Maria Stella Leone

Psychological evaluation of patients undergoing breast reconstruction using two different methods: autologous tissues versus prostheses.

Breast reconstruction has become an available option for most patients undergoing mastectomy. In fact, many authors agree that breast reconstruction does not interfere with possible therapies and improves the womens quality of life. The aim of this study was to evaluate the psychological adjustment of patients who had immediate or delayed reconstruction using two different methods: implants and autologous tissues. Specifically, it was explored whether the different methods of breast reconstruction have caused significant changes in psychological functioning. The study population (102 patients) was derived from patients who underwent breast reconstruction in the period January 1988 to December 1991 at the Department of Plastic and Reconstructive Surgery of the National Institute for Cancer Research in Genoa, Italy. Fifty-two patients underwent breast reconstruction using implants and 50 using the transverse rectus abdominis myocutaneous (TRAM) flap. Demographic information was gathered from each patient. The psychological instruments consisted of three standardized self-administered questionnaires: Psychological Distress Inventory, State Trait Anxiety Inventory, Form Y, and the Eysenck Personality Inventory. To better assess the changes in body image after breast reconstruction, three more specific questions about sexual desire, physical image, and social relationships were added. The 102 patients assessed in this study indicated a low incidence of psychological distress. Impairment was reported regarding body image by patients who underwent delayed reconstruction; these patients also showed higher distress scores. The type of breast reconstruction also seems to influence body image, showing in the patients with TRAM flap reconstruction more relevant psychological discomfort.(ABSTRACT TRUNCATED AT 250 WORDS)

Vertical Mammaplasty: A Personal Approach

Abstract. We have been using the vertical mammaplasty technique with personal adjustments for reduction mammaplasty and glandular resection since 1989. There were 63 cases of aesthetic reduction mammaplasty and mastopexy and 38 cases of reduction mammaplasty and mastopexy contralateral to breast reconstruction with implants and/or autologous tissues performed during the period from 1989 to 1993. The aim of this work is to discuss the complications, long-term results, and limitations to this technique.

Breast Implant Infections after Surgical Reconstruction in Patients with Breast Cancer: Assessment of Risk Factors and Pathogens over Extended Post-Operative Observation

BACKGROUND Infection is a severe potential complication of breast implant positioning in women with cancer. There still is some degree of uncertainty regarding optimal antibiotic prophylaxis regimens, infecting pathogens, and risk factors associated with infection during long-term followup of these patients. METHODS We performed a systematic clinical review to assess infecting microorganisms and risk factors among patients undergoing reconstructive procedures for breast cancer between January 2005 and February 2007. A randomly selected group of infection-free patients treated over the same time span was considered as a control. RESULTS Among 240 women undergoing implant procedures performed and followed up as outpatients, 16 patients with prosthetic infections were observed (infection rate 6.7%). Infection was recorded within six months from surgery in 94% of the cases, with an overall mean time to infection of 95 days. The time interval between surgery and infection did not support a diagnosis of hospital-acquired infection in most cases. Gram-negative microorganisms were identified in seven cases. A higher proportion of patients with implant infection underwent radiotherapy or chemotherapy after surgery for advanced tumors compared with the control patients without infection. CONCLUSIONS Extended post-operative surveillance is indicated, at least for the first six months after breast implant placement, particularly for women who need radiotherapy or chemotherapy after implant surgery. Gram-negative bacilli may be involved more often in late infections than otherwise expected. This finding may influence initial empiric antibiotic treatment.

Can the cost affect the choice of various methods of postmastectomy breast reconstruction

Aim and background A wide range of methodologies for breast reconstruction is now available. For immediate breast reconstruction we prefer to use implants, whereas reconstruction using autologous tissues, such as transverse rectus abdominis musculocutaneous flaps (TRAMF) and muscular latissimus dorsi flaps, is applied only in selected cases. In contrast, for delayed reconstruction the choice between prostheses and autologous tissue depends on various conditions. The different reconstructive methods can be adopted as a single procedure or as a combination of surgical procedures. Following the issue of legislation defining the new structure of the Italian Health Service, the need to accurately assess the costs incurred for the execution of surgical operations has taken on paramount importance. The aim of the study was to evaluate not only the clinical limits of each surgical technique, but also its cost, in order to optimize the choice of the same procedures, conditions being equal. Methods The study population included 105 patients who underwent breast reconstruction in the period 1st January 1994-30th June 1995. The reconstructive procedures included 48 immediate implants, 7 immediate TRAMF, 17 delayed implants, 30 delayed TRAMF, and 3 delayed latissimus dorsi muscular flaps. Results After data evaluation, we concluded that reconstruction using permanent expandable implants is the most convenient among implant reconstructions for its low global treatment cost. In fact, reconstructive procedures using temporary expanders, which require two surgical operations, have a higher cost than breast reconstruction using permanent expandable implants. Breast reconstruction using TRAMF is the most convenient because it limits the cost of surgical materials and because flap versatility limits the number of modifications on the contralateral breast. In contrast, breast reconstruction using latissimus dorsi flaps has high costs. Conclusions There is no balance between price list and effective cost of the different surgical reconstructive procedures, which may be a point of departure to see whether it is impossible to improve the efficiency of the Health Care System and in any case open a debate between the Regions and hospitals to improve the service, keeping it at a good level.

Surgical Correction of Ambiguous Genitalia in 46-Year-Old Woman

The aim of feminizing genitoplasty is to recreate the normal female anatomy, such as in the case of clitoris hypertrophy caused by a sexual development disorder as a result of genetic, hormonal, iatrogenic, tumoral, or idiopathic factors [10]. In the past, the enlarged clitoris structure was amputated. This procedure achieves a satisfactory cosmetic result and was supported by the theory that the clitoris had no function [1]. However, previous papers have emphasized the importance of the clitoris in psychosexual development, demonstrating that patients who had undergone clitorectomy developed sexual inhibitions and ambivalence toward sexual activity [8]. Subsequently, Lattimer [6] described a more refined technique, ‘‘recession clitoroplasty,’’ later argued by Randolph and Hung [10], in which the clitoris is reduced and relocated while preserving the sensitive top of the glans. However, the recession and suture of the hypertrophied clitoris beneath the central pubis, could lead to painful erection in puberty. Novel techniques for reduction were suggested in the 1970s, leaving untouched the ventral mucosa along a third of the circumference to preserve blood supply to the glans [2]. The actual approach of many authors is to preserve as much of the dorsal neurovascular bundle [11] as possible. Moreover, authors started including labioplasty in the technique for clitoroplasty by using the dorsal excess foreskin to reconstruct the rudimentary or absent labia minora [5]. Based on a careful study of these techniques, we report a case of a mature woman in which we combined the most important points of other techniques with our refinements. A 46-year-old woman, diagnosed at infancy with X0/ XY mosaicism by fetal lymphocyte analysis, underwent surgery in childhood to remove gonads (a testicle in one side and an ovotestis in the other) and has been treated with hormonal therapy. She is in a stable heterosexual relationship and has a true sexual identity. She presented as an adult with an enlarged clitoris and with a scrotal aspect of the labia majora, which she found socially embarrassing (Fig. 1). After long psychotherapeutic support she was referred for plastic surgery for treatment of genital malformation. Preoperative magnetic resonance imaging was performed to confirm the clinical findings. The enlarged clitoris was 2 cm long and increased to 3.5 cm with arousal. The labia minora were rudimentary and the labia majora were hypertrophic with a scrotal appearance. Clitoroplasty and reduction of the labia majora were performed in a one-stage procedure. A bladder catheter was placed in a normally positioned urethra. A small area of the clitoris to be preserved was designed and a longitudinal dorsal incision was made and extended proximally on the Presented at the 59th National Congress of Plastic and Reconstructive Surgery, Siena, Italy, September 23–26, 2010.