Transforming Plastic and Reconstructive Surgical Care in Low- and Middle-Income Countries: A Paradigm Shift to the Diagonal Model.

SUMMARY: The article highlights the global lack of access to basic surgical services, particularly in low- and middle-income countries (LMICs), where only 3.5% of surgical procedures serve 34.8% of the population. Plastic and reconstructive surgery, constituting 16% of treatable conditions, is a significant unmet need. Surgical outreach, popular for burns, trauma, and cleft lip, is addressed by organizations like ReSurge, Smile Train, and Operation Smile. The shift from the traditional "vertical model" to a "diagonal model" prioritizes long-term relationships, capacity-building, and sustainable healthcare. Efforts include education through programs like the ReSurge Global Training Program, a blended learning approach, and technology integration for ongoing support. The diagonal model aims to address not just immediate patient needs but also systemic challenges, emphasizing collaboration and empowerment for sustainable healthcare outcomes.

Postmastectomy Functional Impairments.

PURPOSE OF REVIEW: This narrative review aims to offer a thorough summary of functional impairments commonly encountered by breast cancer survivors following mastectomy. Its objective is to discuss the factors influencing these impairments and explore diverse strategies for managing them. RECENT FINDINGS: Postmastectomy functional impairments can be grouped into three categories: neuromuscular, musculoskeletal, and lymphovascular. Neuromuscular issues include postmastectomy pain syndrome (PMPS) and phantom breast syndrome (PBS). Musculoskeletal problems encompass myofascial pain syndrome and adhesive capsulitis. Lymphovascular dysfunctions include lymphedema and axillary web syndrome (AWS). Factors such as age, surgical techniques, and adjuvant therapies influence the development of these functional impairments. Managing functional impairments requires a comprehensive approach involving physical therapy, pharmacologic therapy, exercise, and surgical treatment when indicated. It is important to identify the risk factors associated with these conditions to tailor interventions accordingly. The impact of breast reconstruction on these impairments remains uncertain, with mixed results reported in the literature.

Intraoperative vasopressor use does not increase complications in microvascular post-mastectomy breast reconstruction: Experience in 1729 DIEP flaps at a single center.

INTRODUCTION: Vasopressors are traditionally avoided in microsurgery due to concerns about their effect on free flap survival. We examine the impact of intraoperative vasopressors on microsurgical outcomes in a large series of DIEP flap breast reconstructions. METHODS: A retrospective chart review was performed of patients who underwent DIEP breast reconstruction between January 2010 and May 2020. Intraoperative and postoperative microsurgical outcomes were compared in patients who received vasopressors and those who did not. RESULTS: The study included 1102 women who underwent 1729 DIEP. 878 patients (79.7%) received intraoperative phenylephrine, ephedrine, or a combination of both. There was no significant difference in overall complications, intraoperative microvascular events, takebacks for microvascular complications, or partial or total flap loss between groups. Outcomes were not affected by vasopressor type, dose, or timing of administration. The vasopressor group received significantly lower intraoperative fluid volumes. Multivariate logistic regression found a significant association between overall complications and excessive fluids (OR 2.03, 99% CI 0.98-5.18, p = 0.03) but not vasopressor use (OR 0.79, 99% CI 0.64-3.16, p = 0.7) CONCLUSION: This study demonstrates that vasopressors do not adversely affect clinical outcomes after DIEP breast reconstruction. Withholding vasopressors results in excessive intravenous fluid administration and increased postoperative complications.

Re-examining content validity of the BREAST-Q more than a decade later to determine relevance and comprehensiveness.

PURPOSE: The BREAST-Q is the most used patient-reported outcome measure (PROM) in breast cancer surgery. The purposes of this study were to re-examine the content validity of BREAST-Q cancer modules (mastectomy, lumpectomy and reconstruction) and to determine the need for new scales. METHODS: Interviews were conducted with women with breast cancer (Stage 0-4, any treatment), and were audio-recorded and transcribed verbatim. Deductive (based on original BREAST-Q conceptual framework) and inductive (new codes from the data) content analysis approaches were used to analyze the data. The number of codes that mapped to BREAST-Q were recorded. RESULTS: Dataset included 3948 codes from 58 participants. Most of the breast (n = 659, 96%) and all psychosocial (n = 127, 100%), sexual (n = 179, 100%) and radiation-related (n = 79, 100%) codes mapped to BREAST-Q Satisfaction with Breast, Psychosocial Wellbeing, Sexual Wellbeing and Adverse Effects of Radiation scales, respectively. For the physical wellbeing codes (n = 939) for breast/chest and arm, 34% (n = 321) mapped to the Physical Wellbeing-Chest scale. Most of the abdomen codes (n = 311) mapped to Satisfaction with Abdomen (n = 90, 76%) and Physical Wellbeing-Abdomen (n = 171, 89%) scales. Codes that did not map (n = 697, 30%) covered breast sensation and lymphedema. Concerns related to fatigue, cancer worry, and work impact were most reported and did not map to BREAST-Q. CONCLUSION: The BREAST-Q, which was developed using extensive patient input more than a decade ago, is still relevant. To ensure the BREAST-Q remains comprehensive, new scales for upper extremity lymphedema, breast sensation, fatigue, cancer worry, and work impact were developed.

Canadian Expert Opinion on Breast Reconstruction Access: Strategies to Optimize Care during COVID-19.

BACKGROUND: Breast reconstructive services are medically necessary, time-sensitive procedures with meaningful health-related quality of life benefits for breast cancer survivors. The COVID-19 global pandemic has resulted in unprecedented restrictions in surgical access, including access to breast reconstructive services. A national approach is needed to guide the strategic use of resources during times of fluctuating restrictions on surgical access due to COVID-19 demands on hospital capacity. METHODS: A national team of experts were convened for critical review of healthcare needs and development of recommendations and strategies for patients seeking breast reconstruction during the pandemic. Following critical review of literature, expert discussion by teleconference meetings, and evidenced-based consensus, best practice recommendations were developed to guide national provision of breast reconstructive services. RESULTS: Recommendations include strategic use of multidisciplinary teams for patient selection and triage with centralized coordinated use of alternate treatment plans during times of resource restrictions. With shared decision-making, patient-centered shifting and consolidation of resources facilitate efficient allocation. Targeted application of perioperative management strategies and surgical treatment plans maximize the provision of breast reconstructive services. CONCLUSIONS: A unified national approach to strategically reorganize healthcare delivery is feasible to uphold standards of patient-centered care for patients interested in breast reconstruction.

The Impact of the COVID-19 Pandemic on Breast Reconstruction: A Canadian Perspective.

BACKGROUND: The COVID-19 pandemic has led to unprecedented challenges and restrictions in surgical access across Canada, including for breast reconstructive services which are an integral component of comprehensive breast cancer care. We sought to determine how breast reconstructive services are being restricted, and what strategies may be employed to optimize the provision of breast reconstruction through a pan-Canadian evaluation from the providers' perspective. METHODS: This was a cross-sectional survey of Canadian plastic and reconstructive surgeons who perform breast reconstruction. The 33-item web-based questionnaire was developed by a pan-Canadian working group of breast reconstruction experts and disseminated via email to members of the Canadian Society of Plastic Surgery. The questionnaire queried respondents on the impact of the COVID-19 pandemic and associated restrictions on surgeons' breast reconstruction practice patterns and opinions on strategies for resource utilization. RESULTS: Responses were received from 49 surgeons, who reported practicing in 8 of 10 Canadian provinces. Restrictions on the provision of breast reconstructive procedures were most limited during the First Wave of the COVID-19 pandemic, where all respondents reported at least some reduction in capacity and more than a quarter reporting complete cessation. Average reported reduction in capacity ranged from 31% to 78% across all 3 waves. Autologous, delayed, and prophylactic reconstructions were most commonly restricted. CONCLUSION: This study provides a pan-Canadian impact assessment on breast reconstructive services during the COVID-19 pandemic from the providers' perspective. To uphold the standards of patient-centred care, a unified approach to strategically reorganize health care delivery now and in the future is needed.

HISTORIQUE: La pandémie de COVID-19 a donné lieu à des défis et des restrictions sans précédent en matière d'accès aux interventions chirurgicales au Canada, y compris les services de reconstruction mammaire qui font partie intégrante des soins complets du cancer du sein. Les chercheurs ont voulu déterminer le mode de restriction des services de reconstruction mammaire et les stratégies possibles pour en optimiser la prestation grâce à une évaluation pancanadienne du point de vue des chirurgiens. MÉTHODOLOGIE: La présente étude transversale a été effectuée auprès de chirurgiens plasticiens et reconstructeurs canadiens qui font de la reconstruction mammaire. Un groupe de travail pancanadien d'experts de la reconstruction mammaire a préparé le questionnaire en ligne en 33 points, lequel a été transmis par courriel aux membres de la Société canadienne de chirurgiens-plasticiens. Le questionnaire portait sur les répercussions de la pandémie de COVID-19 et les restrictions connexes sur les modes de pratique de reconstruction mammaire des chirurgiens, de même que sur leurs avis et stratégies à l'égard de l'utilisation des ressources. RÉSULTATS: Un total de 49 chirurgiens, qui ont déclaré exercer dans huit des dix provinces canadiennes, ont répondu au sondage. Les restrictions imposées aux interventions de reconstruction mammaire ont été plus limitées pendant la première vague de la pandémie COVID-19, puisque tous les répondants ont rendu compte d'au moins une certaine restriction de la capacité et que plus du quart ont fait état de leur arrêt complet. La diminution moyenne de la capacité a varié de 31 % à 78 % dans l'ensemble des trois vagues. Ce sont les reconstructions autologues, tardives et prophylactiques qui ont surtout été touchées. CONCLUSION: La présente étude fournit une évaluation pancanadienne des incidences de la pandémie de COVID-19 sur les services de reconstruction mammaire du point de vue des chirurgiens. Pour maintenir les normes des soins axés sur les patients, il faudra procéder à une réorganisation stratégique unifiée de la prestation des soins, tant maintenant qu'à l'avenir.

Identifying the top research priorities in postmastectomy breast cancer reconstruction: a James Lind Alliance priority setting partnership.

BACKGROUND: Major improvements in breast cancer treatment in the last decade include advancements in postmastectomy breast reconstruction (PMBR). Unfortunately, the studies in PMBR are primarily researcher or industry led with minimal input from patients and caregivers. The aim of this study is to use the James Lind Alliance (JLA) approach to bring together the patients, caregivers and clinicians in a priority setting partnership to identify the most important unanswered research questions in PMBR. METHODS: The JLA priority setting methodology involved four key stages: gathering research questions on PMBR from patients, caregivers and clinicians; checking these research questions against existing evidence; interim prioritisation and a final consensus meeting to determine the top 10 unanswered research questions using the modified nominal group methodology. RESULTS: In stage 1, 3168 research questions were submitted from 713 respondents across Canada, of which 73% of the participants were patients or caregivers. Stage 2 confirmed that there were a total of 48 unique unanswered questions. In stage three, 488 individuals completed the interim prioritisation survey and the top 25 questions were taken to a final consensus meeting. In the final stage, the top 10 unanswered research questions were determined. They cover a breadth of topics including personalised surgical treatment, safety of implants and newer techniques, access to PMBR, breast cancer recurrence and rehabilitation. INTERPRETATION: Identification of the top 10 unanswered research questions is an important first step to generating relevant and impactful research that will ultimately improve the PMBR experience for patients with breast cancer.

Development and Psychometric Validation of the BREAST-Q Sensation Module for Women Undergoing Post-Mastectomy Breast Reconstruction.

BACKGROUND: Reconstructive techniques for restoring sensation to the breast after mastectomy continue to evolve. The BREAST-Q is a patient-reported outcome measure that can be used to evaluate outcomes of breast cancer treatments; however, it previously lacked scales to measure breast sensation. This paper outlines the development and validation of the BREAST-Q Sensation Module. METHODS: Phase 1 (January 2017 through December 2018) involved qualitative and cognitive interviews with women who had undergone breast reconstruction, as well as expert input, to develop and refine the scales. In phase 2 (March through June 2019), Love Research Army (LRA) members completed the scales, and Rasch Measurement Theory (RMT) analysis was performed to examine the reliability and validity of the scales. RESULTS: In this study, 36 qualitative and 7 cognitive interviews were conducted, and input from 18 experts was obtained. Three scales were developed to measure breast Symptoms (e.g., throbbing, burning, tingling), Sensation (e.g., feeling with light touch, through clothing, sexually), and Quality of Life impact of sensation loss. In phase 2, 1204 LRA members completed the scales. Data for each scale fit the RMT model. Reliability was high, with Person Separation Index, Cronbach alpha, and intraclass correlation coefficient values of 0.81 or higher (with and without extremes) for all three scales. Mean scores were higher (better) on the Symptoms and Quality of Life impact scales for the participants with unilateral (vs. bilateral) and autologous (vs. alloplastic) reconstruction, and for the participants who were farther out from their reconstruction. CONCLUSION: The BREAST-Q Sensation Module can be used alone or in conjunction with other BREAST-Q scales to inform clinical care and to evaluate outcomes of new surgical approaches to restoration of breast sensation.

Development and Psychometric Validation of BREAST-Q Scales Measuring Cancer Worry, Fatigue, and Impact on Work.

BACKGROUND: The BREAST-Q is a patient-reported outcome measure for women with breast cancer. The aim of this study was to develop new BREAST-Q scales to measure Cancer Worry, Fatigue and Impact on Work. METHODS: Data were collected between January 2017 and November 2019. Phase 1 (qualitative) included participants from Canada and the USA, pre/post any type of breast cancer treatment (surgery, adjuvant, neoadjuvant). Interviews were audio-recorded, transcribed verbatim and coded line-by-line. New scales were drafted and refined through cognitive interviews and expert input. Phase 2 (field-test study) involved USA members of the Love Research Army (LRA). Rasch measurement theory analysis was used to examine reliability and validity. RESULTS: In phase 1, 57 women were interviewed. Three concepts were identified as important to the breast cancer experience that are not currently covered in the BREAST-Q and developed into scales, i.e., Cancer Worry, Fatigue and Impact on Work. Feedback from nine women and 23 experts was used to establish content validity. The scales were field-tested in the LRA sample (n = 1680), of whom 1006 completed a test-retest. Reliability was > 0.81 for the person separation index, > 0.89 for Cronbach's alpha and > 0.83 for interclass correlation coefficients. Lower scores on all three scales were significantly associated with being closer in time to diagnosis and having a higher cancer stage at diagnosis (p < 0.001 on ANOVA). CONCLUSION: These new scales expand the BREAST-Q measurement system and provide a means to evaluate additional important outcomes for breast cancer patients in clinical care and research.

Longitudinal Study of Psychosocial Outcomes Following Surgery in Women with Unilateral Nonhereditary Breast Cancer.

INTRODUCTION: Rates of bilateral mastectomy are rising in women with unilateral, nonhereditary breast cancer. We aim to characterize how psychosocial outcomes evolve after breast cancer surgery. PATIENTS AND METHODS: We performed a prospective cohort study of women with unilateral, sporadic stage 0-III breast cancer at University Health Network in Toronto, Canada between 2014 and 2017. Women completed validated psychosocial questionnaires (BREAST-Q, Impact of Event Scale, Hospital Anxiety & Depression Scale) preoperatively, and at 6 and 12 months following surgery. Change in psychosocial scores was assessed between surgical groups using linear mixed models, controlling for age, stage, and adjuvant treatments. P < .05 were significant. RESULTS: A total of 475 women underwent unilateral lumpectomy (42.5%), unilateral mastectomy (38.3%), and bilateral mastectomy (19.2%). There was a significant interaction (P < .0001) between procedure and time for breast satisfaction, psychosocial and physical well-being. Women having unilateral lumpectomy had higher breast satisfaction and psychosocial well-being scores at 6 and 12 months after surgery compared with either unilateral or bilateral mastectomy, with no difference between the latter two groups. Physical well-being declined in all groups over time; scores were not better in women having bilateral mastectomy. While sexual well-being scores remained stable in the unilateral lumpectomy group, scores declined similarly in both unilateral and bilateral mastectomy groups over time. Cancer-related distress, anxiety, and depression scores declined significantly after surgery, regardless of surgical procedure (P < .001). CONCLUSIONS: Psychosocial outcomes are not improved with contralateral prophylactic mastectomy in women with unilateral breast cancer. Our data may inform women considering contralateral prophylactic mastectomy.

Development and Psychometric Validation of the BREAST-Q Animation Deformity Scale for Women Undergoing an Implant-Based Breast Reconstruction After Mastectomy.

BACKGROUND: To assess the impact of animation deformity on health-related quality of life, a content-specific, valid, and reliable patient-reported outcome measure is needed. This report describes the development and validation of the BREAST-Q Animation Deformity scale. METHODS: Women with breast cancer who had an implant-based reconstruction provided data. In phase 1 (January 2017 and December 2018), qualitive and cognitive patient interviews and expert input were used to develop and refine scale content. In phase 2 (March to June 2019), a field test study with members of the Love Research Army (LRA) was conducted. Rasch Measurement Theory (RMT) analysis was used to examine psychometric properties. RESULTS: In phase 1 of the study, qualitative (n = 11) and cognitive (n = 4) interview data and expert input (n = 9) led to the development of a 12-item scale measuring animation deformity. In phase 2, 651 LRA members provided data and 349 participated in a test-retest study. In the RMT analysis, the data fit the Rasch model (X2(96) = 104.06; p = 0.27). The scale's reliability was high, with person separation index and Cronbach alpha values with/without extremes of ≥ 0.84 and ≥ 0.92 respectively, and an intraclass correlation coefficient of 0.92 (95% confidence interval, 0.90-0.94). Mean scores on the Animation Deformity scale varied as predicted across subgroups of participants who reported differing amounts of change in breast appearance when their arms were lifted overhead or when they lifted something heavy, and for increasing happiness with the overall outcome of their breast reconstruction. CONCLUSION: The 12-item Animation Deformity scale forms a new scale in the BREAST-Q Reconstruction Module that can be used in comparative effectiveness research or to inform clinical care.

An international mixed methods study to develop a new preference-based measure for women with breast cancer: the BREAST-Q Utility module.

BACKGROUND: Generic preference-based measures (PBM), though commonly used, may not be optimal for use in economic evaluations of breast cancer interventions. No breast cancer-specific PBM currently exists, and the generic PBMs fail to capture the unique concerns of women with breast cancer (e.g., body image, appearance, treatment-specific adverse effects). Hence, the objective of this study was to develop a breast cancer-specific PBM, the BREAST-Q Utility module. METHODS: Women diagnosed with breast cancer (stage 0-4, any treatment) were recruited from two tertiary hospitals in Canada and one in the US. The study followed an exploratory sequential mixed methods approach, whereby semi-structured interviews were conducted and at the end of the interview, participants were asked to list their top five health-related quality of life (HRQOL) concerns and to rate the importance of each item on the BREAST-Q. Interviews were audio-recorded, transcribed verbatim, and coded. Constant comparison was used to refine the codes and develop a conceptual framework. Qualitative and quantitative data were triangulated to develop the content of the Utility module  that was refined through 2 rounds of cognitive debriefing interviews with women diagnosed with breast cancer and feedback from experts. RESULTS: Interviews were conducted with 57 women aged 55 ± 10 years. A conceptual framework was developed from 3948 unique codes specific to breasts, arms, abdomen, and cancer experience. Five top-level domains were HRQOL (i.e., physical, psychological, social, and sexual well-being) and appearance. Data from the interviews, top 5 HRQOL concerns, and BREAST-Q item ratings were used to inform dimensions for inclusion in the Utility module. Feedback from women with breast cancer (N = 9) and a multidisciplinary group of experts (N = 27) was used to refine the module. The field-test version of the HSCS consists of 10 unique dimensions. Each dimension is measured with 1 or 2 candidate items that have 4-5 response levels each. CONCLUSION: The field-test version of the BREAST-Q Utility module was derived from extensive patient and expert input. This comprehensive approach ensured that the content of the Utility module is relevant, comprehensive, and includes concerns that matter the most to women with breast cancer.

Preconsultation Educational Group Intervention Can Address the Knowledge Gap in Postmastectomy Breast Reconstruction.

BACKGROUND: Whether to undergo postmastectomy breast reconstruction (PMBR) is a challenging, preference-sensitive decision. It is therefore paramount to optimize decision quality through ensuring patients' knowledge and aligning treatments with their personal preferences. This study assessed the effects of a preconsultation educational group intervention (PEGI) on patient knowledge, state-trait anxiety, and decisional conflict (patient uncertainty in decision making) during the decision-making process. METHODS: This phase 3 randomized controlled trial assessed effects of a PEGI in women without active breast cancer undergoing delayed PMBR, or prophylactic mastectomy with immediate PMBR. Both groups underwent routine education before consultation. In addition, the intervention group underwent a PEGI composed of presentations from a plastic surgeon and nurse, a value clarification exercise, and shared experiences from PMBR patients before the consultation with the plastic surgeon. Before and 1-week after consultation, outcome measures were assessed using the Decisional Conflict Scale, State-Trait Anxiety Inventory, and the BREAST-Q. RESULTS: Of the 219 women deemed eligible, a total of 156 women were recruited and randomized. Treatment fidelity was 96% and retention was 88%. At baseline, there were no significant differences in terms of demographic or clinical status, knowledge, state-trait anxiety, and decisional conflict. Patient knowledge about PMBR improved in both groups; however, the degree of knowledge attainment was significantly greater in the PEGI group (24.5% improvement in the intervention group compared with 13.5% in the routine education group, P < 0.001). The reduction in decisional conflict from baseline to follow-up was greater in the intervention group compared with the routine education; however, the difference only approached significance (P = 0.09). CONCLUSIONS: The provision of a preconsultation educational group intervention has been shown to significantly close the knowledge gap on PMBR in patients seeking delayed breast reconstruction or prophylactic mastectomy with immediate breast reconstruction compared with routine education alone.

Early Postoperative Complications From National Surgical Quality Improvement Program: A Closer Examination of Timing and Technique of Breast Reconstruction.

BACKGROUND: Despite the recent surge in rates of immediate breast reconstruction, there is a paucity of large multicenter studies to compare differences in morbidity after immediate versus delayed breast reconstruction. This study used the National Surgical Quality Improvement Program (NSQIP) to study the association between timing of breast reconstruction and complication rates, stratified by reconstructive modality. STUDY DESIGN: The NSQIP database was used to identify breast reconstructions from 2005 to 2012. Rates of major complications were compared by timing within each reconstructive modality (implant vs autologous). Cohort differences in baseline characteristics and variables associated with increased complication rates were identified in bivariate analyses. A multivariable model was created to compare the association between the timing of reconstruction and major complications. RESULTS: Of 24,506 postmastectomy reconstructions, 85.8% were immediate, 14.2% were delayed, 84% were implant, and 16% were autologous reconstructions. Overall, 10.0% of patients suffered a major complication. After stratification, only implant reconstructions showed a statistically higher complication rate with immediate (8.8%) reconstruction compared with delayed (5.3%) (odds ratio, 1.7, P < 0.01). There was no significant difference in complication rates between autologous immediate (18.4%) or delayed (19.0%) reconstructions. After controlling for baseline cohort differences and other risk factors, immediate reconstruction remained as an independent significant predictor of major complications in implant reconstructions (odds ratio, 1.8, P < 0.01). CONCLUSIONS: Immediate rather than delayed breast reconstruction is associated with a significantly higher rate of major complications in implant reconstruction but not in autologous reconstruction. It is important to include these findings in the routine preoperative surgeon-patient discussion of reconstructive options.

Contralateral prophylactic mastectomy at the time of delayed microvascular breast reconstruction adversely affects patient-reported outcomes: A retrospective cohort study.

PURPOSE: An increasing number of women with unilateral breast cancer are seeking bilateral mastectomies and reconstruction. At our centre, many women who have undergone previous unilateral therapeutic mastectomy request contralateral prophylactic mastectomy (CPM) at the time of delayed reconstruction. These mixed timing reconstructions are particularly challenging as patients have an immediate reconstruction on one side and delayed reconstruction on the other, which may result in asymmetry. This retrospective cohort study evaluates patient-reported satisfaction following mixed timing breast reconstruction and compares them to unilateral delayed reconstruction. METHODS: One hundred and forty-one patients who underwent successful deep inferior epigastric artery perforator (DIEP) flap breast reconstruction and completed baseline and 12-month BREAST-Qs were included in the study. Patient-reported outcomes following bilateral mixed timing reconstruction (n = 56) were compared to those of unilateral delayed reconstruction (UDR) without CPM (n = 85). RESULTS: Women who sought CPM were significantly younger and had lower annual incomes when compared with those who underwent unilateral reconstruction. Mixed timing reconstruction was associated with significantly lower levels of breast satisfaction and psychosocial function as compared to UDR at 12 months post-operatively. BREAST-Q scores (18 months) were available for 75 patients in the cohort and indicated that this decreased breast satisfaction and psychosocial impairment was sustained in the longer-term. CONCLUSIONS: Patients who seek CPM at the time of delayed reconstruction should be advised that this is associated with lower levels of breast satisfaction and psychosocial well-being as compared to unilateral delayed breast reconstruction.

Cross-sectional analysis of bibliometrics and altmetrics: comparing the impact of qualitative and quantitative articles in the British Medical Journal.

OBJECTIVES: In comparison to quantitative research, the impact of qualitative articles in the medical literature has been questioned by the BMJ; to explore this, we compared the impact of quantitative and qualitative articles published in BMJ. DESIGN: Cross-sectional survey. SETTING: Articles published in the BMJ between 2007 and 2017. MAIN OUTCOME MEASURES: Bibliometric and altmetric measures of research impact were collected using Web of Science, Google Scholar, Scopus, Plum Analytics and ProQuest Altmetric. Bibliometric measures consisted of citation numbers, field weighted citation impact and citation percentile. Altmetric measures consisted of article usage, captures, mentions, readers, altmetric attention score and score percentile. Scores were compared using the Wilcoxon Rank-sum test. RESULTS: We screened a total of 7777 articles and identified 42 qualitative articles. Each qualitative article was matched to 3 quantitative articles published during the same year (126 quantitative articles). Citation numbers were not statistically different between the two research types; the median number of citations (google scholar) per quantitative article was 62 (IQR 38-111) versus 58 (IQR 36-85) per qualitative article (p=0.47). Using Plum Analytics, qualitative articles were found to have a significantly higher usage, with a median of 984 (IQR 581-1351) versus 379 (IQR 177-763) for quantitative (p<0.001). The Altmetric Attention Score was higher for quantitative articles at 16 (IQR 7-37) versus qualitative articles at 9 (IQR 5-23, p=0.05), as was the Altmetric Score percentile 93 (IQR 87-96) versus 88 (IQR 76-95; p=0.02). CONCLUSION: Qualitative and quantitative articles published in the BMJ between 2007 and 2017 both have a high impact. No article type was consistently superior in terms of bibliometric or altmetric measures, suggesting that type of article is not the major driver of impact.

Reoperation cascade in postmastectomy breast reconstruction and its associated factors: Results from a long-term population-based study.

BACKGROUND: Unplanned surgeries following postmastectomy breast reconstruction (PMBR) may be required to treat complications or to revise the reconstructed breast. The primary objective of this study was to examine factors that influenced unplanned reoperations after PMBR. METHODS: A retrospective cohort study using provincial databases in Ontario, Canada, was completed. Patients with breast cancer underwent mastectomy between April 2002 and March 2012 followed by immediate or delayed PMBR. Primary outcome was time from PMBR to unplanned reoperations measured in years. The Anderson-Gill counting process model was used to estimate the risk of recurrent unplanned reoperations over time. Univariate and multivariate analyses were completed to examine the association between covariates. RESULTS: A total of 3066 women underwent PMBR and 51.7% had at least one unplanned reoperation. Unplanned breast reoperation was significantly associated with microsurgical tissue vs implant-based reconstruction (hazard ratio [HR]: 1.27), radiation after PMBR (HR: 1.22), surgery at a nonteaching hospital (HR: 1.16), patient comorbidity score (HR: 1.02), and prior unplanned reoperations (HR: 1.25). CONCLUSIONS: Our study provides important long-term population-level data regarding factors influencing unplanned reoperations after PMBR. Patients undergoing microsurgical PMBR or postmastectomy radiation had a higher rate of additional procedures. Every additional reoperation also increases the likelihood of unplanned reoperations resulting in a "reoperation cascade."