Cost-utility of breast reduction surgery--a prospective study.

OBJECTIVE: To assess the cost-utility of routine breast-reduction surgery in the setting of a large university hospital. METHODS: In the framework of a large trial exploring the feasibility of routine health-related quality of life (HRQoL) assessment, 80 patients (mean age: 45 years) entering the Department of Plastic Surgery for operative breast reduction filled in the 15-dimension (15D) HRQoL survey before and 6 months after surgery. Data on hospital costs were obtained from the hospital records. RESULTS: Mean (+/-SD) HRQoL score (on a 0-1 scale) increased as a result of surgery from the preoperative 0.916+/-0.075 to 0.939+/-0.076 (p<0.001) 6 months after surgery, corresponding to a mean (+/-SD) gain of 0.930+/-2.117 quality-adjusted life years (QALYs). Of the 15 health dimensions, discomfort and symptoms showed the greatest improvement (p<0.001). A statistically significant improvement was also seen on the dimensions of breathing, sleeping and distress. Mean hospital cost of treatment was 3383 euro+/-1744, and the cost per QALY was 3638 euro. Using 5% discounting for QALYs, the cost per QALY increased to 8973 euro. CONCLUSION: Breast-reduction surgery improved HRQoL in a statistically significant manner and at a reasonable cost, as the cost per QALY was in the same range as that observed in our material, for example, for hip-replacement surgery.

Late results of skin-sparing mastectomy followed by immediate breast reconstruction.

BACKGROUND: Skin-sparing mastectomy (SSM) facilitates optimal immediate breast reconstruction (IBR) by preserving the inframammary fold and most of the breast skin. Concerns persist that SSM might increase the rate of local recurrence as the surgical approach is less extensive. Patients who had SSM and IBR over 10 years at a single institution were reviewed. METHODS: A total of 207 consecutive women who underwent SSM and IBR from 1992 to 2001 were included in the study. The patient records were analysed retrospectively and follow-up data were included. RESULTS: Postoperative complications included native skin flap necrosis (10.1 per cent), haematoma (10.6 per cent), infection (3.4 per cent), anastomotic thrombosis (5.3 per cent) and hernia (2.6 per cent). During a mean follow-up of 70 months, 5.8 per cent of patients with stage 0-2 disease developed a locoregional recurrence, although none of these later had a systemic recurrence. The rate of locoregional recurrence was 31 per cent (five of 16) in women with stage 3 breast cancer. CONCLUSION: SSM followed by IBR was both surgically and oncologically safe, especially for early-stage breast cancer.

Magnetic resonance imaging of microneurovascular free muscle flaps in facial reanimation.

The purpose of this study was to describe the survival and volume of microneurovascular muscle flaps at different times after two-stage facial reanimation procedure by using magnetic resonance imaging (MRI) and to compare the functional outcome with MRI findings. Fifteen patients with a mean age of 36 years (range 7-63 years) operated on between 1988 and 1999 were available for this study. The muscles used for functional reconstruction were the latissimus dorsi (eight patients), gracilis (six patients) and serratus anterior (one patient). Hospital charts were reviewed and the clinical outcome of facial reanimation was graded on a scale from 1 to 6 according to House. The mean postoperative follow-up time was 7 years (range 3-14 years). Clinical grading and 1.5 T unit MRI of patients were performed concomitantly. The MR images were evaluated semi-quantitatively so that the muscle structure of the free flaps was graded on a scale from 1 to 4. The free flap area of each slice was defined and the volume of the free flap was calculated. Data were analysed statistically. The long-term functional outcome of the facial reanimation was regarded as good in 10 patients, which means they had only mild or moderate dysfunction of facial movements. In MR images, six free flaps displayed normal muscle structure, another six had a fatty appearance and two displayed severe muscle atrophy; in one patient the muscle tissue could not be identified. The volume of the free flap clearly declined in the course of the follow-up. A correlation was found between good functional outcome and normal muscle structure of the free flap in MRI, p = 0.020. The longer the follow-up time after muscle transplantation the poorer the functional result. A similar correlation was found between abnormal muscle structure in MRI and a long follow-up time. Magnetic resonance imaging can be used to assess the muscle structure of free microneurovascular flaps. Normal findings in MRI seem to correlate with a good clinical outcome in facial reanimation. A good functional result correlates with a shorter follow-up time and normal muscle structure in MRI.

Massive intra-abdominal bleeding due to injury in the mesenteric artery during late breast reconstruction with a free TRAM flap: a case report.

We report on a rare case of major intra-abdominal bleeding that occurred in a patient undergoing late breast reconstruction with a transversus rectus abdominis musculocutaneous (TRAM) flap. During the flap-raising procedure, a small rupture was found at the base of the superior mesenteric artery, probably caused by electric current. The ruptured vessel required immediate laparotomy and suturing, and the final outcome of the patient was good. The massive bleeding, almost 8-fold as compared with three normal cases, caused clear activation of coagulation seen with elevated TAT values at the end of the operation, and remarkably enhanced fibrin turnover with elevated D-dimer, up to 25-fold from baseline, on the first postoperative day. As a result of major bleeding, the fibrinolytic system was also activated: a biphasic elevation of tPA was seen, first immediately after the bleeding event at 2 h, and later on the first postoperative day, followed by fibrinolytic shutdown associated with increased PAI-1 values.

Tenascin-C in primary malignant melanoma of the skin.

AIMS: To investigate the expression and the prognostic role of glycoprotein Tenascin-C (Tn-C) in primary melanoma of the skin. METHODS AND RESULTS: The immunohistochemical expression of Tn-C was studied in 98 primary melanomas and related to inflammation, invasion, and patient outcome. Patients were followed up for disease recurrence for 0.04-7.4 years (median 3.9) and for survival for 0.5 to 12.1 years (median 9.3). The expression of Tn-C was evaluated for each tumour invasion border; the stromal and intracytoplasmic Tn-C of the melanoma islets were also recorded. Tn-C is widely expressed in primary melanoma samples, the staining pattern varying from focal to diffuse in different parts of the tumour. No correlation existed between intensity of Tn-C staining and inflammation. No stromal Tn-C was detected at the upper dermal lateral border in 12 patients, nor at the deep, dermal or subcutaneous border in 14 patients. These patients showed better disease-free survival (DFS) than did those cases with focal or diffuse staining (P = 0.06, P = 0.05). Also, absence of intracytoplasmic Tn-C was a beneficial prognostic factor for DFS (P = 0.04). In multivariate analysis, tumour ulceration and intracytoplasmic Tn-C expression of melanoma cells were independent adverse prognostic factors for DFS. CONCLUSIONS: In primary melanoma of the skin, absence of Tn-C in the stroma of invasion fronts and within tumour cells seems to be related to a more benign disease behaviour with a lower risk of developing metastases.

Safety of immediate breast reconstruction.

The benefits of immediate breast reconstructions (IBR) compared with late reconstructions are one operation instead of two and excellent aesthetic result with the skin-sparing mastectomy technique. Indications for mastectomy vary from risk reduction of healthy women to preinvasive, invasive and locally recurrent breast cancer. IBR has been successfully performed in all of these patient groups and local control has been comparable with the series treated with breast conservation or mastectomy without reconstruction. We review this literature and discuss patient selection, the use of skin-sparing mastectomy, possibilities of nipple conservation and limitations with the use of implants. Cooperation of multidisciplinary breast cancer teams is needed to tailor the treatment of breast cancer for each individual patient. To define guidelines for the use of IBR, multicentre studies with follow-up data of large enough series stratified by patient, tumour and treatment characteristics are needed.

HER2 oncogene amplification in extramammary Paget's disease.

AIMS: To study HER2 oncogene amplification and over-expression in skin samples of 23 patients with extramammary Paget's disease (EMP). EMP is a rare intra-epidermal adenocarcinoma, which has been reported to over-express the HER2 oncoprotein. METHODS AND RESULTS: HER2 gene amplification, detected by chromogenic in-situ hybridization, was found in 43% (10/23) of the lesions. HER2 protein over-expression (3+ immunostaining intensity) was found in 12 tumours (52%), including all 10 tumours with gene amplification. Two tumours showed low-level (2+) HER2 immunostaining. Mammary Paget's lesions, which were used as controls, showed HER2 amplification and over-expression in all 10 cases studied. CONCLUSIONS: These results indicate that HER-2 protein over-expression in EMP is common and due exclusively to gene amplification. They open up the possibility of HER2-targetted immunotherapy for patients with HER2+ disease.

Immediate breast reconstruction.

Immediate breast reconstruction (IBR) in conjunction with mastectomy for cancer or high risk of breast cancer is safe from an oncological point of view. The cosmetic outcome can be excellent, especially when performing mastectomy by sparing the skin of the breast and reconstructing the breast mound with autogenous tissue. The majority of women at their working age are willing to have their breast reconstructed. Patients with newly diagnosed cancer undergoing major surgery need extra support compared with those undergoing late reconstructions. Immediate reconstructions with one operation, one hospital stay and one sick leave are economically favourable by diminishing the demand of delayed reconstructions. Preference in patient selection for IBR should be in patients with good prognoses like those with diffuse non-invasive cancer and those with a considerable risk to develop breast cancer. Women with axillary-node negative invasive cancer and women with late local recurrences in a breast earlier conservatively treated are also suitable for IBR. If needed, oncological treatments can be given after IBR, although radiotherapy after pure implant reconstructions is not recommended. In order to give all eligible patients an equal opportunity to have IBR, treatment of breast patients should be centralised to hospitals with a team comprising breast cancer surgeons, pathologists, radiologists, and plastic surgeons.

Hereditary breast cancer and handling of patients at risk.

The identification of BRCA1 and BRCA2, the two known genes causing a dominantly inherited susceptibility for breast and ovarian cancer has allowed genetic testing and identification of high risk individuals in a proportion of breast cancer families. In the future, when both the surveillance methods and prophylactic measures will be further developed this will have even more important clinical value in the management of breast cancer families. To date, as prophylactic mastectomy and/or oophorectomy have been shown to offer a significant risk reduction, these should be considered at least for known mutation carriers. Before considering this, patients should be referred for genetic counseling including risk assessment and genetic testing. Identification of a mutation in the family facilitates carrier detection by allowing predictive testing of healthy individuals. In mutation positive families, a negative test result for an individual has great value as it releases from coping with high risk of cancer and from intensive surveillance. When prophylactic surgery is considered, young age is an important determinant. A skin-sparing mastectomy with implant or autologous tissue transfer is the reconstruction method of choice. Other options like surveillance or chemoprevention can be accepted, but their uncertainty should be pointed out.

Prognosis of primary melanoma.

MATERIALS AND METHODS: To investigate the prognosis of primary melanoma, we studied a Finnish population of 298 primary melanoma patients, the majority with stage I or II tumours. The median clinical follow-up (4.8 years) was acquired from the patients' records, and the overall survival thereafter was collected from patient registries. The median follow-up for overall survival was 9.5 years. RESULTS: The overall survival rate was 66.8%. 24.5% developed metastasis, 17.8% died of melanoma, and 15.4% died of some other cause. Surgical margins had no effect on survival. In univariate analysis the most significant prognostic factors for disease-free and overall survival were stage of tumour (p < 0.0001), thickness of tumour (p < 0.0001), depth of tumour invasion (p < 0.0001) and tumour ulceration (p = 0.0005, p < 0.0002). Ulceration was an unfavorable prognostic marker. Younger patients had better survival outcomes than older ones (p = 0.04). Accordingly, in the multivariate Cox model the independent prognostic factors for both disease-free and overall survival were stage of tumour and thickness of tumour. Tumour location on trunk was an independent adverse prognosticator for overall survival. CONCLUSION: We conclude that the prognosis of primary melanoma has improved in Finland in the last decades being in line with a global tendency.

Activation of coagulation and fibrinolysis in microsurgical reconstructions in the lower extremities.

Coagulation and fibrinolysis activities in relation to trauma, surgery and thrombosed microanastomoses were studied during free-flap surgery in eight patients with lower-extremity defects due to recent trauma or chronic ulcers. One patient had an intraoperative thrombosis, and three more patients required reoperations on the same day due to postoperative thromboses; one of these also required a second reoperation due to flap failure. The baseline level of fibrinogen was slightly elevated in all patients except one, and was significantly higher in the patients who underwent reoperation. At the end of the primary surgery, distinct thrombin generation (TAT and F1+2) was seen in three patients with excessive bleeding, and all three later underwent reoperations. One of these patients generated excessive thrombin on the eighth postoperative day, upon removal of a necrotic flap. Thrombin generation (F1+2) was also seen at baseline in the patient with the intraoperative thrombosis, and persisted on the first postoperative day. D-dimer at baseline was higher in patients with recent trauma, and in two of these, both of whom underwent reoperations on the same day, D-dimer remained high perioperatively. Resistance to fibrinolysis with increased PAI-1 levels was seen in these two patients at the time of reoperation. In all, TAT and F1+2 were associated with the threat of flap failure. A preoperative hypercoagulable state and excessive bleeding during the operation were predictors of reoperation. The markers for coagulation and fibrinolysis could be used preoperatively to target antithrombotic control, and postoperatively to detect the threat of flap failure. Meticulous haemostasis during surgery might help to diminish the need for reoperations.

Activation of coagulation and fibrinolysis during reconstructive microsurgery in patients with cancer.

Cancer patients are subjected to increased systemic risk of thrombotic events and may therefore be at higher risk of even local thrombosis compromising the outcome of reconstructive microsurgery. Coagulation and fibrinolysis activities were studied serially during and after reconstructive microsurgery in seven patients with oropharyngeal cancer or sarcoma in the extremities. A preoperative hypercoagulable state was found in four patients (elevated fibrinogen, TAT, F1+2, or D-dimer); two of these patients also had a local thrombotic event. In all patients, the plasma markers generally varied perioperatively: fibrinogen decreased, whereas TAT and subsequently D-dimer increased at the end of the operation. However, tPA and PAI-1 remained unaltered, except in the patients with thrombosis in whom PAI-1 activity increased progressively during the operation. F1+2 was also clearly elevated in these two patients at the time of thrombosis. Preoperative assessment of hypercoagulability for this group of patients could be helpful in targeting meticulous antithrombotic protection.

Blood flow in a pedal bypass combined with a free muscle flap.

OBJECTIVE: to assess the haemodynamic effect of a free muscle flap on the midterm success of a pedal bypass. DESIGN: prospective consecutive study. MATERIALS: a pedal bypass (autogenous vein graft) combined with a free muscle flap was performed in 13 patients with critical leg ischaemia. The feeding artery of the flap was anastomosed end-to-side to the bypass. METHODS: blood flow was measured in the bypass before and after transplanting the flap. Doppler was used postoperatively to assess the patency. RESULTS: the bypass and flap pedicle were patent in 11 cases six months postoperatively. Two grafts were thrombosed and the legs amputated. In the successful group the median (range) blood flow in the bypass was 50 (10-100) ml/min. It increased (p<0.05) after transplantation to 64 (20-113) ml/min, being 44 (14-97) ml/min distributed to the foot. Blood flow through the flap was 20 (6-37) ml/min. The two failing grafts had a flow of 30 and 51 ml/min before and 48 and 52 ml/min after transplantation, respectively. Blood flow through the flap was 47 ml/min and 36 ml/min, respectively. In the failure group the free flap received most of the blood supply through the bypass. CONCLUSIONS: a free muscle flap connected to an infrapopliteal bypass increases the distal outflow bed and thus decreases the outflow resistance and increases graft flow.

Free flap reconstructions in the management of oral and pharyngeal cancer.

Fifty patients who had undergone microvascular free flap reconstruction of the oral cavity or pharynx for malignancy between 1989 and 1995 were retrospectively analysed to find factors predicting postoperative complications and outcomes. The mean follow-up time was 2.6 years. More than half (26/50) of the patients had a stage IV malignancy and 10 patients had a recurrent tumour. The overall flap success rate, with 2 flap losses, was 96%. Postoperative medical complications occurred in 29/50 (58%) cases. The recipient site of 10/50 (20%) flaps required re-exploration. Mortality was 2%, with 1 death occurring within 30 days. The mean survival rate after the microvascular operation was 1.6 years, and the 3- and 5-year survival rates were 42% and 23%, respectively. Patients with an oropharyngeal tumour seemed to have the best prognosis and those with a hypopharyngeal tumour the poorest. Men had a threefold greater risk of dying within < 1 year postoperatively compared with women. Tumour stage was the strongest attribute influencing survival. The risk of death after the microvascular procedure increased 2.8-fold when the stage advanced from II to III or from II to IV. None of the tested variables alone could predict complications.

Intraoperative evaluation of blood flow in the internal mammary or thoracodorsal artery as a recipient vessel for a free TRAM flap.

Although the free microvascular transverse rectus abdominis musculocutaneous (TRAM) flap is in routine use for breast reconstruction, little is known of its hemodynamics. The purpose of this study was to determine whether any differences exist when the free TRAM flap is anastomosed to the thoracodorsal or internal mammary vessels. The study comprised 25 patients receiving a free TRAM flap for breast reconstruction. The thoracodorsal vessels were used as recipients in 21 patients and the internal mammary vessels were used in 4 patients. Blood flow rate was measured directly in the donor and recipient arteries, and after anastomosis by a transit-time ultrasonic flowmeter (CardioMed). Two- and 3-mm probes were used. The blood flow rate in the donor artery (deep inferior epigastric) before flap dissection was 11 +/- 6 ml per minute (mean +/- standard deviation). The rate was significantly (p < 0.05) lower (5 +/- 3 ml per minute) in the recipient thoracodorsal artery than in the donor, but after transplantation it increased to 14 +/- 5 ml per minute (p < 0.05), attaining the same value as the donor artery. The blood flow rate in the intact internal mammary artery was significantly higher (25 +/- 10 ml per minute) than in the donor and thoracodorsal arteries, but after anastomosis it dropped to the same value (12 +/- 3 ml per minute; p < 0.05) as the donor artery. The intake of blood in TRAM flaps supplied by the intemal mammary artery seems to be no greater than that in free flaps anastomosed to thoracodorsal vessels, although the flow in the internal mammary artery was much higher. The authors concluded that the blood supply in a free TRAM flap is independent of the flow in the recipient artery and that thoracodorsal vessels, although often in a scarred bed and radiated, are as suitable for anastomosing a free TRAM flap as are internal mammary vessels.

Evaluation of blood flow in free microvascular flaps.

Free flap surgery is routine today, yet little is known of its pathophysiology. In this study, the authors evaluated the hemodynamics in different types of free microvascular flaps, by measuring intraoperative transit-time flow. Eighty-six free transplants--21 free TRAM flaps for breast reconstruction, 18 radial forearm flaps for head and neck reconstructions, and 47 muscle flaps for head and neck, trunk and lower extremity reconstructions--were studied. Donor artery flow was highest in the radial artery (mean: 57.5 +/- 50 (SD) ml/min) but dropped (p < 0.001) to one tenth (6.1 +/- 2 ml/min) after anastomosis. The flow was lowest (4.9 +/- 3 ml/min) in the recipient artery of the TRAM flap but, after anastomosis, increased significantly (13.7 +/- 5 ml/min) to the level of the flow in the donor artery. The donor-artery flow in muscle flaps had a mean of 15.9 +/- 11 ml/min, and it significantly increased after anastomosing (23.9 +/- 12 ml/min). Weight-related intake of blood was highest in the radial forearm flap (18.5 +/- 6 ml/ min/100g) and lowest in the TRAM flap (2.5 +/- 1 ml/min/100g). The study showed that blood flow through a free microvascular flap does not depend on recipient artery flow. Even low-flow arteries can be used as recipients, because the flow increases according to free-flap requirements. The blood flow through a free microvascular flap depends on the specific tissue components of the flap.

Sebaceous carcinoma of the eyelid associated with retinoblastoma.

OBJECTIVE: To analyze the association between retinoblastoma (Rb) and sebaceous carcinoma (SC) of the eyelid to improve surveillance of survivors of RB: DESIGN: Case report and systematic literature review. METHODS: Ten patients who had SC develop after Rb were identified by systematic literature review, and a child who died with lymph node, lung, and liver metastases 7 years after irradiation for Rb is described. The data were analyzed by univariate statistics, including cumulative frequency distribution plots and Kaplan-Meier analysis. RESULTS: Of 11 children with SC of the eyelid who all had hereditary RB, 9 (82%; 95% confidence interval, 48-98) received a median of 46 Gy (range, 21-89) of radiotherapy at a median age of 16 months (range, 0.5-15 years) and had SC develop within the field of radiation. Their median age at diagnosis of SC was 14 years (range, 8-30 years), median diagnostic delay 12 months (range, 6 months-3 years), and median interval from irradiation 11 years (range, 5-26 years); 7 of them (78%; 95% confidence interval, 40-97) were diagnosed between 5 and 15 years after radiotherapy. SC also developed at the age of 32 and 54 years in two nonirradiated Rb patients. Five patients had regional lymph node metastases after a median time of 12 months (range, 1 month-24 years). The 5-year cumulative probability of survival was 87%. CONCLUSIONS: SC of the eyelid may occur in patients with hereditary Rb regardless of primary treatment, especially within the field 5 to 15 years after radiotherapy.

Patients with pressure ulcers in Finnish hospitals.

The purpose of this descriptive study was to produce knowledge of the degree of pressure ulcers, pressure ulcer patients' physical and psychological well-being and the association of these factors with pressure ulcers' severity. These patients were treated in Finland's capital area hospitals. The pressure ulcer patients' sampling was gathered during 1 day with two questionnaires, which was completed by nurses. The response rate was 94%, and data analysis was based on percentage distributions. Statistical association was tested with the chi2 test. The measurement identified 164 patients with a total of 257 pressure ulcers. Prevalence was 6.4%. Most of the ulcers (40%) were grade II ulcers. Fifty-six per cent of patients suffered poor general health, 63% of the patients were immobile, but psychological well-being was better with 29% of pressure ulcer patients being adequately motivated to follow treatment for their pressure ulcers. It is essential to identify high-risk patients in order to provide optimal care.

Patients' satisfaction with breast reconstruction and reduction mammaplasty.

Patients' satisfaction is widely recognised as an important measure of the quality of care. This study measured patients' satisfaction with the outcome of breast reconstruction surgery and reduction mammaplasty and with the treatment received in hospital. A questionnaire about patients' reasons for having the operation and postoperative satisfaction was therefore sent to 137 patients after breast reconstruction and 142 who had had reduction mammaplasty. The response rate in the former group was 84% and in the latter 65%. In both groups of patients the main reasons for having the operation were difficulties with physical activities and in finding clothes to fit. Other factors were poor self-esteem and problems with body image. A total of 69% of the patients who had had reconstructions referred to problems with wearing an external prosthesis. In the reduction mammaplasty group one of the most important reasons for having the operation was pain, in particular neck, shoulder, and back pain. In the reconstruction group 94%, and in the reduction group 88%, thought the outcome of the operation was good or very good. They had no regrets about their decision to seek surgical treatment, even when the aesthetic outcome fell short of their expectations. The patients were generally satisfied with the treatment they had received. In the reconstruction group 97%, and in the reduction group 96%, of patients felt satisfied with their overall decision to have the operation. Our results confirm that these surgical procedures help to improve patients' quality of life. Among the patients who had had reconstructions, the resolved problems with body image were considered to be the main benefit of the operation. In the reduction group the main benefits were reduced neck, shoulder, and back pain. In both groups 91% of patients would have recommended the operation to a friend under similar circumstances. In the light of this evidence doctors should more readily recommend reconstruction to patients after mastectomy and reduction to women with heavy breasts.

Asymmetry of gait after free flap reconstruction of severe tibial fractures with extensive soft-tissue damage.

Gait patterns of the preferred speed were investigated on 17 patients recovering (9 months-14 years) after reconstruction of severe tibial fractures. A novel data-acquisition system was used to record the plantar pressures as well as electromyographic (EMG) activities during walking. The results indicated incomplete recovery of symmetrical gait patterns. In particular, the duration of the stance phase was shorter on the operated side (mean (SD) 701 (90) ms compared with 765 (128) ms, p < 0.001). The peak pressure points under the foot were different on bilateral comparison, the operated side being regularly higher under the lateral forefoot area. This may imply attempts to reduce the loading of the ankle joint during stance. The pressure distribution models reflected these asymmetrical patterns more specifically than the EMG activities of the lower leg muscles examined.