Intra-operative digital specimen radiology reduces re-operation rates in therapeutic mammaplasty for breast cancer.

BACKGROUND: The aim of this study was to evaluate our experience with intra-operative imaging of therapeutic mammaplasty specimens at Edinburgh Breast Unit. METHODS: A retrospective review was performed of patients who underwent therapeutic mammaplasty in Edinburgh Breast Unit between 2007 and 2013 who had intraoperative specimen radiography. RESULTS: 98 (100%) patients who underwent therapeutic mammaplasty for breast cancer had intra-operative imaging using the faxitron(®) system. 3 out of those 97 (3%) patients had a re-operation because of positive margins confirmed pathologically on cavity excision specimens, but only 1 out of 3 (1%) patients had residual breast cancer present within the re-excision specimen. None required mastectomy. Median age was 58 (range 34-81). Median follow up was 3.1 years (range 6 months - 5.5 years). There was no local recurrence or conversion to mastectomy in this group. CONCLUSION: Complete excision rate in patients who had intra-operative imaging during therapeutic mammaplsty procedure was 97% in our group. Faxitron(®) system is a useful adjunct in helping to achieve low incomplete excision rates.

Quality of information reporting in studies of standard and oncoplastic breast-conserving surgery.

The aim of this systematic review was to establish the completeness of reporting of key patient, tumour, treatment, and outcomes information in the randomized-controlled trials (RCTs) of standard breast-conserving surgery (sBCS) considered to be the 'gold-standard', and to compare this with the reporting of the same key criteria for all published studies of oncoplastic breast-conserving surgery (oBCS). Pubmed (1966 to 1st April 2013), Ovid MEDLINE (1966 to 1st April 2013), EMBASE (1980 to 1st April 2013), and the Cochrane Database of Systematic Reviews (Issue 4, 2013) were searched separately for the following terms: (i) 'oncoplastic AND breast AND surgery'; and (ii) 'therapeutic AND mammaplasty'. Only English language and full text articles were reviewed. Following a pilot evaluation of all studies, key reporting criteria were identified. 16 RCTs of sBCS (n = 11,767 patients) were included, and 53 studies met the inclusion criteria for oncoplastic BCS (n = 3236 patients), none of which were RCTs. No study reported all of the criteria identified, with a mean of 64% of key criteria (range, 55-75%) reported in studies of sBCS, and 54% of criteria (range, 10-85%) reported in studies of oBCS. It is therefore evident that there is much room for improvement in the quality of reporting is BCS studies. Standards are proposed to give future studies of BCS a framework for reporting key information and outcomes.

Use of boost radiotherapy in oncoplastic breast-conserving surgery - a systematic review.

BACKGROUND: The use of local boost radiotherapy to the tumour bed has been demonstrated in randomised-controlled trials to reduce local recurrence rates following breast-conserving surgery (BCS) and is the standard of care. Oncoplastic BCS techniques with parenchymal rearrangement present new challenges to the localisation of the tumour bed and therefore delivery of local boost radiotherapy. The aim of this review was to evaluate the reporting of boost radiotherapy in the oncoplastic BCS literature. METHODS: Pubmed, Ovid MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews were searched for studies reporting oncoplastic BCS using volume displacement techniques. RESULTS: 24 studies met the inclusion criteria (n = 1933 patients). Use of boost radiotherapy was reported in 11 studies, in 2 of which it was for the treatment of incomplete or close margins, and marking of the tumour bed was only reported in 8 studies. None of the studies reported the number of patients where the tumour bed could not be localised. CONCLUSIONS: The use of local boost radiotherapy and tumour bed marking was not reported in the majority of studies of oncoplastic BCS. Future studies need to provide detailed information regarding the use of boost radiotherapy and difficulties determining the target volume so that current radiotherapy approaches can be reviewed and improved for these advanced techniques.

Male mastectomy: an oncoplastic solution to improve aesthetic appearance.

Mastectomy for breast cancer in men typically results in an unsatisfactory aesthetic appearance due to loss of the normal male chest contour. In this article we present two case studies and a new oncoplastic surgical technique that has given excellent aesthetic results for this challenging problem.

Clinical value of internal mammary lymph node metastases found incidentally during free flap recipient vessel exposure.

INTRODUCTION: The clinical importance of internal mammary (IM) lymph node (LN) metastases in breast cancer remains unclear. The aim of this study was to determine the clinical value of opportunistic IMLN sampling at the time of free flap breast reconstruction using the IM recipient vessels and whether it affected the adjuvant treatment given. METHODS: A prospective study was conducted of IMLN exploration performed by a single surgeon as part of free flap breast reconstruction using IM recipient vessels. Patients where IMLNs were positive for metastatic disease were reviewed with the breast cancer multidisciplinary team for changes in therapy. RESULTS: 122 patients met the inclusion criteria, 111 of whom had immediate reconstructions. 63 patients had IMLNs excised, and of these 13 were positive for metastatic disease, all in immediate breast reconstructions. The adjuvant treatment given was changed in 1 patient with no axillary LN disease as a result of finding a positive IMLN. Positive IMLNs were significantly associated with larger tumours and axillary metastases, but not tumour location. All patients with positive IMLNs were alive at last follow-up with no local or distant recurrences, with mean disease-free survival of 20.5 months (5-56 months). CONCLUSION: Incidental IMLNs positive for metastatic disease were found in 13 of 122 free flap breast reconstructions and resulted in a change in adjuvant treatment in one patient. IMLNs found incidentally during recipient IM vessel exposure for free flap breast reconstruction therefore may upstage a patient's disease and influence the adjuvant treatment for their breast cancer and should therefore be submitted for pathological assessment.

Effect of neoadjuvant chemotherapy on outcomes of immediate free autologous breast reconstruction.

BACKGROUND: Neoadjuvant chemotherapy (NC) is increasingly being utilised although the effects on outcomes of free autologous breast reconstruction and adjuvant treatment remain unclear. The aim of this study was to examine the effect of NC on complications following immediate free flap breast reconstruction. METHODS: A prospective study of immediate free flap breast reconstructions comparing patients who received NC with those who did not was conducted in a single specialist regional unit. RESULTS: Eighty-seven patients (95 flaps) were included in the study, 30 of which (35 flaps) received NC followed by free flap breast reconstruction. Twenty patients in the NC group had one or more complications compared with 37 patients in the control group (p = 0.87). Nine patients in the NC group had more than one complication compared with 11 patients in the control group, although this difference was not significant (p = 0.26). Both obesity (p = 0.016) and current cigarette smoking (p = 0.014) were significantly associated with the occurrence of any complication in patients who had received NC. Adjuvant radiotherapy was delayed in 3 patients in the NC group, and adjuvant chemotherapy was delayed in 3 control patients (p = 1). The mean preoperative haemoglobin was significantly lower in the NC group than in the control group (p = 0.00037), although there was no significant difference in blood transfusion requirements. CONCLUSIONS: Patients undergoing immediate autologous breast reconstruction following NC have a similar complication and reoperation rate to patients not receiving NC. Preoperative blood haemoglobin level was found to be significantly lower following NC and postoperative blood transfusion triggers should take this into account.

Therapeutic mammaplasty--extending indications and achieving low incomplete excision rates.

AIMS: The aim of this study was to report the outcomes of the first 50 consecutive therapeutic mammaplasty procedures at the Edinburgh Breast Unit. METHODS: A retrospective case-notes analysis was performed. In addition a validated patient satisfaction and outcomes questionnaire was sent to all patients. RESULTS: Fifty therapeutic mammaplasty procedures were performed in 48 patients, with contralateral synchronous breast reduction performed in 42 of these patients. The median age was 58 years (range, 34-81). The median total tumour size was 28 mm (range, 7-83 mm) and 11 patients had multifocal tumours. The median wide local excision weight was 119 g (range, 15-815) and the median total excision weight was 354 g (range, 20-1725). Neoadjuvant letrozole was used in 16 patients and neoadjuvant chemotherapy was given in six. Incomplete excision (DCIS) occurred in only one patient who underwent reexcision. Complications occurred in 19 breasts overall, delaying adjuvant chemotherapy in one patient. Median reported patient satisfaction with appearance was 9.5 out of ten, with 33 of 35 respondents reporting that they definitely or probably would choose the same operation again. CONCLUSIONS: Therapeutic mammaplasty can be performed with a low rate of incomplete excision and complications, and high patient satisfaction, even with large tumours and multifocal disease. In this study the use of neoadjuvant letrozole in selected oestrogen receptor positive tumours, intraoperative radiographic imaging of specimens, and targeting further excision to around the tumour bed, was associated with a very low rate of incomplete excision.

Paediatric trigger finger: Literature review and management algorithm.

Trigger finger in the paediatric population is a distinct condition from trigger thumb in the child or trigger finger in the adult. This paper reviews the current practices applied in the treatment of paediatric trigger finger. Intra-operative photographs are used to illustrate the anatomic anomalies that may be present. An operative algorithm is presented suggesting a step-wise approach to check all structures that may cause the symptom of triggering whilst avoiding unnecessary dissection once the cause of the trigger has been corrected.

Soft tissue management of children's open tibial fractures--a review of seventy children over twenty years.

INTRODUCTION: The management of open tibial fractures in children represents a unique reconstructive challenge. The aim of the study was to evaluate the management of paediatric open tibial fractures with particular regard to soft tissue management. PATIENTS AND METHODS: A retrospective case-note analysis was performed for all children presenting with an open tibial fracture at a single institution over a 20-year period for 1985 to 2005. RESULTS: Seventy children were reviewed of whom 41 were males and 29 females. Overall, 91% (n = 64) of children suffered their injury as a result of a vehicle-related injury. The severity of the fracture with respect to the Gustilo classification was: Grade I, 42% (n = 29); Grade II, 24% (n = 17); Grade III, 34% (n = 24; 7 Grade 3a, 16 Grade 3b, 1 Grade 3c). The majority of children were treated with external fixation and conservative measures, with a mean hospital in-patient stay of 13.3 days. Soft tissue cover was provided by plastic surgeons in 31% of all cases. Four cases of superficial wound infection occurred (6%), one case of osteomyelitis and one case of flap failure. The limb salvage was greater than 98%. CONCLUSIONS: In this series, complications were associated with delayed involvement of plastic surgeons. Retrospective analysis has shown a decreased incidence of open tibial fractures which is reported in similar studies. Gustilo grade was found to correlate with length of hospital admission and plastic surgery intervention. We advocate, when feasible, the use of local fasciocutaneous flaps (such as distally based fasciocutaneous and adipofascial flaps), which showed a low complication rate in children.

Long-term results of posterior suturing with postauricular fascial flap otoplasty.

BACKGROUND: Posterior suturing with postauricular fascial flap otoplasty has previously been shown to be associated with a significantly reduced rate of complications and better aesthetic outcome when compared with the anterior scoring and posterior suturing techniques. This study evaluates the long-term results of this technique. MATERIAL AND METHODS: A retrospective casenote analysis of all paediatric patients who underwent otoplasty within a four-year period were retrieved. Sixty patients (112 ears) met the inclusion criteria (mean age 8.5 years; range 4 to 14). The perpendicular distance from the mastoid to the helical rim at the Frankfort line was recorded preoperatively and immediately postoperatively. Patients were invited to a follow up clinic where further measurements were taken by two observers. Photographs were evaluated by an independent blinded observer. RESULTS: The clinical recurrence rate was 4.5%. Thirty patients (57 ears) attended the follow-up clinic (mean 3.9 years since surgery). Mean loss of medialisation was 0.7 mm (6.2%), with loss of medialisation of > or =1 mm seen in 26 ears (46%), and improvement in medialisation of > or =1 mm in 15 ears (26%). Mean visual analogue scores for overall appearance and symmetry were higher at follow-up than at six weeks postoperatively. There was no relationship between measurements or visual analogue scores and duration since surgery. CONCLUSIONS: In conclusion posterior suturing with braided polyester permanent sutures covered with a postauricular fascial flap results in longevity of postoperative appearance and symmetry with low clinical recurrence rates and with excellent patient and parent satisfaction.

Comparison of outcomes and donor-site morbidity in unilateral free TRAM versus DIEP flap breast reconstruction.

BACKGROUND: At long-term follow up we cannot easily differentiate between patients who have undergone free transverse rectus abdominis musculocutaneous (TRAM) flap and deep inferior epigastric artery perforator (DIEP) flap breast reconstruction in terms of subjective functional limitations of daily activities. The aim of this study was to evaluate postoperative outcomes and long-term subjective functional deficit in patients following unilateral free TRAM compared with DIEP flap breast reconstruction. METHODS: Sixty consecutive patients who underwent unilateral autologous breast reconstruction were included in the study, 30 of whom had undergone a DIEP flap, and 30 a free TRAM flap. Surgical and postoperative outcome data were collected and a postal questionnaire was sent to each patient at least 6 months postoperatively consisting of a short functional assessment questionnaire and a Short Form 36 (SF-36) survey. RESULTS: We found no significant difference in postoperative outcomes or in the subjective ability to perform activities of daily living, including work, domestic activities, sports and hobbies, between patients who underwent TRAM flap breast reconstruction and those who underwent a DIEP flap, and no significant difference between the groups for scores on the physical functioning, role-physical, or bodily pain scales of the SF-36. CONCLUSION: We conclude that harvesting of the free TRAM flap results in no significant difference in postoperative outcomes or in the subjective ability to perform activities of daily living compared with the DIEP flap.