Patient satisfaction with postmastectomy breast reconstruction

BACKGROUND. At a time when the safety and effectiveness of breast implants remains under close scrutiny, it is important to provide reliable and valid evidence regarding patient outcomes. In the setting of postmastectomy reconstruction, patient satisfaction and quality of life may be the most significant outcome variables when evaluating surgical success. The objective of the current study was to identify predictors of patient satisfaction with breast appearance, including implant type, in a large sample of women who underwent breast reconstruction surgery using implants. METHODS. A multicenter, cross-sectional study design was used. A total of 672 women who had completed postmastectomy, implant-based reconstruction at 1 of 3 centers in North America were asked to complete the BREAST-Q (Reconstruction Module). Multivariate linear regression modeling was performed. RESULTS. Completed questionnaire data were available for 482 of the 672 patients. In 176 women, silicone implants were placed and in 306, saline implants were used. The multivariate model confirmed that patients' satisfaction with their breasts was significantly higher in patients with silicone implants ( P = .016). The receipt of postmastectomy radiotherapy was found to have a significant, negative effect on breast satisfaction ( P <.000) in both silicone and saline implant recipients. In addition, for women who received either silicone or saline implants, satisfaction diminished over time ( P = .017). CONCLUSIONS. In the setting of postmastectomy reconstruction, patients who received silicone breast implants reported significantly higher satisfaction with the results of reconstruction than those who received saline implants. This information can be used to optimize shared medical decision-making by providing patients with realistic postoperative expectations. Cancer 2010. © 2010 American Cancer Society.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/78475/1/25552_ftp.pd

An Aesthetic Factor Priority List of the Female Breast in Scandinavian Subjects

Background: There is little consensus about the relative determinative value of each individual factor in female breast aesthetics. When performing breast surgery with an aesthetic goal, certain factors will be more important than others. The purpose of this study was to make an aesthetic factor rank list to determine the relative contributions to overall breast aesthetics. Method: Volunteers were scanned using the 3-dimensional Vectra system. Ten Scandinavian plastic surgeons rated 37 subjects, using a validated scoring system with 49 scoring items. The correlation between specific aesthetic factors and overall breast aesthetic scores of the subjects were calculated using Pearson's r, Spearman's rho, and Kendall's tau. Results: A very strong correlation was found between overall breast aesthetic score and lower pole shape (0.876, P <0.0001). This was also true for upper pole shape (0.826, P <0.0001) and breast height (0.821, P <0.0001). A strong correlation was found between overall breast aesthetic score and nipple position (0.733, P <0.0001), breast size (0.644, P <0.0001), and breast width (0.632, P <0.0001). Factors that were only moderately correlated with aesthetic score were intermammary distance (0.496, P = 0.002), nipple size and projection (0.588, P <0.0001), areolar diameter (0.484, P <0.0001), and areolar shape (0.403, P <0.0001). Perceived symmetry was a weak factor (0.363, P = 0.027). Conclusions: Aesthetic factors of the female breast can be ranked in a priority list. Shape of the lower pole and upper pole and breast height are primary factors of female breast aesthetics. These should be prioritized in any aesthetic breast surgery. Vertical dimensional factors seem to be more determinative than horizontal factors.Peer reviewe

A critical experimental study of the classical tactile threshold theory

<p>Abstract</p> <p>Background</p> <p>The tactile sense is being used in a variety of applications involving tactile human-machine interfaces. In a significant number of publications the classical threshold concept plays a central role in modelling and explaining psychophysical experimental results such as in stochastic resonance (SR) phenomena. In SR, noise enhances detection of sub-threshold stimuli and the phenomenon is explained stating that the required amplitude to exceed the sensory threshold barrier can be reached by adding noise to a sub-threshold stimulus. We designed an experiment to test the validity of the classical vibrotactile threshold. Using a second choice experiment, we show that individuals can order sensorial events below the level known as the classical threshold. If the observer's sensorial system is not activated by stimuli below the threshold, then a second choice could not be above the chance level. Nevertheless, our experimental results are above that chance level contradicting the definition of the classical tactile threshold.</p> <p>Results</p> <p>We performed a three alternative forced choice detection experiment on 6 subjects asking them first and second choices. In each trial, only one of the intervals contained a stimulus and the others contained only noise. According to the classical threshold assumptions, a correct second choice response corresponds to a guess attempt with a statistical frequency of 50%. Results show an average of 67.35% (STD = 1.41%) for the second choice response that is not explained by the classical threshold definition. Additionally, for low stimulus amplitudes, second choice correct detection is above chance level for any detectability level.</p> <p>Conclusions</p> <p>Using a second choice experiment, we show that individuals can order sensorial events below the level known as a classical threshold. If the observer's sensorial system is not activated by stimuli below the threshold, then a second choice could not be above the chance level. Nevertheless, our experimental results are above that chance level. Therefore, if detection exists below the classical threshold level, then the model to explain the SR phenomenon or any other tactile perception phenomena based on the psychophysical classical threshold is not valid. We conclude that a more suitable model of the tactile sensory system is needed.</p

Pedicled and free TRAM flaps in breast reconstructions : a comparative study

The transverse rectus abdominis musculocutaneous (TRAM) flap is frequently used when autologous tissue is desired for breast reconstruction, and it can be transferred pedicled or free. The pedicled TRAM flap is elevated as a lower transverse abdominal flap with the rectus abdominis muscle attached in the epigastric area, by which means the deep superior epigastric vessels nourish the flap. The flap is tunneled to its new position on the thoracic wall. The free TRAM flap consists of the same skin-fat paddle but the vascular pedicle consists of the deep inferior epigastric artery and vein. This artery is usually the dominant supplier of the flap area. The flap is raised with a small portion of the rectus muscle, disconnected and anastomosed to recipient vessels in the axillae or to the internal mammary vessels. The free flap procedure is more time- and resource-consuming, requiring microsurgery. If the anastomoses do not function, the whole flap is lost. On the other hand, the pedicled TRAM flap carries a greater risk of partial flap loss and subsequent longer healing than the free flap. It is therefore important to evaluate whether one technique is superior to the other. The most serious complication in all flap surgery is insufficient blood circulation, leading to changed metabolism in the tissue. The microdialysis technique provides a new way to survey local metabolic changes in flaps. A slower stabilization with remaining ischemic signs, such as lower glucose and higher lactate and glycerol values, was found in flap zones with inferior circulation. More pronounced ischemic signs, but a faster recovery were seen in free TRAM flaps than in pedicled ones. The fact that the metabolites returned to normal earlier in the free flaps than in the pedicled flaps indicates better perfusion. Trunk muscle strength after TRAM flap surgery was evaluated prospectively as more of the rectus abdominis muscle is included in the pedicled than in the free TRAM flaps. An isokinetic dynamometer (KIN-COM) was used to objectively assess maximal voluntary muscle strength preoperatively and up to one year postoperatively. A transient decrease in abdominal strength in both groups occurred at 6 months but was essentially regained at 12 months. The use of pedicled or free TRAM flap did not influence postoperative abdominal strength per se. Large individual variations indicated more important factors than the type of surgery. As alteration of sensibility is unavoidable when transferring tissue, the somatosensory status (tactile and thermal perception thresholds, i.e., warmth, cold, heat pain, cold pain, measured by von Frey's hair and Termotest, respectively) was assessed quantitatively at least two years postoperatively. No clinically relevant differences between pedicled and free TRAM flaps were demonstrated. The somatosensory status was still impaired compared to a control group, but the majority of patients in both groups reported that the reconstructed breast felt like a real breast. A new thermoplastic cast system was introduced to evaluate breast volume. The method is simple and can measure the contralateral breast volume preoperatively in a delayed breast reconstruction, indicating the volume of the planned TRAM flap. It is also sufficiently accurate to evaluate breast symmetry after breast reconstruction. Since a breast reconstruction is performed mainly to improve the quality of life of the patient, the most important issue would be the patient's satisfaction with the result. The esthetic result was evaluated subjectively and objectively. The free TRAM flap breast reconstructions gave a higher degree of breast symmetry as judged by both the patients and a three-member panel. These findings were supported by objective measurements, such as breast symmetry and breast volume. Satisfaction with the breast reconstruction and health-related quality of life did not differ statistically between the two groups. In conclusion, better perfusion was indicated in the free TRAM flaps as well as a better esthetic result in terms of breast symmetry. However, no findings favoring either technique were seen in terms of patient satisfaction, trunk muscle strength, or tactile and thermal sensibility