Is satisfaction with surgeon a determining factor in patient reported outcomes in breast reconstruction?

BACKGROUND: Patient reported outcomes are increasingly being taken into account in planning health service provision. Few studies have examined how the process of care influences patients' perception of outcome. The aim of the current study was to quantify patient satisfaction with breast reconstruction and to examine the demographic, disease and process-of-care variables that contributed to satisfaction with breasts and overall outcome. METHODS: A cross-sectional study was designed and the BREAST-Q outcomes assessment instrument was used to evaluate patient-reported psychosocial, physical and sexual well-being, as well as satisfaction with breasts, overall outcome and process of care. To identify factors predictive of satisfaction with breasts and overall outcome, the relation between covariates and each of these scales was assessed using linear regression models. RESULTS: Sixty one patients, with a mean age of 50 years, completed the survey. Mean satisfaction with breasts was 59.6% and satisfaction with overall outcome was 73.2%. Satisfaction across health-related quality of life scales ranged from 44.6% for sexual well-being to 74.6% for physical well-being. The mean rating for psychosocial well-being was 67.9%. Satisfaction ratings for surgeon, medical staff and office staff were all over 90%. Satisfaction with plastic surgeon was predictive of satisfaction with outcome and satisfaction with breasts (P = 0.001 and 0.021 respectively). DISCUSSION: The surgeon-patient relationship significantly influences patient reported outcomes in breast reconstruction. Further service development must recognize the need for additional time and personnel to deliver high standard, patient-centered care.

Giant congenital melanocytic nevus with cartilaginous differentiation.

We report the unusual presence of a benign focus of cartilage in an excised portion of giant congenital melanocytic nevus.

Local hemodynamic effects of radiation on the rabbit orbitozygomatic complex with and without cytoprotection.

BACKGROUND: The authors have previously demonstrated that radiation-induced craniofacial bone growth inhibition may be ameliorated using the known cytoprotectant amifostine in the infant rabbit orbitozygomatic complex. The authors' hypothesis is that reduction in blood supply plays an important role in inhibiting craniofacial bone growth following radiotherapy and that cytoprotective pretreatment exerts its protective effect by maintaining blood supply. METHODS: Seven-week-old New Zealand male infant rabbits underwent single-dose orthovoltage irradiation to the right orbitozygomatic complex using established protocols: 0 Gy (sham), 35 Gy, and 35 Gy following pretreatment with amifostine (300 mg/kg administered intravenously). Blood flow to the orbitozygomatic complex, orbitozygomatic complex periosteum, masseter, hemimandible, and overlying skin was measured 1, 14, and 63 days after irradiation, using the modified 15-µm radioactive microsphere technique (n = 18 per group, n = 6 per time point). Orbitozygomatic complex bone specimens were harvested for blood vessel morphometry using safranin O stains at days 1 and 100 after irradiation (n = 20 per group, n = 10 per time point). RESULTS: Blood flow to the irradiated orbitozygomatic complex was significantly (p < 0.05) greater 1 day after single-dose orthovoltage irradiation compared with nonirradiated controls. This increase was not observed in the amifostine-pretreated animals and was also not seen 14 and 63 days after irradiation. No histomorphometric vessel changes were detected at any time point after irradiation in this study. CONCLUSIONS: Single-dose orthovoltage irradiation results in a temporary elevation in regional blood flow to the orbitozygomatic complex, returning to control levels within 14 days. Although pretreatment with amifostine attenuates this response, radiation-induced craniofacial bone growth inhibition in this model does not appear to be secondary to hemodynamic alterations.

Radiation-induced craniofacial bone growth inhibition: acute and long-term effects on bone histopathology with and without cytoprotection.

BACKGROUND: The authors previously established an animal model of radiation-induced craniofacial bone growth inhibition and demonstrated the effectiveness of cytoprotection in preserving growth using amifostine, but the mechanism is unclear. The objective of this study was to investigate the acute and long-term histopathologic effects of single-dose orthovoltage irradiation on craniofacial bone with and without cytoprotection. METHODS: Sixty infant New Zealand White rabbits (7-week-old) were randomized into three groups (n = 20 per group): group 1, 0-Gy, sham irradiation; group 2, 35-Gy single-dose orthovoltage irradiation; and group 3, cytoprotection with amifostine before irradiation. Orbitozygomatic complex bone was harvested from animals 12 hours after irradiation and at skeletal maturity (21 weeks of age). Histologic parameters measured included native bone cell (osteoblast, osteoclast, and osteocyte) populations, periosteal proliferation indices (MIB-1 stains), bone turnover rates [triple fluorochromes: tetracycline administered at 7 weeks of age (before irradiation), alizarin complexone at 12 weeks, and calcein at 16 weeks of age], and endosteal space fibrosis levels. RESULTS: Orthovoltage irradiation significantly (p < 0.05) reduced osteoblast and osteoclast counts 12 hours after irradiation (age, 7 weeks) with or without pretreatment with amifostine but had no effect on osteocyte populations. Long-term analysis at age 21 weeks demonstrated significantly (p < 0.05) increased osteoblast counts, reduced endosteal space fibrosis, reduced periosteal proliferation indices, and improved bone turnover (fluorochrome stains) in amifostine-treated animals. CONCLUSION: This study suggests that amifostine cytoprotection is mediated through a combination of reduced cellular injury with enhanced promotion of cellular bone rebuilding potential.

Risk and outcome analysis of 1832 consecutively excised basal cell carcinomas in a tertiary referral plastic surgery unit.

BACKGROUND: Basal cell carcinomas are the most prevalent of all skin cancers worldwide and form the majority of the surgical workload for most modern cutaneous malignancy centres. Primary surgical removal of basal cell carcinomas remains the gold standard of treatment but, despite almost two centuries of surgical experience, rates of incomplete surgical excision of up to 50% are still reported. The aim of this study was to assess, quantify and perform comparative analysis of the outcomes and predictive factors of consecutive primarily-excised basal cell carcinomas in a tertiary centre over a six-year period. METHODS: Retrospective audit was conducted on all patients who underwent surgical excision of basal cell carcinomas from January 2000 to December 2005. Assessment parameters included patient biographics, tumour management differences and detailed histopathological analysis of tumour margins and subtypes. RESULTS: One thousand eight hundred and thirty two basal cell carcinomas were excised from 1329 patients over the designated time period. Two hundred and fifty one (14%) lesions were incompletely excised with 135 (7.4%) involving the peripheral margin only, 48 (2.6%) the deep margin only and 41 (2.2%) involving both. Nasal location was the most common predictor of incomplete excision. CONCLUSIONS: Overall basal cell carcinomas excision rates compared favourably with international reported standards but attention to a variety of surgical and histological risk factors may improve this further.

Radiation-induced craniofacial bone growth inhibition: efficacy of cytoprotection following a fractionated dose regimen.

BACKGROUND: Severe craniofacial growth disturbances are noted in 66 to 100 percent of children with head and neck cancers who received radiotherapy during their growing years. The authors have previously demonstrated the prevention of radiation-induced craniofacial bone growth inhibition following single-dose orthovoltage radiation to the orbitozygomatic complex in an infant rabbit model through the administration of the cytoprotective agent amifostine (WR-2721) before radiation treatment. The purpose of this study was to investigate the efficacy of cytoprotection using a fractionated dose regimen that better approximates the clinical application of radiation therapy. METHODS: Thirty 7-week-old male New Zealand rabbits were randomized into three groups (n = 10), each receiving six fractions of orthovoltage radiation to the right orbitozygomatic complex: group C, sham irradiation control; group F35, total dose of 35 Gy; and group F35A, total dose of 35 Gy with administration of amifostine 200 mg/kg intravenously 20 minutes before each fraction. Bone growth was evaluated up to skeletal maturity (age 21 weeks) with serial radiographs and computed tomography scans for cephalometric analysis, bone volume, and bone density measurements. RESULTS: Fractionated radiation resulted in significant (p < 0.05) bone growth inhibition compared with sham radiation in 16 of 21 cephalometric parameters measured and significantly (p < 0.05) reduced bone volume of the rabbit orbitozygomatic complex. Pretreatment with amifostine before each radiation fraction prevented growth deformities in four cephalometric parameters and significantly (p < 0.05) attenuated these effects in another seven parameters compared with radiated animals. Bone volumes were also significantly (p < 0.05) improved in F35A animals compared with F35 animals. CONCLUSIONS: This study establishes that fractionation of orthovoltage radiation does not prevent the development of growth disturbances of the rabbit craniofacial skeleton and also demonstrates that preirradiation administration of amifostine is highly effective in the prevention and attenuation of radiation-induced craniofacial bone growth inhibition.

Solitary fibrous tumor of the orbit.

Painless unilateral proptosis is a frequent manifestation of numerous orbital neoplastic and non-neoplastic processes. Various mesenchymal tumors of both fibrohistiocytic and vascular origin are well-described causes. Solitary fibrous tumors (SFTs) are rare spindle-cell neoplasms usually found associated with serosal surfaces, especially the pleura, but they have recently been described in a number of extrapleural sites including the orbit. The authors describe the case of an 18-year-old man who presented with a 6-month history of painless proptosis in the right eye. A visible nontender mass in the right supermedial orbit producing ptosis of the upper lid was present. Magnetic resonance imaging (MRI) showed a well-circumscribed soft tissue mass located above the right globe with no obvious invasion of adjacent orbital structures. Uneventful surgical excision through a right frontal-orbitotomy approach was performed. Histological evaluation showed a solid, highly vascular tumor mass composed of spindle cells arranged in short ill-defined fascicles. Intense immunohistochemistry staining for CD34 and B-cell lymphoma 2 (BCL-2) differentiated the lesion from the more common hemangiopericytoma. Though considered benign, local recurrence and extraorbital extension of orbital SFTs have been described. Malignant behavior, including distant metastases, has been documented in as many as 20% of pleural cases with mortality rates as high as 50%. The natural history of this tumor in the orbit is unclear. The authors report the 35th case of orbital solitary fibrous tumor and discuss the differential diagnosis, histopathology, radiological features, and clinical course.

Efficacy of radioprotection in the prevention of radiation-induced craniofacial bone growth inhibition.

It has been reported that radiotherapy-induced craniofacial deformities can occur in 66 to 100 percent of survivors of childhood head and neck cancers. Recent interest in the effectiveness of radioprotectors in the protection of normal tissue against radiation injury led us to investigate a possible role of radioprotection in the prevention of radiation-induced craniofacial bone growth inhibition. Therefore, the objective of this study was to use the radioprotective agent amifostine (Ethyol, WR-2721) as a probe to determine the effectiveness of radioprotection in the prevention of radiation-induced craniofacial bone growth inhibition after single-dose orthovoltage radiation to the infant rabbit orbital-zygomatic complex. Seven-week-old male New Zealand white rabbits were randomized into three groups (n = 10 each): group 1, 0 Gy (sham radiation); group 2, 35-Gy single-dose orthovoltage radiation; and group 3, 35-Gy single-dose orthovoltage radiation and amifostine (300 mg/kg intravenously, given 20 minutes before radiation). Serial radiographs and computed tomographic scans were obtained for cephalometric analysis, bone volume, and bone density measurements until skeletal maturity at 21 weeks. Significant (p < 0.05) reductions in orbital-zygomatic complex linear bone growth, bone volume, and bone density were observed after 35-Gy radiation compared with nonirradiated controls. No significant differences were noted between groups in cephalometric analysis of the nontreated (nonirradiated) left orbital-zygomatic complex, indicating no crossover effect from the radiation beam. However, pretreatment with amifostine, 20 minutes before 35-Gy radiation, resulted in significant (p < 0.05) preservation of linear bone growth, bone volume, and bone mineral density in the rabbit orbital-zygomatic complex compared with controls. This study demonstrated for the first time the effectiveness of a radioprotector in the prevention of radiation-induced craniofacial bone growth inhibition, and it paves the way for investigation into the pathogenic mechanism and prevention of radiotherapy-induced craniofacial deformities.