Intercostal Artery Perforator Flap Research Articles

Preventing Bird’s Beak Deformity: A narrative review of Innovations in Oncoplastic Surgery

Background: In the field of breast surgery, breast conserving surgery (BCS) is widely valued for its ability to preserve the breast while also achieving cosmetically acceptable outcomes and an overall survival rate comparable to that of total mastectomy. However, BCS has not always managed to achieved satisfactory cosmetic results. Among its challenges is the “bird’s beak” deformity, which is characterized by skin retraction and a downward deviation of the nipple areolar complex due to tissue excision from the lower pole of the breast. Methods: Various forms of oncoplastic surgery (OPS) have been developed to prevent bird’s beak deformity. These include volume displacement operations (such as superior pedicle mammoplasty, rotation technique and downward-mobilization procedure), as well as volume replacement techniques, including the latissimus dorsi mini-flap, thoracodorsal artery perforator flap, lateral intercostal artery perforator flap, anterior intercostal artery perforator flap, inframammary adipofascial flap and lipofilling. Conclusion: Choosing the most suitable approach for OPS requires careful consideration of various factors, notably the defect’s size and location, the size of the breast, and the thickness of subcutaneous fatty tissue. Further studies are required to firmly position these forms of OPS techniques in an evidence-based framework.

Evaluation of the Intercostal Artery Perforator (ICAP) Flaps versus Lateral Thoracic Artery Perforator (LTAP) Flap in Partial Breast Reconstruction Following Breast Conservative Surgery.

Evaluation of the Intercostal Artery Perforator (ICAP) Flaps versus Lateral Thoracic Artery Perforator (LTAP) Flap in Partial Breast Reconstruction Following Breast Conservative Surgery.

New Applications of the Anterior Intercostal Artery Perforator Flap for Prosthetic Breast Reconstruction in the Setting of Postoperative Radiotherapy.

Several studies have reported preliminary experiences with the anterior intercostal artery perforator (AICAP) flap for treating partial breast defects or breast implant exposure following reconstruction. As radiotherapy is commonly administered for breast cancer, some patients may present with heavily damaged skin flaps and chronic radiodermatitis. We describe new applications of a de-epithelialized AICAP flap, used in combination with an implant, for breast reconstruction when other treatment options are unavailable. A retrospective study was conducted, including all patients who underwent implant-based breast reconstruction with the aid of an AICAP flap. A literature review was also performed. Between November 2022 and August 2023, four pedicled AICAP flaps were harvested in four patients. The indications were breast implant coverage in cases of chronic dermatitis of the mastectomy skin flaps (two unilateral flaps) and inferolateral coverage of partially submuscular expanders for immediate breast reconstruction (two unilateral flaps). All four flaps were based on one perforator. The mean harvesting time was 40 minutes. Complete flap survival was achieved, with no complications at the donor site. The AICAP flap is a safe and reliable technique for difficult cases of breast reconstruction when no other options are available. Moreover, this technique can easily provide additional coverage for the breast implant when needed.

A revised modified LICAP flap as a novel oncoplastic breast-conserving surgery technique for Mammary Paget’s disease

Mammary Paget’s disease is a rare form of breast cancer that presents a unique challenge to surgeons for patients who opt for breast-conserving surgery. Due to oncoplastic techniques, the options for breast-conserving surgery have diversified and allow for improved cosmetic outcomes. We present a 68-year-old lady with Mammary Paget’s disease who underwent a modified lateral intercostal artery perforator flap with a skin paddle to reconstruct the new areolar region. With this technique, we achieved complete oncological resection with excellent cosmetic outcome.

Evaluation of the Efficacy and Safety of Pedicled Perforator Flap Technique for Salvage Nipple Reconstruction in Breast Cancer Patients: A Pilot Study.

We propose a pedicled perforator flap technique for salvage nipple reconstruction after initial nipple reconstruction fails in breast cancer patients. This is a pilot study. A total of 21 female breast cancer patients who underwent nipple reconstruction following initial nipple reconstruction fails were enrolled, and salvage nipple reconstruction based pedicled perforator flap were performed between 2016 and 2020. Operative time, perforator design, postoperative complications, follow-up duration, projection of nipple, as well as patient-reported outcomes measured by the BREAST-Q and visual analogue scale (VAS) were assessed. Sixteen patients underwent fifth lateral intercostal artery perforator reconstruction, while 5 patients underwent fifth anterior intercostal artery perforator flap reconstruction. The surgeries were successful without intraoperative complications, with a mean operative time of 67 minutes. Postoperative complications were absent. The mean follow-up duration was 18 months. The mean nipple projection was 8mm (range, 6-10mm) with a shrinkage of 20% at 6 months after surgery. The average scores for psychosocial well-being, satisfaction with breasts, and satisfaction with nipples domains of the BREAST-Q significantly increased (P < .01) at 6 months post-reconstruction. Sexual well-being subdomain showed no statistical difference (P = .9369). The VAS scores for cosmesis and patient satisfaction with surgery were 9 and 9.3, respectively. The pedicled perforator flap technique for salvage nipple reconstruction is a safe and effective approach.

Combining Wise-pattern Volume Displacement and Autologous Volume Replacement to Facilitate Oncoplastic Breast Conservation

Background: Oncoplastic breast conservation has been classically divided into volume displacement (VD) or volume replacement (VR) techniques. There have been few descriptions of merging these two approaches. This report describes our experience combining Wise-pattern VD and autologous VR to repair extensive partial mastectomy defects in patients with ptosis. Methods: A retrospective chart review was performed for patients who underwent combined Wise-pattern VD surgery and autologous VR by the author from June 2017 to June 2023, with at least 6 months follow-up. Patient demographics, oncological and intraoperative details, and complications were recorded. Results: Forty patients underwent Wise-pattern VD surgery combined with a medial intercostal artery perforator flap (five patients), lateral thoracic artery perforator/lateral intercostal artery perforator flap (18 patients), anterior intercostal artery perforator flap (five patients), or muscle-sparing latissimus dorsi flap (12 patients). The average tumor size was 4.0 cm (range, 1.5–9.1 cm), and specimen weight was 152 g (range, 33–415 g). Six patients (15%) required re-operation for positive margins. There was delayed healing of three (7.5%) donor sites. There were no flap failures. Two (5%) patients had clinically apparent fat necrosis without requirement for surgical revision. Conclusions: This report demonstrates the feasibility of combining Wise-pattern VD and autologous VR. We propose that oncoplastic breast-conserving surgery be no longer divided into two mutually exclusive approaches and that surgeons make liberal use of combining these approaches to address challenging cases of breast-conserving surgery.

Chest wall perforator flap partial breast reconstruction: a retrospective analysis of surgical, cosmetic and survival outcome.

Oncoplastic breast surgery includes volume replacement as well as volume displacement. Autologous tissue is the preferred approach for volume replacement and includes chest wall perforator flaps (CWPF). Although described more than a decade ago, CWPFs have not been adopted widely in clinical practice till recently. We report the largest single-centre institutional data on CWPFs. The study includes all patients who underwent breast conservation surgery (BCS) using CWPFs from January 2015 to December 2022. Data were retrieved from the institutional electronic record and Redcap database. The analysis was done using SPSS 23 and STATA 14. 150 patients were included in the study. The mean age was 48.8 years (SD 10.4), and the body mass index was (26.6 kg/m2, SD 4.3). >50% of patients had breasts with small cup sizes (A&B) and mild ptosis (Non-ptotic and Grade 1 ptosis). 44.7% of patients underwent lateral intercostal artery perforator flap (LICAP), anterior intercostal artery perforator flap in 31.3%, lateral thoracic perforator flap (LTAP) in 12%, LICAP + LTAP in 11.3% and thoracodorsal artery perforator flap in 1%. Post-operatively, haematoma was seen in 1.3%, complete flap necrosis in 1.3%, seroma in 7%, wound dehiscence in 12%, and positive margin in 6.7%. 92 patients responded to the satisfaction assessment, of which >90% were happy with the surgical scars, comfortable going out in a public place, satisfied with the symmetry of the breast, and no one chose mastectomy in hindsight. The 5-year predicted disease free survival and overall survival were 86.4% and 94.7%, respectively. BCS with CWPF is an excellent option for reconstruction in small to medium-sized breasts. It is associated with minimal morbidity and comparable patient-reported cosmetic and survival outcomes.

Feasibility and early cosmetic outcome of modified lateral intercostal artery perforator flap after breast conservative surgery

BackgroundThe lateral intercostal artery perforator (LICAP) flap aims at replacing the excised breast lump with axillary tissue rich blood supply. The purpose of this study is to report the initial results of a modification LICAP flap technique in terms of intraoperative technical feasibility and short-term cosmetic outcomes in the early postoperative period.MethodsModified LICAP flap technique was performed on 36 female patients with pathologically proven BC located in the outer half of the breast in the period from June 1, 2021, to April 30, 2022.ResultsThe LICAP flap modification enabled performing the procedure with the patient in supine position without repositioning. The majority of the patients (90%) had satisfactory early cosmetic results as reported by the patients and oncoplastic independent surgeon.ConclusionModified LICAP flap reconstruction is feasible to be performed with the patient in supine position without repositioning and it has satisfactory early cosmetic outcomes.

The Utility of a Novel Bidirectional Lateral Intercostal Artery Perforator Flap for Reconstructing Partial Mastectomy Defects.

Smaller breasts require volume replacement to allow for breast conservation for large tumor to breast size ratios. The lateral intercostal artery perforator (LICAP) flap is one of the most commonly used approaches to replace volume as it readily fills lateral breast defects where most cancers typically arise. The LICAP flap was initially described with the bulk of its tissue volume oriented posteriorly, lateral to the breast footprint. Recently, the "reverse LICAP" flap was described, which uses the same perforators but recruits tissue instead from below the inframammary fold. Here, we combine these two approaches, preserving the same perforators, but harvesting tissue from both below the inframammary fold and lateral to the breast footprint, to create a single, larger, bidirectional LICAP flap. This modified flap replaces more volume than previously described for uni-directional approaches allowing us to potentially avoid mastectomy or more extensive flap reconstructions. Here, we describe 10 consecutive patients where the bidirectional LICAP flap was used to facilitate oncoplastic breast conservation.

The Extended Chest Wall Perforator Flap: Expanding the Indication for Partial Breast Reconstruction.

The intercostal artery perforator flap has traditionally been used to reconstruct small or moderate-sized single defects in the lateral or lower medial breast during breast-conserving surgery. We report a modification of the intercostal artery perforator flap that allows for reconstruction of larger breast tumors than previously described flap designs. A retrospective study of breast cancer patients undergoing breast-conserving surgery and immediate partial breast reconstruction with an extended chest wall perforator flap. Primary outcomes were successful tumor excision, adequate radial margins, postoperative complications, and delays to adjuvant radiotherapy. Thirty patients were included. Mean radiological tumor size was 27 mm (11-56 mm) and excision volume, 123 cm3 (18-255 cm3). All tumors had satisfactory excision margins, and no patient required further surgery for re-excision. In the early postoperative period, one patient required radiological drainage of seroma, and one returned to theater for debridement of fat necrosis affecting the flap. Ten other patients were managed on an outpatient basis for minor wound complications. All patients were followed up annually for 5 years. No patients had a delay to adjuvant treatment or required revisional procedures for cosmesis. The modified chest wall perforator flap allows for breast conservation for larger tumors from all quadrants of the breast, including centrally located tumors and reconstruction of the axillary defect following lymph node clearance. The length of the flap allows for the use of multiple perforators in the pedicle area and freedom of the flap to reach the defects. This can be performed with low morbidity and no delay to adjuvant radiotherapy.

A before and after evaluation of patient reported outcomes assessed by Breast Q following LICAP turnover flap in breast conservative therapy.

Chest-wall perforator-based techniques to replace volume for breast conservative therapy allow excision of large breast areas with minimal sequalae, such as the nipple-areolar complex displacement, parenchymal indentation or contour deformity. Furthermore, chest wall perforator flaps facilitate the maintenance of breast symmetry, hence decreasing the need for contralateral surgery. Lateral intercostal flap was described in numerous variants among which the most famous are the propeller flap and the turnover version. The turnover version is the easiest and fastest version that allows the replacement of large amount of volume. In this paper, we evaluate patients reported outcomes, before and after surgery, collected through the Breast Q. This study was conducted on 21 patients who were admitted to the plastic surgery department. A prospectively maintained database was used to identify the patients and their records were assessed retrospectively. The pre/post operative patients data were collected. The Breast-Q questionnaire was administered before the surgery and at least 1year after. No major surgical complications were reported. Mean Breast-Q scores were evaluated at least 1year after surgery and radiotherapy and compared with pre-surgical scores. Among all the modules, no significant differences between the pre-surgical and post-surgical Breast-Q scores were observed. Until now, the lateral intercostal artery perforator flap has not been widely used, due to a difficult dissection and a challenging preoperative planning. According to the reported surgical technique, the execution is easy. This technique provides the same breast-related quality of life compared to preoperative values, reduces the mastectomy rate and increases the overall survival.

No Doppler Single Position-Lateral Intercostal Artery Perforator Flap (NDSP-LICAP):a Safe and Versatile Flap for Breast Oncoplasty in Resource-Limited Setting.

The lateral intercostal artery perforator flap (LICAP) has emerged as one of the safest and less morbid flaps for lateral and central breast defects. We hereby describe a reproducible no Doppler single position (NDSP) technique to harvest it in single position without handheld Doppler, making it a versatile flap for lateral breast defects in resource-limited setting also. With this technique, we performed a total of 22 LICAP turnover flaps over a period of 18months from January 2020 to June 2021. In all 22 cases, the indication of flap was to fill the post-breast conservation surgery (BCS) defects in outer quadrant of breast. All LICAP flaps were harvested by surface marking of anatomical landmarks and without handheld Doppler. Out of 22 LICAP turnover flaps, thirteen were harvested for left breast and nine for right breast. The median width and length of the flap were 12.2cm and 19.6cm, respectively. The additional mean operative time was 41min. All LICAP flaps survived well, and grade 1 Clavien-Dindo morbidity was documented in four cases. Mean hospital stay was 2.6days. All patients received radiotherapy on their stipulated schedule. Early cosmetic outcome was good, and long-term outcomes are awaited. NDSP-LICAP flap is a workhorse for lateral breast defects. Precise knowledge of perforators and anatomical landmarks can be used for harvesting these flaps, thus avoiding ultrasound Doppler and dedicated training for perforator localization. This technique has short learning curve without the need for any plastic surgery training. The early cosmetic outcomes are good.

Intercostal artery perforator flaps for partial breast reconstruction after breast-conserving surgery

Introduction Breast conservative surgery’s objectives include a thorough oncologic excision and a satisfactory aesthetic outcome. The greatest strategy to prevent undesirable aesthetic outcomes is to use oncoplastic procedures to do so during conservative surgery in one step. For small to medium-sized breasts (up to C or D cup size), volume replacement treatments are advised, particularly in cases of bigger tumors. This entails inserting tissue into the tumor excision defect from a nearby or distant site. Musculocutaneous flaps, fasciocutaneous flaps, and most recently ‘perforator’ skin flaps have all been used in autologous tissue restoration. Due to the intercostal artery’s strong blood supply, anterior and lateral intercostal artery perforator (LICAP) flaps are dependable tissue sources. These flaps have the benefit of being able to fill the resection cavity, preventing further deformities. The study aimed to assess the feasibility of intercostal artery perforator flaps in partial breast reconstruction following breast-conserving surgery. Materials and methods The study was carried out on 42 breast cancer patients admitted to the surgical oncology unit, at Alexandria Main University Hospital in the duration between January 2021 and December 2022. A modified lateral intercostal artery perforator flap (mLICAP) and anterior intercostal artery perforator flap (AICAP) were used depending on the tumor location within the breast. The postoperative assessment was done by another breast surgeon and by the patient. Results Modified LICAP was used in 37 patients and AICAP was used in 5 patients. 90.5% of patients were satisfied with the aesthetic outcomes (85.7 gave excellent results). 69% of patients had excellent results based on the surgeon’s assessment. Complications were encountered in 11 patients in the form of seroma, hematoma, and minimal wound dehiscence. Conclusion Modified LICAP affords excellent access to the axilla and offers an option that facilitates both a pleasing aesthetic result and obviates the need for symmetrizing contralateral surgery to maintain breast symmetry. AICAP is a good option to partially reconstruct the breast following BCS for tumors located in the lower half of the breast.

Clinical Applications of the Intercostal Artery Perforator Flap for Trunk Reconstruction

Background Trunk defects can occur because of surgical site infections after spinal surgery, resection of malignant tumors, or trauma. Herein, we present our experience of using intercostal artery perforator (ICAP) flaps to reconstruct trunk defects without noteworthy complications. Fourteen patients underwent reconstruction with ICAP flaps between March 2015 and March 2019. Methods Patients' data, including age, sex, the cause of the defect, defect size, perforator location, flap size, complications, and follow-up period, were retrospectively reviewed. The mean age of the patients was 56.5 years (range, 19-80 years). All operations were performed after the results of bacterial culture from the wound showed no microbial growth. We found reliable perforators around the defect using Doppler ultrasonography. The perforator flaps were elevated with a pulsatile perforator and rotated in a propeller fashion to the defects. We performed five dorsal and two lateral ICAP flaps. The mean flap dimensions were 12 × 5.5 cm 2 (range, 6 × 5 to 18 × 8 cm 2 ). Results Primary closure of the donor site was performed. Marginal congestion was observed as a complication in one case, but it healed with no need for revision. The mean follow-up period was 8 months. All patients were satisfied with the surgical outcomes. Conclusion ICAP flaps can be easily mobilized, thereby reducing donor site morbidity without sacrificing the underlying muscles for trunk reconstruction. Therefore, these flaps are useful options for the reconstruction of trunk defects.

Perforator-Based Cross-Midline Flaps of the Trunk: A Paradigm Shift in Flap Design.

The traditional design for truncal perforator flaps is ipsilateral without midline decussation. The presumed rationale is to minimize the risk of distal flap necrosis. In this article, the authors present their experience and results with contralateral truncal perforator flaps designed and raised crossing the midline. This retrospective analysis included 43 patients (25 men and 18 women) who underwent reconstructive surgery from 1984 to 2021 using a contralateral flap design crossing the midline in the anterior trunk and upper back. Considerations included pathology, location, and the dimensions of the defect and flap. Arithmetic and weighted means with their 95% confidence intervals were estimated to compare ipsilateral and contralateral techniques. Contralateral flaps used included the internal mammary perforator flap ( n = 28) superficial superior epigastric artery flap ( n = 8), superior epigastric perforator flap ( n = 2), and the second or ninth dorsal intercostal artery perforator flap ( n = 5). All of these flaps, excluding the superficial superior epigastric artery flap, demonstrated length and coverage surface averages that were significantly greater than those of traditional ipsilateral flaps. However, with the contralateral superficial superior epigastric artery, both measures were statistically similar to those of traditional ipsilateral flaps. The anatomical variation design suggests that the trunk midline is not a barrier and that perforator flaps in these two regions may be raised on different longitudinal axes without compromising vitality. Therapeutic, IV.

P239 Multi-institutional Experience of Modified Lateral Intercostal Artery Perforator (LICAP) Flap Operation: Surgical and Patient Reported Outcomes (PROMs)

P239 Multi-institutional Experience of Modified Lateral Intercostal Artery Perforator (LICAP) Flap Operation: Surgical and Patient Reported Outcomes (PROMs)

Evaluation of Anterior Intercostal Artery Perforator Flap for Oncoplastic Immediate Reconstruction Following Breast-Conserving Surgery in Lower Breast Quadrants Lesions; an Institutional-Based Study

Evaluation of Anterior Intercostal Artery Perforator Flap for Oncoplastic Immediate Reconstruction Following Breast-Conserving Surgery in Lower Breast Quadrants Lesions; an Institutional-Based Study

Case report of stacked intercostal artery perforator flaps: a novel technique using anterior and lateral intercostal artery perforator flaps for full autologous breast reconstruction post-mastectomy

: Surgery is the mainstay of curative treatment for breast cancer with mastectomy offering the lowest risk of local recurrence. Post-mastectomy reconstruction options include autologous flaps and/or implants. Autologous flaps are commonly harvested from various areas, including rectus abdominis muscle, latissimus dorsi muscle, gracilis muscle and gluteal areas. While good cosmetic outcomes are often achieved, donor site morbidity and long patient downtime remain an issue. The intercostal perforator flaps have fewer of these problems but it often does not have sufficient volume for full reconstruction after mastectomy. Intercostal perforator flaps were developed for volume replacement after breast-conserving surgery. These perforator flaps are not used for full autologous reconstruction after mastectomy as the volume from a single perforator flap is often inadequate. Hence, the authors describe the first report of a novel approach of combining the anterior intercostal artery perforator (AICAP) flap and lateral intercostal artery perforator (LICAP) flap, the stacked intercostal artery perforator (STICAP) flaps, for full autologous reconstruction following an areolar-sparing mastectomy. Our patient is a 76-year-old lady diagnosed with a left breast 6 o’clock retro-areolar invasive ductal carcinoma measuring 2.8 cm × 1.6 cm × 2.3 cm. The patient underwent a left breast areolar-sparing mastectomy and axillary sampling followed by immediate STICAP (AICAP and LICAP) flaps reconstruction which achieved an excellent aesthetic appearance and high level of patient satisfaction.

Oncoplastic breast volume replacement with the use of lateral intercostal artery perforator flap

Breast cancer is very common, and there has been a lot of progress in terms of diagnosing and treating it. Surgical intervention, which is tailored to the patient's particular needs and numerous clinical concerns, is one of the management methods used. Some indicators that can be used are, for instance, the size and the stage. Smaller and earlier stage malignancies can be treated with a wide excision. However, getting a proper excision margin around the tumor and not removing too much tissue is problematic. Several studies have shown that when 20% of the breast volume is removed, there is a significant risk of deformity. Currently, oncoplastic surgery is the gold standard for breast reconstruction to minimize such a risk, and one of the techniques is volume replacement, which includes reconstruction of the breast with the transposition of tissue from elsewhere. Numerous volume replacement procedures were performed in the reported patients. The thoracodorsal artery perforator (TDAP) and lateral intercostal artery perforator (LICAP) flaps showed good outcomes in terms of cosmetic and oncological aspects, yet LICAP was found to be an excellent choice for the lateral breast defect and the aesthetic result was satisfactory. We present the case of a 19-year-old woman who had a borderline phyllodes tumor and 49-year-old woman with invasive breast cancer ductal carcinoma in situ (DCIS) that was treated with a wide excision and volume replacement with a LICAP. Following the success of the LICAP treatment, the defect appears symmetrical with the contralateral breast a few weeks following surgery. In conclusion, LICAP and TDAP flaps oncoplastic surgery offer advantages that should be considered to increase satisfactory of the patients after breast construction surgery in Indonesia.

Partial breast reconstruction of 30 cases with peri-mammary artery perforator flaps

BackgroundVolume replacement is one of the vital techniques of oncoplastic surgery (OPS) when applying breast-conserving surgery. The clinical application of peri-mammary artery perforator flaps for this indication is uneven in China. Here, we describe the results of our clinical experience with peri-mammary artery flaps for partial breast reconstruction.MethodsIn this study, 30 patients underwent partial breast resection for quadrant breast cancer followed by partial breast reconstruction with peri-mammary artery perforator flaps, which included the thoracodorsal artery perforator flap (TDAP), anterior intercostal artery perforator flap (AICAP), lateral intercostal artery perforator flap (LICAP), and lateral thoracic artery perforator flap (LTAP). All the patients’ operation plans were discussed comprehensively and were performed by sticking to every step. The satisfaction outcome was assessed with the extracted version of the BREAST-Q version 2.0, Breast Conserving Therapy Module Preoperative and Postoperative Scales both preoperatively and postoperatively.ResultsAccording to the study outcomes, the mean flap size was 5.3*4.2*2.8 cm (3.0–7.0*3.0–5.0*1.0–3.5 cm). The mean surgical time was 142 min (100–250 min). No partial flap failure was detected, and no severe complications were observed. Most patients were satisfied with the outcomes regarding the dressing, sexual life, and breast shape postoperation. Furthermore, the sensation of the surgical area, scar satisfaction, and recovery state gradually improved. Overall, LICAP and AICAP had higher scores when different flaps were compared.ConclusionsBased on this study, we found that peri-mammary artery flaps had significant value in breast-conserving surgery, especially in patients with small or medium-sized breasts. Perforators could be detected by vascular ultrasound before the operation. More than one perforator could be found most of the time. No severe complications occurred when performing a suitable plan, including discussing and recording the operation procedure; the focus of care, the choice for precise and proper perforators, and the mechanism for hiding the scars were all considered and recorded in a specific chart. Patients were satisfied with the reconstruction technique of peri-mammary artery perforator flaps after breast-conserving, and the satisfaction of AICAP and LICAP was higher. In general, this technique is suitable for partial breast reconstruction and has no negative impact on patient satisfaction.