Is three better than two? The use of 3D scanners in the assessment of aesthetic results in local breast cancer treatment.

Aesthetic results of local treatment of breast cancer, comprising surgery and radiotherapy, have always been difficult to evaluate in a concise way. The obstacles to aesthetical evaluation are familiar to all clinicians working in the field, and since the establishment of conservative breast cancer treatment as an alternative to mastectomy a myriad of methodologies have been used to evaluate aesthetic outcomes. But while oncological results aremore easily measurable aesthetic outcomes are difficult to evaluate. Who should evaluate, what needs to be evaluated, when should results be measured and how should this be performed have remained unanswered questions in the topic of aesthetic evaluation. Subjective appreciation of patients using qualitative scales was the norm until 1985 when Pezner showed the limited usefulness of subjective evaluation due to a very low agreement between observers.1 Pezner again, in the same year made the first real transition from subjective evaluation to objective measurement of asymmetry, with the introduction of the BRA (Breast Retraction Assessment), demonstrating a good correlation of this asymmetry difference between breasts, in classic breast conservative treatment, with the final aesthetic result evaluated subjectively.2 However, either using subjective evaluation and/or objective asymmetry measurements, available methods for evaluation of aesthetic results remained without a gold standard. Tomakematters evenmore difficult, patients’ self-evaluation, in spite of its fundamental importance in the process, was very difficult to integrate into overall aesthetic outcome as patients’ impressions seldom coincide with evaluation by healthcare professionals. Until the 21st century the lack of a standard method remained, leading to time consuming and difficult processes that included, in most series, the simultaneous use of several methods: subjective, objective and patients’ self-evaluation. In addition, the lack of standardization resulted in the impossibility of comparing outcomes from different centers. Professionals treating breast cancer were aware of the heterogeneity of aesthetic results in conservative treatment but remained unable to measure outcomes in a standardized way. By 2005 oncoplastic surgery paved the way trying to improve some of the bad results in breast conservation treatment using techniques familiar to plastic surgeons like breast reduction mammaplasties. At this point in time it became even more important to have feedback on cosmetic results, not only to evaluate the quality of treatment but, even more important, to be able to predict how