Geographic variation in breast reconstruction surgery after mastectomy for females with breast cancer in Alberta, Canada.

BACKGROUND: Breast cancer is the most common cancer affecting females in Canada, and about half of females with breast cancer are treated with mastectomy. We sought to evaluate geographic variation in breast reconstruction surgery in Alberta, Canada. METHODS: Using linked population-based administrative databases, we extracted data on all Alberta females aged 18 years and older who were diagnosed with breast cancer and treated with mastectomy during 2004-2017. Analyses included regression modelling of odds of reconstruction at 1 year and a spatial scan to identify geographic clusters of lower numbers of reconstruction. RESULTS: A total of 16 198 females diagnosed with breast cancer were treated with a mastectomy, and 1932 (11.9%) had reconstruction within 1 year postmastectomy. Those with reconstruction were more likely to be younger (adjusted odds ratio [OR] 16.7, 95% confidence interval [CI] 13.7-20.3; aged 21-44 yr v. ≥ 65 yr) and were less likely to be from lower-income neighbourhoods. They were more likely to have at least 1 comorbidity and were more likely to have advanced stages of cancer and to require chemotherapy (adjusted OR 0.55, 95% CI 0.47-0.65) or radiotherapy after mastectomy (adjusted OR 0.59, 95% CI 0.39-0.87) than females without reconstruction. We identified rural northern and southeastern clusters with frequencies of reconstruction that were 69.6% and 41.6% of what was expected, respectively. CONCLUSION: We found an overall postmastectomy rate of breast reconstruction of 11.9%, and we identified geographic variation. Predictors of reconstruction in Alberta were similar to those previously described in the literature, specifically with patients in rural communities having lower rates of reconstruction than their urban counterparts. These results suggest that further interventions are required to identify the specific barriers to reconstruction within rural communities and to create strategies to ensure equitable access to all residents.

Why Do Canadians Travel Abroad for Cosmetic Surgery? A Qualitative Analysis on Motivations for Cosmetic Surgery Tourism.

Background: Canadians are increasingly engaging in medial tourism. The purpose of this study was to review Canadians' experiences with travelling abroad for cosmetic surgery, including primary motivations for seeking care outside of Canada. Methods: A qualitative analysis was conducted using semistructured interviews following a pre-determined topic guide. People who had undergone cosmetic surgery outside of Canada were interviewed. The interviews were transcribed and coded to determine motivational themes. Patients were recruited until thematic saturation was achieved. Results: Thematic saturation was achieved after recruitment of 11 patients. The most common motivational themes identified in this study for seeking cosmetic surgery outside of Canada included cost, post-operative care provided, marketing/customer service, and word-of-mouth. Member checking and theory triangulation were validation techniques used to verify identified themes. Mexico was the most common location for cosmetic tourism. The most common procedures were breast augmentation, mastopexy, and abdominoplasty. Participants gathered pre- and post-operative information primarily through pamphlets and contact with surgeons' offices. Follow-up was only available for half of the participants in this study, and only 5 of the participants felt that they had received informed consent. Conclusions: The majority of participants engaged in cosmetic tourism due to cost reasons and the level of post-operative care provided.

Historique: Les Canadiens font de plus en plus de tourisme médical. La présente étude vise à analyser les expériences des Canadiens qui se rendent à l'étranger pour recevoir des soins de chirurgie esthétique, y compris leur motivation primaire à faire ce choix. Méthodologie: Les chercheurs ont effectué une analyse qualitative au moyen d'entrevues semi-structurées selon un guide de sujets préétablis auprès de personnes ayant subi des chirurgies esthétiques hors du Canada. Les entrevues ont été transcrites et codées pour en tirer les thèmes. Des patients ont été recrutés jusqu'à ce que tous les thèmes aient été abordés. Résultats: Onze patients ont été recrutés pour parvenir au point de saturation des thèmes. Les principales motivations pour obtenir une chirurgie esthétique hors du Canada incluaient les coûts, les soins postopératoires reçus, les services de marketing et à la clientèle et le bouche-à-oreille. Les chercheurs ont utilisé la vérification des membres et la triangulation des théories pour vérifier les thèmes établis. Le tourisme esthétique avait surtout lieu au Mexique. Les interventions les plus courantes étaient l'augmentation mammaire, la mastopexie et l'abdominoplastie. Les participants accumulaient l'information préopératoire et postopératoire d'abord à l'aide de dépliants et de contacts au bureau des chirurgiens. Seulement la moitié des participants à l'étude ont eu accès au suivi, et seulement cinq ont eu l'impression d'avoir donné leur consentement éclairé. Conclusions: La majorité des participants faisaient du tourisme esthétique pour une question d'argent et pour le taux de soins postopératoires fournis.

Nerve transfers and neurotization in peripheral nerve injury, from surgery to rehabilitation.

Peripheral nerve injury (PNI) and recent advances in nerve reconstruction (such as neurotization with nerve transfers) have improved outcomes for patients suffering peripheral nerve trauma. The purpose of this paper is to bridge the gap between the electromyographer/clinical neurophysiologist and the peripheral nerve surgeon. Whereas the preceding literature focuses on either the basic science behind nerve injury and reconstruction, or the surgical options and algorithms, this paper demonstrates how electromyography is not just a 'decision tool' when deciding whether to operate but is also essential to all phases of PNI management including surgery and rehabilitation. The recent advances in the reconstruction and rehabilitation of PNI is demonstrated using case examples to assist the electromyographer to understand modern surgical techniques and the unique demands they ask from electrodiagnostic testing.

Patient-reported outcome measures in reconstructive breast surgery: is there a role for generic measures?

BACKGROUND: Patient-reported outcomes provide an invaluable tool in the assessment of outcomes in plastic surgery. Traditionally, patient-reported outcomes have consisted of either generic or ad hoc measures; however, more recently, there has been interest in formally constructed and validated questionnaires that are specifically designed for a particular patient population. The purpose of this systematic review was to determine whether generic measures still have a role in the evaluation of breast reconstruction outcomes, given the recent popularity and push for use of specific measures. METHODS: A systematic review was performed to identify all articles using patient-reported outcomes in the assessment of postmastectomy breast reconstruction. Frequency of use was tabulated and the most frequently used tools were assessed for success of use, using criteria described previously by the Medical Outcomes Trust. RESULTS: To date, the most frequently used measures are still generic measures. The 36-Item Short-Form Health Survey was the most frequently used and most successfully applied showing evidence of responsiveness in multiple settings. Other measures such as the Hospital Anxiety and Depression Scale, the Hopwood Body Image Scale, and the Rosenberg Self-Esteem Scale were able to show responsiveness in certain settings but lacked evidence as universal tools for the assessment of outcomes in reconstructive breast surgery. CONCLUSIONS: Despite the recent advent of measures designed specifically to assess patient-reported outcomes in the breast reconstruction population, there still appears to be a role for the use of generic instruments. Many of these tools would benefit from undergoing formal validation in the breast reconstruction population.

Exclusion of the hamate in 4-corner fusion: technique and outcomes of a novel approach to intercarpal arthrodesis.

Scapholunate ligament disruptions and scaphoid nonunions are known to follow predictable patterns of arthritis. Advanced cases of such degenerative arthritis have traditionally been treated by either 4-corner fusion or proximal row carpectomy. Four-corner fusion has relied on the surface area provided by the capitate, lunate, triquetrum, and hamate to achieve a union. Earlier attempts in decreasing the involved surface area, that is, through fusion of only the capitolunate joint were not met with great success. With the advent of compression screws, however, we feel it is possible to achieve union while incorporating less surface area into the fusion block. We propose a novel procedure, the "2-corner, 3-carpal" fusion, which fuses only the capitate, lunate, and triquetrum, excluding the hamate. By taking advantage of compression screw technology we were able to achieve union and acceptable range of motion in 10 patients in our institution who underwent this procedure.

Long-term follow-up of osseointegrated auricular reconstruction.

BACKGROUND: Auricular deformity presents a formidable challenge for the reconstructive surgeon, and osseointegrated auricular reconstruction provides a safe and reliable option. The authors sought to review long-term results of osseointegrated auricular reconstruction at the Institute for Reconstructive Sciences in Medicine. METHODS: A chart review examining demographics, skin reactions (defined by a modified Holgers classification), and complications at the Institute for Reconstructive Sciences in Medicine was completed. A multivariate binary linear logistic regression analysis was performed to determine whether there was a correlation between the likelihood of a skin reaction and certain patient demographics. A survey was then developed to assess patient satisfaction. RESULTS: Seventy-five osseointegrated auricular reconstructions were performed on 69 patients at the Institute for Reconstructive Sciences in Medicine from 1989 to 2007; mean patient age was 39 years (range, 9 to 76 years). The most common indication for reconstruction was posttraumatic, then congenital and oncologic. The frequency of Holgers reactions was as follows: no reaction, 69 percent; red tissue, 15 percent; excessive tissue, 10 percent; red and moist tissue, 3 percent; granulation tissue, 2 percent; and soft-tissue necrosis, 1 percent. Multivariate binary linear logistic regression analysis found that smoking, younger age, and female gender were associated with the occurrence of a reaction. The overall failure rate of osseointegration in the mastoid region was 2 percent. Survey results found generally satisfied patients willing to undergo the same procedure again, although 55 percent felt that they had had a skin reaction. CONCLUSION: The authors present long-term results showing both success and complications of the osseointegrated prosthetic ear reconstruction for a variety of different etiologies and age groups.

Median nerve reconstruction after entrapment in the elbow.

Median nerve entrapment in the elbow is a known but rare complication of pediatric elbow dislocations. It is classified on the anatomical basis of entrapment. Due to a variety of factors, it is often diagnosed late. Because of this, substantial injury occurs to the nerve, requiring some form of restorative surgery in addition to release from the joint. Such nerve injury has been treated in a variety of ways including neurolysis, end-to-end anastomosis and nerve grafting. To date, there has been no conclusive evidence in the literature that one method should be preferred over another. A case of median nerve entrapment that was treated with sural nerve grafting is presented. In a review of the literature, previous treatment of such cases is discussed and compared.