Can the cost affect the choice of various methods of postmastectomy breast reconstruction?

AIM AND BACKGROUND: A wide range of methodologies for breast reconstruction is now available. For immediate breast reconstruction we prefer to use implants, whereas reconstruction using autologous tissues, such as transverse rectus abdominis musculocutaneous flaps (TRAMF) and muscular latissimus dorsi flaps, is applied only in selected cases. In contrast, for delayed reconstruction the choice between prostheses and autologous tissue depends on various conditions. The different reconstructive methods can be adopted as a single procedure or as a combination of surgical procedures. Following the issue of legislation defining the new structure of the Italian Health Service, the need to accurately assess the costs incurred for the execution of surgical operations has taken on paramount importance. The aim of the study was to evaluate not only the clinical limits of each surgical technique, but also its cost, in order to optimize the choice of the same procedures, conditions being equal. METHODS: The study population included 105 patients who underwent breast reconstruction in the period 1st January 1994-30th June 1995. The reconstructive procedures included 48 immediate implants, 7 immediate TRAMF, 17 delayed implants, 30 delayed TRAMF, and 3 delayed latissimus dorsi muscular flaps. RESULTS: After data evaluation, we concluded that reconstruction using permanent expandable implants is the most convenient among implant reconstructions for its low global treatment cost. In fact, reconstructive procedures using temporary expanders, which require two surgical operations, have a higher cost than breast reconstruction using permanent expandable implants. Breast reconstruction using TRAMF is the most convenient because it limits the cost of surgical materials and because flap versatility limits the number of modifications on the contralateral breast. In contrast, breast reconstruction using latissimus dorsi flaps has high costs. CONCLUSIONS: There is no balance between price list and effective cost of the different surgical reconstructive procedures, which may be a point of departure to see whether it is impossible to improve the efficiency of the Health Care System and in any case open a debate between the Regions and hospitals to improve the service, keeping it at a good level.

[The cost as an additional variable in the choice among different techniques of postmastectomy breast reconstruction]. / Il costo come ulteriore variabile di scelta tra le diverse metodiche di ricostruzione mammaria postmastectomia.

Breast reconstruction is an important step for patients after mastectomy. In our Department for immediate reconstruction, smooth or textured temporary tissue expanders filled with saline solution or permanent expandable implants (PEI) with silicon gel saline solution or soyabean oil are usually used. Only in a few selected cases reconstruction using autologous tissues are performed. Delayed reconstruction is performed using autologous tissues: Transversus Rectus Abdominis Myocutaneus Flap (TRAMF) or Latissimus Dorsi flap (LD). The choice between reconstruction with prostheses or muscular flaps depends on previous demolition, local skin condition, contralateral breast size and ptosis, body structure, medical problems, patients' wishes and expectation. Following the legislation defining the privatisation of Italian Health Care Structure and in particular the Decree of December 14, 1994, the need to accurately assess the costs incurred for surgical operations is very important. The aim of this study is to evaluate the clinical limits of each surgical technique and their cost in order to optimize the cost-benefit relationship.

Mammographic visualization of a nonpalpable breast mass through a radiolucent breast implant.

We report a woman who underwent augmentation mammaplasty as part of a clinical trial of the Trilucent (soybean oil-filled) breast implant in Genoa, Italy. Five months after surgery a mammography was performed in response to the patient's complaints of pressure and tightness in the area of her left breast. The mammogram clearly demonstrated a 5-mm fibroadenoma of the left breast. This is the first documented case of a nonpalpable breast lesion that was detected by mammography through the new radiolucent, triglyceride-filled implant.

Psychological evaluation of patients undergoing breast reconstruction using two different methods: autologous tissues versus prostheses.

Breast reconstruction has become an available option for most patients undergoing mastectomy. In fact, many authors agree that breast reconstruction does not interfere with possible therapies and improves the women's quality of life. The aim of this study was to evaluate the psychological adjustment of patients who had immediate or delayed reconstruction using two different methods: implants and autologous tissues. Specifically, it was explored whether the different methods of breast reconstruction have caused significant changes in psychological functioning. The study population (102 patients) was derived from patients who underwent breast reconstruction in the period January 1988 to December 1991 at the Department of Plastic and Reconstructive Surgery of the National Institute for Cancer Research in Genoa, Italy. Fifty-two patients underwent breast reconstruction using implants and 50 using the transverse rectus abdominis myocutaneous (TRAM) flap. Demographic information was gathered from each patient. The psychological instruments consisted of three standardized self-administered questionnaires: Psychological Distress Inventory, State Trait Anxiety Inventory, Form Y, and the Eysenck Personality Inventory. To better assess the changes in body image after breast reconstruction, three more specific questions about sexual desire, physical image, and social relationships were added. The 102 patients assessed in this study indicated a low incidence of psychological distress. Impairment was reported regarding body image by patients who underwent delayed reconstruction; these patients also showed higher distress scores. The type of breast reconstruction also seems to influence body image, showing in the patients with TRAM flap reconstruction more relevant psychological discomfort.(ABSTRACT TRUNCATED AT 250 WORDS)

[Psychological assessment of patients who have ++undergone breast reconstruction using 2 different technics: autologous tissue versus prosthesis]. / Valutazione psicologica di pazienti sottoposte a ricostruzione mammaria mediante uso di due differenti tecniche: tessuti autologhi verso protesi.

Breast reconstruction has become an available option for most patients undergoing mastectomy: in fact many authors agree that breast reconstruction does not interfere with possible therapies and improves the quality of life of women. The aim of the study was to evaluate the psychological adjustment of patients who had immediate or delayed reconstruction using 2 different methods: implants and autologous tissues. The study population (115 patients) was derived from patients who underwent breast reconstruction in the period January 1988-December 1991, in follow-up at the Department of Plastic and Reconstructive Surgery; no patient was undergoing psychological therapy. 58 patients underwent breast reconstruction using implants and 57 using Transverse Rectus Abdominis Myocutaneous Flap (TRAMF). Informations were gathered, including the patient's age, the number of offspring, the marital status, the scholastic education, the job and the relapse between mastectomy and reconstruction. The psychological instruments consisted in three standardized self-administered questionnaires: Psychological Distress Inventory (PDI), State Trait Anxiety Inventory form Y (STAI), Eysenk Personality Inventory (EPQ-R). These tests were chosen to gauge the psychological distress, such anxiety, anger, depression and psychosocial maladjustment. To better perform the changes of body image after breast reconstruction, women were requested to answer three more specific questions about the sexual desire, physical image and social relationships. The 102 patients assessed in this study indicate low incidence of psychological distress and adaptive coping strategies. Impairment was reported, regarding body image, by patients undergoing delayed reconstruction; in these patients higher scores in distress tests were observed.

Combined management in the treatment of epidoxorubicin extravasation. A case report.

Inadvertent extravasation during intravenous antitumor therapy is not an unusual complication and can cause damage ranging from minor erythema to severe local necrosis. The appropriate management of these iatrogenic accidents as a part of supportive care in oncology has been addressed by several experimental studies, but there has been little clinical study and no conclusive evidence on the best therapeutic strategies to adopt. The case reported here of a patient suffering from severe soft-tissue injury caused by extravasation of epidoxorubicin demonstrates the usefulness of a combined management (medical, surgical and rehabilitative) in the appropriate care of extravasation.