Cosmetic Results In Patients Research Articles

Can nipple-areola-sparing mastectomy be an alternative to mastectomy? Over 10 years of follow up at a Japanese institution.

Abstract Abstract #22 Introduction: Cosmetic outcome is one of the most important aspects of surgical treatment of breast cancer. Therefore, to maximize the cosmetic outcome for patients who require a mastectomy, what can be done from an oncologically safe perspective must be considered. Recent reports have suggested that nipple-areola-sparing mastectomy (NSM) is oncologically as safe as a classical mastectomy (MT) and provides a better cosmetic outcome than MT. However, little is known about the long-term outcome of NSM.
 Aim: To determine the oncological and technical outcomes of NSM compared with MT using long term follow-up data.
 Patients and Methods: We retrospectively analyzed 788 patients, median age 51 years, with primary breast cancer who underwent NSM from 1985 to 2004. The indication of NSM in this study was defined as being for any stage, any tumor size and any tumor-areola distance. Briefly, NAC was preserved when palpation and the outlook of the nipple was normal. Median tumor size and tumor-areola distance were 2.5cm (0-10.0) and 1.8cm (0-9.0), respectively. Our surgical notes for NSM were; (1) a thin flap (approximately 5 mm thick subcutaneous adipose tissue) was placed close to the tumor, and a thick flap (more than 1cm thick subcutaneous adipose tissue) was created more than 2cm away from the tumor to conserve breast volume using subcutaneous fat, and (2) tissue under the NAC was left at 5 mm in thickness, but the major ducts were removed from within its lumen. Eighty-one patients (10%) underwent immediate breast reconstruction (IBR) using implants. We also analyzed 144 patients with breast cancer who underwent MT in the same period as those who underwent NSM. No patient received radiotherapy. We compared the local recurrence rate (LRR), disease-free survival (DFS) and overall survival (OS) between 788 NSM and 144 MT cases.
 Results: Median follow-up of NSM and MT was 92 (10-252) and 87 (0-231) months, respectively. To our surprise, no complications of NSM including nipple and areola necrosis were recorded (0/788). For NSM, there were 70 patients (8.9%) with local recurrence, including 23 (2.9%) at the nipple, 4 (0.5%) at the areola, 4 (0.5%) at both nipple and areola, and 39 at the skin flap (4.9%). This suggested that the rate of NAC relapse was quite low. There were no significant differences in LLR between NSM and MT, (10y, 8.9% vs. 7.6%, p=0.62), DFS (10y, 83% vs. 83%, p=0.34) and OS (10y, 88% vs. 86%, p=0.34), respectively. Cosmetic outcome of NSM was better than that of MT in the majority of patients.
 Conclusion: These results suggested that NSM provides a good cosmetic outcome and is as safe oncologically as MT. Our long term follow-up data shows that NSM is a possible alternative to mastectomy. Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 22.

Reconstruction of Large Iliac Crest Defects After Graft Harvest Using Autogenous Rib Graft

Prospective controlled study analyzing the donor site morbidity after reconstruction of full thickness iliac crest defects, using autologous rib grafts. To compare the pain and cosmetic outcomes of patients with iliac crest reconstruction with those who have had no reconstruction of the iliac crest. Chronic donor site pain and poor cosmesis have been the major deterrents in using iliac crest for long-segment spinal reconstructions. Iliac crest reconstruction with rib has been reported but most studies are uncontrolled and retrospective. Patients with iliac defects <25 mm after graft harvest were excluded. Twenty patients were reconstructed using autogenous rib graft harvested during the anterolateral approach to spine. Rib graft of the appropriate contour was impacted into the notches created in the iliac crest defect. The control group comprised 16 patients without reconstruction of the iliac crest. The pain, cosmesis, and functional disability were assessed on the basis of visual analog scores and a predesigned questionnaire. Judet iliac views were used to assess the incorporation of the rib graft. Evaluation was performed at 1.5, 3, 6, and 12 months, respectively. Intensity and incidence of pain was significantly lower in the reconstructed group. Cosmetic outcome was also significantly better in this group. Patients in control group had significant complications related to the tenting of skin over the defect such as bursitis and skin necrosis. Radiologic incorporation was documented in 95% of patients with 1 patient having resorption of the rib graft. Rib graft reconstruction provides a cheap and effective alternative for iliac crest reconstruction. Patients undergoing thoracotomy or thoraco-phrenico-lumbotomy for spinal reconstruction, the unutilized rib graft should be used to reconstruct the iliac defect. Reduced donor site morbidity and better cosmesis are the major benefits of reconstruction.

Factors Associated with Skin Telangectasias and Cosmetic Outcome in Patients Treated on the American Society of Breast Surgeons MammoSite Registry Trial

Cosmetic outcome is an important endpoint of breast conservation. The MammoSite brachytherapy applicator has an associated incidence of telangectasias. The ASBS Registry Trial is examined for factors impacting telangectasia formation and cosmetic results.

Timing of Chemotherapy After MammoSite Radiation Therapy System Breast Brachytherapy: Analysis of the American Society of Breast Surgeons MammoSite Breast Brachytherapy Registry Trial

To evaluate cosmetic outcome and radiation recall in the American Society of Breast Surgeons registry trial, as a function of the interval between accelerated partial breast irradiation (APBI) and initiation of chemotherapy (CTX). A total of 1440 patients at 97 institutions participated in this trial. After lumpectomy for early-stage breast cancer, patients received APBI (34 Gy in 10 fractions) with MammoSite RTS brachytherapy. A total of 148 patients received CTX within 90 days of APBI. Cosmetic outcome was evaluated at each follow-up visit and dichotomized as excellent/good or fair/poor. Chemotherapy was initiated at a mean of 3.9 weeks after the final MammoSite procedure and was administered </=3 weeks after APBI in 54 patients (36%) and >3 weeks after APBI in 94 patients (64%). The early and delayed groups were well balanced with respect to multiple factors that may impact on cosmetic outcome. There was a superior cosmetic outcome in those receiving chemotherapy >3 weeks after APBI (excellent/good in 72.2% at </=3 weeks vs. excellent/good in 93.8% at >3 weeks; p = 0.01). Radiation recall in those receiving CTX at </=3 weeks was 9 of 50 (18%), compared with 6 of 81(7.4%) in those receiving chemotherapy at >3 weeks (p = 0.09). The majority of patients receiving CTX after APBI have excellent/good cosmetic outcomes, with a low rate of radiation recall. Chemotherapy initiated >3 weeks after the final MammoSite procedure seems to be associated with a better cosmetic outcome and lower rate of radiation recall. An excellent/good cosmetic outcome in patients receiving CTX after 3 weeks was similar to the cosmetic outcome of the overall patient population who did not receive CTX.

Intra-operative Touch Preparation Cytology; Does It Have a Role in Re-excision Lumpectomy?

Breast carcinoma is the most frequently diagnosed malignancy in women of North America. The combination of breast conservation surgery and radiotherapy has become a standard of treatment for the majority of breast cancers. It is critical to obtain clear margins to minimize local recurrence. However, avoiding multiple re-excisions for margin clearance helps optimize cosmetic results in patients undergoing breast conservation surgery. Intra-operative touch preparation cytology (IOTPC) may decrease the need for multiple re-excisions and thereby improve cosmesis. The literature suggests that IOTPC can be useful in evaluation of margins. Klimberg et al. evaluated the touch preparation technique prospectively in 428 patients undergoing breast biopsy for undiagnosed breast masses. Margin evaluation was correct in 100% of the lesions and was used to re-excise the margins when touch prep results were positive. They reported a diagnostic accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of 100% for the touch prep technique. To the best of our knowledge, there has been no published data on the role of IOTPC for evaluation of margins in re-excision cases. This report describes our experience with IOTPC for margin assessment for re-excision partial mastectomy at Beth Israel Medical Center (BIMC). The purpose of this study is to determine whether IOTPC is reliable for evaluating margins in patients undergoing re-excision for involved or close margins. A prospective study of 30 patients, who have undergone re-excision partial mastectomy for involved or close margins after breast conservation surgery with the use of IOTPC for margin assessment at BIMC was performed. The re-excision lumpectomy specimens were oriented by the surgeon intra-operatively and were submitted fresh to pathology for cytologic assessment. The touch prep method consisted of touching the corresponding margin onto the glass slide. The principle of this technique is that if cancer cells are present they will stick to the slide, while fat cells will not. A slide was prepared for each re-excision specimen. Air-dried samples were stained immediately using the Diff-Quik method and examined under the microscope by a cytopathologist. Thirty patients underwent re-excision lumpectomy for involved or close margins with touch preparation cytology for assessment of 68 margins. Twenty-six patients had invasive ductal carcinoma and/or ductal carcinoma in situ, three patients had invasive lobular carcinoma and the remaining one patient had a combination of invasive lobular and ductal carcinoma. There was a correlation between touch prep cytology and final pathology in 56/68 margins, which accounts for 82.4% of the cases. Intra-operative touch preparation cytology for assessment of margins in patients undergoing re-excision lumpectomy for involved or close margins has a sensitivity of 75%, specificity of 82.8%, positive predictive value of 21.4%, and negative predictive value of 98.2%. This high negative predictive value and a single false negative margin are quite significant. Therefore, based on our experience, IOTPC can be a useful tool for intra-operative assessment of margins for patients undergoing re-excision partial mastectomy.

Cosmetic outcome of three sutures levator aponeurosis tuck procedure in congenital ptosis.

To determine the results of three sutures aponeurosis tuck procedure in patients with congenital ptosis. A quasi-experimental study. Department of Ophthalmology, Khyber Teaching Hospital, Peshawar from January 2004 to January 2005. Twenty-four eyes of 20 patients (13 males and 7 females) with congenital ptosis were included in the study. All these lids had either good or fair levator function. Amount of ptosis in all lids were measured before surgery and their mean calculated. Single surgeon performed the three sutures levator aponeurosis tuck procedure on all these lids. Degree of ptosis, after surgery was measured on multiple occasions and mean of measures of last follow-up was calculated. At this stage, the patients' satisfaction level was also documented. Mean amount of ptosis was 3.25 +/-0.99 mm before surgery and 0.33 +/- 0.56 mm after surgery (p < 0.0001). Satisfaction level of 18 (90%) patients was 70-90%, while in 2 (10%) patients it was 50-60%. Levator aponeurosis tuck procedure had good cosmetic outcome in patients with congenital ptosis having good and fair levator function in this series.

Initial Outcomes for Patients Treated on the American Society of Breast Surgeons MammoSite Clinical Trial for Ductal Carcinoma-In-Situ of the Breast

The MammoSite device was designed as a breast brachytherapy applicator and is currently used to deliver accelerated partial breast irradiation (APBI). We hypothesized that APBI delivered with the MammoSite device would be well tolerated and be associated with a good cosmetic outcome in patients with ductal carcinoma-in-situ (DCIS). From 2002 to 2004, 191 patients with DCIS were enrolled in a registry trial to assess the MammoSite applicator. Fifteen patients were excluded from analysis because of device- or patient-related factors; 7 patients were excluded after receiving a radiotherapy boost, thus leaving 169 patients available for study. Follow-up information was available for 158 patients. The average length of follow-up was 7.35 months. Forty-three patients had at least 1 year of follow-up. Skin spacing for the MammoSite applicator was as follows: < 5 mm, 3 patients (1.78%); 5 to 7 mm, 18 patients (10.65%); and > or = 7 mm, 148 patients (87.57%). Patients with a device-to-skin distance of > or = 7 mm had the best cosmetic result. Patients with a device-to-skin distance of > or = 7 mm also had a lower incidence of radiation dermatitis. Data on 43 patients who were followed up for at least 1 year confirmed these findings. Additional adverse events were primarily related to skin changes, with breast infections occurring in five patients (3.16%). No patient in the study has experienced a recurrence. APBI delivered via MammoSite is well tolerated in patients with DCIS, and the lowest toxicity was obtained in patients with the greatest device-to-skin distance. Long-term follow-up data regarding patient satisfaction, cosmesis, and efficacy are needed and will be determined from a recently opened large randomized study.

Trigonocephaly

Trigonocephaly accounts for approximately 10% of all craniosynostosis. Severe trigonocephaly results in a triangular-shaped forehead, superior-lateral orbital depression, hypotelorism, and compensatory occipital-parietal calvarial changes. Radiographic findings include ovoid orbits with parallel medial borders, thickened keel-shaped frontal bone, small ethmoid sinuses, and a short anterior cranial fossa with pitched sphenoid wings. Our experience with 50 infantile cases of severe nonsyndromic trigonocephaly patients treated from 1987 to 2005 is clinically reviewed to assess long-term growth based on a standardized operative technique. The average age of the patients at surgery was 6 months and the mean follow-up was 12 years. Our complication rate was 2%; the reoperative rate was 12%. The use of resorbable rigid plate fixation combined with alloplastic augmentation has improved the cosmetic outcome in patients treated since 1996 and reduced the reoperative rate.

Reconstruction of the upper lip and philtrum

The procedure used to repair upper lip defects depends on various factors: size and location of the defect, the conditions of neighbouring tissues, and the aetiology of the deformity. A single-stage procedure rarely gives a satisfactory cosmetic outcome in patients who have also lost the philtrum or a philtral crease. Here, we describe a single-step procedure for the reconstruction of the upper lip and philtrum that resulted in a good aesthetic appearance.

Traitement chirurgical des expositions d’implants d’éviscération en hydroxyapatite par greffe d’aponévrose temporale: À propos de 4 cas

Using hydroxyapatite porous implants improves the functional and cosmetic results for patients after evisceration. However, exposure is still the most frequent complication and requires various surgical treatments. We present four patients who had an autologous temporalis fascia graft for an exposed hydroxyapatite implant 6 months to 5 years after the first evisceration. Mean follow-up was 17 months. We describe our surgical procedure and its results, and we discuss its advantages and its place in the management of exposed porous implants.

Excisional Breast Specimen Orientation/Processing: A Multidisciplinary Approach for Breast Conservation

Breast carcinoma is the most frequently diagnosed malignancy in women of North America. The combination of breast conservation surgery and radiotherapy has become a standard of treatment for the majority of breast cancers. It is critical to obtain clear margins to minimize local recurrence. However avoiding multiple re-excisions for margin clearance helps optimize cosmetic results in patients undergoing breast conservation surgery. Careful attention to the details of peri-operative evaluation and management are critical for success. The objective of this article is to define safe and effective techniques of preoperative planning and intraoperative breast specimen orientation and processing. The importance of a multidisciplinary approach with excellent communication between team members is stressed. Accurate pre-operative diagnosis, precise localization of the area of concern, volume of the surgical excision, specimen orientation, specimen radiography, intraoperative margin evaluation, specimen inking, and pathology processing are discussed. The specifics of the policy for breast specimen handling will vary depending on the resources and expertise available at each treating facility. This paper describes the approach used at Beth Israel Medical Center.

Reconstructive surgery following resection of primary vulvar cancers

Objective. This study describes the surgical treatment and follow-up of 213 patients with primary vulvar cancer; particular attention is given to reconstructive surgical procedures. Methods. The clinical and pathological parameters of the patients were recorded according to standardized procedures, and the data concerning type of operation, surgical reconstruction and postoperative course of disease (recurrence-free and overall survival) were analyzed. Results. In about one-third of the cases, plastic surgery reconstruction involving skin-flaps was performed. In the present group of patients, plastic surgery procedures led to an elevated degree of operability as well as to more satisfactory results in terms of wound healing. For minor cosmetic defects, local (fasciocutaneous) skin-flaps resulted in excellent wound healing and short periods of in-patient treatment, even in patients with larger tumors. In cases exhibiting more severe wounds extending over larger areas of the vulva and its surrounding regions, similarly encouraging results were achieved using regional (myocutaneous) skin-flaps. Conclusion. The present study shows that reconstructive surgery of the vulva leads to good results in patients with vulvar cancer. Plastic surgery enlarges the spectrum of available operative therapy in vulvar cancer, especially in large tumors, and its application leads to a favorable oncological outcome as well as excellent cosmetic results in patients with vulvar cancer.

Teilbrustbestrahlung beim Mammakarzinom mit günstigen prognostischen Faktoren: 3-Jahres-Ergebnisse der deutsch-österreichischen Phase II-Studie

To evaluate perioperative morbidity, toxicity and cosmetic outcome in patients treated with interstitial brachytherapy to the tumor bed as the sole radiation modality after breast conserving surgery. From 11/2000 to 11/2004, 240 women with early stage breast cancer participated in a protocol of tumor bed irradiation alone using pulsed dose rate (PDR) or high dose rate (HDR) interstitial multi-catheter implants (partial breast irradiation). Perioperative morbidity, acute and late toxicity as well as cosmetic outcome were assessed. Of the first 51 patients treated in this multicenter trial, we present interim findings after a median follow-up of 36 months. Perioperative Morbidity: Bacterial infection of the implant: 2 % (1/51). Acute toxicity: radiodermatitis Grade 1: 4 % (2/51). Late toxicity: breast pain Grade 1: 8 % (4/51), Grade 2: 2 % (1/51); dyspigmentation Grade 1: 8 % (4/51); fibrosis Grade 1: 4 % (2/51), Grade 2: 8 % (4/51); telangiectasia Grade 1: 10 % (5/51), Grade 2: 4 % (2/51). Cosmetic results: Excellent and good in 94 % (48/51) of the patients. This analysis indicates that accelerated partial breast irradiation with 192-iridium interstitial multicatheter PDR-/HDR-implants (partial breast irradiation) is feasible with low perioperative morbidity, low acute and mild late toxicity at a median follow-up of 36 months. The cosmetic result is not significantly affected.

Temporary Fixation With the Agee-Wristjack During Correctional Osteotomies for Malunions and Nonunions of the Distal Radius

Upper extremity surgeons are often responsible for managing complex malunions and nonunions of distal radius fractures. Studies have demonstrated that corrective osteotomies of the malunited distal radius with placement of sculpted bone grafts produce the best functional and cosmetic results in patients. We describe a technique for providing provisional stabilization of the osteotomy site for treatment of distal radius malunions and nonunions using the Agee-Wristjack external fixator device. The Agee-Wristjack has several features that make it superior to other available small external fixators. Its gear mechanisms confer stable distraction of the distal radius following osteotomy and greatly facilitate appropriate positioning of the distal fragment. Iliac crest bone graft may be harvested and shaped precisely to fit the osteotomy defect. Placement of the Agee-Wristjack's distal fixator pins into the index metacarpal instead of the distal radius fragment facilitates application of a plate, with minimal interference from the distal pins. Finally, the Agee-Wristjack may be maintained following surgery to supplement the internal fixation.

Minimally invasive aortic valve replacement - the patient's view

Objectives: Aortic valve replacement (AVR) has been performed through a median sternotomy for many years. Over the last decade various minimally-invasive methods have been developed to improve outcome and patient's satisfaction. This study compares postoperative variables including quality of life (QOL) after conventional and minimally-invasive AVR. Material and Methods: Between 01/1999 and 12/2001 371 patients underwent an conventional (CONV) (n=268) or an upper J-shaped minimally-invasive (n=103) AVR (MIC). In 2002 a postoperative survey including a SF-36 QOL questionnaire was sent to the patients. Follow-up was 100% complete in each group. Patients were equally matched according to age, sex, ventricular function, valvular lesion, and valve prosthesis. Results: No differences between the two groups were recorded for operative time, cardio-pulmonary-bypass-time, cross clamp-time, and minimal core temperature. There were no deaths within 30 days after the operation in the MIC group versus 4.1% in the CONV group (p=0.04). Mortality over the whole study period was 3.9% in the MIC group and 9.3% in the CONV group (p=0.08). Freedom from embolism was 97.8% in CONV group versus 97.1% in MIC group. Freedom from wound healing complications was 97.0% in the CONV group versus 97.1% in the MIC group. There were no statistically significant differences regarding any of the SF-36 QOL categories. Conclusions: Although the minimally-invasive approach is well accepted regarding postoperative cosmetic results for patients requiring AVR, there seem to be no clinically measurable differences in postoperative outcome or QOL.

Thirty month results with the MammoSite breast brachytherapy applicator: Cosmesis, toxicity and local control in partial breast irradiation

Thirty month results with the MammoSite breast brachytherapy applicator: Cosmesis, toxicity and local control in partial breast irradiation

Minimally invasive thoracoscopic sympathectomy for palmar hyperhidrosis via a transaxillary single-port approach*1

The aim of this retrospective study was to evaluate the mid-term outcome (average follow-up 10 months, range 6-18 months) and value of transaxillary single-port thoracic sympathectomy using a thoracoscope with an operating channel for the treatment of hyperhidrosis. Between December 1992 and October 2002, 176 consecutive patients (94 men, 82 women, mean age 21 years) with hyperhidrosis underwent thoracoscopic sympathectomy via a 12-mm single-port approach. Data on postoperative morbidity and outcome were analyzed to validate the technique. Mean operative time per side was 9 min; there was no conversion to an open procedure. Ninety-five percent of the patients were discharged the next day. Thirty-day mortality was zero. Complications included unilateral transient Horner's syndrome (n=1), residual pneumothorax requiring chest drainage from the port entry (n=4), and segmental atelectasis of the lung (n=4) which was treated conservatively. Complete relief of symptoms was observed in all patients at the 6-month follow-up; 45% experienced compensatory hyperhidrosis. Single-port thoracoscopic sympathectomy produces excellent medical and cosmetic results in patients with hyperhidrosis, and is associated with a short hospital stay and a low risk of complications. Overall satisfaction is high. A few patients may experience compensatory symptoms.

Brachytherapy with 192Ir as treatment of carcinoma of the tarsal structure of the eyelid

Purpose Some eyelid tumors present a great challenge for surgical therapy because of the cosmetic and functional impairment. Interstitial radiation with 192Ir is an optimal alternative treatment modality. The aim of this study was to evaluate the local tumor control and cosmetic results in patients with eyelid tumors treated by interstitial 192Ir wires. Methods and materials Twenty-four previously untreated carcinomas involving the eyelid tarsal structure in 23 patients were treated with 192Ir wire implantation. The tumor location was in the lower eyelid in 22 cases and in the upper eyelid in 2. The mean tumor size was 1.33 cm. Of the 24 tumors, 79.2% were basal cell carcinoma, 16.7% were squamous cell carcinoma, and 4.2% were adenocarcinoma. The total radiation dose was 4000 cGy, delivered to 2-mm depth (mean dose rate, 73 cGy/h). Results The mean follow-up was 43 months. Local control was obtained in 22 (91.6%) of 24 tumors. Good functional results were achieved in all patients. Conclusion 192Ir interstitial brachytherapy in a braided silk filament appears to be an excellent method to treat carcinomas involving the eyelid tarsal structure for tumor control and functional and cosmetic results.

Ｆａｃｅｌｉｆｔ ｉｎｃｉｓｉｏｎによる耳下腺腫よう摘出術

In Japan, most commonly used incision for parotidectomies is an S-shaped incision. The major problem with this incision is the visible scar in the preauricular and cervical area. To obtain more cosmetic approach to parotid surgery, Appiani suggested in 1967 that a facelift incision (rhytidectomy incision) be used to expose the parotid gland. We employed this incision for a motivated patient who was suspected of having a benign tumor. Eleven parotidectomies using this incision were performed between 1 January 2001 and 1 April 2004, in 10 females and 1 male, ranging in age from 23 to 62 years old (mean 39.6 years old). The pathology was pleomorphic adenoma in all cases. The duration of surgery ranged from 1.98 hours to 3.25 hours (mean 2.48 hours). In all cases, excellent exposure could be achieved through this approach, and the facial nerves were preserved. There were no remarkable complications. In conclusion, the facelift incision can provide adequate surgical exposure and good cosmetic results in patients with parotid tumor.

Transmediastinal approach to exploring the lung contralateral to the thoracotomy site.

The approach to contralateral lung through the mediastinum is assumed useful in managing oddly distributed bilateral lung tumors. To remove a tumor located in the contralateral lung, a transmediastinal approach from the thoracotomy site to the contralateral lung was used in 6 patients having oddly distributed bilateral lung tumors, 1 of which was located in the contralateral lung close to the anterior or posterior mediastinum. All cases were treated successfully. One patient required an additional small incision on the contralateral anterior chest wall to insert an endoscopic stapler without intraoperative postural change. The postoperative course was uneventful and, to date, no local recurrence has been seen at the resected margin of the contralateral lung. This novel approach is useful, offering the advantages of reduced invasiveness and pain, shorter surgical duration, and favorable cosmetic results for patients with a tumor close to the mediastinum in the contralateral lung.