Questioning the Utility of Temporal Artery Biopsy in Giant Cell Arteritis: A Negative Biopsy May Facilitate Decision-making.

Plastic surgeons are frequently consulted to perform temporal artery biopsy (TAB), even though patients meet the American College of Rheumatology diagnostic criteria for giant cell arteritis (GCA) and are already treated. This study aimed to analyze the impact of TAB on steroid duration in patients undergoing TAB. Methods: We undertook a prospective study of adult patients undergoing TAB for GCA in Calgary. Consecutive, multicenter recruitment was performed over 2 years. Primary outcomes included initiation or discontinuation and duration of corticosteroids. Results: Twenty-one TABs were performed in 20 patients. Nineteen percent of TABs were positive, and 71.4%, negative. In 9.5% of patients, accidental sampling of a vessel other than the superficial temporal artery occurred. Fifty-two percent of patients received steroids before TAB, of which the mean duration was 8.0 days for TAB+ (postive temporal artery biopsy result) patients and 8.4 days for TAB- (negative temporal artery biopsy result; P = 0.22) patients. Before TAB, the American College of Rheumatology score was 2.5 for TAB+ patients and 2.4 for TAB- (P = 0.74). Postbiopsy, the American College of Rheumatology score was 3.5 for TAB+ patients (therefore reaching diagnostic threshold of 3) but remained 2.4 for TAB- (P = 0.02). TAB+ patients were treated for 352.3 days, whereas TAB- patients for 16.7 days (P = 0.29). Complications were more likely with long-term (>6 weeks) steroids (P = 0.17). Conclusion: In patients with a low suspicion of GCA, a negative TAB helps bolster physician confidence and leads to a shorter steroid duration.

Temporal Artery Biopsy Debate: Positive TAB Result Prolongs Steroid Use in Giant Cell Arteritis.

Temporal artery biopsy (TAB) in diagnosing giant cell arteritis has been criticized due to surgical risks, a high false negative rate, and redundant information when patients already met American College of Rheumatology criteria. The objective of this study was to investigate TAB's impact on steroid treatment duration. Methods: A retrospective chart review garnered patient demographics, symptoms, comorbidities, and steroid treatment duration in patients undergoing TAB at a single center. Steroid treatment was compared between TAB+ and TAB - patients. Results: One hundred seven patients undergoing TAB were included. Patients were predominantly women (70.1%) with a median age of 74 years (46 -91). Of 107 TAB results, 74 (69.2%) were negative, 23 (21.5%) were positive, and 10 (9.3%) were found to be indeterminate. In TAB+ patients, the mean erythrocyte sedimentation rate was not significantly different than TAB - patients (60.2 versus 43.7, P = 0.45), nor was the median C-reactive protein (38.8 versus 18.1, P = 0.17). Regarding steroid use, both TAB+ and TAB - patients had a similarly high rate of prebiopsy steroid initiation (82.6% versus 70.3%, P = 0.32). More TAB+ patients remained on steroids at 6 weeks (95.0% versus 57.4%, P = 0.004), 6 months (95% versus 37.7%, P < 0.001), 1 year (65.0% versus 31.1%, P = 0.024), and 18 months (50.0% versus 19.7%, P = 0.045). By 2 years, the difference no longer met significance (35.0% versus 14.8%, P = 0.12). P = 0.12). Conclusion: TAB positivity does seem to influence maintenance of steroids up to 18 months after biopsy.

Necessity of Temporal Artery Biopsy for Giant Cell Arteritis: A Systematic Review.

Temporal artery biopsy (TAB) is currently the gold standard procedure to diagnose giant cell arteritis. Despite low sensitivity, TAB is routinely performed even if a clinical diagnosis has already been made. The objective of this study was to determine the usefulness of TAB for giant cell arteritis management. Methods: We performed a systematic review to identify studies that compared steroid treatment between TAB+ and TAB- patients. EMBASE, MEDLINE, and the Cochrane Central Register of Controlled Trials were searched from inception until April 4, 2020. Titles, abstracts, and full texts were reviewed by two independent reviewers and conflicts resolved by consensus. Studies reporting TAB result and steroid treatment were included. Information pertaining to steroid treatment was compared between TAB+ and TAB- groups. Steroid duration was compared by grouping patients in a less than 6 month group, a 6-24 month group, and a more than 24 month group. Results: An estimated 5288 abstracts were screened and 13 studies involving 1355 patients were included. Rate of prebiopsy steroid treatment was higher in TAB+ patients compared with TAB- patients [93% versus 63% (P < 0.001)]. The TAB+ group was more likely to be started on steroids prebiopsy [28% versus 8% (P < 0.001)]. TAB+ and TAB- patients had similar steroid duration for all groups [<6-month group 17% versus 19% (P-0.596), the 6-24-month group 16% versus 19% (P-0.596), and the >24-month group 66% versus 63% (P-0.642)]. Conclusion: TAB results have minimal impact on treatment, and the utility should be reconsidered when a clinical diagnosis of giant cell arteritis is possible.

Tumor MHC Class I Expression Associates with Intralesional IL2 Response in Melanoma.

Cancer immunotherapy can result in lasting tumor regression, but predictive biomarkers of treatment response remain ill-defined. Here, we performed single-cell proteomics, transcriptomics, and genomics on matched untreated and IL2 injected metastases from patients with melanoma. Lesions that completely regressed following intralesional IL2 harbored increased fractions and densities of nonproliferating CD8+ T cells lacking expression of PD-1, LAG-3, and TIM-3 (PD-1-LAG-3-TIM-3-). Untreated lesions from patients who subsequently responded with complete eradication of all tumor cells in all injected lesions (individuals referred to herein as "extreme responders") were characterized by proliferating CD8+ T cells with an exhausted phenotype (PD-1+LAG-3+TIM-3+), stromal B-cell aggregates, and expression of IFNγ and IL2 response genes. Loss of membranous MHC class I expression in tumor cells of untreated lesions was associated with resistance to IL2 therapy. We validated this finding in an independent cohort of metastatic melanoma patients treated with intralesional or systemic IL2. Our study suggests that intact tumor-cell antigen presentation is required for melanoma response to IL2 and describes a multidimensional and spatial approach to develop immuno-oncology biomarker hypotheses using routinely collected clinical biospecimens.

Supporting Women's BIA-ALCL Decision-making: Role of the Individual Consult in Empowering the Patient-Physician Team.

BACKGROUND: Breast implant associated anaplastic large cell lymphoma (BIA-ALCL) is a T-cell non-Hodgkin's lymphoma and an uncommon risk of textured breast implants. Over the past decade, concern about BIA-ALCL has been increasing among both patients and surgeons. Patients are seeking a better understanding of their BIA-ALCL risk toward identifying a personalized care plan. This quality improvement project examines the value added by pairing group-based patient education seminars with one-on-one consults. METHODS: Individual consults were held following educational group seminars. Consult field notes underwent qualitative thematic analysis. Themes were cross referenced against a quantitative chart review of patient BIA-ALCL prophylaxis decisions over time. RESULTS: Four key themes were identified: weighing, perceiving, guiding, and supporting. Weighing considers the risk-benefit assessments patients make when weighing their BIA-ALCL risk. Perceiving describes the underlying psychosocial factors that frame patient perceptions of BIA-ALCL risk. Guiding presents the levels of guidance that patients require when making BIA-ALCL prophylaxis decisions. Supporting explores the therapeutic value of the individual consult. Ultimately, 41% of post-seminar consult attendees sought explantation, compared with 4% among patients who did not participate in this program (P < 0.001). CONCLUSIONS: Key lessons include the following: (1) patients weigh BIA-ALCL risk against perceived surgical risks and the value of their reconstruction; (2) patients can benefit from a personalized balance of autonomy and surgeon guidance when selecting a BIA-ALCL prevention plan; (3) surgeons should seek to understand the psychosocial factors that may underlie patient perceptions of BIA-ALCL risk; and (4) individual consults can be therapeutic and help strengthen the patient-surgeon relationship.

Patient-Reported Outcomes after Fibula Free Flap Harvest: A Pilot Study.

SUMMARY: Patient-reported outcomes regarding donor-site morbidity and quality of life for the fibula free flap in head and neck reconstruction patients have not been studied. The authors reviewed and identified patients who had undergone head and neck reconstruction using a fibula free flap (2011 to 2016). Patients were assessed via physical examination and two patient-reported outcomes questionnaires: the Foot and Ankle Outcome Score (score range, 0 to 100) and the Pain Disability Questionnaire (score range, 0 to 100). Quantitative data were analyzed with appropriate statistical tests. Semistructured interviews exploring donor-site challenges were performed and analyzed using thematic analysis. Seventeen patients agreed to participate. Their mean age was 62 years (range, 41 to 81 years). Mean follow-up was 38 months (range, 12 to 65 years). Mean perceived level of function compared to baseline was 67 percent. Mean scores for the Foot and Ankle Outcome Score subscales were 84.6 (pain), 80.5 (symptoms), 86.7 (activities of daily living), 67.7 (sport), and 65.6 (quality of life). The mean Pain Disability Questionnaire score was 26.3 (mild/moderate perceived disability). Higher perceived level of function was associated with higher Foot and Ankle Outcome Score values (pain, symptoms, and activities of daily living, p < 0.05). Donor limbs had decreased range of motion and manual muscle testing scores compared with their contralateral limbs (p < 0.05). Lack of ankle support and balance, resulting in limitations and aversions to daily and sporting activities, were the most common themes regarding donor-site challenges. In conclusion, patients who have undergone fibula free flap harvest struggle with ankle support and balance and face functional difficulties that have an impact on their quality of life. Multidisciplinary approaches for targeted rehabilitation after fibula free flap harvest should be explored to determine the impact on patients' quality of life.

Attitudes of Canadian Plastic Surgeons on Temporal Artery Biopsy in Giant Cell Arteritis Management.

Temporal artery biopsies (TAB) rarely impact management of patients with suspected giant cell arteritis and carry complications. We sought plastic surgeons' perspectives on this procedure's risks and benefits. METHODS: An email survey was designed, piloted, and refined to elicit Canadian Society of Plastic Surgeons (CSPS) members about TAB's diagnostic contribution, complications, usefulness as a resident education tool, and surgeons' insight into emerging diagnostic modalities like ultrasound. Text comments were sought at each question. A reminder was emailed one week later. Data was compared and analyzed using the chi-squared test and student t-test. RESULTS: An estimated 83 responses were received from 435 surgeons (19%). Of the surgeons, 20% voiced uncertainty regarding TAB indications; 40% were unsure if TAB results changed steroid duration and dose; 83% did not see patients postoperatively. Surgeons recalled 29 cases of hematoma and three facial nerve injuries from TAB. In total, 80% felt TAB was a valuable learning opportunity for residents, although residents were involved in only 21% of cases; 65% of surgeons supported a changeover to ultrasound as primary diagnostic modality. Analysis of text comments revealed a sense of futility from TAB and disdain toward being mere technicians. Several participants wished for stakeholders to collaborate and potentially endorse noninvasive diagnostic modalities. CONCLUSIONS: This survey demonstrated varying attitudes to TAB. Generally, plastic surgeons were uncertain of TAB's contribution to treatment, tended not to follow-up on results or patients, and recognized a number of complications. Conversations are desired regarding switching from scalpel to probe to evaluate the temporal artery.

Assessing exposure to dermoscopy in plastic surgery training programs.

BACKGROUND: Dermoscopy is a noninvasive tool that improves the diagnostic accuracy of melanoma and other cutaneous malignancies; yet, it is not widely used by plastic surgeons, who commonly manage skin lesions. Thus, the purpose of this study was to explore current practice patterns and knowledge of dermoscopy among plastic surgeons and postgraduate plastic surgery trainees. Additionally, interest to establish a formal dermoscopy curriculum as part of plastic surgery residency training was evaluated. METHODS: An online electronic questionnaire was developed and distributed through email to practicing plastic surgeons and plastic surgery trainees at two Canadian universities. RESULTS: Of the 59 potential participants, 27 (46%) responded. While the majority of participants were familiar with dermoscopy (n = 26; 96%), only one respondent reported using dermoscopy in clinical practice. However, all respondents reported exposure to melanoma clinically (n = 26; one participant did not provide a response). A lack of training, along with lack of access to dermatoscopes, were the most frequently cited reasons for not using dermoscopy. Knowledge scores with regard to dermoscopic features were also low; coupled with a noted propensity toward diagnostic or excisional biopsy, whichcould raise the benign to malignant ratio. Overall, 89% (n = 24) of respondents expressed interest in dermoscopy training in plastic surgery postgraduate training. CONCLUSIONS: Few responding plastic surgeons or plastic surgery residents currently use dermoscopy in training or practice but are interested in formal dermoscopy training in residency.

The use of indocyanine green and near-infrared fluorescence imaging to assist sentinel lymph node biopsy in cutaneous melanoma: A systematic review.

BACKGROUND AND OBJECTIVES: Despite the use of blue dye and radioisotopes, sentinel lymph node biopsy (SLNB) is still associated with a high false-negative rate (FNR). The off-label use of indocyanine green (ICG) and near-infrared fluorescence (NIRF) imaging has been introduced with the objective of assisting SLNB and thereby improving regional control in melanoma. The objective of this study was to review and summarize the general experience, protocols and outcomes of the use of ICG and NIRF to assist SLNB in melanoma. METHODS: A systematic literature review was performed in December 2019 as per the PRISMA guidelines. Inclusion criteria were articles written in English describing the applications of ICG in patients with melanoma. Systematic reviews, animal studies, case reports and letters to editors were excluded. RESULTS: Of the 585 studies retrieved, 13 articles met the inclusion criteria. The reported sentinel lymph node (SLN) detection rate using ICG was between 86 and 100% of nodes identified by lymphoscintigraphy. The average number of nodes per patient detected using ICG was 2. ICG fluorescence imaging contributed to the identification of 2.0% of the total number of SLNs harvested. CONCLUSIONS: ICG fluorescence may be a useful adjunct to lymphoscintigraphy, although high-level comparative data is lacking. It was found to be superior to blue dye at detecting sentinel lymph nodes.

Navigating Women's BIA-ALCL Information Needs: Group Seminars May Offer an Opportunity to Empower the Patient-Surgeon Team.

BACKGROUND: Breast Implant Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) is a T-cell non-Hodgkin's lymphoma that has been linked to textured breast implants, and is an emerging concern within the plastic and reconstructive surgery community. Many surgeons are struggling with how best to inform their patients and manage BIA-ALCL care without overwhelming their standard clinical practice. METHODS: Five educational group seminars were held for 53 patients. A thematic analysis of the field notes taken at each seminar was conducted to identify recurring patient and surgeon behaviors. RESULTS: The thematic analysis identified 5 key themes: seeking, amplifying, framing, trusting, and empowering. Seeking describes the knowledge sought by patients and their varying engagement in their care. Amplifying underlines how the emotionally charged topic of BIA-ALCL impacted patient and surgeon behaviors. Framing presents surgeon efforts to help patients understand the risk level of BIA-ALCL. Trusting addresses the ways BIA-ALCL has impacted patient trust in the medical community and the mechanisms to rebuild this trust. Empowering outlines surgeon efforts to engage patients in shared decision-making. CONCLUSIONS: Herein is presented a possible framework for efficient BIA-ALCL patient education that can be adapted to different surgical practices. Lessons learned are: (1) patients want information on BIA-ALCL's clinical features and prophylactic implant removal; (2) BIA-ALCL discussions are emotionally charged and surgeons must remain cognizant of group dynamics and that the physician-patient power differential may impact patient decision-making; (3) patient trust has been strained but can be restored; and (4) patient responses to BIA-ALCL are variable and subjective; thus, surgeons should emphasize patient-centered care.

Adoption of Enhanced Recovery after Surgery Protocols in Breast Reconstruction in Alberta Is High before a Formal Program Implementation.

BACKGROUND: Enhanced recovery after surgery (ERAS) techniques have consistently demonstrated improved patient outcomes across multiple surgical specialties. We have lead international consensus guidelines on ERAS protocols for breast reconstruction and recently implemented these guidelines in Alberta. This study looks at adoption rates of ERAS pathways for breast reconstruction within Alberta, whereas also addressing barriers to ERAS implementation. METHODS: A retrospective analysis of online operative reports in the Synoptec database consisting of patients undergoing alloplastic or autogenous breast reconstruction in Alberta was conducted. Primary outcomes of interest included whether ERAS protocols were utilized and what the reported barriers to ERAS utilization were. RESULTS: Of the 372 patients undergoing breast reconstruction surgery, 215 (57%) patients were placed on an ERAS protocol. Autogenous reconstruction patients were more likely than alloplastic reconstruction patients to be placed on ERAS protocols (72% versus 53%, P = 0.002). A lack of resources was the most commonly cited reason for not adopting ERAS protocols for both autogenous and alloplastic reconstruction groups (53% and 53%). Surgeons in Southern Alberta were more likely than surgeons in Northern Alberta to utilize ERAS protocols for their alloplastic (73% versus 8%, P < 0.001) and autogenous (99% versus 4%, P < 0.001) reconstructions. CONCLUSIONS: Adoption of ERAS protocols in Alberta was strong (57% adherence) before a formal program implementation. We are encouraged that the recent official launch of ERAS protocols in breast reconstruction within the province will further enhance the uptake and care of this unique surgical population.

Direct-to-implant Breast Reconstruction with Autoderm.

BACKGROUND: Traditional transverse mastectomies yield suboptimal results in women with higher body mass index, wide breast footprint, and ptotic breasts. An option for this patient population is a reduction-pattern style mastectomy, and recruiting an inferiorly based dermal flap using the lower mastectomy flap. This is analogous to a vascularized dermal matrix supporting the lower pole of the implant, termed "Autoderm" breast reconstruction. This allows for aesthetically appealing skin reduction mastectomies with the added safety of a vascularized dermal flap to facilitate an immediate direct-to-implant breast reconstruction. This study assesses patient satisfaction using the validated BRECON-31 questionnaire to enhance shared-decision making with women contemplating breast reconstruction. METHODS: A 2-year retrospective review of women who underwent Autoderm direct-to-implant breast reconstruction comparing patients who underwent unilateral and bilateral reconstruction in terms of characteristics, complications, and BRECON-31 scoring. RESULTS: Overall patient scores were high (81.6 of 100). In particular, women scored very high on self-image (85.0), arm concerns (86.4), intimacy (87.4), satisfaction (88.3), and expectations subscales (85.5). Women choosing bilateral reconstruction outperformed unilateral reconstruction in every subgroup, but only attained statistical significance in the "self-consciousness" subgroup. Compared with a historical cohort of a mix of implant reconstruction types, Autoderm patients showed improved satisfaction (88.3 versus 82.5; P = 0.07) and breast appearance (73.9 versus 66.8; P = 0.06), approaching significance. Safety was demonstrated by low major complications (4.7%) and low implant loss rates (2.3%). CONCLUSIONS: Autoderm breast reconstruction is a safe option in women with large, ptotic breasts, with patients reporting high satisfaction using a validated instrument.

Avoiding Skin Grafts: The Keystone Flap in Cutaneous Defects.

The Keystone Design Perforator Island Flap is a fasciocutaneous perforator flap resembling two end-to-end VY flaps. We used a modification of the original design to avoid extending the incision into an elliptical pattern, and maintained a trailing skin bridge whilst incising fascia in a tunneling fashion. Thirty patients underwent 32 flaps mainly on the lower leg to close defects that would traditionally require skin grafting. All flaps survived completely, with minor complications in four patients. All but five patients were allowed unrestricted ambulation after surgery. The modified design is straightforward to learn, has reliable perfusion, and provides a simpler recovery for patients. CLINICAL QUESTIONS/LEVEL OF EVIDENCE: Therapeutic, IV.

Treatment of in-transit melanoma with intra-lesional interleukin-2: a systematic review.

BACKGROUND: Several phase II studies have assessed intra-lesional interleukin-2 (IL-2) for the treatment of in-transit melanoma. This systematic review addresses the efficacy and side effect profile of IL-2. METHODS: MEDLINE, EMBASE, Cochrane Library, and Google Scholar databases were searched from 1980 to 2012 for studies evaluating the clinical response to IL-2 for in-transit melanoma. Titles and abstracts were screened by two independent researchers for suitability using predetermined inclusion and exclusion criteria. A modified quality assessment tool for observational studies was used. Data were pooled and analyzed to determine lesion and patient response rates. RESULTS: Forty-nine studies were identified. Forty-three did not meet inclusion criteria, leaving six observational trials. Heterogeneity was seen in IL-2 dosage and treatment interval. Response rate was variable as well. Overall, 2,182 lesions and 140 patients were treated in these six studies. Pooling the lesions, complete response was seen in 78%. Pooling subjects, 50% achieved a complete response. Treatment was generally well tolerated, with localized pain and swelling, and mild flu-like symptoms. There were only three grade 3 adverse events reported, including rigors, headache, and fever with arthralgia. CONCLUSIONS: Intra-lesional IL-2 safely and effectively provides locoregional control of in-transit melanoma.

Intra-lesional interleukin-2 therapy for in transit melanoma.

Intra-lesional interleukin-2 (IL-2) is effective in treating in transit melanoma metastases. Results from multiple studies were examined to evaluate the efficacy of IL-2 for in transit disease. In the published literature, complete response ranged from 0% to 69% per patient, and 41% to 96% per lesion, with excellent tolerability. Combining the results of six studies show complete response in 50% of patients and 78% of lesions. Intra-lesional IL-2 should be considered early in the course of treatment for in transit disease, ahead of other, more toxic therapies.

Incidental Internal Mammary Nodes during Recipient Vessel Dissection in Breast Reconstruction: Are They Significant?

SUMMARY: Internal mammary (IM) lymph nodes may be exposed during recipient vessel preparation in free-flap breast reconstruction, and in rare cases, positivity of these nodes may affect treatment in patients with breast cancer. This systematic review examines the incidence and significance of IM nodes identified by plastic surgeons. Eligibility criteria included free-flap breast reconstruction with concurrent IM node biopsy. Data were analyzed for incidence of IM node biopsy and nodal positivity. Ten studies met inclusion criteria, with a total of 2055 patients and 717 nodes submitted to pathology. Incidence of IM positivity ranged approximately from 1% to 11%, for a calculated gross overall incidence of 2.9%. Of 59 patients with a positive IM node, 50 patients received additional adjuvant therapy, with insufficient data to determine the effect of treatment on survival.

The breast reconstruction satisfaction questionnaire (BRECON-31): an affirmative analysis.

OBJECTIVE: To verify the subscale structure of the BRECON-31 using a test sample of women naïve to the questionnaire. METHODS: The BRECON-31 was administered to women following breast reconstruction. Their responses were subjected to principal components analysis (PCA) with a varimax rotation. Components were maintained with an Eigenvalue greater than one. Internal consistency reliability was measured with Cronbach's Alpha (CA). Components on the test pool analysis were then compared with the subscales developed on 128 women who completed the questionnaire during the development phase. RESULTS: Fifty women completed the BRECON-31. Development and test pools of women were similar across demographics, pathology, and surgical details, except the development sample was somewhat older (53 yo vs. 49 yo, P = 0.02). Using PCA, eight subscales again emerged: self-image, arm concerns, intimacy, satisfaction, recovery, self-consciousness, expectations, and breast appearance. A nipple, and abdominal strength and appearance subscales also emerged. Forty-one of the 45 items loaded similarly in the development and test pools. Internal consistency reliability was high, with CA in the test pool equaling or exceeding CA in the development pool in the majority of the subscales. CONCLUSIONS: The BRECON-31 factor structure identified in the development pool was supported by the test pool, with similar reliability.

Development of a breast reconstruction satisfaction questionnaire (BRECON-31): principal components analysis and clinimetric properties.

BACKGROUND: A reliable, valid questionnaire is essential to assess patient satisfaction with breast reconstruction. METHODS: A 105-item pilot BRECON questionnaire was previously developed. One hundred eighty-one women with breast reconstruction were mailed the pilot BRECON, BREAST-Q, and EQ-5D questionnaires. Fifty women were re-mailed the BRECON. Based on the responses, the BRECON was refined using statistical means and principal components analysis (PCA). Reliability was assessed using the intraclass correlation coefficient (ICC) and Cronbach's alpha. Validity was assessed by comparing subscales of the BRECON to the BREAST-Q and comparing a summary score of the BRECON-31 to the EQ-5D using the Pearson's correlation coefficient (PCC). RESULTS: A total of 71% (128/181) of women completed the three questionnaires, and 86% (43/50) of women responded to the re-mailed BRECON. Statistical methods and PCA maintained 31 items covering eight components including self-image, arm concerns, intimacy, satisfaction, recovery, self-consciousness, expectations, and breast appearance. A 4-item "nipple" subscale and a 10-item "abdominal" subscale were developed for use where applicable. Measures of reliability and validity were high: Cronbach's alpha ranged from 0.67 to 0.91, ICC ranged from 0.55 to 0.85, and PCC ranged from 0.42 to 0.76. CONCLUSIONS: A reliable, valid 31-item breast reconstruction satisfaction questionnaire was developed.