Australian women's experiences of post-partum rectus diastasis: A qualitative study.

BACKGROUND: Post-partum rectus diastasis, or the separation of the abdominal muscles after pregnancy, occurs in conjunction with physical symptoms and impaired quality of life. In Australia, health funding for surgery to treat diastasis was ceased in 2016, but reinstated in mid-2022, providing a unique context from which women's experiences of this condition can be analysed. OBJECTIVES: The objective is to examine the experiences of Australian women with post-partum rectus diastasis. DESIGN: This is an interview-style study with qualitative content analysis. METHODS: Women diagnosed with rectus diastasis were recruited to complete a baseline questionnaire (n = 45). Twenty-three responded to invitation for one-on-one interview via Zoom® between November 2021 and May 2022. Interviews were recorded, transcribed, and analysed using qualitative content analysis to identify key themes. RESULTS: Eighteen women had undergone caesarean section and eight had twins. Thirteen had private health insurance. Women were most often diagnosed by a physiotherapist (n = 10). Key themes identified included changed physical appearance and function; issues with self-esteem and intimacy; barriers to treatment; lack of recognition as a medical condition; and overall frustration. The impact of rectus diastasis extended beyond physical and psychological symptoms to affect women's social functioning, child rearing, and return to work. There was a complex interaction between healthcare providers' knowledge of rectus the removal of funding for surgical treatment, and limitations of conservative therapy, with women's lived experiences and symptoms. The lack of an established medical definition also influenced the experiences of these women and their engagement with treatment. CONCLUSION: This study contextualizes women's experience of post-partum rectus diastasis with respect to the unique landscape of Australia's healthcare economy and provides evidence of women's absorption of health policy surrounding this condition. Our qualitative analysis provides critical knowledge for future quantitative studies, the results of which in combination could advance the definition of rectus diastasis and inform healthcare policy surrounding treatment.

Is tropical pus in the hand special? A retrospective study comparing hand infection cases in Darwin and Adelaide.

BACKGROUND: Hand infections are a common reason for presenting to hospital and can be associated with significant morbidity and prolonged antibiotic use. Factors recognized to influence patient outcomes include resistant organisms and delayed presentation. Surgeons working around Australia may assume that hand infections and appropriate treatment algorithms will be similar between sites. This is the first study to examine differences between hand infections presenting in Darwin (with its tropical climate) vs. those in a more temperate city (Adelaide). METHODS: This is a two-site retrospective study, where diagnostic discharge codes were used to identify cases for a 12-month period and patient age, sex and rurality, duration of hospital stay, microbiology results and subsequent trips to theatre were reviewed. RESULTS: Despite significant differences in rurality between FMC and RDH patients, there was no significant difference in length of hospital stay, duration of intravenous antibiotics or return trips to theatre across the two sites. RDH reported a 25% rate of MRSA, compared to 18% at FMC, as well as a statistically significant increase in uncommon microbes, with 30% compared to 12% of patients growing microbes that may not be covered by antibiotics routinely administered in metropolitan areas. A limitation of this study was that compliance with antibiotics and hospital stay were not accounted for. CONCLUSION: It is often our training years that determine our norms of everyday practice, but fewer Australian surgical training posts are located in tropical centres. The results of this study highlight the importance of not assuming that the spectrum of organisms causing hand infections are the same as that in the surgeons' state of origin.

Self-reported breast size, exercise habits and BREAST-Q data - an international cross-sectional study of community runners.

Women with larger breasts tend not to participate in high-intensity exercise and exercise less frequently. This study investigates how breast size impacts exercise habits and how breast reduction surgery changes women's participation in recreational exercise. Recruitment was generated via parkrun Limited (Richmond, UK), an organization offering weekly community-based runs. Female parkrun members aged over 18 years with no history of breast cancer were invited to complete a survey, including questions about their exercise habits, breast size, any breast alteration surgery, and BREAST-Q questionnaires. A total of 1987 women completed the survey, including 56 women who had undergone breast reduction. Results demonstrate that women with bigger breasts believe that reducing their breast size would improve their exercise performance and participation and that their breast size significantly impacts their type of exercise. Women who had undergone breast reduction reported increased overall frequency, enjoyment, and willingness to exercise in a group. Additionally, women that have undergone breast reduction report higher BREAST-Q scores than their non-surgical counterparts. This study supports the existing literature that breast size can impact exercise habits and demonstrates that women who have undergone breast reduction participate in healthier lifestyle practices. We suggest that if breast size impacts women's participation in sport and fitness, health practitioners and policymakers should advocate for better access to reduction mammoplasty in the publicly funded health sector.

Outcomes of DCIS treated with breast conserving surgery without radiotherapy on recurrence, survival, and health-related quality of life.

BACKGROUND: Sector resection for Ductal Carcinoma in Situ (DCIS) allows wide excision without compromising breast shape. There are concerns that radiotherapy for some DCIS after sector resection is unnecessary and reduces patient satisfaction and quality of life without affecting survival. This study aimed to investigate whether women with DCIS managed with sector resection without radiotherapy had acceptable rates of recurrence and health-related quality of life outcomes. METHODS: Retrospective study of patients who underwent sector resection for DCIS without adjuvant radiotherapy from 1992 to 2021. Tumour size, grade, necrosis, margins, follow up and time to ipsilateral recurrence was recorded. Patients were posted a BREAST-Q to assess health-related quality of life. RESULTS: One hundred and thirty-eight patients were treated for pure DCIS by two surgeons from 1992 to 2018. One hundred and sixteen patients underwent sector resection, 22 had mastectomy. Average age 61 years. Mean follow up 9.14 years. Recurrence rate after sector resection was 18.97%. 55% were DCIS. Annualized recurrence rate was 2.07%. There were no cancer-related deaths. BREAST-Q completion rate was 44%. Satisfaction with breasts, physical, psychosocial, and sexual well-being scores were significantly higher than normative Australian values and a mixed cohort of women who underwent breast conserving surgery with radiotherapy. CONCLUSION: DCIS can be safely managed with sector resection without radiotherapy and regular long-term follow up. This approach results in low annualized recurrence rates, high levels patient satisfaction and health-related quality of life and should be considered a safe alternative for patients with DCIS to minimize morbidity without affecting cancer survival.

Long-term outcomes of breast reduction surgery: A prospective cohort study.

BACKGROUND: Breast reduction surgery has been shown to be the most effective treatment for symptomatic breast hypertrophy in women. However, existing studies have been limited to a relatively short-term follow-up. This study aimed to assess the long-term outcomes following breast reduction surgery. METHODS: This is a prospective cohort study of women aged 18 years and above who underwent breast reduction surgery over a 12-year period. Participants completed a series of patient-reported outcome measures, including the Short Form-36 (SF-36), BREAST-Q reduction module, Multidimensional Body-Self Relations Questionnaire (MBSRQ), and study-specific questions preoperatively, 12 months postoperatively, and at a long-term follow-up of up to 12 years postoperatively. RESULTS: Long-term outcome data were obtained from 103 participants. The median follow-up time following surgery was 6.0 years, range 3-12 years. The mean SF-36 scores remained stable and significantly higher than baseline over time, with no significant differences found in all eight subscales or summary scales. BREAST-Q scores remained significantly higher than baseline in all four scales. MBSRQ scores for appearance evaluation, health evaluation, and body areas satisfaction score remained significantly higher than scores reported preoperatively; in contrast, scores for appearance and health orientation and self-classified weight were significantly lower. Compared with normative data, long-term outcome scores remained stable and at levels equivalent or beyond population norms. CONCLUSIONS: This study demonstrated that patients continue to report a high level of satisfaction and improved health-related quality of life in the longer term following breast reduction surgery.

A comparison of reconstructive outcomes following rotation flap approach (RoFA) versus standard mastectomy: a randomized controlled trial.

BACKGROUND: The rotation flap approach (RoFA) mastectomy is a skin-sparing technique that actively imports skin to the centre of the skin envelope and therefore aids in achieving natural ptosis to the reconstructed breast. The objective of this study was to compare clinical outcomes, aesthetics, patient satisfaction and health-related quality of life between the ROFA mastectomy and standard mastectomy approach. METHODS: This study is a prospective randomised controlled trial of participants undergoing mastectomy using either the RoFA technique or standard technique with breast reconstruction. The BREAST-Q was administered pre-operatively and at 3-, 6-, 9- and 12-months following mastectomy. A panel assessment of clinical photographs was conducted to score aesthetics and outcomes of reconstruction. RESULTS: A total of 100 participants were enrolled in the study; of these, 51 underwent RoFA incision, 47 underwent standard incision and 2 were lost to follow up. There were no statistically significant differences in BREAST-Q scores or panellist assessment between the mastectomy groups following breast reconstruction. The post-operative incidence of mastectomy skin flap tip necrosis was high in the RoFA incision group, with rates of other complications such as seroma being similar. CONCLUSION: The RoFA skin-sparing mastectomy incision showed no significant difference in results across patient-reported outcomes or aesthetics when compared to the standard approach, however, did rate higher for skin flap tip necrosis.

A five-year retrospective cohort study of carpal tunnel surgery complications in an Australian population.

BACKGROUND: Carpal tunnel syndrome is a common compressive neuropathy. There is a lack of comprehensive studies evaluating carpal tunnel release (CTR) complications in Australia. This study aimed to evaluate complication rates associated with open and endoscopic CTR in an Australian population, and to identify associated risk factors. METHODS: Retrospective cohort study of 1287 CTR from 2015 to 2020. Methods of release were endoscopic, open and surgery concomitant with synovectomy or other. Outcomes included wound infection, dehiscence, nerve injury, complex regional pain syndrome, incomplete release, and re-operation. Statistical analysis included Chi-squared test, Fisher's exact test, Odds ratio and logistic regression. RESULTS: There were 71 total complications (5.5%), including 35 Clavien-Dindo IIIb complications. There was no difference in complication rates for endoscopic (3.3%) versus open (8.3%) CTR (P = 0.18). The overall rate of complications was higher in CTR with concomitant surgery (8.5%) compared to CTR alone (5.2%), though this was not statistically significant (P = 0.058). There was no association between rates of complications and immune suppression (p = 0.55), rheumatoid disease (P = 0.61), or smoking status (P = 0.72). Diabetes mellitus was associated with an increased risk of Clavien-Dindo IIIb complications (P = 0.028, OR 2.15, 95% CI 1.07-4.32). There was no association between surgical experience and complication rate (P = 0.55). CONCLUSION: Open and endoscopic CTR surgeries have similar rates of complications. Diabetes is associated with higher rates of Clavien-Dindo IIIb complications. Identification of high-risk patients allows for the application of risk-mitigation strategies in the perioperative setting.

Qualitative study informing the development and content validity of the HAND-Q: a modular patient-reported outcome measure for hand conditions.

OBJECTIVES: The purpose of this study was to identify and understand the issues that are relevant to patients with hand conditions. The data were used to develop a patient-reported outcome measure (PROM) for adults with hand conditions (HAND-Q) and refine it with input from patients and clinician experts. DESIGN: Semistructured qualitative interviews were used to understand what matters to patients. Cognitive debriefing was used to refine preliminary HAND-Q scales. SETTING: Hand clinics in tertiary healthcare centres in Canada, Australia and USA. PARTICIPANTS: Eligible participants were English-speaking adults who had experienced hand surgery in the preceding 12 months and were at least 4 weeks post-hand surgery A total of 62 in-depth interviews (females, n=34; mean age=65 years) were conducted to develop an item pool and draft the HAND-Q scales. The preliminary scales were refined through cognitive debriefing interviews with 20 participants and feedback from 25 clinician experts. All interviews were audiorecorded, transcribed verbatim and coded using a line-by-line approach. RESULTS: Qualitative data were organised into two top-level domains of health-related quality of life and satisfaction with treatment outcomes. The scales were refined iteratively, and the field-test version included 319 unique items and 20 independently functioning scales. CONCLUSIONS: The HAND-Q is a comprehensive PROM developed using extensive patient and clinician expert input, following established guidelines for PROM development and validation. In the next phase, the psychometric properties of the HAND-Q will be established in an international field test, following which the HAND-Q will be available for use in clinical research and practice .

Normative data for the BREAST-Q Reconstruction module in an Australian population and comparison with US norms and breast reconstruction patient outcomes.

BACKGROUND: Normative data for interpreting the BREAST-Q reconstruction module are currently limited to the US population. This study aimed to generate normative BREAST-Q data from women in the Australian general population and compare it to US norms. Secondary aims were to compare normative scores to those of women undergoing breast reconstruction post-mastectomy. METHODS: Women aged 18 years and older without a history of breast cancer or breast surgery were recruited according to the Australian Census-derived population distribution. Participants completed the pre-operative BREAST-Q Reconstruction module and provided socio-demographic information. A comparison was made to a breast reconstruction patient cohort and published US norms. RESULTS: BREAST-Q data were obtained from 500 women. Mean BREAST-Q scores were as follows: Satisfaction with Breasts (Aus. 50.4 ± 15.2, US 57.8 ± 18.4), Psychosocial Well-being (Aus. 55.4 ± 15.8, US 70.7 ± 17.6), Physical Well-being Chest (Aus. 78.5 ± 14.8, US 92.6 ± 10.7), Physical Well-being Abdomen (Aus. 76.1 ± 19.6, US 78.1 ± 20.3) and Sexual Well-being (Aus. 41.5 ± 20.6, US 56.5 ± 8.2). Australian women with a higher BMI or chronic health condition reported lower scores for four of the five BREAST-Q scales. Lower scores were reported by younger women for Psychosocial Well-being and Sexual Well-being. Mean BREAST-Q scores for the Australian population were significantly lower than US norms in four of the five scales. When compared to normative data, breast reconstruction patients had significantly higher BREAST-Q scores post-operatively in all scales except for Physical Well-being Chest. CONCLUSION: This study derived only the second set of normative scores for the BREAST-Q reconstruction module reported globally and found that significant differences exist between populations.

The HAND-Q: Psychometrics of a New Patient-reported Outcome Measure for Clinical and Research Applications.

The perspective of the patient in measuring the outcome of their hand treatment is of key importance. We developed a hand-specific patient-reported outcome measure to provide a means to measure outcomes and experiences of care from the patient perspective, that is, HAND-Q. METHODS: Data were collected from people with a broad range of hand conditions in hand clinics in six countries between April 2018 and January 2021. Rasch measurement theory analysis was used to perform item reduction and to examine reliability and validity of each HAND-Q scale. RESULTS: A sample of 1277 patients was recruited. Participants ranged in age from 16 to 89 years, 54% were women, and a broad range of congenital and acquired hand conditions were represented. Rasch measurement theory analysis led to the refinement of 14 independently functioning scales that measure hand appearance, health-related quality of life, experience of care, and treatment outcome. Each scale evidenced reliability and validity. Examination of differential item functioning by age, gender, language, and type of hand condition (ie, nontraumatic versus traumatic) confirmed that a common scoring algorithm for each scale could be implemented. CONCLUSIONS: The HAND-Q was developed following robust psychometric methods to provide a comprehensive modular independently functioning set of scales. HAND-Q scales can be used to assess and compare evidence-based outcomes in patients with any type of hand condition.

Cost-utility analysis of breast reduction surgery for women with symptomatic breast hypertrophy.

OBJECTIVE: To assess the cost-effectiveness of breast reduction surgery for women with symptomatic breast hypertrophy in Australia. DESIGN: Cost-utility analysis of data from a prospective cohort study. SETTING, PARTICIPANTS: Adult women with symptomatic breast hypertrophy assessed for bilateral breast reduction at the Flinders Medical Centre, a public tertiary hospital in Adelaide, April 2007 - February 2018. The control group included women with breast hypertrophy who had not undergone surgery. MAIN OUTCOME MEASURES: Health care costs (for the surgical admission and other related hospital costs within 12 months of surgery) and SF-6D utility scores (measure of health-related quality of life) were used to calculate incremental costs per quality-adjusted life-year (QALY) gained over 12 months, extrapolated to a 10-year time horizon. RESULTS: Of 251 women who underwent breast reduction, 209 completed the baseline and at least one post-operation assessment (83%; intervention group); 124 of 350 invited women waiting for breast reduction surgery completed the baseline and 12-month assessments (35%; control group). In the intervention group, the mean SF-6D utility score increased from 0.313 (SD, 0.263) at baseline to 0.626 (SD, 0.277) at 12 months; in the control group, it declined from 0.296 (SD, 0.267) to 0.270 (SD, 0.257). The mean QALY gain was consequently greater for the intervention group (adjusted difference, 1.519; 95% CI, 1.362-1.675). The mean hospital cost per patient was $11 857 (SD, $4322), and the incremental cost-effectiveness ratio (ICER) for the intervention was $7808 per QALY gained. The probability of breast reduction surgery being cost-effective was 100% at a willingness-to-pay threshold of $50 000 per QALY and 88% at $28 033 per QALY. CONCLUSIONS: Breast reduction surgery for women with symptomatic breast hypertrophy is cost-effective and should be available to women through the Australian public healthcare system.

Predicted versus actual complications in Australian women undergoing post-mastectomy breast reconstruction: a retrospective cohort study using the BRA Score tool.

INTRODUCTION: The Breast Reconstruction Risk Assessment (BRA) Score tool is a risk calculator developed to predict the risk of complications in individual patients undergoing breast reconstruction. It was developed in a North American population exclusively undergoing immediate breast reconstruction. This study sought to assess the predictions of the BRA Score tool against the measured outcomes of surgery for an Australian public hospital population, including both immediate and delayed reconstructions. METHOD: This was a retrospective cohort study of data from women at a single Australian public teaching hospital unit. Data from the Flinders Breast Reconstruction Database was retrieved and compared to BRA Scores calculated for each patient. Receiver operating curve area under the curve analysis was performed as well as Brier scores to compare predicted versus observed complications. RESULTS: BRA Score predictions were reasonable or good (C-statistic >0.7, Brier score <0.09) for the complications of overall surgical complications, surgical site infection (SSI) and seroma at 30 days, and similarly accurate for prediction of the same complications for implant reconstructions at 12 months. There were similar findings between delayed and immediate reconstructions. CONCLUSION: The BRA Score risk calculator is valid to detect some risks in both patients undergoing immediate and delayed breast reconstruction in an Australian public hospital setting. SSI is the best predicted complication and is well-predicted across both autologous and prosthetic reconstruction types.

The anatomical distribution of non-melanoma skin cancer: a retrospective cohort study of 22 303 Australian cases.

BACKGROUND: Non-melanoma skin cancers (NMSC) are the most common skin cancers worldwide with research establishing that ultraviolet (UV) radiation influences occurrence. However, recent studies about NMSC tumour frequencies suggested high NMSC predilections in low UV-exposed skin regions. METHODS: The 'Human Surface Anatomy Labeling System' was used to define 100 skin regions to map NMSC locations excised at Flinders Medical Centre (FMC) between 1 January 2012 and 31 December 2017. Data were retrieved from the FMC histopathology database. A customised phrase algorithm was used to run a systematic word search on the dataset to quantify NMSC locations. RESULTS: A total of 22 303 NMSC excisions were identified; 80% were head and neck excisions. Scalp, periocular and nasal regions showed a significantly greater predilection for basal cell carcinomas (BCC). Squamous cell carcinomas (SCC) had significantly more excisions in lip, neck and scalp regions. Regarding gender-related variations, more males had BCC excisions in ear regions and more females had nasal, lip, and ankle excisions. In SCC excisions, more males had scalp excisions and more females had leg and lip excisions. Considering age-related variation, significantly higher proportions of BCC were found with forehead excisions compared to scalp, neck and lower limb regions for SCC, all being highest for 60-79-year age groups. CONCLUSION: The relationship between NMSC type and anatomical distribution may be partially explained by gender and age affecting NMSC predilections particularly in the head and neck. However, other skin regions could not be explained solely by these factors.

Normative data for the Nasal Obstruction Symptom Evaluation Scale in the general Australian population.

BACKGROUND: Recent changes to the Australian Medicare Benefits Scheme have introduced the NOSE Score as a criteria threshold for funding rhinoplasty. On review of the literature, however, there is minimal normative Nasal Obstruction Symptom Evaluation (NOSE) score data to provide context for these changes. METHODS: Participants were recruited according to the general Australian population distribution of age (18-65 years), gender and geographical locations using the market research company Pureprofile. The data included demographic details, risk factors for nasal obstruction such as smoking, obstructive sleep apnoea, use of continuous positive airway pressure, history of nasal trauma, operations to the nose and a history of cleft lip/palate and each participant completed the NOSE Scale. Analysis of data included descriptive statistics, independent t-tests and one-way analysis of variances to assess differences in NOSE scores between risk factors. RESULTS: The NOSE score was completed by 247 males and 255 females with a mean age of 41(±13.39) years. The cohort had a mean NOSE score of 16 (±18.89) with a range from 0 to 95. A total of 48 respondents had a NOSE score greater than the Medicare threshold of >45. Cleft lip/palate, obstructive sleep apnoea and continuous positive airway pressure use were shown to have a statistically significant impact on NOSE score while other variables including body mass index, gender, smoking, location and other surgery to the nose were not shown to significantly impact results. CONCLUSIONS: This study found that 9.6% of the general Australian population would have a NOSE score >45 and qualify for the Medicare Benefits Scheme rhinoplasty benefit.

Does breast reduction surgery improve health-related quality of life? A prospective cohort study in Australian women.

OBJECTIVES: To assess the health burden of breast hypertrophy and the comparative effectiveness of breast reduction surgery in improving health-related quality of life. DESIGN: Prospective cohort study. SETTING: A major public tertiary care hospital in Australia. PARTICIPANTS: Women with symptomatic breast hypertrophy who underwent breast reduction surgery were followed for 12 months. A comparison control cohort comprised women with breast hypertrophy who did not undergo surgery. INTERVENTIONS: Bilateral breast reduction surgery for women in the surgical cohort. MAIN OUTCOME MEASURES: The primary outcome measure was health-related quality of life measured preoperatively and at 3, 6 and 12 months postoperatively using the Short Form-36 (SF-36) questionnaire. Secondary outcome measures included post-surgical complications. RESULTS: 209 patients in the surgical cohort completed questionnaires before and after surgery. 124 patients in the control hypertrophy cohort completed baseline and 12-month follow-up questionnaires. At baseline, both groups had significantly lower scores compared with population norms across all scales (p<0.001). In the surgical cohort significant improvements were seen across all eight SF-36 scales (p<0.001) following surgery. Within 3 months of surgery scores were equivalent to those of the normal population and this improvement was sustained at 12 months. SF-36 physical and mental component scores both significantly improved following surgery, with a mean change of 10.2 and 9.2 points, respectively (p<0.001). In contrast, SF-36 scores for breast hypertrophy controls remained at baseline across 12 months. The improvement in quality of life was independent of breast resection weight and body mass index. CONCLUSION: Breast reduction significantly improved quality of life in women with breast hypertrophy. This increase was most pronounced within 3 months of surgery and sustained at 12-month follow-up. This improvement in quality of life is comparable to other widely accepted surgical procedures. Furthermore, women benefit from surgery regardless of factors including body mass index and resection weight.

The Superiorly Based Partial Rectus Abdominis and External Oblique Flap for Lower Pole Coverage in Prosthetic Breast Reconstruction: A Prospective Cohort Study of 47 Consecutive Flaps.

BACKGROUND: This study evaluated health related quality of life and morbidity in patients who had a superiorly based partial rectus abdominis and external oblique (SPREO) flap for lower pole coverage as a component of 2-stage prosthetic breast reconstruction. METHODS: A prospective cohort study of patients undergoing immediate and delayed 2-stage breast reconstruction including a SPREO flap for lower pole coverage was conducted. The BREAST-Q and a study-specific questionnaire were used to determine outcomes after this procedure. BREAST-Q questionnaires were completed preoperatively and postoperatively and compared with normative values. RESULTS: BREAST-Q questionnaires were completed by 27 women. The mean patient age was 54.3 ± 9.6 years. Mean BREAST-Q scores improved significantly between preoperative and postoperative time points in Satisfaction with Breasts (preoperative 43.2 ± 26.9, postoperative 66.2 ± 19.5, P = 0.001) and Psychosocial Wellbeing (preoperative 59.4 ± 16.4 postoperative 75.5 ± 19.4, P = 0.002). Mean scores were not significantly different in the domains Physical Wellbeing Chest, Physical Wellbeing Abdomen and Sexual Wellbeing. Postoperative BREAST-Q scores were significantly higher (P < 0.05) than previously published normative scores in Satisfaction with Breasts. CONCLUSIONS: This study reports the use of the SPREO flap for lower pole coverage in 2-stage prosthetic breast reconstruction and demonstrates that it may be a useful addition to the existing repertoire of flaps used in breast reconstruction.

Prospective Randomized Cohort Study to Explore the Acceptability of Patient-Reported Outcome Measures to Patients of Hand Clinics.

Purpose: The purpose of this randomized prospective cohort study was to assess the acceptability of administering patient-reported outcome measures (PROMs) in the waiting room of hand clinics. Methods: Participants were randomly assigned to receive the Patient-Rated Wrist and Hand Evaluation (PRWHE), Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, or Michigan Hand Questionnaire (MHQ). Acceptability was measured in terms of data quality, participation, and retention rates. Data quality was determined by the number of incomplete questionnaires, unanswered questions, and unscorable questionnaires. Most frequently unanswered questions were identified. The participant-reported time taken to complete the questionnaires was collected. Results: A total of 491 participants enrolled in this study. A participation rate of 85% with a retention rate of 94% indicated that patients found the administration of PROMs in the waiting room of the clinic to be acceptable. The proportion of missing data for each questionnaire was 4.2% for PRWHE, 3.9% for DASH and 6.3% for MHQ. Whether a questionnaire could be used to generate a score was determined by the scoring rules of each instrument. The proportion of questionnaires that were not completed sufficiently for a score to be generated was 0% for PRWHE, 9% for DASH, and 4% for MHQ. No association was found between whether a questionnaire could generate a score and participants' sex, age, or the nature of the condition. Over 80% of participants reported taking 10 minutes or less to complete the questionnaire. Conclusions: This study shows that hand clinic patients will complete PROMs while waiting for the clinical review. The PRWHE and MHQ groups demonstrated good usability, because less than 5% were unable to produce a score. The usability of the DASH group was lower, because 9% were unable to be scored. This indicates that PRWHE and MHQ are more suitable than DASH to application in a hand clinic setting. Type of study/level of evidence: Therapeutic III.

Efficacy of an external volume expansion device and autologous fat grafting for breast reconstruction following breast conserving surgery and total mastectomy: Small improvements in quality of life found in a prospective cohort study.

BACKGROUND: Although autologous fat grafting (AFG) for breast reconstruction is feasible, the best methods have yet to be established. This study aimed to assess the efficacy of fat grafting using an external expansion device for complete breast reconstruction post breast cancer surgery hypothesizing that it would improve quality of life. METHODS: A prospective cohort study was conducted in women who had undergone breast cancer surgery and complete reconstruction using AFG. An external expansion device was used previously (as per Miami protocol) to a single-stage AFG. Quality of life outcomes were determined using the validated BREAST-Q questionnaire, and 3D laser and magnetic resonance imaging scan were used to measure fat graft retention. RESULTS: Twenty-six participants were recruited, with seven withdrawing. The remaining 19 women were compliant with external expander use. The mean volume of AFG was 270.4 mL (98-490 mL) with a mean of 48.8% retained at 12 months following injection. Symmetry improved but did not meet the acceptable symmetry ratio of 0.8. Nine patients (47.3%) noted increased skin elasticity and softening of areas of scarring. Skin irritation occurred in 11 out of 19 patients. Mean BREAST-Q scores improved significantly in the domains of satisfaction with breast (40 vs. 49, p < 0.001), psychosocial well-being (55 vs. 68, p < 0.001), physical well-being abdomen (73 vs. 87, p < 0.001), and sexual well-being (41 vs, 48, p < 0.001). CONCLUSION: Improved quality of life and breast volume increase were achieved following external expansion and AFG. However, breast fat engraftment retention was similar to that reported in previous studies using fat grafting alone.