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%

The Impact of Same Gender Speed-Mentoring on Women's Perceptions of a Career in Surgery – A Prospective Cohort Study

BACKGROUND: Mentoring is critically important for the personal and professional development of a surgeon. Early career stage mentoring by same-gender role models may help ameliorate the gender imbalance in surgery based on our understanding of barriers for women pursuing surgical careers. A novel method of establishing these relationships is speed mentoring. This study aims to examine the impact of a one-day speed-mentoring session with same gender mentors on a cohort's perceptions of a career in surgery. DESIGN: This prospective pre-post study compared attitudes and perceptions of a career in surgery before and after a speed-mentoring session with female surgeons. Mentees were assigned into groups of 1 or 2 and were paired with a female surgeon for 8 minutes. Each mentee group then rotated to another mentor for the same amount of time and this process continued for a total of twelve sessions. Mentees completed a 19-point questionnaire before and after the speed mentoring intervention. Setting: This multicenter study included participants from across the United Kingdom. PARTICIPANTS: Inclusion criteria were female gender and medical student or foundation year doctor (internship year 1 or 2) status. Three hundred and forty participants participated in the intervention, 191 were included in the analysis. RESULTS: Following intervention, the percentage of participants who agreed that having a family would negatively impact a woman's surgical career progression significantly decreased from 46.6% to 23.0%. The percentage of participants who agreed that an “old boys’ club” attitude exists in surgery also significantly decreased (73.8%-58.1%). The percentage of participants who agreed it was more difficult for a woman to succeed in her surgical career than a man significantly decreased (73.8%-64.9%). One hundred and eighty-three (96%) participants agreed that mentorship is important for career progression and 153 (71.2%) participants stated that they did not have someone who they considered a mentor. CONCLUSIONS: Conducting a speed mentoring program with same-gender role models significantly changed female medical students’ and junior doctors’ perceptions of women in surgery. The results suggest that such programs may be effective tools for facilitating mentor-mentee relationships and could be employed by surgical organizations to encourage a diverse uptake into surgery

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

Serum inflammatory markers and amputations in hand osteomyelitis: a retrospective review of 146 cases

Background: The diagnosis of hand osteomyelitis requires correlation of clinical, radiological, and microbiological findings. The role of serum inflammatory markers in diagnosing and prognosticating hand osteomyelitis remains uncertain. We sought to determine the utility of inflammatory markers in the diagnosis and follow-up of hand osteomyelitis, and their ability to predict outcomes, particularly amputation. Methods: We retrospectively reviewed 146 patients diagnosed with hand osteomyelitis and with serum inflammatory marker levels measured after the onset of symptoms and within 14 days either side of diagnosis. Blood results at first presentation including white cell count (WCC), neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), and C-reactive protein (CRP) were reviewed, and associations with amputations assessed. Follow-up markers taken at 15 to 60 days from diagnosis were analyzed where available. Results: Mean WCC and CRP at diagnosis were 9.2 (SD: 4.6) and 30.2 (SD: 42.4) respectively, compared with 8.2 (SD: 3.9) and 30.2 (SD: 42.4) at follow-up. At diagnosis, sensitivity of CRP was 74%, and WCC was 31%. Each marker had a low positive predictive value for amputation at diagnosis (<29%). A rise in CRP between diagnosis and follow-up was associated with an increased risk of amputation compared with a fall in CRP. The finding that WCC and CRP were both normal at diagnosis had a high negative predictive value against amputation (96%). Conclusion: C-reactive protein has a higher sensitivity than WCC, NLR, and PLR when used as a diagnostic adjunct in hand osteomyelitis. White cell count and CRP both within reference ranges at diagnosis was highly negatively predictive against amputation

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

Global and regional left ventricular function improvement following successful percutaneous coronary intervention in patients with ischemic left ventricular dysfunction

This study assessed changes in global and regional systolic left ventricular function after successful percutaneous recanalization of coronary artery occlusions. A consecutive series of 110 patients with mean ± SD age of 53.6 ± 9.1 years, in whom a complete angiographic evaluation was available before angioplasty, underwent successful percutaneous recanalization of significant occlusions of coronary arteries. Left ventricular ejection fraction and wall motion score index were assessed by echocardiography at baseline, and 1, and 6 months after recanalization. Left ventricular ejection fraction increased from a mean ± SD of 40.7 ± 4.52 at baseline to 50 ± 8.3 after one month (P < 0.001) and to 50.9 ± 8.5 after 6 months. There was no significant difference between left ventricular ejection fraction at the end of the first and the sixth month of treatment (P = NS). The wall motion score index decreased from 1.3 ± 0.2 at baseline to 1.1 ± 0.2 after one month (P < 0.01). There was no significant difference between 1 and 6 months results. Six-month follow-up of all patients showed significant improvement in both angina severity and NYHA class. The restoration of coronary potency of occluded coronary arteries by successful percutaneous recanalization is associated with significant improvement in regional and global left ventricular function and clinical outcome