Analysis of Utility Assessment Scores to Objectify the Health Burden Caused by Breast Conservation Therapy.

BACKGROUND: Lumpectomy followed by radiation, known as breast conservation therapy (BCT), is a viable surgical treatment option for early-stage breast cancer. However, the current literature suggests that patients prefer mastectomy over BCT, likely due to the wide variety of postmastectomy reconstructive options. Our aim is to investigate the objective health burden of living with BCT to help surgeons gain a better understanding of patient treatment preferences. METHODS: Three validated health state utility tools were used to objectify the burden of living with post-BCT results: visual analogue scale (VAS), time trade-off (TTO), and standard gamble (SG). A prospective sample of the general population and medical students were recruited, and their responses analyzed to attain these scores. RESULTS: Utility scores for living with BCT are VAS 0.81 ± 0.19, TTO 0.93 ± 0.10, and SG 0.92 ± 0.14. The TTO and SG suggest a willingness to trade 2.5 years of life years and an 8% chance of death undergoing reconstructive procedures to correct a BCT defect, respectively. Age, gender, race, education, and income were not statistically significant independent predictors for higher or lower utility scores. CONCLUSION: The impact of the health burden of BCT was ascertained using validated objective numeric utility scores. These indices demonstrate a willingness to trade less life years to undergo correction of a BCT defect than reconstruction following unilateral mastectomy. They can provide surgeons with the best objective understanding of patient preferences for shared decision-making in the management of breast cancer.

HISTORIQUE: La lumpectomie suivie d'une radiothérapie, ou conservation mammaire (CM), est un traitement chirurgical viable du cancer du sein précoce. Selon les publications, les patients préfèrent toutefois la mastectomie à la CM, probablement en raison du large éventail de possibilités de reconstructions après la mastectomie. Les chercheurs visent à explorer le fardeau objectif d'une vie avec une CM pour la santé, afin d'aider les chirurgiens à mieux comprendre les préférences des patientes en matière de traitement. MÉTHODOLOGIE: Les chercheurs ont utilisé trois outils utilitaires validés sur l'état de santé pour objectiver le fardeau de la vie après une CM : l'échelle visuelle analogique (ÉVA), l'arbitrage temporel (AT) et le pari standard (PS). Ils ont recruté un échantillon prospectif de la population générale et d'étudiants en médecine et ont analysé leurs réponses pour obtenir les scores. RÉSULTATS: Les scores d'utilité d'une vie avec une CM s'établissent comme suit : ÉVA 0,81 ± 0,19, AT 0,93 ± 0,10 et PS 0,92 ± 0,14. L'AT et le PS indiquent respectivement la volonté de perdre 2,5 années de vie et d'accroître le risque de décès de 8 % pendant les interventions de reconstruction pour corriger une anomalie de CM. L'âge, le genre, la race, l'instruction et le revenu n'étaient pas des prédicteurs indépendants statistiquement significatifs des scores d'utilité plus élevés ou plus faibles. CONCLUSION: Les chercheurs ont évalué les répercussions du fardeau de la CM sur la santé au moyen de scores d'utilité numériques validés. Ces indices démontrent la volonté de réduire le nombre d'années de vie pour corriger une anomalie de la CM plutôt qu'une reconstruction après une mastectomie unilatérale. Ils peuvent aider les chirurgiens à mieux comprendre les préférences des patientes pour parvenir à une décision commune en matière de prise en charge du cancer du sein.

Regional incidence of and reconstructive management patterns in melanoma and nonmelanoma skin cancer of the head and neck: A 3-year analysis in the inpatient setting.

INTRODUCTION: Currently, there is limited literature on reconstructive trends for inpatient head and neck skin cancer. Rather, studies have focused primarily on patients treated on an outpatient basis. To gain a better understanding of the effect that reconstructive correction of complex skin cancer defects has on the healthcare system, we examined the existing incidence and reconstructive trends of head and neck melanoma and nonmelanoma skin cancer (NMSC) in the inpatient setting. METHOD: We performed the analysis of the Healthcare Cost and Utilization Project Nationwide Inpatient Sample Database (NIS) for the years 2012-2014 of the United States (US). Adults diagnosed with melanoma skin cancer or NMSC of the head and neck region were included. Patient characteristics, reconstructive modality, surgical specifics, and outcomes were retrieved. Trends with time for reconstruction techniques were analyzed. RESULTS: In total, 41,185 patients with a diagnosis of skin malignancy were identified, of whom 5,480 (13.3%) underwent reconstruction. Most patients were white (90.0%), male (71.6%), and had a diagnosis of NMSC (79.2%). An increase in flap reconstruction (p < 0.001) was observed. After population adjustment, the highest incidence of skin malignancy was found in the Northeast. CONCLUSION: There has been a trending increase in inpatient NMSC and melanoma skin cancer of the head and neck region, correlating to an increase in the reconstructive procedures performed, and greater cost burden. Resources may be allocated toward early identification and treatment for skin cancer to help control the current rise in complex skin cancer cases necessitating inpatient admission.

The Influence of Surgical Specialty on Oncoplastic Breast Reconstruction.

BACKGROUND: The integration of oncological surgery with reconstructive techniques has gained popularity in the treatment of breast cancer. oncoplastic reconstruction after partial mastectomy can be performed by the breast surgeon or in cooperation with a consulted plastic surgeon. This study aims to objectively assess the differences in outcomes for partial mastectomy and subsequent oncoplastic reconstruction performed by either general surgery alone or in combination with a plastic and reconstructive surgery team. METHODS: Unilateral oncoplastic breast reconstruction cases were extracted from the National Surgical Quality Improvement Program databases from 2005 to 2017. Outcomes of cases performed by the general surgery team alone were compared with those in which the partial mastectomy was performed by the general surgeon with subsequent reconstruction performed by plastic surgeons. To account for cohort baseline differences, propensity score-matched analysis was performed. RESULTS: In total, 4,350 patients were included in this study; 3,759 procedures were performed by general surgery alone versus 591 combined with plastic surgery. The analysis of propensity score-matched cohorts, comprising 490 patients each, showed no statistical difference in the risk for postoperative complications when surgery was performed by either of the 2 specialty services. A longer operative time and length of stay were found in the group reconstructed by plastic surgeons. CONCLUSIONS: This study found no significant differences in adverse postoperative outcomes for oncoplastic reconstructions after partial mastectomy between the 2 groups. The data may indicate collaboration between both surgical specialties in oncoplastic breast care was not associated with increased morbidity in these patients.

A Comparative Multimetric Assessment of English and Spanish Carpal Tunnel Syndrome Materials.

BACKGROUND: Spanish-speaking Hispanics living in the United States utilize the internet as a primary means to obtain health information. Accurate, accessible information is important for English speakers; however, it could have even greater utility for Spanish speakers who have lower health literacy levels. The aim of this study was to evaluate and compare online English and Spanish carpal tunnel surgery materials provided by using a multimetric approach. MATERIALS AND METHODS: A web search using the English term "carpal tunnel surgery" was performed. The first 10 institutional/organizational websites that provided carpal tunnel surgery information in English and Spanish were included. All relevant online materials were evaluated using the Patient Education and Materials Assessment Tool (PEMAT), Cultural Sensitivity Assessment Tool (CSAT), and Simplified Measure of Gobbledygook, Spanish (SOL) to assess understandability and actionability, cultural sensitivity, and readability, respectively. RESULTS: There were no statistically significant differences in understandability or actionability scores between Spanish and English materials. Average cultural sensitivity scores for Spanish materials were significantly lower than English materials (P = 0.015). The average reading grade level of online English materials was greater than that for Spanish materials (P = 0.011). Both mean values were above the recommended sixth-grade reading level. CONCLUSIONS: Online patient-directed information regarding carpal tunnel surgery exceeded the recommended reading grade level for both English and Spanish-speaking populations. Most Spanish materials were often direct translations and were not contoured to the elevated literacy needs of this demographic. Institutions must caution their authors to tailor their web material in a way that is sensitive to their target population to optimize understanding.

A Multimetric Evaluation of Online Spanish Health Resources for Lymphedema.

BACKGROUND: Breast cancer is a leading cause of death in US Hispanic females. This demographic is more likely to present with later-stage disease and require more extensive surgical treatment, including axillary lymph node dissection, which increases risk of lymphedema. The Spanish-speaking Hispanic population has a lower health literacy level and requires materials contoured to their unique needs. The aim of this study was to evaluate online Spanish lymphedema resources. METHODS: A web search using the Spanish term "linfedema" was performed, and the top 10 websites were identified. Each was analyzed using validated metrics to assess readability, understandability, actionability, and cultural sensitivity using the SOL (Simplified Measure of Gobbledygook, Spanish), Patient Education and Materials Assessment for Understandability and Actionability (Patient Education and Assessment Tool), and Cultural Sensitivity and Assessment Tool (CSAT), respectively. Online materials were assessed by 2 independent evaluators, and interrater reliability was determined. RESULTS: Online lymphedema material in Spanish had a mean reading grade level of 9.8 (SOL). Average understandability and actionability scores were low at 52% and 36%, respectively. The mean CSAT was 2.27, below the recommended value of 2.5. Cohen κ for interrater reliability was greater than 0.81 for the Patient Education and Assessment Tool and CSAT, suggesting excellent agreement between raters. CONCLUSIONS: Available online Spanish lymphedema resources are written at an elevated reading level and are inappropriate for a population with lower health literacy levels. As patients continue to use the internet as their primary source for health information, health care entities must improve the quality of provided Spanish resources in order to optimize patient comprehension.

Reconstruction of Mohs Defects Located in the Head and Neck.

BACKGROUND: Defects following Mohs micrographic surgery (MMS) can range in size from small defects requiring linear closure to large defects needing flap coverage. Reconstruction is dependent on defect size and facial aesthetic unit involvement. The aim of this study was to review the types of facial reconstruction per aesthetic unit involvement and describe their outcomes. METHODS: All data were retrieved for patients ≥18 years who underwent multidisciplinary treatment including dermatological MMS and plastic surgical reconstruction at a single tertiary hospital center (2001-2017). Patient characteristics, tumor pathology, surgical specifics, reconstructive modalities, and surgical outcomes were analyzed. RESULTS: A total of 418 patients were included. Patients were predominantly White, non-Hispanic (97%) and female (58%) with a mean age of 60 ±â€Š13.9 years. Tumor pathology was predominantly basal cell carcinoma in 73% of all cases followed by squamous cell carcinoma in 14%. The nasal aesthetic unit was mostly affected (50%). Local advancement flaps and different types of grafts were used in 51% and 25% of reconstructions, respectively. Complications were observed in 3% and local cancer recurrence in 4% of the patients. Scar revision was needed in 6% of the patients. CONCLUSION: Reconstruction of facial defects after Mohs micrographic surgery can be challenging due to its technical complexity and aesthetic implications. There were differences in complications in reconstructions performed within the same day versus 1 week, with a majority of complications occurring within same-day Mohs reconstructions. A multidisciplinary structured approach, which incorporates patient-reported outcomes, may be needed to optimize surgical results.

Facial Reconstruction After Mohs Surgery: A Critical Review of Defects Involving the Cheek, Forehead, and Perioral Region.

Facial defects following Mohs surgery can cause significant functional, cosmetic, and psychologic sequelae. Various techniques for nasal reconstruction after Mohs surgery have been analyzed in the medical literature, yet there has been less attention given to procedures for other crucial facial aesthetic regions. A literature search using PubMed, EMBASE, and ISI Web of Science for studies assessing reconstructive techniques of the forehead, cheek, and perioral regions after Mohs surgery was performed. No limitations on date or language were imposed. Studies meeting inclusion criteria consisted of an entirely post-Mohs population, specified technique for aesthetic unit reconstruction, and detailed complications. The initial search yielded 2177 citations. Application of the author's inclusion and exclusion criteria resulted in 21 relevant studies. Linear closure was highlighted as the predominant technique when possible in all 3 aesthetic zones. Local flaps remained the workhorse option for cheek and forehead defects. Cheek and perioral reconstruction were associated with higher complication rates. Eighty-one percent of studies did not include patient-reported outcomes or standardized outcome measurement assessments. Mohs surgery has become a valuable approach for treatment of skin malignancies of the face. This review has identified significant study heterogeneity in methodology, design, and outcome assessment. Currently, there is no evidence-based literature to support an algorithm to guide surgeon choice of treatment in these 3 central areas. Recommendations are provided to improve the quality of future studies to better inform appropriate surgical technique for each facial unit analyzed.

National Mortality Rates after Outpatient Cosmetic Surgery and Low Rates of Perioperative Deep Vein Thrombosis Screening and Prophylaxis.

BACKGROUND: Concerns have arisen over reports of deaths occurring after certain outpatient plastic surgery procedures. Here, the authors present a national analysis, reporting on deaths occurring after outpatient cosmetic surgical procedures and venous thromboembolism screening. METHODS: A retrospective analysis of the American Association for Accreditation of Ambulatory Surgical Facilities database was performed for the years 2012 to 2017. The authors retrieved data for all deaths occurring in association with cosmetic plastic surgery procedures. Patient demographics, procedural data, venous thromboembolism risk factor assessment, and cause of death were analyzed. Deidentified medical records, including coroner's reports, were reviewed where available. RESULTS: Data for 42 deaths were retrieved. Of these, 90.5 percent (n=38) were female, and 61.9 percent were Caucasian (n=26). Mean age was 51.6 years, while mean body mass index was 29.5 kg/m(2). Overall, 54.8 percent of these deaths occurred after abdominoplasty: 42.9 percent in isolation, 9.5 percent in combination with breast surgery, and 2.4 percent with facial surgery. Of the causes of death, most (38.1 percent) were thromboembolic in origin. Notably, in 25 of 42 cases, venous thromboembolism risk factor assessment was incorrect or absent (59.5 percent). CONCLUSIONS: Accreditation agencies provide transparency and insight into outpatient surgical mortality on a national scale. Results suggest that adoption of venous thromboembolism screening techniques may not be universal despite an existing large body of published evidence. Optimization of thromboembolism prevention pathways remains vital, and consideration of anticoagulation in those undergoing abdominoplasty may be important in lowering outpatient mortality.

The Influence of Connective Tissue Disease in Breast Reconstruction: A National Database Analysis.

BACKGROUND: Patients with connective tissue diseases (CTD), or collagen vascular diseases, are at risk of potentially higher morbidity after surgical procedures. We aimed to investigate the complication profile in CTD versus non-CTD patients who underwent breast reconstruction on a national scale. METHODS: A retrospective analysis of the Healthcare Cost and Utilization Project NIS Database between 2010 and 2014 was conducted for patients 18 years or older admitted for immediate autologous or implant breast reconstruction. Connective tissue disease was defined as systemic lupus erythematosus, rheumatoid arthritis, systemic sclerosis, scleroderma, Raynaud phenomenon, psoriatic arthritis, or sarcoidosis. Independent t test/Wilcoxon-Mann-Whitney was used to compare continuous variables and Pearson χ/Fischer exact test was used for categorical variables. Outcomes of interest were assessed using multivariable linear regressions for continuous variables and multivariable logistic regressions for categorical variables. RESULTS: There were 19,496 immediate autologous breast reconstruction patients, with 357 CTD and 19,139 non-CTD patients (2010-2014). The CTD patients had higher postoperative complication rates for infection (2.8% vs 0.8%, P < 0.001), wound dehiscence (1.4% vs 0.4%, P = 0.019), and bleeding (hemorrhage and hematoma) (6.7% vs 3.5%, P < 0.001). After multivariable analysis, CTD remained an independent risk factor for bleeding (odds ratio [OR], 1.568; 95% confidence interval [CI], 1.019-2.412). There were a total of 23,048 immediate implant breast reconstruction patients, with 431 CTD and 22,617 non-CTD patients (2010-2014). The CTD patients had a higher postoperative complication rate for wound dehiscence/complication (2.3% vs 0.6%, P < 0.001). They also experienced a longer length of stay (2.31 days vs 2.07 days, P < 0.001). After multivariable analysis, CTD remained an independent risk factor for wound dehiscence (OR, 4.084; 95% CI, 2.101-7.939) and increased length of stay by 0.050 days (95% CI, -0.081 to 0.181). CONCLUSIONS: Connective tissue disease patients who underwent autologous breast reconstruction had significantly higher infection, wound dehiscence, and bleeding rates, and those who underwent implant breast reconstruction had significantly higher wound dehiscence rates. Connective tissue diseases appear to be an independent risk factor for bleeding and wound dehiscence in autologous and implant breast reconstruction, respectively. This information may help clinicians be aware of this increased risk when determining patients for reconstruction.

Long-Term Patient-Reported Outcomes following Free Flap Lower Extremity Reconstruction for Traumatic Injuries.

BACKGROUND: Reconstruction of severe lower extremity injuries using free flaps has become a reliable approach. Knowledge of long-term surgical outcomes, limb function, and quality of life is limited. METHODS: Two hundred thirty-nine patients undergoing a free flap reconstruction of an open lower extremity fracture between 1993 and 2014 were divided into three groups and studied, as follows: group 1, early free flap reconstruction within 6 weeks; group 2, delayed reconstruction after 6 weeks; and group 3, delayed reconstruction with osteomyelitis. Patient-reported outcomes were assessed with the 36-Item Short-Form Health Survey and the Lower Extremity Functional Scale. Independent variables predicting outcomes were identified using multivariate analyses. RESULTS: Patients in group 3 significantly more often experienced delayed union. Questionnaires were completed by 108 patients (mean follow-up, 9.7 years). The 36-Item Short-Form Health Survey physical component scores were significantly lower in all three groups compared with Dutch norms, as was the mental health score in group 3. There were no significant differences in quality of life and lower limb function among the three groups. Chronic pain was an independent predictor for decreased quality of life and limb function in groups 1 and 2, as was delayed union for decreased limb function in group 3. CONCLUSIONS: After free flap reconstruction of severe lower extremity injuries, all patient groups showed significantly lower quality of life compared to the Dutch population; however, there were no significant differences between the groups. Predictors for poorer quality of life and limb function were chronic pain and delayed union.