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1.
Plast Reconstr Surg ; 146(2): 127e-136e, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32740569

RESUMO

BACKGROUND: Reduction mammaplasty is the standard of care for symptomatic macromastia. The process of requesting insurance coverage for reduction mammaplasty is cumbersome and potentially controversial, and insurance policies vary significantly. The goal of our analysis is to identify trends in insurance coverage rates, assess for the presence of disparities, and propose ways to increase chances of successful preauthorization. METHODS: The authors performed a retrospective review of preauthorizations for reduction mammaplasty at a single institution from 2012 to 2017. Insurance company names were deidentified. Preauthorization denial rates were assessed by year, insurance carrier, and reason for denial. Multiple regression analysis was performed to identify predictors for predetermination denial by insurance companies. RESULTS: Among 295 preauthorizations, 212 were approved (72 percent) and 83 were denied (28 percent), among which 18 were appealed, 13 successfully. Rates of insurance denials have been increasing steadily, from 18 percent to 41 percent. Medicaid had the lowest denial rates (9.3 percent), whereas private carriers denials ranged from 21.4 to 62.1 percent. In terms of reason for denial, 30 percent were because of contract exclusion, 39 percent were because of inadequate documentation or not meeting medical criteria, and 12 percent were because of inadequate predicted resection weight. Certain private insurance carriers were the only independent predictors of predetermination denial. CONCLUSIONS: Rate of preauthorization denials is high and has been increasing steadily. Insurance criteria remain arbitrary. A proper documentation and appeal process by the plastic surgeon may improve rates of insurance approval. Although resection weight does not correlate with symptom relief, predicted breast tissue resection weight continues to be critical for insurance approval.


Assuntos
Mama/anormalidades , Hipertrofia/cirurgia , Reembolso de Seguro de Saúde/economia , Mamoplastia/economia , Garantia da Qualidade dos Cuidados de Saúde/normas , Adulto , Mama/cirurgia , Feminino , Seguimentos , Humanos , Cobertura do Seguro/economia , Mamoplastia/métodos , Estudos Retrospectivos , Estados Unidos
2.
Plast Reconstr Surg ; 145(5): 1125-1133, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32332524

RESUMO

BACKGROUND: Direct-to-implant breast reconstruction continues to grow in popularity among reconstructive breast surgeons and patients alike. Women with large breasts and ptosis are often thought not to be candidates for nipple sparing or direct-to-implant reconstruction. The authors utilized a single-stage, nipple-sparing, direct-to-implant reconstruction with simultaneous mastopexy, while the nipple-areolar complex was kept viable on an inferiorly based adipodermal flap in a single stage. They report their experience and outcomes using this approach in women with breast ptosis and/or macromastia. METHODS: The authors reviewed all direct-to-implant reconstructions with simultaneous nipple-sparing mastopexies performed from June of 2015 to March of 2019. Sixty-five patients and 125 breast reconstructions were analyzed. RESULTS: Among the 65 patients (125 breast reconstructions), 15 (23 percent) had implants placed in the prepectoral space, and 50 (77 percent) had them placed subpectorally. Forty-seven patients (72 percent) had acellular dermal matrix used. Partial nipple-areolar complex necrosis occurred in six patients (9 percent). Other complications included partial mastectomy flap necrosis (n = 8 patients, 12 percent), implant exposure (n = 3, 4 percent), infection (n = 1, 1 percent), capsular contracture (n = 4, 6 percent), and reoperation (n = 11, 16 percent). Mean follow-up was 17 months (range, 3 to 47 months). There have been no cancer recurrences reported in any participants to date. CONCLUSIONS: Nipple-sparing mastectomy with mastopexy and immediate direct-to-implant reconstruction dramatically improved the authors' results for implant-based breast reconstruction patients. The higher than expected explantation rate of 7 percent early in the study has since improved. This approach provides an opportunity to expand indications for nipple-sparing mastectomy and direct-to-implant reconstruction to women with breast ptosis and/or macromastia. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.


Assuntos
Mama/anormalidades , Hipertrofia/cirurgia , Mamoplastia/métodos , Mastectomia Subcutânea/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Retalhos Cirúrgicos/transplante , Derme Acelular , Adulto , Mama/cirurgia , Implantes de Mama/efeitos adversos , Neoplasias da Mama/cirurgia , Estética , Feminino , Seguimentos , Humanos , Mamoplastia/efeitos adversos , Mamoplastia/instrumentação , Pessoa de Meia-Idade , Mamilos/cirurgia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Resultado do Tratamento
3.
Plast Reconstr Surg ; 145(4): 914-920, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-32221203

RESUMO

BACKGROUND: Nipple-sparing mastectomy has been associated with superior aesthetic outcomes and oncologic safety. However, traditional contraindications, such as breast ptosis/macromastia, have excluded a large number of patients. The purpose of this study was to determine whether a staged approach would expand the indications for nipple-areolar complex preservation and permit greater control over nipple-areolar complex position and skin envelope following autologous reconstruction. METHODS: A retrospective analysis was conducted of female patients with a diagnosis of breast cancer or BRCA mutation with grade 2 or 3 ptosis and/or macromastia who underwent bilateral (oncoplastic) reduction/mastopexy (stage 1) followed by bilateral nipple-sparing mastectomy with immediate reconstruction with free abdominal flaps (stage 2). The authors were specifically interested in the incidence of mastectomy skin necrosis and nipple-areolar complex necrosis and malposition following stage 2. RESULTS: Sixty-one patients with a mean age of 45.1 years (range, 28 to 62 years) and mean body mass index of 32.6 kg/m (range, 23.4 to 49.0 kg/m) underwent reconstruction with 122 flaps. The mean interval between stage 1 and 2 was 16.9 weeks (range, 3 to 31 weeks). Clear margins were obtained in all cases of invasive cancer and in situ disease following stage 1. Complications following stage 2 included partial nipple-areolar complex necrosis (n = 5, 8.2 percent), complete nipple-areolar complex necrosis (n = 4, 6.6 percent), nipple-areolar complex malposition (n = 1, 1.6 percent), and mastectomy skin necrosis (n = 4, 6.6 percent). No flap loss was noted in this series. CONCLUSION: Patients with moderate to severe breast ptosis and/or macromastia who wish to undergo mastectomy with reconstruction can be offered nipple-sparing approaches safely if a staged algorithm is implemented. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.


Assuntos
Neoplasias da Mama/cirurgia , Mama/anormalidades , Hipertrofia/cirurgia , Mamoplastia/métodos , Mastectomia/métodos , Mamilos/cirurgia , Tratamentos com Preservação do Órgão/métodos , Adulto , Proteína BRCA2/genética , Mama/cirurgia , Neoplasias da Mama/genética , Feminino , Retalhos de Tecido Biológico , Humanos , Hipertrofia/genética , Pessoa de Meia-Idade , Mutação/genética , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Transplante Autólogo , Ubiquitina-Proteína Ligases/genética
4.
Plast Reconstr Surg ; 145(6): 1022e-1028e, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32195861

RESUMO

BACKGROUND: Reduction mammaplasty is a well-established procedure. Studies have shown benefits of using antibiotics in this procedure. Nevertheless, there is no solid evidence to support postoperative antibiotic prophylaxis. The authors evaluated the influence of postoperative antibiotic delivery on infection rates after reduction mammaplasty. METHODS: The authors conducted a randomized trial of noninferiority, with two parallel groups, with triple blinding. The participants were 124 women with breast hypertrophy, with reduction mammaplasty already scheduled, selected consecutively. All patients underwent reduction mammaplasty, performed by the same surgical team, using the superomedial pedicle technique for ascending the nipple-areola complex. All patients received cephalothin (1 g) intravenously at the anesthetic induction and every 6 hours for 24 hours. At hospital discharge, they were assigned randomly to either the placebo (n = 62) or antibiotic group (n = 62) and were instructed to take identical capsules containing 500 mg of cephalexin or placebo, respectively, every 6 hours, for 7 days. Patients were assessed weekly, for 4 weeks, regarding the occurrence of surgical-site infection, by a surgeon who was unaware of the allocation. The criteria and definitions of the Centers for Disease Control and Prevention were adopted. RESULTS: There was no statistical difference between groups regarding age, body mass index, or resected breast tissue weight. The overall surgical-site infection rate was 0.81 percent. Only one patient, allocated to the antibiotic, presented infection, classified as superficial incisional (p = 1.00). In the placebo group, surgery time was higher (p = 0.003). CONCLUSION: The maintenance of antibiotics in the postoperative period of reduction mammaplasty did not influence the rates of surgical-site infection. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, I.


Assuntos
Antibacterianos/uso terapêutico , Antibioticoprofilaxia/métodos , Mamoplastia/efeitos adversos , Cuidados Pós-Operatórios/métodos , Infecção da Ferida Cirúrgica/epidemiologia , Adulto , Mama/anormalidades , Mama/cirurgia , Cefalotina/uso terapêutico , Feminino , Seguimentos , Humanos , Hipertrofia/cirurgia , Incidência , Infecção da Ferida Cirúrgica/etiologia , Infecção da Ferida Cirúrgica/prevenção & controle , Resultado do Tratamento
5.
Plast Reconstr Surg ; 145(3): 499e-506e, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-32097298

RESUMO

BACKGROUND: Breast reduction mammaplasty is a common plastic surgery operation. Although many contemporary surgeons provide breast reduction mammaplasty as an outpatient procedure, roughly 15 percent of patients are still observed postoperatively. The authors hypothesize that observation confers no safety benefit but engenders significant cost. METHODS: The authors reviewed cases of breast reduction mammaplasty in a commercial database and formulated three propensity score-matched cohorts: inpatient, 23-hour observation, and outpatient. Comparisons were made between inpatients and outpatients and between 23-hour observation patients and outpatients. The primary outcome variable was 14-day re-presentation rate to the emergency department or readmission. Financial data were also collected. RESULTS: Comparison of inpatients and outpatients included 1237 patients each (n = 2474 total patients). The 23-hour observation-outpatient comparison included 8153 patients each (n = 16,306 total patients). For inpatients versus outpatients, the 14-day re-presentation rate was 1.4 percent for inpatients and 0.3 percent for outpatients (p < 0.01). The overall surgical complication rate was higher for inpatients (7.8 percent) than for outpatients (4.9 percent) (p < 0.01). Comparing outpatients to 23-hour observation patients, the 14-day re-presentation rate was similar (0.5 percent observation versus 0.3 percent outpatient; p = 0.10). The complication rate was higher for 23-hour observation patients (4.8 percent) than for outpatients (3.2 percent) (p < 0.01). When compared with outpatients (median, $9077), inpatients (median, $19,975) generated $10,898 more in costs. Similarly, 23-hour observation patients (median, $12,451) generated $4050 more in costs than outpatients (median, $8401) (p < 0.01). CONCLUSIONS: Outpatient breast reduction mammaplasty is equally safe when compared to observation or admission. Non-outpatient breast reduction mammaplasty had median costs of 148 to 220 percent that of outpatient breast reduction mammaplasty. In an era of cost consciousness, ambulatory reduction mammaplasty may offer a relatively simple method of decreasing expenditures. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.


Assuntos
Procedimentos Cirúrgicos Ambulatórios/economia , Mama/anormalidades , Hipertrofia/cirurgia , Mamoplastia/economia , Cuidados Pós-Operatórios/economia , Complicações Pós-Operatórias/epidemiologia , Demandas Administrativas em Assistência à Saúde/estatística & dados numéricos , Adulto , Procedimentos Cirúrgicos Ambulatórios/efeitos adversos , Procedimentos Cirúrgicos Ambulatórios/métodos , Mama/cirurgia , Estudos de Coortes , Análise Custo-Benefício , Bases de Dados Factuais/estatística & dados numéricos , Feminino , Custos de Cuidados de Saúde/estatística & dados numéricos , Humanos , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Masculino , Mamoplastia/efeitos adversos , Mamoplastia/métodos , Pessoa de Meia-Idade , Readmissão do Paciente/economia , Readmissão do Paciente/estatística & dados numéricos , Cuidados Pós-Operatórios/métodos , Cuidados Pós-Operatórios/estatística & dados numéricos , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Pontuação de Propensão , Fatores de Tempo , Estados Unidos/epidemiologia
6.
J Plast Reconstr Aesthet Surg ; 73(4): 690-695, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-31928958

RESUMO

BACKGROUND: Breast reconstruction is routinely used to alleviate the psychological adverse effects of mastectomy. Nipple preservation further improves the cosmetic result, and causes less trauma on the body surface. Nipple-sparing mastectomy, however, comes with challenges, especially in the case of large, ptotic breasts to the degree that large-sized breasts have conventionally been a contraindication for nipple preservation. In this report, we describe a novel technique for nipple preservation in immediate reconstruction of large, ptotic breasts. METHODS: From 2013 to 2018, 24 patients (30 breasts) with large, ptotic breasts were treated with mastectomy and immediate reconstruction with nipple preservation. Median BMI was 28 and 8 patients were smokers. The technique involves the de-epithelialisation of a large area of the breast skin, the mastectomy through a lateral full-thickness incision within the de-epithelialised area, imbrication of the de-epithelialised skin, lifting of the nipple to a higher position and finally closure of wound. RESULTS: There were no full, 4 partial nipple necroses and 3 re-operations were done under local anaesthetic to correct partial peripheral necrosis of the areola. Six patients needed seroma aspiration and 4 presented with cellulitis. No implants were lost and there were no delays to adjuvant treatment. CONCLUSIONS: The proposed technique has significant advantages and may be ideal when large skin reductions are necessary in immediate breast reconstruction with nipple preservation. The low complication rate makes the method ideal when adjuvant treatment is to follow and/or patients are of high risk for surgical complications.


Assuntos
Mama/anormalidades , Mama/patologia , Mama/cirurgia , Procedimentos Cirúrgicos Dermatológicos/métodos , Hipertrofia/cirurgia , Mamoplastia/métodos , Mastectomia Subcutânea/métodos , Adulto , Idoso , Feminino , Humanos , Pessoa de Meia-Idade , Mamilos , Tamanho do Órgão
7.
Support Care Cancer ; 28(3): 1481-1489, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31273506

RESUMO

PURPOSE: We conducted a randomized, double-blind, vehicle-controlled clinical trial to investigate the use of a new proprietary hyaluronan (HA) formulation for the prevention of acute skin toxicity in breast cancer patients undergoing radiotherapy (RT). METHODS: Thirty women with breast cancer undergoing whole breast RT were enrolled. Each patient was randomly assigned to HA formulation (study cream, S) on the medial or lateral half of the irradiated breast and the control cream (placebo, P) on the other half. The primary endpoint was physician's evaluation of skin symptoms at week 5 during RT and week 2 post-RT. We also collected patients' independent assessment of skin after RT, patient's product preference, and an independent physician panel assessment of skin reactions based on photographs. RESULTS: Twenty-eight patients were evaluable. On physician's evaluation, there was no significant difference in radiation dermatitis between S and P and no overall preference to either cream at week 5 during or week 2 post-RT. More patients preferred S in evaluating skin appearance and skin reactions, but this did not reach statistical significance. Univariate analysis showed that physicians had an overall preference to the S cream at week 2 post-RT in patients with larger breasts. On the independent panel assessment, 3 reviewers saw no significant difference in radiation toxicity, whereas one reviewer reported better skin outcome with S cream at week 5. CONCLUSIONS: We found a nonstatistically significant patient preference but overall no significant radioprotective effects for this HA formulation compared with placebo except in patients with larger breasts. TRIAL REGISTRATION: The study was registered at www.clinicaltrials.gov (NCT02165605).


Assuntos
Neoplasias da Mama/radioterapia , Mama/anormalidades , Ácido Hialurônico/uso terapêutico , Hipertrofia/prevenção & controle , Lesões por Radiação/prevenção & controle , Radiodermatite/prevenção & controle , Adulto , Idoso , Mama/efeitos dos fármacos , Mama/efeitos da radiação , Método Duplo-Cego , Feminino , Humanos , Pessoa de Meia-Idade , Pomadas , Radiodermatite/tratamento farmacológico , Pele/patologia , Pele/efeitos da radiação
8.
Ann R Coll Surg Engl ; 102(2): 115-119, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31538808

RESUMO

BACKGROUND: Surgical management of breast cancer with gigantomastia can be challenging when planning breast conservation, as major breast reduction is required. Complex oncoplastic procedures can carry an additional surgical risk in this situation. We suggest batwing mammoplasty as a simple and safe oncoplastic procedure for those patients. MATERIALS AND METHODS: Fourteen patients with gigantomastia diagnosed with breast cancer were included in this prospective cohort study. All underwent batwing mammoplasty and contralateral symmetrisation procedure between May 2016 and June 2018. Patient satisfaction assessed by the Breast-Q questionnaire. RESULTS: All patients had a body mass index above 30kg/m2 with a mean of 36.7kg/m2 (range 31.6-44.9kg/m2). The mean distance from midclavicular point to nipple was 42cm (range 38-50cm). The mean operative time was 83 minutes for procedures done by a single surgeon. Mean specimen weight was 1.2kg (ranging from 1.035-1.63kg). Postoperative complications occurred in 14.2% of patients. Nipple-areola complex viability was not compromised nor sensation impaired. The mean Breast-Q score for patient satisfaction with breasts was 68.6 (range 61-74). The mean score for physiological wellbeing was 77.3 (range 64-84) and the mean score for physical wellbeing was 35 (range 31-40). CONCLUSION: Batwing mammoplasty is a safe and simple oncoplastic procedure in patients who have breast cancer with gigantomastia. It has short operative time and low complications rate. In our cohort of patients, there was no delay in the delivery of adjuvant treatment. The cosmetic outcome was favourable with a high patient satisfaction.


Assuntos
Neoplasias da Mama/cirurgia , Mama/anormalidades , Hipertrofia/cirurgia , Mamoplastia/métodos , Mastectomia/métodos , Complicações Pós-Operatórias/epidemiologia , Adulto , Idoso , Mama/cirurgia , Neoplasias da Mama/complicações , Feminino , Humanos , Hipertrofia/complicações , Mamoplastia/efeitos adversos , Mastectomia/efeitos adversos , Pessoa de Meia-Idade , Duração da Cirurgia , Satisfação do Paciente , Complicações Pós-Operatórias/etiologia , Estudos Prospectivos , Resultado do Tratamento
9.
Br J Radiol ; 93(1105): 20190328, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31661305

RESUMO

OBJECTIVE: Exposure to sex hormones is important in the pathogenesis of breast cancer and inability to tolerate such exposure may be reflected in increased asymmetrical growth of the breasts. This study aims to characterize, for the first time, asymmetry in breast volume (BV) and radiodense volume (DV) in a large ethnically diverse population. METHODS: Automated measurements from digital raw mammographic images of 54,591 cancer-free participants (aged 47-73) in a UK breast screening programme were used to calculate absolute (cm3) and relative asymmetry in BV and DV. Logistic regression models were fitted to assess asymmetry associations with age and ethnicity. RESULTS: BV and DV absolute asymmetry were positively correlated with the corresponding volumetric dimension (BV or DV). BV absolute asymmetry increased, whilst DV absolute asymmetry decreased, with increasing age (P-for-linear-trend <0.001 for both). Relative to Whites, Blacks had statistically significantly higher, and Chinese lower, BV and DV absolute asymmetries. However, after adjustment for the corresponding underlying volumetric dimension the age and ethnic differences were greatly attenuated. Median relative (fluctuating) BV and DV asymmetry were 2.34 and 3.28% respectively. CONCLUSION: After adjusting for the relevant volumetric dimension (BV or DV), age and ethnic differences in absolute breast asymmetry were largely resolved. ADVANCES IN KNOWLEDGE: Previous small studies have reported breast asymmetry-breast cancer associations. Automated measurements of asymmetry allow the conduct of large-scale studies to further investigate these associations.


Assuntos
Densidade da Mama/etnologia , Mama/anormalidades , Mama/diagnóstico por imagem , Grupos Étnicos/estatística & dados numéricos , Fatores Etários , Idoso , Feminino , Humanos , Mamografia , Pessoa de Meia-Idade , Estudos Retrospectivos
10.
Plast Reconstr Surg ; 144(5): 743e-750e, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31688748

RESUMO

BACKGROUND: Reduction mammaplasty is the most effective means of improving symptoms of macromastia. Although studies have shown lasting benefits in adult patients, there is a paucity of data that explore this topic in young patients. In this study, the long-term satisfaction and well-being of young reduction mammaplasty patients was assessed. METHODS: A retrospective review was performed for all female patients younger than 25 years who underwent reduction mammaplasty performed by a single surgeon from 1980 to 2003. Demographic characteristics, comorbidities, surgical details, and length of follow-up were recorded. Participants completed the postoperative version of the BREAST-Q Reduction module. Responses were scored on a scale of 0 to 100. Scores were summarized with descriptive statistics and compared to normative values. RESULTS: Thirty-seven of 52 eligible participants completed the survey (response rate, 71.2 percent). Median age at surgery was 21 years (range, 12.4 to 24.6 years), and median follow-up was 21.4 years (range, 11.4 to 32.4 years). Overall, participants demonstrated high satisfaction and well-being. Mean Q-Scores for Satisfaction with Breasts and Sexual Well-being were significantly higher than normative values (p = 0.0012 and p < 0.0001, respectively), and were as follows: Satisfaction with Breasts, 66.6 ± 16.5 (normative, 57 ± 16); Psychosocial Well-being, 75.9 ± 21.3 (normative, 68 ± 1 9); Sexual Well-being, 72 ± 18.2 (normative, 55 ± 19); and Physical Well-being, 81.1 ± 13.6 (normative, 76 ± 11). CONCLUSIONS: Young reduction mammaplasty patients experience excellent breast-related quality of life decades after surgery. Compared with normative values, young reduction mammaplasty patients reported higher satisfaction with breasts and sexual well-being. Surgeons and third-party payers should be aware of these data and advocate for young patients to gain access to care.


Assuntos
Mama/anormalidades , Hipertrofia/cirurgia , Mamoplastia/métodos , Mamoplastia/psicologia , Qualidade de Vida , Inquéritos e Questionários , Centros Médicos Acadêmicos , Mama/cirurgia , Estudos de Coortes , Feminino , Humanos , Hipertrofia/psicologia , Modelos Lineares , North Carolina , Satisfação do Paciente , Estudos Retrospectivos , Adulto Jovem
12.
Niger J Clin Pract ; 22(9): 1304-1306, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31489872

RESUMO

Macromastia can cause serious psychological problems in women as well as psychosocial problems due to esthetic appearances. For this reason, proper technique in breast reduction surgery yields a dramatic physical and psychological improvement for the patient. Inverted T-scar breast reduction using the inferior pedicle technique is the most commonly used breast reduction method. The most common complication in this technique regards wound healing at the T-junction area. There are no literature reports citing the use of local flaps for the repair of tissue defects in the T-junction area following reduction mammoplasty. In this study, we present a case of using a salvaged local, Limberg-like fasciocutaneous flap for tissue defect repair at the T-junction area after the inverted T-scar reduction mammoplasty using an inferior pedicle.


Assuntos
Mama/anormalidades , Hipertrofia/cirurgia , Mamoplastia/métodos , Retalhos Cirúrgicos , Adulto , Arritmias Cardíacas , Mama/cirurgia , Cicatriz , Feminino , Humanos , Mamoplastia/efeitos adversos , Resultado do Tratamento
14.
Plast Reconstr Surg ; 144(5): 1023-1032, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31373992

RESUMO

BACKGROUND: Nipple-sparing mastectomy in patients with large, ptotic breasts is a reconstructive challenge. Staged breast reduction before prophylactic nipple-sparing mastectomy has been shown to decrease complications; however, a direct comparison of outcomes between staged and nonstaged techniques is lacking. METHODS: A retrospective review of all patients that underwent staged breast reduction before nipple-sparing mastectomy was conducted. Staged cases were matched to nonstaged nipple-sparing mastectomy cases according to known risk factors for complications. Individual staged cases with appropriate matches in all these categories were then each paired to two nonstaged cases according to the nearest higher and lower mastectomy weight. Staged and nonstaged cohorts were compared with regard to demographics, operative characteristics, and reconstructive outcomes. RESULTS: Eighteen staged breast reductions were identified, performed at an average of 5.0 months before nipple-sparing mastectomy. Staged reductions were matched to 36 prophylactic nonstaged reductions. Average combined mastectomy weight (breast reduction and mastectomy weight) in the staged group was significantly higher than in the nonstaged group (992.6 g versus 640 g; p = 0.0004), although isolated mastectomy weights were comparable (607.1 g versus 640.0 g, respectively; p = 0.6311). Major mastectomy flap necrosis rates were significantly lower in the staged cohort than in the nonstaged cohort (0 percent versus 22.2 percent, respectively; p = 0.0415). Rates of minor mastectomy flap necrosis, partial nipple necrosis, and explantation trended lower in the staged cohort. CONCLUSION: In patients with large breast size, staged breast reduction before nipple-sparing mastectomy had significantly lower rates of major flap necrosis compared with nonstaged cases after controlling for other known risk factors for complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.


Assuntos
Índice de Massa Corporal , Mama/anormalidades , Hipertrofia/cirurgia , Mamoplastia/métodos , Mastectomia Subcutânea/métodos , Satisfação do Paciente/estatística & dados numéricos , Adulto , Mama/cirurgia , Estudos de Casos e Controles , Feminino , Seguimentos , Humanos , Mamoplastia/efeitos adversos , Mastectomia Subcutânea/efeitos adversos , Pessoa de Meia-Idade , Mamilos , Seleção de Pacientes , Complicações Pós-Operatórias/fisiopatologia , Complicações Pós-Operatórias/cirurgia , Reoperação/métodos , Estudos Retrospectivos , Medição de Risco , Resultado do Tratamento
15.
Gynecol Obstet Fertil Senol ; 47(9): 650-654, 2019 09.
Artigo em Francês | MEDLINE | ID: mdl-31386918

RESUMO

OBJECTIVE: Describe our experience of Oncoplasty according to Thorek in gigantomastia with hard and less plastic breasts and a major ptosis. METHODOLOGY: Thirteen cases of breast carcinoma on gigantomastia operated using the Thorek technique between 2014 and 2019 in Burkina Faso were analyzed retrospectively. The operative indications, technique and results were considered. Breast Q was used to assess patient satisfaction. RESULTS: The indication of oncoplasty by the Thorek's technique was breast lower quadrants carcinoma, associated with a major ptosis, gigantomastia. There was a consequence on the spine in 9 over 13 cases. The breasts were hard and less plastic, making the other breast reduction techniques difficult. This technique helped remove the carcinoma, reduce the volume of the breast and address the ptosis. The patients were satisfied with the volume of the remaining breasts and their aesthetic look. The resection margins were safe. Two cases of aerolar dyschromia were noticed. CONCLUSION: The Thorek technique remains an alternative concerning tumours on gigantomastia, with hard and less plastic breasts and a major ptosis. The results combine carcinological and aesthetic requirements.


Assuntos
Neoplasias da Mama/complicações , Neoplasias da Mama/cirurgia , Mama/anormalidades , Hipertrofia/complicações , Mamoplastia/métodos , Mama/patologia , Mama/cirurgia , Burkina Faso , Feminino , Humanos , Hipertrofia/patologia , Hipertrofia/cirurgia , Satisfação do Paciente , Estudos Retrospectivos
16.
Aust J Gen Pract ; 48(3): 146-151, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-31256478

RESUMO

BACKGROUND AND OBJECTIVES: While breast cancer is rare in adolescents and young adults (AYAs), breast symptoms are common. The aim of this study was to report breast symptoms that prompted referral of AYAs and to examine diagnoses and treatment. METHOD: A retrospective study of AYAs aged ≤25 years who presented in a specialist breast clinic (2007-18) was conducted. Data regarding presentation, diagnosis and management were collected. RESULTS: One hundred and thirty-four (128 female, six male) AYAs, with a median age of 21 years, attended the breast clinic in the study period. There was one case of breast cancer (incidence 0.8%). In females, the most frequent presenting symptoms were 'lump' (n = 68, 53.1%), 'nipple/areola symptom' (n = 14, 10.9%) and 'discuss risk of breast cancer' (n = 10, 8.3%). In males, 'lump' was the most common presenting symptom (n = 5, 83%) and all were cases of gynaecomastia. DISCUSSION: A range of breast symptoms are found in AYAs and most can be treated conservatively. Awareness of symptoms and their management will help general practitioners treat young people with breast issues.


Assuntos
Mama/anormalidades , Síndrome , Adolescente , Instituições de Assistência Ambulatorial/organização & administração , Instituições de Assistência Ambulatorial/estatística & dados numéricos , Mama/lesões , Neoplasias da Mama/complicações , Neoplasias da Mama/psicologia , Feminino , Humanos , Incidência , Masculino , Dor/etiologia , Estudos Retrospectivos , Adulto Jovem
17.
Plast Reconstr Surg ; 144(1): 18e-27e, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31246797

RESUMO

BACKGROUND: Reduction mammaplasty is a highly effective procedure for treatment of symptomatic macromastia. Prediction of resection weight is important for the surgeon and the patient, but none of the current prediction models is widely accepted. Insurance carriers are arbitrarily using resection weight to determine medical necessity, despite published literature supporting that resection weight does not correlate with symptomatic relief. What is the most accurate method of predicting resection weight and what is its role in breast reduction surgery? METHODS: The authors conducted a retrospective review of patients who underwent reduction mammaplasty at a single institution from 2012 to 2017. A senior biostatistician performed multiple regression analysis to identify predictors of resection weight, and linear regression models were created to compare each of the established prediction scales to actual resected weight. Patient outcomes were evaluated. RESULTS: Three-hundred fourteen patients were included. A new prediction model was created. The Galveston scale performed the best (R = 0.73; p < 0.001), whereas the Schnur scale performed the worst (R = 0.43; p < 0.001). The Appel and Descamps scales had variable performance in different subcategories of body mass index and menopausal status (p < 0.01). Internal validation confirmed the Galveston scale's best predictive value; 38.6 percent and 28.9 percent of actual breast resection weights were below Schnur prediction and 500-g minimum, respectively, yet 97 percent of patients reported symptomatic improvement or relief. CONCLUSIONS: The authors recommend a patient-specific and surgeon-specific approach for prediction of resection weight in breast reduction. The Galveston scale fits the best for older patients with higher body mass indices and breasts requiring large resections. Medical necessity decisions should be based on patient symptoms, physical examination, and the physician's clinical judgment. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, IV.


Assuntos
Mama/anormalidades , Hipertrofia/cirurgia , Adulto , Índice de Massa Corporal , Peso Corporal , Mama/cirurgia , Feminino , Humanos , Reembolso de Seguro de Saúde , Mamoplastia/métodos , Pessoa de Meia-Idade , Tamanho do Órgão , Análise de Regressão , Estudos Retrospectivos
18.
Pan Afr Med J ; 32: 50, 2019.
Artigo em Francês | MEDLINE | ID: mdl-31143355

RESUMO

We here report the case of a 29-year old gravida 2, para 2 patient with no particular past medical history. Symptoms evolved over 2 months and were marked by bilateral breast growth impairing her daily activities. Clinical examination showed hypertrophied breasts and bilateral breast ulcers. She had a history of 28-weeks amenorrhea. Anatomopathological examination of ulcers showed fleshy bud-like tissue. The patient had high levels of prolactin (1345 µUI/ml). The levels of FSH and LH were normal. The patient underwent bromocriptine therapy without success. Patient's evolution was marked by decrease in size and regression in skin ulcers six months after vaginal birth. Gestational gigantomastia is a breast hypertrophy characterized by a breast volume exceeding 1500 cm3 . Its cause is unknown. Radical treatment is based on bilateral mastectomy.


Assuntos
Mama/anormalidades , Hipertrofia/patologia , Complicações na Gravidez/patologia , Prolactina/sangue , Adulto , Mama/patologia , Bromocriptina/administração & dosagem , Feminino , Humanos , Gravidez
19.
Diagn Interv Radiol ; 25(4): 265-269, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31124788

RESUMO

PURPOSE: We aimed to evaluate the detectability of contrast enhancing lesions, initially demonstrated in standard prone dynamic contrast-enhanced MRI (DCE-MRI), in a supplementary supine breast MRI examination performed following the standard prone DCE-MRI examination and to show the correlation of spatial displacement of the lesions with breast size and density. METHODS: Forty-two patients with 45 lesions were prospectively evaluated. Supine breast MRI was acquired with a 6-channel body coil following a standard DCE-MRI in prone position after repositioning the patient. No additional contrast media was administered. Images were evaluated by two radiologists in consensus for the visibility of the lesions. Lesion localization relative to the sternal midline, chest wall and nipple was measured in both prone and supine positions. Correlations between lesion displacement and breast size or breast density were analyzed. RESULTS: Of 45 lesions, 23 (52.3%) were masses, 22 (47.7%) were nonmass enhancements (NME). Forty-four lesions (97.8%) could be detected on supine images. One linear NME of 33 mm in length could not be seen on supine images. Twenty (46.5%) of the detected lesions in supine position were equal to or smaller than 10 mm (11 NME [55%] and 9 masses [45%]). Lesion displacement relative to the chest wall increased with increasing breast size (P < 0.001). CONCLUSION: An abbreviated supine sequence following a standard prone DCE-MRI with single contrast media administration is an effective method for defining the lesion location in supine position.


Assuntos
Neoplasias da Mama/diagnóstico por imagem , Mama/diagnóstico por imagem , Meios de Contraste/administração & dosagem , Imagem por Ressonância Magnética/métodos , Adulto , Mama/anormalidades , Mama/patologia , Neoplasias da Mama/patologia , Carcinoma Intraductal não Infiltrante/diagnóstico por imagem , Feminino , Humanos , Hipertrofia/diagnóstico por imagem , Hipertrofia/patologia , Imageamento Tridimensional , Imagem por Ressonância Magnética/estatística & dados numéricos , Pessoa de Meia-Idade , Decúbito Ventral/fisiologia , Estudos Prospectivos , Radiologistas , Decúbito Dorsal/fisiologia , Parede Torácica/diagnóstico por imagem
20.
Work ; 62(4): 647-656, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31104050

RESUMO

BACKGROUND: Clinical Breast Examination (CBE) is the examination of a women's breasts by a healthcare professional, such as a breast surgeon, family physician or breast-care nurse who is trained to recognise many different types of abnormalities and warning signs in the breast [1]. CBE is particularly important in rural areas and developing countries who have limited access to technology such as mammography. CBE needs to be taught to health professionals like any other clinical skill used by medical professionals in the workplace. CBE in part involves palpation of the breast, that is, determining by touch which breast lumps are normal and which are suspicious in feeling. The gold standard for assessing tactile skills in CBE is seeing whether students can accurately identify and discriminate between different breast lumps also known as masses (IDBM) on actual patients in a clinical setting. However, this is not practical in a medical education setting. Usually the testing methods 'go through the motions' of feeling the breast as part of CBE. So the students' technique is examined either using unrealistic simulation models or using an intimate examination associate (IEA), an actor/volunteer who permits students to examine their intimate body parts such as breast or genitals for teaching purposes. These volunteers do not have any abnormalities so this teaching does not include the actual detection of suspicious lumps. We undertook a study of clinical skill with 10 medical students to examine different methods of assessing novice student clinical skills after a brief training in CBE. OBJECTIVES: This study aims to evaluate the effectiveness of current training and assessment of novice students in CBE and their capacity to identify and discriminate breast masses (IDBM) on actual patients. METHODS: We assessed each student's IDBM ability in an actual clinical situation, a breast clinic with a mixture of eight IEAs and one real patient with a large, easily palpable, putative breast cancer. We recruited 10 clinically inexperienced medical students, who were trained for 30 minutes by two breast surgeons using an IEA. Students were tested in a simulated clinical setting, a breast clinic where each examined 4 IEAs and one patient. The students were blind to who was the real patient and who was an IEA. Patients were examined by a breast surgeon in private prior to the commencement in the study. The breast surgeon recorded any clinical finding on the patients during the initial examination. The surgeon coached each patient on how to mark the students and showed the patient their results so the patients had a benchmark. After each examination was finished the students had four different assessments: 1) patients marked each student, 2) students were independently proctored - that is, marked by an expert, 3) students recorded their clinical findings and 4) students recorded how confident they were that they had the correct findings. Results from different kinds of student assessments were compared.RESULTSA chi-square test for independence between true positive or negative masses versus student-assessed positive or negative masses was not significant at alpha = .05. This means that there was no statistical association in the indication of positive or negative presence of masses versus whether such masses were actually present or absent. By comparison, experts (breast surgeons) were able to detect normal and abnormal breast masses by palpation alone 100% of the time and rate their confidence level as 'certain'. Unlike the experts, student self-reported confidence was unrelated to their competence score (CS). Proctoring was inversely related to the students' CS.CONCLUSIONSThe main conclusion is that novice students do not seem to be able to accurately detect breast masses in a clinical setting even after training. On the basis of these results, we believe that a comprehension component in the current CBE testing is needed in addition to the current methods of testing.


Assuntos
Neoplasias da Mama/diagnóstico , Mama/anormalidades , Exame Físico/normas , Adulto , Mama/fisiopatologia , Distribuição de Qui-Quadrado , Competência Clínica/normas , Educação de Graduação em Medicina/métodos , Avaliação Educacional/métodos , Feminino , Humanos , Palpação/métodos , Palpação/normas , Exame Físico/métodos , Estudantes de Medicina/estatística & dados numéricos
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