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Three-dimensional volume

rendering and display of skin and

subcutaneous tissues
Karen M. Horton, MD, Pamela T. Johnson, MD, David G. Heath, PhD,
Derek R. Ney, BS, and Elliot K. Fishman, MD

n the past, 3-dimensional rendering
was reserved for computed tomogra-
phy (CT) angiography and orthope-
dic applications. However, coupled with
advancements in multidetector (MDCT)
hardware, 3-dimensional volume ren-
dering has become an essential tool for
assessment of a range of organ systems,
including pulmonary, hepatobiliary, gen-
itourinary and gastrointestinal applica-
tions, due to the inherent versatility of
this robust display technique. Three-
dimensional volume rendering can also
provide valuable diagnostic information
about the skin, subcutaneous soft tissues
and muscle.1,2 Over the past decade, lim- This article explains how to optimize arterial or venous phase acquisition
ited applications of skin imaging with the volume-rendering technique for although in select cases dual-phase
CT have been reported in the literature.3–5 display of skin, soft tissues and muscle, imaging was used.
Nonetheless, in the authors’ experience it and it illustrates the clinical utility of Scan parameters included 0.6 mm
is extremely useful for comprehensive this application. collimators, 0.75 mm slice thickness
evaluation of skin ulcers, infection/ with a reconstruction interval of 0.5 mm.
inflammation, trauma, soft tissue tumors, MDCT data acquisition The typical kVp was120 and the mAs
and pre- and postoperative imaging and All studies were done on a 64-slice between 120 mAs and 200 mAs. All
vascular collateralization. This may have MDCT scanner (SOMATOM Sensation, images were reconstructed with a soft-
significant impact on patients seen in the Siemens Healthcare, Malvern, PA). All tissue kernel; the high-resolution bone
emergency room setting. patients were referred by their treating kernel is not used because the images
physicians for a range of clinical indica- have increased noise which degrades
Dr. Horton is a Professor of Radiology, tions. Unless contraindicated, studies quality. Once the datasets were recon-
Dr. Johnson is an Assistant Professor were performed with intravenous structed, all images were sent to a work-
of Radiology and Dr. Fishman is a (IV) contrast, either Omnipaque-350 station (Leonardo running InSpace,
Professor of Radiology, at The Russell or Visipaque-320 (GE Healthcare, Siemens Healthcare) for 3-dimensional
H. Morgan Department of Radiology
and Radiologic Sciences, Johns Hopkins
Chalfont, St. Giles, U.K.), depending rendering by the radiologist.
School of Medicine, Baltimore, MD. on the patient’s renal status or clinical
Dr. Heath is President and Mr. Ney history. Injection rate for 100 cc to Data analysis: A practical approach
is CEO of HipGraphics Inc., Towson, 120 cc of IV contrast was 4 cc/sec. Stud- The evaluation of a volumetric
MD. ies are routinely done using a single dataset is usually done interactively

6 ■ APPLIED RADIOLOGY © July–August 2009



FIGURE 1. CT of the normal hand. All these images are at the same level, and only the rendering algorthims were changed. Each of these
images can be created in a few seconds. (A) Surface rendering to accentuate the skin; the sheet under the patientʼs hand is also visible. (B) The
rendering has been changed to make the skin invisible and to highlight the subcutaneous tissues, muscle and superficial vessels. (C) In this
image, the soft tissues have been rendered transparent, so only the blood vessels and bones are visible. (D) In this image, all the soft tissues
and blood vessels are now transparent, so only the bone is visible. (E) This is an example of how the soft tissues can be made see-through,
while still being able to see the underlying bone. (F) Surface-variant volume rendering showing the effect of having the light source shining on
the dorsum of the hand. (G) Surface-variant volume rendering showing the effect of having the light source positioned from right. (H) Surface-
variant volume rendering showing the effect of having the light source positioned from the left. (I) Surface-variant volume rendering showing the
effect of having the light source positioned from above. (J) Surface-variant volume rendering showing the effect of having the light source posi-
tioned from below.
using a combination of axial CT, multi- Technical aspects of soft tissue rendered. The gradient is used for 2 pur-
planar reconstruction (MPR), and 3- imaging poses during rendering:
dimensional postprocessing with vol- The surface of the skin is best imaged 1) The size (magnitude) of the gradi-
ume rendering (VR) and maximum using the “shaded” variant of the ent is used to modulate what parts
intensity projection (MIP) techniques. volume-rendering technique. Not to be of the volume are visualized. Parts
However, for cases requiring soft tis- confused with shaded-surface render- of the volume data that have a
sue imaging, volume rendering is the ing, this shaded-rendering variant of small gradient are suppressed from
only technique necessary for data post- VR is designed to show and enhance the final image; this enhances the
processing. Images can be optimized the boundaries between materials. In boundaries between structures.
to define the tissue surface and inter- the case of the skin, the boundary is 2) A simulated light source is placed
faces. Understanding how to select and between air and the skin. The shaded- in space, usually relative to the
adjust the volume-rendering parame- rendering technique calculates 3- viewing direction. The direction of
ters for this type of display and analy- dimensional gradients in the Hounsfield the gradient vector is combined
sis is essential. units of each voxel in the data being with the light-direction vector to

8 ■ APPLIED RADIOLOGY © July–August 2009


FIGURE 2. 57-year-old man with diabetes and ulceration on the fourth digit. The CT was performed to evaluate for possible abscess or evi-
dence of osteomyelitis. (A) Surface skin rendering of the palmar surface of the hand nicely shows the soft tissue swelling of the mid and distal
fourth digit (arrow). (B) Surface skin rendering of the dorsal surface of the hand shows ulcers (arrow) on the distal fourth digit. (C) Rendering in
which the skin is made translucent and the bones are visible, shows decreased mineralization of the distal tuft (arrow) of the fourth digit, compat-
ible with osteomyelitis.


FIGURE 3. 45-year-old woman with sickle cell disease and nonhealing ulcer over ankle. (A) Surface-variant volume rendering shows the
patientʼs sock. (B) Surface skin rendering makes the sock transparent and nicely demonstrates the large skin ulcer (arrows). (C) Rendering to
visualize the bone shows lucency and periosteal reaction along the distal fibula and tibia compatible with osteomyelitis.

produce a shading effect in which The shading model is very important allowing the user to melt away the skin
boundaries facing the light source are for visualizing skin with VR. Unshaded and look at structures within the body
enhanced and those facing away from techniques result in images in which simply by changing window settings
the light source are diminished. An the surface is difficult to visualize. and retaining the high image quality
effect called “specular reflection” can Maximum intensity projection is virtu- typical of volume rendering (Figure 1).
also be used. This lighting effect adds ally useless for rendering skin. Surface- The use of a simulated light source and
“shininess” to the resulting image. rendering techniques (such as marching lighting effects such as “specular reflec-
For the surface of the skin, this often cubes) can make good images of skin. tion” enhance the visualization of places
enhances the 3-dimensional nature of However, volume-rendering produces where the skin surface is curving. The
the image. similar images and has the advantage of “curviness” is seen because the simulated

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FIGURE 4. 44-year-old man with pain, swelling and redness posterior to ankle. (A) 3-dimensional rendering in which the soft tissues have been
rendered transparent, so only the blood vessels and bones are visible. Significant hyperemia (arrows) is noted posterior to the ankle. (B) Sagittal
reconstruction shows the abscess (arrow) posterior to the ankle, and just deep to the Achilles tendon. (C) Coronal reconstruction also shows the
abscess collection.
reflection of the light modulates the color
or brightness of the surface over the curv-
A B ing section (Figure 1). Without the simu-
lated reflection it would be difficult to see
the curves. This is especially true for
small features such as wrinkles, nodules
or bumps. The fact that there is a high
degree of curvature in such features
means that the simulated reflection will
make them visible.

Clinical applications
The role of CT imaging of the skin
and muscle is best considered part of an
in-depth CT evaluation, which would
include analysis of the vascular map
and bone when imaging an extremity or
analysis of the liver, pancreas, kidneys,
small bowel, etc. when imaging the
abdomen. For the purposes of this arti-
cle, we will focus only on the imaging
of the skin, soft tissue and muscle to
define this imaging technique. The list
of applications and the illustrated cases
were selected for their teaching points.
FIGURE 5. 45-year-old woman with pain and redness over
lateral thigh. (A) Axial image shows a focal area of indurated Soft tissue inflammation
skin and swelling over anterior lateral thigh. (B) 3-dimensional
rendered images in which the normal skin is translucent,
and infection
nicely highlights the swelling and skin thickening, compatible Volume rendering can be used to iden-
with cellulitis. tify defects, such as skin ulcers (Figures 2

10 ■ APPLIED RADIOLOGY © July–August 2009


FIGURE 6. 35-year-old man with trauma to the third interphalangeal joint. (A) Surface skin rendering of the dorsal surface of the hand shows a
small laceration (arrow) over the third interphalangeal joint. (B) Rendering in which the skin and soft tissues are transparent, shows the hyper-
emia (arrow) to the third interphalangeal joint. (C) Rendering in which the skin is made translucent and the bones are visible shows no evidence
of fracture.

and 3) or sites of puncture wounds. The

A B technique here can delineate changes in
subcutaneous tissues in relationship to
underlying soft tissue, muscle or bone
pathologies. Further, it can define the
location and extent of soft tissue inflam-
mation, including abscess (Figure 4) and
cellulitis (Figure 5).

Soft tissue and muscle injury

following trauma
Shaded-rendering VR can also define
skin and muscle injury to elucidate the
trajectory of the penetrating trauma or
location of blunt trauma (Figure 6). It is
helpful in determining the extent of lac-
eration and muscle involvement in com-
plex muscle injury and fractures (Fig-
ure 7). CT techniques allow radiologists
to correlate soft tissue injury in relation
to muscle, vascular structures and bone.

Tumors of the skin, soft tissues

and bone
Radiologists can use these CT shaded-
rendering VR techniques to examine soft
tissue or muscle involvement in relation
to underlying bone tumors. The tech-
FIGURE 7. 45-year-old man status post MVA. (A) Volume rendering demonstrating extensive
nique is adequate for delineating neo-
soft tissue/muscle injury. (B) 3-dimensional rendering accentuating visualization of the bones plasms such as melanoma (Figures 8
shows fractures of tibia and fibula. and 9), lymphoma and neurofibromas.

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FIGURE 8. 37-year-old man with ulcerating lesion left midaxillary line. Biopsy-proven
melanoma. (A) Coronal volume-rendered image shows focal skin thickening in the left axilla
(arrow). (B) Surface skin rendering also shows the skin lesion (arrow).


FIGURE 9. 38-year-old woman with metastatic melanoma. (A) Surface skin rendering also
shows numerous skin lesions (B) 3-dimensional rendering making normal skin transparent
highlights the skin lesions.


FIGURE 11. 35-year-old man with der-

matofibrosarcoma protuberans for preoper-
ative evaluation. (A) Surface skin rendering
shows the large exophytic mass arising from
the left aspect of the forehead. (B) 3-dimen-
sional rendering highlighting the bones
shows only minimal bone erosion.

Miscellaneous applications
Besides the above clinical applica-
tions, CT imaging of the skin can be
used to define the extent of collateral
vascular flow in the chest wall and neck
(Figure 10). It can also be used for soft-
tissue mapping in craniofacial pathology
(Figure 11). In cosmetic surgery applica-
FIGURE 10. 49-year-old woman with SVC occlusion. (A) Surface rendering with transparent
tions, the technique can be combined
skin shows extensive abdominal wall collaterals. (B) 3-dimensional rendering with skin and with anatomic mapping of skin in rela-
muscles transparent, again shows extensive venous collaterals. tion to underlying pathology.

12 ■ APPLIED RADIOLOGY © July–August 2009

Discussion (e.g. ulcer and cellulitis). Furthermore, has addressed one of the new opportu-
The ability to create the “ CT physi- adjustment of volume-rendering parame- nities provided by the coupling of 64-
cal examination” provides a unique ters to depict underlying muscle and slice MDCT data with advanced
diagnostic advantage. However, 3- bone aid in delineating the extent of dis- postprocessing techniques like volume
dimensional rendered CT display of ease, as shown by the demonstrations of rendering. As CT continues to evolve
skin and superficial tissues has not seen abscess and osteomyelitis. Using CT to and as new, advanced rendering algo-
widespread application. Heretofore, determine the relationship of the skin to rithms are developed, we can look for-
physicians have been largely unaware underlying anatomic and pathologic ward to improved image resolution and
of the diagnostic potential available structures has proven valuable to guide fidelity.
from this shaded-variant volume ren- interventional procedures.2,3 Specifically,
dering of 64-slice MDCT. For example, skin imaging with MPR CT has been REFERENCES
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reported that “Unfortunately, CT scan- vein catheter placement.3 In patients with dimensional: Real time interactive volume render-
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However, this series of cases illus- Conclusion Biol Phys. 1998;40:629-635.
trates that improvements in dataset reso- Knowledge of 3-dimensional CT 4. Jung C-W, Seao J-H, Lee W, Bahk J-H. A novel
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vein based on three-dimensional computed
postprocessing algorithm can generate utility. In addition to the clinical appli- tomography. Anesth Analg. 2007;105:200-204.
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