BREAST-Q Measurement of the Patient Perspective in Oncoplastic Breast Surgery: A Systematic Review.

BACKGROUND: Since BREAST-Q was developed in 2009, it has been widely used by clinicians and researchers to capture information regarding health-related quality of life (HRQoL) and patient satisfaction related to breast surgery. Yet clinical guidelines regarding the use of BREAST-Q for assessment of success of surgery in women with breast cancer remain limited. To maximize the benefits of using BREAST-Q to inform clinical decision making, this systematic review aimed to identify and appraise current evidence on patient-reported outcomes (PROs) assessed by BREAST-Q associated with breast oncoplastic surgery. METHODS: A detailed search strategy was implemented and electronic databases searched include PubMed, MEDLINE, CINAHL, and PsycINFO. Review was limited to peer-reviewed studies published in English from 2009 to January 2018. Any interventional and observational studies that used BREAST-Q to assess PROs in the assessment of breast oncoplastic surgery were included. RESULTS: Fifty-four peer-reviewed articles met inclusion criteria. Fifty-three studies were observational, 1 study was interventional. Current comparative studies using BREAST-Q indicated that abdominal flap, buttock flap, or thigh flap reconstruction offered highest satisfaction with breast; contralateral prophylactic mastectomy with immediate reconstruction offered higher levels of satisfaction with breast, but poor postsurgical physical well-being. Silicone implant and no radiation therapy offered higher level satisfaction and HRQoL. CONCLUSIONS: Current evidence showed that BREAST-Q can effectively measure patient's satisfaction and HRQoL in relation to different type of breast oncoplastic surgeries. BREAST-Q captured meaningful and reliable information from the patients' perspective and may be useful for clinical decision making.

The iBRA (implant breast reconstruction evaluation) study: protocol for a prospective multi-centre cohort study to inform the feasibility, design and conduct of a pragmatic randomised clinical trial comparing new techniques of implant-based breast reconstruction.

BACKGROUND: Implant-based breast reconstruction (IBBR) is the most commonly performed reconstructive procedure in the UK. The introduction of techniques to augment the subpectoral pocket has revolutionised the procedure, but there is a lack of high-quality outcome data to describe the safety or effectiveness of these techniques. Randomised controlled trials (RCTs) are the best way of comparing treatments, but surgical RCTs are challenging. The iBRA (implant breast reconstruction evaluation) study aims to determine the feasibility, design and conduct of a pragmatic RCT to examine the effectiveness of approaches to IBBR. METHODS/DESIGN: The iBRA study is a trainee-led research collaborative project with four phases:Phase 1 - a national practice questionnaire (NPQ) to survey current practicePhase 2 - a multi-centre prospective cohort study of patients undergoing IBBR to evaluate the clinical and patient-reported outcomesPhase 3- an IBBR-RCT acceptability survey and qualitative work to explore patients' and surgeons' views of proposed trial designs and candidate outcomes.Phase 4 - phases 1 to 3 will inform the design and conduct of the future RCT All centres offering IBBR will be encouraged to participate by the breast and plastic surgical professional associations (Association of Breast Surgery and British Association of Plastic Reconstructive and Aesthetic Surgeons). Data collected will inform the feasibility of undertaking an RCT by defining current practice and exploring issues surrounding recruitment, selection of comparator arms, choice of primary outcome, sample size, selection criteria, trial conduct, methods of data collection and feasibility of using the trainee collaborative model to recruit patients and collect data. DISCUSSION: The preliminary work undertaken within the iBRA study will determine the feasibility, design and conduct of a definitive RCT in IBBR. It will work with the trainee collaborative to build capacity by creating an infrastructure of research-active breast and plastic surgeons which will facilitate future high-quality research that will ultimately improve outcomes for all women seeking reconstructive surgery. TRIAL REGISTRATION: ISRCTN37664281.

#PlasticSurgery.

BACKGROUND: Social media use is growing inexorably, and there is public appetite for evidence-based information. Little is known about engagement by plastic surgeons with social media. The aim of this study was to examine posting about plastic surgery on Twitter, to best inform how board-certified plastic surgeons could use the hashtag #PlasticSurgery as a tool to educate patients and the public. METHODS: A prospective analysis of 2880 "tweets" containing the words "plastic surgery" was performed. The following were assessed: identity of author, use of the hashtag #PlasticSurgery, subject matter, whether link to study was provided, and whether posts by surgeons were self-promotional or educational. RESULTS: Social media posting about plastic surgery is dominated by the public, accounting for 70.6 percent of posts versus only 6.0 percent by plastic surgeons. Only 5.4 percent of all tweets contained the hashtag #PlasticSurgery, although almost half of those that did were by plastic surgeons. Of these, 61.3 percent of posts by plastic surgeons were about aesthetic surgery; additional posts were about basic science, patient safety, and reconstruction (13.9, 4.0, and 2.3 percent, respectively). Eighteen scientific articles were referenced, with a link to the Journal site posted in two tweets. Of posts by plastic surgeons, 37.0 percent were self-promotional. CONCLUSIONS: The American Society of Plastic Surgeons and its Journal have recognized that social media may be used to educate and engage. Board-certified plastic surgeons have a great opportunity to promote evidence-based plastic practice by means of #PlasticSurgery in the interests of supporting patients and the profession.

Cell assisted lipotransfer in breast augmentation and reconstruction: A systematic review of safety, efficacy, use of patient reported outcomes and study quality.

BACKGROUND: Cell assisted lipotransfer serves as a novel technique for both breast reconstruction and breast augmentation. This systematic review assesses the efficacy, safety and use of patient reported outcome measures in studies involving cell assisted lipotransfer. We also carry out an objective assessment of study quality focussing on recruitment, follow-up and provide an up-to-date clinical trial landscaping analysis. METHODS: Key electronic databases were searched according to PRISMA guidelines and pre-defined inclusion and exclusion criteria. Two independent reviewers examined the retrieved publications and performed data extraction. RESULTS: 3980 publications were identified. Following screening, 11 studies were included for full review, representing a total of 336 patients with a follow-up time ranging from six to 42 months. A degree of variation was noted in graft retention and reported satisfaction levels, although there were only three comparative studies with conflicting results. Complications occurred at a rate of 37%. Additionally, there was a paucity of objective outcomes assessments (e.g. 3D assessment modalities or validated patient reported outcome measures) in the selected studies. CONCLUSIONS: Cell assisted lipotransfer is a surgical technique that is currently employed sparingly within the plastic & reconstructive surgery community. Presently, further technical and outcome standardization is required, in addition to rigorous randomized controlled trials and supporting long-term follow-up data to better determine procedural safety and efficacy. Routine use of more objective outcome measures, particularly 3D assessments and validated patient reported outcome measures, will also help facilitate wider clinical adoption and establish procedural utility.

PET-CT imaging in patients with chronic sternal wound infections prior to reconstructive surgery: A case series.

Late presenting and recurrent sternal wound infections post-sternotomy are difficult to treat, with the clinical picture not necessarily reflecting the underlying problem. As a result of our experience, we suggest that these chronic cases should be managed using a different algorithm to acute sternal wound infection. Positron emission tomography combined with computerized tomography (PET-CT) imaging may be potentially useful in enabling accurate localization of disease sites, which guides adequate debridement prior to definitive reconstruction. It may also allow for disease surveillance and monitoring of the response to antimicrobial treatment. We present three cases which support the need for pre-operative imaging using PET-CT.

Population analysis of the perfect breast: a morphometric analysis.

BACKGROUND: The authors previously identified key objective parameters that define the aesthetic ideal of the breast in a study of 100 models with natural breasts. In this follow-up article, the opinion of the general public on ideal breast proportions was surveyed. METHODS: One thousand three hundred fifteen respondents were asked to rank the attractiveness of images of four women with varying breast sizes. Each of the women's breasts were morphed into four different proportions. One of the key features was the upper pole-to-lower pole percentage proportion, corresponding to ratios of 35:65, 45:55, 50:50, and 55:45. Rankings were analyzed according to population demographics. Effects of age, sex, nationality, and ethnicity were evaluated. The responses of 53 plastic surgeons were included. RESULTS: Breasts with an upper pole-to-lower pole ratio of 45:55 were universally scored highest, in particular, by 87 percent of women in their thirties (n = 190), 90 percent of men (n = 655), 94 percent of plastic surgeons (n = 53), 92 percent of North Americans (n = 89), 95 percent of South Americans (n = 23), 86 percent of Europeans (n = 982), 87 percent of Caucasians (n = 1016), and 87 percent of Asians (n = 209). CONCLUSIONS: This study reaffirms the authors' previous findings that the 45:55 ratio has universal appeal in defining the ideal breast. The authors propose that this proportion should be used as a basis for design in aesthetic surgery.

Subfascial harvest of the extended latissimus dorsi myocutaneous flap in breast reconstruction: a comparative analysis of two techniques.

BACKGROUND: Widespread adoption of the extended latissimus dorsi myocutaneous flap in breast reconstruction has been limited by donor-site complications. The dissection plane may be either above or below the superficial layer of the thoracolumbar fascia, which may be transferred with the flap or retained on the back skin flaps. The aim of this study was to investigate whether varying the plane of dissection improves donor-site morbidity and complications. METHODS: A comparative analysis of consecutive women treated with extended latissimus dorsi myocutaneous breast reconstruction by a single surgeon (D.F.) between 2006 and 2012 was performed. RESULTS: Eighty patients were reviewed. Between 2006 and 2011, 47 patients were treated with traditional suprafascial harvest (group A); the subsequent 33 patients between 2011 and 2012 had subfascial harvest (group B), retaining the superficial fascia on the back skin flaps. When compared with group A, group B patients showed significant reduction in both mean number of seroma drainage events (p = 0.027) and mean total aspirated seroma volume, which was reduced by half (p = 0.006). Group B patients also reported significant reduction in donor-site pain (p = 0.041) and donor-site scar adherence to the chest wall (p = 0.026). No increases in flap or donor-site dehiscence, partial flap loss, or other minor or major complications were observed. CONCLUSION: The technique of subfascial harvest during autologous latissimus dorsi flap breast reconstruction significantly improves back donor-site morbidity without compromising flap survival. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Delayed repair in a case of forearm fascial muscle herniation using non-cross-linked acellular porcine dermal matrix.

The options for treatment of symptomatic muscle herniation in the limbs traditionally include fasciotomy, direct repair, tendon weave graft (palmaris longus), fascial graft (tensor fascia lata), and synthetic mesh (prolene). A recent case report has described the use of acellular cadaveric dermal matrix to reconstruct fascial defects in 2 cases. We describe the use of Strattice, a non-cross-linked acellular porcine dermal matrix, as a fascial underlay graft in a case of symptomatic upper limb muscle herniation. We propose that Strattice has the advantages over cadaveric dermal matrices in terms of avoiding the use of human donor tissue. It has suitable tensile properties to be used for reconstructing fascial defects.

Palmar granuloma following flexor tendon repair using Ticron: a case for absorbable suture material?

Non-absorbable sutures are routinely used in flexor tendon repair. Silicone coated sutures are known to cause intense granuloma formation, and Ticron is well known to cause such late foreign body type reactions. We report a case of palmar granuloma following flexor tendon repair using Ticron. Although commonly used in flexor tendon repair, the authors could not find any other description of palmar granuloma following Ticron use in the literature. The granuloma was successfully treated by excision under antibiotic cover. We advise that surgeons should be aware of this complication, that suture granuloma may mimic other common conditions, and present a brief review of the literature. We conclude that the use of absorbable suture materials should be considered in flexor tendon repair, as outcomes are not dissimilar and may avoid such foreign body granulomas.

The quantitative assessment of wrinkle depth: turning the microscope on botulinum toxin type A.

This prospective study was designed to produce a quantitative model for wrinkle depth assessment, and to compare scientific and clinical methods of evaluation, in the context of botulinum toxin type A treatment. Ten patients were assessed at baseline and 3 weeks after treatment using silicone masks and standardized photography in forehead, glabellar, and lateral canthal areas, at rest and during maximal expression. Wrinkle depth was measured on masks using multiphoton microscopy. Clinical improvement was judged by a panel of observers according to the Hay scale. There was a statistically significant improvement in wrinkle depth after treatment in all areas. Dynamic rhytides demonstrated greatest improvement, notably in the forehead (89% reduction). The objective improvement in static rhytides (43%-56%) has not previously been demonstrated. Clinical evaluation was less accurate than scientific methodology for static lines. This model may have a place in comparing products or treatment regimes, particularly when changes are subtle.

The effect of epigallocatechin-3-gallate, a constituent of green tea, on transforming growth factor-beta1-stimulated wound contraction.

Dermal fibrosis, or scarring, following surgical incisions, traumatic wounds and burns presents a major clinical burden. Transforming growth factor (TGF)-beta1 is a major factor known to stimulate fibroblast proliferation, collagen production, and the differentiation of fibroblast to myofibroblast promoting wound contraction. Furthermore, excessive or prolonged TGF-beta1 has been shown to be associated with scarring. Green tea contains high amounts of polyphenols with the major polyphenolic compound being epigallocatechin-3-gallate (EGCG). EGCG has been shown to be anti-inflammatory, anti-oxidant, and may improve wound healing and scarring, though its precise effect on TGF-beta1 remains unclear. This study aimed at determining the effect of EGCG on TGF-beta1 collagen contraction, gene expression and the differentiation of fibroblast to myofibroblast. EGCG appears to affect the role that TGF-beta1 plays in fibroblast populated collagen gel contraction and this seems to be through both myofibroblast differentiation and connective tissue growth factor gene expression and reduces the expression of collagen type I gene regulation.

A novel biomimetic material for engineering postsurgical adhesion using the injured digital flexor tendon-synovial complex as an in vivo model.

BACKGROUND: Many surgical procedures are complicated by adhesions. These restrictive fibrotic bands form between normally separate gliding tissue layers, potentially impairing function. The authors tested the adhesion-modifying effect of a novel fibronectin-derived biomimetic biomaterial in a tendon-synovial complex injury model. METHODS: The deep flexor tendons of digits 2 and 4 in the right forepaw of 15 New Zealand White rabbits were subjected to 5-mm-long partial tenotomies. Animals were randomized to receive biomaterial tubes enveloping the tendon injuries or left untreated. Digits, amputated at 2 weeks, were randomized to mechanical pullout assessments of adhesion strength or to quantitative histologic cellularity and immunohistochemical proliferation (Ki67) assessments. RESULTS: The mean peak pullout force required to break the adhesions was reduced from 7.70 N (n = 6) in untreated digits to 0.31 N (n = 7) in biomaterial-treated digits (p = 0.001). The mean structural stiffness of the adhesions was also significantly reduced (p = 0.001). Histologically, treated and untreated digits demonstrated an equal incidence of adhesions. The treated adhesions were 55 percent less cellular at their surface than the untreated injured controls (p = 0.003). Treated tendons were 8 percent more cellular (with equal numbers of proliferating cells) at their surface and significantly more cellular within their bulk than positive controls (p