Heather R. Faulkner

Psychological impact of breast asymmetry on adolescents: a prospective cohort study.

Background: This study measures the impact of adolescent breast asymmetry compared with macromastia and female controls. Methods: The following surveys were given to patients with breast asymmetry, macromastia, and controls aged 12 to 21 years: Short Form Health Survey, Version 2 (Short Form-36), the Rosenberg Self-Esteem Scale, and the Eating Attitudes Test. Demographics were compared, and linear regression models, adjusted for body mass index category and age, were fit to determine the effect of case status on survey score. Results: Fifty-nine adolescents with asymmetry, 142 controls, and 160 macromastia patients participated. After controlling for differences in body mass index category, asymmetry patients scored lower on psychological Short Form-36 domains and the Rosenberg Self-Esteem Scale than controls (p < 0.05), but did not differ in physical health. When compared with macromastia adolescents, asymmetry patients scored significantly better on Short Form-36 physical health domains (p < 0.05), but had similar decrements in emotional functioning, mental health, self-esteem, and eating behaviors/attitudes, after accounting for differences in age. Age and asymmetry type and severity had no effect on survey scores, independent of body mass index category (p > 0.05). Asymmetry patients had a higher mean body mass index percentile than controls (83.36 versus 73.52) but did not differ from that of macromastia patients (83.39). Conclusions: Breast asymmetry may negatively impact the psychological quality of life of adolescents similar to macromastia. Breast asymmetry is not just a cosmetic issue. Providers should be aware of the psychological impairments associated with asymmetry and provide proper support. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Thermal Injury to Reconstructed Breasts from Commonly Used Warming Devices: A Risk for Reconstructive Failure

Background: Sensation is decreased or absent after breast reconstruction. This leaves reconstructed breasts vulnerable to injury from common household thermal sources such as heating pads and hot water bottles. We sought to categorize these injuries, provide a treatment plan, and prevent these injuries in the future. Methods: A retrospective review of patients who had sustained burns to reconstructed breasts with household devices was performed at a single institution. A PubMed search was performed to identify and summarize articles cataloguing patients who had suffered burns to breast reconstructions. Results: Five patients in our practice were affected. Fifteen articles were identified in the literature search. A total of 40 patients had sustained thermal injury to reconstructed breasts, with the majority being full thickness burns (67.5%). Patients who sustained full thickness burns to reconstructed breasts were more likely to require an operative procedure compared with patients who sustained partial thickness burns (P = 0.0076). Conclusions: Reconstructed breasts are at risk for injury from commonly used household warming devices and ambient heat from the sun. As a result, patients should be counseled about these risks accordingly, to avoid injury or loss of reconstruction. These injuries require immediate vigilant treatment.

Three Years Experience with Absorbable Mesh in Single-Stage Breast Reconstruction: A Cost-Effective Alternative.

PURPOSE: The current circumstances of US healthcare mandate elimination of unnecessary costs while increasing efficiency in patient care. Traditional implant-based breast reconstruction encompasses multiple stages and using acellular dermal matrix (ADM); both increase cost. The senior author (WGA) has used absorbable knitted mesh (VicrylTM polyglactin 910) as an inferior pole sling in single-stage directto-implant (DTI) breast reconstruction since 2011. We report 3 year outcomes and cost savings data using this material.

Ability to Cope with Pain Puts Migraine Surgery Patients in Perspective

Background: Candidates for migraine surgery are chronic pain patients with significant disability. Currently, migraine-specific questionnaires are used to evaluate these patients. Analysis tools widely used in evaluation of better understood pain conditions are not typically applied. This is the first study to include a commonly used pain questionnaire, the Pain Self-Efficacy Questionnaire (PSEQ) that is used to determine patients’ pain coping abilities and function. It is an important predictor of pain intensity/disability in patients with musculoskeletal pain, as low scores have been associated with poor outcome. Methods: Ninety patients were enrolled prospectively and completed the Migraine Headache Index and PSEQ preoperatively and at 12 months postoperatively. Scores were evaluated using paired t tests and Pearson correlation. Representative PSEQ scores for other pain conditions were chosen for score comparison. Results: All scores improved significantly from baseline (p < 0.01). Mean preoperative pain coping score (PSEQ) was 18.2 ± 11.7, which is extremely poor compared with scores reported for other pain conditions. Improvement of PSEQ score after migraine surgery was higher than seen in other pain conditions after treatment (112 percent). Preoperative PSEQ scores did not influence postoperative outcome. Conclusions: The PSEQ successfully demonstrates the extent of debility in migraine surgery patients by putting migraine pain in perspective with other known pain conditions. It further evaluates functional status, rather than improvement in migraine characteristics, which significantly adds to our understanding of outcome. Poor preoperative PSEQ scores do not influence outcome and should not be used to determine eligibility for migraine surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Abstract 17: Reduction Mammaplasty Improves Quality-of-Life in Adolescents with Macromastia: A Longitudinal Cohort Study

METHODS: Mice carrying the floxed FOP mutation (ACVR1 R206H) received a simultaneous hindlimb injection of Ad.cre to induce gene transformation and cardiotoxin to induce local injury (Ad.cre/CTX). Mice were treated with either daily vehicle control or rapamycin (5 mg/kg) administered i.p. (n=10/group). The presence of mesenchymal cells at the injury site was determined using immunofluorescent staining for PDGFRa and Sca-1 five days after injury. Ectopic cartilage and bone were determined using histology and microCT imaging 21 days after injury. PLGA microparticles were synthesized to deliver rapamycin as a slow-release; flow cytometry was used to quantify release time profile. Finally, a separate set of mice underwent Ad.cre/CTX injection with resection of formed HO 3 weeks after injury and subsequent treatment with or without rapamycin to eliminate recurrence.

Abstract: Long-Term Outcomes Following Flap Reconstruction in Pediatric Pressure Ulcers

Long-Term Outcomes Following Flap Reconstruction in Pediatric Pressure Ulcers The Harvard community has made this article openly available. Please share how this access benefits you. Your story matters Citation Firriolo, Joseph M., Ingrid M. Ganske, Carolyn M. Pike, Catherine Caillouette, Heather R. Faulkner, and Brian I. Labow. 2017. “Abstract: Long-Term Outcomes Following Flap Reconstruction in Pediatric Pressure Ulcers.” Plastic and Reconstructive Surgery Global Open 5 (9 Suppl): 166-167. doi:10.1097/01.GOX.0000526404.47863.87. http:// dx.doi.org/10.1097/01.GOX.0000526404.47863.87. Published Version doi:10.1097/01.GOX.0000526404.47863.87 Citable link http://nrs.harvard.edu/urn-3:HUL.InstRepos:34492185 Terms of Use This article was downloaded from Harvard University’s DASH repository, and is made available under the terms and conditions applicable to Other Posted Material, as set forth at http:// nrs.harvard.edu/urn-3:HUL.InstRepos:dash.current.terms-ofuse#LAA

The Effect of Reduction Mammaplasty on Quality of Life in Adolescents With Macromastia

By using validated surveys, this study prospectively evaluates the long-term physical and psychosocial effects of breast reduction in an adolescent population. OBJECTIVES: To measure changes in health-related quality of life and breast-related symptoms after reduction mammaplasty in adolescents. METHODS: In this longitudinal cohort study, we administered the Short-Form 36v2 (SF-36), Rosenberg Self-Esteem Scale (RSES), Breast-Related Symptoms Questionnaire (BRSQ), and Eating Attitudes Test-26 to 102 adolescents with macromastia and 84 female controls, aged 12 to 21 years. Patients with macromastia completed surveys preoperatively and after reduction mammaplasty at 6 months and 1, 3, and 5 years. Controls completed baseline and follow-up surveys at the same intervals. RESULTS: Patients with macromastia demonstrated significant score improvements postoperatively from baseline on the RSES, BRSQ, and in 7 out of 8 SF-36 domains: physical functioning, role-physical, bodily pain, vitality, social functioning, role-emotional, mental health (P < .001, all). By the 6-month follow-up visit, postoperative subjects scored similarly to or more favorably than controls on the RSES, BRSQ, Eating Attitudes Test-26 , and SF-36; these benefits persisted for at least 5 years and were not significantly affected by BMI category or age. CONCLUSIONS: Reduction mammaplasty was significantly associated with improvements in health-related quality of life and breast-related symptoms of adolescent patients, with measureable improvements in physical and psychosocial well-being evident by 6 months postoperatively and still demonstrable after 5-years. These results largely do not vary by BMI category or age. Patients and providers should be aware of the potential positive impact that reduction mammaplasty can provide adolescents with symptomatic macromastia. Historic concerns regarding age and BMI category at the time of surgery should be reconsidered.

Long-term Outcomes After Flap Reconstruction in Pediatric Pressure Ulcers

Background Pressure ulcers refractory to nonoperative management may undergo flap reconstruction. This study aims to evaluate the long-term outcomes and recurrence rates of flap reconstruction for pediatric pressure ulcers. Methods We reviewed the records of patients who underwent flap reconstruction for pressure ulcer(s) from 1995 to 2013. Results Twenty-four patients with 30 pressure ulcers, requiring 52 flaps were included. Ulcers were stages III and IV and mostly involved either the ischia (15/30) or sacrum (8/30). Flaps were followed for a median of 4.9 years. Twenty-three patients were wheelchair dependent, and 20 had sensory impairment at their ulcer site(s). Ten patients had a history of noncompliance with preoperative management, 8 of whom experienced ulcer recurrence. Twenty-one ulcers had underlying osteomyelitis, associated with increased admissions (P = 0.019) and cumulative length of stay (P = 0.031). Overall, there was a 42% recurrence rate in ulceration after flap reconstruction. Recurrence was associated with a preoperative history of noncompliance with nonoperative therapy (P = 0.030), but not with flap type or location, age, sex, body mass index, osteomyelitis, or urinary/fecal incontinence (P > 0.05, all). Conclusions Flap reconstruction can be beneficial in the management of pediatric pressure ulcers. Although high rates of long-term success with this intervention have been reported in children, we found rates of ulcer recurrence similar to that seen in adults. Poor compliance with nonoperative care and failure to modify the biopsychosocial perpetuators of pressure ulcers will likely eventuate in postoperative recurrence. Despite the many comorbidities observed in our patient sample, compliance was the best indicator of long-term skin integrity and flap success.

Reply: Psychological Impact of Breast Asymmetry on Adolescents: A Prospective Cohort.

109e sample was nulliparous, we were unable to quantify or comment on the negative effects of impaired lactation because of breast asymmetry. It must be noted that of the roughly 75 percent of American mothers who choose to breastfeed, nearly 77 percent discontinue breastfeeding before the Centers for Disease Control and Prevention–recommended 1-year mark because of physical and lifestyle constraints.4 Compared with these figures, a study of 34 women with breast asymmetry who had not undergone surgical treatment found that 85 percent of their sample could not produce at least half of the milk volume necessary to nourish their infant within the first postpartum week.3 Although many women face difficulties breastfeeding, certainly women with breast asymmetry are at an increased disadvantage. We suggest in our article that early intervention for adolescent breast asymmetry may help alleviate the negative psychosocial effects of the condition. We must, however, acknowledge that the effect of surgery in the developing breast on future lactation is the source of some debate. Despite conflicting data, a recent meta-analysis has found that women undergoing breast augmentation were more likely to experience lactation difficulties than unaffected women who had not undergone breast surgery.5 As such, we agree that breast functionality must not be forgotten when considering the negative effects of breast asymmetry. Adolescents and parents in particular must be counseled regarding the possibility of diminished future lactation as a result of surgical intervention. Pregnant and postpartum women with breast asymmetry should also be counseled with respect to their increased risk for breastfeeding difficulties and encouraged by their health care provider to seek lactation support services. It remains unknown to what extent a diminished capacity to lactate would offset the potential benefits of improved breast symmetry in this population. We aim to address this question as we follow our young patients through adulthood.