Clinical determinants of patient satisfaction with breast reconstruction.

The main objective of this study was to examine the relationship between specific treatment variables and patient satisfaction with breast reconstruction. A questionnaire was developed that included questions on population demographics and satisfaction with the reconstruction. Of 206 women who completed the questionnaire, 23 (11.2 percent) responded that they were not satisfied, whereas 183 (88.8 percent) indicated that they were satisfied overall. A detailed retrospective chart review permitted a comparison of the treatment received by these two groups. Variables analyzed included patient age, time since surgery, reason for surgery, method and timing of reconstruction, additional surgical procedures received (mound revisions and nipple-areola complex reconstruction), and postoperative complications. Data analysis showed that the treatment received by the two groups was similar in many respects. There was no statistical association between the method or timing of reconstruction and a patient's satisfaction with the results. Furthermore, there was no difference in the number of mound revisions or nipple reconstructions performed on satisfied versus dissatisfied patients. However, the latter group experienced a substantially higher incidence of postsurgical complications (27 percent versus 61 percent, p = 0.0015). Patients were also asked to provide a written response explaining their feelings on breast reconstruction. Satisfied patients described benefits from reconstruction such as improved appearance or feelings of normalcy and wholeness. Conversely, unsatisfied patients were displeased because of poor cosmetic results, complications with the reconstructed breast, or abdominal problems. Although overall satisfaction with breast reconstruction is undoubtedly determined by multiple and complex clinical, emotional, and psychological factors, this study suggests that postoperative complications are a particularly important indicator of dissatisfaction with reconstruction.

Lymphocyte recirculation, exercise, and immune responses.

Alterations in leukocyte concentrations in the blood are associated with exercise, stress, and other pathophysiological perturbations. The continuous migration and redistribution of cells of the recirculating lymphocyte pool between the blood and lymphatic systems can be influenced by a variety of physiological, immunological, and pathological processes. The phenotypic distribution of lymphocyte subsets is not the same in blood, afferent lymph, and efferent lymph, and cell-tracking experiments have shown that lymphocytes vary in their migratory properties. The most comprehensive physiological studies tracking these cells in vivo have been done in sheep. It has been shown that lymph-derived cells have different migratory capacities than blood-derived lymphocytes, that antigenic challenge of a single lymph node can first reduce the output of lymphocytes from the node and then markedly increase the recruitment from the blood and subsequently the output into efferent lymph. In most mammals, the blood pool of lymphocytes represents only about 1% of the total lymphocytes and only a small fraction of the recirculating lymphocyte pool. Therefore, testing the effects of exercise on lymphocyte recirculation by examining blood samples only requires considerable deduction and inference to interpret multicompartmental effects.

The relationship of blood lymphocytes to the recirculating lymphocyte pool.

Lymphocyte recirculation facilitates the detection and elimination of pathogens and the dissemination of immunologic memory. It is generally assumed that all small lymphocytes in the blood are actively recirculating, yet there is little quantitative data directly comparing the migration of this population with actively recirculating, lymph-derived lymphocytes. In this study blood lymphocytes were labeled with fluorescein isothiocyanate (FITC), and lymph lymphocytes were labeled with CM-DiI, reinfused intravenously, and monitored in blood and lymph. After equilibration the concentration of blood lymphocytes was several times higher in blood than in lymph, whereas lymph lymphocytes displayed the opposite behavior. This suggested that blood lymphocytes did not recirculate as efficiently as lymph lymphocytes, so we examined the following blood lymphocyte subsets in greater detail: B cells, CD4+, CD8+, and gammadelta T cells. Within 4 hours postinjection the percentage of FITC+ CD8+ and CD4+ lymphocytes fell in the blood and remained significantly lower than the injected sample. In contrast, the concentration of FITC+ gammadelta T cells did not change, and the percentage of FITC+ B cells increased. These data suggest that subpopulations of B and perhaps gammadelta T lymphocytes in the blood do not recirculate efficiently through lymph nodes.

A method for tracking the migration of blood lymphocytes.

A method has been devised for labeling whole blood with the fluorescent dye fluorescein isothiocyanate (FITC) so the migration of blood lymphocytes can be studied in the sheep. Although lymphocytes can be purified from blood using density gradient media or elutriation it is difficult to obtain a large number of cells, because many cells are usually lost during the purification steps. It is desirable to label at least 10(8)-10(9) lymphocytes for lymphocyte tracking studies, because a smaller number is difficult to subsequently detect and quantitate in blood and lymph even using flow cytometry. Also, it is desirable to minimize the in vitro manipulation of lymphocytes, because dead or damaged lymphocytes will not recirculate. By labeling all the cellular components of a sample of whole blood rather than first purifying the lymphocytes we have been able to satisfy both of these criteria. Although labeled blood cells of all types are reinjected into the animal, the lymphocytes are easily distinguishable from other cells using a flow cytometer. In these studies between 2.4-12.4 x 10(8) lymphocytes were injected intravenously, and they were detectable in the blood and lymph for at least 10 days. The recovery of FITC-labeled (FITC+) lymphocytes in efferent lymph is comparable to that of lymphocytes labeled with other fluorescent or radioactive markers. The presence of labeled non-lymphoid cells in the animal makes this technique impractical for studies of lymphocyte localization within histologic sections. However, it is useful for studies in animals in which lymphatic vessels can be cannulated and the blood-to-lymph recirculation of labeled lymphocytes monitored, and it also may be applicable for studies in which lymphoid organ suspensions are analyzed using flow cytometry.