Adelyn L. Ho

Measuring quality of life and patient satisfaction in facial paralysis patients: a systematic review of patient-reported outcome measures.

Background: Incomplete recovery from facial nerve damage has functional deficits and significant social and psychological consequences. To evaluate the success of surgical and nonsurgical interventions in facial paralysis patients, patient satisfaction and impact on quality of life should be considered. The objective of this study is to identify existing patient-reported outcome instruments that measure quality-of-life outcomes in the facial paralysis population. Methods: A systematic review of the English-language literature was performed to identify patient-reported outcome instruments that have been developed and validated for use in facial paralysis patients. Each qualifying measure was evaluated for content and psychometric properties, as outlined by international recommended guidelines for item generation, item reduction, and psychometric evaluation. Results: From 598 articles, 28 questionnaires assessing facial paralysis were identified. Only three questionnaires satisfied the inclusion and exclusion criteria: the Facial Clinimetric Evaluation Scale, the Facial Disability Index, and a questionnaire developed to study aberrant facial nerve regeneration. Although these patient-reported outcome instruments show evidence of development and validation, no measures satisfy all instrument development and validation guidelines. All instruments were limited in domains that address self-perception of facial appearance and procedure-related symptoms or satisfaction. Conclusions: Although instruments are available for measuring outcomes with respect to facial function, there are few instruments developed to specifically evaluate the impact of facial paralysis on quality of life. To quantify treatment outcomes of facial paralysis patients, future research to develop and validate a new patient-reported outcome instrument is needed.

Patient satisfaction and health-related quality of life following breast reconstruction: patient-reported outcomes among saline and silicone implant recipients.

Background: In recent years, there has been a growing acceptance of the value of breast reconstruction. The majority of women who choose to proceed will undergo alloplastic reconstruction. The primary objective of this study was to determine whether the type of implant used in alloplastic breast reconstruction has an impact on patient-reported satisfaction and quality of life. Methods: Patients were deemed eligible if they had completed alloplastic reconstruction at least 1 year before study initiation. Patients were contacted by mail: two questionnaires [the BREAST-Q and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30 (Br23) (EORTC QLQC30 (Br23))], a contact letter, and an incentive gift card were included. Scores were compared between silicone and saline implant recipients. Results: Seventy-five silicone implant recipients and 68 saline implant recipients responded, for a response rate of 58 percent. BREAST-Q responses showed silicone implant recipients to have higher scores on all nine subscales. This difference reached statistical significance on four of nine subscales: overall satisfaction (p = 0.008), psychological well-being (p = 0.032), sexual well-being (p = 0.05), and satisfaction with surgeon (p = 0.019). Regression analysis adjusted for follow-up time, timing of surgery, unilateral versus bilateral surgery, radiation, and age. Results from the EORTC QLQC30 (Br23) showed a statistically significant difference on two of 22 subscales: silicone recipients had higher overall physical function, and saline recipients had higher systemic side effects. Conclusions: This study has shown higher satisfaction with breast reconstruction in silicone gel implant recipients compared with saline recipients using the BREAST-Q. There was no difference in overall global health status between the two patient groups as measured by the EORTC-QLQC30 (Br23).

Optimizing patient-centered care in breast reconstruction: the importance of preoperative information and patient-physician communication.

Background: In breast reconstruction, achieving patient satisfaction is a central goal. While much is known about clinical variables that may influence satisfaction, little is known about how the process of care may affect patient perceptions of outcome. The aim of this study was to examine how preoperative information and interactions with the surgical and medical teams might influence patient satisfaction with the outcome. Methods: A multicenter, cross-sectional study design was used. The BREAST-Q (breast reconstruction module) was administered in a postal survey to a cohort of breast reconstruction patients in North America. The association between patient satisfaction with the process of care and satisfaction with the outcome of breast reconstruction was evaluated using linear regression. Multivariate regression models were constructed to control for confounders and to identify predictors of outcome. Results: The study sample (n = 510; response rate, 66 percent) was characterized by a mean age of 54.3 ± 9.3 years (range, 21.0 to 81.0 years) and a mean body mass index of 25.2 ± 4.3 (range, 16.3 to 48.9). On multivariate analysis, satisfaction with information and satisfaction with the plastic surgeon predicted higher satisfaction with breasts (information, p < 0.001; plastic surgeon, p = 0.003; R2 = 0.29) and higher satisfaction with overall outcome (satisfaction with information, p < 0.001; satisfaction with plastic surgeon, p < 0.001; R2 = 0.31). Conclusions: Patient-centered care is an important aspect of quality of care. Patients’ levels of satisfaction with preoperative information and their interaction with their plastic surgeon significantly influence satisfaction with their breasts and overall outcome. Future research to develop methods to enhance information delivery and the surgeon-patient relationship may optimize outcomes in breast reconstruction patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Patient-reported satisfaction and health-related quality of life following breast reconstruction: a comparison of shaped cohesive gel and round cohesive gel implant recipients.

Background: Decision-making in breast reconstruction is complicated as women are offered an increasingly large range of options. Alloplastic surgery continues to evolve with the introduction of new prostheses to the breast reconstruction market but with limited patient-reported outcomes data. Evaluating the outcomes of surgical interventions and their impact on patients is imperative to improve the patient decision-making process and to improve quality of care. The authors evaluated the effect of the two most commonly used silicone prostheses on patient-reported satisfaction and health-related quality of life following alloplastic breast reconstruction. Methods: Patients were deemed eligible if they had completed alloplastic reconstruction at least 1 year before study initiation. Patients were contacted by mail with the BREAST-Q questionnaire, a contact letter, and an incentive gift card. BREAST-Q scores were compared between shaped cohesive and round cohesive silicone gel implant recipients. Results: Sixty-five round, cohesive, non–form-stable and 63 shaped, cohesive, form-stable silicone gel implant recipients responded, for an overall response rate of 75 percent. BREAST-Q responses showed no difference on any scale, including overall satisfaction with breast and outcome. Item-wise analysis revealed that implant recipients find shaped cohesive form-stable implants to be significantly firmer than cohesive round implants. No difference was found in implant rippling. Conclusion: Although previous studies have shown silicone implant recipients to be more satisfied overall than saline implant recipients after alloplastic breast reconstruction, this study showed that patients do not differ in terms of satisfaction with outcome when compared regarding reconstruction using round versus shaped cohesive silicone gel implants. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Postmastectomy radiation therapy after immediate two-stage tissue expander/implant breast reconstruction: a University of British Columbia perspective.

Background: An increasing number of women who undergo immediate two-stage tissue expander/implant breast reconstruction will require postmastectomy radiation therapy. An important variable is the timing of radiotherapy relative to surgery. The authors report their experience treating a large consecutive series of patients who underwent postmastectomy radiation therapy to the tissue expander before exchange for a permanent implant. Methods: Patients who had their tissue expander irradiated before implant exchange were identified. Complications, capsular contracture, revision surgery, and autologous salvage rates of irradiated patients were compared with a control group of nonirradiated patients. Results: Immediate two-stage tissue expander/implant reconstruction was initiated in 604 patients, with 113 irradiated breasts meeting inclusion criteria. Three hundred thirty-nine nonirradiated breasts constituted the control group. There was a 4.2 increased odds of major complications in the irradiated group, after adjusting for plastic surgeon, age, body mass index, smoking, chemotherapy, and cancerous breast (OR, 4.2; p = 0.001). The grade III and IV capsular contracture rate was significantly higher in the irradiated group compared with the control group (21.7 percent versus 10 percent; p < 0.008). The revision rate in the control group was higher compared with the irradiated group (30.2 percent versus 20.9 percent; p < 0.001). Conclusions: Postmastectomy irradiation to the tissue expander is associated with high complications; however, these patients have an acceptable capsular contracture rate that compares favorably with other implant-based radiotherapy algorithms. Revision rates were less than expected in irradiated breasts. This study suggests that immediate tissue expander/implant reconstruction is a reasonable surgical option in the setting of postmastectomy radiation therapy. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Comparison of Outcomes following Autologous Breast Reconstruction Using the Diep and Pedicled Tram Flaps: A 12-year Clinical Retrospective Study and Literature Review

BACKGROUND There are few studies that compare the deep inferior epigastric artery perforator (DIEP) flap to the pedicled transverse rectus abdominis myocutaneous (pTRAM) flap for use in reconstructive breast surgery. The authors examined four factors that aid in decision-making: donor-site morbidity, need for surgery related to abdominal morbidity, operative time, and complications. METHODS This is a retrospective review of patients undergoing breast reconstruction using the DIEP or pTRAM flap at the University of British Columbia between 2002 and 2013. The authors compared operative time and abdomen- and flap-related complications in both groups. RESULTS Reconstruction was performed in 507 patients; 25.6 percent received DIEP flaps (n = 183 breasts) and 74.4 percent underwent pTRAM flap surgery (n = 444 breasts). Pedicled TRAM flap patients were more likely to require abdominal closure with mesh (44.2 percent versus 8.1 percent; p < 0.001); 21.2 percent of them had a postoperative bulge and/or hernia versus 3.1 percent of DIEP flap patients; and 12.7 percent of pTRAM flap patients required surgery for hernia/bulge. Controlling for confounders, there were five times the odds of a hernia/bulge in the pTRAM flap group. DIEP flap surgery was 234 minutes longer than pTRAM flap surgery. CONCLUSIONS The benefits of the pTRAM flap may be offset by the need to correct abdominal wall complications. DIEP flap reconstruction had lower donor complications but increased operative time. A cost analysis is needed to determine the most economical procedure. CLINCIAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.

Predictors of Mastectomy Flap Necrosis in Patients Undergoing Immediate Breast Reconstruction: A Review of 718 Patients.

BackgroundMastectomy flap necrosis (MFN) after mastectomy and immediate breast reconstruction can compromise postsurgical recovery, lead to additional surgeries, and compromise aesthetic outcome. The objective of this study was to determine if there is a difference in the rate of MFN in patients undergoing immediate alloplastic versus immediate autologous breast reconstruction. The secondary objective was to identify additional patient and surgical factors that may influence the rate of MFN. MethodsA retrospective chart review of patients who underwent immediate breast reconstruction between 2003 and 2011 in the University of British Columbia Breast Program was performed. Demographic, oncologic, reconstructive, and surgical data were compiled. ResultsApproximately 404 alloplastic and 314 autologous patients were reviewed. The overall rate of MFN was 12.9%. There was a trend toward a higher MFN rate in the autologous patient group (15.2% vs 11.6%, P = 0.095). After controlling for age, body mass index (BMI), smoking status, preoperative breast radiation, surgery duration, cancer side, mastectomy type, and postoperative chemotherapy, no association was found between reconstruction type and MFN. BMI greater than 30, smoking status, and preoperative radiation were independent predictors of MFN. Surgical factors including longer duration of surgery and Wise pattern mastectomy incision were also found to be associated with increased odds of MFN. ConclusionWe found no difference in the rate of MFN when comparing immediate alloplastic and autologous reconstruction methods. A number of patient and surgical factors were found to be predictors of MFN. The results of this large, retrospective study will help surgeons to tailor their reconstruction based on a patient’s risk factors to minimize the incidence of MFN.

Direct-to-implant single-stage immediate breast reconstruction with acellular dermal matrix: predictors of failure.

Background: Direct-to-implant single-stage immediate breast reconstruction using acellular dermal matrix is a cost-effective alternative to two-stage expander-implant reconstruction. The purpose of this study was to identify predictors of direct-to-implant single-stage immediate breast reconstruction failure, defined as need for early (⩽6 months) revision surgery. Methods: The authors conducted a retrospective cohort study of all patients with direct-to-implant single-stage immediate breast reconstruction in 2010 and 2011 at three University of British Columbia hospitals. Data were compared between successful and failed single-stage reconstructions. Predictors of failure were identified using multivariate logistic regression. Patient demographics and complications were compared to a random sample of control patients with two-stage alloplastic reconstruction without acellular dermal matrix. Results: Of 164 breasts that underwent direct-to-implant single-stage immediate breast reconstruction, 52 (31.7 percent) required early revision. Increasing breast cup size was the only significant predictor of early revision compared with bra size A (OR for bra size B, 4.86; C, 4.96; D, 6.01; p < 0.05). Prophylactic mastectomies showed a trend toward successful single stage (OR, 0.47; p = 0.061), whereas smoking history trended toward failure (OR, 1.79; p = 0.065). Mastectomy flap necrosis was significantly higher in direct-to-implant single-stage immediate reconstruction cases compared to two-stage controls. Conclusions: Direct-to-implant breast reconstruction can be reliably performed in a single stage in patients with small breast size. Increasing breast cup size confers a higher chance of early revision. A two-stage approach may be more cost-effective in larger breasted patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

The effect of combined topical-intracameral anaesthesia on neuroleptic requirements during cataract surgery

OBJECTIVE To evaluate whether the addition of intracameral lidocaine to topical anaesthesia during cataract surgery leads to a decrease in the administration of intraoperative midazolam and fentanyl. DESIGN Retrospective case-control study. PARTICIPANTS The eyes of 124 patients undergoing phacoemulsification were included in the study, with 62 in the intracameral group and 62 in the control group. METHODS A single-centre, retrospective chart review of cases between April and October 2007 in which patients had undergone small-incision phacoemulsification with foldable intraocular lens insertion and received preoperatively either topical tetracaine 0.5% with unpreserved intracameral lidocaine 1% (intracameral group) or topical tetracaine 0.5% alone (control group). Intraoperatively, midazolam and fentanyl were administered as needed based on pain and anxiety. RESULTS A total of 124 eyes (124 patients) were included. There was no statistically significant difference between the mean intraoperative midazolam doses given for the 2 groups (p = 0.08). The mean intraoperative dose of fentanyl was lower in the intracameral than in the control group (p < 0.0001). A comparison of intraoperative fentanyl requirements between groups using a multivariate regression analysis for age, gender, surgical time, and preoperative fentanyl levels confirmed the lower need for intraoperative fentanyl in the intracameral compared with the control group (p = 0.0037). There were no anaesthetic complications among any of the study patients. CONCLUSIONS Patients receiving topical tetracaine 0.5% with unpreserved intracameral lidocaine 1% during cataract surgery demonstrated a reduction in intraoperative fentanyl requirements. Surgeons performing cataract surgery under topical anaesthesia should consider the addition of intracameral lidocaine 1% to decrease fentanyl requirements and improve patient safety and comfort.

A Review of 101 Consecutive Subcutaneous Mastectomies and Male Chest Contouring Using the Concentric Circular and Free Nipple Graft Techniques in Female-to-Male Transgender Patients

Background: Many techniques exist for subcutaneous mastectomy in female-to-male transgender patients. The authors review outcomes for two techniques and present an algorithm to aid surgeons in technique selection. Methods: One hundred one consecutive female-to-male transgender patients undergoing subcutaneous mastectomy using the concentric circular or free nipple graft technique were retrospectively reviewed. An algorithm for procedure selection was created using classification and regression tree analysis. Aesthetic results (nipple-areola complex, scar, and chest contour) were also independently reviewed. Results: Two hundred two subcutaneous mastectomies were performed (concentric circular, 92 breasts; free nipple graft, 110 breasts). The overall complication rate was 21.3 percent, with 6.4 percent requiring operative intervention (free nipple graft, 1 percent; concentric circular, 13 percent; p < 0.001). The overall revision rate was 23.8 percent (free nipple graft, 12.7 percent; concentric circular, 37.0 percent; p < 0.001). In the concentric circular group, there were 3.3 times the odds of total complications (p = 0.03) and 4.0 times the odds of revision surgery (p < 0.001). Mean aesthetic scores for the concentric circular technique were superior to free nipple graft for scar (3.39 versus 2.62; p < 0.001) and contour (3.82 versus 3.34; p < 0.001). Conclusions: In patients who meet selection criteria, the concentric circular technique is preferred because of fewer scars, improved aesthetic contour, and potential for retained nipple sensation. These patients must be counseled regarding the higher rate of complications and revisions. It was determined that smokers and those with a nipple-to–inframammary fold distance greater than 7 cm or nipple-to–inframammary fold distance less than 7 cm and a body mass index greater than 27 kg/m2 should undergo the free nipple graft technique because of the increased risk of complications with the concentric circular technique. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.