Development and Validation of the BREAST-Q Breast-Conserving Therapy Module.

BACKGROUND: In breast cancer surgery, patient-reported outcome measures are needed to measure outcomes best reported by patients (e.g., psychosocial well-being). This study aimed to develop and validate a new BREAST-Q module to address the unique concerns of patients undergoing breast-conserving therapy (BCT). METHODS: Phase 1 involved qualitative and cognitive interviews with women who had BCT and clinical expert input to establish content for the BCT module. A field-test (phase 2) was performed, and Rasch measurement theory (RMT) analysis was used for item reduction and examination of reliability and validity. Validation of the item-reduced scales in a clinical sample (phase 3) was conducted for further assessment of their psychometric properties. RESULTS: Qualitative interviews with 24 women resulted in the addition of 15 new items across multiple existing BREAST-Q scales and the development of two new scales (Adverse Effects of Radiation and Satisfaction With Information-Radiation Therapy). Feedback from 15 patients and 5 clinical experts were used to refine the instructions, response options, and item wording. An RMT analysis of data from 3497 women resulted in item reduction. The final set of scales showed evidence of ordered response option thresholds, good item fit, and good reliability, except for the Adverse Effects of the Radiation Scale. Validity and reliability were further supported by the phase 3 data from 3125 women. CONCLUSIONS: The BREAST-Q BCT module can be used in research and clinical care to evaluate quality metrics and to compare surgical outcomes across all breast cancer surgery patients.

Vertical Mastectomy Incision in Implant Breast Reconstruction After Skin Sparing Mastectomy: Advantages and Outcomes.

BACKGROUND: The type of since skin-sparing mastectomy (SSM) incision directly impacts the final aesthetic and functional results of reconstruction. Different incisions are used for SSM depending on tumor location, previous biopsy scars, breast weight, and ptosis degree. A vertical scar is less visible to the patient, reminiscent of a mastopexy, and patients may not have the stigma of mastectomy. OBJECTIVE: This study investigates complication rates, patient demographics, patient reported outcomes, and plastic surgeon evaluations to compare vertical incision mastectomy to other incisions. METHODS: After institutional review board approval, a retrospective chart review was performed. A total population of 167 patients that underwent mastectomy with tissue expander reconstruction was separated into vertical incision and nonvertical incision mastectomy groups consisting of 38 and 129 patients, respectively. Patient demographics, complications, tumor margins, staging, breast weight, and breast implant volume were compared. BREASTQ Survey analysis was conducted using patient reported outcomes from the patient's perspective. Aesthetic evaluations of postoperative photos were systematically scored by plastic surgeons to obtain data from the plastic surgeon's perspective. RESULTS: Vertical incision orientation did not increase surgical complication rates or mastectomy skin necrosis (P = 0.142). Vertical incisions did not interfere with obtaining adequate tumor margins (P = 0.907). Vertical incisions did not have a significantly different breast weight or implant volume. There was no statistical difference for patient satisfaction or plastic surgeon aesthetic evaluation. CONCLUSIONS: The use of vertical incision does not increase complication rates; does not interfere with tumor margins; and can be applied to all age, BMI, breast weight, and breast implant volume groups.

A national snapshot of satisfaction with breast cancer procedures.

PURPOSE: Women with early-stage breast cancer face the complex decision to undergo one of three equally effective oncologic surgical strategies: breast-conservation surgery with radiation (BCS), mastectomy, or mastectomy with breast reconstruction. With comparable oncologic outcomes and survival rates, evaluations of satisfaction with these procedures are needed to facilitate the decision-making process and to optimize long-term health. METHODS: Women recruited from the Army of Women with a history of breast cancer surgery took electronically administered surgery-specific surveys, including the BREAST-Q© and a background survey evaluating patient-, disease-, and procedure-specific factors. Descriptive statistics and regression analysis were used to evaluate the effect of procedure type on breast satisfaction scores. RESULTS: Overall, 7,619 women completed the questionnaires. Linear regression revealed that women who underwent abdominal flap, or buttock or thigh flap reconstruction reported the highest breast satisfaction score, scoring an average of 5.6 points and 14.4 points higher than BCS, respectively (p < 0.0001 and p = 0.027, respectively). No difference in satisfaction was observed in women who underwent latissimus dorsi flap reconstruction compared with those who underwent BCS. Women who underwent implant reconstruction reported scores 8.6 points lower than BCS (p < 0.0001). Those with mastectomies without reconstruction or complex surgical histories scored, on average, 10 points lower than BCS (p < 0.0001). CONCLUSION: Women who underwent autologous tissue reconstruction reported the highest breast satisfaction, while women undergoing mastectomy without reconstruction reported the lowest satisfaction. These findings emphasize the value of patient-reported outcome measures as an important guide to decision making in breast surgery and underscore the importance of multidisciplinary participation early in the surgical decision-making process.

Toolbox to Reduce Lumpectomy Reoperations and Improve Cosmetic Outcome in Breast Cancer Patients: The American Society of Breast Surgeons Consensus Conference.

BACKGROUND: Multiple recent reports have documented significant variability of reoperation rates after initial lumpectomy for breast cancer. To address this issue, a multidisciplinary consensus conference was convened during the American Society of Breast Surgeons 2015 annual meeting. METHODS: The conference mission statement was to "reduce the national reoperation rate in patients undergoing breast conserving surgery for cancer, without increasing mastectomy rates or adversely affecting cosmetic outcome, thereby improving value of care." The goal was to develop a toolbox of recommendations to reduce the variability of reoperation rates and improve cosmetic outcomes. Conference participants included providers from multiple disciplines involved with breast cancer care, as well as a patient representative. Updated systematic reviews of the literature and invited presentations were sent to participants in advance. After topic presentations, voting occurred for choice of tools, level of evidence, and strength of recommendation. RESULTS: The following tools were recommended with varied levels of evidence and strength of recommendation: compliance with the SSO-ASTRO Margin Guideline; needle biopsy for diagnosis before surgical excision of breast cancer; full-field digital diagnostic mammography with ultrasound as needed; use of oncoplastic techniques; image-guided lesion localization; specimen imaging for nonpalpable cancers; use of specialized techniques for intraoperative management, including excisional cavity shave biopsies and intraoperative pathology assessment; formal pre- and postoperative planning strategies; and patient-reported outcome measurement. CONCLUSIONS: A practical approach to performance improvement was used by the American Society of Breast Surgeons to create a toolbox of options to reduce lumpectomy reoperations and improve cosmetic outcomes.

Effects of Marijuana Use in Patients Undergoing Abdominal Free Flap Breast Reconstruction.

Background: Marijuana use has been associated with vascular inflammation and clotting, resulting in endothelial damage and arteritis. As marijuana use rises in the United States, few studies have evaluated its impact on surgical outcomes and wound healing in free flap breast reconstruction. Methods: A retrospective cohort study of patients undergoing abdominal free flap breast reconstruction between 2016 and 2022 at a large metropolitan healthcare system was performed. Patient demographics, comorbidities, procedural details, and complications were analyzed. Minor complications were defined as skin or fat necrosis not requiring intervention, nipple loss, any wound requiring management in the clinic, hematoma, and seroma. Major complications were defined as reoperation, flap loss, cardiac or thromboembolic events, and hospital readmission. Active marijuana users were those with marijuana use within 12 weeks of surgery. Results: In total, 168 patients underwent 276 deep inferior epigastric artery-based flaps for breast reconstruction. There were 21 active marijuana users. There were no significant differences in patient demographics, cancer treatment, or minor and major complications. However, there were higher rates of active nicotine use (P = 0.001) and anxiety/depression amongst active marijuana users (P = 0.002). Active users had higher rates of bilateral breast reconstruction (P = 0.029), but no significant differences in other operative details. Conclusions: Active marijuana use of unknown frequency may be safe in patients undergoing breast free flap reconstruction. Advising marijuana abstinence preoperatively may not alter patient outcomes. Further studies of greater sample size are needed to evaluate marijuana's impact on outcomes associated with breast reconstruction using free flap.

The choice for breast cancer surgery: can women accurately predict postoperative quality of life and disease-related stigma?

BACKGROUND: To make an informed choice, breast cancer patients facing surgery must imagine the effect of surgery on their future life experiences. However, the accuracy of patient predictions of postoperative quality of life (QoL) and disease-related stigma is not well understood. MATERIALS AND METHODS: Four groups of breast cancer patients at the University of Michigan Medical Center were surveyed by mail and interview (response rate 76.3%): (1) preoperative (N = 59), (2) mastectomy (N = 146), (3) mastectomy with reconstruction (N = 250), and (4) breast conservation (N = 705). Subjects rated their QoL (1 = lowest, 100 = highest) and stigma (1 = lowest, 5 = highest) and estimated QoL and stigma associated with mastectomy alone, mastectomy with reconstruction, and breast conserving surgery (BCS). Mean scores were compared using linear regression controlling for age, race, partnered status, and income. RESULTS: Preoperatively, women inaccurately predicted postoperative QoL and stigma for all surgical options, particularly for mastectomy. Preoperative patients underestimated the postoperative QoL for mastectomy alone (predicted: 56.8 vs actual: 83.7; P < .001). Preoperative patients underestimated QoL following mastectomy following reconstruction (predicted: 73.4 vs actual: 83.9; P < .001) and BCS (predicted: 72.2 vs actual: 88.6; P < .001). Additionally, preoperative patients overestimated stigma related to mastectomy (predicted: 3.25 vs actual: 2.43; P < .001). Finally, preoperative women overestimated stigma related to mastectomy with reconstruction (predicted: 2.54 vs actual: 2.03; P < .001) and BCS (predicted: 1.90 vs actual: 1.76; P < .001). CONCLUSION: Predicting QoL and stigma following breast cancer surgery is challenging for patients facing a diagnosis for surgery. Identifying strategies to better inform patients of surgical outcomes can improve the decision-making process.

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.

The Evolution of Breast Satisfaction and Well-Being after Breast Cancer: A Propensity-Matched Comparison to the Norm.

BACKGROUND: Breast cancer survival continues to improve, with women living longer after treatment. It is not well understood how long-term satisfaction and well-being differ following treatment or how types of reconstruction differ when compared to the norm. METHODS: In a propensity-matched sample, the authors compared patient-reported outcomes in breast cancer patients at various time intervals from surgery with normative BREAST-Q data. All data were obtained using the Army of Women, an online community fostering breast cancer research. Breast cancer patients were stratified by surgical treatment and reconstruction type. Regression lines were estimated and differences in slope tested between cancer patients and noncancer controls. RESULTS: The authors compared normative (n = 922) and breast cancer (n = 4343) cohorts in a propensity-matched analysis. Among the breast cancer patients, 49.4 percent underwent lumpectomy, 17.0 percent underwent mastectomy, 21.7 percent underwent implant reconstruction, and 11.9 percent underwent autologous reconstruction. Median time since surgery was 4.7 years, with 21.1 percent more than 10 years after surgery. At the time of survey, breast cancer patients reported higher Satisfaction with Breasts and Psychosocial Well-being scores compared to noncancer controls (p < 0.01), with the cohorts undergoing lumpectomy and autologous reconstruction both reporting higher scores than the normative controls. After mastectomy, scores averaged lower than the noncancer controls, but improved over time. However, all breast cancer groups reported significantly lower Physical Well-being scores than the noncancer cohort (all p < 0.01). CONCLUSIONS: Breast cancer patients undergoing lumpectomy or autologous reconstruction reported higher psychosocial well-being compared to noncancer controls. These differences were influenced both by time since treatment and by choice of surgical procedure.

A systematic review of abdominal wall function following abdominal flaps for postmastectomy breast reconstruction.

Perforator flap breast reconstruction potentially offers patients greater postoperative abdominal strength compared with traditional TRAM techniques. Our purpose was to perform a systemic review of the published literature regarding abdominal wall function following breast reconstruction and compare outcomes between pedicle TRAM, free TRAM, and perforator flap procedures. We used the MEDLINE, EMBASE, CINAHL, the Cochrane Network, and HAPI databases from January 1966 through November 1, 2007 to identify potentially relevant studies. Inclusion criteria included studies that evaluated subjective or objective functional abdominal outcomes for postmastectomy patients receiving either pedicle TRAM, free TRAM, or deep inferior epigastric perforator (DIEP) flaps. All study designs were included in the review-prospective studies, cross-sectional studies, and retrospective case series. Our search yielded 20 studies on abdominal wall function after autogenous tissue breast reconstruction. Objective measures of abdominal wall function using isometric dynamometry revealed that pedicle TRAM patients experienced up to a 23% deficit, whereas free TRAM patients experienced up to an 18% deficit in trunk flexion. For trunk extension, pedicle TRAM patients experienced up to a 14% deficit, whereas free TRAM patients experienced minimal to no deficits. However, none of the comparative studies of pedicle and free TRAM procedures found significant differences in abdominal wall function between the 2 groups. Studies that compared free TRAM to DIEP flaps found significantly higher flexion abilities in the DIEP groups, with one study reporting an advantage in measures of extension for DIEP flaps. Functional deficits assessed by physiotherapy measures revealed that patients with pedicle TRAM reconstructions experienced the greatest deficit in rectus and oblique muscle function (up to 53%). Free TRAM groups experienced minimal deficit in rectus muscle function, whereas DIEP flaps returned to baseline for both rectus and oblique muscle function. Subjective measures of abdominal wall function were similar across unipedicle TRAM, free TRAM, and DIEP flap procedures. Patients with bilateral pedicle TRAM reconstruction suffered up to a 40% deficit in trunk flexion and up to a 9% deficit in trunk extension. Patients with bilateral pedicle or free TRAM reconstruction also experienced a significant decrease in the ability to perform sit-ups and a significant decrease in activities of daily living, recreational, and laborious activities. With the exception of those who had bipedicled TRAM or bilateral free TRAM procedures, most women reported return to their preoperative function without a decrease in their ability to perform activities of daily living. Although some studies report an objective advantage of DIEP flaps, this does not appear to translate to detriments in the performance of activities of daily living. However, the current data have limitations in study design and generalizability. A multicenter, longitudinal study is needed to assess objective and subjective outcomes in patients with pedicle TRAM, free TRAM, and perforator flaps using standardized and validated measures.

The efficacy of the surgical delay procedure in pedicle TRAM breast reconstruction.

Although experimental evidence suggests that the preliminary surgical delay procedure physiologically improves the circulation of the TRAM flap, there are no published controlled studies evaluating the clinical outcomes associated with this procedure. The purpose of this study was to evaluate the efficacy of the surgical flap delay versus no delay in consecutive patients having pedicle TRAM breast reconstruction. This was a retrospective cohort study of breast cancer patients at the University of Michigan who had pedicle TRAM reconstruction between January 2004 and March 2008. Prior to September 2005, all patients had pedicle TRAM reconstruction without the delay procedure. Starting in September 2005, all patients had the delay procedure prior to TRAM flap reconstruction. Descriptive statistics were used to compare demographic data, comorbidities, and complication rates between the 2 cohorts. Regression analysis was used to determine the effects of the surgical delay procedure on the incidence of flap ischemia and major and minor complications while controlling for patient and treatment level factors. Eighty-seven postmastectomy breast cancer patients had unipedicle TRAM flap reconstruction, in which 112 flaps were used to reconstruct breasts. The nondelay cohort consisted of 42 consecutive patients (51 flaps) and the delay cohort consisted of 45 consecutive patients (61 flaps). Of the patients without the surgical delay procedure 17.6% experienced at least one ischemic complication of the flap compared with 6.6% of those who were surgically delayed (P = 0.082). When controlling for patient and treatment level factors, the delay procedure was found to significantly decrease the incidence of flap ischemia (OR = 0.21, P = 0.018). In addition, there were no significant differences in the incidence of major or minor complication rates in the surgically delayed versus nondelayed groups (P = 0.247, P = 0.486, respectively). When patient and treatment level factors were taken into consideration, undergoing the delay procedure also did not increase the incidence of having a major or minor complication. These data support the use of the preliminary surgical delay procedure to decrease ischemic complications of the flap in pedicle TRAM postmastectomy breast reconstruction.

A National Snapshot of Patient-Reported Outcomes Comparing Types of Abdominal Flaps for Breast Reconstruction.

BACKGROUND: This study aimed to identify differences in patient-reported abdominal well-being, satisfaction, and quality of life in women with muscle-preserving free abdominal versus pedicle transverse rectus abdominis musculocutaneous (TRAM) flap for breast reconstruction. METHODS: Women with a history of breast cancer surgery were recruited from the Army of Women foundation to take the BREAST-Q and a background questionnaire. Descriptive statistics and regression analyses were used to compare abdominal physical well-being, breast satisfaction, chest physical, psychosocial well-being, and sexual well-being in women undergoing free versus pedicle TRAM flaps. RESULTS: Of 657 women, 273 (41 percent) underwent free flap surgery and 384 (58 percent) underwent pedicle TRAM flap surgery. Compared with unilateral pedicle TRAM flaps, those with unilateral free flaps scored an average of 9.5 points higher (95 percent CI, 5.4 to 13.6; p < 0.0001) and those with bilateral free flaps reported no difference in physical well-being of the abdomen. Compared with bilateral pedicle TRAM flaps, the following groups scored higher in physical well-being of the abdomen: unilateral free flaps, an average of 17.4 (95 percent CI, 11.5 to 23.3; p < 0.0001); bilateral free flaps, an average of 6.8 (95 percent CI, 0.3 to 13.3; p = 0.04); and unilateral pedicle TRAM flaps, an average of 7.9 (95 percent CI, 2.4 to 13.4; p = 0.005) higher. Women with bilateral pedicle flaps reported sexual well-being scores 7.4 (95 percent CI, 0.6 to 14.3; p = 0.03) and 6.8 (95 percent CI, 0.3 to 13.2; p = 0.04) points lower than those with unilateral free and unilateral pedicle flaps. CONCLUSIONS: Muscle-preserving techniques result in improved abdominal wall function and decreased morbidity compared with pedicle TRAM flap reconstruction. These data highlight the importance of offering patients the option of microsurgical techniques.

Prospective analysis of long-term psychosocial outcomes in breast reconstruction: two-year postoperative results from the Michigan Breast Reconstruction Outcomes Study.

OBJECTIVE: To prospectively evaluate the psychosocial outcomes and body image of patients 2 years postmastectomy reconstruction using a multicenter, multisurgeon approach. BACKGROUND: Although breast reconstruction has been shown to confer significant psychosocial benefits in breast cancer patients at year 1 postreconstruction, we considered the possibility that psychosocial outcomes may remain in a state of flux for years after surgery. METHODS: Patients were recruited as part of the Michigan Breast Reconstruction Outcome Study, a 12 center, 23 surgeon prospective cohort study of mastectomy reconstruction patients. Two-sided paired sample t tests were used to compare change scores for the various psychosocial subscales. Multiple regression analysis was used to determine whether the magnitude of the change score varied by procedure type. RESULTS: Preoperative and postoperative year 2 surveys were received from 173 patients; 116 with immediate and 57 with delayed reconstruction. For the immediate reconstruction cohort, significant improvements were observed in all psychosocial subscales except for body image. This occurred essentially independent of procedure type. In the cohort with delayed reconstruction, significant change scores were observed only in body image. Women with transverse rectus abdominis musculocutaneous flaps had significantly greater gains in body image scores (P = 0.003 and P = 0.034, respectively) when compared with expander/implants. CONCLUSIONS: General psychosocial benefits and body image gains continued to manifest at 2 years postmastectomy reconstruction. In addition, procedure type had a surprisingly limited effect on psychosocial well being. With outcomes evolving beyond year 1, these data support the need for additional longitudinal breast reconstruction outcome studies.

Validation of the electronic version of the BREAST-Q in the army of women study.

Women undergoing surgery for primary breast cancer can choose between breast conserving therapy and mastectomy (with or without breast reconstruction). Patients often turn to outcomes data to help guide the decision-making process. The BREAST-Q is a validated breast surgery-specific patient-reported outcome measure that evaluates satisfaction, quality of life, and patient experience. It was originally developed for paper-and-pencil administration. However, the BREAST-Q has increasingly been administered electronically. Therefore, the aim of this study was to evaluate the psychometric properties of an electronic version of the BREAST-Q in a large online survey. Women with a history of breast cancer surgery recruited from the Love/AVON Army of Women program completed an electronic version of the BREAST-Q in addition to the Impact of Cancer Survey and PTSD Checklist. Traditional psychometric analyses were performed on the collected data. BREAST-Q data were collected from 6748 women (3497 Breast Conserving Therapy module, 1295 Mastectomy module, 1956 Breast Reconstruction module). Acceptability was supported by a high response rate (82%), low frequency of missing data (<5%), and maximum endorsement frequencies (<80%) in all but 17 items. Scale reliability was supported by high Cronbach's α coefficients (≥0.78) and item-total correlations (range of means, 0.65-0.91). Validity was supported by interscale correlations, convergent and divergent hypotheses as well as clinical hypotheses. The electronically administered BREAST-Q yields highly reliable, clinically meaningful data for use in clinical outcomes research. The BREAST-Q can be used in the clinical setting, whether administered electronically or using paper-and-pencil, at the choice of the patient and surgeon.

Facial Fractures in the Aging Population.

BACKGROUND: As the U.S. population ages and life expectancy increases, the number of elderly patients seeking trauma care and treatment for facial fractures will increase. Understanding age-related differences in the pattern, cause, and management of these fractures is essential for improving care. METHODS: A retrospective review of adults presenting to a Level I trauma center was performed to evaluate age-related differences in facial fractures. Descriptive statistics were used to compare fracture number, type, cause of injury, management, and adverse events between elderly (older than 64 years) and younger cohorts (aged 18 to 64 years). Logistic regression was used to evaluate the effect of age on fracture type while controlling for potential confounding variables. RESULTS: Two thousand twenty-three adult patients sustained a facial fracture from 2001 to 2011. Two hundred nine patients were elderly and 1814 were younger. Regarding cause of injury, older patients were more likely to fall and younger patients were more likely to be injured through assaults, motor vehicle collisions, or sports (p < 0.0001). Elderly patients sustained a higher incidence of maxillary (16.3 percent versus 11.4 percent; p = 0.0401), nasal (54.1 percent versus 45.3 percent; p = 0.0156), and orbital floor fractures (28.2 percent versus 18.1 percent; p = 0.004) and a lower incidence of mandible fractures (10.1 percent versus 21.3 percent; p = 0.0001). The elderly had significantly less operative intervention (24.9 percent versus 43 percent; p < 0.0001) and were less likely to experience complications (5.3 percent versus 10.5 percent; p = 0.0162). CONCLUSION: Elderly patients tend to suffer from less severe facial fractures, requiring less need for operative intervention, likely secondary to low-energy mechanisms of injury. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Patient-Reported Outcomes After Choice for Contralateral Prophylactic Mastectomy.

PURPOSE: The rate of contralateral prophylactic mastectomies (CPMs) continues to rise, although there is little evidence to support improvement in quality of life (QOL) with CPM. We sought to ascertain whether patient-reported outcomes and, more specifically, QOL differed according to receipt of CPM. METHODS: Volunteers recruited from the Army of Women with a history of breast cancer surgery took an electronically administered survey, which included the BREAST-Q, a well-validated breast surgery outcomes patient-reporting tool, and demographic and treatment-related questions. Descriptive statistics, hypothesis testing, and regression analysis were used to evaluate the association of CPM with four BREAST-Q QOL domains. RESULTS: A total of 7,619 women completed questionnaires; of those eligible, 3,977 had a mastectomy and 1,598 reported receipt of CPM. Women undergoing CPM were younger than those who did not choose CPM. On unadjusted analysis, mean breast satisfaction was higher in the CPM group (60.4 v 57.9, P < .001) and mean physical well-being was lower in the CPM group (74.6 v 76.6, P < .001). On multivariable analysis, the CPM group continued to report higher breast satisfaction (P = .046) and psychosocial well-being (P = .017), but no difference was reported in the no-CPM group in the other QOL domains. CONCLUSION: Choice for CPM was associated with an improvement in breast satisfaction and psychosocial well-being. However, the magnitude of the effect may be too small to be clinically meaningful. Such patient-reported outcomes data are important to consider when counseling women contemplating CPM as part of their breast cancer treatment.

A prospective study in search of an optimal B-natriuretic peptide level to screen patients for cardiac dysfunction.

BACKGROUND: Although echocardiography is the gold standard test for suspected left ventricular dysfunction, its cost and availability limits its use as a routine screening tool. The high negative predictive value of B-natriuretic peptide (BNP) in dyspneic patients suggests its possible utility in screening patients prior to echocardiography. Determining an appropriate BNP level below which the need for echocardiography is precluded would be valuable. We hypothesized that a fixed plasma BNP level of 20 pg/mL and simple clinical parameters are an effective pre-echocardiographic screening tool for left ventricular dysfunction. METHODS: Two hundred and two patients at a Veterans Administration facility with symptoms suggestive of heart disease (male to female ratio 193:9, mean age 65 years) were screened prior to echocardiography. Patients with known cardiac dysfunction were excluded. RESULTS: BNP levels of > or =20 pg/mL were 79% sensitive and 44% specific in screening for any abnormality of ventricular function. The negative predictive value was 69%. When broken down into categories of dysfunction, the cutoff point of 20 pg/mL had a better negative predictive value for those with systolic dysfunction (96%) or systolic plus diastolic dysfunction (100%) if patients with diastolic dysfunction were excluded. The majority of patients with falsely low BNP levels (<20 pg/mL with positive echocardiographic findings) had mild diastolic dysfunction, with 3 patients exhibiting mild systolic dysfunction. CONCLUSIONS: BNP may be a useful screening tool for left ventricular dysfunction in patients with history suggestive of heart disease and be used to assist in forming a pretest probability, which in turn could greatly assist in appropriateness of patient referral and in optimization of drug therapy.

Use of autologous and microsurgical breast reconstruction by U.S. plastic surgeons.

BACKGROUND: Concern exists that plastic surgeons are performing fewer autologous and microsurgical breast reconstructions, despite superior long-term outcomes. The authors describe the proportion of U.S. plastic surgeons performing these procedures and evaluate motivating factors and perceived barriers. METHODS: A random national sample of American Society of Plastic Surgeons members was surveyed (n = 325; response rate, 76 percent). Surgeon and practice characteristics were assessed, and two multiple logistic regression models were created to evaluate factors associated with (1) high-volume autologous providers and (2) microsurgical providers. Qualitative assessments of motivating factors and barriers to microsurgery were also performed. RESULTS: Fewer than one-fifth of plastic surgeons perform autologous procedures for more than 50 percent of their breast cancer patients, and only one-quarter perform any microsurgical breast reconstruction. Independent predictors of a high-volume autologous practice include involvement with resident education (odds ratio, 2.57; 95 percent CI, 1.26 to 5.24) and a microsurgical fellowship (odds ratio, 2.09; 95 percent CI, 1.04 to 4.27). Predictors of microsurgical breast reconstruction include involvement with resident education (odds ratio, 6.8; 95 percent CI, 3.32 to 13.91), microsurgical fellowship (odds ratio, 2.4; 95 percent CI, 1.16 to 4.95), and high breast reconstruction volume (odds ratio, 6.68; 95 percent CI, 1.76 to 25.27). The primary motivator for microsurgery is superior outcomes, and the primary deterrents are time and reimbursement. CONCLUSIONS: The proportion of U.S. plastic surgeons with a high-volume autologous or microsurgical breast reconstruction practice is low. Involvement with resident education appears to facilitate both, whereas time constraints and reimbursement are primary deterrents. Future efforts should focus on improving the feasibility and accessibility of all types of breast reconstruction.

Patterns and correlates of postmastectomy breast reconstruction by U.S. Plastic surgeons: results from a national survey.

BACKGROUND: : Concern exists that plastic surgeons have lost interest in postmastectomy breast reconstruction, which has helped enable the oncoplastic movement by general surgery. The authors evaluated patterns and correlates of postmastectomy breast reconstruction among U.S. plastic surgeons. METHODS: A survey was mailed to a national sample of 500 randomly selected members of the American Society of Plastic Surgeons (73 percent of eligible subjects responded; n = 312). The dependent variable was surgeon's annual volume of breast reconstructions (dichotomized into >50 and ≤ 50 cases per year). Logistic regression was used to evaluate factors associated with annual volume, including surgeon demographic and practice characteristics, community support for reconstruction, and surgeons' attitudes toward insurance reimbursement. RESULTS: Ninety percent found doing breast reconstruction personally rewarding, and nearly all enjoyed the technical aspects of the procedure. The majority of surgeons, however, were low-volume to moderate-volume providers, and 43 percent reported decreasing their volume over the past year due to poor reimbursement. Resident availability was significantly associated with high volume (odds ratio, 4.93; 95 percent CI, 2.31 to 10.49); years in practice and perceived financial constraints by third-party payers were inversely associated with high volume (>20 years compared with ≤ 10 years: odds ratio, 0.23. 95 percent CI, 0.07 to 0.71; odds ratio, 0.22, 95 percent CI, 0.08 to 0.56, respectively). CONCLUSIONS: Although plastic surgeons find breast reconstruction professionally rewarding, many are decreasing their practice. Factors associated with low volume include lack of resident coverage and perceived poor reimbursement. Advocacy efforts must be directed at facilitating reconstructive services for this highly demanding patient population.

Ipsilateral pedicle TRAM flaps for breast reconstruction: are they as safe as contralateral techniques?

INTRODUCTION: Many surgeons are using the ipsilateral rotation of the TRAM flap because of easier flap insetting and improved aesthetic outcomes; however studies evaluating these techniques are limited to case series without groups for comparison. Our purpose was to evaluate the safety of the ipsilateral technique through a retrospective cohort study. METHODS: We retrospectively evaluated consecutive contralateral and ipsilateral TRAM flaps for mastectomy breast reconstruction. The incidence of ischemia-related flap complications and the incidence of major and minor complications were compared between the two groups. Multiple logistic regression was used to assess the effect of rotation type on complication rates, while controlling for potential confounding variables. RESULTS: Comparing 58 ipsilateral to 32 contralateral pedicle TRAM patients, the rate of a major complication was 20.7% and 28.1%, respectively, p=0.425; a minor complication was 50.0% vs. 34.4%, respectively, p=0.153; and total ischemic-related flap complications were 22.4% and 25.0% respectively, p=0.781. When controlling for potential confounders, the type of pedicle TRAM flap did not have a significant effect on the above complications. Advanced patient age was significantly correlated with an increased incidence of major complications (OR=1.09, p=0.031) and ischemic flap complications (OR=1.11, p=0.016). CONCLUSION: The ipsilateral pedicle TRAM flap appears as safe as the contralateral technique for breast reconstruction. Given the increased pedicle length and preservation of both the medial inframammary fold and xiphoid subunit, we believe that the ipsilateral technique is preferred over the contralateral rotation.