Preservation of the Pectoral Fascia in Mastectomy With Immediate Reconstruction: A Nationwide Survey.

INTRODUCTION: Pectoral fascia (PF) removal during mastectomy still seems to be the standard procedure. However, preservation of the PF might improve postoperative and cosmetic outcomes, without compromising oncological safety. Here, we report on a national survey among Dutch plastic surgeons and oncological breast surgeons to evaluate their techniques and opinions regarding the PF. MATERIALS AND METHODS: A survey based study was performed in the Netherlands, in which both plastic surgeons and oncological breast surgeons were included, each receiving a different version of the survey. The surveys were distributed to 460 and 150 e-mail addresses, respectively. RESULTS: A total of 68 responses were included from more than half of all Dutch medical centers. The results of this study indicate that circa one in five plastic surgeons and breast surgeons routinely preserve the PF during mastectomies and even more surgeons preserve the PF in specific cases. The surgical techniques and opinions regarding PF preservation widely differ between surgeons. CONCLUSIONS: Preservation of the PF does occur in a substantial part of the Dutch medical centers and techniques and opinions are contradictory. Future studies on this topic should clarify the effect of PF preservation on oncological safety, complication rates, postoperative pain, cosmetic outcomes, and patient satisfaction.

Breast-conserving surgery following neoadjuvant therapy-a systematic review on surgical outcomes.

PURPOSE: Neoadjuvant chemotherapy (NACT) is increasingly used in breast cancer treatment. One of the main goals of NACT is to reduce the extent of local surgery of the breast and axilla. The aim of this study was to determine surgical outcomes for patients receiving breast-conserving therapy (BCT) after NACT, including margin status plus secondary surgeries, excision volumes, and cosmetic outcomes. METHODS: A systematic review was performed in accordance with PRISMA principles. Pubmed, MEDLINE, Embase, and the Cochrane Library were searched for studies investigating the results of BCT following NACT. The main study outcomes were margin status, additional local therapies, excision volumes, and cosmetic outcomes. Non-comparative studies on NACT were also included. Exclusion criteria were studies with less than 25 patients, and studies excluding secondary mastectomy patients. FINDINGS: Of the 1219 studies screened, 26 studies were deemed eligible for analysis, including data from 5379 patients treated with NACT and 10,110 patients treated without NACT. Included studies showed wide ranges of tumor-involved margins (2-39.8%), secondary surgeries (0-45.4%), and excision volumes (43.2-268 cm3) or specimen weight (26.4-233 g) after NACT. Most studies were retrospective, with a high heterogeneity and a high risk of bias. Cosmetic outcomes after NACT were reported in two single-center cohort studies. Both studies showed acceptable cosmetic outcomes. INTERPRETATION: There is currently insufficient evidence to suggest that NACT improves surgical outcomes of BCT. It is imperative that clinical trials include patient outcome measures in order to allow monitoring and meaningful comparison of treatment outcomes in breast cancer.

Correction to: Breast-conserving surgery following neoadjuvant therapy-a systematic review on surgical outcomes.

In the original publication of the article, Table 2 was published incorrectly. The corrected Table 2 is given in this erratum. The original article has been corrected.

Breast-specific factors determine cosmetic outcome and patient satisfaction after breast-conserving therapy: Results from the randomized COBALT study.

BACKGROUND AND OBJECTIVES: To identify breast-specific factors and the role of tumor, treatment, and patient-related items in influencing patient opinion on cosmesis and satisfaction after breast-conserving therapy (BCT). METHODS: Data from the randomized COBALT study was used. At 3, 12, and 36 months, 128 patients with T1-T2 breast cancer completed a questionnaire on breast-specific factors and overall cosmetic outcome and patient satisfaction, using a 4-point Likert scale. RESULTS: There was a strong positive correlation between breast-specific factors, overall cosmetic outcome,and satisfaction at all time-points. Excellent/good cosmetic outcomes and satisfaction decreased during follow-up. A shift was noted in the degree of influence of the various breast-specific factors. At 3 years, symmetry factors such as size, shape, and nipple position largely determined a patient's opinion on the final cosmesis, followed by firmness. The risk of an unacceptable outcome was associated with young age and large excision volumes. CONCLUSION: A questionnaire including breast-specific questions provides important information on final cosmetic results and satisfaction after BCT. These outcomes can also be of great value as quality indicators and pre-operative counseling. The major influence of breast-specific factors on asymmetry underlines the importance of achieving an optimal excision volume at the initial procedure.

Intraoperative evaluation of perfusion in free flap surgery: A systematic review and meta-analysis.

BACKGROUND: Free flap survival relies on adequate tissue perfusion. We aim to give an overview of the available literature of all objective methods to intraoperatively assess free flap tissue perfusion, and the effects on (partial) flap loss. METHODS: A systematic review and meta-analysis according to the PRISMA guidelines was performed (PubMed, Cochrane Library, Embase) regarding English language articles. Meta-analyses were performed by pooling means and slopes using random-effect models. RESULTS: Sixty-four articles were included reporting on 2369 procedures in 2009 patients with various indications. Reported methods were fluorescence imaging (FI), laser Doppler, oxygen saturation, ultrasound, (dynamic) infrared thermography, venous pressure, and microdialysis. Intraoperative tissue perfusion was adequately measured by the use of FI and laser Doppler, leading to surgical intervention or altered flap design, and increased flap survival. Meta-analysis showed a mean time until onset of the dye to become visible of 18.4 (7.27; 29.46, Q P < 0.001) sec. The relative intensity of the flap compared to the intensity curve of normal tissue was 75.92% (65.85; 85.98, Q P = 0.719). The mean difference in the slope value of the oxygen tensions before and after the anastomosis was -0.09 (-0.12; -0;06 Q P = 0.982). No convincing evidence was found for the use of other methods. CONCLUSIONS: Based on the current literature, FI and laser Doppler are most suitable to intraoperatively measure free flap tissue perfusion, resulting in improved flap survival. However, this review was limited by the available literature. Additional studies are necessary to investigate the predictive value of intraoperative perfusion measurement.

Cosmetic outcome and quality of life are inextricably linked in breast-conserving therapy.

INTRODUCTION: Cosmetic results and quality of life (QoL) are increasingly important in the treatment of breast cancer. This study was designed to determine the relationship between QoL and both subjectively and objectively measured cosmetic outcomes of breast-conserving therapy (BCT), and its course over time. METHODS: A total of 128 breast cancer patients who underwent BCT as part of a prospective randomized controlled trial were included. QoL was measured using the EORTC QLQ-C30 and QLQ-BR23 at baseline, 3, 6, 12, and 36 months. Cosmetic outcome was determined by patient self-evaluation, panel evaluation, and BCCT.core software. RESULTS: By 36 months, all QoL factors except arm symptoms had returned to baseline or improved. After adjustment for patient and tumor characteristics, a significantly better QoL in terms of body image, pain, and arm and breast symptoms was found for good/excellent cosmetic outcomes compared to fair/poor outcomes, as measured by both patient self-evaluation and panel evaluation. The BCCT.core showed no correlation with any QoL factors. CONCLUSION: There is a high correlation between poor cosmetic outcome and low scores on quality of life indicators, underlining the importance of achieving a good cosmetic outcome after BCT.

Intraoperative Ultrasound Guidance in Breast-Conserving Surgery Improves Cosmetic Outcomes and Patient Satisfaction: Results of a Multicenter Randomized Controlled Trial (COBALT).

BACKGROUND: Ultrasound-guided breast-conserving surgery (USS) results in a significant reduction in both margin involvement and excision volumes (COBALT trial). Objective. The aim of the present study was to determine whether USS also leads to improvements in cosmetic outcome and patient satisfaction when compared with standard palpation-guided surgery (PGS). METHODS: A total of 134 patients with T1­T2 invasive breast cancer were included in the COBALT trial (NTR2579) and randomized to either USS (65 patients) or PGS (69 patients). Cosmetic outcomes were assessed by a three-member panel using computerized software Breast Cancer Conservative Treatment cosmetic results (BCCT.- core) and by patient self-evaluation, including patient satisfaction. Time points for follow-up were 3, 6, and 12 months after surgery. Overall cosmetic outcome and patient satisfaction were scored on a 4-point Likert scale (excellent, good, fair, or poor), and outcomes were analyzed using a multilevel, mixed effect, proportional odds model for ordinal responses. RESULTS: Ultrasound-guided breast-conserving surgery achieved better cosmetic outcomes, with 20 % excellence overall and only 6 % rated as poor, whereas 14 % of PGS outcomes were rated excellent and 13 % as poor. USS also had consistently lower odds for worse cosmetic outcomes (odds ratio 0.55, p = 0.067) than PGS. The chance of having a worse outcome was significantly increased by a larger lumpectomy volume (ptrend = 0.002); a volume [40 cc showed odds 2.78-fold higher for a worse outcome than a volume B40 cc. USS resulted in higher patient satisfaction compared with PGS. CONCLUSION: Ultrasound-guided breast-conserving surgery achieved better overall cosmetic outcomes and patient satisfaction than PGS. Lumpectomy volumes[40 cc resulted in significantly worse cosmetic outcomes.

Intraoperative ultrasound guidance for palpable breast cancer excision (COBALT trial): a multicentre, randomised controlled trial.

BACKGROUND: Breast-conserving surgery for palpable breast cancer is associated with tumour-involved margins in up to 41% of cases and excessively large excision volumes. Ultrasound-guided surgery has the potential to resolve both of these problems, thereby improving surgical accuracy for palpable breast cancer. We aimed to compare ultrasound-guided surgery with the standard for palpable breast cancer-palpation-guided surgery-with respect to margin status and extent of healthy breast tissue resection. METHODS: In this randomised controlled trial, patients with palpable T1-T2 invasive breast cancer were recruited from six medical centres in the Netherlands between October, 2010, and March, 2012. Eligible participants were randomly assigned to either ultrasound-guided surgery or palpation-guided surgery in a 1:1 ratio via a computer-generated random sequence and were stratified by study centre. Patients and investigators were aware of treatment assignments. Primary outcomes were surgical margin involvement, need for additional treatment, and excess healthy tissue resection (defined with a calculated resection ratio derived from excision volume and tumour diameter). Data were analysed by intention to treat. This trial is registered at http://www.TrialRegister.nl, number NTR2579. FINDINGS: 134 patients were eligible for random allocation. Two (3%) of 65 patients allocated ultrasound-guided surgery had tumour-involved margins compared with 12 (17%) of 69 who were assigned palpation-guided surgery (difference 14%, 95% CI 4-25; p=0·0093). Seven (11%) patients who received ultrasound-guided surgery and 19 (28%) of those who received palpation-guided surgery required additional treatment (17%, 3-30; p=0·015). Ultrasound-guided surgery also resulted in smaller excision volumes (38 [SD 26] vs 57 [41] cm(3); difference 19 cm(3), 95% CI 7-31; p=0·002) and a reduced calculated resection ratio (1·0 [SD 0·5] vs 1·7 [1·2]; difference 0·7, 95% CI 0·4-1·0; p=0·0001) compared with palpation-guided surgery. INTERPRETATION: Compared with palpation-guided surgery, ultrasound-guided surgery can significantly lower the proportion of tumour-involved resection margins, thus reducing the need for re-excision, mastectomy, and radiotherapy boost. By achieving optimum resection volumes, ultrasound-guided surgery reduces unnecessary resection of healthy breast tissue and could contribute to improved cosmetic results and quality of life. FUNDING: Dutch Pink Ribbon Foundation, Osinga-Kluis Foundation, Toshiba Medical Systems.

A systematic review of oncoplastic breast-conserving surgery: current weaknesses and future prospects.

OBJECTIVE: The primary objectives of this systematic review on oncoplastic breast surgery (OPBS) were to evaluate the oncological and cosmetic outcomes of OPBS. The secondary objectives were to assess morbidity, quality of life, and applied algorithms. BACKGROUND: Breast-conserving therapy (BCT) has become the standard of care, and survival is now excellent. Consequently, the focus of BCT has increasingly shifted to cosmetic outcome, quality of life, and patient satisfaction. Nonetheless, excision of certain tumors still presents a considerable challenge. Specialized approaches combining oncological surgery and plastic surgery techniques are collectively referred to as OPBS. A summary of OPBS outcomes would facilitate decision-making and best treatment selection by both clinicians and patients. METHODS: Using specific inclusion and exclusion criteria to analyze 2090 abstracts on the topic of OPBS published between 2000 and 2011, the authors evaluated each study with respect to design and outcomes. RESULTS: A total of 88 articles were identified for potential inclusion and reviewed in detail by the lead authors. No randomized controlled trials were identified. Eleven prospective observational or comparative studies fulfilled inclusion criteria and were selected. In these studies, 80% to 93% of the tumors were invasive. Tumor-free resection margins were observed in 78% to 93%, resulting in a 3% to 16% mastectomy rate. Local recurrence was observed in 0% to 7% of the patients. Good cosmetic outcome was obtained in 84% to 89% of patients. However, most studies showed significant weaknesses including lack of robust design and important methodological shortcomings, negatively influencing generalizability. CONCLUSIONS: This systematic review reveals that current evidence supporting the efficacy of OPBS is based on poorly designed and underpowered studies. Given the increasing importance and application of OPBS, there is a pressing need for robust comparative studies, including both randomized controlled trials and well-designed, multicenter prospective longitudinal studies.

Ultrasound-guided breast-sparing surgery to improve cosmetic outcomes and quality of life. A prospective multicentre randomised controlled clinical trial comparing ultrasound-guided surgery to traditional palpation-guided surgery (COBALT trial).

BACKGROUND: Breast-conserving surgery for breast cancer was developed as a method to preserve healthy breast tissue, thereby improving cosmetic outcomes. Thus far, the primary aim of breast-conserving surgery has been the achievement of tumour-free resection margins and prevention of local recurrence, whereas the cosmetic outcome has been considered less important. Large studies have reported poor cosmetic outcomes in 20-40% of patients after breast-conserving surgery, with the volume of the resected breast tissue being the major determinant. There is clear evidence for the efficacy of ultrasonography in the resection of nonpalpable tumours. Surgical resection of palpable breast cancer is performed with guidance by intra-operative palpation. These palpation-guided excisions often result in an unnecessarily wide resection of adjacent healthy breast tissue, while the rate of tumour-involved resection margins is still high. It is hypothesised that the use of intra-operative ultrasonography in the excision of palpable breast cancer will improve the ability to spare healthy breast tissue while maintaining or even improving the oncological margin status. The aim of this study is to compare ultrasound-guided surgery for palpable tumours with the standard palpation-guided surgery in terms of the extent of healthy breast tissue resection, the percentage of tumour-free margins, cosmetic outcomes and quality of life. METHODS/DESIGN: In this prospective multicentre randomised controlled clinical trial, 120 women who have been diagnosed with palpable early-stage (T1-2N0-1) primary invasive breast cancer and deemed suitable for breast-conserving surgery will be randomised between ultrasound-guided surgery and palpation-guided surgery. With this sample size, an expected 20% reduction of resected breast tissue and an 18% difference in tumour-free margins can be detected with a power of 80%. Secondary endpoints include cosmetic outcomes and quality of life. The rationale, study design and planned analyses are described. CONCLUSION: The COBALT trial is a prospective, multicentre, randomised controlled study to assess the efficacy of ultrasound-guided breast-conserving surgery in patients with palpable early-stage primary invasive breast cancer in terms of the sparing of breast tissue, oncological margin status, cosmetic outcomes and quality of life. TRIAL REGISTRATION NUMBER: Netherlands Trial Register (NTR): NTR2579.

Implant Loss and Associated Risk Factors following Implant-based Breast Reconstructions.

Implant loss is the most severe complication of implant-based breast reconstructions. This study aimed to evaluate the incidence of implant loss and other complications, identify associated risk factors, and create a risk model for implant loss. METHODS: This was a retrospective cohort study of all patients who underwent a mastectomy, followed by either a two-stage or a direct-to-implant breast reconstruction. Patient variables, operative characteristics, and postoperative complications were obtained from the patient records. A multivariate mixed-effects logistic regression model was used to create a risk model for implant loss. RESULTS: A total of 297 implant-based breast reconstructions were evaluated. Overall, the incidence of implant loss was 11.8%. Six risk factors were significantly associated with implant loss: obesity, a bra cup size larger than C, active smoking status, a nipple-preserving procedure, a direct-to-implant reconstruction, and a lower surgeon's volume. A risk model for implant loss was created, showing a predicted risk of 8.4%-13% in the presence of one risk factor, 21.9%-32.5% in the presence of two, 47.5%-59.3% in the presence of three, and over 78.2% in the presence of four risk factors. CONCLUSIONS: The incidence of implant loss in this study was 11.8%. Six associated significant risk factors were identified. Our risk model for implant loss revealed that the predicted risk increased over 78.2% when four risk factors were present. This risk model can be used to better inform patients and decrease the risk of implant loss by optimizing surgery using personalized therapy.

Pectoral Fascia Preservation in Oncological Mastectomy to Reduce Complications and Improve Reconstructions: A Systematic Review.

Excision of the pectoral fascia (PF) is routinely performed in oncological mastectomies. Preservation of the PF may, however, decrease postoperative complication rates for bleeding, infections, and seroma. It may also improve reconstructive outcomes by better prosthesis coverage, thereby reducing implant extrusion rates and improving cosmetic outcomes. METHODS: A systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis principles was performed. Studies describing PF preservation were searched in 3 databases. All studies including more than 10 patients were included. The main outcomes were oncological safety (local recurrence, regional and distant metastases, and mortality rates), complication rates (bleeding, infections, seroma), loss of the prosthesis after reconstructive surgery, and cosmetic outcomes following reconstruction. RESULTS: Five studies were included. Three reported on 2 different randomized controlled trials (n = 73, and n = 244), and 2 studies were retrospective case series (n = 203 and n = 256). PF preservation did not affect oncological outcomes in terms of local recurrences, regional and distant metastases, or mortality rates. One study described a significantly lower incidence of seroma in the PF preservation group. No differences were found for bleeding complications and infections. No objective data were provided for reconstructive complications or cosmetic outcomes. CONCLUSIONS: The literature on PF preservation is scarce. Based on the current evidence, PF preservation seems oncologically safe while potentially reducing postoperative complication rates. It is expected that reconstructive outcomes will benefit from PF preservation, but these studies lack evidence on this topic. Future studies should provide insight into all aspects of PF preservation.

Breast-conserving therapy for breast cancer: Cosmetic results and options for delayed reconstruction.

OBJECTIVES: Optimisation of the cosmetic outcome after breast-conserving therapy (BCT) is important. We aimed to determine the cosmetic outcome following BCT and factors influencing this cosmesis and identify the most favourable options for delayed breast reconstruction. MATERIALS AND METHODS: Four reconstructive surgeons evaluated the cosmetic outcome of 109 patients after BCT. Additionally, the surgeons indicated which patients were amenable for delayed reconstruction and the preferred type of reconstruction. The inter- and intra-observer agreement of the surgeons was rated. RESULTS: The mean overall cosmetic outcome was rated as fair (2.7/4.0, SD 0.9, 1.0-4.0). Risk factors for a poor cosmesis were larger breast size (OR 3.81, p = 0.040), larger tumour (OR 1.63, p = 0.028) and axillary lymph node dissection (ALND) (OR 3.09, p = 0.013). Reconstruction of the ipsilateral side was recommended in 55.6% and 94.5% and contralateral reconstruction in 16.7% and 73.3% of patients with good and poor cosmesis, respectively. Flap reconstruction and lipofilling were most commonly reported for the ipsilateral, and breast reduction for the contralateral breast, with reasonable improvement expected (2.2/4.0, SD 0.5, 1.08-3.3). The inter- (0.5-0.7) and intra-observer (0.63-0.79) agreement of the cosmesis was moderate to good, however, poor regarding the recommended reconstruction techniques (mainly < 0.50). CONCLUSION: Cosmetic outcome after BCT is influenced by breast and tumour size and ALND. Although several reconstructive options are available, the optimal method for revision surgery has not yet been determined. Future studies are necessary to obtain evidence-based guidelines for reconstructive surgery after BCT.

[Ultrasonically guided breast-conserving surgery for palpable mammary tumours]. / Echogeleide borstsparende chirurgie voor palpabel mammacarcinoom.

Breast-conserving surgery for palpable mammary tumours is usually guided by palpation. It appears, however, that identifying tumour margins only by palpation can be problematic, resulting in less than optimal effectiveness of this type of operation. The use of ultrasonography is a simple and non-invasive way of facilitating real-time localisation of breast carcinoma during surgery so that a tumour can be excised with controlled precision. Ultrasound is used to localise the tumour prior to surgery; its location is subsequently marked on the skin. During tissue dissection, ultrasound can be used to inspect the location and depth of the tumour as well as determining whether the tumour's surrounding margins are sufficient, thereby preventing the unnecessary removal of healthy tissue. Ultrasound can be used again after the excision to verify that the tumour was indeed radically removed. The efficacy of ultrasonically guided surgery for palpable mammary tumours is currently being studied in a prospective, randomised, multicentre trial.

[Breast-conserving surgery for breast cancer: still much to be gained]. / Mammasparende chirurgie voor borstkanker: er is nog winst te behalen.

OBJECTIVE: To conduct qualitative research into breast-conserving surgery for palpable and non-palpable breast tumours and the various methods of excising these, measured by the volume exised and surgical radicality. DESIGN: Retrospective, multicentre study. METHOD: The pathology reports from 726 patients who had undergone breast-conserving surgery for invasive breast cancer were reviewed for excision volume and radicality. Any excess resected breast tissue was expressed by a Calculated Resection Ratio (CRR) and calculated by dividing the volume of the surgical specimen by the tumour volume plus an ideal 1-cm-margin of tumour-free breast tissue. A CRR of 1.0 meant that the volume excised was ideal; a CRR of 2.0 meant that twice the necessary amount of tissue had been removed. RESULTS: Of all the 726 tumours, 72% appeared to be palpable. The median CRR in this group was 2.2 (range: 0.1 - 43.0) and the percentage of tumour-involved margins (irradicality) was 22.5%. Of all the non-palpable tumour (n = 201) excisions, 58% had been guided by wire-localisation, 26% by ultrasonography, and 16% by ROLL (Radio-guided Occult Lesion Localization). The CRRs were 2.8, 3.2 and 3.8, respectively (p < 0.05). Ultrasound-guided surgery resulted in the lowest rate of tumour-involved margins (ultrasound-guided: 3.8%, wire-guided localisation: 21.4%, ROLL: 25.0% (p = 0.05)). CONCLUSION: Breast-conserving surgery is associated with an average of a 2 to 4-fold removal of excessive tissue. Nevertheless, 1 out of 5 excisions are not radical. Ultrasound-guided surgery for non-palpable breast cancer is the most effective method for achieving radical excision. A multicentre, prospective, randomised trial has been started to assess whether ultrasound-guided lumpectomy for palpable breast cancer can lead to optimisation of the excision volume and radicality.

Is breast specimen shrinkage really a problem in breast-conserving surgery?

BACKGROUND: Breast-conserving surgery currently focuses on improving margin clearance and excision volume, the main pathology report parameters for oncological and cosmetic outcomes. AIM: To quantitatively evaluate discrepancies in surgical and pathological estimates of breast specimen sizes, including the influence of formalin fixation. METHODS: This prospective multicentre study included 68 breast specimens of consecutive patients undergoing breast-conserving surgery for breast cancer in three affiliated hospitals between November 2010 to May 2011. Specimens were weighed immediately after excision. Specimen volumes were calculated from the length, width and height. Actual specimen volumes were measured using volume displacement. Specimens were weighed once again after arrival at the pathology department, and volumes recalculated. The smallest pre- and post-fixation distances to the tumour-free margin were compared. RESULTS: The mean surgical specimen weight was 47.7 g and was approximately similar to the actual specimen volume of 49.8 cm(3). The weights of specimens immediately following surgery and on pathological appraisal were equal (p=0.94). The calculated volumes differed significantly from the actual specimen volumes (p>0.05). The mean distance to the closest tumour-free margin, 0.35 cm, was not altered by formalin fixation (p=0.1). CONCLUSIONS: No evidence was found to suggest that surgical breast specimens shrink in the period between the surgical procedure and pathological examination, or following formalin fixation. The pathological appraisal of specimen margins and volumes is not affected by changes in specimen size. As calculations of specimen volumes are unreliable, the use of water displacement or the more readily available specimen weight is recommended for accurate volume measurement. Pathologists should be encouraged to always measure and record specimen weight.

[Effect of surgical treatment on patients with cerebral palsy: improvement of manual dexterity but not of perceived competence]. / Effect van chirurgische behandeling op patiënten met cerebrale parese: wel betere handvaardigheid, beleving competentie niet verbeterd.

OBJECTIVE: To examine the relationship between impaired manual dexterity and perceived competence in children with cerebral palsy and the effect of surgical intervention, with the question whether the perceived competence is applicable as an outcome measure for surgical reconstruction of hand function. METHOD: The Dutch version of the Michigan Hand Outcomes Questionnaire (MHQ-DLV) for perceived manual dexterity and the Dutch version of the Harter Scales for perceived competence were used in a sample of 25 children and adolescents with hemiplegic cerebral palsy of the spastic type. 10 patients underwent surgical treatment to improve hand function. In this 'surgical group' both questionnaires were repeated at least one year postoperatively. RESULTS: Perceived manual dexterity was low (mean MHQ-DLV-score: 63.2; SD: 18.9), as were the scores of perceived overall competence (2.92; SD: 0.84), social competences (2.66; SD: 0.92) and athletic competences (2.29; SD: 0.79). There was no correlation between the degree of perceived impairment in manual dexterity and the perceived competence (r = -0.16; p = 0.43). After surgical reconstruction manual dexterity improved (mean increase in score: 24; SD: 10.4; p < 0.01), but perceived competence did not improve (p = 0.39). CONCLUSION: Children with cerebral palsy and impaired manual dexterity did have a lower perceived competence than children without this disorder. The extent to which manual dexterity was impaired did not correlate with the extent to which perceived competence was lowered. Surgical intervention substantially improved perceived manual dexterity, but perceived competence did not improve. Perceived competence does not seem to be applicable as an outcome measure for surgical reconstruction of manual dexterity.