Results of a surgeon-directed quality improvement project on breast cancer surgery outcomes in South-Central Ontario.

BACKGROUND: Gaps in breast cancer (BC) surgical care have been identified. We have completed a surgeon-directed, iterative project to improve the quality of BC surgery in South-Central Ontario. METHODS: Surgeons performing BC surgery in a single Ontario health region were invited to participate. Interventions included: audit and feedback (A&F) of surgeon-selected quality indicators (QIs), workshops, and tailoring interviews. Workshops and A&F occurred yearly from 2005-2012. QIs included: preoperative imaging; preoperative core biopsy; positive margin rates; specimen orientation labeling; intraoperative specimen radiography of nonpalpable lesions; T1/T2 mastectomy rates; reoperation for positive margins; sentinel lymph node biopsy (SLNB) rates, number of sentinel lymph nodes; and days to receive pathology report. Semistructured tailoring interviews were conducted to identify facilitators and barriers to improved quality. All results were disseminated to all surgeons performing breast surgery in the study region. RESULTS: Over 6 time periods, 1,828 BC charts were reviewed from 12 hospitals (8 community and 4 academic). Twenty-two to 40 participants attended each workshop. Sustained improvement in rates of positive margins, preoperative core biopsies, specimen orientation labeling, and SLNB were seen. Mastectomy rates and overall axillary staging rates did not change, whereas time to receive pathology report increased. The tailoring interviews concerning positive margins, SLNB, and reoperation for positive margins identified facilitators and barriers relevant to surgeons. CONCLUSIONS: This surgeon-directed, regional project resulted in meaningful improvement in numerous QIs. There was consistent and sustained participation by surgeons, highlighting the importance of integrating the clinicians in a long-term, iterative quality improvement strategy in BC surgery.

The implementation of a surgeon-directed quality improvement strategy in breast cancer surgery.

BACKGROUND: The investigators designed a sustained, surgeon-directed, iterative project to improve the quality of breast cancer surgery in south central Ontario. METHODS: The strategy included audit and feedback of surgeon-selected quality indicators, workshops, and tailoring interviews. Workshops were held to discuss quality improvement strategies, select quality indicators, review audited results, and select interventions for subsequent implementation. Semistructured tailoring interviews were conducted to identify facilitators and barriers to improved quality. All presentations and results were disseminated to all surgeons performing breast surgery in the study region. RESULTS: Forty-four surgeons performing breast surgery across 12 hospitals are involved in the project. Five workshops have been held since 2005. Surgeons' enthusiasm and involvement in the project have been positive. Interim results demonstrated that over 4 audit cycles (2006-2010), the preoperative core biopsy rate increased from 73% to 92%. The tailoring interviews indicated that 18 of 21 surgeons performed preoperative core biopsies. CONCLUSIONS: This project highlights the feasibility of a surgeon-directed, iterative quality improvement strategy in breast cancer surgery. Interim results demonstrate consistent improvements in a key selected quality indicator.

Topical mitomycin C in the prevention of keloid scar recurrence.

OBJECTIVE: To assess the ability of mitomycin C to prevent the recurrence of surgically excised keloid scars. Mitomycin C has been successfully used to prevent scar tissue formation at the site of subglottic stenosis in the field of pediatric otolaryngology. It appears that mitomycin C interferes with the ability of fibroblasts to produce a scar without causing changes in epithelialization. DESIGN: We excised keloid scars from various sites in the head and neck and then applied mitomycin C to the resected bed prior to closure of the wound at a concentration of 0.4 mg/mL for 5 minutes. All patients had multiple keloids and acted as their own control. At 1 month after the procedure both wounds were started on a regimen of triamcinolone acetonide, 40 mg/mL injections, repeated every month for 6 months. At the end of the study, photos and measurements were again taken. RESULTS: Fifteen patients (13 female and 2 male) ranging in age from 10 to 55 years enrolled in the study. No infections or nonhealing wounds were seen. There was no difference in postoperative pain. Eight patients completed the triamcinolone injections, 5 had fewer than 6 injections, and 2 patients had no steroid injections. Twelve patients completed follow-up and were evaluated for surgical complications and recurrence of the keloids at either site. Two patients had partial postoperative follow-up in person and then completed follow-up via telephone. One patient could not be found for follow-up. Four patients had recurrence of both excised lesions. Ten patients had no recurrence of their keloids at either site. CONCLUSION: Mitomycin C made no difference in the prevention of keloid recurrence after excision when topically applied.

African American rhinoplasty.

This article describes the topographic and surgical anatomy of the African American nose and the surgical techniques used in the authors' practice.

Accuracy of ultrasound in localization of breast boost field.

BACKGROUND AND PURPOSE: To prospectively compare diagnostic ultrasound to the 'gold standard' of surgical clips for localization of the lumpectomy site for electron boost irradiation. PATIENTS AND METHODS: Consecutive breast cancer patients referred following lumpectomy underwent diagnostic ultrasound in radiation treatment position 21-100 days post-surgery. All patients had 3-6 surgical clips defining the excision cavity. The site was marked on the skin and depth was measured. Target depth was the deepest aspect of the cavity plus a 1 cm deep margin. Treatment fields were prescribed with a 2 cm margin on the cavity, and electron energy was chosen to cover the target depth. Surgical clip position was assessed on orthogonal simulator films. RESULTS: Localizations were performed in 54 breasts (52 women). The mean interval post-surgery was 53 (SD 17) days. Overall, 35/54 (65%) of localizations were adequate, 15/54 (28%) were marginal and 4/54 (7%) were inadequate. Regression showed that lower patient weight (r=-0.37, P=0.006) predicted adequacy of localization, with better accuracy in lighter women. CONCLUSIONS: The accuracy rate for ultrasound exceeds the 20-50% reported for clinical localization. Diagnostic ultrasound may be used to improve the accuracy when surgical clips are not present.

Aggressive fibromatosis of the parapharyngeal space: two cases and treatment recommendations.

Aggressive fibromatosis is an uncommon tumor that is locally aggressive but not malignant. Therefore, its classification falls between the benign and malignant neoplasms of soft-tissue origin. In the past, these lesions were misdiagnosed as low-grade fibrosarcomas. Otolaryngologists should be familiar with these lesions because as many as 15% of them occur in the head and neck. The treatment of choice is wide surgical excision, which is often difficult. Postexcision recurrence rates are high. Nonsurgical treatment includes radiation and chemotherapy, both of which are usually reserved for recurrences. We describe two cases of aggressive fibromatosis of the parapharyngeal space, and we review the available treatment options.

The AbCs of rhinophyma management.

BACKGROUND: Rhzinophyma is a benign inflammatory growth of the nose. It usually involves the caudal one-third of the nose in men. It not only affects the patient's appearance, but also can have profound functional implications. Many difficult treatment methods have been advocated, often with acceptable success. Because there appears to be no distinct advantages in the different therapeutic modalities, no one modality is universally endorsed. METHODS: We performed a retrospective review of patients from 1990-2001 who underwent treatment of their rhinophyma at Louisiana State University, Health Science Center and Overton Brooks Veteran's Hospital in Shreveport, LA. The tumescent anesthesia. Weck blade excision and argon beam coagulator technique (TWA) was used on 51 patients. RESULTS: Patients undergoing this technique have operating times no greater than ten minutes. The average blood loss was less than 5cc. No surgical complications were noted. CONCLUSION: The TWA technique yields good cosmetic results and is cost-effective.

Management of severe bilateral nasal wall collapse.

OBJECTIVE: The aim of this study was to examine and analyze the pathology contributing to severe bilateral nasal wall collapse seen in certain revision rhinoplasty patients and identify those surgical maneuvers in the previous nasal surgery, which may have contributed to this complication; suggest alternatives or modifying steps in nasal surgery to prevent lateral wall collapse; analyze consecutive revision rhinoplasties and identify those patients who have complete bilateral nasal collapse at the internal nasal valve; and analyze the results achieved after surgical reconstruction of complete bilateral nasal collapse. PATIENTS: We identified 49 patients, who presented from 1990 to 2000 for revision surgery, who had bilateral collapse of the upper lateral cartilage. All patients had at least one previous rhinoplasty and all but 14 patients had undergone two or more procedures. The patients were reconstructed with a conchal cartilage graft placed through an external rhinoplasty approach. RESULTS: All patients complained of nasal obstruction with forced nasal inspiration. The collapse was visualized on inspiration and when prevented with intranasal positioning of a bayonet, all patients experienced an immediate improvement in nasal breathing. Postoperatively, all patients experienced this same improvement in their nasal airway. Collapse was not identified in any of the patients after surgery. Two patients underwent revision because of cosmetic asymmetries. CONCLUSION: We strongly recommend a cartilage overlay to reconstitute the rigid midline continuity of the upper lateral cartilages. Unfortunately, with any significant hump removal, this structural interruption is, to varying degrees, inevitable in most rhinoplasty techniques. The upper lateral cartilages can be sutured to circumvent some of the inferior drift, but this will not reconstitute the rigid lateral cantilever effect of the intact cartilage.

A method to repair auricular defects after perichondrial cutaneous grafting.

OBJECTIVE: To describe and illustrate the technique for closing the auricular bowl defect after perichondrial cutaneous grafting. The postauricular flip-flop flap is used for this purpose. STUDY DESIGN: A retrospective clinical study of 354 patients using the perichondrial cutaneous graft for various reconstructions of the face and then performing the postauricular flip-flop flap procedure. METHODS: The perichondrial cutaneous graft is a reliable, versatile graft that possesses unique properties for reconstructive surgery of the face. The postauricular flip-flop flap is our particular technique for closure of the donor site wound after using the perichondrial cutaneous graft. It is a relatively simple procedure that has predictable results. We used this technique in patients ranging in age from 7 days to 92 years and noted excellent cosmetic results and rare complications. RESULTS: Two patients had failure of the perichondrial cutaneous graft. Two patients had partial necrosis of the postauricular flip-flop flap. Two patients had dehiscence of the postauricular closure. CONCLUSION: The postauricular flip-flop flap is a reliable method to repair the donor site after perichondrial cutaneous grafting.