E. Dale Collins

The effectiveness of surgical and nonsurgical interventions in relieving the symptoms of macromastia

&NA; In this report, the authors evaluate the effectiveness of breast reduction in alleviating the symptoms of macromastia by comparing baseline and postoperative health status using a series of well‐validated self‐report instruments. The study had a prospective design with a surgical intervention group and two control groups: a hypertrophy control group with bra cup sizes D or larger and a normal control group with bra cup sizes less than D. The effectiveness of nonsurgical interventions in relieving the symptoms of macromastia was also evaluated, both in the operative subjects and in the control groups. Surgical candidates and controls completed a self‐administered baseline survey that consisted of the following validated and standardized instruments commonly used to evaluate outcomes: SF‐36, EuroQol, Multidimensional Body‐Self Relations Questionnaire (MBSRQ), and the McGill Pain Questionnaire (MPQ). A specially designed and validated instrument, the Breast‐Related Symptoms (BRS), was also used. There were also questions about prior nonsurgical treatments, comorbid conditions, bra size, and a physical assessment. Additional information obtained on the operative subjects included surgical procedure data, resection weight, and complications. Approximately 6 to 9 months postoperatively, surgical subjects completed the same questionnaire as described above, and a final physical assessment was performed. The cohort included 179 operative subjects with matched preoperative and postoperative data sets, 96 normal controls and 88 hypertrophy controls. The women were predominantly Caucasian, middle‐aged, well educated, and employed. Fifty percent of the operative subjects reported breast‐related pain all or most of the time in the upper back, shoulders, neck, and lower back preoperatively compared with less than 10 percent postoperatively. Operative subjects and hypertrophy controls tried a number of conservative treatments, including weight loss, but none provided adequate permanent relief. Compared with population norms, the preoperative subjects had significantly lower scores (p < 0.05) in all eight health domains of the SF‐36, and in the mental and physical component summary scores. After surgery, the operative subjects had higher means (better health) than national norms in seven of the eight domains and improved significantly from presurgical means in all eight domains (p< 0.05). Before surgery, the operative subjects reported high levels of pain with a Pain Rating Index (PRI) score from the MPQ of 26.6. After surgery, pain was significantly lower with a mean PRI score of 11.7, similar to that of our controls (mean PRI score, 11.2). Regression analysis was used to control for covariate effects on the main study outcomes. Among the operative subjects, benefits from breast reduction were not associated with body weight, bra cup size, or weight of resection, with essentially all patients benefiting from surgery. Breast hypertrophy has a significant impact on womens health status and quality of life as measured by validated and widely used self‐report instruments including the SF‐36, MPQ, and EuroQol. Pain is a significant symptom in this disease, and both pain and overall health status are markedly improved by breast reduction. In this population, conservative measures such as weight loss, physical therapy, special brassieres, and medications did not provide effective permanent relief of symptoms. (Plast. Reconstr. Surg. 109: 1556, 2002.)

Benchmarking Outcomes in Plastic Surgery: National Complication Rates for Abdominoplasty and Breast Augmentation

Background: The authors evaluated the use of national databases to track surgical complications among abdominoplasty and breast augmentation patients. Methods: Their study population included all patients with abdominoplasty or breast augmentation in the Tracking Operations and Outcomes for Plastic Surgeons (TOPS) and CosmetAssure databases from 2003 to 2007. They evaluated the incidence of hematoma, infection, and/or deep venous thrombosis/pulmonary embolism. Chi-square and t tests were used for the analyses. Results: The TOPS and CosmetAssure databases included 7310 and 3350 patients with abdominoplasty and 30,831 and 14,227 patients with breast augmentation, respectively. In the TOPS and CosmetAssure populations, the complication rates for abdominoplasty were 0.9 percent and 0.5 percent with hematoma (p = 0.29), 3.5 percent and 0.7 percent with infection (p < 0.001), and 0.3 percent and 0.1 percent with deep venous thrombosis/pulmonary embolism (p = 0.05), respectively. The complication rates for breast augmentation in TOPS and CosmetAssure were 0.6 percent and 0.7 percent with hematoma (p = 0.21), 0.3 percent and 0.1 percent with infection (p < 0.001), and 0.02 percent and less than 0.01 percent with deep venous thrombosis/pulmonary embolism (p = 0.31), respectively. Conclusions: Complication rates for abdominoplasty and breast augmentation were similar in TOPS and CosmetAssure, providing a measure of cross-validation. The low complication rates support the safety of these procedures when they are performed by plastic surgeons. These data should be used by individual practitioners for outcomes benchmarking.

Electromyographic assessment of rectus abdominis muscle function after deep inferior epigastric perforator flap surgery.

The authors evaluated rectus abdominis muscle function after deep inferior epigastric perforator (DIEP) flap elevation. Fifteen consecutive patients who were operated on for breast reconstruction with a free DIEP flap were included in the study. A turn-amplitude electromyographic analysis was used. For each patient, the muscle activity was recorded in the portion of the muscle that was split for the epigastric perforator vessel dissection, and also in the similar portion of the contralateral nondissected muscle. A first electromyographic examination was carried out soon after surgery (mean follow-up, 9 weeks), and a second electromyographic examination was carried out at a later date (mean follow-up, 15 months). The mean activity of the dissected muscles was 50 percent of the activity of the nondissected muscles at the first electromyographic examination and 70 percent at the second electromyographic examination. The authors suggest that the DIEP flap procedure induces a partial denervation of the rectus abdominis muscle in the area of dissection and that reinnervation occurs over time because the entire width of the muscle and sufficient segmental motor innervation are preserved.

The impact of breast reconstruction on the delivery of chemotherapy.

The purpose of this study was to evaluate the impact of postmastectomy breast reconstruction on the timing of chemotherapy.

Reduction Mammaplasty: Defining Medical Necessity:

The authors evaluated existing and new criteria for defining the medical necessity for breast reduction surgery. Two cohorts of women (those requesting breast reduction surgery [N = 266] and a group of controls [N = 184]) completed a questionnaire including breast-specific symptom severity, the Short Form 36, the EuroQol, the McGill Pain Questionnaire, and the Multidimensional Body Self Relations Questionnaire. To evaluate prediction validity, the most widely accepted decision criteria and a new definition of medical necessity were applied to the data set to determine whether women meeting the definition had more favorable outcomes than those who did not as measured by validated self-report instruments. For existing criteria, women not meeting and meeting the criterion gained equal benefit from surgery. Women meeting the new definition (2 of 7 physical symptoms all or most of the time) had significantly greater improvement scores on 4 of the 5 health burden measures compared to women not meeting this definition. The authors conclude that medical necessity for breast reduction surgery is better defined by self-report of symptoms than by existing criteria.

Where Do We Find the Best Evidence

Summary: As pressure on resources increases, decision makers in health care are increasingly seeking high-quality, scientific evidence to support clinical and health policy choices. Ultimately, legislators will look to develop performance measures based on evidence, rather than on consensus or commonality of practice. As plastic surgeons, we can take an increased role in producing impartial evidence on the efficacy of our surgical interventions. We can move away from the retrospective reporting of cases and nonrandomized studies and instead rely on prospective, randomized trials addressing important clinical issues. In doing so, we will challenge the common practice of basing clinical decisions solely on what we are taught, procedures we are most comfortable doing, or procedures that are most financially rewarding. These efforts will not only afford us the best opportunity to provide optimal care to patients but also allow us to demonstrate the inherent quality of our surgical specialty.

Tissue and plasma levels of endothelin in free flaps.

&NA; The goal of the study was to assess whether endothelin‐1 levels are increased in tissue and plasma in free flaps. To assess this hypothesis, blood samples were taken from the general circulation before and after reperfusion and from the flap after reperfusion in 20 patients undergoing breast reconstruction with free transverse rectus abdominis musculocutaneous or deep inferior epigastric perforator flaps. Tissue samples were also taken from the flap before and after the period of ischemia. Peripheral blood samples of 10 ml each were taken before the vessels were clamped and at 10 minutes and 1 hour after the flap was recharged. The flap vein was catheterized with a smooth catheter to avoid endothelial trauma, and ischemic blood from the flap was obtained immediately after the artery was unclamped and 10 minutes later. Two skin samples of 2 cm2 each were taken: one after dissection of the flap before division of the vessels and one after reanastomosis of the veins (one or two veins). Statistical analyses were performed with the (nonparametric) Wilcoxon signed rank test. Flap ischemia time, from vessel division to the completion of the arterial anastomosis, ranged from 35 to 120 minutes (mean, 48 minutes). The plasma endothelin‐1 level extracted from the flap was 4.34 ± 0.85 pg/ml, significantly higher than baseline, 3.87 ± 0.81 pg/ml (p < 0.0001). There was a small increase, 4.5 ± 1.03 pg/ml (p = NS), 10 minutes after reperfusion. The peripheral level after venous anastomosis was 3.78 ± 0.79 pg/ml, not significantly different from the peripheral plasma level, before the flap was raised. The peripheral plasma level 1 hour after reperfusion was 3.83 ± 0.8 pg/ml, with no difference from baseline. The tissue level of endothelin‐1 before clamping was 3.8 ± 0.8 pg/mg and in postischemic tissue, 5.2 ± 0.6 pg/mg, a statistically significant increase. The authors concluded that endothelin‐1 levels are elevated in free flaps. This could be an explanation for vasospasm and may lead to therapy directed against the no‐reflow phenomenon. (Plast. Reconstr. Surg. 111: 85, 2003.)

Interval inset of TRAM flaps in immediate breast reconstruction: a technical refinement.

Purpose:Healthy, viable mastectomy skin is a critical factor in the outcome of immediate breast reconstruction. Unfortunately, mastectomy skin viability can be problematic and intraoperative assessment is unreliable. For this reason, we have modified our approach to immediate transverse rectus abdominus myocutaneous flap (TRAM) reconstruction. Instead of completing the reconstruction with a definitive inset at the time of the mastectomy, the TRAM flap is left intact and buried beneath the mastectomy skin for 3 to 5 days. This falls within the normal period of postoperative hospitalization, and at this point, the viability of the mastectomy skin is clear. Ischemic skin is debrided and replaced with healthy TRAM skin, and nipple reconstruction can be performed at the time of this interval inset. The purpose of this study was to review a large case series of patients who underwent an interval inset of their TRAM flap in the setting of immediate skin-sparing mastectomy. Methods:Retrospective chart data were obtained for all TRAM patients who underwent immediate postmastectomy breast reconstruction by a single surgeon during a 5-year period. Data were collected on procedures, complications, margin status, and number of immediate versus delayed nipple reconstructions. Results:There were 63 patients who underwent immediate TRAM reconstruction with interval inset of the flap. This included 25 bilateral cases, for a total of 89 flaps. Interval insets were performed an average of 3.9 days after the TRAM. Twenty-seven percent (17/63) required replacement of nonviable mastectomy skin with TRAM skin and had no nipple reconstruction; 4.8% (3/63) had additional skin taken because of residual tumor close to or at the mastectomy margins. Seventy-three percent of patients (46/63) had a nipple reconstruction with minimal or no mastectomy skin loss. Conclusion:We present the interval inset of TRAM flaps during the normal period of postoperative hospitalization as a technical refinement to optimize cosmetic outcomes. Mastectomy skin viability can be more easily assessed and necrotic or ischemic skin replaced with TRAM skin as needed. This avoids the need for prolonged dressing changes or a compromised aesthetic result from skin loss. When there is no major skin loss, the nipple reconstruction can be performed concurrently with the inset. These refinements optimize the appearance of the reconstructed breast and reduce the need for future surgeries. In addition, the surgical oncologist has the opportunity to excise close or positive margins as indicated by pathologic findings. Thus, the benefits of the interval inset of TRAM flaps are shared by the reconstructive surgeon, the surgical oncologist, and most importantly, the patient.