Breast reduction outcome study.

The outcome of 75 consecutive bilateral breast reduction procedures on 73 patients (65 inferior pedicle and 9 superior pedicle with inverted-T closure, and 1 ultrasonic-assisted lipoplasty) is evaluated. Fifty-six surveys at an average follow-up of 35 months, 36 standardized examinations at an average follow-up of 31 months, 52 paired preoperative/postoperative photographs, and 73 chart reviews comprise the data. Mean age at surgery was 32 years. Of the patients surveyed, there were 51 whites, 18 blacks, and 4 other races. The majority of survey respondents reported improvement in breast appearance (93%), self-esteem (85%), posture (84%), and activity level (77%). The percentage of patients free of back pain rose from 9% preoperatively to 59% postoperatively. Some decrease in nipple sensitivity was noted by survey in 34 nipple-areolar complexes (31%), and clinical examination detected decreased sensitivity in 16% of nipples. Thirty-one percent of patients reported improvement in their intimate relationship postoperatively and 65% reported no change. Ninety-five percent felt they had made the right decision in having breast reduction surgery. Physical examination revealed excellent maintenance of shape and impressive fading of surgical scars over the years in the majority of patients. The postoperative aesthetic result depends on several important preoperative factors, including skin tone, breast shape, and degree of ptosis. Adverse sequelae included infection (1.3%), nipple cyanosis (1.3%) but no nipple-areolar necrosis, and wound dehiscence (4.0%) but no skin flap necrosis. Late complications included underresection requiring reoperation (4.0%), fat necrosis (2.7%), hypertrophic scars (6.7%), and pseudoptosis (12.0%). Breast reduction surgery results in a good outcome for most patients, with high patient satisfaction. Patients are accepting of the large T-pattern scar that fades surprisingly well with time in exchange for symptomatic relief and substantial improvement in breast size and shape.

Do Canadian female surgeons feel discriminated against as women?

OBJECTIVE: To describe female surgeons' perceptions of discrimination against them as women during the selection and training process and in career development and advancement, and to describe trends over time. DESIGN: Population survey of practising Canadian female surgeons. SETTING: Canada. PARTICIPANTS: All 459 female members in good standing of the Royal College of Physicians and Surgeons of Canada or the Corporation professionnelle des médecins du Québec, or both, practising in Canada as of March 1990. Participants completed a survey between March 1990 and May 1992, the response rate was 91% (419/459). OUTCOME MEASURES: Reported levels of discrimination during selection and training and in career development and advancement, institutional policies on maternity leave and job sharing, and the existence of female role models or mentors. RESULTS: Discrimination during the process of selection for residency was reported by 15% (63/413) of the respondents. Just over half of the respondents (206/405) reported male attending staff as being discriminatory during training, and 41% (168/407) reported nursing staff as being discriminatory. Almost half of the respondents (199/408) indicated that discrimination did not hinder their career development or advancement at all, and 29% (118) indicated that it had little effect. Almost two thirds (245/381) reported no maternity leave policies during residency or practice, and 78% (296/379) reported having no job-sharing opportunities. Although 82% (338/413) agreed that female medical students need female role models, 80% (330/415) reported they did not have a female mentor. CONCLUSIONS: Although most of our respondents perceived no discrimination in their selection for residency and reported that discrimination did not hinder their career development or advancement, the perception of discrimination during surgical training suggests that there needs to be a concentrated effort to identify and address problems. Moreover, since few respondents reported having institutional policies on maternity leave and job-sharing or female mentors, these issues need to be examined.

Endoscopic abdominoplasty with repair of diastasis recti and abdominal wall hernia.

Endoscopic abdominoplasty is feasible, safe, and effective in the proper surgical candidate. Excellent results can be expected when proper patient selection criteria are followed. With future refinements in technique and equipment, this procedure may be extended safely to those patients with more severe deformities.

Women surgeons: career and lifestyle comparisons among surgical subspecialties.

A national survey of 459 women surgeons yielded a 91.3 percent response rate. The largest subspecialties were obstetrics-gynecology (41 percent), ophthalmology (21 percent), and general surgery (12 percent). Representation in all "other" surgical specialties was small (26 percent). A comparison of career and lifestyle patterns among the four major subspecialties demonstrated no differences in marital status, although ophthalmologists were least likely to remain childless (32 percent) and general surgeons most likely (58 percent). Surgeons in obstetrics-gynecology worked the longest hours, and those in ophthalmology worked the shortest hours. No subspecialty differences were reported in quality-of-life parameters.

Assessment of the abdominal wall after pedicled TRAM flap surgery: 5- to 7-year follow-up of 150 consecutive patients.

To define the long-term abdominal consequences of the TRAM flap procedure, 150 consecutive patients were evaluated 5 to 7.5 years postoperatively. Of 137 surviving patients, 135 (98.5 percent) returned a questionnaire (68 single pedicle, 63 double rectus harvest, and 4 single pedicle with contralateral microvascular augmentation) and 132 (96.4 percent) were examined and tested. By questionnaire, 64 percent noted overall improvement of the abdomen, 72 percent noted improved abdominal appearance, and 20 percent noted improved posture. Decreased abdominal strength was noted by 46 percent, and decreased exercise ability was noted by 25 percent. These figures were higher after double rectus harvest (60 and 35 percent) than after single rectus harvest (35 and 16 percent) (p = 0.005 and p = 0.014, respectively). Activities of daily living were rarely (4.0 to 5.8 percent) affected. Three of the patients had uncomplicated pregnancies and deliveries (two vaginal, one cesarean section). Situp performance was worse comparing postoperative patients with unoperated controls (p < 0.0005) and comparing double rectus harvest with single rectus harvest patients (p < 0.0005). Comparing double rectus harvest patients with direct abdominal closure and those closed with mesh, there was a trend toward poorer situp performance in the mesh subgroup; however, this was not statistically significant. On examination, a classic post-TRAM hernia was not encountered in any patient, but three single-pedicle patients had asymptomatic diffuse bulges through the fascial harvest site, visible only on straining to do a situp. Eight patients (seven bilateral and one single pedicle) had varying degrees of abdominal laxity, but only one had operative correction of diffusely attenuated abdominal fascia following pregnancy and delivery. Examiners' ratings of aesthetic abdominal appearance were higher for postoperative patients than for unoperated controls (p = 0.05). The vast majority of patients considered the TRAM procedure worthwhile (93 percent) and continued to recommend it to others (96 percent).

Abdominal function after pedicled TRAM flap surgery.

Through the years, many surgeons have considered the potential for weakness in the abdominal wall as a major drawback to the use of the pedicled TRAM flap. This article begins with a review of the surgical anatomy of the abdominal wall. It continues with a review of technical details; beginning with a method of partial rectus muscle and fascia harvest that respects the vascular anatomy, and followed by multilayered direct fascial closure in all patients with selective alloplastic mesh reinforcement as necessary. It is the authors' opinion that these methods optimize postoperative abdominal function, leaving a competent abdominal wall that does not deteriorate through time. Supportive data gained through a 13-year experience with 662 patients are presented.

Women surgeons. Results of the Canadian Population Study.

OBJECTIVE: A national survey of women surgeons in Canada was undertaken to evaluate their ability to combine career with personal and family life. SUMMARY BACKGROUND DATA: Despite increasing numbers of women entering the medical profession, women continue to select nonsurgical careers. Although there are many reports regarding women in medical specialties there is little information available regarding women who choose surgical careers. Such data will be useful in increasing the enrollment of women in surgical training programs. METHODS: A 93-item questionnaire was mailed in July 1990 to the 459 eligible female surgeons. The survey was conducted using a modified Dillman 5-step computerized method. The study was closed in May 1991. RESULTS: Of the 459 surgeons who were located, 419 (91.3%) responded. Most surgeons (65.5%) were married. Only 6.5% were separated or divorced. The majority married another professional (91.4%). One quarter married another surgeon. Of all women who married at least once, 70.9% had at least one child. Most surgeons delayed child bearing until after they had completed their surgical training. The majority of respondents were in active surgical practice (82.3% full-time, 6.0% part-time). The most common surgical subspecialty was obstetrics and gynecology (40.9%), followed by ophthalmology (21.2%), and general surgery (12.1%). Surgeons were rarely dissatisfied (4-9%) with career, marriage, health, friendships, financial status, and hobbies. Overall, 88.3% were happy with their decision to pursue a career in surgery. CONCLUSIONS: Women surgeons practicing in Canada are able to combine productive careers with rewarding family lives and are satisfied with their decision to do so despite the compromises involved.

Electrolyte handling by the superficial nephron of the rabbit.

A micropuncture study of the rabbit was performed to evaluate the function of the superficial nephron. The mean glomerular filtration rate of the left micropunctured kidney was 4.0 +/- 0.8 ml/min. The concentration profile of electrolytes within the proximal tubule was similar to that of species previously investigated except for potassium. The mean tubular fluid (TF)-ultrafilterable (UF) concentration ratios were as follows: sodium, 1.01 +/- 0.03; chloride, 1.14 +/- 0.04; calcium, 1.12 +/- 0.04; magnesium, 1.47 +/- 0.08; and phosphate, 0.94 +/- 0.09, with a mean TF-plasma (P) inulin concentration ratio of 1.78 +/- 0.14 (n = 32). The TF/UF potassium value significantly increased in association with TF/P inulin to a mean value of 1.26 +/- 0.06. Accordingly, 29% of the filtered potassium was reabsorbed in the superficial proximal tubule compared with 43% of the filtered sodium. The loop of Henle reabsorbed 55-60% of the filtered sodium, chloride, and calcium, whereas considerably less magnesium (33%) was reabsorbed. Segments beyond the distal tubule collection site reabsorbed little of the delivered magnesium, which supports the notion that the loop of Henle is the principal segment accounting for adjustments in magnesium balance. These studies indicate that the superficial nephron of the rabbit performs similar to other species reported, except potassium reabsorption is significantly less in the proximal convoluted tubule.

Effects of intraluminal pH and dietary phosphate on phosphate transport in the proximal convoluted tubule.

The proximal tubule cell adjusts its phosphate absorption appropriately to meet the needs of the organism. Studies were performed to characterize some of the cellular changes involved with dietary phosphate adaptation. First, early proximal convoluted tubules were perfused with equilibrium Ringer solutions buffered to pH 7.65 or 6.5. Saturation kinetics for phosphate transport were determined at each pH value. Rats maintained on a diet of normal phosphate composition demonstrated the apparent Jmax and Km parameters about twofold greater with intraluminal pH 7.65 vs. pH 6.5. The Jmax values increased to 53.47 +/- 3.71 and 42.73 +/- 5.48 pmol X min-1 X mm-1, respectively, when the rats were placed on a phosphate-restricted diet for 5 days. By contrast, adaptation to a high dietary phosphate content resulted in diminished phosphate absorption, 8.53 +/- 1.80 and 12.87 +/- 1.61 pmol X min-1 X mm-1, for the respective pH 7.65 and 6.5 values. Second, the effect of peritubule phosphate concentration was evaluated at constant intraluminal phosphate concentrations. Unidirectional lumen-to-blood phosphate efflux was inhibited at all plasma phosphate concentrations in animals maintained on normal dietary phosphate. By contrast, rats adapted to a low phosphate diet exhibited an increase in phosphate absorption: pH 7.65, 86.21 +/- 2.63, and pH 6.5, 140.84 +/- 86.76 pmol X min-1 X mm-1 when plasma concentrations were elevated two- or three-fold from 2.4 to 6.4 mM. This was attributed to enhanced phosphate exchange on the basolateral membrane. Further hyperphosphatemic levels, above 6.4 mM, inhibited phosphate absorption. These data suggest that net phosphate absorption is determined, in part, by factors other than sodium-dependent uptake of phosphate by the brush border membrane including intracellular pH and peritubular phosphate that act in concert to control renal phosphate absorption.