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ABSTRACT: Abstract Background: Lower limb lymphedema (LLL) is a common complication of cancer treatment. The disease is chronic and progressive with no cure. Although a common and significant source of morbidity, the impact of this condition on health-related quality of life (HRQOL) has only recently been addressed. In effort to identify valid treatment strategies for LLL, we performed a systematic review, identifying studies describing HRQOL outcomes in patients with LLL secondary to cancer. Methods and Results: Seven medical databases were searched to identify reports using validated Patient Reported Outcome (PRO) instruments on patients with cancer-related LLL. Studies were classified by levels of evidence set by the Agency for Healthcare Research and Quality (AHRQ) and evaluated using the Efficace criteria. 25 studies were identified, 6 met inclusion criteria. Levels of evidence included: no level I studies, level II (n=3), level III (n=1), and level 4 (n=2). 50% of studies were compliant with the Efficace criteria. 5 PRO HRQOL instruments were used, but only 1 was specific to cancer-related lymphedema. Treatment strategies assessed included complete decongestive physiotherapy (CDP), exercise, and compression bandaging. CDP yielded significant enhancements in HRQOL. Conclusions: There is a deficit in high quality studies for HRQOL in patients with LLL secondary to cancer. Furthermore, of the studies present, most did not conform to guidelines set for assessment of HRQOL, nor did they use lymphedema condition specific PRO instruments. New measures specific to assessing LLL are necessary to gain more accurate evaluation of how this debilitating disorder affects HRQOL.
Lymphatic Research and Biology 03/2013; 11(1):14-9.
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ABSTRACT: BACKGROUND: A variety of tumors arise in or extend to the infratemporal fossa. We investigated the outcome of surgical management of these tumors. METHODS: We conducted a retrospective review of a craniofacial approach to resection of infratemporal fossa tumors from 1992 to 2008 in a cancer center. RESULTS: Forty-three patients underwent resection of a infratemporal fossa tumors (68% men). Median age was 46 years (range, 1-81 years). The most common pathology was sarcoma (13; 30%). Twenty-two tumors (51%) were recurrent. Twenty patients (46%) underwent resection of tumors from the infratemporal fossa, 5 (12%) required resection of the anterior skull base, and 18 (42%) required orbital exenteration, additionally. Thirty-one patients (72%) required reconstruction with free tissue transfer. Twenty-seven patients (62.8%) required further treatment with radiation and/or chemotherapy. Complications occurred in 9 patients (21%). Six patients (14%) underwent salvage operations. Median follow-up was 24 months. Median overall survival and 3-year survival were 40 months and 59.6%. CONCLUSION: Tumors involving the infratemporal fossa can be resected with acceptable morbidity and long-term survival. © 2013 Wiley Periodicals, Inc. Head Neck, 2013.
Head & Neck 01/2013; · 2.40 Impact Factor
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ABSTRACT: Many women with early-stage breast cancer choose breast reconstruction following mastectomy with the goal to improve physical and psychological quality of life. Breast reconstruction procedures vary in surgical complexity, types of postsurgical complications, and time to recovery, all of which can affect a women's well-being. Although there is a growing body of literature on the satisfaction with aesthetic outcomes following breast reconstruction, there is little research addressing the recovery process. This qualitative study explores woman's physical and emotional recovery experiences. Findings may be useful for improving educational and counseling services for women who undergo breast cancer reconstructive surgeries.
Journal of Psychosocial Oncology 11/2011; 29(6):664-76. · 0.98 Impact Factor
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ABSTRACT: Nipple-sparing mastectomy (NSM) has been gathering increased recognition as an alternative to more traditional mastectomy approaches. Initially, questions concerning its oncologic safety limited the use of NSM. Nevertheless, mounting evidence supporting the practice of NSM for both prophylactic and oncologic purposes is leading to its more widespread use and broadened indications.
Using a prospectively maintained database, we reviewed our experience of 353 NSM procedures performed in 200 patients over the past 10 years.
The indications for surgery were: 196 prophylactic risk-reduction (55.5%), 74 ductal carcinoma in situ (DCIS) (20.8%), 82 invasive cancer (23.2%), and 1 phyllodes tumor (0.5%). The nipple areolar complex (NAC) was entirely preserved in 341 mastectomies (96.7%). There were 11 patients (3.1%) who were found to have cancer at the nipple margin, warranting further excision. A total of 69 breasts (19.5%) had some degree of skin desquamation or necrosis, but only 12 (3.3%) required operative debridement, of which 3 breasts (1%) necessitated removal of a breast implant. Also, 6 patients (2%) were treated for infection. Of the 196 prophylactic NSMs, 11 specimens (5.6%) were found to harbor occult cancer (8 DCIS and 3 invasive cancers). One patient who underwent NSM for invasive ductal carcinoma in 2006 developed metastatic disease to her brain. No other recurrences are attributable to the 353 NSMs.
The trends demonstrate the increasing acceptance of NSM as a prophylactic procedure as well as for therapeutic purposes. Although NSM is not standard, our experience supports the selective use of NSM in both prophylactic and malignant settings.
Annals of Surgical Oncology 08/2011; 18(11):3117-22. · 4.17 Impact Factor
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Journal of the American College of Surgeons 07/2011; 213(4):543-51. · 4.55 Impact Factor
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ABSTRACT: Unfulfilled expectations can lead to patient dissatisfaction with surgical outcomes. Understanding expectations allows surgeons to identify those patients who hold inaccurate expectations preoperatively, and to reset those expectations through focused preoperative education. The purpose of this study was to investigate preoperative expectations of women undergoing implant breast reconstruction. Identifying inaccurate or unfulfilled expectations is a critical step toward the advancement of preoperative education and subsequently improving patient satisfaction with surgical outcomes.
In-depth, open-ended interviews were conducted with 28 women undergoing implant breast reconstruction. The interviews were recorded and transcribed, and data were coded using standard qualitative techniques.
Interviews ascertained that implant-based breast reconstruction patients may have inaccurate expectations regarding the results of their surgery despite having received standard preoperative teaching. Specifically, patients often had unclear expectations regarding the appearance and physical outcome of the reconstructed breast(s). Some patients were surprised by the "flatness" of the tissue expander immediately after its insertion. Most patients felt unprepared for the "unnatural" final appearance of the breast(s). Furthermore, they did not expect many of the physical outcomes, including loss of sensation, firmness of the reconstructed breast(s), and lack of movement of the reconstructed breast(s). Inaccurate expectations corresponded to areas of dissatisfaction highlighted by the patients in postoperative interviews.
This study has important implications for preoperative education of women undergoing implant breast reconstruction. Physicians and nurses involved in the preoperative preparation process should take care to explore patients' expectations regarding the appearance, feel, sensation, and movement of reconstructed breasts to increase overall postoperative satisfaction.
Plastic and reconstructive surgery 12/2010; 126(6):1825-30. · 2.74 Impact Factor
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ABSTRACT: As breast cancer surgery techniques continue to advance, treatment options continue to increase, bringing with them increased scrutiny of health outcomes and healthcare cost. In addition, patients are becoming more involved in their own medical care and are demanding meaningful data to help them better understand expected outcomes. With these changes and advancements, there is a growing emphasis on evidence-based practice. In this article, we focus on scientific considerations, challenges to and opportunities for improving outcome measurement related to breast cancer surgery. There are two main messages from this article. First, until recently, rigorously developed specific patient-reported outcome (PRO) measures for breast cancer surgery patients have not been available for use. However, with the recent introduction of new PRO measures, such as the BREAST-Q, there is now good potential to collect useful outcome data on patient satisfaction and health-related quality of life, and to better understand the relative impact of different surgical procedures, decision making and clinical practice on patient outcome. Thus, PRO research using rigorously developed breast cancer surgery-specific measures is in its infancy, but growing steadily. Second, there is a great need but lack of specific health economic measures developed for use in breast cancer surgery research. In fact, research into the economic evaluation of breast cancer surgery is an area that has received less attention than that of PRO measure development, but there is good opportunity to expand this area of research in breast cancer surgery. Further studies are required to gain a clearer view of the role that generic preference and utility measures could play, how best to synthesize health-related quality of life and economic metrics data, and the potential use of new disease-specific tools.
Expert Review of Pharmacoeconomics & Outcomes Research 10/2010; 10(5):583-94.
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ABSTRACT: Mastectomy flap necrosis after immediate tissue expander placement can have profound implications, resulting in prosthetic infection necessitating tissue expander removal. The purpose of this investigation was to evaluate the safety and efficacy of timed, surgical excision during continued serial expansion in the setting of mastectomy flap necrosis and to identify an algorithm for surgeons faced with the management of this difficult problem.
Consecutive patients in whom documented mastectomy flap necrosis developed following immediate tissue expander placement from 1995 to 2008 were identified. Patient demographic, reconstructive, and complication data were obtained from a prospectively maintained clinical database. Medical records were then retrospectively reviewed to further characterize the extent of mastectomy flap necrosis and its management.
Over the 13-year study period, 178 patients with documented mastectomy flap necrosis following immediate tissue expander were identified. In 58 patients (33 percent), surgical excision of the mastectomy flap necrosis was performed. Surgical excision occurred a mean 36 days (range, 8 to 153 days) after tissue expander placement. Mean surface area of eschar excised was 42.5 cm (range, 2.5 to 240 cm). In nine (15.5 percent) of the 58 patients, resection of such an extensive area of mastectomy flap necrosis necessitated explantation of the tissue expander and subsequent flap closure (local advancement flaps, n = 8; latissimus flap, n = 1). Of the remaining patients, only three (6 percent) developed a subsequent infection necessitating the premature removal of a tissue expander.
Timed excision with continued expansion is a straightforward procedure associated with a low incidence of failure. This approach allows for salvage of a significant percentage of threatened tissue expanders and may be coordinated with adjuvant oncologic therapy without excessive delays.
Plastic and reconstructive surgery 09/2009; 124(2):356-63. · 2.74 Impact Factor
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ABSTRACT: The overriding goal of reconstructive breast surgery is to satisfy the patient with respect to her own self-image and expectations. Ultimately, individualized selection of a reconstructive technique for each patient will be a predominant factor in achieving a reconstructive success. The authors reviewed their institutional experience with postmastectomy reconstruction over the past 2 years and discuss indications, contraindications, advantages, and disadvantages of autogenous tissue and prosthetic breast reconstruction.
Plastic and reconstructive surgery 04/2009; 124(1):43-52. · 2.74 Impact Factor
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ABSTRACT: To review existing patient reported outcomes measures (PROMs) used in dysphonic populations to assess the procedures used in their development and the extent to which these meet current development standards for content generation and psychometric evaluation. The study is a systematic review. A systematic review of Medline, Cumulative Index to Nursing & Allied Health, and Health and Psychosocial Instruments databases was completed using voice, quality of life, and PROMs as keywords. We identified all patient or parent-reported questionnaires measuring quality of life associated with voice disorders from the review findings. Questionnaires were appraised for adherence to international guidelines for the development and evaluation of PROMs as outlined by the Scientific Advisory Committee of the Medical Outcome Trust. Nine PROMs fulfilled the inclusion criteria. The quality of these questionnaires was variable with regard to instrument development and none met all of the current, recommended criteria. Of the nine questionnaires, the Voice Symptom Scale underwent the most rigorous development process. Furthermore, many instruments have been augmented to allow for proxy administration, failing to address quality of life-related issues specific to the target population. Instrument development is often overlooked when attempting to quantify patient reported outcomes in dysphonic patients. Careful instrument development procedures are required to ensure that PROMs are valid, reliable, and responsive. Our review suggests that the deficits in psychometric properties of the current voice-related PROMs may be, at least in part, due to deficits in the development process. Furthermore, these data suggest the potential utility of a novel PROM adhering to rigorous international standards to better ensure that clinicians appreciate the variables most relevant to patients with voice disorders and address some of the psychometric shortcomings of the currently used questionnaires.
Journal of voice: official journal of the Voice Foundation 01/2009; 24(2):193-8. · 0.95 Impact Factor
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ABSTRACT: Abstract
Background
In cosmetic and reconstructive breast surgery, measurement of patient-reported outcomes has become increasingly important to research efforts and clinical care. We aimed to describe how breast conditions and breast surgery impact on patient satisfaction and quality of life.
Methods
We conducted qualitative, in-depth interviews with 48 women who had undergone either breast reduction (n = 15), breast augmentation (n = 12), or breast reconstruction (n = 21) surgery in order to begin to build a theoretical understanding of patient satisfaction and quality of life in breast surgery patients. Interviews were audio-taped, transcribed verbatim and analyzed thematically.
Results
The patient interviews revealed that breast conditions and breast surgery impact women in the following six main areas: satisfaction with breasts; satisfaction with overall outcome; psychosocial well-being; sexual well-being; physical well-being; and satisfaction with the process of care. We used these six themes to form the basis of a conceptual framework of patient satisfaction and quality of life in women who undergo breast surgery.
Conclusion
Our conceptual framework establishes the main issues of concern for breast surgery patients. This new framework can be used to help develop local guidelines for future clinical assessment, management and measurement, establish the validity of the current management strategies, and develop evidence-based guidance for the development of new patient reported outcome measures for future outcomes research.
BMC Women's Health. 01/2009;
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ABSTRACT: A great deal has been written on the versatility of the anterolateral thigh flap in reconstructive head and neck surgery. We present a modification to the 'paddle flap' (Agarwal et al, 2006), which extends its potential further in the reconstruction of combined pharyngoesophageal and anterior neck defects.
Journal of Plastic Reconstructive & Aesthetic Surgery 12/2008; 62(6):e142-4. · 1.49 Impact Factor
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ABSTRACT: Hand-sparing surgery is now the most common option for sarcomas of the hand. The importance of obtaining widely negative margins has increased the complexity of operations and the importance of soft-tissue and bony reconstruction. The authors review the experience at a single institution of hand reconstruction following sarcoma resection based on prospectively collected data.
Data were collected for all patients undergoing sarcoma resection by a single surgeon. Variables evaluated included patient demographics, tumor pathologic findings, location, size, depth, grade, stage, method of resection and reconstruction, adjuvant therapies, complications, and patient outcomes.
Fifty-five patients (30 male and 25 female) fulfilled eligibility criteria. The median age was 36 years (range, 1 to 80 years). The most common abnormalities were epithelioid sarcoma (n = 9), soft-tissue malignant fibrous histiocytoma (n = 8), synovial sarcoma (n = 6), and fibrosarcoma (n = 4). Flap reconstructions were required in 27 patients. The most common reconstruction method was a finger fillet flap in eight patients, followed by the radial forearm flap in five patients and the gracilis flap and skin grafting in three patients each. A suboptimal biopsy before presentation was strongly predictive of the need for flap reconstruction (p < 0.001). Nine patients had complications (delayed healing or skin necrosis, fracture, nonunion, epidermolysis, and tendon adhesion). No microvascular complications occurred.
The choice of hand reconstruction method following sarcoma resection depends on a complete knowledge of options, risks, and benefits. Extensive use of a limited number of techniques by the authors' institution appears to contribute to excellent success and complication rates, with safe, reliable, and effective soft-tissue coverage.
Plastic and reconstructive surgery 03/2008; 121(2):534-43. · 2.74 Impact Factor
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ABSTRACT: Numerous protocols exist to prevent thrombosis after free-tissue transfer. Many surgeons advocate using aspirin or other antiplatelet agents, but little objective evidence supports this practice. This study evaluates the rate of microvascular thrombosis in patients undergoing free-tissue transfer treated with or without antiplatelet agents.
All consecutive free flaps from 2002-2005 at a single center were reviewed using a prospectively maintained database. Patients were in 2 groups based on postoperative anticoagulation administration. In group 1, 325 mg of aspirin was administered daily for 5 days postoperatively. In group 2, patients were treated with 5000 units of low-molecular-weight heparin (LMWH) per day until ambulating. Patient demographics, procedure type, diagnosis, adjuvant treatment, and procedure type were recorded. Outcome variables included microvascular thrombosis, partial or total flap loss, hematoma, bleeding, deep venous thrombosis (DVT), pulmonary embolism, and death.
Four hundred seventy patients underwent 505 microvascular free flaps to reconstruct oncologic defects. Two hundred sixty flaps (group A) received postoperative aspirin therapy; 245 flaps (group B) received LMWH therapy. Both groups were statistically similar in their composition. No statistically significant difference was noted between the 2 groups when comparing outcome variables including microvascular thrombosis, partial or total flap loss, hematoma, bleeding, DVT, pulmonary embolism, and death.
Postoperative anticoagulation choice has no statistically significant effect on the incidence of free flap complications, including bleeding, thromboembolism, and flap loss. We conclude that aspirin or LMWH therapy demonstrates equivalent outcomes when used as single-agent postoperative anticoagulation in oncologic free flap reconstruction.
Annals of Plastic Surgery 08/2007; 59(1):36-9; discussion 39-40. · 1.32 Impact Factor
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ABSTRACT: Microvascular free tissue transfer is a reliable method for reconstruction of complex surgical defects. However, there is still a small risk of flap compromise necessitating urgent reexploration. A comprehensive study examining the causes and methods of avoiding or treating these complications has not been performed. The purpose of this study was to review the authors' experience with a large number of microvascular complications over an 11-year period.
This was a retrospective review of all free flaps performed from 1991 to 2002 at Memorial Sloan-Kettering Cancer Center. All patients who required emergent reexploration were identified, and the incidence of vascular complications and methods used for their management were analyzed.
A total of 1193 free flaps were performed during the study period, of which 6 percent required emergent reexploration. The most common causes for reexploration were pedicle thrombosis (53 percent) and hematoma/bleeding (30 percent). The overall flap survival rate was 98.8 percent. Venous thrombosis was more common than arterial thrombosis (74 versus 26 percent) and had a higher salvage rate (71 versus 40 percent). Salvaged free flaps were reexplored more quickly than failed flaps (4 versus 9 hours after detection; p = 0.01). There was no significant difference in salvage rate in flaps requiring secondary vein grafting or thrombolysis as compared with those with anastomotic revision only.
Microvascular free tissue transfer is a reliable reconstructive technique with low failure rates. Careful monitoring and urgent reexploration are critical for salvage of compromised flaps. The majority of venous thromboses can be salvaged. Arterial thromboses can be more problematic. An algorithm for flap exploration and salvage is presented.
Plastic and reconstructive surgery 07/2007; 119(7):2092-100. · 2.74 Impact Factor
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ABSTRACT: To identify, summarize, and evaluate patient-reported outcome questionnaires for use in head and neck cancer surgery with the view to making recommendations for future research.
A systematic review of the English-language literature, with the use of head-and-neck-surgery-specific keywords, was performed in the following databases: Medline, Embase, HAPI, CINAHL, Science/Social Sciences Citation Index, and PsycINFO from 1966 to March 2006. DATA EXTRACTION AND STUDY SELECTION: All English-language instruments identified as patient-reported outcome questionnaires that measure quality of life and/or satisfaction that had undergone development and validation in a head and neck cancer surgery population were included.
Twelve patient-reported outcome questionnaires fulfilled our inclusion criteria. Of these, four were developed from expert opinion alone or did not have a published development process and seven questionnaires lacked formal item reduction. Only three questionnaires (EORTC Head and Neck Module, University of Michigan Head and Neck Quality-of-life Questionnaire, and Head and Neck Cancer Inventory) fulfilled guidelines for instrument development and evaluation as outlined by the Medical Outcomes Trust.
Rigorous instrument development is important for creating valid, reliable, and responsive disease-specific questionnaires. As a direction for future instrument development, an increased focus on qualitative research to ensure patient input may help to better conceptualize and operationalize the variables most relevant to head and neck cancer surgery patients. In addition, the use of alternative methods of psychometric data analysis, such as Rasch, may improve the value of health measurement in clinical practice for individual patients.
Otolaryngology Head and Neck Surgery 05/2007; 136(4):525-35. · 1.72 Impact Factor
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ABSTRACT: Scalp reconstruction after oncologic resection can be challenging. Wide surgical resections, in combination with co-morbid conditions such as infected alloplastic material, cerebrospinal fluid (CSF) leak, or devascularized bone after craniotomy necessitate healthy, vascularized tissues for reconstruction. Although primary closure is feasible in some cases, the mainstay of treatment involves local tissue rearrangement with or without split thickness skin grafting. In addition, free tissue transfer is an important adjunct to therapy in patients with poor local tissues. Careful analysis of the defect and local tissues can help tailor the method of reconstruction and result in satisfactory closure in a majority of patients. Current techniques used for scalp reconstruction after surgical ablation are the subject of this review.
Journal of Surgical Oncology 12/2006; 94(6):504-8. · 2.10 Impact Factor
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ABSTRACT: Oncologic reconstruction in obese patients can be challenging. Donor tissues, such as the rectus flap, can be excessively bulky and result in significant cosmetic and functional deformities. Although the use of the anterolateral thigh (ALT) flap as an alternative to the radial forearm flap has been extensively described, few studies have evaluated the use of the ALT flap as an alternative to the rectus flap. The purpose of this study was to evaluate our experience with the ALT flap in overweight or obese patients.
A retrospective review was conducted of all ALT flaps performed over a 2-year period at Memorial Sloan-Kettering Cancer Center. All patients with a body mass index (BMI) >25 kg/m2 were identified and evaluated.
Twenty-seven patients underwent ALT flap reconstruction during the study period. Of these, 11 patients were overweight (BMI, 25.1-30 kg/m2) or obese (BMI, >30 kg/m2). Reconstructions were performed for a variety of oncologic defects, including head and neck (n = 7), extremity (n = 2), chest wall (n = 1), and abdominal wall (n = 1). Complications were, in general, mild and infrequent. One patient experienced a minor infection, 1 patient had partial flap loss, and 2 patients had partial skin graft loss at the donor site. There were no flap losses.
The ALT flap is a safe and reliable flap for reconstruction of diverse defects in overweight or obese patients. Large flaps can be designed and tailored to the defect by harvesting variable amounts of skin, subcutaneous tissues, fascia, and muscle. The ALT flap may be a good alternative to the rectus flap in overweight or obese patients.
Annals of Plastic Surgery 06/2006; 56(5):536-9. · 1.32 Impact Factor
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ABSTRACT: In 2008, approximately 500,000 women in the United States underwent breast surgery, either cosmetic surgery or reconstruction following mastectomy for breast cancer. There is a growing body of literature on women's motivations to have these types of surgical procedures and on satisfaction with the aesthetic outcomes, but little is known about the information needs and expectations of women who choose to undergo these procedures. Therefore, the purpose of this qualitative study was to gain a better understanding of the informational needs of women who underwent breast augmentation, breast reduction, or breast reconstruction following breast cancer surgery.
Plastic surgical nursing: official journal of the American Society of Plastic and Reconstructive Surgical Nurses 30(2):70-4; quiz 75-6.
