The Effect of Surgical Treatment on the Quality of Life of Young Women with Breast Asymmetry: A Longitudinal, Cohort Study.

BACKGROUND: Young women with congenital breast asymmetry have impaired psychological well-being and self-esteem. However, little is known regarding the effects of surgical intervention in this population. This cohort study aims to assess postoperative changes in health-related quality of life following surgical treatment of breast asymmetry in young women using a prospective, longitudinal study design. METHODS: From 2008 to 2018, 45 young women undergoing surgical correction of breast asymmetry of benign cause and 101 unaffected, female controls completed the following surveys: Short-Form 36v2, Rosenberg Self-Esteem Scale, and Eating-Attitudes Test-26. Surveys were administered at baseline and at up to 9-year follow-up. RESULTS: Participants with breast asymmetry scored significantly worse than controls at baseline on the Rosenberg Self-Esteem Scale and in two Short-Form 36v2 domains: Social-Functioning and Role-Emotional. Asymmetry participants experienced significant postoperative improvements on the Rosenberg Self-Esteem Scale, and in three Short-Form 36v2 domains: Role-Physical, Social Functioning, and Mental Health. These improvements were sustained for a minimum of 5 years. Postoperatively, asymmetry participants' quality of life was comparable to controls and did not vary by age at the time of surgery, asymmetry severity, or diagnosis. CONCLUSIONS: Surgical treatment of breast asymmetry in young women yields significant and sustained improvements in psychosocial quality of life. Postoperatively, patients returned to a level of functioning commensurate with their peers. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Complications and Quality of Life following Reduction Mammaplasty in Adolescents and Young Women.

BACKGROUND: Adolescent reduction mammaplasty remains controversial because of concerns of postoperative breast growth, complications, and the effect on well-being. The authors sought to prospectively quantify early and late complications following reduction mammaplasty in adolescents and young women, and examine the intersection of surgical complications and postoperative health-related quality of life. METHODS: From 2008 to 2017, female patients aged 12 to 21 years undergoing reduction mammaplasty were asked to complete the 36-Item Short-Form Health Survey (version 2), the Rosenberg Self-Esteem Scale, the Breast-Related Symptoms Questionnaire, and the Eating-Attitudes Test-26 preoperatively and postoperatively at 6 months and 1, 3, 5, and 7 years. Clinical evaluations using standardized forms assessed baseline and postoperative symptomatology, complications, and surgical outcomes. RESULTS: In the authors' sample of 512 participants, the most common complications included hypertrophic scarring (20.0 percent) and altered sensation of the nipple (8.4 percent) or breast (7.8 percent). Patient age, body mass index category, and amount of tissue resected did not significantly increase the odds of developing a complication. Significant postoperative improvements on the Rosenberg Self-Esteem Scale, the Breast-Related Symptoms Questionnaire, the Eating-Attitudes Test-26, and in all 36-Item Short-Form Health Survey domains (i.e., physical functioning, role-physical, bodily pain, general health, vitality, social functioning, role-emotional, and mental health) were largely seen irrespective of whether complications occurred. CONCLUSIONS: Although complications following reduction mammaplasty were common, the vast majority were minor. Patients had significant postoperative improvements in their physical and psychosocial well-being regardless of whether they experienced a complication. Concerns for potential complication, especially in younger and overweight or obese patients, should not preclude otherwise healthy adolescents and young women from the benefits of reduction mammaplasty. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The Effect of Surgical Treatment for Gynecomastia on Quality of Life in Adolescents.

PURPOSE: Despite the psychosocial deficits associated with gynecomastia, surgical treatment of adolescent gynecomastia remains controversial. This longitudinal cohort study measures changes in health-related quality of life following surgical treatment of gynecomastia in adolescents. METHODS: The following surveys were administered to adolescents with gynecomastia and male controls, aged 12-21 years: Short-Form 36v2 (SF-36), Rosenberg Self-Esteem Scale (RSES), and Eating-Attitudes Test-26. Subjects completed surveys at baseline and postoperatively/at follow-up at 6 months, 1 year, 3 years, and 5 years. RESULTS: From 2008 to 2017, 44 patients undergoing surgical treatment of gynecomastia and 64 unaffected male controls participated in our study. At baseline, gynecomastia patients scored significantly worse than controls on the RSES and in five SF-36 domains: general health, vitality, social functioning, role-emotional, and mental health. Scores significantly improved postoperatively on the RSES, and in four SF-36 domains: physical functioning, role-physical, bodily pain, and social functioning. Postoperatively, gynecomastia subjects scored similarly to controls in all SF-36 domains and the RSES. Young and overweight/obese patients and those with severe gynecomastia had the greatest postoperative improvement across survey measures. CONCLUSIONS: Surgical treatment of gynecomastia significantly improves the quality of life of adolescents, with measurable improvements in physical and psychosocial functioning. Postoperatively, gynecomastia patients performed comparably to unaffected controls. Surgical treatment of gynecomastia in adolescents and young men has the potential to significantly improve quality of life, particularly in younger and overweight/obese patients and those with moderate to severe gynecomastia. Concerns regarding patient age and body mass index alone should not contraindicate surgery.

Long-term Outcomes After Flap Reconstruction in Pediatric Pressure Ulcers.

BACKGROUND: Pressure ulcers refractory to nonoperative management may undergo flap reconstruction. This study aims to evaluate the long-term outcomes and recurrence rates of flap reconstruction for pediatric pressure ulcers. METHODS: We reviewed the records of patients who underwent flap reconstruction for pressure ulcer(s) from 1995 to 2013. RESULTS: Twenty-four patients with 30 pressure ulcers, requiring 52 flaps were included. Ulcers were stages III and IV and mostly involved either the ischia (15/30) or sacrum (8/30). Flaps were followed for a median of 4.9 years. Twenty-three patients were wheelchair dependent, and 20 had sensory impairment at their ulcer site(s). Ten patients had a history of noncompliance with preoperative management, 8 of whom experienced ulcer recurrence. Twenty-one ulcers had underlying osteomyelitis, associated with increased admissions (P = 0.019) and cumulative length of stay (P = 0.031). Overall, there was a 42% recurrence rate in ulceration after flap reconstruction. Recurrence was associated with a preoperative history of noncompliance with nonoperative therapy (P = 0.030), but not with flap type or location, age, sex, body mass index, osteomyelitis, or urinary/fecal incontinence (P > 0.05, all). CONCLUSIONS: Flap reconstruction can be beneficial in the management of pediatric pressure ulcers. Although high rates of long-term success with this intervention have been reported in children, we found rates of ulcer recurrence similar to that seen in adults. Poor compliance with nonoperative care and failure to modify the biopsychosocial perpetuators of pressure ulcers will likely eventuate in postoperative recurrence. Despite the many comorbidities observed in our patient sample, compliance was the best indicator of long-term skin integrity and flap success.

The Effect of Reduction Mammaplasty on Quality of Life in Adolescents With Macromastia.

OBJECTIVES: To measure changes in health-related quality of life and breast-related symptoms after reduction mammaplasty in adolescents. METHODS: In this longitudinal cohort study, we administered the Short-Form 36v2 (SF-36), Rosenberg Self-Esteem Scale (RSES), Breast-Related Symptoms Questionnaire (BRSQ), and Eating Attitudes Test-26 to 102 adolescents with macromastia and 84 female controls, aged 12 to 21 years. Patients with macromastia completed surveys preoperatively and after reduction mammaplasty at 6 months and 1, 3, and 5 years. Controls completed baseline and follow-up surveys at the same intervals. RESULTS: Patients with macromastia demonstrated significant score improvements postoperatively from baseline on the RSES, BRSQ, and in 7 out of 8 SF-36 domains: physical functioning, role-physical, bodily pain, vitality, social functioning, role-emotional, mental health (P < .001, all). By the 6-month follow-up visit, postoperative subjects scored similarly to or more favorably than controls on the RSES, BRSQ, Eating Attitudes Test-26 , and SF-36; these benefits persisted for at least 5 years and were not significantly affected by BMI category or age. CONCLUSIONS: Reduction mammaplasty was significantly associated with improvements in health-related quality of life and breast-related symptoms of adolescent patients, with measureable improvements in physical and psychosocial well-being evident by 6 months postoperatively and still demonstrable after 5-years. These results largely do not vary by BMI category or age. Patients and providers should be aware of the potential positive impact that reduction mammaplasty can provide adolescents with symptomatic macromastia. Historic concerns regarding age and BMI category at the time of surgery should be reconsidered.

Pediatric Orbital Floor Fractures: Clinical and Radiological Predictors of Tissue Entrapment and the Effect of Operative Timing on Ocular Outcomes.

Orbital floor fractures can produce acute constitutional symptoms and poor ocular outcomes. This study aims to determine the clinical and radiological predictors of tissue entrapment in pediatric orbital floor fractures and to explore the effect of operative timing on ocular outcomes. The authors reviewed medical records from pediatric patients with orbital floor fractures from 2007 to 2015. One hundred fifty-two patients with 159 orbital floor fractures were included. One hundred twenty-two (80.3%) patients were male, and the mean age was 12.2 years. Twelve patients sustained orbital floor fractures with tissue entrapment. At presentation extraocular movement (EOM) restriction, diplopia, nausea, and vomiting were all associated with tissue entrapment (P < 0.001). Among patients with trapdoor fractures (determined by facial computed tomography), the presence of nausea and/or vomiting was predictive of tissue entrapment: positive predictive value 80%, negative predictive value 100%. For all the patients, regardless of fracture configuration, the presence of nausea and/or vomiting was valuable in ruling out tissue entrapment: sensitivity 83.3%, negative predictive value 98.1%. In tissue entrapment patients, poorer ocular outcomes (EOM restriction and diplopia) were associated with the length of operation (P = 0.007), but not the time interval to operation (P = 0.146). The authors conclude that nausea and vomiting are valuable predictors of tissues entrapment, particularly when EOM restriction and diplopia are equivocal. In the authors' study, radiological findings were also predictive of entrapment, but inconsistent language in this area limits the external validity of these results. The authors' study draws attention to the relationship between operation length and poorer ocular outcomes, suggesting that case severity/complexity and surgeon technique/experience may influence outcomes.

A Nonsurgical Approach to Adolescent Breast Asymmetry Using External Prostheses.

PURPOSE: Currently, there are few nonsurgical treatment options for pediatric patients with developmental breast asymmetry. Our group established a partnership with a prosthetic unit within a local oncology center to provide custom-fit breast prostheses for young women with breast asymmetry. The purpose of this study was to describe the effect of this experience on patients' self-esteem and body image. METHODS: Patients were administered an anonymous satisfaction survey at least 1 month after their first fitting at the prosthetic unit. The survey was designed to evaluate body image, self-esteem, as well as social and emotional well-being before and after treatment. Thematic analysis was used to assess their experiences. RESULTS: Seventeen patients, aged 12-19 years, visited the prosthetic unit and subsequently completed the retrospective survey. After using the breast prostheses, 14 (82.4%) patients reported an improvement in body image and 12 (70.6%) patients reported an improvement in self-esteem. Benefits pertaining to three emergent themes were revealed: "body wholeness/symmetry," "body image and psychological well-being," and "esthetic outcome." CONCLUSIONS: Results from the survey demonstrate the ease and efficacy of a form of nonsurgical treatment for adolescent breast asymmetry. Our partnership with an adult oncology center can serve as a national model to support the development of similar treatment programs. Existing resources that have been previously used only for adult breast cancer survivors can be effectively applied to the adolescent population to ameliorate the negative psychological effects of breast asymmetry.

Overgrowth of the Hand and Upper Extremity and Associated Syndromes.

The family of overgrowth disorders affecting the hand and upper extremity constitutes a wide spectrum of clinical phenotypes. These conditions and malformations may be isolated to the upper limb or part of an underlying syndrome. When present, these conditions will challenge even the most experienced hand surgeon. Overlapping clinical presentations and a lack of insight into the fundamental pathogenesis that drives overgrowth in these conditions have created confusion in diagnosis and classification, and have also hampered treatment outcome research. In recent years, advances in molecular biology have identified genetic mutations within the affected tissues of overgrowth patients that appear to mediate these disorders. This may elucidate further understanding, classification, and treatment of these conditions. The purpose of this article is to discuss a range of overgrowth conditions, review some of the newer biological insights, and delineate the general treatment principles.

Weight Changes After Reduction Mammaplasty in Adolescents.

PURPOSE: The ability to exercise more easily and weight loss are often cited benefits of reduction mammaplasty. However, measured weight outcomes after this common procedure are lacking. The purpose of this study was to measure body mass index (BMI) changes in an otherwise healthy adolescent sample after bilateral breast reduction. METHODS: We retrospectively reviewed the records of patients aged 12-21 years who underwent reduction mammaplasty at our institution between 2007 and 2013, with a minimum postoperative follow-up time of 1 year. Charts were reviewed for preoperative and postoperative height and weight, amount of breast tissue resected, and medical comorbidities. No formal nutritional support or weight loss program was instituted before or after surgery. RESULTS: Eighty patients meeting eligibility criteria were identified. The mean follow-up time was 2.0 ± 1.0 years. Mean postoperative BMI did not differ significantly from mean preoperative BMI (27.8 ± 7.1 kg/m(2) vs. 27.3 ± 6.4 kg/m(2)). However, among overweight and obese patients, a significant gain in preoperative to postoperative BMI was observed, on average (p = .019). Twelve (22.2%) of these patients increased their BMI by at least 10% after reduction mammaplasty. Although approximately one third (37%) of overweight/obese patients decreased their BMI, only 5.6% decreased BMI by at least 10%. CONCLUSIONS: We found no significant difference between mean preoperative and postoperative BMI among patients who underwent reduction mammaplasty. Our results suggest that although reduction mammaplasty may facilitate exercise and help some patients lose weight, meaningful postoperative weight loss without additional support is rare.

Preoperative electrocardiograms for nonsyndromic children with hand syndactyly.

PURPOSE: To examine the efficacy of preoperative electrocardiogram (EKG) screening for Timothy syndrome, a rare and fatal condition characterized by prolonged QT, in children referred for syndactyly release. METHODS: We reviewed the records of nonsyndromic syndactyly patients seen by a hand surgeon at our institution between 2007 and 2013. All underwent a preoperative screening EKG for Timothy syndrome. We reviewed the medical records for demographics, presentation, EKG results, and operative findings, and calculated median age at the time of EKG and surgery and frequency distributions for sex, side affected, EKG result, and clinical finding. The mean patient charge for EKG and interpretation was calculated. RESULTS: We identified 128 syndactyly patients, 72% of which were boys. Median age at the time of EKG testing and syndactyly release was 1 year. A total of 92% of patients had normal EKG results; one patient exhibited a prolonged QT. Ten patients (8%) had further cardiac evaluation because of the EKG result and were found to be normal on repeat testing. No patient met QT threshold for Timothy syndrome and all patients were cleared for surgery. The minimum patient charge for EKG testing was $183. CONCLUSIONS: To improve patient safety, some have advocated preoperative EKG testing for all children undergoing syndactyly release to rule out Timothy syndrome. Analysis of our experience failed to yield an instance of Timothy syndrome over a 7-year period. Although EKG charges were relatively low, costs resulting from additional testing, cardiology consultation, and provider and parent time should be considered. Our study does not support routine EKG testing for children referred for syndactyly release, and we have abandoned this practice. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Interaction of anesthetics with neurotransmitter release machinery proteins.

General anesthetics produce anesthesia by depressing central nervous system activity. Activation of inhibitory GABA(A) receptors plays a central role in the action of many clinically relevant general anesthetics. Even so, there is growing evidence that anesthetics can act at a presynaptic locus to inhibit neurotransmitter release. Our own data identified the neurotransmitter release machinery as a target for anesthetic action. In the present study, we sought to examine the site of anesthetic action more closely. Exocytosis was stimulated by directly elevating the intracellular Ca(2+) concentration at neurotransmitter release sites, thereby bypassing anesthetic effects on channels and receptors, allowing anesthetic effects on the neurotransmitter release machinery to be examined in isolation. Three different PC12 cell lines, which had the expression of different release machinery proteins stably suppressed by RNA interference, were used in these studies. Interestingly, there was still significant neurotransmitter release when these knockdown PC12 cells were stimulated. We have previously shown that etomidate, isoflurane, and propofol all inhibited the neurotransmitter release machinery in wild-type PC12 cells. In the present study, we show that knocking down synaptotagmin I completely prevented etomidate from inhibiting neurotransmitter release. Synaptotagmin I knockdown also diminished the inhibition produced by propofol and isoflurane, but the magnitude of the effect was not as large. Knockdown of SNAP-25 and SNAP-23 expression also changed the ability of these three anesthetics to inhibit neurotransmitter release. Our results suggest that general anesthetics inhibit the neurotransmitter release machinery by interacting with multiple SNARE and SNARE-associated proteins.

Etomidate and propofol inhibit the neurotransmitter release machinery at different sites.

The mechanism of general anaesthetic action is only partially understood. Facilitation of inhibitory GABAA receptors plays an important role in the action of most anaesthetics, but is thought to be especially relevant in the case of intravenous anaesthetics, like etomidate and propofol. Recent evidence suggests that anaesthetics also inhibit excitatory synaptic transmission via a presynaptic mechanism(s), but it has been difficult to determine whether these agents act on the neurotransmitter release machinery itself. In the present study we sought to determine whether the intravenous anaesthetics propofol and etomidate inhibit the release machinery. For these studies we used an experimental approach that directly regulated [Ca2+]i at neurotransmitter release sites, thereby bypassing anaesthetic effects on channels and receptors in order to allow anaesthetic effects on the neurotransmitter release machinery to be examined in isolation. The data show that clinically relevant concentrations of propofol and etomidate inhibited the neurotransmitter release machinery in neurosecretory cells and in cultured hippocampal neurons. md130A is a mutant form of syntaxin with a truncated C-terminus. Overexpressing md130A in PC12 cells completely eliminated the reduction in neurotransmitter release produced by propofol, without affecting release itself. In contrast, overexpressing md130A in PC12 cells had little or no effect on the response to etomidate. These results suggest that both propofol and etomidate inhibit neurotransmitter release by a direct interaction with SNAREs and/or SNARE-associated proteins but they do so at different sites.

Fabrication of amperometric electrodes.

Carbon fiber electrodes are crucial for the detection of catecholamine release from vesicles in single cells for amperometry measurements. Here, we describe the techniques needed to generate low noise (<0.5 pA) electrodes. The techniques have been modified from published descriptions by previous researchers (1,2). Electrodes are made by preparing carbon fibers and threading them individually into each capillary tube by using a vacuum with a filter to aspirate the fiber. Next, the capillary tube with fiber is pulled by an electrode puller, creating two halves, each with a fine-pointed tip. The electrodes are dipped in hot, liquid epoxy mixed with hardener to create an epoxy-glass seal. Lastly, the electrodes are placed in an oven to cure the epoxy. Careful handling of the electrodes is critical to ensure that they are made consistently and without damage. This protocol shows how to fabricate and cut amperometric electrodes for recording from single cells.