Quality-of-Life Outcomes Improve with Nipple-Sparing Mastectomy and Breast Reconstruction.

BACKGROUND: Loss of the nipple-areola complex can be psychologically and sexually devastating. Nipple-sparing mastectomy provides robust cosmetic results, but few studies have investigated the quality-of-life outcomes associated with it. METHODS: The authors performed an institutional review board-approved retrospective study of 32 patients who underwent nipple-sparing mastectomy with implant-based or autologous reconstruction and 32 control patients who underwent non-nipple-sparing mastectomy with reconstruction matched by reconstruction type and operative period. They then compared premastectomy and postreconstruction responses to the BREAST-Q, a validated and breast reconstruction-specific quality-of-life questionnaire, within and between their study and control populations. RESULTS: The nipple-sparing and non-nipple-sparing mastectomy groups were statistically similar in terms of mean age [49.9 ± 8.5 years (range, 36 to 69 years) and 47.7 ± 10.3 years (range, 26 to 68 years) (p = 0.29), respectively] and mean body mass index [24.3 ± 3.5 kg/m (range, 17.9 to 33.7 kg/m) and 25.5 ± 5.4 kg/m (range, 19.2 to 39.2 kg/m) (p = 0.29), respectively]. There were no significant between-group differences in occurrence of postreconstruction complications. The authors found significantly higher mean postreconstruction scores in the nipple-sparing mastectomy group within the Satisfaction with Breasts (p = 0.039) and the Satisfaction with Outcome (p = 0.017) domains. Finally, they noted higher median postreconstruction scores in the nipple-sparing mastectomy group within the Psychosocial Well-being (p = 0.043) and Satisfaction with Breasts (p = 0.004) domains. CONCLUSIONS: Psychological concerns regarding malignancy may negatively impact premastectomy patient quality of life. Reconstructive surgery improves patients' postmastectomy quality of life. Nipple-sparing mastectomy appears to provide significantly better improvement in postreconstruction quality of life, specifically in the Satisfaction with Breasts and Satisfaction with Outcome domains of the BREAST-Q, compared with non-nipple-sparing mastectomies. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Matching Procedures at the Time of Immediate Breast Reconstruction: An American College of Surgeons National Surgical Quality Improvement Program Study of 24,191 Patients.

BACKGROUND: The purpose of this study was to assess for compounded risk of postoperative morbidity with the addition of a simultaneous contralateral breast matching procedure at the time of mastectomy and immediate breast reconstruction. METHODS: 2005 to 2012 American College of Surgeons National Surgical Quality Improvement Program databases were used to identify cases of mastectomy and immediate breast reconstruction with and without simultaneous contralateral breast matching procedures. Matching procedures included mastopexy, reduction mammaplasty, and augmentation mammaplasty. Thirty-day postoperative morbidity was assessed using univariable and multivariable logistic regression. RESULTS: Of 59,766 mastectomy patients, 24,191 (40 percent) underwent immediate breast reconstruction: 903 (3.7 percent) underwent matching procedures and 23,288 (96.3 percent) did not. Univariable logistic regression demonstrated that the matching procedure group had statistically significantly higher overall morbidity (OR, 1.288; 95 percent CI, 1.022 to 1.623; p = 0.032). Although surgical and systemic morbidity did not differ significantly, the matching procedure group demonstrated higher risk for superficial surgical-site infection (OR, 1.57; 95 percent CI, 1.066 to 2.31; p = 0.022), reconstruction failure (OR, 1.69; 95 percent CI, 1.014 to 2.814; p = 0.044), and pulmonary embolism (OR, 2.54; 95 percent CI, 1.01 to 6.37; p = 0.048). Controlling for possible confounders, multivariable logistic regression rendered the relationship between matching procedure and complications insignificant (OR, 1.17; 95 percent CI, 0.92 to 1.48; p = 0.2). CONCLUSION: These data suggest that preoperative comorbidities and other patient-related factors may have a larger influence on postoperative morbidity than the addition of a contralateral matching procedure alone. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Failure mode and effects analysis applied to the maintenance and repair of anesthetic equipment in an austere medical environment.

OBJECTIVE: Medical technology designed for Western settings frequently does not function adequately or as intended when placed in an austere clinical environment because of issues such as the instability of the electrical grid, environmental conditions, access to replacement parts, level of provider training and general absence of biomedical engineering support. The purpose of this study was to demonstrate the feasibility of applying failure mode and effects analysis as part of an implementation strategy for medical devices in austere medical settings. DESIGN: Observational case-study. SETTING/PARTICIPANTS/INTERVENTION: We conducted failure mode and effects analysis sessions with 16 biomedical engineering technicians at two tertiary-care hospitals in Freetown, Sierra Leone. The sessions focused on maintenance and repair processes for the Universal Anaesthesia Machine. Participating biomedical engineers detailed local maintenance and repair processes and failure modes, including resource availability, communication challenges, use errors and physical access to the machine. MAIN OUTCOME MEASURE(S): Qualitative descriptive themes in barriers perceived and solutions generated by biomedical engineers. RESULTS: Solutions generated involved redesigned work processes to increase the efficiency of identifying machine malfunctions, clinician engagement strategies, a formal plan for acquiring spare parts and plans for improving access to the machine. Follow-up interviews indicated solutions generated were implemented and perceived to be effective. CONCLUSIONS: This study demonstrates the feasibility of using the failure mode and effects analysis approach to improve implementation of technology in austere medical environments.