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.

Sensitivity and specificity of the Distress Thermometer for depression in newly diagnosed breast cancer patients.

BACKGROUND: Receiving a new diagnosis of breast cancer is a distressing experience that may precipitate an episode of major depressive disorder. Efficient screening methods for detecting depression in the oncology setting are needed. This study evaluated the receiver operating characteristics (ROC) of the single-item Distress Thermometer (DT) for detecting depression in women newly diagnosed with Stage I-III breast cancer. METHODS: We assessed 321 patients (of 345 consecutive patients) at the time of their pre-surgical consultation at a Comprehensive Breast Cancer Program. Patients were administered the DT along with the Patient Health Questionnaire 9-Item Depression Module (PHQ-9) as a gold standard diagnostic assessment of depression status. RESULTS: Mean DT scores (11-point scale, 0-10) were significantly higher for depressed versus non-depressed patients (8.1 versus 4.4). In ROC analyses the DT showed strong discriminatory power relative to the PHQ-9-derived diagnosis of depression, with an area under the curve of 0.87. Patient age, education, marital status and stage of disease resulted in similar operating characteristics. A score of 7 represented the optimal trade-off between sensitivity (0.81) and specificity (0.85) characteristics for detecting depression. CONCLUSIONS: The single-item DT performs satisfactorily relative to the PHQ-9 for detecting depression in newly diagnosed breast cancer patients. A cutoff score of 7 on the DT possesses the optimal sensitivity and specificity characteristics. The strength of these findings suggests that a careful psychosocial evaluation should follow a positive screen.

Initial experience with laparoscopic inferior epigastric vessel ligation for delayed transverse rectus abdominus musculocutaneous flap breast reconstruction.

HYPOTHESIS: Transverse rectus abdominus musculocutaneous (TRAM) flap breast reconstruction provides excellent cosmetic results. Pedicle flap viability is greatly enhanced by prereconstruction inferior epigastric vessel ligation, which encourages collateral arterial flow (delayed TRAM). We report our initial experience with laparoscopic inferior epigastric vessel ligation. DESIGN: Prospective case series. SETTING: Tertiary academic center. PATIENTS: Female patients with breast cancer who chose pedicle TRAM reconstruction. INTERVENTIONS: Vessel ligations were performed 7 to 14 days prior to reconstruction. Abdominal access was achieved with a 3-mm umbilical trocar. A 5-mm trocar was placed lateral to the rectus sheath in the right lower quadrant. Five-millimeter Teflon clips were used to ligate the vessels near their origin. MAIN OUTCOME MEASURES: Complications of surgery and subsequent flap viability. RESULTS: From January 2001 to July 2006, 130 patients had laparoscopic inferior epigastric vessel ligation, of whom 123 patients had bilateral ligation. Additional procedures in conjunction with vessel ligation were performed in 38 patients (sentinel node biopsy [27], bilateral oophorectomy [7], liver biopsy [2], breast biopsy [1], and Nissen fundoplication [1]). Median operative time for those patients undergoing ligation only was 32.6 minutes (range, 14-121 minutes). The inferior epigastric vessels were not identified in 2 patients. Metastatic breast cancer involving the liver was found in 1 patient. There were no conversions or complications. Subsequent TRAM flap viability was excellent in most cases, with 1 complete flap necrosis in a high-risk, morbidly obese patient. CONCLUSION: Laparoscopic inferior epigastric vessel ligation for delayed TRAM flap breast reconstruction is a safe, effective procedure.

Communication and decision making in cancer care: setting research priorities for decision support/patients' decision aids.

The following is a summary report from a special symposium titled, "Translating Research into Practice: Setting a Research Agenda for Clinical Decision Tools in Cancer Prevention, Early Detection, and Treatment," that was held on 23 October 2005 in San Francisco at the Annual Meeting of the Society for Medical Decision Making (SMDM). The symposium was designed to answer the question: "What are the top 2 research priorities in the field of patients' cancer-related decision aids?" After introductory remarks by Dr. Barry, each of four panelists-Drs. Hilary Llewellyn-Thomas, Ellen Peters, Laura Siminoff, and Dale Collins-addressed the question and provided their rationale during prepared remarks. The moderator, Dr. Michael Barry, then facilitated a discussion between the panelists, with input from the audience, to further explore and add to the various proposed research questions. Finally, Dr. Amber Barnato conducted a simple vote count (see Table 1) to prioritize the panelists' and the audience's recommendations.

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 (> or = 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.

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

SUMMARY: 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 effectiveness of surgical and nonsurgical interventions in relieving the symptoms of macromastia.

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 women's 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.

Tissue and plasma levels of endothelin in free flaps.

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 cm 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.

Surgical treatment of breast cancer among the elderly in the United States.

BACKGROUND: Breast-conserving therapy (BCT) has emerged as the preferred treatment for most women with early stage breast cancer. However, there is concern for underuse in the elderly, with previously documented low rates of BCT and large variations in practice patterns. The authors' purpose was to examine patterns and correlates of BCT for breast cancer in the elderly US population. METHODS: The primary outcome was receipt of BCT. The 2003 to 2004 Medicare inpatient, outpatient, and carrier files were used to identify incident breast cancer patients and the American Medical Association to ascertain surgeon information. The primary independent variables were US state where treatment was performed along with patient and surgeon sociodemographic information. Multivariate logistic regression was used for the analyses. RESULTS: BCT was performed in 81.8% of patients (N = 20,032). Variation in use of BCT across states was low, ranging from 74.2% in Utah to 84.0% in New Mexico. Several factors were significantly associated with low use of BCT: advanced patient age (>85 vs <70 years: odds ratio [OR], 0.50; 95% confidence interval [CI], 0.42-0.59); comorbidities (>3 vs ≤ 3: OR, 0.26; 95% CI, 0.24-0.28), and low socioeconomic status (SES) (lowest quintile vs highest quintile SES: OR, 0.60; 95% CI, 0.52-0.68). Variation in use of BCT by surgeon was low, although female surgeons aged 40 to 49 years and ≥ 60 years had significantly higher use compared with younger men. CONCLUSIONS: BCT has become the primary management among elderly breast cancer patients. Despite earlier studies to the contrary, there is now little variation in BCT use among Medicare patients.

The impact of breast reconstruction on the delivery of chemotherapy.

BACKGROUND: : The purpose of this study was to evaluate the impact of postmastectomy breast reconstruction on the timing of chemotherapy. METHODS: : The authors included stage I-III breast cancer patients from 8 National Comprehensive Cancer Network institutions for whom guidelines recommended chemotherapy. Surgery type was categorized as breast-conserving surgery (BCS), mastectomy alone, mastectomy with immediate reconstruction (M + IR), or mastectomy with delayed reconstruction (M + DR). A Cox regression analysis was used to assess the association between surgery type and timing of chemotherapy initiation. RESULTS: : Of the 3643 patients, only 5.1% received it > or =8 weeks from surgery. In the multivariate analysis, higher stage, Caucasian and Hispanic race/ethnicity, lower body mass index, and absence of comorbid conditions were all significantly associated with earlier time to chemotherapy. There was also significant interaction among age, surgery, and chemotherapy delivery. Among women <60, time to chemotherapy was shorter for all surgery types compared with M + IR (statistical significant for all surgery types in the youngest age group and for BCS in women 40 to <50 years old). In contrast, among women > or =60, time to chemotherapy was shorter among women receiving M + IR or M + DR compared with those undergoing BCS or mastectomy alone, a difference that was statistically significant for the M + IR versus BCS comparison. CONCLUSIONS: : Immediate postmastectomy breast reconstruction does not appear to lead to omission of chemotherapy, but it is associated with a modest, but statistically significant, delay in initiating treatment. For most, it is unlikely that this delay has any clinical significance. Cancer 2010. (c) 2010 American Cancer Society.

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.

Can women with early-stage breast cancer make an informed decision for mastectomy?

PURPOSE: The purpose of this study was to measure the degree to which informed women chose mastectomy, and to reveal their reasons for this choice. PATIENTS AND METHODS: This was a prospective cohort study of patients radiographically and pathologically eligible for either mastectomy or breast-conserving surgery (BCS; n = 125). Participants completed questionnaires at three time points: baseline, after viewing a decision aid, and after a surgical consultation. Questionnaires assessed clinical history, preference for participation in decision making, information comprehension, values, decisional conflict, and preferred treatment. RESULTS: Of 125 participants, 44 (35%) chose mastectomy. Most understood that BCS and mastectomy offer an equivalent survival benefit (98%) and that BCS has a slightly higher local recurrence risk (63%); most accurately identified the magnitude of ipsilateral local recurrence risk (91%). Values assigned to three treatment attributes/outcomes ("remove breast for peace of mind," "avoid radiation," and "keep breast") clearly discriminated between patients choosing mastectomy or BCS. High decisional conflict scores improved after both the decision aid and surgical consultation. CONCLUSION: Although conventional wisdom may view BCS as the preferred treatment, a notable proportion of well informed women choose mastectomy. Whereas prior studies have linked objective factors to treatment choice, this study reveals subjective preferences that underlie decision making. The systematic use of a decision aid before the surgical consultation may help women make informed, values-based decisions, while clearly reducing decisional conflict.

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.

Extending the P4P agenda, part 1: how Medicare can improve patient decision making and reduce unnecessary care.

The decision to undergo many discretionary medical treatments should be based on informed patient choice. Shared decision making is an effective strategy for achieving this goal. The Centers for Medicare and Medicaid Services (CMS) should extend its pay-for-performance (P4P) agenda to assure that all Americans have access to a certified shared decision-making process. This paper outlines a strategy to achieve informed patient choice as the standard of practice for preference-sensitive care.

Measuring quality of life in cosmetic and reconstructive breast surgery: a systematic review of patient-reported outcomes instruments.

BACKGROUND: Patient-reported outcomes in cosmetic and reconstructive breast surgery are increasingly important for clinical research endeavors. Traditional surgical outcomes, centered on morbidity and mortality, remain important but are no longer sufficient on their own. Quality of life has become a crucial research topic augmenting traditional concerns focused on complications and survival. Given this, reliable and valid patient questionnaires are essential for aesthetic and reconstructive breast surgeons. METHODS: The authors performed a systematic literature review to identify patient-reported outcome measures developed and validated for use in cosmetic and reconstructive breast surgery patients. Qualifying instruments were assessed for adherence to international guidelines for health outcomes instrument development and validation. RESULTS: The authors identified 227 health outcomes questionnaires used in breast surgery studies. After 135 generic instruments, 65 ad hoc instruments, seven oncologic instruments, 11 education questionnaires, and two non-English-language questionnaires were excluded, seven measures remained. Detailed analysis revealed that six of the seven measures had undergone limited development and validation. Only one measure, the Breast-Related Symptoms Questionnaire, demonstrated adequate development and validation in its target population. It had, nevertheless, significant content limitations. CONCLUSIONS: Valid, reliable, and responsive instruments to measure patient-reported outcomes in cosmetic and reconstructive breast surgery are lacking. To demonstrate the benefits of aesthetic and reconstructive breast surgery, future research to rigorously develop and validate new cosmetic and reconstructive breast surgery-specific instruments is needed.

Distress, psychiatric syndromes, and impairment of function in women with newly diagnosed breast cancer.

BACKGROUND: Emotional distress and psychiatric syndromes are prevalent in the breast cancer population at large. However, to date there is a paucity of literature specifically concerning presurgical breast cancer patients. METHODS: The authors assessed 236 newly diagnosed patients at the time of their presurgical consultation at the Comprehensive Breast Cancer Program of Dartmouth-Hitchcock Medical Center in Lebanon, NH. RESULTS: Of patients in this study, 41% rated their distress in the clinically significant range on the Distress Thermometer (ie, >5, 0-10 scale). Nearly one-half (47%) of patients met established thresholds for positivity on 1 or more screens for distress or psychiatric disorders. Prevalence rates were 11% for major depression (60% of these patients were moderately severe to severely depressed) and were 10% for posttraumatic stress disorder (PTSD). Emotional symptoms markedly interfered with daily function in both groups. Of depressed patients, 56% were already taking a psychotropic medication, yet they still met screening criteria for major depression. CONCLUSIONS: Emotional distress and psychiatric syndromes (major depression and PTSD) were prevalent in this population. Markedly impaired function was evident for both depressed and PTSD patients. Future research should refine current screening procedures and develop interventions to better address emotional distress and psychiatric disorders in newly diagnosed breast cancer patients.

Analysis of breast reduction complications derived from the BRAVO study.

BACKGROUND: Analysis of complication data derived from the Breast Reduction Assessment: Value and Outcomes (BRAVO) study, a 9-month prospective, multicenter trial, is presented. METHODS: Data derived from 179 patients were analyzed, including bivariate associations between complications and single predictor variables (Fisher's exact test or chi-square testing) or continuous variables (two-sample t test) and, finally, logistic regression. RESULTS: The overall complication rate was 43 percent (77 patients). Simple, bivariate analysis linked preoperative breast volume, shoulder strap grooving, and a vertical incision with an increased incidence of complications (p < 0.05, 0.02, and 0.02, respectively). Delayed wound healing, the most common complication, correlated directly with average preoperative breast volume (p < 0.045), average resection weight/breast (p < 0.027), and smoking (p < 0.029) and inversely with age (p < 0.011). Vertical incision techniques were associated with an increased complication frequency (p < 0.05) without a link to specific complications. Logistic regression analysis associated resection weight as the sole variable for increased risk of complications (p = 0.05) and with absolute number of complications [mean resection weight of 791 g for patients without complications versus 847, 882, and 1752 g for patients with one, two, and three complications, respectively (p = 0.0022)]. Each 10-fold increase in resection weight increased the risk of complication 4.8 times and increased the risk of delayed healing 11.6 times. CONCLUSIONS: Complication data revealed several significant features: (1) resection weight correlated with increased risk and absolute number of complications; (2) delayed healing correlated directly with resection weight and inversely with increasing age, anesthesia times, and preoperative Short Form-36 bodily pain score; (3) a vertical incision may be associated with increased incidence of complications but requires further analysis; and most importantly, (4) the presence of complications had no negative effect on improvement in Short Form-36 and Multidimensional Body-Self Relations Questionnaire scores.