Current trends in breast reconstruction: survey of American Society of Plastic Surgeons 2010.

BACKGROUND: We conducted a retrospective survey of American Society of Plastic Surgeons to ascertain the current trends in breast reconstruction (BR). METHODS: Surveys were sent to 2250 active American Society of Plastic Surgeons members by e-mail with a cover letter including the link using Survey Monkey for the year 2010. In all, 489 surveys (a response rate of 21.7%) were returned. Three hundred fifty-eight surveys from respondents performing BR in their practices were included in the study. The survey included questions on surgeon demographics, practice characteristics, BR after mastectomy, number of BR per year, type and timing of BR, use of acellular dermal matrix, reconstructive choices in the setting of previous irradiation and in patients requiring postmastectomy radiation therapy, timing of contralateral breast surgery, fat grafting, techniques used for nipple-areola reconstruction, the complications, and physician satisfaction and physician reported patient satisfaction. Returned responses were tabulated and assessed. RESULTS: After prophylactic mastectomy, 16% of BRs were performed. In all, 81.2% of plastic surgeons predominantly performed immediate BR. In patients requiring postmastectomy radiation therapy, 81% did not perform immediate BR. Regardless of practice setting and laterality of reconstruction, 82.7% of respondents predominantly performed implant-based BR. Half of the plastic surgeons performing prosthetic BR used acellular dermal matrix. Only 14% of plastic surgeons predominantly performed autologous BR. Surgeons in solo, plastic surgery group practices, and multispecialty group practices preferred implant-based BR for both unilateral and bilateral cases more frequently than those in academic practices (P < 0.05). Overall, plastic surgeons in academic settings preferred autologous BR more frequently than those in other practice locations (P < 0.05). Of total respondents, 64.8% did not perform microsurgical BR at all; 28% reported performing deep inferior epigastric perforator flap BR. Pedicled transverse rectus abdominis myocutaneous flap was the most often used option for unilateral autologous reconstruction, whereas deep inferior epigastric perforator flap was the most commonly used technique for bilateral BR. The overall complication rate reported by respondents was 11%. CONCLUSION: The survey provides an insight to the current trends in BR practice with respect to surgeon and practice setting characteristics. Although not necessarily the correct best practices, the survey does demonstrate a likely portrayal of what is being practiced in the United States in the area of BR.

Visiting nature is associated with lower socioeconomic inequalities in well-being in Wales.

Natural environments can promote well-being through multiple mechanisms. Many studies have investigated relationships between residential green/blue space (GBS) and well-being, fewer explore relationships with actual use of GBS. We used a nationally representative survey, the National Survey for Wales, anonymously linked with spatial GBS data to investigate associations of well-being with both residential GBS and time in nature (N = 7631). Both residential GBS and time spent in nature were associated with subjective well-being. Higher green-ness was associated with lower well-being, counter to hypotheses (predicting the Warwick and Edinburgh Mental Well-Being Scale (WEMWBS): Enhanced vegetation index ß = - 1.84, 95% confidence interval (CI) - 3.63, - 0.05) but time spent in nature was associated with higher well-being (four hours a week in nature vs. none ß = 3.57, 95% CI 3.02, 4.13). There was no clear association between nearest GBS proximity and well-being. In support of the equigenesis theory, time spent in nature was associated with smaller socioeconomic inequalities in well-being. The difference in WEMWBS (possible range 14-70) between those who did and did not live in material deprivation was 7.7 points for those spending no time in nature, and less at 4.5 points for those spending time in nature up to 1 h per week. Facilitating access and making it easier for people to spend time in nature may be one way to reduce socioeconomic inequalities in well-being.

Reconstruction of large supra-eyebrow and forehead defects using the hatchet flap principle and sparing sensory nerve branches.

BACKGROUND: To reconstruct a forehead defect, a plastic surgeon must be knowledgeable about the neural, vascular, and muscular anatomy. The position of fixed structures such as eyebrows and hairline should be respected. For the past 5 years, we have used double hatchet flaps for reconstruction of relatively large supra-eyebrow and forehead defects. Because this flap does not appear to be among the techniques used by young plastic surgeons, we thought that it would be valuable to report our experience. METHODS: Supra-eyebrow and forehead defects ranging from 2.5 × 2.5 cm to 3.5 × 3.5 cm were reconstructed using double hatchet flaps in 10 patients. Pearls and pitfalls of the technique are discussed along with the presentation of 3 cases. RESULTS: The reconstructions were uneventful and the flaps were highly viable in all patients. There was no significant distortion in the eyebrow or hairline due to reconstruction in any of the patients. All the flaps were sensate. A mild anesthesia in the distribution of supraorbital/trochlear nerve proximal to the flaps was noted only in 3 patients. This was associated with inevitable nerve damage during excision of malignant skin lesions and/or flap dissection. No recurrence was noted during the follow-up period which ranged from 6 to 36 months (mean, 13.5 months). Overall patient satisfaction score based on scar appearance and perceived degree of forehead anesthesia was 3 (neither satisfied nor dissatisfied) in 1 patient, was 4 (somewhat satisfied) in 4 patients, and was 5 (very satisfied) in 5 patients. CONCLUSION: Hatchet flaps have similar color and texture to that of the adjacent supra-eyebrow and forehead defects. The scarring is acceptable with reliable and reproducible results. Oftentimes, sensory nerve branches can be preserved with careful planning and tedious dissection. This type of reconstruction should be considered in the armamentarium of supra-eyebrow and forehead defects.

Incorporation of a preexisting scar in the star-flap technique for nipple reconstruction.

BACKGROUND: This report describes the authors' currently favored method of nipple reconstruction in cases of a pre-existing scar on the breast mound that passes through the intended site of nipple reconstruction. METHODS: The star flap technique incorporating a previous scar is used at least 3 months after satisfactory implant-based breast reconstruction. If the intended site of nipple reconstruction bisects through a vertical mastectomy scar, the star flap is designed as medially or laterally based with its 2 lateral limbs lying adjacent to the scar and the transverse central component incorporating the vertical scar. On the other hand, if the selected site of nipple reconstruction passes into a horizontal scar, the flap is positioned as inferiorly or superiorly based along the scar with its 2 lateral limbs adjacent to the scar and vertical central limb including the scar. Upon ensuring viability, the limbs are inset for nipple reconstruction. The flap donor wounds of the lateral limbs are closed primarily along the previous scar, and all of the scars including that of the central limb are maintained within the area of the intended areola. RESULTS: The procedure was used 16 times in 24 patients who have undergone bilateral implant-based breast reconstruction. All flaps were viable. One nipple reconstruction had an early complication of partial flap loss in the central flap that subsequently healed with wound care. CONCLUSIONS: It is possible to use a mastectomy scar in the star flap design for nipple reconstruction with no significant vascular compromise. This novel design enables positioning of the nipple in an optimal location on the breast mound in relation with the scar, use of existing scar, and inclusion of extra skin and subcutaneous tissue within the central limb. Nipple projection and volume have been satisfactory and consistently maintained.

The history and illustration of anatomy in the Middle Ages.

This article reviews the influence of key figures on the pictorial representation of anatomy and the evolution of anatomical illustration during the Middle Ages until the time of the Renaissance, based on medical history books, journals and ancient medical books. During the early period in the Middle Ages, most illustrations were traditional drawings of emblematic nature, oftentimes unrealistic, not only because the precise knowledge of anatomy was lacking but also because the objective was to elucidate certain principles for teaching purposes. Five figure-series that came down to us through ancient manuscripts and textbooks represent the best examples of such traditional illustrations. With the advent of human dissection in the 13th and 14th centuries, a significant transformation in the depiction of anatomy began to project the practice of human dissection, as we see in the works of Mondino de Luzzi, Henri de Mondeville and Guido de Vigevano. After the invention of book printing in the second half of the 15th century, the reproduction of books was commonly practised and the woodcut made multiplication of pictures easier. Peter of Abano, Hieronymous Brunschwig, Johannes de Ketham, Johannes Peyligk, Gregory Reisch, Magnus Hundt, Laurentius Phryesen and many more included several anatomical illustrations in their treatises that demonstrated the development of anatomical illustration during the later Middle Ages.

A classification system in the massive weight loss patient based on skin lesions and activity of daily living.

OBJECTIVE: Massive weight loss patients frequently have recalcitrant skin rashes and/or infections in the abdominal region and interference with activities of daily living (ADL) due to the redundant abdominal tissues. MATERIALS AND METHODS: A classification of these functional problems is described on the basis of the authors' experience with 75 consecutive massive weight loss patients undergoing surgery between March 2006 and August 2010. Patients are classified in 3 types. Type I: Chronic skin problems confined to the lower abdomen under the pannus and/or the skin folds of redundant pannus (± posterior lower torso). Type II: Chronic skin problems around the navel and/or under a secondary pannus in the mid/upper abdomen in addition to those observed in type I. Type III: Abdominal pannus and/or secondary roll in the abdomen with no chronic skin problems. These 3 types are further categorized on the basis of the abdominal pannus size and associated ADL interference by the subtypes: (A) those with a small pannus and no ADL interference (B) for the large excessive pannus and ADL interference. RESULTS: Fifty-two patients (70%) were classified as type I. Fifteen patients (20%) were type II. Only 8 patients (10%) had no skin problems. Overall complication rate was 21%. Mean follow-up was 13.3 months postoperatively. CONCLUSIONS: The classification system is proposed to provide a practical method by which to categorize massive weight loss patients based upon the presence and location of skin problems and ADL interference. Surgical guidelines to address these functional requirements are presented on the basis of the classification system.

Umbilical transposition in functional panniculectomy of the massive weight loss patient: is it aesthetic or medically necessary?

BACKGROUND: We review the procedures used in panniculectomy and explore the necessity of umbilical transposition when adequately treating the medical and functional problems associated with panniculus in the massive weight loss patient. METHODS: Thirty-five consecutive patients with symptomatic panniculus after massive weight loss undergoing panniculectomy during the time period from November 2008 to October 2010 at Denver Health Medical Center were retrospectively analyzed. Inclusion criteria consisted of insurance approval for the panniculectomy. All patients had persistent skin problems in the lower abdomen. Seven patients had additional skin problems in the skin around navel and/or mid-abdomen. Eleven patients complained of difficulty in performing activities of daily living. Nine patients had a concomitant ventral hernia repair. RESULTS: An infraumbilical panniculectomy was adequate in treating the medical and functional symptoms of the abdominal region in 3 patients with no need for umbilical transposition. The remaining 32 patients required a different procedure instead of only an infraumbilical panniculectomy. Among these 32 patients, 3 patients underwent panniculectomy with sacrifice of the umbilicus. Umbilical transposition following abdominal undermining was needed in the remaining 29 patients undergoing panniculectomy. CONCLUSIONS: Functional umbilical transposition was required to avoid unnatural displacement of the navel while treating chronic skin problems in the lower abdomen, or additional persistent skin problems around the navel or in the mid-abdomen, and to access the supraumbilical region, particularly for large ventral hernia repair during panniculectomy. Therefore, umbilical transposition in these cases was not aesthetic in nature but an integral part of achieving a functional surgical treatment.

Functional reconstruction of total lower lip defects using innervated gracilis flap in the setting of high-energy ballistic injury to the lower face: preliminary report.

BACKGROUND: Reconstruction of total full-thickness lower lip defects combined with extensive composite mandibular defects particularly in the setting of close-range high-energy ballistic injury presents a formidable challenge for the reconstructive plastic surgeon. While the fibular flap has been widely accepted for its usefulness in the reconstruction of composite mandibular defects, to date, there is no definitive widely established method of total lower lip reconstruction. The article presents authors' approach using innervated gracilis muscle flap for total lower lip reconstruction in the setting of high-energy gunshot injuries to the face. METHODS: Three patients underwent composite mandibular defect reconstruction using fibular osteocutaneous flap and functional lower lip reconstruction using innervated gracilis muscle flap. Lip lining was reconstructed using the skin paddle of the fibular flap. The external surface of the gracilis muscle was skin-grafted. Facial artery myomucosal flap provided vermilion reconstruction in two patients. RESULTS: All fibular (n=3) and gracilis flap transfers (n=3) were viable. An electromyographic study at 1 year postoperatively demonstrated successful re-innervation of the gracilis muscle. Starting at about 10 weeks postoperatively, patients exhibited voluntary lip movements and oral competence. In addition, all patients achieved near-normal speech, evidence of recovered protective sensitivity and satisfactory appearance. The mean follow-up was 16.1 months. CONCLUSIONS: Our preliminary report in three patients demonstrated that innervated gracilis muscle transfer combined with fibular flap provides a successful reconstruction of extensive composite mandibular and total lower lip defects resulting from gunshot injuries to the face. Oral continence was achieved by combination of regained tonicity and voluntary movement of the gracilis muscle following re-innervation and assistance of the cheek muscles on the gracilis muscle. The described technique was reliable and the results were promising.

The role of education in managing fatigue, anxiety, and sleep disorders in women undergoing chemotherapy for breast cancer.

This study examined the effect of informational audiotapes on patients' self-care behaviors (SCBs) to manage chemotherapy side effects of fatigue, anxiety, and sleep disturbance. Seventy-one women with breast cancer participated. Thirty-three received audiotapes on SCBs to manage side effects. Three telephone interviews were conducted. Overall, women who received education demonstrated more SCBs, a wider range of SCBs, increased use of SCBs over time, and less anxiety. Nursing time for education in busy clinics is minimal. Patient anxiety in the clinic environment interferes with learning. Audiotapes are an effective tool for use at home, providing for teaching and reinforcement of patient education.

Anxiety and quality of life of women who receive radiation or chemotherapy for breast cancer.

PURPOSE/OBJECTIVES: To examine quality of life (QOL) and anxiety in a sample of women receiving radiation or chemotherapy for breast cancer. DESIGN: Longitudinal, descriptive. SETTING: A cancer center in the southeastern United States. SAMPLE: 48 women participated; 17 received radiation and 31 received chemotherapy. METHODS: The Ferrans and Powers Quality of Life Index (QLI) and Speilberger's State-Trait Anxiety Inventory (STAI) were administered. The QLI was administered at the start of treatment and one year later. The STAI was administered at the start of treatment. The state portion of the STAI also was administered 4 weeks and 12 weeks after the start of treatment. MAIN RESEARCH VARIABLES: QOL and anxiety. FINDINGS: Total QOL improved significantly over time for the entire sample, as did scores on the health/functioning, psychological/spiritual, and family subscales of the QLI. No significant differences existed for total QOL or any subscales by treatment. Trait anxiety was significantly higher for women receiving chemotherapy, and state anxiety was significantly higher at all three measurement times for the women. State anxiety did not decrease significantly over the course of the treatment for either group. Trait anxiety and state anxiety at the start of treatment were significantly negatively correlated with total QLI score and the psychological/spiritual subscale. State anxiety at the start of treatment also was significantly negatively correlated with total QOL and the health/functioning and psychological/spiritual QLI subscales both at the start of treatment and one year later. CONCLUSIONS: QOL improves over time for women who have received radiation or chemotherapy. Women receiving chemotherapy have higher anxiety scores, and higher anxiety at the start of treatment is associated with decreased QOL at the start of treatment and postdiagnosis. IMPLICATIONS FOR NURSING: Nursing interventions to reduce anxiety at the start of treatment, especially for chemotherapy recipients, are indicated. Research also should target methods to reduce anxiety at the start of treatment.

The effect of education in managing side effects in women receiving chemotherapy for treatment of breast cancer.

PURPOSE/OBJECTIVES: To determine the effectiveness of informational audiotapes on self-care behaviors, state anxiety, and use of self-care behaviors; to describe the occurrence and intensity of common side effects in patients with breast cancer. DESIGN: Randomized clinical trial. SETTING: Outpatient chemotherapy clinics operated by a university center in a rural area. SAMPLE: 70 women receiving their first treatment of chemotherapy. METHODS: Subjects completed demographic data and the Spielberger State-Trait Anxiety instrument (stai). The experimental group received two audiotapes. At one and three months, subjects completed the modified nail self-care diary and stai via telephone. MAIN RESEARCH VARIABLES: State anxiety, side-effect severity, and use and efficacy of self-care behaviors. FINDINGS: The most frequent side effects were fatigue, nausea and vomiting, and taste change. The experimental group reported symptom improvements that were not found in the control group. The experimental group increased the use of recommended self-care behaviors, whereas the control group continued to use the same self-care behaviors without effectiveness. State anxiety for both groups diminished over time; however, anxiety in the control group was consistently higher. CONCLUSIONS: Audiotapes are effective teaching tools. Self-care behaviors can be taught and can be effective in managing side effects. Anxiety was high in both groups, but the symptom decreased in the women who received audiotapes and telephone calls. IMPLICATIONS FOR NURSING: Constraints on nurses decrease the length of teaching time available, but audiotapes provide effective teaching and reinforcement of education. Anxiety in clinical environments interferes with patient learning. Teaching effective self-care behaviors enhances patients' independence, comfort, control, and quality of life.