ABSTRACT
BACKGROUND: Problems with implant-based breast reconstructions can lead to patient dissatisfaction and a request for total autologous reconstruction. This 12-year study aimed to determine the rate of conversion from implant-based to autologous reconstruction, to identify potential risk factors, compare the rate of conversion in implant-only and latissimus dorsi/implant reconstructions, and assess patient satisfaction following conversion. METHODS: Implant-based reconstructions performed between 2000 and 2008 were reviewed. The cohort was then followed prospectively until 2012. RESULTS: One hundred thirty-nine implant-based reconstructions were performed in 118 patients. Sixty-nine patients underwent latissimus dorsi/implant (80 breasts) and 49 underwent implant-only reconstructions (59 breasts). Twenty-one underwent bilateral reconstructions following risk-reduction surgery. Sixteen percent (19 of 118) of patients and 14 percent of breasts (19 of 139) underwent conversion to autologous tissue. None of the 21 bilateral cases converted (hazard ratio, 4.6; p < 0.05). Median time to conversion was 64 months (range, 18 to 142 months). The main motivating factors for conversion included poor aesthetic result (36.8 percent), capsular contracture (31.6 percent), change in weight (21.1 percent), and implant infection/extrusion (10.5 percent). Implant-only reconstructions were more likely to convert (hazard ratio, 3.6; p < 0.05) and at an earlier stage (p < 0.05) than latissimus dorsi/implant reconstructions. Neither radiotherapy (p = 0.68) nor capsular contracture (p = 0.94) significantly increased the risk of conversion. The BREAST-Q demonstrated high patient satisfaction after conversion. CONCLUSIONS: Autologous tissue conversion offers a definitive means of improving the quality of the result, patient satisfaction, and quality of life in troublesome implant-based breast reconstructions. Latissimus dorsi coverage of implants and bilateral reconstructions appear to be protective. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.
Subject(s)
Breast Implants/adverse effects , Mammaplasty/methods , Patient Satisfaction , Postoperative Complications/epidemiology , Risk Assessment/methods , Surgical Flaps , Adult , Aged , Female , Follow-Up Studies , Humans , Incidence , Mammaplasty/ethics , Middle Aged , Muscle, Skeletal/transplantation , Postoperative Complications/psychology , Prospective Studies , Reoperation/methods , Risk Factors , Time Factors , Transplantation, AutologousABSTRACT
OBJECTIVE: To audit response times by all acute NHS hospital switchboards in England for external incoming calls. As with any audit, we set out to draw attention to efficiencies and deficiencies in the system, highlight problems, and suggest the first steps towards improving standards in a very important and poorly acknowledged part of our healthcare system. DESIGN: Telephone calls were made to hospital switchboards, and time to response was measured. The results were then audited. SETTING: Acute hospital NHS Trust switchboards in England. MAIN OUTCOME MEASURES: Time to response by hospital switchboards. The target time was 20 seconds. RESULTS: Only 36% of 219 hospital switchboards met the 20 second target, with the average answering time across all switchboards being 45 seconds. The best performer was University Hospital North Durham (mean = 1 second) and the worst Bristol Royal Infirmary (mean = 381 seconds). We found that automated answer systems substantially increase the answer time to an operator; the fastest automated service was at Princess Royal University Hospital, which was ranked 69th. CONCLUSIONS: We recommend a formal NHS-wide audit system for switchboard response times.