Women's Impression of the Expected Breast Appearance and its Association with Breast Cancer Operations.

BACKGROUND: Significant concern exists from clinicians in all fields that rates of bilateral mastectomy and prophylactic mastectomy are increasing. This study was performed to evaluate women's perception of breast appearance and its association with breast cancer operations. METHODS: From April 2012 to May 2013, all women attending a breast clinic were shown two breast pictures, "natural" and "augmented," and asked which photograph represented the current expected appearance of breasts. Among breast cancer patients, the choice of breast cancer operation was correlated with picture selection. RESULTS: Of 1,177 consecutive women, mean age was 45 years. Overall, 70 % of patients felt that the augmented appearance is expected. This impression was seen in all racial/ethnic groups: non-Hispanic White 65 %, African American 67 %, Hispanic 71 %, and other groups 70 %. Younger age was strongly associated with the augmented appearance (p < 0.0001). Patients older than age 60 years selected the augmented appearance only 51 % of the time. This percentage increased with each younger decade with patients younger than 40 years selecting the augmented appearance in 85 %. Among breast cancer patients, augmented appearance selection was more likely for patients who underwent reconstruction (92 %; p < 0.001), as well as for those undergoing bilateral mastectomy (74 %; p = 0.057) compared with mastectomy alone (49 %). CONCLUSIONS: Most women felt that the augmented appearance of breasts is currently expected, and this impression was more common in young women. This impression may be another factor contributing to the current trend of more extensive breast cancer operations and implant-based reconstructions.

An alternative technique for immediate breast reconstruction.

Immediate reconstruction has demonstrated superior cosmesis compared with delayed reconstruction, however, unexpected final pathology may necessitate post mastectomy radiation. We describe an alternative technique for immediate breast reconstruction. Twelve patients underwent 14 skin-sparing mastectomies from July 2006 to December 2009. The skin-sparing mastectomies and sentinel node biopsies were performed through a periareolar incision. At the completion of the operation the incision was closed in a transverse fashion. No simultaneous reconstruction was performed. No drains were placed. After 3 days seroma developed, which maintained the integrity of the skin envelope and appearance of a breast. Nine patients (75%) had a contraindication to breast conservation. All patients were clinically node negative and 67 per cent were clinical stage 0. The majority (75%) experienced an adverse change from clinical stage to final pathologic stage. Four patients (33%) required postmastectomy radiation. The mean time from oncologic procedure to initial reconstruction procedure was 14 days. Two patients (17%) developed postoperative infections. This technique allows immediate reconstruction and avoids the fear of adverse final pathology indicating radiation to the reconstructed breast. In addition, it provides flexibility in scheduling for the surgeons and allows the patient to maintain the appearance of the breast.

Traditional Lower Blepharoplasty: Is Additional Support Necessary? A 30-Year Review.

BACKGROUND: Several refinements have been made in lower eyelid rejuvenation, and there is now strong belief that the traditional approach places too little emphasis on lower eyelid support. The purpose of this study was to retrospectively review the 30-year experience of the senior author (J.A.F.) performing primary lower blepharoplasty by the traditional approach and to determine the complication rate when lower lid-tightening procedures were not performed concomitantly. METHODS: A retrospective chart review of all traditional blepharoplasties performed by the senior author over the past 30 years was performed. The traditional approach was performed through an external, subciliary incision. Concomitant lower lid-tightening procedures were not performed. The authors determined the complication rate of the procedure, such as symptomatic lower eyelid malposition and chemosis. RESULTS: A total of 3014 patients underwent traditional lower blepharoplasties and, after applying the exclusion criteria, 2007 patients were studied. A postoperative complication was defined as the development of either chemosis or symptomatic lower eyelid malposition. Chemosis developed in only 1.2 percent of the patients (24 of 2007). Eight of the 2007 patients (0.4 percent) developed symptomatic lower eyelid malposition. CONCLUSIONS: This study proves that when performed meticulously and precisely, traditional lower blepharoplasty is safe and effective. Correction of preoperatively diagnosed lower lid laxity is essential; however, when lower eyelid tone is adequate, the authors believe that the routine addition of a tightening procedure for support or the routine use of combined internal and external approaches is unnecessary. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

MOC-PS(SM) CME article: abdominoplasty.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Understand the reasoning behind obtaining a thorough medical history from abdominoplasty patients and determine how that information (e.g., history of massive weight loss, prior operations with abdominal scars) may affect the surgical plan. 2. Understand the thromboembolic risks associated with abdominoplasty patients, especially when abdominoplasty is performed in conjunction with other surgical procedures, and appropriate and currently accepted prophylaxis. 3. Describe the indications and potential risks of performing liposuction as an adjunct to abdominoplasty. 4. Evaluate a patient's abdomen, taking into consideration all the aesthetic subunits of the trunk and lower body, and determine the appropriate type of abdominoplasty indicated. 5. Identify and understand the treatment of early and late complications associated with abdominoplasty. SUMMARY: In this article, the authors review the preoperative assessment, surgical treatment plan, and outcomes of abdominoplasty. Preoperative assessment emphasizes obtaining an accurate and detailed medical history, conducting a thorough physical examination, and determining suitable and safe anesthetic options in appropriate surgical facilities. Preoperative planning stresses measures taken to minimize perioperative complications, and intraoperative planning reviews the various surgical techniques. Postoperative complications and their treatments are discussed, as well as the safety of combining abdominoplasty with other procedures. Current procedural terminology is also reported, since there have been recent changes to those codes commonly used in abdominoplasty.

Enhanced survival using the distally based sural artery interpolation flap.

The reverse sural artery flap is frequently used for reconstruction of the distal third of the leg, ankle, and heel. The major disadvantage of the flap is compression of the pedicle within the subcutaneous tunnel and venous congestion. Others have cited a decrease in this problem by harvesting a midline cuff of gastrocnemius muscle, including more subcutaneous tissue and using a wider-than-usual pedicle. We describe an interpolation flap technique of simply avoiding a subcutaneous tunnel and exteriorizing the pedicle with no other alterations to flap design or elevation techniques. Seven distally based reverse sural artery flaps were performed on ambulatory patients between 2001 and 2002. Venous congestion did not occur in any of the flaps. All patients were ambulatory after surgery and did not require the use of a custom shoe. We conclude that transferring the flap in 2 stages without the use of a tunnel improves the reliability of the flap and eliminates venous congestion.