Claire Temple

Reduction mammaplasty improves breast sensibility.

The belief that breast hypesthesia is an expected consequence of reduction mammaplasty is based on past reports that failed to objectively quantify breast sensibility. Forty-five women undergoing reduction mammaplasty by one plastic surgeon using a single operative technique were followed prospectively for change in breast sensation. Pressure threshold measurements were taken preoperatively and at 2 and 6 weeks postoperatively, by using Semmes-Weinstein monofilaments. Areas tested included the nipple, four points on the areola, and four points 1 cm from the areola on the breast skin. The data were nonparametric and were analyzed by using the Wilcoxon signed rank test. For all areas tested, sensation significantly improved from preoperatively to 2 weeks (i.e., nipple: 33.1 versus 29.3, p<0.0004) and again from 2 to 6 weeks (i.e., nipple: 29.3 versus 19.3, p<0.002). Relief of chronic nerve traction injury is conjectured as the reason for sensibility improvement. Numb nipples persisted in 2 percent of breasts at 6 weeks.

Choice of Recipient Vessels in Delayed TRAM Flap Breast Reconstruction after Radiotherapy

This study compared the use of the internal mammary and thoracodorsal recipient vessels in a uniform group of patients who underwent delayed TRAM flap reconstruction after radiotherapy, focusing on usability rates and outcomes. The authors identified 123 delayed TRAM flap patients who had undergone postmastectomy radiotherapy from a prospective database (1990 to 2001). Recipient vessel unusability rates were calculated on the basis of reports of inspection of a vessel, either by direct intraoperative dissection or by findings from color Doppler examination (internal mammary vessels only). Charts were reviewed for outcomes including flap loss, vascular complications, fat necrosis, and lymphedema; t-test and chi-square analyses were performed to compare outcomes and unusability rates, and multiple regression analysis was performed to determine factors influencing outcome. Of the 123 planned free TRAM flaps, 106 were completed as free flaps and 17 were performed as pedicled flaps because of unusable recipient vessels. Of the free flaps, 45 were anastomosed to the internal mammary vessels, 55 to the thoracodorsal vessels, and six to other vessels. The internal mammary and thoracodorsal groups did not differ significantly in body mass index, abdominal scars, smoking history, time delay between irradiation and TRAM flap reconstruction, or flap ischemia time. Radiation doses to the axilla (thoracodorsal), internal mammary chain, and supraclavicular fossa were similar between the groups. The internal mammary vessels were rejected in 11 (20 percent) of 56 cases, and the thoracodorsal vessels were rejected in 19 (26 percent) of 74 cases (p = 0.42). In cases with unusable internal mammary vessels, 46 percent (n = 5) had inadequate veins, 27 percent (n = 3) had inadequate arteries, and in 27 percent (n = 3) both vessels were inadequate. In the 19 cases with unusable thoracodorsal vessels, 84 percent (n = 16) were excessively scarred, 11 percent (n = 2) had inadequate vessels, and 5 percent (n = 1) were absent. Outcomes were similar regardless of recipient vessels used (internal mammary versus thoracodorsal): total flap loss, 0 percent versus 4 percent (p = 0.20); vascular complications, 6.7 percent versus 11 percent (p = 0.46); arm lymphedema, 4.4 percent versus 9 percent (p = 0.37); partial flap loss, 9 percent versus 6 percent (p = 0.54); and fat necrosis, 18 percentversus 15 percent (p = 0.69). Multivariate analysis revealed a trend for higher complication rates in smokers and with the use of the thoracodorsal vessels as the recipients. Overall, no discernible unusability or outcome differences were detected between the internal mammary and thoracodorsal groups.

Immediate postmastectomy reconstruction is associated with improved breast cancer-specific survival: evidence and new challenges from the Surveillance, Epidemiology, and End Results database.

Although immediate breast reconstruction is increasingly offered as part of postmastectomy psychosocial rehabilitation, concerns remain that it may delay adjuvant therapy or impair detection of local recurrence. No single population‐based study has examined the relationship between immediate breast reconstruction and breast cancer‐specific survival.

A new, validated instrument to evaluate competency in microsurgery: the University of Western Ontario Microsurgical Skills Acquisition/Assessment instrument [outcomes article].

Background: The authors present a model for microsurgery learning as well as a validated instrument to evaluate microsurgical competency. Methods: Novice microsurgeons participated in three 3-hour sessions wherein they completed a number of increasingly complex, standardized microsurgical tasks. Performance was recorded and graded using a newly developed University of Western Ontario Microsurgery Skills Acquisition/Assessment (UWOMSA) instrument. The knot-tying and anastomosis modules contained three categories with five-point Likert scales. Each learners performance was assessed by two blinded surgeons. Reznicks validated global rating scale for operative performance was utilized to establish criterion validity. Within-scale scores were compared via intraclass correlation and between-scale scores with Pearson correlation coefficient. Linear regression was used to evaluate the effect of various predictors on UWOMSA scores. Results: Thirty-seven videos (9.6 hours) were reviewed, including 20 knot-tying sessions and 17 anastomoses. Interrater reliability of UWOMSA was high, with an intraclass correlation coefficient of 0.75 (0.57, 0.87). The intraclass correlation of the global rating scale was 0.79 (0.62, 0.89). Intrarater reliability of the UWOMSA was also high, with an intraclass correlation of 0.69 (0.48, 0.83). The intraclass correlation of the global rating scale was 0.69 (0.47, 0.84). Measures of criterion validity demonstrated strong agreement between UWOMSA and the global rating scale (Pearson correlation coefficient, 0.96; p < 0.001). Measures of construct validity demonstrated that higher scores on the UWOMSA were associated with faster knot tying (p < 0.0001) and higher postgraduate year level (p = 0.05). Conclusions: The UWOMSA instrument performed well in terms of reliability and validity. Further study is planned to assess the instruments ability to predict microsurgical skills translation to the clinical setting.

Intra-lesional interleukin-2 for the treatment of in-transit melanoma†

To investigate the role of intra‐lesional interleukin‐2 (IL‐2) injection for treatment of in‐transit melanoma metastases.

Sensibility following innervated free TRAM flap for breast reconstruction.

Background: The free transverse rectus abdominis musculocutaneous (TRAM) flap has proven to be a reliable means of recreating the aesthetic breast form after mastectomy. The purpose of this study was to determine whether neurotization of the free TRAM flap improved sensation of the reconstructed breast. Methods: Twenty-seven patients undergoing 37 free TRAM flap reconstructions were randomized to receive either an innervated (12 patients, 18 breasts) or a noninnervated flap (15 patients, 19 breasts). A nerve repair between the T10 intercostal of the TRAM flap and the anterior sensory branch of the fourth intercostal nerve was performed for innervation. Sensory testing (Semmes-Weinstein monofilaments, hot-cold discrimination, two-point discrimination) was performed by one blinded examiner in a standardized pattern. Results: Mean follow-up was 16 months. Demographic analysis revealed no significant differences in patient age, height, smoking, radiation therapy, and nipple-areola reconstruction between patient groups (p > 0.3). Patients in the noninnervated group, however, were heavier (p = 0.03). Preoperative sensation was not significantly different in the noninnervated and innervated groups. Postoperative pressure threshold and temperature discrimination were significantly improved in the innervated flaps (p < 0.05). Noninnervated flaps displayed a pattern of increasing sensibility from the center toward the periphery while innervated flaps regained sensation throughout. Conclusions: Innervation of the free TRAM flap provides improved sensation to the reconstructed breast and is a simple adjunct to breast reconstruction.

Topical Imiquimod Therapy for Lentigo Maligna

Lentigo maligna (LM) presents a challenge for complete surgical excision. Imiquimod is a topical immune-response modifier that acts on the immune system. We report our experience using imiquimod 5% cream as a surgical alternative for treatment of LM. Consecutive patients between December 2004 and February 2006 with LM were treated with topical imiquimod. Data on patient and lesion characteristics, side effects of therapy, posttreatment biopsy results, and follow-up was collected. Seven patients were treated with imiquimod 5 nights/wk for 12.4 weeks. Complete histologic and clinical resolution was seen in 86% (6 of 7 patients), at 19.1 months follow-up. Side effects included erythema (86%) and crusting (71%), resulting in dose alteration in 71% of patients. Topical imiquimod therapy demonstrates a high response rate for treatment of LM, with tolerable side effects. Further investigation into its efficacy in the treatment of LM in controlled clinical trials is warranted.

Sensibility following Innervated Free TRAM Flap for Breast Reconstruction: Part II. Innervation Improves Patient-Rated Quality of Life

Background: Restoring sensory innervation may be a useful adjunct in free flap head and neck reconstruction but, as yet, has not been shown to improve outcomes of breast reconstruction. The authors’ previous study demonstrated objectively improved sensation in a group of innervated transverse rectus abdominis musculocutaneous (TRAM) flap breast reconstruction patients relative to noninnervated flaps. This study compared patient-rated outcomes of free TRAM breast reconstruction in innervated versus noninnervated flaps. Methods: Twenty-seven women were randomized prospectively to undergo either innervated or noninnervated free TRAM flap breast reconstruction. For innervated flaps, the T10 intercostal nerve was harvested with the TRAM flap and neurotized to the T4 sensory nerve at the recipient site. Three validated outcome tools were administered after surgery: the Medical Outcomes Study 36-Item Short Form Health Survey, the Body Image after Breast Cancer Questionnaire, and the Functional Assessment of Cancer Therapy–Breast. Results were correlated with previously reported objective sensibility outcomes. Results: Eighteen of 27 women returned their questionnaires a mean 48 months after free TRAM flap reconstruction. Demographic analysis revealed no significant differences in patient age, height, smoking, radiation therapy, and nipple-areola complex reconstruction between randomized patient groups. There was a statistically significant improvement in all three measures in patients who were randomized to receive innervated free TRAM flaps compared with those receiving noninnervated flaps. Conclusion: This study demonstrates that innervation of free TRAM flaps used for breast reconstruction not only improves sensibility but also has a positive effect on patient-rated quality of life.

Development of a breast reconstruction satisfaction questionnaire (BRECON): dimensionality and clinical importance of breast symptoms, donor site issues, patient expectations, and relationships.

To develop a valid, reliable and responsive, self‐administered questionnaire to assess womens satisfaction with breast reconstruction.

The Role of the Randomized Controlled Trial in Plastic Surgery

This article discusses the role of the randomized controlled trial (RCT) in plastic surgery. There are unique challenges in the execution of an RCT in plastic surgery, including: (1) surgical equipoise, (2) the surgical learning curve, (3) differential care, (4) randomization, (5) concealment, (6) expertise-based design, (7) blinding, (8) intention-to-treat analysis, (9) loss to follow-up, and (10) treatment effect and implications for sample size calculations. The RCTs conducted in plastic surgery to date are generally of poor quality in design and reporting, are fraught with bias, and have small sample sizes, thus this article attempts to help future investigators perform better quality RCTs.