Birgit Stark

Evaluation of arm and shoulder mobility and strength after modified radical mastectomy and radiotherapy

Seventy-five women, of whom 30 had received postoperative radiotherapy, were tested for range of motion (ROM) and shoulder strength with a goniometer and an isokinetic device (Orthotron II), respectively. On the individual level, irradiated patients exhibited significantly reduced range of motion (varying from p<0.05 to p<0.001) for all movements compared with the non-operated side. In contrast, in the non-irradiated patients only flexion was significantly reduced (p<0.05). The same individual pattern was evident for shoulder strength where all movements except external rotation were significantly reduced in irradiated patients (varying from p<0.05 to p<0.001). Non-irradiated patients exhibited a significant reduction in shoulder strength for flexion and abduction (p<0.05), whereas other movements were less affected. The observed differences in ROM and strength were less pronounced when analyzed on a group level, but were still significant for ROM (p<0.001) for flexion and abduction. Group level analysis also showed reduced shoulder strength for all movements but only rotation was significantly (p<0.01) impaired.

A prospective randomized study comparing two different expander approaches in implant-based breast reconstruction: one stage versus two stages.

Background: Implant-based reconstruction is performed in the majority of women offered primary reconstruction for breast cancer. Methods: Two different expander implants were compared prospectively. The primary endpoint was the number of operations needed in each group to obtain patient satisfaction. Secondary endpoints were evaluation of breast volume and shape and aspects of quality of life. Seventy consecutive breast cancer patients were randomized to either a one-stage reconstruction with a round permanent expander implant (Becker 25; n = 35) or a two-stage reconstruction with a crescent-shaped expander (LV 133; n = 35), later replaced by a form-stable anatomical implant. Thirty patients had to be excluded and 40 patients, 20 in each group, were evaluated. The median follow-up for both groups was 3.5 years (range, 1.5 to 5 years). Plastic cups, plastic casts, and two -and three-dimensional scanning techniques were used for objective assessment of breast volume and shape. The aesthetic outcome was evaluated by a panel of experts and lay people, and by the patients. Quality of life was evaluated with a validated questionnaire (36-Item Short Form Health Survey). Results: Of the patients in the one-stage group, 70 percent had revision surgery, mostly because of upper pole fullness and poor ptosis. These findings agreed with the data from the two-dimensional scanning and from the expert panel and the patients subjective judgment. Quality of life was similar in the two groups. Conclusions: The permanent expander method failed significantly as a one-stage procedure. The crescent two-stage method gave the most acceptable results both objectively and subjectively. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, I.

Early experience with the crescent expander in immediate and delayed breast reconstruction.

Traditional breast expanders have known drawbacks, such as undesirable fullness at the upper pole, inadequate expansion of the residual breast tissue, and poor ptosis of the reconstructed breast. Crescent-shaped expanders are thought to improve the result in that expansion is concentrated at the basal breast pole. The aim of this prospective pilot study was to evaluate our results with the crescent-shaped expander in immediate and delayed breast reconstructions. Twenty-five patients, median age 51 (27–75) years, underwent 28 operations. The median follow-up time was 8 (4–15) months. Four patients developed complications including superficial infections, capsular contractions (Baker III–IV), and fullness of the upper pole. Three of these patients had been given irradiation. Breast reconstructions with the crescent-shaped expander allowed expansion of the lower pole and led to an anatomical breast shape. Patients’ satisfaction during expansion was good. Our data indicate a correlation between complications and radiotherapy.

Evaluation of volume and shape of breasts: Comparison between traditional and three-dimensional techniques

Abstract There have been many attempts to evaluate the shape, volume, and contour of breasts both before and after operation. To evaluate and compare results objectively in a reproducible, low-cost way is difficult. The aim of this study was to compare three-dimensional techniques with traditional methods in evaluating the volume and shape of breasts. Twelve patients with breast cancer were evaluated, 6 patients preoperatively and 6 patients postoperatively, using plastic cups, thermoplastic casts, magnetic resonance imaging (MRI), and three-dimensional imaging techniques. Thermoplastic casts and plastic cups measured better accordance with the volume of the operated breast than either the three-dimensional technique or MRI, which resulted in significantly higher values. The three-dimensional technique offered a new possibility to evaluate the shape of breasts objectively.

Lower extremity soft tissue reconstruction and amputation rates in patients with open tibial fractures in Sweden during 1998–2010

BackgroundThe rates of soft tissue reconstruction and amputation after open tibial fractures have not been studied on a national perspective. We aimed to determine the frequency of soft tissue coverage after open tibial fracture as well as primary and secondary amputation rates.MethodsData on all patients (> = 15xa0years) admitted to hospital with open tibial fractures were extracted from the Swedish National Patient Register (1998–2010). All surgical procedures, re-admissions, and mechanisms of injury were analysed accordingly. The risk of amputation was calculated using logistic regression (adjusted for age, sex, mechanism of injury, reconstructive surgery and fixation method). The mean follow-up time was 6 (SD 3.8) years.ResultsOf 3,777 patients, 342 patients underwent soft tissue reconstructive surgery. In total, there were 125 amputations. Among patients with no reconstructive surgery, 2% (n = 68 patients) underwent amputation. In an adjusted analysis, patients older than 70xa0years (OR = 2.7, 95%, CI = 1.1-6) and those who underwent reconstructive surgery (OR = 3.1, 95% CI = 1.6-5.8) showed higher risk for amputation. Fixations other than intramedullary nailing (plate, external fixation, closed reduction and combination) as the only method were associated with a significant higher risk for amputation (OR 5.1-14.4). Reconstruction within 72xa0hours (3xa0days) showed better results than reconstruction between 4–90 days (p = 0.04).ConclusionsThe rate of amputations after open tibial fractures is low (3.6%). There is a higher risk for amputations with age above 70 (in contrast: male sex and tissue reconstruction are rather indicators for more severe soft tissue injuries). Only a small proportion of open tibial fractures need soft tissue reconstructive surgery. Reconstruction with free or pedicled flap should be performed within 72xa0hours whenever possible.

The latissimus dorsi flap - still a valuable tool in breast reconstruction: Report of 32 cases

Breast reconstruction with a pedicled latissimus dorsi flap (LDF), with or without implants, is an established method. At the Breast Cancer Unit, Huddinge University Hospital, 32 patients with soft tissue deficiencies of the chest such as damaged skin or lack of pectoral muscle after the initial operation, or complications of radiotherapy had breasts reconstructed with a pedicled LDF during the years 2002–2004. We made a retrospective assessment of the results of this procedure, which showed that the pedicled LDF, usually combined with an implant, still should be considered as an option to microsurgery as it is safe, with great satisfaction and few complications.

Definitive reconstruction of full-thickness abdominal wall defects initially treated with skin grafting of exposed intestines

BackgroundThe reconstruction of wide, full-thickness abdominal wall defects of the midline presents a continuing challenge, and consensus concerning the appropriate surgical treatment is lacking.MethodIn this retrospective review, we describe a simple method of reconstruction in full-thickness defects initially treated with skin grafting directly on to the surface of the intestines. Instead of removing the split-thickness grafts from the surface of the intestines, the abdominal wall was reconstructed by inverting the grafted area and advancing the rectus muscles towards the midline.ResultsFour patients with full-thickness transverse defects larger than 10xa0cm at the level of the waist and extending from the xiphoid to the suprapubic region were operated with this method. All healed uneventfully. In one case, microscopic examination of the inverted skin showed transformation to normal connective tissue.ConclusionReconstruction of abdominal wall defects previously treated with skin grafting directly on to the intestines can be safely done by reposition of the skin-grafted intestines into the abdominal cavity and realignment of the rectus muscles in the midline.

The Telemark Breast Score: A Reliable Method for the Evaluation of Results after Breast Surgery.

Background: Validated instruments for assessing results after breast surgery are sparse. The authors present here a method used for the past 10 years at their institution for evaluation of outcome after breast-conserving surgery and microsurgical breast reconstruction. Methods: The Telemark Breast Score is a method based on standard two-dimensional photographs assessing the outcome after breast surgery in terms of volume, shape, and symmetry. Three panels comprising two plastic surgeons, two breast surgeons, and two nurses tested the Telemark Breast Score on 346 patients who underwent breast-conserving surgery for cancer and 31 other patients who underwent deep inferior epigastric perforator flap reconstruction. All patients were assessed at least 1 year after their operation. Consistency of agreement between and within the panels was studied. Results: Interobserver and intraobserver reliability was good after consensus discussion. Good rating stability was shown using test-retest measurements. Conclusion: The Telemark Breast Score is an inexpensive, statistically reliable method and can be applied for quality control after breast surgery. CLINCAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

LONG-TERM RESULTS WITH THE PROXIMALLY-BASED NEUROVASCULAR LATERAL CALCANEAL FLAP

From 1995 to 1997, the proximally-based neurovascular lateral calcaneal flap was used in eight patients to cover defects in the Achilles tendon area or the lateral malleolar region. The mean postoperative follow-up was 40 months (range 29-51). The outcome of the operation was investigated both clinically and using a questionnaire sent to patients. All flaps healed uneventfully within a mean of 33 days. Revisional operations were required in two cases because of pain at the donor site. No flaps had broken down up to the follow-up, which was between three and five years. Two of the patients operated on were paraplegic, and the other six patients had sensate flaps. Five of the six patients with sensate flaps were able to wear normal shoes and one patient needed a shoe elevated by about 7.5 r cm because of a disease independent of the flap. All but two patients were satisfied with the functional and aesthetic results. The proximally-based neurovascular lateral calcaneal flap proved to be safe and can be recommended as a good option to cover tissue defects in the Achilles tendon area or the lateral malleolar region.

Breast Implant Registries: A Call to Action

Silicone breast implants have evolved through five generations and over 240 styles of breast implants have been delivered to the marketplace.1 However, there are little high quality data with which to make reliable, evidence-based evaluations of the risks of breast implants, and to date, the advantage of one type over the other is uncertain. Clinical quality registries (CQRs) enable evaluation of device performance, safety, and quality of care for patients. Just as breast implants have evolved and improved over the last decades, so too has clinical registry expertise and technology.2 Registries now support improved data capture, data linkage, analysis and reporting, and are a recognized contributor to health systems that provide high-quality patient care.3 The current generation breast implant registries promises to improve long-term breast implant safety, but key stakeholder support and participation is critical.