Analysis of patient satisfaction and donor-site morbidity after different types of breast reconstruction.

BACKGROUND AND AIMS: Breast reconstruction has been shown to improve quality of life. However, factors involved in long-term patient satisfaction are largely unknown. Our aim was to evaluate patient satisfaction and donor-site morbidity in five types of breast reconstruction. MATERIAL AND METHODS: A prospectively collected database of all breast surgery patients at Hospital Rudolfstiftung, Vienna, Austria, was searched for five types of breast reconstruction (2000-2006): implant, latissimus dorsi-flap, latissimus dorsi-flap with implant, free transverse rectus abdominis musculocutaneous-flap, and deep inferior epigastric perforator-flap. Patients were sent a study-specific questionnaire to assess satisfaction. Short-form 36-item health survey was used to analyze (quality of life), and complication data were retrieved from the database and assessed during a follow-up visit. RESULTS: There were 257 patients identified, of whom, 126 responded to the survey (17 implant, 5 latissimus dorsi + implant, 64 latissimus dorsi, 22 transverse rectus abdominis musculocutaneous, and 18 deep inferior epigastric perforator reconstructions). No statistical differences were found in complication or reoperation rates. Deep inferior epigastric perforator-flap patients were significantly more satisfied compared to patients from the implant group (p = 0.007). However, there was no significant difference regarding quality of life scores among the groups. After logistic regression analysis, only "impairment on daily life" showed to be independently correlated with patient satisfaction. This contrary to both operation type and complication rate which did not correlate with patient satisfaction. CONCLUSIONS: Our results indicate that operation type, complication rate, and revision rate did not independently correlate with patient satisfaction. Therefore, to further improve patient satisfaction, future research should be focused on other pro-operative factors, for example, patient education, expectations, and personality characteristics.

An oncoplastic procedure for central and medio-cranial breast cancer.

Breast conserving therapy shows remarkable oncologic results and is eligible for up to 73% of patients with breast cancer. Cosmetic results are good, however, in patients with central or medio-cranial ("no-man's land") located breast cancer, the cosmetic result may be unsatisfying. The use of different breast reduction techniques have been shown to increase resection free margins and improve cosmetic results. We report here about the use of the Hall Findlay breast reduction technique for oncoplastic surgery to improve the cosmetic result in 11 patients. The Hall Findlay technique shows good postoperative breast symmetry, all patients had resection free margins above 5mm and are free of disease at a mean follow-up of 12 months. The technique may be used for breast cancer at various locations and reduces scar visibility and morbidity.

Clinical and ultrasound evaluation of donor site morbidity after tram-flap for breast reconstruction.

The TRAM-flap has become a well-established method for breast reconstruction. Even though the aesthetic result is superior to implant reconstruction, a main disadvantage is the potential risk to create weakness of the abdominal wall. For evaluation of abdominal wall function, an imaging method has to be used which is able to prove functional properties of the remaining muscle. This study was undertaken in order to verify if ultrasound imaging is a reasonable method to examine muscle movements after TRAM-flap procedures in addition to clinical examination. In 8 patients, a DIEP-flap, in 11 patients, a free TRAM-flap, and in 3 patients, a pedicled TRAM-flap were used for breast reconstruction. Patients were examined 10-72 months (mean, 32 months) after surgery. Ultrasound imaging of the abdominal wall was performed in longitudinal as well as cross sections (multifrequent, 13 Mhz; Siemens Elegra, Erlangen, Germany). The diameter of the remaining muscle was measured 2 cm below the rib bow, at the level of the umbilicus, and at the level of the skin scar. The operated side was compared to the nonoperated contralateral side. In order to evaluate the contractility of the remaining rectus muscle, patients were invited to perform sit-ups during ultrasound monitoring of muscle movement. Clinically the functional testing was performed by the method of Janda (Muskelfunktionsdiagnostik, 2nd ed. Berlin: Volk- und Gesundheit; 1986). The abdominal wall was inspected for bulging or hernia formation. Additionally, patients answered a six-scale self-designed questionnaire concerning the impairment of daily living and pain. Muscle contractility as well as muscle diameter were graded into four degrees from 0-3. The highest degree of 3 with normal muscle contractility and muscle diameter was found in 1 of 5 patients after DIEP-flap. Degree 2, with reduced muscle contractility and reduced muscle diameter, was found in 10 of 22 patients, especially after unilateral TRAM-flap. Degree 1, with no muscle contractility and remaining muscle, and degree 0, with scar tissue, were found in 11 patients. Impairment in daily-life activity was found in 10 patients, while 8 patients complained of pain. Muscle strength scored by the method of Janda (Muskelfunktionsdiagnostik, 2nd ed. Berlin: Volk- und Gesundheit; 1986) reached 4 and 5 in 19 patients after all kinds of flap harvesting; 3 patients reached Janda 2 and 3 after unilateral free TRAM or unilateral DIEP-flap. In one patient, a hernia was detected after unilateral DIEP-flap; 10 patients showed bulging of the abdominal wall. Functional testing of the abdominal wall by the method of Janda as well as CT-scans or MRI for evaluation of the remaining muscle is reported in the literature. As there is a need for cost reduction in medical treatment, we were looking for a more cost-effective evaluation method compared to CT-scan or MRI. Ultrasound imaging of the donor site after TRAM-flap harvesting in order to evaluate the remaining function of the rectus muscle is not yet reported in the literature. We consider ultrasound imaging to be superior to CT-scan or MRI in terms of functional evaluation and cost effectiveness.

[Reconstruction of the breast areola complex. Comparison of different techniques]. / Die Rekonstruktion des Mamillen-Areola-Komplexes. Ergebnisse unterschiedlicher Techniken im Vergleich.

Different methods have been used in our department for nipple-areola reconstruction. This study was undertaken in order to find out which method of reconstruction shows optimal long-term results. Between 1983 and 1999, breast reconstruction was performed in 204 patients and different methods were used for nipple-areola reconstruction. 91 patients could be examined. For areola reconstruction full-thickness skin grafts from the groin were used as well as skin grafts from the contralateral areola, vaginal mucosal grafts, and tattoos. For nipple reconstruction we used nipple sharing, labium grafts, local flaps, and a tattoo. Areola reconstruction with full-thickness skin grafts from the groin was performed in 45 patients, in 16 patients a graft from the contralateral areola was used and in 19 patients the technique of intradermal tattoo was applied. One patient had a vaginal mucosal graft, in another patient the nipple areola complex was transplanted to the groin after mastectomy for later reconstruction. Nipple projection was measured and the colour of the reconstructed areola was compared to the other side. Concerning the match of colour, best results were achieved with grafting from the contralateral areola, followed by areola tattoo and skin grafts from the groin. The vaginal mucosal graft was too dark. The transplanted original nipple-areola complex maintained its colour. Nipple projection between 3 and 4 mm was achieved by nipple sharing and local flaps. With grafts from the labium, a projection from 1 to 2 mm was achieved. Thus, best results were achieved by nipple sharing, local flaps for nipple reconstruction and areola skin grafts from the contralateral side. Vaginal mucosal grafts and grafts from the labium are not recommended.

The influence of the donor nerve on the function and morphology of a mimic muscle after cross innervation: an experimental study in rabbits.

In the present study we used the scutuloauricularis muscle in the rabbit to investigate the functional and morphometric alterations in the mimic-muscle system after cross-reinnervation. The scutuloauricularis muscle is the first experimental model that allows functional assessment of a mimic muscle by force measurements. A total of 36 rabbits were separated into three groups. In group 1 the scutuloauricularis nerve was cut and re-sutured to itself to achieve self-reinnervation; in group 2 the buccal nerve was used to cross-reinnervate the fast scutuloauricularis muscle and in group 3 the slow buccinator muscle was cross-reinnervated by the scutuloauricularis nerve. After a period of 6 months the maximal tetanic tensions of the reinnervated scutuloauricularis muscles were determined and histomorphometric examinations of muscle and nerve biopsies were carried out. Force measurements showed no loss of muscle force after self- and cross-reinnervation. The normal scutuloauricularis muscle contained 33%, and the buccinator muscle 46%, slow type I fibres. After self-reinnervation of the scutuloauricularis muscle the fibre-type composition remained unchanged. After cross-reinnervation we saw a significant fast-to-slow transformation of the scutuloauricularis muscle and a significant slow-to-fast transformation of the buccinator muscle. The number of myelinated nerve fibres in the scutuloauricularis nerve increased after cross-reinnervation from 1531 to 4077 (group 2) and to 3813 (group 3). The number of nerve fibres in the buccal nerve (3209) was unchanged after cross-reinnervation. The results of the present study might be relevant in the treatment of irreversible facial palsy by functional muscle transplantation and cross-face nerve grafting. The facial nerve branch used for cross-reinnervation seems to determine the functional outcome.

[A comparison of long-term outcome of 6 techniques of breast reduction]. / Ein Vergleich der Langzeitergebnisse von sechs Techniken der Mammareduktionsplastik.

In a retrospective study we examined 192 patients who underwent breast reduction between 1973 and 1993 to compare the long-term results of six various reduction mammaplasty techniques. We investigated patient's satisfaction, the relief of preoperative symptoms as well as the possibility of lactation. The sensitivity of the areola was measured with Semmes-Weinstein monofilaments and the breast contour, the scar formation, and the complication rate were evaluated. 89% of our patients were very satisfied with the cosmetic result. Breast-feeding was possible after all techniques except for free-nipple grafting. The sensitivity of the areola was found to be more decreased after using a superior pedicle technique. Breast ptosis was obtained in 30% of our patients and correlated significantly with postoperative weight loss. Breast ptosis was less frequent after using an inferior pedicle technique. Length and width of the scar, as well as the complication rate correlated with the resection weight.

[Contour defects after breast preserving therapy of breast carcinoma. Primary and secondary possibilities of correction]. / Konturdefekte bei brusterhaltender Therapie des Mammakarzinoms. Primäre und sekundäre Möglichkeiten der Korrektur.

BACKGROUND: Breast conserving treatment is increasing for primary treatment of breast carcinoma because of the importance of the cosmetic outcome. PATIENTS AND METHOD: We examined 195 patients after breast conserving therapy which was performed between 1983 and 1992. For evaluation of the cosmetic result symmetry, contour of the breast and location of the areola were examined. Radiation effect on breast tissue was evaluated by the Lent score. 72% of the patients had been treated with quadrantectomy and 28% with lumpectomy. RESULTS: Deformities of the contour were visible in 59% of the patients depending on the primary location of the tumor. Lumpectomy from medial quadrants caused poor results. Dislocation of the areola of more than 2 cm was detected in 32% of the patients. The dislocation depended on the primary kind of incision and resulted in 89% of the patients after a radial incision and only in 11% after curvilinear incisions. Telangiectasias were absent in 84% of the patients, the others showed telangiectasias Grade 1 to 3. In 48% of the patients no signs of fibrosis could be detected, in 49% fibrosis Grade 1 to 2 was found. 68% of the patients estimated the cosmetic result as very good or good. Only 10% of the patients estimated the result as fair or bad. The examiner estimated the results as good or very good in 28%. Examples of operative procedures for primary and secondary correction are demonstrated. CONCLUSIONS: Our results showed an adverse effect of long radial incisions. For lumpectomy and axillary node dissection separate incisions should be used. Correction of contour deformities should be done primarily in breast conserving procedures. This is possible by using modified reduction mammaplasties, local flaps of the breast tissue or switching a latissimus dorsi muscle flap. For secondary correction of defects after breast conserving treatment a latissimus dorsi muscle can be used as well as z-plasty for scar contracture.

[Analysis of hand function with the Millesi examination scale in patients with pollicisation after aplasia or hypoplasia of the thumb]. / Handfunktionsanalyse mit dem Untersuchungsschema nach Millesi bei Patienten mit Pollizisation nach Aplasie oder Hypoplasie des Daumens.

Pollicisation of a single long finger is the method of choice to treat congenital thumb aplasia or thumb hypoplasia. Using Millesi's scale for the functional analysis of the hand, we examined six patients treated in the years 1983 to 1994 in our service. Average age at the time of surgery was 2.4 years and the follow-up time was seven years on average. Of the six patients, four suffered from additional malformations of the ipsilateral arm. These anomalies required early surgical treatment and therefore delayed the pollicisation procedure. The results of the anatomical part of the examination ranged between 39 and 94% of the achievable value. The final results including sensibility, strength, and skills reached 11 to 50%. Development of skills and muscle strength in the operated hand was dependent on the follow-up time. Millesi's scale could be applied successfully in this special group of children with congenital malformation of hands.

[Actinic brachial plexus lesion]. / Aktinische Plexus brachialis-Läsion.

Radiation-induced brachial plexus lesions are progressive and irreversible complications. Until now, there is no way to successful prevention and treatment of this problem. In our series, relief of pain could be achieved by neurolysis in some cases, but there was no recovery of sensory and motor function. In order to improve the vascularity and nerve tissue regeneration, we performed muscle or gliding tissue flaps after neurolysis in our department. Since 1975, 25 patients who developed radiation-induced plexopathy were treated in our department. We followed 18 patients to evaluate the benefits of our surgical intervention. None of the patients had improvement of their sensory or motor impairment. Relief of severe pain was achieved in 83% either by neurolysis only with or without muscle or gliding tissue flap. In some cases, paresis worsened postoperatively. We also observed a return of severe pain after the operation.

Normal cutaneous sensibility of the breast.

A total of 150 healthy women were studied to determine normal values for breast sensibility and to investigate the influence of breast size and ptosis on breast sensation. Cutaneous pressure thresholds were evaluated bilaterally in six areas including the nipple, the areola, and the skin of the breast using the Semmes-Weinstein monofilaments. We found that the skin of the superior quadrant was the most sensitive part of the breast, the areola was less sensitive, and the nipple was the least sensitive part. The cutaneous sensibility of all tested areas decreased significantly with increasing breast size and increasing breast ptosis. The nipple was less sensitive in women who had a previous pregnancy. Age, smoking history, or hormonal contraception had no significant influence on breast sensation. The study shows that the Semmes-Weinstein test is an adequate method for assessing sensation in the breast.

[Interdisciplinary status of plastic, esthetic and reconstructive surgery in Austria]. / Interdisziplinäre Stellung der Plastischen, Asthetischen und Wiederherstellungschirurgie in Osterreich.

To evaluate the actual status of interdisciplinary treatment involving plastic surgery in Austria in 1993 and 1994, standardised questionnaires were sent to all Departments of Plastic Surgery and to 129--mainly surgically orientated--medical departments in Vienna. The survey revealed that more than 50 percent of interdisciplinary co-operation took place with the departments of traumatology, general surgery and dermatology. The demand for co-operation with plastic surgeons was especially felt in tumor surgery, peripheral nerve surgery and hand surgery. An additional demand for co-operation represented larger soft tissue defects and congenital anomalies.

Sliding door technique for the repair of midline incisional hernias.

We describe a technique that enables the autologous repair of large midline incisional hernias by restoring the functional musculoaponeurotic support of the abdominal wall. Unlike other methods of hernia repair, the essential step of the sliding door technique is the complete release of the rectus abdominis muscles from the anterior and posterior layers of their sheaths. The released muscles are thus overlapped and sutured together without tension. Another step of the technique is the release of both rectus sheaths by incising the aponeuroses of the external oblique muscles. We report on the use of this technique in 10 patients with midline incisional hernias (mean size of the abdominal musculofascial defect 14 x 11 cm). The patients were examined 14 months to 5.5 years after hernia repair. Two postoperative complications occurred: one marginal skin necrosis and one subcutaneous seroma. Recurrences were not observed. Ultrasound examination showed that the rectus muscles maintained their overlapped position postoperatively. Clinical muscle testing indicated that the strength of the released rectus muscles provides functional support to the reconstructed anterior abdominal wall.

The value of MRI in silicone granuloma of the breast.

MRI can be a valuable technique in patients with silicone-granulomas to screen for cancers which are not visible on mammography and/or sonography.

[sensorimotor differentiated reconstruction of peripheral nerves--a methods of intraoperative identification of motor fascicles]. / Sensomotorisch differenzierte Rekonstruktion peripherer Nerven--Eine Methode zur intraoperativen Identifikation motorischer Faszikel.

In 1975, Freilinger et al. identified motor fibres by acetylcholinesterase (AChE) histochemistry. Precise identification of motor fascicles in cases of mixed peripheral nerve dissection became possible, and selective fascicular nerve repair could be performed. Using this technique, two separate operations were necessary for definitive nerve repair, since histochemical analysis took 28 hours. A modified AChE staining technique now offers results within one hour. In seven cases of human median and three cases of human ulnar nerve lesions, nerve biopsies were obtained and underwent both modified and standard histochemical staining. The standard procedure did not render any further information about the AChE activity indicating that both methods are equally reliable. Photomicrographs of the nerve specimen with motor fascicles marked on them were completed in all cases of the modified AChE staining method one hour after obtaining the biopsies. Intraoperative identification of motor fascicles by rapid AChE staining technique was performed in two cases of acute injuries of the median nerve, radial artery and musculotendineous system of the forearm. Biopsies were obtained at the beginning of the operation. Histochemical analysis was done while tendons and arteries were reconstructed and selective fascicular nerve repair was possible at the end of the operation. The rapid AChE staining may be applied intraoperatively to acute nerve injury and late peripheral nerve reconstruction provided the nerve is expected to already contain segregated motor fascicles.

Scutuloauricularis muscle of the rabbit: a new model for free functional muscle transplantation in the mimic system.

There is little information on the specific process of free, functional muscle transplantation to the face trying to restore mimic function. Up to now one of the main reasons was the impossibility of functional assessment of mimic muscles as well as their transplanted substitutes. The scutuloauricularis muscle provides an ideal model for quantitative assessment of muscle function because of its circumscript tendinous insertion and is suitable for microsurgical transplantation. In a series of 26 adult, female New Zealand rabbits the anatomical and microsurgical details were studied. The scutuloauricularis muscle weighs 1.018 +/- 0.106 g, it is supplied by the auricularis rostralis artery (diameter 0.4 +/- 0.1 mm) and the auricularis rostralis vein (diameter 1.3 +/- 0.1 mm) and one oligofascicular (2-3 fascicles) branch of the facial nerve. During isometric contraction under supramaximal electrostimulation the maximal tetanic tension was 2.995 +/- 0.928 N. Histomorphometric studies in ATP-ase stained cross-sections showed 40.5 +/- 4.6% type I fibres, 32.3 +/- 5.2% type IIA fibres, and 27.2 +/- 7.1% type IIB fibres.

Donor-site morbidity of the gracilis flap.

To determine whether there is a specific donor-site morbidity inherent in the elevation of the gracilis flap, we retrospectively examined 42 patients who underwent elevation of their gracilis muscles. We found, on dynamometric measurement, that the adduction strength of the hip joint was decreased by 11 percent when the gracilis muscle was elevated. This decrease in strength was not noticed by the patients. We also found an area of hypesthesia corresponding to the cutaneous territory of the obturator nerve in 40.5 percent of the patients. In addition, many patients were dissatisfied with the aesthetic appearance of the donor site, and a contour deformity of the thigh was present when a myocutaneous flap was elevated. Therefore, we conclude that the gracilis flap has a low but definite rate of donor-site morbidity. The advantages of the flap outweigh by far, however, the sequelae at the donor site.

[Results of various reconstructive methods after subcutaneous mastectomy and objective evaluation of tissue fibrosis with a new measurement procedure]. / Ergebnisse verschiedener rekonstruktiver Verfahren nach subkutaner Mastektomie und Objektivierung der Gewebsfibrose mit einer neuen Messmethode.

Of 35 patients undergoing subcutaneous mastectomy performed within the last 15 years, 25 were evaluated for follow-up studies. Reconstruction had been achieved either using silicone implants or autologous tissue formed from the resulting dermal-fat pedicles. The patients were interviewed for subjective results. In addition, firmness of the breast according to the classification of Baker was investigated. The compressibility of the breast was electronically measured, employing a new compression device. In 13 patients, the breast was distorted after reconstruction with implants. The deformity did not correlate with submuscular or subcutaneous placement of the implants. The aesthetic results after dermal-fat pedicle techniques were superior to reconstruction with silicone implants. Compressibility to 32% of breast diameter was defined to be a border value between a soft and firmer breast, correlating with clinical conditions between Baker 2 and Baker 3.

[Functional and esthetic assessment of donor site defects following transfer of the gracilis muscle]. / Funktionelle und ästhetische Beurteilung der Hebedefekte nach Entnahme des Musculus gracilis.

In order to determine donor-site morbidity after elevation of the gracilis flap, 53 patients from four different departments were examined. The patients filled out a questionnaire about their complaints. 36 patients underwent dynamometric measurements. The adduction strength of the hip-joint was decreased by 11% after elevation of the gracilis muscle. This decrease in strength was not noticed by the patients. 53% of the patients complained about hypesthesia or dysesthesia corresponding to the cutaneous territory of the obturator nerve. The contour of the thigh was adversely affected after elevation of a musculocutaneous flap. The gracilis flap has a low but definite donor-site morbidity, especially concerning the esthetic aspect.

[Which changes occur in nerve grafts harvested with a nerve stripper? Morphological studies]. / Welche Veränderungen entstehen an einem mit dem Nervenstripper entnommenen Nerventransplantat? Morphologische Untersuchungen.

A histological and morphometric study was undertaken in order to evaluate the alterations in sural nerves harvested for nerve grafting using a nerve stripper. In 19 nerves biopsies were taken from the proximal and/or the distal end of the stripped nerve graft. Cross sections were examined for alterations of the perineurium and the myelin sheaths. In four nerves alterations within the perineurium were found, which affected 37% of the endoneural cross-sectional area on the average. In all specimens, the perineurial sheath was seen to be intact. The results of the present study suggest that harvesting of a nerve graft using a stripper does not cause major injuries to the graft and therefore successful neurotization of the graft should not be impaired.