Application of the Lalonde (horizontal-only scar) breast reduction technique for correction of gynaecomastia in dark skinned patients

Surgical correction of gynaecomastia correction sometimes necessitates skin reduction in addition to resection of glandular tissue and liposuction of the fat deposits. Many skin reduction techniques have been described but all suffer from very noticeable and often poor scars that can manifest as hypertrophic or keloid scars in patients with dark skin. Three large gynaecomastia patients undergoing a modification of the Lalonde “no vertical scar” breast reduction technique designed to reduce the extent of scarring were reviewed. The Lalonde “no vertical scar” technique was successfully applied to three patients of African extraction with acceptable postoperative scarring. A description of the technique and the cosmetic results are presented. The Lalonde technique of female breast reduction can be applied to the treatment of male breast enlargement in patients at high risk of scar complications. It provides an alternative to the more widely used concentric skin reduction techniques. To our knowledge, this is the first report in literature of the application of the Lalonde “no vertical scar” surgical technique to the treatment of gynaecomastia in patients with darkly pigmented skin

Postmastectomy Breast Reconstruction With the Totally Autologous Latissimus Dorsi Flap in the Thin, Small-Breasted Woman: Give It More Thought!

Introduction: Thin women have fewer autologous tissue breast reconstructive options than their higher body mass index counterparts—due to a lack of adequate donor sites. They are therefore usually offered expander/implant techniques. The total autologous latissimus dorsi flap is generally used in “well-padded” individuals, as they have enough fat on their back on which a completely autologous reconstruction could be based. When implant-based reconstruction is contraindicated (for instance due to planned adjuvant radiotherapy) or unacceptable to the patient, the total autologous latissimus dorsi flap can provide adequate tissue volume by utilizing the additional back fat deposits even in the thin, small-breasted patient. This option is often overlooked by many surgeons. Our case series assesses indications and patient and surgeon satisfaction with the cosmetic outcome of this technique. Methods: The oncological and clinical details of 6 patients with breast cancer who underwent total autologous latissimus dorsi myocutaneous flap immediate breast reconstruction by a single surgeon over an 8-year period were reviewed. An objective assessment of satisfaction with the cosmetic result was made by whether any additional surgical interventions (ipsilateral fat grafting/implant augmentation or contralateral liposuction/ reduction) were needed or not. A subjective assessment of breast symmetry by the surgeon using photographic records was also undertaken. The aesthetic outcomes were also objectively quantified using the BCCT.core software, initially developed for assessing the results of breast conservation surgery. Results: All 6 patients had small breasts and a low or normal body mass index. The mastectomies were performed for invasive carcinoma (n = 3) and extensive high-grade ductal carcinoma in situ (n = 3). Four had axillary surgery (2 sentinel lymph node biopsies and 2 axillary clearances), and 3 received adjuvant radiotherapy. All were happy with their reconstructive outcomes, and none suffered major postoperative complications or disease recurrence. None requested or needed any subsequent ipsilateral adjustment or contralateral symmetrizing procedures. Subjectively, the reconstructions provided acceptable or excellent cosmetic results. The cosmetic results were categorized as excellent or good on the BCCT.core scoring system. Conclusion: This underutilized method of totally autologous breast reconstruction in thinner patients with lower body mass indexes yielded good, well-accepted cosmetic results without recourse to adjustment procedures, contralateral balancing surgery, or complex microvascular surgery. We recommend that the total autologous latissimus dorsi flap should be given more consideration when planning immediate breast reconstruction in this challenging group of thin, small-breasted patients

Utilizing the Total Design Method in medicine: maximizing response rates in long, non-incentivized, personal questionnaire postal surveys

Introduction: Maximizing response rates in questionnaires can improve their validity and quality by reducing non-response bias. A comprehensive analysis is essential for producing reasonable conclusions in patient-reported outcome research particularly for topics of a sensitive nature. This often makes long (≥7 pages) questionnaires necessary but these have been shown to reduce response rates in mail surveys. Our work adapted the “Total Design Method,” initially produced for commercial markets, to raise response rates in a long (total: 11 pages, 116 questions), non-incentivized, very personal postal survey sent to almost 350 women. Patients and methods: A total of 346 women who had undergone mastectomy and immediate breast reconstruction from 2008–2014 (inclusive) at Addenbrooke’s University Hospital were sent our study pack (Breast-Q satisfaction questionnaire and support documents) using our modified “Total Design Method.” Participants were sent packs and reminders according to our designed schedule. Results: Of the 346 participants, we received 258 responses, an overall response rate of 74.5% with a useable response rate of 72.3%. One hundred and six responses were received before the week 1 reminder (30.6%), 120 before week 3 (34.6%), 225 before the week 7 reminder (64.6%) and the remainder within 3 weeks of the final pack being sent. The median age of patients that the survey was sent to, and the median age of the respondents, was 54 years. Conclusion: In this study, we have demonstrated the successful implementation of a novel approach to postal surveys. Despite the length of the questionnaire (nine pages, 116 questions) and limitations of expenses to mail a survey to ~350 women, we were able to attain a response rate of 74.6%

A case at crossroads-urological presentation, cardiac complication and haematological diagnosis: should imaging be pursued prior to orchidectomy at all costs?

This case report explores the interesting case of a 71-year-old gentleman who presented with a testicular lump following trauma. Ultrasound imaging of the testicle demonstrated malignancy and subsequently orchidectomy was listed. Due to a scheduling difficulty, this was prioritized ahead of his whole-body computed tomography scan. Intraoperatively, he developed electrocardiogram changes suggestive of a non-ST elevated myocardial infarction. Post-operative imaging demonstrated a diffuse large B-cell lymphoma encroaching the heart and greater vessels. This case report highlights the importance of preoperative imaging, even where it may prove challenging. We assess the adequacy of current guidelines within the UK on imaging for new testicular malignancies

Assessment of breast symmetry in breast cancer patients undergoing therapeutic mammaplasty using the Breast Cancer Conservation Therapy cosmetic results software (BCCT.core)

Background: Therapeutic mammaplasty (TM) is a standard oncoplastic technique utilising aesthetic breast reduction principles to facilitate tumour resection and breast reshaping. Simultaneous contralateral mammaplasties are often performed to maintain symmetry. BCCT.core software, which principally assesses breast symmetry, has been previously employed for evaluating cosmetic results after standard breast conservation therapy and latterly TMs for upper pole tumours. The purpose of this study was to validate this novel tool for TMs in all breast zones. Methods: Standardised photographs of 20 consecutive patients who underwent TM were evaluated for symmetry using BCCT.core versus a plastic surgical panel completing a visual analogue scale. Results were rated as (excellent/good/fair/poor). Outcomes between the two methods were compared. Results: Twenty patients aged 37 to 63 years with a median 36G bra size had 22 TMs (18 unilateral, 2 bilateral). Indications were invasive breast cancer (87%) and ductal carcinoma in situ (DCIS) (13%). The median (range) tumour size was 22.5 mm (6–90 mm) with a resection weight of 245.8 g (16–1,079 g). Primary nipple pedicles were superomedial (63%), inferior (21%) and superolateral (16%). Five patients required a secondary glandular pedicle for volume redistribution to maintain breast shape. The BCCT.core software vs. panel symmetry assessments were 37% vs. 39% (excellent), 63% vs. 50% (good) and 0% vs. 11% (fair). Wilcoxon matched-pairs sign rank tests and Spearman rank correlations found the pairings to be statistically significant (P<0.05). Conclusions: Despite small patient numbers, BCCT.core gave comparable findings with the panel and is thus useful for objectively assessing cosmesis of TMs in all breast zones

The successful use of disparate pedicle types for bilateral therapeutic mammaplasties during breast conservation surgery

This case illustrates the successful use of non-identical pedicles in bilateral therapeutic mammaplasty (TM). A 58-year-old patient presented with a left-sided upper inner quadrant multifocal invasive [no special type (NST)] tumour and a right-sided upper outer quadrant unifocal invasive tubular carcinoma with surrounding ductal carcinoma in situ (DCIS). Her tumour locations necessitated simultaneous bilateral TM using different pedicle types. A superomedial pedicle T-scar breast reduction was undertaken on the right to resect the upper outer quadrant tumour whilst a superolateral nipple transposition pedicle was used on the left breast to enable the wide resection of the two tumours located superomedial to the nipple. The location and size of the tumour also required the use of a secondary infero-medially based pedicle for volume displacement on the left breast. Patient received adjuvant chemotherapy and radiotherapy. A year after surgery the patient has acceptable cosmetic results in terms of symmetry, breast contour and increasingly inconspicuous scars

Evaluating the impact of Brexit on the pharmaceutical industry.

INTRODUCTION: The UK Pharmaceutical Industry is arguably one of the most important industries to consider in the negotiations following the Brexit vote. Providing tens of thousands of jobs and billions in tax revenue and research investment, the importance of this industry cannot be understated. At stake is the global leadership in the sector, which produces some of the field's most influential basic science and translation work. However, interruptions and losses may occur at multiple levels, affecting patients, researchers, universities, companies and government. GOALS: By understanding the current state of pharmaceutical sector, the potential effect of leaving the European Union (EU) on this successful industry can be better understood. This paper aims to address the priorities for negotiations by collating the analyses of professionals in the field, leading companies and non-EU member states. RESEARCH METHODS: A government healthcare policy advisor and Chief Science Officer (CSO) for a major pharmaceutical firm were consulted to scope the paper. In these discussions, five key areas were identified: contribution, legislative processes, regulatory processes, research and outcomes, commercial risk. Multiple search engines were utilised for selecting relevant material, predominantly PubMed and Google Scholar. To supplement this information, Government documents were located using the "GOV.UK" publications tool, and interviews and commentaries were found through the Google News search function. CONCLUSION: With thorough investigation of the literature, we propose four foundations in the advancement of negotiations. These prioritise: negotiation of 'associated country' status, bilaterally favourable trade agreements, minimal interruption to regulatory bodies and special protection for the movement of workforce in the life sciences industry

A comparison of patient satisfaction (using the BREAST-Q questionnaire) with bilateral breast reconstruction following risk-reducing or therapeutic mastectomy

Introduction: Patients undergoing mastectomy and immediate breast reconstruction for cancer may be expected to have different perceptions of long-term outcomes compared with those who have this operation prophylactically. Methods: Patients who underwent bilateral mastectomy and breast reconstruction from 2008 to 2014 at the Cambridge Breast Unit were identified from a prospective register and their notes were audited. They were classified according to their indication for surgery as follows: bilaterally therapeutic, bilaterally risk-reducing or combination. The BREAST-Q™ questionnaire was posted to participants using the ‘total Dillman method’. Q-SCORE software was utilised to analyse patient satisfaction scores. Results: Sixty-five (58%) responses were received, of which 8 were excluded, leaving 57 usable for the study. The therapeutic group had higher patient satisfaction than the risk-reducing group across most domains including breast, outcome, psychosocial, sexual, physical and information. The combination group scored lower and BRCA gene mutation-positive patients scored the lowest. Physical well-being was maintained across all groups but psychosocial/sexual well-being varied. Good psychosocial well-being was linked to a higher satisfaction with the outcome in the combination and risk-reducing groups. Conclusion: This study highlights the need for clinicians to take into account the indication for surgery as a major psychological factor in patients’ perception of self and experience of surgery. It demonstrates that bilateral immediate reconstruction patients report similar physical symptoms irrespective of indication for mastectomy, but the decision-making process in terms of risk-balancing and diagnosis influences satisfaction with self and surgery. It underlines the importance of preoperative management of expectations for patients undergoing risk-reducing procedures

Patient-Reported Satisfaction following mastectomy and immediate reconstruction does not change with time

Background: Patients undergoing mastectomy and immediate breast reconstruction (IBR) for cancer may be expected to reflect differently on their procedure with time. As time from the surgery increases, their perceptions of self and their satisfaction with the procedure could change. Method: Patients undergoing mastectomy and reconstruction from 2008–2014 at the Cambridge Breast Unit were retrospectively identified from a prospective register and their notes audited. The Breast-Q™ questionnaire was posted to participants using the “total Dillman method” in January 2016. Q-SCORE software was utilised to analyse patient satisfaction scores. Linear regressions were conducted with respect to time since procedure and satisfaction scores. Results: Of the 346 participants, we received 258 responses leading to an overall response rate of 74.5% and useable response rate of 72.3%. Across all satisfaction domains (breast, outcome, psychosocial, sexual well-being, physical symptoms, information), patient scores were independent of time since procedure. Conclusion: This study demonstrates that patients’ satisfaction with their procedure does not change significantly between 1 and 8 years post-operatively. It highlights that a patient’s reflection of self at 12 months is maintained in subsequent years. This suggests the importance of complementary intervention to improve outcome before this point