Um
3
x
x
x
Angle
Ac acromion, Ax axillary line, Cl clavicle, EpL lateral epicondyle, IJ jugular notch, LM anterior midine, PAP nipple, Pu pubis, SMMe inframammary fold, SMLa lateral mammary fold, Um humerus, Umb umbilicus, Xi xiphoid, 1/2Um half the distance between the acromion and the olecranon, perf profile, obl oblique, olec olecranon
Total = 16
–
1999
Brown et al. [7]
1 21
1955
35
1989
1997
Westreich [4]
Loughry et al. [13]
1986b
Smith et al. [10]
Citations
Penn [5]
Publ. year
Authors
Table 2 Anthropometric and anatomical points and line segments found in the literature
346 Aesth Plast Surg (2014) 38:344–349
Aesth Plast Surg (2014) 38:344–349
Fig. 1 Schematic representation of the eight anatomical landmarks and the formation of the eight linear segments on each side of the body and one angular measurement. Anatomical landmarks: IJ jugular notch center, Xi base of the xiphoid process, PAP center of the mammary papilla, Ac acromion, EpL anterior projection of the lateral epicondyle, xCl point corresponding to half the distance between the center of the jugular notch and the acromion, called the ‘‘x’’ point of the clavicle, Ax proximal point of the anterior axillary line, yUm point corresponding to half the distance between the acromion and the lateral epicondyle, called the ‘‘y’’ point of the humerus. Linear segments: IJ–Xi, IJ–PAP, xCl–PAP, Ac–PAP, Ax– PAP, LM–PAP, Ac–EpL and Ac–yUm. Angular measurement, a is the angle formed by the junction of the segments IJ–Xi and IJ–PAP
1295, during which he encountered many people from different ethnic groups who differed from each other by size and body height, among other aspects. According to Westreich [4], diversity in curvature, protrusion, and relief in the thoracic region may cause inaccuracy in direct anthropometric measurements due to variations between measurements. Any movement of the chest wall during the breathing cycle and postural oscillations of an individual are also factors that corroborate these variations. The most difficult measurements are those from the segment of the most cranial point of the axilla to the center of the mammary papilla and the identification of the landmark at the most lateral prolongation of the mammary fold. According to Westreich, soft tissue landmarks vary too much to be included in studies of breast measurements. Those landmarks will vary from woman to woman and change with the slightest movement of the same patient. In a study by Smith et al. [10], differences of 15–20 % could be found in measurements from the most cranial
347
point of the anterior axillary line to any of the points on the chest wall. The authors concluded that minor position changes could alter these measurements. Of the articles retrieved from the literature review, 15 described anatomical or anthropometric landmarks for breast measurements (Table 2). Fourteen landmarks have been found with the patient in the anterior position and/or the profile position. From these, it was verified that four landmarks were not suitable for reproduction in photogrammetry: the inferior and midpoint of the SMMe, the point at the lateral SMLa, the Um, and the Pu. In this context, it was verified that large breasts or breasts with ptosis that overlapped with the inferior and midpoint of the mammary fold prevented its visualization, both in the anterior position and the profile position. It was not possible to define precisely the lateral end of the mammary fold in breasts with accentuated lateral prolongation and small breasts (hypomastia). The reference points of the Um and the Pu were also excluded since they did not represent the correct position of the midline, and spine and pelvic deviations could alter the centering of the midline. Therefore, we decided to use the base of the xiphoid process for marking the midline. By direct anthropometry it is possible to quantify different patterns of breasts using a tape measure, compass, anthropometer, or caliper to obtain linear and angular measurements between anatomical or anthropometric landmarks [4, 6, 7, 10, 11]. Regarding the measurements with the tape measure, the differences in the segments from the acromion to the anterior projection of the lateral epicondyle (Ac–EpL), and the point corresponding to half the distance from the acromion to the anterior projection of the lateral epicondyle (Ac–yUm), could be explained by the ease of movement provided by this segment and that this was the largest segment measured in this study. According to Kouchi et al. [12], measurements smaller than 10 cm were more reliable and did not differ significantly when compared to the larger measurements. Our results showed that there was a difference between the measurements obtained by the tape measure and the compass. Because the tape measure follows the body’s contours it causes a discrepancy with the measurements from the compass, which gives linear measurements in the spatial sense. In regions where the breast skin’s relief does not come into play, the measurements obtained by tape measure and by compass were also not comparable. In conclusion, this study shows that once a measurement tool is chosen, it should be used for both pre- and postoperative measurements. Also, for breast region measurements, previously marked anthropometric or anatomical landmarks should be used.
123
348
Aesth Plast Surg (2014) 38:344–349
Fig. 2 Measurements of the breasts. a Linear measurement with tape measure, b linear measurement with compass, c detail of the tape measure measurement, d transposition of the compass opening to the ruler
Table 3 Median values (in cm) for the measurements obtained with the measuring tape and the compass Segment
Measuring tape
Compass
N
p valuea
IJ–Xi
16.6
16.1
80
\0.0001*
IJ–PAP
21.8
21.5
80
\0.0001*
CI–PAP
21.4
21.2
80
\0.0001*
Ac–PAP
21.4
21.1
80
\0.0001*
Ax–PAP
14.3
14.2
80
\0.0001*
ME–PAP
11.4
11.2
80
0.0003*
Ac–EpL Ac–1/2 Um
29.6 14.7
29.3 14.6
80 80
\0.0001* \0.0001*
3.4
3.5
80
Projection N sample number a
Wilcoxon test
* Statistical significance
123
0.36
Conflict of interest disclose. Funding
The authors have no conflicts of interest to
There was no funding received for this study.
References 1. Nechala P, Mahoney J, Farkas L (1999) Digital two-dimensional photogrammetry: a comparision of the three techniques of obtaining digital photographs. Plast Reconstr Surg 103(7): 1819–1825 2. Hochman B, Castilho HT, Ferreira LM (2002) Padronizac¸a˜o fotogra´fica e morfome´trica na fotogrametria computadorizada do nariz. Acta Cir Bras 17(4):258–266 3. Ward CM (1979) An analysis, from photographs, of the results of four approaches to elongating the columella after repair of bilateral cleft lip. Plast Reconstr Surg 64(1):68–75
Aesth Plast Surg (2014) 38:344–349 4. Westreich M (1999) Anthropomorphic breast measurement: protocol and results in 50 women with aesthetically perfect breast and clinical application. Cosmetic 100(2):468–479 5. Penn J (1995) Breast reduction. Br J Plast Surg 7:357–371 6. Smith DJ, Palin WE, Katch U, Bennett JE (1986) Surgical treatment of congenital breast asymmetry. Ann Plast Surg 17(2):92–101 7. Brown TP, Ringrose RE, Hyland AA, Brotherston TM (1999) A method of assessing female breast morphometry and its clinical application. Br J Plast Surg 52:355–359 8. Odo LM (2009) Avaliac¸a˜o do tratamento ciru´rgico da assimetria mama´ria por meio de medidas lineares. Arq Catarin Med 38(Suppl 1):43–45 9. Roebuck JA Jr, Kroemer KH, Thomson WG (1975) Engineering anthropometry methods, 1st edn. Wiley, New York 10. Smith DJ, Palin WE, Katch U, Bennett JE (1986) Breast volume and anthropomorphic measurements: normal values. Plast Reconstr Surg 78(3):331–335 11. Malata CM, Boot JC, Bradbury ET, Ramli AR, Sharpe DT (1994) Congenital breast asymmetry: subjective and objective assessment. Br J Plast Surg 47(2):95–102 12. Kouchi M, Mochimaru M, Tsuzuki K, Yokoi T (1996) Random errors in anthropometry. J Hum Ergol 25(2):155–166 13. Loughry CW, Sheffer DB, Price TE, Einsporn RL, Bartfai RG, Morek WM, Meli NM (1989) Breast volume measurement of 598 women using biostereometric analysis. Ann Plast Surg 22(5): 380–385 14. Qiao Q, Zhou G, Ling Y (1997) Breast volume measurement in young Chinese women and clinical applications. Aesthetic Plast
349 Surg 21(5):362–368 15. Sigurdson LJ, Kirkland SA (2006) Breast volume determination in breast hypertrophy: an accurate method using two anthropomorphic measurements. Plast Reconstr Surg 118(2):313–320 16. Denoel C, Aguirre MF, Bianco G, Mahaudens PH, Vanwijck R, Garson S, Sinna R, Debrun A (2009) Idiopathic scoliosis and breast asymmetry. J Plast Reconstr Aesthet Surg 62(10): 1303–1308 17. Pozzobon AV, Sabino Neto M, Veiga DF, Abla LE, Pereira JB, Biase TL, Ferreira LM et al (2009) Magnetic resonance images and linear measurements in the surgical treatment of breast asymmetry. Aesthetic Plast Surg 33(2):196–203 18. Vandeput JJ, Nelissen M (2002) Considerations on anthropometric measurements of the female breast. Aesthetic Plast Surg 26(5):348–355 19. Kim MS, Reece GP, Beahm EK, Miller MJ, Atkinson EN, Markey MK (2007) Objective assessment of aesthetic outcomes of breast cancer treatment: measuring ptosis from clinical photographs. Comput Biol Med 37(1):49–59 20. Agbenorku P, Agbenorku M, Iddi A, Amevor E, Sefenu R, Osei D (2011) Measurements of breasts of young West African females: a guideline in anatomical landmarks for adolescent breast surgery. Aesthetic Plast Surg 35(1):49–54 21. Liu YJ, Thomson JG (2011) Ideal anthropomorphic values of the female breast. Ann Plast Surg 67(1):9–11
123
ORIGINAL ARTICLE
BREAST
Anthropometry of the Breast Region: How to Measure? Paulo R. Quieregatto • Bernardo Hochman • Soraia F. Ferrara • Fabianne Furtado • Richard E. Liebano • Miguel Sabino Neto • Lydia M. Ferreira
Received: 27 August 2013 / Accepted: 31 January 2014 / Published online: 8 March 2014 Ó Springer Science+Business Media New York and International Society of Aesthetic Plastic Surgery 2014
Abstract Background Breast region measurements are important for research, but they may also become significant in the legal field as a quantitative tool for preoperative and postoperative evaluation. Direct anthropometric measurements can be taken in clinical practice. The aim of this study was to compare direct breast anthropometric measurements taken with a tape measure and a compass. Methods Forty women, aged 18–60 years, were evaluated. They had 14 anatomical landmarks marked on the breast region and arms. The union of these points formed eight linear segments and one angle for each side of the body. The volunteers were evaluated by direct anthropometry in a standardized way, using a tape measure and a compass. Results Differences were found between the tape measure and the compass measurements for all segments analyzed (p [ 0.05). Conclusion Measurements obtained by tape measure and compass are not identical. Therefore, once the measurement tool is chosen, it should be used for the pre- and postoperative measurements in a standardized way. Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings,
Study conducted at the Graduate Program in Plastic Surgery, Universidade Federal de Sa˜oPaulo (Unifesp), Sa˜o Paulo, SP, Brazil. P. R. Quieregatto B. Hochman (&) S. F. Ferrara F. Furtado R. E. Liebano M. Sabino Neto L. M. Ferreira Plastic Surgery Division, Universidade Federal de Sa˜o Paulo (UNIFESP), Rua Napolea˜o de Barros, 715, 4° andar, Vila Clementino, Sa˜o Paulo, SP 04023-002, Brazil e-mail: [email protected]; [email protected]
123
please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266. Keywords Anthropometry Breast Body weights and measures Mammaplasty Thorax
Introduction Measurements of the human body or its parts are an important chapter in any area of medicine. They are of particular relevance in plastic surgery as millimeters or centimeters can make a difference in getting a positive result. Nowadays, in addition to the clinical and research areas, measurements can also be taken into account in the legal field. In daily practice, plastic surgeons may use different anthropometric tools, sometimes without distinction, using, for instance, one for preoperative procedures, another during surgery, and a third postoperatively. For that reason it is important to emphasize that in the clinical practice of plastic surgeons, there is still no standard of measurements in general, including of the breast region. Direct anthropometry is performed directly on the individual using tools such as a tape measure, ruler, compass, protractor, calipers, and anthropometers [1]. The use of anthropometric or anatomical landmarks is recommended; it can reduce biases generated by absolute linear measurements when associated with angular measurements [2, 3]. Direct anthropometry has some measurement limitations such as difficulty in regions with protrusions and curvatures of the skin, inappropriate application of pressure on the skin by rigid instruments during the measurement, questionable reproducibility due to movements of the chest wall during breathing, loss of initial posture due to fatigue and discomfort
Aesth Plast Surg (2014) 38:344–349
345
Table 1 Search strategies a
‘‘Breast’’[Mesh] AND ‘‘Body Surface Area’’[Mesh] = 13 ‘‘Breast’’[Mesh] AND ‘‘Anthropometry’’[Majr] = 109a
(‘‘Breast’’[Mesh] AND ‘‘Anthropometry’’[Majr]) NOT ‘‘Breast Neoplasm’’[Mesh] = 109a ‘‘Breast’’[Mesh] AND (‘‘Body Weights and Measures’’[Mesh] OR ‘‘Body Weights and Measures/methods’’[Mesh]) = 782a (‘‘Photogrammetry’’[Mesh] OR ‘‘Photography’’[Mesh]) AND ‘‘Breast’’[Mesh] = 1,013a (‘‘Photogrammetry’’[Majr] AND ‘‘Breast’’[Majr]) OR (‘‘Anthropometry’’[Mesh] AND ‘‘Anthropometry/ methods’’[Mesh]) AND ‘‘Body Weights and Measures’’[Majr] = 1,280a (((‘‘Photogrammetry’’[Mesh] OR ‘‘Anthropometry’’[Mesh]) OR ‘‘Anthropometry/methods’’[Mesh]) AND ‘‘Breast’’[Mesh]) AND ‘‘Body Weights and Measures’’[Mesh] = 687a ‘‘Breast’’[Mesh] AND ‘‘Photogrammetry’’[Mesh] = 15a (‘‘Photogrammetry’’[Mesh Major Topic]) AND ‘‘Breast’’[Mesh] = 10a (‘‘Photogrammetry’’[Mesh] OR ‘‘Photogrammetry’’[All Fields]) AND (‘‘Breast’’[Mesh] OR ‘‘Breast’’[All Fields]) AND (‘‘Body Weights and Measures’’[Mesh] OR ‘‘Body Weights and Measures’’[All Fields]) OR (‘‘Anthropometry ‘‘[Mesh] OR ‘‘Anthropometry’’[All Fields]) = 355243a a
Number of articles retrieved
of the patient during relatively long evaluation periods, and even patient embarrassment due to the exposure of the naked body and application of measurement tools [2, 4]. Female breasts are difficult to measure accurately. In addition to the factors described above, other complicating factors arise from aspects inherent to breasts, such as volume and degree of sagging [4]. Using direct anthropometry, several authors [4–8] created primary reference parameters related to placement, shape, and volume. They also identified factors that influenced these measurements, i.e., weight, age, pregnancy, lactation, and biotype. The main tools used by plastic surgeons to measure the breast region are the tape measure and the compass. However, there is no consensus about a reference standard of landmarks and measurements. Thus, with respect to breasts and given the peculiar characteristics of this anatomical region, a standardized protocol is lacking, not only concerning the anatomical landmarks, but also the choice of the measuring tool. Therefore, the objective of this study was to compare direct breast anthropometric measurements taken with tape measure and compass.
of MEDLINE for articles from 1966 to December 2012. The search strategy used was formulated using the keywords shown in Table 1. Of the articles retrieved from the literature review, 16 authors have described anatomical or anthropometric landmarks for breast measurements, as shown in Table 2. Fourteen landmarks have been found with the patient in the anterior position and/or the profile. From these, it was verified in a preliminary study that four landmarks were not suitable for reproduction in photogrammetry: the inferior and midpoint of the mammary fold (SMMe), the point at the lateral mammary fold (SMLa), the navel point (Um), and the pubic point (Pu). After approval by the Research Ethics Committee (CEP No. 1054/10, Sa˜o Paulo, August 27, 2010), 40 volunteers, aged 18–60 years, from the Plastic Surgery Division Outpatient Service of the Universidade Federal de Sa˜o Paulo (UNIFESP) were included in the study. Each volunteer was instructed to remain in the anatomical position, with the head in the Frankfurt position, while being measured. Self-adhesive labels (0.6 cm in diameter and 0.3 mm in its internal part) were used to mark two landmarks on the midline and six landmarks on each side of the body to form linear segments. The connection of one point to another formed eight line segments on each side of the body, seven of which were formed bilaterally: IJ–PAP, XCL–PAP, PAP–Ac, Ac–EpL, Ax–PAP, PAP–LM, and the segment Ac–Yum (Fig. 1). The first measurement was done with a tape measure with the scale in millimeters. The tape measure was placed in the center of the label and pulled with uniform tension toward the center of the opposite label (Fig. 2a, c). The second measurement was conducted using a compass with a safety blunt tip. One tool arm was placed at the center of a label and the other arm at the center of the opposite label (Fig. 2b). The opening of the compass was transferred to a stainless steel ruler 30 cm long with a scale in millimeters (Fig. 2d). All measurements were compared using the Wilcoxon test (p \ 0.05).
Results Differences were found in all linear measurements when the results of the two measurement methods (p \ 0.001), tape measure and compass, were compared (Table 3). Statistical analysis was not performed on the angular measurement because only one measuring tool was used (protractor).
Methods
Discussion
To obtain the anatomical and anthropometric landmarks, a PubMed search was conducted in the electronic databases
According to Roebuck et al. [9], the origin of anthropometry reportedly was Marco Polo’s travels from 1273 to
123
123 38
–
1994
1986a 1997
2006
2009
2009
2009
2002
2007 2011
2011
Malata et al. [11]
Smith et al. [6] Quiao et al. [14]
Sigurson and Kirkland [15]
Denoel et al. [16]
Pozzobon et al. [17]
Odo [8]
Vandeput and Nelissen [18]
Kim et al. [19] Agbenorku et al. [20]
Liu and Thomson [21]
13 13
18
8
4
3
6
5
2
5
6 8
4
4
16
6
Measurements
5
x
x
x
x
x
IJ– Xi
14
x
(obl) x
x
x
x
x
x
x x
x
x
x
x
IJ– PAP
1
x
IJ– Pu
1
x
IJ– Umb
2
x
x
IJ– SMMe
5
x
x
x
x
(5 cm)
Cl– PAP
1
x
Ac– PAP
6
x
(perf)
x
x
x
x
Ax– PAP
11
x
x
x
x
x
x x
x
x
x
PAP– LM
6
x
x
x
x x
x
x
PAP– SMLa
13
x
x
x
(perf)
x
x
x
x x
(perf)
x
x
x
PAP– SMMe
5
x
x
x
x
x
PAP– PAP
6
x
x
x
x x
x
PAP– Dia
2
(olec)
Ac– EpL
1
x
Ac– Um
3
x
x
x
Angle
Ac acromion, Ax axillary line, Cl clavicle, EpL lateral epicondyle, IJ jugular notch, LM anterior midine, PAP nipple, Pu pubis, SMMe inframammary fold, SMLa lateral mammary fold, Um humerus, Umb umbilicus, Xi xiphoid, 1/2Um half the distance between the acromion and the olecranon, perf profile, obl oblique, olec olecranon
Total = 16
–
1999
Brown et al. [7]
1 21
1955
35
1989
1997
Westreich [4]
Loughry et al. [13]
1986b
Smith et al. [10]
Citations
Penn [5]
Publ. year
Authors
Table 2 Anthropometric and anatomical points and line segments found in the literature
346 Aesth Plast Surg (2014) 38:344–349
Aesth Plast Surg (2014) 38:344–349
Fig. 1 Schematic representation of the eight anatomical landmarks and the formation of the eight linear segments on each side of the body and one angular measurement. Anatomical landmarks: IJ jugular notch center, Xi base of the xiphoid process, PAP center of the mammary papilla, Ac acromion, EpL anterior projection of the lateral epicondyle, xCl point corresponding to half the distance between the center of the jugular notch and the acromion, called the ‘‘x’’ point of the clavicle, Ax proximal point of the anterior axillary line, yUm point corresponding to half the distance between the acromion and the lateral epicondyle, called the ‘‘y’’ point of the humerus. Linear segments: IJ–Xi, IJ–PAP, xCl–PAP, Ac–PAP, Ax– PAP, LM–PAP, Ac–EpL and Ac–yUm. Angular measurement, a is the angle formed by the junction of the segments IJ–Xi and IJ–PAP
1295, during which he encountered many people from different ethnic groups who differed from each other by size and body height, among other aspects. According to Westreich [4], diversity in curvature, protrusion, and relief in the thoracic region may cause inaccuracy in direct anthropometric measurements due to variations between measurements. Any movement of the chest wall during the breathing cycle and postural oscillations of an individual are also factors that corroborate these variations. The most difficult measurements are those from the segment of the most cranial point of the axilla to the center of the mammary papilla and the identification of the landmark at the most lateral prolongation of the mammary fold. According to Westreich, soft tissue landmarks vary too much to be included in studies of breast measurements. Those landmarks will vary from woman to woman and change with the slightest movement of the same patient. In a study by Smith et al. [10], differences of 15–20 % could be found in measurements from the most cranial
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point of the anterior axillary line to any of the points on the chest wall. The authors concluded that minor position changes could alter these measurements. Of the articles retrieved from the literature review, 15 described anatomical or anthropometric landmarks for breast measurements (Table 2). Fourteen landmarks have been found with the patient in the anterior position and/or the profile position. From these, it was verified that four landmarks were not suitable for reproduction in photogrammetry: the inferior and midpoint of the SMMe, the point at the lateral SMLa, the Um, and the Pu. In this context, it was verified that large breasts or breasts with ptosis that overlapped with the inferior and midpoint of the mammary fold prevented its visualization, both in the anterior position and the profile position. It was not possible to define precisely the lateral end of the mammary fold in breasts with accentuated lateral prolongation and small breasts (hypomastia). The reference points of the Um and the Pu were also excluded since they did not represent the correct position of the midline, and spine and pelvic deviations could alter the centering of the midline. Therefore, we decided to use the base of the xiphoid process for marking the midline. By direct anthropometry it is possible to quantify different patterns of breasts using a tape measure, compass, anthropometer, or caliper to obtain linear and angular measurements between anatomical or anthropometric landmarks [4, 6, 7, 10, 11]. Regarding the measurements with the tape measure, the differences in the segments from the acromion to the anterior projection of the lateral epicondyle (Ac–EpL), and the point corresponding to half the distance from the acromion to the anterior projection of the lateral epicondyle (Ac–yUm), could be explained by the ease of movement provided by this segment and that this was the largest segment measured in this study. According to Kouchi et al. [12], measurements smaller than 10 cm were more reliable and did not differ significantly when compared to the larger measurements. Our results showed that there was a difference between the measurements obtained by the tape measure and the compass. Because the tape measure follows the body’s contours it causes a discrepancy with the measurements from the compass, which gives linear measurements in the spatial sense. In regions where the breast skin’s relief does not come into play, the measurements obtained by tape measure and by compass were also not comparable. In conclusion, this study shows that once a measurement tool is chosen, it should be used for both pre- and postoperative measurements. Also, for breast region measurements, previously marked anthropometric or anatomical landmarks should be used.
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Aesth Plast Surg (2014) 38:344–349
Fig. 2 Measurements of the breasts. a Linear measurement with tape measure, b linear measurement with compass, c detail of the tape measure measurement, d transposition of the compass opening to the ruler
Table 3 Median values (in cm) for the measurements obtained with the measuring tape and the compass Segment
Measuring tape
Compass
N
p valuea
IJ–Xi
16.6
16.1
80
\0.0001*
IJ–PAP
21.8
21.5
80
\0.0001*
CI–PAP
21.4
21.2
80
\0.0001*
Ac–PAP
21.4
21.1
80
\0.0001*
Ax–PAP
14.3
14.2
80
\0.0001*
ME–PAP
11.4
11.2
80
0.0003*
Ac–EpL Ac–1/2 Um
29.6 14.7
29.3 14.6
80 80
\0.0001* \0.0001*
3.4
3.5
80
Projection N sample number a
Wilcoxon test
* Statistical significance
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0.36
Conflict of interest disclose. Funding
The authors have no conflicts of interest to
There was no funding received for this study.
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