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Background: As the use of patient-owned devices, including smartphones and tablets, to manage day-to-day activities grows, so does healthcare industry's interest to better leverage technology to engage patients. For surgical care, a unique opportunity exists to capture patient-generated health data (PGHD) including photographs. As part of a broader initiative to evaluate PGHD for surgical site infection (SSI) surveillance, we sought evidence regarding patient involvement and experience with PGHD for SSI monitoring and surveillance. Methods: Through a scoping review of the literature and semi-structured stakeholder interviews we gathered evidence on what is currently known about patient perspectives of and experiences with mobile health (mHealth) interventions for post-operative recovery. We presented findings to and discussed with the ASSIST PGHD Stakeholder Advisory Group (PSAG) to generate priorities for further examination. Results: Our scoping review yielded 34 studies that addressed post-discharge use of PGHD for monitoring and surveillance of SSI. Of these, 16 studies addressed at least one outcome regarding patient experience; the most commonly measured outcome was patient satisfaction. Only three studies reported on patient involvement in the development of PGHD tools and interventions. We conducted interviews (n = 24) representing a range of stakeholder perspectives. Interviewees stressed the importance of patient involvement in tool and program design, noting patient involvement ensures the “work” that patients do in their daily lives to manage their health and healthcare is recognized. Discussion of evidence with the ASSIST PSAG resulted in formal recommendations for direct involvement of patients and caregivers for future work. Conclusions: While mHealth initiatives to advance post-operative management offer the ability to improve patient engagement, work is needed to ensure the patient voice is reflected. Active engagement with patients and caregivers in the development of new technology, the design of new workflows, and the conduct of research and evaluation ensures that the patient experiences and values are incorporated.

Background:. Breast surgery is an area of practice where patients value before and after photographs (BAPs). Consensus is needed to develop guidelines to address the deficit in the literature regarding appropriate use of BAPs, as these may ultimately play a significant role in the breast surgery consent process. Methods:. Expert breast reconstructive surgeons participated in a modified nominal group technique (NGT) to establish expert consensus on categories and criteria to be used when evaluating appropriate use of BAPs as part of informed consent. Endorsement rate of 75% and coefficients of variance within and between rounds were conducted to determine validity of each criteria item’s rank order. Results:. Eight experts participated in the NGT in-person meeting and subsequent online survey. five of seven categories were endorsed for discussion: purpose, image type, anatomy, results, and photographic integrity. Overall consensus was obtained for six of 11 criteria. Criteria items found to have consensus were: patients considering surgery being the intended photograph audience (100% endorsement, CV1 – CV2 = 0.01), use of photographic images (75% endorsement, CV1 – CV2 = 0.04), defining the standard clinical photograph by having patients in the same body position (100% endorsement, CV1 – CV2 = 0.14), anonymizing images by removing all digital tags (88% endorsement, CV1 – CV2 = 0.03) and patient identifiers (75% endorsement, CV1 – CV2 = 0.00), not limiting the number of photograph sets needed for sufficient representation (100% endorsement, CV1 – CV2 = 0.07), and representing average outcomes (100%, CV1 – CV2 = 0.06). Conclusions:. Early use of this validated and effective technique helps identify potential consensus categories and criteria that surgeons recommend for the use of BAPs in the informed consent process. Further study is required.

Background The BODY-Q Chest module is a patient-reported outcome (PRO) instrument that measures satisfaction with how the chest (10 items) and nipples (5 items) look. This PRO instrument was previously field tested in an international sample of people seeking treatment for gynecomastia (n = 174), weight loss (n = 224), and chest masculinization (n = 341). Objectives The aim of this study was to examine the psychometric performance of the BODY-Q Chest module in a new chest masculinization surgery sample. Methods Data were collected from patients attending a private plastic surgery outpatient clinic in Canada between January 2018 and June 2019. Rasch measurement theory analysis was used to examine how the scales performed psychometrically. Results The sample provided 266 assessments (115 preoperative, 151 postoperative). All items had ordered thresholds, providing evidence that the 4 response options for each scale worked as expected. Item fit was within ±2.5 for all items, with all Bonferroni adjusted chi-square values nonsignificant. The data for the chest (χ2(20) = 18.72, P = 0.54) and nipples (χ 2(10) = 12.28, P = 0.27) scales fit the requirements of the Rasch model. Reliability was high with person separation index and Cronbach’s α values of ≥0.95 for the chest and ≥0.87 for the nipple scales, respectively. More depressive symptoms on the Patient Health Questionnaire-9 and lower health-related quality of life scales were weakly correlated with worse scores on the chest and nipple scales (P < 0.001). Conclusions The BODY-Q Chest module was shown to be scientifically sound in an independent sample of patients seeking chest masculinization surgery.

Background Delayed breast reconstruction is an option for women who have undergone mastectomy; however, uptake is low. The purpose of this study was to identify premastectomy and postmastectomy demographic, clinical, and psychosocial predictors of uptake of delayed breast reconstruction in the long-term survivorship period. Methods This was a prospective longitudinal survey study of mastectomy patients in which a repeated measures design was used to evaluate uptake of delayed breast reconstruction. Demographic, clinical, and psychosocial variables were collected before mastectomy and 1 year after mastectomy. Information regarding uptake of delayed breast reconstruction was collected at approximately 6 years after mastectomy. A predictive model was designed using a multivariate logistic regression model and Akiake information criterion stepwise algorithm. Results Ninety-six mastectomy patients were followed from before mastectomy to 75.2 months after mastectomy, and 35 women (36.5 percent) underwent delayed breast reconstruction. Women who elected for delayed breast reconstruction experienced worsening of body concerns from before mastectomy to 1 year after mastectomy, compared with women who did not elect to undergo delayed breast reconstruction (p = 0.03). Mean scores for psychological distress were significantly worse both before mastectomy and 1 year after mastectomy in women who went on to undergo delayed breast reconstruction compared with those who did not undergo delayed breast reconstruction (p = 0.034 and p = 0.022, respectively). A predictive model for the uptake of delayed breast reconstruction was developed using demographic, clinical, and psychosocial characteristics. The area under the receiver operating characteristic curve was 85 percent, indicating good precision. Conclusions Women who are experiencing higher levels of distress, anxiety, and body concerns both before and after mastectomy appear to be significantly likely to select delayed breast reconstruction. This may have implications for postreconstruction satisfaction and psychosocial functioning. Clinical question/level of evidence Risk, III.

Background: The implementation of health information technology interventions is at the forefront of most hospital institutional policy agendas. Despite the availability of numerous apps a...

Semple, John L., G.W. Kent Moore, Petros Koutrakis, Jack M. Wolfson, Paolo Cristofanelli, and Paolo Bonasoni. High concentrations of ozone air pollution on Mount Everest: health implications for Sherpa communities and mountaineers. High Alt Med Biol. 17:365-369, 2016.-Introduction: Populations in remote mountain regions are increasingly vulnerable to multiple climate mechanisms that influence levels of air pollution. Few studies have reported on climate-sensitive health outcomes unique to high altitude ecosystems. In this study, we report on the discovery of high-surface ozone concentrations and the potential impact on health outcomes on Mount Everest and the high Himalaya.Surface ozone measurements were collected during ascending transects in the Mount Everest region of Nepal with passive nitrite-coated Ogawa filter samplers to obtain 8-hour personal exposures (2860-5364 m asl). In addition, the Nepal Climate Observatory-Pyramid, a GAW-WMO Global Station sited in the Khumbu Valley (5079 m asl), collected ozone mixing ratios with photometric gas analyzer.Surface ozone measurements increased with altitude with concentrations that exceed 100 ppb (8-hour exposure). Highest values were during the spring season and the result of diverse contributions: hemispheric background values, the descent of ozone-rich stratospheric air, and the transport of tropospheric pollutants occurring at different spatial scales.Multiple climate factors, including descending stratospheric ozone and imported anthropogenic air masses from the Indo-Gangetic Plain, contribute to ambient ozone exposure levels in the vicinity of Mount Everest that are similar to if not higher than those reported in industrialized cities.

The internet and social media are increasingly being used by patients not only for health-related research, but also for obtaining information on their surgeon. Having an online presence via a website and social media profile is one-way plastic surgeons can meet this patient driven demand. The authors sought to document current website and social media usage of Canadian plastic surgeons and to determine if this usage correlated with years in practice. A Google search was performed using publicly available lists of all plastic surgeons registered with the Royal College of Physicians and Surgeons of Canada (RCPSC) and the Canadian Society for Aesthetic Plastic Surgery (CSAPS). This search found 42% (268/631) of RCPSC plastic surgeons had a website and 85% (536/631) had a profile on social media. Younger RCPSC surgeons (registered for less years) were significantly more likely to have a website (12.8 vs. 21.9 years, P < 0.0001) and an active social media profile (16.2 vs. 23.9 years, P < 0.002). The social media platform most used was RateMDs (81%) followed in decreasing order by: LinkedIn (28%), RealSelf (22%), Facebook (20%), Google+ (17%) and Twitter (16%). Dual RCPSC-CSAPS members were more likely than RCPSC-only members to have a website (56 vs. 36%, P < 0.0001) and an active social media profile ( P < 0.05). Overall, current website usage and social media presence by Canadian plastic surgeons is comparable to counterparts in the US and UK. It may be possible to better optimize online presence through education of current search engine technology and becoming active on multiple social media platforms.

In the age of information and patient-centered care, new methods of delivering postoperative care must be developed and evaluated.To determine whether follow-up care delivered via a mobile app can be used to avert in-person follow-up care visits compared with conventional, in-person follow-up care in the first 30 days following ambulatory surgery.A randomized clinical trial was conducted from February 1 to August 31, 2015, among ambulatory patients undergoing breast reconstruction at an academic ambulatory care hospital. Patients were randomly assigned to receive follow-up care via a mobile app or at an in-person visit during the first 30 days after the operation. Analysis was intention-to-treat.The primary end point was the number of in-person follow-up visits during the first 30 days after the operation. Secondary end points were the number of telephone calls and emails to health care professionals, patient-reported convenience and satisfaction scores, and rates of complications.Of the 65 women in the study (mean [SD] age, 47.7 [13.4] years), 32 (49%) were in the mobile app group, and 33 (51%) were in the in-person follow-up care group. Those in the mobile app group attended a mean of 0.66 in-person visits, vs 1.64 in-person visits in the in-person follow-up care group, for a difference of 0.40 times fewer in-person visits (95% CI, 0.24-0.66; P .001) and sent more emails to their health care professionals during the first 30 days after the operation (mean, 0.65 vs 0.15; incidence rate ratio, 4.13; 95% CI, 1.55-10.99; P = .005) than did patients in the in-person follow-up care group. This statistically significant difference was maintained at 3 months postoperatively. The mobile app group reported higher convenience scores than the in-person follow-up care group (incidence rate ratio, 1.39; 95% CI, 1.09-1.77; P = .008). There was no difference between groups in the number of telephone communications, satisfaction scores, or complication rates.Patients undergoing ambulatory breast reconstruction can use follow-up care via a mobile app to avert in-person follow-up visits during the first 30 days after the operation. Mobile app follow-up care affects neither complication rates nor patient-reported satisfaction scores, but it improves patient-reported convenience scores.clinicaltrials.gov Identifier: NCT02318953.

Introduction: Patients with Turner syndrome demonstrate a variety of breast deformities that can contribute to their reported lack of self-esteem, sexual health and social adjustment. Breast reconstruction is an option for women with TS to correct breast deformities. Methods: We present three cases of women with Turner syndrome referred to the Breast Cancer Clinic at Women's College Hospital in Toronto between 1996 and 2009. Each woman had a breast deformity despite being on hormone replacement therapy and was requesting reconstruction to increase their self-esteem, feelings of femininity and sexual confidence. Results: Women with Turner syndrome may present with various breast deformities, including tubular deformities, bilateral developmental mammary hyperplasia, hypoplasia and asymmetry. Pre-operative self-ratings of breast appearance ranged from 3 to 6 (1 = hate, 10 = love). All patients reported breast deformities as having negative effect on self-esteem. All patients received bilateral implant reconstruction resulting in an improved self-rating of breast appearance. Conclusions: Women with Turner syndrome and breast deformities may benefit from bilateral breast reconstruction.

Background: The initial 6 weeks after surgery has been identified as an area for improvement in patient care. During this period, the persistence of symptoms that go unchecked can lead to unscheduled emergency room and clinic visits, calls to surgeons’ offices, and readmissions. Purpose: To analyze postoperative data from a previous study examining postoperative outcomes in 2 patient populations following breast reconstruction and anterior cruciate ligament (ACL) reconstruction with use of a patient-centered mobile application. Here, the authors establish whether this method of follow-up can provide useful insight specific to the orthopaedic patient population, and they determine whether the mobile platform has the potential to modify their postoperative treatment. In addition, the authors examine its utility for orthopaedic physicians and patients. Study Design: Case series; Level of evidence, 4. Methods: Eligible patients undergoing ACL reconstruction from 2 surgeons were consecutively recruited to use a mobile smartphone application that allowed physicians to monitor their recovery at home. Data from 32 patients were collected via the application and analyzed to evaluate recovery trends during the first 6 postoperative weeks. Following completion of the study, patients and physicians were interviewed on their experience. Results: Data collected from each question in the mobile application provided insightful trends on daily real-time indicators of postoperative recovery. The application identified 1 patient who required in-person reassessment to rule out a possible infection, following surgeon review of an uploaded image. It was estimated that the majority of patients could have avoided follow-up at 2 and 6 weeks, owing to the application’s efficacy. Participants described their satisfaction with the device as excellent (43%), good (40%), fair (10%), and poor (7%), and 94% (n = 30) of patients reported that they would respond to questions using a similar application in the future. Both physicians rated their experience as positive and identified useful traits in the web portal. Conclusion: This system can accurately assess patient recovery; it has the potential to change how postoperative orthopaedic patients are followed, and it is well received by patients and physicians. Recognition of the study’s limitations and employment of user feedback to improve the current application are essential before a formal randomized controlled trial is conducted.

IntroductionA critical barrier to outcome assessment in gender-affirming healthcare is the lack of a specific patient-reported outcome measure (PROM). This phase I protocol describes an international collaboration between investigators in Canada, Denmark, the Netherlands and the USA who have coalesced to develop a new PROM (ie, the GENDER-Q) to evaluate outcomes of psychological, hormonal and surgical gender-affirming treatments.Methods and analysisThis phase I study uses an interpretive description approach. Participants aged 16 years and older seeking any form of gender-affirming treatments in centres located in Canada, Denmark, the Netherlands and the USA will be invited to take part in qualitative interviews. Participants will review BREAST-Q and FACE-Q scales hypothesised to contain content relevant to specific gender-affirming treatments. Interviews will elicit new concepts for additional scale development. Each interview will be digitally recorded, transcribed and coded. The main outcome of this phase I study will be the development of a conceptual framework and set of scales to measure outcomes important to evaluating gender-affirming treatments. To this end, analysis will be used to add/drop/revise items of existing scales to achieve content validity. For new concepts, coding will assign top-level domains and themes/subthemes to participant quotes. Codes will be used to develop an item pool to inform scale development. Draft scales will be shown to transgender and gender diverse persons and experts to obtain feedback that will be used to refine and finalise the scales. The field-test version of the GENDER-Q will be translated by following rigorous methods to prepare for the international field-test study.Ethics and disseminationThis study is coordinated at McMaster University (Canada). Ethics board approval was received from the Hamilton Integrated Ethics Board (Canada), the Medical Ethical Committee at VUmc (The Netherlands) and Advarra (USA). Findings will be published in peer-reviewed journals and presented at national and international conferences and meetings.

Enhanced recovery following surgery can be achieved through the introduction of evidence-based perioperative maneuvers. This review aims to present a consensus for optimal perioperative management of patients undergoing breast reconstructive surgery and to provide evidence-based recommendations for an enhanced perioperative protocol.A systematic review of meta-analyses, randomized controlled trials, and large prospective cohorts was conducted for each protocol element. Smaller prospective cohorts and retrospective cohorts were considered only when higher level evidence was unavailable. The available literature was graded by an international panel of experts in breast reconstructive surgery and used to form consensus recommendations for each topic. Each recommendation was graded following a consensus discussion among the expert panel. Development of these recommendations was endorsed by the Enhanced Recovery after Surgery Society.High-quality randomized controlled trial data in patients undergoing breast reconstruction informed some of the recommendations; however, for most items, data from lower level studies in the population of interest were considered along with extrapolated data from high-quality studies in non-breast reconstruction populations. Recommendations were developed for a total of 18 unique enhanced recovery after surgery items and are discussed in the article. Key recommendations support use of opioid-sparing perioperative medications, minimal preoperative fasting and early feeding, use of anesthetic techniques that decrease postoperative nausea and vomiting and pain, use of measures to prevent intraoperative hypothermia, and support of early mobilization after surgery.Based on the best available evidence for each topic, a consensus review of optimal perioperative care for patients undergoing breast reconstruction is presented.Therapeutic, V.

Background: Breast reconstruction (BR) is an option for women who are treated with mastectomy; however, there has been concern regarding the oncologic safety of BR. In this study, we evaluated recurrences and mortality in women treated with mastectomy and compared outcomes in those treated with mastectomy alone to those with mastectomy plus transverse rectus adbominis (TRAM) flap BR. Methods: The prospective cohort study included women treated with mastectomy at Women’s College Hospital from 1987 to 1997. Women with TRAM flap BR were matched to controls based on age and year of diagnosis, stage, and nodal status. Patients were followed from the date of diagnosis until death or date of last follow-up. Hazard ratios were generated to compare cases and controls for outcome variables using Cox’s proportional hazards models. Results: Of 443 women with invasive breast cancer, 85 subjects had TRAM flap BR. Sixty-five of these women were matched to 115 controls. The mean follow-up was 11.2 (0.4–26.3) years. There were no significant differences between those with and without BR with weight, height, or smoking status. Women with TRAM flap were less likely to experience a distant recurrence compared to women without a TRAM flap (relative risk, 0.42; P = 0.0009) and were more likely to be alive (relative risk, 0.54; P = 0.03). Conclusions: Women who elect for TRAM flap BR after an invasive breast cancer diagnosis do have lower rates of recurrences and mortality than women treated with mastectomy alone. This cannot be explained by differences in various clinical or lifestyle factors.

Introduction For women who have mastectomy, breast reconstruction is an option which may improve psychosocial functioning. The purpose of this study was to evaluate changes in psychosocial functioning over a long follow-up period after mastectomy, specifically examining the differences between those with mastectomy alone and those who underwent postmastectomy delayed breast reconstruction (DBR). Methods This was a prospective longitudinal survey study of women with mastectomy in which a repeated measures design was used to compare psychosocial function scores over 3 timepoints: 1) pre-mastectomy; 2) one year post-mastectomy; and 3) long-term post-mastectomy (mean 6.3 years). In addition, psychosocial functioning was compared between the mastectomy alone group and the group who elected for DBR. Results 67 women who completed questionnaires at all three time points were included. The long-term follow-up time post-mastectomy was 75.2 months (6.3 years). Twenty-eight women (41.8%) underwent DBR in the study period. For the entire cohort, between one-year and long-term post-mastectomy, there were significant improvements in scores for body concerns (P = 0.03), cancer-related distress (P = 0.01), and total distress (P = 0.04). At long-term follow-up, women with DBR had significantly higher levels of total distress (P = 0.01), obsessiveness (P = 0.03), and cancer-related distress (P = 0.02) compared to those with mastectomy alone. There were no differences in quality of life between the two groups at any time point. Conclusions Psychosocial functioning improves over time in patients treated with mastectomy in the long-term breast cancer survivorship period, which may be related to the effect of time post-treatment, rather than an effect of choice for or against DBR. J. Surg. Oncol. 2015 111:258–264. © 2014 Wiley Periodicals, Inc.

Background:Regional anesthesia improves postoperative analgesia and enhances quality of recovery (QoR) after ambulatory surgery. This randomized, double-blinded, parallel-group, placebo-controlled trial examines the effects of multilevel ultrasound-guided paravertebral blocks (PVBs) and total intravenous anesthesia on QoR after ambulatory breast tumor resection.Methods:Sixty-six women were randomized to standardized general anesthesia (control group) or PVBs and propofol-based total intravenous anesthesia (PVB group). The PVB group received T1–T5 PVBs with 5 ml of 0.5% ropivacaine per level, whereas the control group received sham subcutaneous injections. Postoperative QoR was designated as the primary outcome. The 29-item ambulatory QoR tool was administered in the preadmission clinic, before discharge, and on postoperative days 2, 4, and 7. Secondary outcomes included block success, pain scores, intra- and postoperative morphine consumption, time to rescue analgesia, incidence of nausea and vomiting, and hospital discharge time.Results:Data from sixty-four patients were analyzed. The PVB group had higher QoR scores than control group upon discharge (146 vs. 131; P < 0.0001) and on postoperative day 2 (145 vs. 135; P = 0.013); improvements beyond postoperative day 2 lacked statistical significance. None of the PVB group patients required conversion to inhalation gas–based general anesthesia or experienced block-related complications. PVB group patients had improved pain scores on postanesthesia care unit admission and discharge, hospital discharge, and postoperative day 2; their intraoperative morphine consumption, incidence of nausea and vomiting, and discharge time were also reduced.Conclusion:Combining multilevel PVBs with total intravenous anesthesia provides reliable anesthesia, improves postoperative analgesia, enhances QoR, and expedites discharge compared with inhalational gas- and opioid-based general anesthesia for ambulatory breast tumor resection.

Breast reconstruction is an option for women with BRCA1 or BRCA2 mutations who elect to undergo prophylactic mastectomy to prevent breast cancer. We report on the uptake of breast reconstruction after prophylactic mastectomy in women with BRCA mutations from eight countries.Women with a BRCA1 or BRCA2 mutation were questioned regarding their cancer preventive practices. Information was recorded on prophylactic mastectomy and breast reconstruction.A total of 1,635 women with a BRCA1 or BRCA2 mutation who elected to undergo prophylactic mastectomy from eight countries were included. A total of 1,137 women (69.5%) had breast reconstruction after prophylactic mastectomy. A total of 58.7% of women over the age of 45 years at the time of prophylactic mastectomy had breast reconstruction compared to 77.6% of women 35 years of age or younger [odds ratio (OR) 0.36, 95% confidence interval (CI) 0.26-0.50, p0.001]. In addition, 62.9% of women with a breast cancer diagnosis (contralateral prophylactic mastectomy) had breast reconstruction after prophylactic mastectomy compared to 79.7% of women without a previous breast cancer diagnosis (OR 0.48, 95% CI 0.38-0.61, p0.001). A total of 66.9% of women from Canada had breast reconstruction after mastectomy compared to 71.9% of American women (OR 0.75, 95% CI 0.59-0.96, p = 0.02).The majority of women elect for breast reconstruction after prophylactic mastectomy. However, younger women and those without a previous diagnosis of breast cancer are more likely to have breast reconstruction than older women or those with a previous diagnosis of cancer.

Smartphone technology appears to be the next phase of development in telemedicine. With the increased focus on patient-centred care, mobile technology is being used to connect patients and their health care teams. Numerous mobile applications are available that can assist with both surgical and

The clinical significance of nodal micrometastasis is debated. Our primary objective was to determine whether, among women with early-stage breast cancer, regional lymph node micrometastasis is an independent risk factor for mortality. The secondary objective was to identify subgroups of women who have the highest risk of death from early-stage breast cancer with micrometastases. 206,625 women diagnosed with early-stage breast cancer (IA, IB, and IIA) from 2004 to 2012 were identified in the Surveillance, epidemiology, and end results database. Nodal status was classified as node-negative, isolated-tumor cells, micrometastases, and macrometastases. Women were classified into eight ethnic groups. Logistic regression was performed to estimate the odds ratio of being diagnosed with micrometastases. The Cox proportional hazard model was used to estimate the hazard ratio (HR) of breast cancer-specific death associated with micrometastases for each ethnic group. The 8-year breast cancer-specific survival was 96.6 % for women with node-negative breast cancers and was 94.6 % for women with micrometastases (adjusted HR 1.49; 95 % CI 1.31–1.69; P

The authors' objective was to test whether the transplantation of an autologous lymph node into a nodal excision site in sheep would restore lymphatic transport function and reduce the magnitude of postsurgical lymphedema.As a measure of lymph transport, iodine-125 human serum albumin was injected into prenodal vessels at 8 and 12 weeks after surgery, and plasma levels of the protein were used to calculate the transport rate of the tracer to blood (percent injected per hour). Edema was quantified from the circumferential measurement of the hind limbs.The transplantation of avascular lymph nodes at 8 (n = 6) and 12 weeks (n = 6) produced lymphatic function levels of 12.3 +/- 0.5 and 12.6 +/- 0.8, respectively. These values were significantly less (p0.001) than those measured at similar times in the animals receiving sham surgical procedures (16.6 +/- 0.7, n = 6; and 16.1 +/- 0.7, n = 6, respectively). When vascularized transplants were performed, lymphatic function was similar to the sham controls and significantly greater (p0.001) than that of the avascular group (8 weeks, 15.8 +/- 0.9, n = 8; 12 weeks, 15.7 +/- 1.0, n = 10). Lymph transport correlated significantly with the health of the transplanted nodes (scaled with histologic analysis) (p0.0001). The vascularized node transplants (n = 18) were associated with the greatest clinical improvement, with the magnitude of edema in these limbs exhibiting significantly lower levels of edema (p = 0.039) than nontreated limbs (n = 18).The successful reimplantation of a lymph node into a nodal excision site has the potential to restore lymphatic function and facilitate edema resolution. This result has important conceptual implications in the treatment of postsurgical lymphedema.

Inadequate blood supply can limit tissue graft size and thickness. As a result, there is considerable interest in vascularization strategies that might extend these limits. Beads of a copolymer of methacrylic acid and methyl methacrylate were used to enhance rat composite myocutaneous skin graft vascularization and to assess the effect on the gross morphology of the panniculus carnosus.Beads (45 or 65 mol% methacrylic acid (n = 8) or control 100 mol% methyl methacrylate (n = 6) were spread over the wound bed and covered with the composite myocutaneous graft and analyzed 11 days later in comparison with a no-bead control group (n = 22).Microvessel density counts were significantly higher (p0.001) for grafts treated with either 45 mol% methacrylic acid or 65 mol% methacrylic acid beads compared with grafts treated with methyl methacrylate beads or no beads. There was no significant difference between grafts treated with 45 mol% methacrylic acid or 65 mol% methacrylic acid beads, and no significant differences between grafts treated with methyl methacrylate beads and no beads. Most importantly, the panniculus carnosus was significantly thicker (p0.001) for grafts treated in either methacrylic acid bead group compared with grafts treated with either methyl methacrylate beads or no beads.The data provide supporting evidence that methacrylic acid beads augment graft vascularization and the health of the panniculus carnosus.

Despite the overwhelming advantages of breast-feeding, there is a persistent concern that maternal exposure to chemical contaminants may result in contamination of breast milk and have an effect on the child's growth and development. A parallel concern regarding lactation in women with silicone implants over the past years has led to confusion and anxiety relating to the potential risks to the child.The author reviewed the facts and issues as he knows them, including biomaterials, lactation toxicology, and a previous study where no difference was found in silicon (a proxy measurement of silicone) in women breast-feeding with silicone implants and those without.In the author's previous study, he compared women with implants to women without implants as controls and showed that mean silicon levels were not significantly different in breast milk (55.45 +/- 35 and 51.05 +/- 31 ng/ml, respectively) or in blood (79.29 +/- 87 and 103.76 +/- 112 ng/ml, respectively). However, silicon levels in alternative methods of infant nutrition were much higher. The mean silicon level measured in store-bought cow's milk was 708.94 ng/ml, whereas that for 26 brands of commercially available infant formula was 4402.5 ng/ml.In this review, the author looked only at silicon/silicone and did not address other potential contaminants that may be associated with silicone gel or the elastomer shell. This report may provide plastic surgeons and other healthcare workers with information regarding silicon/silicone for discussion with women with gel implants who are contemplating breast-feeding.

We examined the impact of lymph flow obstruction in large post-nodal lymphatic vessels in sheep. A silk ligature was placed 2 cm downstream from the prescapular or popliteal lymph node and tightened to interrupt flow. At 6, 12 and 16 weeks after lymph flow blockage, a network of small interconnecting lymphatics (approximately 10-40 microm in diameter) could be observed in the vicinity of the ligature. These were identified using antibodies to the lymphatic endothelial markers LYVE-1 or VEGFR-3 or unequivocally, with the upstream intraluminal injection of the non-specific cell dye CFDA-SE. The observed lymphangiogenesis coincided with increased levels of Prox1, Tie2 (Y992) phosphorylation, MAPK activation, and decreased Akt activition. In the popliteal preparations, saline was infused into the prenodal ducts upstream of the regeneration site. The slopes of the inflow pressure versus flow relationships were 17.3+/-3.6, immediately after vessel obstruction, 36.2+/-9.6 at 6 weeks and 15.0+/-5.3 at 12-16 weeks. For comparison, the average slope in a completely intact popliteal system was 3.1+/-0.3 (from a previous publication). The resistance to flow remained high up to 12-16 weeks after flow obstruction suggesting that normal flow parameters had not been achieved over this time. The lymph node appeared to have some role in limiting the impact of post-nodal lymph obstruction, a function that appeared to be compromised by lymph stasis.

The purpose of this study is to estimate the age-specific annual risks of breast cancer in a woman with a germline BRCA mutation and an affected first-degree relative according to the age of breast cancer diagnosis in the relative. Women with BRCA mutations with no previous diagnosis of breast cancer and with one first-degree relative with breast cancer were followed for breast cancers for a mean of 5.9 years (minimum 2 years). Age-specific annual breast cancer risks were calculated, according to the age of breast cancer diagnosis in the proband and the first-degree relative. 1114 cancer-free women with a BRCA mutation with a single first-degree relative with breast cancer were eligible for the study. 122 women (11.0 %) were diagnosed with incident breast cancer. The annual risk of breast cancer was 2.0 % for women with BRCA1 mutations and was 1.6 % for women with BRCA2 mutations. The age of breast cancer diagnosis in the first-degree relative did not affect the annual breast cancer risks for BRCA1 mutation carriers. For BRCA2 mutation carriers, the annual breast cancer risk was 4.5 % for women with a first-degree relative diagnosed with breast cancer under the age of 30 years and was 0.7 % for women with a relative diagnosed over the age of 60. Among women with BRCA2 mutations, a family history of early-onset breast cancer is a risk factor for developing breast cancer. Risk assessment for healthy BRCA2 mutation carriers should consider the ages of breast cancers diagnosed in first-degree relatives.

Nipple-sparing prophylactic mastectomy (PM) is an option for women at high-risk for breast cancer, and may offer better cosmetic results than a skin-sparing PM where the nipple-areolar complex (NAC) is removed. However, there may be residual breast cancer risk due to the maintained NAC. It is unclear if sparing the NAC with PM impacts on psychosocial functioning, including cancer-related distress and body image after PM. This was a cross-sectional survey study of women who had undergone bilateral PM (no previous breast cancer) recruited through surgical or cancer genetics clinics. All women completed standardized questionnaires assessing cancer-related distress, anxiety, depression, satisfaction with decision, decision regret, and health-related quality of life related to breast surgery. Outcomes were compared between women with nipple-areola-sparing PM (NAC-PM) and skin-sparing PM (SS-PM). Overall, 137 women completed the study; 53 (39 %) had NAC-PM and 84 (61 %) had SS-PM. The mean age of the study population was 41.5 years [standard deviation (SD) 8.8] and the mean time between PM and questionnaire completion was 50 months (SD 31). On the BREAST-Q, we found that women with NAC-PM had significantly higher levels of satisfaction with breasts (p = 0.01), satisfaction with outcome (p = 0.02), and sexual well-being (p

BACKGROUND This study compared overall and breast cancer-specific survival using long-term follow-up data among women diagnosed with invasive breast cancer undergoing mastectomy or breast reconstruction. METHODS Retrospective study using population-based data from Ontario Cancer Registry (1980 to 1990) including women receiving breast reconstruction within 5 years after mastectomy and controls of age- and cancer histology-matched women with mastectomy alone. We compared overall and breast cancer-specific survival using an extended Cox hazards model. Secondary analysis examined conditional survival across early, intermediate, and late follow-up. RESULTS Seven hundred fifty-eight matched pairs formed the cohort, with a median follow-up of 23.4 years (interquartile range, 1.1 to 33.0 years). Fewer breast reconstruction patients died overall or from breast cancer compared with controls (overall survival, 44.5 percent versus 56.7 percent, p < 0.0001; breast cancer-specific survival, 31.8 percent versus 42.6 percent, p = 0.0002, respectively). Breast reconstruction was associated with a 17 percent reduced risk of death and a 19 percent reduced risk of breast cancer death, after adjustment (overall survival hazard ratio, 0.83; 95 percent CI, 0.72 to 0.96; breast cancer-specific survival hazard ratio, 0.81; 95 percent CI, 0.68 to 0.99). Among 885 women (58 percent) surviving 20 or more years, there was no difference in risk of death from breast cancer (hazard ratio, 0.59; 95 percent CI, 0.31 to 1.10). CONCLUSION In a large cohort with invasive breast cancer followed over 20 years, there is no evidence that breast reconstruction is associated with worse survival outcomes compared with mastectomy alone. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.

Investigating protective strategies against chronic neuropathic pain (CNP) after breast cancer surgery entails using valid screening tools. The DN4 (Douleur Neuropathique en 4 questions) is 1 tool that offers important research advantages. This prospective 6-month follow-up study seeks to validate the DN4 and assess its responsiveness in screening for CNP that satisfies the International Association for the Study of Pain (IASP) definition and fulfills its grading system criteria after breast tumor resection with and without paravertebral blocks (PVBs). We randomized 66 females to standardized general anesthesia and sham subcutaneous injections, or PVB and total intravenous anesthesia. The 6-month CNP risk was assessed using the IASP grading system and the DN4 screening tools. We evaluated the DN4 sensitivity, specificity, and responsiveness in capturing the impact of PVB on the CNP risk relative to the IASP grading system. Data from 64 patients showed similar demographic characteristics in both groups. Twenty patients in both groups met the grading system CNP criteria; among these, 18 patients also met the DN4 CNP criteria. Furthermore, 15 patients in both groups did not meet the grading system CNP criteria; among these, 9 patients also did not meet the DN4 CNP criteria. Therefore, the sensitivity and specificity of the DN4 were estimated at 90% and 60%, respectively. Both screening tools suggested that PVB reduced the 6-month CNP risk. Our results suggest that the DN4 can reliably identify CNP at 6 months after breast tumor resection and detect the preincisional PVB effect on the risk of developing such pain.

A tissue-engineered adipose substitute would be invaluable to plastic surgeons for reconstructive, corrective, and cosmetic procedures. This work involves the design of a scaffold for soft tissue augmentation incorporating the decellularized extracellular matrix (ECM) of human placenta. We have developed a protocol to decellularize an intact, large segment (8 cm by 8 cm) of the human placenta. To facilitate the complete decellularization of the dense matrix, a system was designed to perfuse the required chemicals into the placenta via the existing vasculature. Following processing, the original architecture of the placental ECM was preserved, including an intact vascular network. Histological, immunohistochemical, and scanning electron microscopic analyses confirmed the removal of the cells and cellular debris and characterized the composition and structure of the matrix. In vitro cell culture experimentation showed that the placental decellular matrix (PDM) could facilitate the adhesion of primary human adipose precursor cells at early time points. The PDM has great potential for use as a scaffold for adipose tissue engineering, as the placenta is a rich source of human ECM components that can be readily harvested without harm to the donor.

Dermal substitutes derived from xenograft materials require elaborate processing at a considerable cost. Acellularized porcine dermis is a readily available material associated with minimal immunogenicity. The objective of this study was to evaluate acellularized pig dermis as a scaffold for human fibroblasts.In vitro methods were used to evaluate fibroblast adherence, proliferation, and migration on pig acellularized dermal matrix. Acellular human dermis was used as a control.Pig acellularized dermal matrix was found to be inferior to human acellularized dermal matrix as a scaffold for human fibroblasts. Significantly more samples of human acellularized dermal matrix (83 percent, n = 24; p0.05) demonstrated fibroblast infiltration below the cell-seeded surface than pig acellularized dermal matrix (31 percent, n = 49). Significantly more (p0.05) fibroblasts infiltrated below the surface of human acellularized dermal matrix (mean, 1072 +/- 80 cells per section; n = 16 samples) than pig acellularized dermal matrix (mean, 301 +/- 48 cells per section; n = 16 samples). Fibroblasts migrated significantly less (p0.05) distance from the cell-seeded pig acellularized dermal matrix surface than in the human acellularized dermal matrix (78.8 percent versus 38.3 percent cells within 150 mum from the surface, respectively; n = 5). Fibroblasts proliferated more rapidly (p0.05) on pig acellularized dermal matrix (n = 9) than on the human acellularized dermal matrix (7.4-fold increase in cell number versus 1.8-fold increase, respectively; n = 9 for human acellularized dermal matrix). There was no difference between the two materials with respect to fibroblast adherence (8120 versus 7436 average adherent cells per section, for pig and human acellularized dermal matrix, respectively; n = 20 in each group; p0.05).Preliminary findings suggest that substantial differences may exist between human fibroblast behavior in cell-matrix interactions of porcine and human acellularized dermis.

Genetic testing for women at increased risk of developing breast cancer has moved from the research setting to become part of established clinical practice. By testing for inherited mutations in BRCA1 and BRCA2, we are identifying more and more women who have an 80% or more lifetime risk of developing breast cancer. Since the discovery of BRCA1 in 1994, several clinical studies have led to strategies for reducing the risk of developing breast cancer, including prophylactic mastectomy, prophylactic oophorectomy, and preventive tamoxifen. We believe that in 2005, all prophylactic options, including subcutaneous and total mastectomy should be discussed and made available to women who find themselves unfortunate enough to have inherited a BRCA mutation.

BACKGROUND Many women who are at an elevated risk of developing breast carcinoma choose prophylactic mastectomy to decrease their risk. We conducted a population-based study to review the indications for, and patterns of practice of prophylactic mastectomy in Ontario, Canada, since 1991. METHODS A medical chart review was conducted at 33 hospitals that were identified as having conducted at least one prophylactic mastectomy. All bilateral mastectomy patients with no diagnosis of invasive or in situ breast carcinoma were eligible. RESULTS The number of prophylactic bilateral mastectomies performed varied from 6 to 19. The mean age of women undergoing prophylactic mastectomy was 43.5 years. Eighty percent of the women had prophylactic mastectomy performed because of a family history of breast carcinoma (89 of 99) or because of a known BRCA1 or BRCA2 mutation (10 of 99). Twenty percent of the women had no family history, but had the surgery for other benign breast conditions. Women with a family history of breast carcinoma were much more likely to have a total mastectomy (89%) than a subcutaneous mastectomy (11%). Sixty percent of the women had reconstructive surgery following mastectomy. CONCLUSIONS Prophylactic mastectomy is not performed on a large scale. The introduction of genetic testing for BRCA1 and BRCA2 has the potential to change the patterns of practice for prophylactic mastectomy. Cancer 2002;95:236–42. © 2002 American Cancer Society. DOI 10.1002/cncr.10680

Background: Women’s College Hospital (WCH) offers specialized surgical procedures, including ambulatory breast reconstruction in post-mastectomy breast cancer patients. Most patients receiving ambulatory surgery have low rates of postoperative events necessitating clinic visits. Increasingly, mobile monitoring and follow-up care is used to overcome the distance patients must travel to receive specialized care at a reduced cost to society. WCH has completed a feasibility study using a mobile app (QoC Health Inc, Toronto) that suggests high patient satisfaction and adequate detection of postoperative complications. Objective: The proposed cost-effectiveness study models the replacement of conventional, in-person postoperative follow-up care with mobile app follow-up care following ambulatory breast reconstruction in post-mastectomy breast cancer patients. Methods: This is a societal perspective cost-effectiveness analysis, wherein all costs are assessed irrespective of the payer. The patient/caregiver, health care system, and externally borne costs are calculated within the first postoperative month based on cost information provided by WCH and QoC Health Inc. The effectiveness of telemedicine and conventional follow-up care is measured as successful surgical outcomes at 30-days postoperative, and is modeled based on previous clinical trials containing similar patient populations and surgical risks. Results: This costing assumes that 1000 patients are enrolled in bring-your-own-device (BYOD) mobile app follow-up per year and that 1.64 in-person follow-ups are attended in the conventional arm within the first month postoperatively. The total cost difference between mobile app and in-person follow-up care is $245 CAD ($223 USD based on the current exchange rate), with in-person follow-up being more expensive ($381 CAD) than mobile app follow-up care ($136 CAD). This takes into account the total of health care system, patient, and external borne costs. If we examine health care system costs alone, in-person follow-up is $38 CAD ($35 USD) more expensive than mobile app follow-up care over the first postoperative month. The baseline difference in effect is modeled to be zero based on clinical trials examining the effectiveness of telephone follow-up care in similar patient populations. An incremental cost-effectiveness ratio (ICER) is not reportable in this scenario. An incremental net benefit (INB) is reportable, and reflects merely the cost difference between the two interventions for any willingness-to-pay value (INB=$245 CAD). The cost-effectiveness of mobile app follow-up even holds in scenarios where all mobile patients attend one in-person follow-up. Conclusions: Mobile app follow-up care is suitably targeted to low-risk postoperative ambulatory patients. It can be cost-effective from a societal and health care system perspective. [J Med Internet Res 2014;16(9):e213]

Assessing residents' understanding and application of the 6 intrinsic CanMEDS roles (communicator, professional, manager, collaborator, health advocate, scholar) is challenging for postgraduate medical educators. We hypothesized that an objective structured clinical examination (OSCE) designed to assess multiple intrinsic CanMEDS roles would be sufficiently reliable and valid.The OSCE comprised 6 10-minute stations, each testing 2 intrinsic roles using case-based scenarios (with or without the use of standardized patients). Residents were evaluated using 5-point scales and an overall performance rating at each station. Concurrent validity was sought by correlation with in-training evaluation reports (ITERs) from the last 12 months and an ordinal ranking created by program directors (PDs).Twenty-five residents from postgraduate years (PGY) 0, 3 and 5 participated. The interstation reliability for total test scores (percent) was 0.87, while reliability for each of the communicator, collaborator, manager and professional roles was greater than 0.8. Total test scores, individual station scores and individual CanMEDS role scores all showed a significant effect by PGY level. Analysis of the PD rankings of intrinsic roles demonstrated a high correlation with the OSCE role scores. A correlation was seen between ITER and OSCE for the communicator role, while the ITER medical expert and total scores highly correlated with the communicator, manager and professional OSCE scores.An OSCE designed to assess the intrinsic CanMEDS roles was sufficiently valid and reliable for regular use in an orthopedic residency program.Évaluer la compréhension et l’application des 6 rôles intrinsèques CanMEDS (communicateur, professionnel, gestionnaire, collaborateur, promoteur de la santé, érudit) chez les résidents pose un défi pour les responsables de la formation médicale postdoctorale. Nous avons émis l’hypothèse selon laquelle un examen clinique objectif structuré (ECOS) conçu pour évaluer plusieurs rôles CanMEDS intrinsèques serait suffisamment fiable et valide.L’ECOS comportait 6 stations de 10 minutes, permettant chacune d’évaluer 2 rôles intrinsèques à l’aide de scénarios basés sur des cas (avec ou sans recours à des patients standardisés). Les résidents ont été notés au moyen d’échelles en 5 points et d’une évaluation globale de leur rendement à chacune des stations. La validité convergente a été vérifiée par corrélation avec les rapports d’évaluation en cours de formation (RÉF) des 12 mois précédents et un classement chiffré créé par les directeurs du programme (DP).Vingt-cinq résidents des années 0, 3 et 5 y ont participé. La fiabilité interstation pour les scores totaux aux tests (en pourcentage) a été de 0,87, tandis que la fiabilité pour chacun des rôles de communicateur, collaborateur, gestionnaire et professionnel, a été supérieure à 0,8. Les scores totaux aux tests, les scores aux stations individuelles et les scores pour les rôles CanMEDS individuels ont tous fait état d’un effet significatif selon le niveau des résidents. L’analyse des classements établis par les DP quant aux rôles intrinsèques a révélé une forte corrélation avec les scores au test ECOS pour les rôles. On a observé une corrélation entre les RÉF et l’ECOS pour le rôle de communicateur, tandis que les RÉF pour le rôle d’expert médical et les scores totaux ont été en forte corrélation avec les scores de l’ECOS pour les rôles de communicateur, de gestionnaire et de professionnel.Un ECOS conçu pour évaluer les rôles CanMEDS intrinsèques s’est révélé suffisamment valide et fiable pour un usage régulier dans un programme de résidence en orthopédie.

Lymph nodes are often the target of radiotherapy procedures. Unfortunately, the impact of nodal irradiation on lymphatic function is uncertain. In this study, our aim was to quantify the impact of lymph node irradiation on lymph flow.The popliteal node or the nodal excision site of rabbits was treated with four daily 8 Gy doses of radiation. A FITC-dextran tracer was infused into a prenodal popliteal lymphatic. The area under the tracer blood recovery curve (AUC) indicated lymphatic functionality and the inflow pressure versus flow rate relationship inferred resistance through the system. Fluoroscopic and histological examination provided supporting data. Radiation of intact nodes decreased lymph transport significantly at 1 week, 1 month, and 6 months post-treatment (AUCs of 207.9 ± 79.87, 191.6 ± 62.95, and 250.44 ± 46.45) in comparison to controls (667.32 ± 104.18). Surprisingly, this functional decline was similar to that detected with a combination of node removal and irradiation of the excision site. The pressure-flow relationships in all treatment groups were significantly different from controls. This may be due in part to fibrosis and the thickening of the nodal capsules and trabeculae observed at 1 and 6 months. Fluoroscopy and Evans blue dye studies revealed vigorous new lymphatic vessel growth and occasionally, vessels anastomosed with local veins.Irradiation of the popliteal lymph node impaired lymph transport and increased the pressure required to maintain flow through the system. New vessel formation and the growth of lymph-venous anastomoses indicated the development of alternative drainage pathways as a compensatory response.

Milk of mammalian species contains a wide spectrum of anti-infectious factors, some of which are heat stable. Focusing on recently discovered heat-stable antibacterial peptides called defensins, which are expressed in epithelial tissues such as airway, skin, and kidney, we hypothesized that mammary gland epithelia produce and secrete defensins onto the epithelial surface and into milk. Using a reverse-transcription PCR assay, we identified the human beta-defensin-1 (hBD-1) gene transcript in a human mammary gland epithelial cell line, MCF-12A, and in mammary glandular tissue of nine nonlactating women. Epithelial cells harvested from milk of lactating women also expressed hBD-1 mRNA. Presence of hBD-1 peptide in mammary epithelia was confirmed by immunostaining with an hBD-1 antibody. In contrast, expression of human beta-defensin-2 was not apparent both at mRNA and protein levels. Our findings suggest a biologic role of hBD-1 in the human mammary gland.

The increase, in the last two decades, in the application of silicones (polysiloxanes) and inorganic silicon compounds in medicine and the food industry, has exposed the human body to extensive contacts with these substances. Most silicone breast implants contain a gel consisting of a crosslinked silicone elastomer swollen by silicone oil (PDMS). Diffusion of PDMS through the silicone elastomer envelope and rupture of the envelope with release of the gel contents both occur clinically. The amount and distribution of silicone compounds in various tissues are key issues in the assessment of health problems connected with silicone implants. We have measured by GFAAS the Si content of tissues from normal and implant patients and the organic solvent extractable Si levels (assumed to be silicone), using careful control of sample collection and preparation. Whole blood levels were: implant patients mean 38.8 (SD 25.6) (microg/kg), controls mean 24.2 (SD 26.7) (microg/kg) in one study and subsequently 103.8 (SD 112.1) and 74.3 (SD 86.5) (microg/kg) in another study. Capsular tissue levels were: gel implants 25047 (SD 39313) (mg/kg of dry tissue), saline implants 20.0 (SD 27.3) (mg/kg of dry tissue) and controls 0.24 (SD 0.39) (mg/kg of dry tissue). Breast milk levels were: implant patients mean 58.7 (SD 33.8) (microg/kg), controls mean 51.1 (SD 31.0) (microg/kg); infant formula mean was 4.40 (mg/kg). Various precautions were undertaken to avoid Si contamination in this work, the most important being a) the use of a Class 100 laboratory for sample preparation and b) application of strict and elaborate washing procedure for specimen collection tools and laboratory plasticware. This data demonstrated that to properly interpret the importance of these numbers for human health, a larger study of "normal" levels of Si in human tissues should be undertaken and factors such as diet, water, race and geographical location should be considered.

Prophylactic nipple-areolar complex (NAC)-sparing mastectomy (NSM) in BRCA1/2 mutation carriers is controversial over concern regarding residual fibroglandular tissue (FGT) with malignant potential. The objective of this study was to model the volume of FGT in the NAC at a standard retroareolar margin (5 mm) and examine the change in this amount with a greater retroareolar margin or areola-sparing technique.A segmentation protocol was applied to breast MRIs from 105 BRCA1/2 patients to quantify volumes of FGT for total breast and NAC. The proportion of FGT in the NAC relative to the breast was calculated as the primary outcome and was compared for 5 mm versus 10 mm retroareolar depths. The proportion of FGT in the areola was compared with the NAC.At 5 mm retroareolar thickness, residual NAC FGT comprised 1.3 % of the total breast FGT. This amount was not significantly greater than the proportion in the areola (p = 0.3, d = 0.1). Increasing the retroareolar thickness to 10 mm led to a statistically and possibly clinically significant increase in the amount of NAC FGT (p0.001, d = 1.1).The proportion of FGT remaining in the spared NAC with a 5 mm margin is extremely small, suggesting that leaving the entire NAC would create very little added risk. Doubling the retroareolar margin may translate into a clinically meaningful increase. Overall, our findings support the safety of the current trend toward increased rates of prophylactic NSM performed in this high-risk population.

A multidisciplinary patient care plan was developed to facilitate early discharge following autogenous breast reconstruction and included (1) preadmission patient education, (2) perioperative multimodal pain management, (3) intraoperative nerve blocks, and (4) postdischarge telephone advice. This study evaluated the success of this care plan in the first 18 months after its implementation.A retrospective cohort study of all consecutive women undergoing pedicled transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction (November of 2009 to May of 2011) was performed. The primary outcome was time to discharge; secondary outcomes included complications, readmission, and self-report pain at discharge. Predictors of discharge time were analyzed using stepwise multivariable regression modeling.Ninety-one women (mean age, 50.0 ± 8.5 years) underwent pedicled TRAM flap reconstruction (76 percent unilateral and 81 percent delayed), with 77 percent receiving the intended multimodal analgesia protocol. Mean time to discharge was 38.7 ± 27.6 hours. Overall, 40 percent of patients were discharged within 24 hours, but successful early discharge increased significantly over the study period. Key predictors of shorter time to discharge were use of multimodal analgesia, lower American Society of Anesthesiologists class, and surgery more than 6 months after implementation of the care plan.The authors' initial experience has supported the safety and feasibility of expedited discharge following pedicled TRAM flap breast reconstruction, with adherence to the authors' care plan improving steadily over the study period. Multimodal pain management proved a key modifiable factor in facilitating early discharge. A prospective study is currently underway to evaluate patient-reported quality of recovery following ambulatory surgery in this population.

Currently, little is known about which variables are most critical to the subjective appearance of symmetry of the nipple-areola complex. Clinical photographs were transferred onto a compact disc and then imported into a computer photoshop program. Alterations to the nipple-areola complex were then performed, creating 1 symmetrical image and 19 asymmetrical images. The asymmetries were produced by altering position, diameter, or pigmentation. The images were converted to 35-mm slides and shown to four separate panels of three members each. A "symmetry score" was given for each slide. Results showed that any deviation from symmetrical was reliably detectable by the observers. Changes in areola diameter were detected most easily, and the specific direction of positional change was not found to be a significant factor. Differences were seen between individual panel assessments. This study has shown an application for CD-ROM technology in analyzing well-identified variables and has helped in delineating which factors are most critical to the subjective impression of symmetry of the nipple-areola complex.

More than two million women in the United States have undergone augmentation mammaplasty. A woman's lifetime risk of developing breast cancer is nearing 1 in 9, which means that over 200,000 augmented women may go on to develop breast cancer. Several studies have implied that women who develop breast cancer following augmentation mammaplasty are less likely to present with occult disease. They present more often with a palpable mass and are more likely to have involved axillary nodes. This paper looks at seven patients who developed breast cancer in the presence of subglandular mammary implants. Mode of presentation, pathologic type, nodal status, relationship of the tumour to the breast capsule and surgical treatment will be discussed. Consideration should be given to recommending against augmentation mammaplasty in those women with a strong family history of breast cancer or other significant risk factors. Women who undergo breast augmentation should be informed that the detection of occult disease with mammography may be more difficult following augmentation. The prognostic significance of this has yet to be fully determined.

There is a growing interest in high resolution, subsurface imaging of cutaneous tissues using higher frequency ultrasound, and several commercial systems have been developed recently which operate at 20 MHz. Some of the possible applications of higher frequency skin imaging include tumour staging, boundary definition, and studies of the response of tumours to therapy, investigations of inflammatory skin conditions such as psoriasis and eczema, and basic studies of skin aging, sun damage and the effects of irritants. Investigation of these areas is quite new, and the role of ultrasound skin imaging is continuing to evolve. Lateral resolution in the 20 MHz imaging systems ranges from 200 to 300 microns, which limits imaging applications to cutaneous structures which are relatively large in size. In this paper, a real-time ultrasound backscatter microscope (UBM) for skin imaging is described which operates in the 40-100 MHz range, providing axial resolution between 17 and 30 microns and lateral resolution between 33 and 94 microns. This improvement in resolution over current skin ultrasound systems should prove useful in determining the margins of small skin lesions, and in obtaining more precise, in vivo skin thickness measurements to characterize nonmalignant skin disease. Example images of normal skin, seborrhoeic keratosis and malignant melanoma illustrate the imaging potential of this system.

Hypothermia is an acknowledged risk for those who venture into high altitude regions. There is however little quantitative information on this risk that can be used to implement mitigation strategies. Here we provide an analysis of the meteorological and hypothermic risk parameters, wind chill temperature, and facial frostbite time, during the spring 2006 Mount Everest climbing season. This season was marked by two high profile events where a solo climber was forced to spend the night in highly exposed conditions near the summit. One climber survived, while the other did not. Although this retrospective examination of two individual cases has admittedly a small sample size, and there are other factors that undoubtedly contributed to the difference in outcomes, we show that wind chill temperature and facial frostbite time experienced by the two climbers were dramatically different. In particular, the climber who did not survive experienced conditions that were approximately one standard deviation more severe that usual for that time of the year; while the climber who survived experienced conditions that were approximately one standard deviation less severe then usual. This suggests that the environmental conditions associated with hypothermia played an important role in the outcomes. This report confirms the importance of providing quantitative guidance to climbers as the risk of hypothermia on high mountains.

PP Narini, JL Semple, JB Hay, SJ Lugowski, D Smith. Does silicone gel migrate via lymphatics after subcutaneous injection? Can J Plast Surg 1994;2(2):67-70. Reports have documented the presence of elemental silicon, evidence of silicone elastomer, or silicone polymers (gel) in lymph nodes and other sites distant from implanted prostheses. It has been suggested that this occurs via the lymphatic system; however, the mechanism of spread or migration of silicone has not been previously studied. This study investigated the possible role of lymphatics in the migration of silicone gel. In the sheep model, it is possible to obtain continuous samples of both afferent and efferent lymph by cannulating lymphatic vessels. The drainage areas of subcutaneous lymph nodes in the sheep have previously been studied. In our model, the efferent lymphatic vessel from the prefemoral lymph node was cannulated to obtain samples of lymph (efferent and ‘pseudoafferent’). After baseline samples were collected, 3 to 5 mL of free silicone gel was injected subcutaneously in the drainage area of this node. Samples (5 to 10 ml.) of lymph were continuously collected (for up to 50 days), sealed, stored at −20°C, and then submitted as a group for trace element analysis to quantitate the levels of elemental silicon. No statistically significant increase was seen in baseline levels of elemental silicon after silicone gel injections. Statistically significant higher levels of silicon were found in afferent (mean 799 ± 22 part per billion [ppb]) compared with efferent lymph (mean 607 ± 19 ppb). This experimental study did not identify significant increases in elemental silicon levels in lymphatic vessels after the subcutaneous introduction of free silicone gel. Higher levels were found in afferent versus efferent lymph. This implies that migration of silicone gel does not occur soon after the exposure of a subcutaneous space to free silicone gel, or that the migration of silicone gel may occur by a cellular mechanism that can bypass the lymphatic vessels.

Modern trends in breast reconstruction with the TRAM flap have promoted adequate blood supply to the flap while minimizing the donor-site defect in the anterior abdominal wall. Preservation of the rectus abdominis muscle (both unipedicled and bipedicled), supercharging, delayed, and free-flap techniques all have promoted these principles. A new technique is presented utilizing the single pedicle with a transmidline retrograde microvascular loop anastomosis of the deep inferior epigastric artery and vein. The turbocharging allows increased blood flow to the remote areas of the flap as well as augmented venous outflow. In addition, the abdominal-wall donor site is similar to that of a single pedicle. This technique is ideal for reconstruction where the entire flap is required, a lower abdominal scar is present, or the recipient vessels for the free flap are absent or damaged.

The subject of microbial growth within the saline medium of prosthetic breast implants has been one of great controversy in recent years. Although several articles have described microbial growth within the tissue surrounding implanted breast prostheses, few have attempted to determine the possibility of such contamination of the luminal saline. The authors studied the intraluminal saline medium of a series of explanted breast prostheses with the objective of identifying any microbial contamination. Over a 6-month period, a consecutive series of saline-filled breast implants and tissue expanders were removed from 37 patients. Under the supervision of a microbiologist, saline extracted from each implant was subjected to bacterial and fungal cultures, Gram staining, and acid-fast staining. A total of 24 saline-filled breast implants were removed from 15 patients, and 32 saline-filled tissue expanders were removed from 22 patients. The average length of implantation was 28.1 months for the implants and 7.1 months for the expanders. None of the saline within the implants or expanders within our series displayed any evidence of microbial contamination. These results suggest that microbial contamination of the luminal saline of prosthetic breast implants is an extremely unlikely event.

In this study, we report on the changes in psychosocial functioning over 1 year following breast cancer surgery in 3 groups of women, including those with mastectomy alone, those with mastectomy and immediate reconstruction, and those with delayed reconstruction.Women with breast cancer at 2 teaching hospitals in Ontario who were undergoing mastectomy alone, mastectomy with immediate reconstruction, or delayed reconstruction were asked to complete a battery of psychosocial questionnaires at their preoperative appointment and 1 year following surgery.A total of 190 women consented to participate in the study and completed the presurgical questionnaires. There were no presurgical differences between the 3 groups in quality of life, anxiety, depression, or sexual functioning. However, women who were undergoing delayed breast reconstruction (i.e., already had a mastectomy) had higher levels of body stigma (P = 0.01), body concerns (P = 0.002), and transparency (P = 0.002) than women who were undergoing mastectomy alone or mastectomy with immediate reconstruction. Of these women, 158 (83.2%) completed the 1-year follow-up. There were no significant differences in any of the psychosocial functioning scores between the 3 groups.Contrary to the assumed psychological benefits of breast reconstruction, psychological distress was evident among women regardless of reconstruction or timing of reconstruction. Further, psychosocial functioning (including quality of life, sexual functioning, cancer-related distress, body image, depression, and anxiety) was not different at 1-year postsurgery between women with mastectomy alone, mastectomy with immediate reconstruction, and delayed reconstruction. These results suggest that women need psychosocial support after breast cancer diagnosis, even if they have breast reconstruction.

Introduction: Lymphedema is a frequent consequence of lymph node excision during breast cancer surgery. Current treatment options are limited mainly to external compression therapies to limit edema development. We investigated previously, postsurgical lymphedema in a sheep model following the removal of a single lymph node and determined that autologous lymph node transplantation has the potential to reduce or prevent edema development. In this report, we examine the potential of lymphangiogenic therapy to restore lymphatic function and reduce postsurgical lymphedema. Methods: Lymphangiogenic growth factors (vascular endothelial growth factor C (VEGF-C)) and angiopoietin-2 (ANG-2) were loaded into a gel-based drug delivery system (HAMC; a blend of hyaluronan and methylcellulose). Drug release rates and lymphangiogenic signaling in target endothelial cells were assessed in vitro and vascular permeability biocompatibility tests were examined in vivo. Following, the removal of a single popliteal lymph node, HAMC with the growth factors was injected into the excision site. Six weeks later, lymphatic functionality was assessed by injecting 125Iodine radiolabeled bovine serum albumin (125I-BSA) into prenodal vessels and measuring its recovery in plasma. Circumferential leg measurements were plotted over time and areas under the curves used to quantify edema formation. Results: The growth factors were released over a two-week period in vitro by diffusion from HAMC, with 50% being released in the first 24 hr. The system induced lymphangiogenic signaling in target endothelial cells, while inducing only a minimal inflammatory response in sheep. Removal of the node significantly reduced lymphatic functionality (nodectomy 1.9 ± 0.9, HAMC alone 1.7 ± 0.8) compared with intact groups (3.2 ± 0.7). In contrast, there was no significant difference between the growth factor treatment group (2.3 ± 0.73) and the intact group indicating improved function with the molecular factors. An increase in the number of regenerated lymphatic vessels at treatment sites was observed with fluoroscopy. Groups receiving HAMC plus growth factors displayed significantly reduced edema (107.4 ± 51.3) compared with nontreated groups (nodectomy 219.8 ± 118.7 and HAMC alone 162.6 ± 141). Conclusions: Growth factor therapy has the potential to increase lymphatic function and reduce edema magnitude in an animal model of lymphedema. The application of this concept to lymphedema patients warrants further examination. peerReviewed

[1] Increasing air pollution in Southeast Asia has the potential for dramatic impacts on the population and climate in relatively pristine regions such as the Himalaya. Recent measurements near Mount Everest indicate the presence of elevated levels of ozone at elevations from 5000m to 9000m that are the result of both the long-range transport of tropospheric pollutants from Southeast Asia as well as the descent of ozone-rich stratospheric air. Here we report on the first surface ozone concentration transect in the Mount Everest region. The data collected at elevations from 2900m to 5200m indicate an increase in concentration with height as well as 8-hour average exposures in excess of 140ppb. Satellite data and meteorological diagnostics suggest a stratospheric source for the high levels observed. The majority of values observed exceed guidelines for human exposure and therefore are of a magnitude to suggest that they are of physiological relevance.