Adam M. Tobias

Patient Satisfaction in Postmastectomy Breast Reconstruction: A Comparative Evaluation of DIEP, TRAM, Latissimus Flap, andImplant Techniques

Background: Despite a growing literature on patient satisfaction in breast reconstruction, few studies have compared perforator flaps with the more commonly practiced methods. The authors compared four reconstructive techniques and identified factors influencing patient satisfaction. Methods: All patients undergoing postmastectomy breast reconstruction between 1999 and 2006 at a single academic institution were included in our study. A total of 583 patients with tissue expander/implant, latissimus, pedicle transverse rectus abdominis muscle (TRAM), and deep inferior epigastric perforator (DIEP) flap reconstructions received a validated questionnaire on satisfaction, health-related quality of life, and sociodemographic data. Results: Patient response was 75 percent, with 439 completed questionnaires including 87 tissue expander/implant, 116 latissimus, and 119 pedicle TRAM and 117 DIEP flap patients. DIEP patients had the highest level of general satisfaction at 80 percent, and pedicle TRAM patients had the highest level of aesthetic satisfaction at 77 percent (p < 0.001 and p < 0.001, respectively). Health-related quality of life and length of time since surgery were identified as significant covariates influencing patient satisfaction. After logistic regression analysis, autologous reconstruction had significantly higher general and aesthetic satisfaction than implant-based reconstruction (p = 0.017 and p < 0.001). Among the autologous reconstructions, abdominal-based flaps had significantly higher general and aesthetic satisfaction than latissimus flaps (p = 0.011 and p = 0.016). When comparing the abdominal-based reconstructions, general and aesthetic satisfaction were no longer statistically significant between pedicle TRAM and DIEP flaps (p = 0.659 and p = 0.198). Conclusions: Autologous, abdominal-based reconstructions had the highest satisfaction rates across all four groups. After logistic regression analysis, differences in patient satisfaction between pedicle TRAM and DIEP flap reconstruction were no longer observed. Discussing satisfaction outcomes with patients will help them make educated decisions about breast reconstruction.

Impact of Complications on Patient Satisfaction in Breast Reconstruction

Background: The development of a complication after surgery can be difficult for both patient and surgeon. With a growing body of literature evaluating patient satisfaction after breast reconstruction, few studies directly focus on the impact of surgical complications on satisfaction. This study analyzed the effect of complications on general and aesthetic satisfaction after breast reconstruction. Methods: All women at an academic institution undergoing breast reconstruction between 1999 and 2006 were identified. Patient demographics and history of complications were collected. A questionnaire adapted from the Michigan Breast Reconstruction Outcomes Survey was administered examining general and aesthetic satisfaction. Patients with complications were compared with patients with no complications. Results: Overall, 716 women underwent 932 reconstructions; 233 patients had a complication. Patient demographics and response rate were similar between the two groups (overall response rate 75.4 percent). Development of a complication correlated with increased odds of aesthetic dissatisfaction (odds ratio = 1.61, p = 0.047). Other predictors of dissatisfaction were older age, reconstruction with an implant, and a longer time interval between reconstruction and survey, while autologous reconstruction was a predictor of satisfaction. Among patients with a complication, implant reconstruction and mastectomy for prophylaxis were significant predictors of dissatisfaction. Conclusions: Aesthetic satisfaction after breast reconstruction is lower in patients developing a complication, older patients, and those receiving an implant reconstruction. Furthermore, patients with a prophylactic mastectomy are more likely than those with a therapeutic mastectomy to be dissatisfied when complications arise. These relationships are important, as measures to improve quality and decrease complications can directly improve patient satisfaction.

First-in-human pilot study of a spatial frequency domain oxygenation imaging system.

Oxygenation measurements are widely used in patient care. However, most clinically available instruments currently consist of contact probes that only provide global monitoring of the patient (e.g., pulse oximetry probes) or local monitoring of small areas (e.g., spectroscopy-based probes). Visualization of oxygenation over large areas of tissue, without a priori knowledge of the location of defects, has the potential to improve patient management in many surgical and critical care applications. In this study, we present a clinically compatible multispectral spatial frequency domain imaging (SFDI) system optimized for surgical oxygenation imaging. This system was used to image tissue oxygenation over a large area (16×12 cm) and was validated during preclinical studies by comparing results obtained with an FDA-approved clinical oxygenation probe. Skin flap, bowel, and liver vascular occlusion experiments were performed on Yorkshire pigs and demonstrated that over the course of the experiment, relative changes in oxygen saturation measured using SFDI had an accuracy within 10% of those made using the FDA-approved device. Finally, the new SFDI system was translated to the clinic in a first-in-human pilot study that imaged skin flap oxygenation during reconstructive breast surgery. Overall, this study lays the foundation for clinical translation of endogenous contrast imaging using SFDI.

High body mass index and smoking predict morbidity in breast cancer surgery: a multivariate analysis of 26,988 patients from the national surgical quality improvement program database.

Objective:The purpose of this study was to examine the incidence of complications of breast cancer surgery in a multi-institutional, prospective, validated database and to identify preoperative risk factors that predispose to these complications. Background:There is an increased emphasis on clinical outcomes to improve the quality of surgical care. Although mastectomy and breast conserving surgery have low risk for complications, few US studies have examined the incidence of these complications in large, multicenter patient populations. The broad scale of the National Surgical Quality Improvement Program (NSQIP) data set facilitates multivariate analysis of patient characteristics that predispose to development of postoperative complications in breast cancer surgery. Methods:A prospective, multi-institutional study of patients undergoing mastectomy and breast conserving surgery was performed from the National Surgical Quality Improvement Program from 2005 to 2007. Study subjects were selected as a random sample of patients at more than 200 participating community and academic medical centers. Thirty-day morbidity was prospectively collected and the incidence of postoperative complications was determined, with particular emphasis on superficial and deep surgical site infections. Multivariate logistic regression was performed to identify independent risk factors for postoperative wound infections in each. Results:A total of 26,988 patients were identified who underwent mastectomy (N = 10,471) and breast conserving surgery (N = 16,517). As expected, the overall 30-day morbidity rate for all procedures was low (5.6%), with significantly higher morbidity for mastectomies (4.0%) than breast conserving surgery (1.6%, P < 0.001). The most common complications in all procedures were superficial surgical site infections and deep surgical site infections. Independent risk factors for development of any wound infection in patients undergoing mastectomy were a high body mass index, smoking, and diabetes (ORs = 1.8, 1.6, 1.8). In patients who had a lumpectomy, a high body mass index, smoking, and a history of surgery within 90 days prior to this procedure (ORs = 1.7, 1.9, 2.0) were independent risk factors. Conclusions:Although complication rates in breast cancer surgery are low, wound infections remain the most common complication. A high body mass index and current tobacco use were the only independent risk factors for development of a postoperative wound infection across all procedures. This study highlights the benefit of a multi-institutional database in assessing risk factors for adverse outcomes in breast cancer surgery.

Postmastectomy radiation therapy and breast reconstruction: an analysis of complications and patient satisfaction.

The indications for postmastectomy radiotherapy (PMRT) have expanded over the past decade. This study examines PMRT and reconstruction compared with a control group without radiotherapy. There were 919 reconstructed breasts identified (1999–2006) and separated into 3 groups: mastectomy with PMRT before reconstruction (n = 57), immediate reconstruction then PMRT (n = 59), and reconstruction without PMRT (n = 665). A validated questionnaire assessed patient satisfaction (response rate 73.7%). Overall complication rates for patients undergoing PMRT (before and after reconstruction) were higher than that of the controls (39.66% vs. 23.16%, P < 0.001). Immediate reconstruction before PMRT had increased overall and late (>90 days) complication rates, compared with controls (47.46% vs. 23.16%, P < 0.001; 33.90% vs. 15.59%, P < 0.001, respectively); however general and aesthetic satisfaction was similar. In contrast, PMRT before reconstruction has similar complication rates and general satisfaction with controls, but decreased aesthetic satisfaction (50% vs. 66.88%, P < 0.035).

Patient satisfaction in unilateral and bilateral breast reconstruction [outcomes article].

Background: The goal of reconstruction after mastectomy is to provide a long-term and symmetric reconstruction. Providing symmetry entails different decision making when faced with a unilateral or bilateral reconstruction. In unilateral reconstruction, the goal is to match the contralateral breast; however, in bilateral reconstruction, symmetry between the reconstructed breasts is more important. The purpose of this study was to examine patient satisfaction between unilateral and bilateral reconstruction. Methods: All women at Beth Israel Deaconess Medical Center undergoing breast reconstruction between 1999 and 2006 were identified. Patient demographics and complications were collected. A survey was administered examining general and aesthetic satisfaction. Patients with unilateral reconstruction were identified and compared with patients with bilateral reconstruction. Additional analysis was performed based on the type of reconstruction, including autologous, autologous with implant, and tissue expander/implant-based reconstruction. Results: Overall, 702 women underwent 910 breast reconstructions (494 unilateral, 416 bilateral). Patients in the bilateral reconstruction group were more likely to have prophylactic mastectomy and immediate reconstruction. Complication rates were similar between unilateral and bilateral reconstruction. Patient satisfaction was highest in unilateral patients with autologous compared with implant reconstruction (general satisfaction, 73.9 versus 40.9 percent, p < 0.0001; aesthetic satisfaction, 72.3 versus 43.2 percent, p < 0.0001). Bilateral reconstruction had similar general and aesthetic satisfaction scores across autologous, autologous with implant, and implant-based reconstruction. Conclusions: Patients undergoing unilateral reconstruction have the highest satisfaction with autologous reconstruction. As symmetry between reconstructed breasts is essential for patient satisfaction in bilateral reconstruction, it is important to use the same type of reconstruction, whether autologous or implant-based.

Precision Measurement of the Neutron Spin Asymmetries and Spin-dependent Structure Functions in the Valence Quark Region

We report on measurements of the neutron spin asymmetries

Cost analysis of implant-based breast reconstruction with acellular dermal matrix.

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Precision Measurement of the Neutron Spin Asymmetry A1 n and Spin-Flavor Decomposition in the Valence Quark Region

and polarized structure functions

Effects of vasopressor administration on the outcomes of microsurgical breast reconstruction.

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