Shout Outs

Updated 3/2017--photos and all links removed as many no longer active. 

Paul Ware, Life with Huntington's, is (suppose to be) the host for this week’s Grand Rounds. You can read this week’s edition here.

Next week’s host is Dr. Rob (@doc_rob): What’s Grand and Round and Comes in an RSS Feed?

……To submit your GR post for next week’s GR, fill out the attached submission form. I must have submissions in before Sunday, March 4th at 6 PM EST……

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H/T to @jilltomlinson who asks.

Was this 27yo man's life lost in ill-conceived race to perform "World 1st" surgery? bit.ly/x2bGEJ #retrospectoscope

The link is to this Mai lOnline article: Man, 27, who had world's first quadruple limb transplant dies days after operation.

A 27-year-old Turkish man who underwent the world's first would-be quadruple limb transplant died yesterday, hours after the limbs were removed due to metabolic failure, the hospital said…….

I thought it was too risky when I first heard about the transplant prior to them having to later remove the limbs. We are certainly pushing the limits with transplants these days with double hand, face, multiple organ, etc.

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From Letters of Notes a letter that gives a glimpse of breast Cancer in 1855. This woman had surgery with no pain meds: 'Deep Sickness Seized Me"

In September of 1855, Lucy Thurston — a 60-year-old missionary who had been living in Hawaii with her husband since 1820 — underwent a mastectomy after being diagnosed with breast cancer. Incredibly, she somehow endured the operation wide-awake, without any form of anaesthetic. She wrote the following letter to her daughter a month later and described the unimaginably harrowing experience.

The procedure was a success. Lucy Thurston lived for another 21 years………………

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From @Skepticscalpel comes a post with his take on the survey in the Archives of Surgery: Surgeons and alcohol abuse.

“Prevalence of alcohol use disorders among American surgeons” appeared in the February, 2012 issue of Archives of Surgery.

A survey of 7197 surgeons, all members of the American College of Surgeons [ACS], had a 28.7% response rate and revealed that 15.4% had scores on an alcohol use assessment test that indicated abuse of or dependence on alcohol. This is consistent with the rate of such alcohol problems in the general public…………….

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VIDEO: Kyle Dyer, 9NEWS anchor, interviews with the Denver Post

Channel 9 news morning anchor Kyle Dyer talked to the Denver Post on Wednesday, February 23, 2012, about the injuries she sustained from a dog bite and her road to recovery.……. Video by Mahala Gaylord

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H/T to @impactednurse ‏for this tweet:  “Very cool. Federico Carbajal's anatomical sculptures made with galvanized wire: bit.ly/yRSvFk”

Mindful of Two Breast Implant Scandals

This year began with a breast implant scandal.  This one has brought back memories of the one early in my private practice.

The current one involves the PIP-branded breast implants produced by the French company Poly Implant Prothese and rebranded by the Dutch company Rofil as Rofil M-implants breast implants.  The first one involved silicone implants made by American companies including Dow Corning who no longer makes breast implants.

This picture of 3 implants includes:  top -- an old McGhan double lumen (silicone gel implant surrounded by a saline implant); bottom left – Dow Corning textured silicone implant; and bottom right – Dow Corning smooth silicone implant.  Dow Corning has not made breast implants since approximately 1992.

My post Breast Implants -- Some History (March 3, 2008) covers much of the history of implants in the United States.  Kira Cochrane, The Guardian, wrote about the first patient to receive a breast implant:

It was in 1962 that Timmie Jean Lindsey was offered a solution to a non-existent problem. A factory worker from Texas, ….. And the doctors had another proposal. Had she ever thought about breast implants?

Lindsey had not. ….

……...She's 80 today, still living in Texas, working night shifts in a care home, and those first, experimental globes remain in her chest. ……

I would love to know if they are soft or have become hardened by capsular contractures.  The article doesn’t say.

In the current breast implant scandal, I haven’t noticed anyone urging a class action lawsuit against the French company Poly Implant Prothese or the Dutch company Rofil.  The big issues are 1. do the implants need to be removed or just checked and 2. who will pay for the removal, the government or the private clinics.  The issue isn’t just a European one, it affects women in South American, Mexico, and the United States.

The old scandal in the early 1990s was handled by a class action lawsuit.  I had not been in practice long enough for it to truly affect my then current patients, but I saw many who’s doctors were no longer in practice or non-plastic surgeons who has decided due to the scandal to quit doing breast implants.  I did exams for free, but not the surgeries.  I did, however, not raise prices or take advantage of the situation. 

When I was in practice, I encouraged my breast implant patients to return every year or two for a complimentary breast exam.  This keep us in contact so if anything (ie ALCL and implants, or faulty implants) came up I had current addresses.  I made sure each woman had the information on her implants and encouraged her to keep up with it.  I also encouraged the extended warranty on the implants.  This helps settle who pays for what, at least for the first 10 years.

Women and their doctors need to be mindful that implants are foreign bodies we are placing into the human body.   Women and their doctors should be mindful of future costs that might be incurred from breast implant surgery.   In the United States, many things related to implants, especially those placed for cosmetic reasons only, are not covered by insurance or the extended warranty.

Related posts:
Breast Implants -- Some History (March 3, 2008)
FDA Updates Safety Data for Silicone Breast Implants  (June 23, 2011)
ALCL and Breast Implants  (January 31, 2011)

REFERENCES
1.  Breast implant scandal: now women with Rofil M-implants 'are at risk';  The Telegraph, Matthew Holehouse, January 5, 2012
2.  Breast implants – a brief history of the first 50 years; The Guardian, Kira Cochrane, January 11, 2012
3.  Q&A: PIP breast implant s health scare; BBC Health News, James Gallagher, January 11, 2012
4.  Confusion Reigns Abroad Over Faulty Breast Implants; MedPage Today, Cole Petrochko, January 13, 2012
5.  PIP breast implants: European Commission says reform needed;  BBC Health News, James Gallagher, January 14, 2012
6.  Keeping patients safe: The case for a breast implant registry; The Atlantic,  Anna Yukhananov, January 5, 2012

Additional Benefits to Reduction Mammoplasty

Updated 3/2017 -- all links removed (except to my own posts) as many no longer active.

This article (full reference below) on the additional benefits an individual gains from having a reduction mammoplasty (RM) has been published online ahead of print.  The authors performed a systemic review of the literature focusing on functional outcomes after RM with regard to physical and psychological symptom improvement.

The authors performed a systematic review of the English literature using PUBMED for the period between 1977 to 2010. Studies were chosen that addressed the physical and psychological benefits of RM using a validated questionnaire.

The authors note that nearly eighty thousand breast reductions
were performed in 2009.  For insurance coverage in the United States a woman seeking breast reduction must have complaints of physical symptoms (ie neck pain, upper back pain, inframammary rashes, etc). 

The authors of this article choose to look at the other benefits a reduction mammoplasty can have:

Even less common are investigations on the effect of RM on weight loss, exercise, and eating behavior.  Women with large breasts often find exercising difficult due to public scrutiny and physical constraints. They may even develop eating disorders in an attempt to match their breast size to the rest of their body. ……..Women with macromastia often have
diminished self-esteem, poor psychosexual function, depression, and anxiety.

I want to applaud them for their article.  There are 52 article in their reference list.  Table I is a breakdown of 6 articles on physical symptoms/improvements.  Table II is a reference does the same for 8 articles on the effects of reduction mammoplasty on exercise, weight and eating behaviors.  Table III does the same for 5 articles on the effects of reduction mammoplasty on psyche.  Table IV summarizes 3 articles on the effects of reduction mammoplasty on appearance.

The results of their summary:

Women who undergo RM have a functional improvement in musculoskeletal pain, headaches, sleep, and breathing. Psychological benefits are vast and include improved self esteem, sexual function, and quality of life, as well as less anxiety and depression. Following RM, women appear to exercise more and have a reduction in eating disorders.

This is what I saw over my 21 years of practice in taking care of these women.
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Related post: 
Reduction Mammoplasty (December 19, 2007)
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REFERENCE

Additional Benefits to Reduction Mammaplasty: A Systemic Review of the Literature; Singh, Kimberly A.; Losken, Albert; Plastic & Reconstructive Surgery., POST ACCEPTANCE, 15 November 2011; doi: 10.1097/PRS.0b013e31824129ee

Prophylactic Mastectomy in BRCA Carriers: Can the Nipple Be Preserved? (an article review)

Updated 3/2017 -- photos and all links removed as many no longer active.

The entire article is available via open access (full reference below).  Women with the BRCA gene (both 1 and 2) often elect to have prophylactic mastectomy to reduce their risks of developing breast carcinoma.  This is even more so for the contralateral breast when a primary is found.  Skin-sparing mastectomies (SSM) and nipple-sparing mastectomies (NSM) greatly improve the cosmetic results for women undergoing reconstruction.  Traditionally, the NAC has been removed due to concerns of possible tumor recurrence or development of a new primary in the remaining breast tissue of the NAC. 

The article notes "numerous retrospective studies have shown a wide range(0-58%) of nipple involvement by tumor in mastectomy specimens." 

This retrospective study involves a small cohort of 33 patients (25 BRCA1, 8 BRCA2) who underwent mastectomy between March 1987 and June 2009 treated at Mayo Clinic.  The entire nipple-areolar complex (NAC) was excised and evaluated histologically.  There was a total of 62 NACs available for evaluation. [TDLS = terminal duct lobular units]

Sixty-two NACs from 33 women (25 BRCA1, 8 BRCA2) were studied. TDLUs were present in 15 (24%) NAC specimens. No evidence of atypical hyperplasia, carcinoma in situ, or invasive carcinoma was found in any of the 33 prophylactic mastectomy specimens. Among the 29 breasts with cancer and available tissue, 2 (7%) had malignant findings and 1 (3%) had atypia in the NAC. One woman who underwent bilateral mastectomy for bilateral invasive carcinoma had one nipple with tumor within lymphatics, and her contralateral nipple had atypical lobular hyperplasia. A second woman had ductal carcinoma in situ involving a single major lactiferous duct..

They conclude the probability of premalignant or malignant lesions in the NAC of BRCA carriers is low overall.  It must be remembered that it is higher (10%) in the subgroup of women undergoing therapeutic mastectomy.  It may be safe for select women with BRCA mutations to have a nipple sparing procedure, but she and her physicians (oncologist and surgeon) should have a frank discussion about her individual case.

REFERENCE

Prophylactic and Therapeutic Mastectomy in BRCA Mutation Carriers: Can the Nipple Be Preserved?; Carol Reynolds, Jennifer A. Davidson, Noralane M. Lindor, Katrina N. Glazebrook, James W. Jakub, Amy C. Degnim, Nicole P. Sandhu, Molly F. Walsh, Lynn C. Hartmann and Judy C. Boughey; Annals of Surgical Oncology Volume 18, Number 11, 3102-3109, DOI: 10.1245/s10434-011-1908-8

Bariatric Surgery Should Come Before Breast Reduction

Updated 3/2017-- all links removed (except to my own posts) removed as many no longer active. 

Many women with large breast and weight issues seek breast reduction.  I was taught to encourage them to lose weight first.  Now there is a very small study that backs this up  (full reference below).

The American Society of Plastic Surgeons issued a press release entitled “Breast Reduction and Bariatric Surgery—Which Should Be Done First?” and provided the answer “ Final Results May Be Better When Weight Loss Comes First.”  I agree, but find it odd that such a small study was published.  There should have been more patients included.

Jeffrey A. Gusenoff, MD, and colleagues reviewed two groups of patients who sought consultation for body contouring surgery August of 2008 and February of 2010 after massive weight loss (defined as a weight loss of greater than 50 pounds).

Group I (n=15) included any patients who underwent reduction mammoplasty for symptomatic macromastia before massive weight loss.  Group II (the control group, n=14) included any patients who did not undergo breast surgery before massive weight loss.

The patients were given a prospective phone survey to assess self-ratings of breast appearance before and after breast reduction and after massive weight loss, ability to exercise, which would have preferred to have first—massive weight loss or breast reduction surgery—and what they would recommend to a friend.

Of the 15 patients (7.9%) in group I, 14 completed the survey (93%). 

For group I, all patients felt the appearance of their breasts improved after reduction (p < 0.001) but felt appearance worsened or stayed the same after weight loss (p = 0.003).

Seventy-one percent of patients were able to exercise more and 64 percent were able to lose weight on their own because of their reduction. ……..

Ten patients (71 percent) would recommend that a friend lose weight before breast reduction surgery. …

For group II, 79 percent of patients felt the appearance of their breasts worsened or stayed the same after massive weight loss (p = 0.03). ……

All 14 patients (100 percent) would recommend losing weight before undergoing breast surgery.

Even though I tend to agree that patients should loss weight prior to breast surgery.  It is much easier to achieve the cosmetic goals of the patient if she is at or near her goal weight.  Otherwise, the surgeon and patient are left to guess at how her skin will retract with weight loss and how much deflation or loss of volume will occur.

I wish the study had ask how many of the Group I patients desired an augmentation as part of their revision. 

Eleven patients (79 percent) felt a secondary lift following massive weight loss should be covered by insurance, and seven patients (50 percent) plan on having revision breast surgery.

They noted it with Group II patients

Eleven patients (79 percent) wished their breasts currently appeared different, with eight (57 percent) desiring lifted breasts, seven (50 percent) desiring general reshaping, two (14 percent) desiring reduced breasts, and two (14 percent) desiring larger breasts.

I have augmented four patients over my 21 years of practice who had previous breast reductions prior to losing weight (one was mine).  This should be included in the discussion as well as the high probability that a revision to reshape or re-lift the breasts will be needed if the reduction is done prior to the (massive) weight loss.

Related posts:
Reduction Mammoplasty (December 19, 2007)
Breast Reduction: Safe in the Morbidly Obese?—Article Review  (August 25, 2008)
Tennis Star Brings Breast Reduction Surgery into Press (June 4, 2009)
Impact of Obesity on Breast Surgery Complications – article review  (June 16, 2011)


REFERENCE

Reduction Mammaplasty, Obesity, and Massive Weight Loss: Temporal Relationships of Satisfaction with Breast Contour; Coriddi, Michelle; Koltz, Peter F.; Gusenoff, Jeffrey A.; Plastic & Reconstructive Surgery. 128(3):643-650, September 2011; doi: 10.1097/PRS.0b013e318221da6b

Recent FDA Advisory Meeting on Implants

Updated 3/2017-- all links removed (except to my own posts) removed as many no longer active. 

It’s amazing what you will find sorting through more than 20 years of stuff.  This picture of 3 implants includes:  top -- an old McGhan double lumen (silicone gel implant surrounded by a saline implant); bottom left – Dow Corning textured silicone implant; and bottom right – Dow Corning smooth silicone implant.  Dow Corning has not made breast implants since approximately 1992.

Last week the FDA met to discuss and make recommendations on postmarketing issues related to silicone gel-filled breast implants.  As a condition of placing silicone implants back on the market in 2006, both Mentor and Allergan (McGhan) were suppose to enroll patients in 10-year-long follow up studies on side effects related to implants.  The aim was for 80,000 women.

I agree these studies are needed, but it is difficult to get women to return year after year.  This is evident in the data presented at the meeting:

After two years, about 60 percent of Allergan patients were still participating, but just 21 percent of Mentor patients were involved.

I, like Dr Rob Oliver (Plastic Surgery 101 Blog),  found the requirement of routine MRI screening at three years after getting implants and every two years following to look for silent ruptures to be unrealistic and unnecessary.  Insurance often did not cover this expense to the patient.  The FDA has now removed this requirement.

Several advisory panel members said the FDA's requirement that women have frequent MRIs to make sure the implants haven't ruptured is unrealistic and should be removed from the product label. Insurance usually doesn't pay for the scans, so most women don't get them done. But it's the only way to find out whether the implant has ruptured in the absence of symptoms.

The advisory panel did recommend the creation of a nationwide database to follow women who have had silicone-gel breast implants for at least a decade after they had the surgery.  I think it should be for 20 years.

Related posts:
Breast Implants -- Some History (March 3, 2008)

FDA Updates Safety Data for Silicone Breast Implants  (June 23, 2011)

REFERENCES
Breast Implant Safety to Be Focus of FDA Panel; Emily P. Walker, Washington Correspondent, MedPage Today; August 29, 2011

Breast Implant Follow-Up Far Short of FDA Goals; Emily P. Walker, Washington Correspondent, MedPage Today; August 30, 2011

FDA Panel Calls for Silicone Breast Implant Registry; Emily P. Walker, Washington Correspondent, MedPage Today; August 31, 2011

F.D.A. Affirms Safety of Breast Implants; Gardiner Harris, NY Times, August 31, 2011

Is Prophylactic Mastectomy Worth It?

Updated 3/2017--  all links (except to my own posts) removed as many no longer active. 

There is a recent article which asks this question (full reference below).  I think it is a question which must be answered on an individual basis.  

For someone like me, the answer would be no.  I have no family history or personal history of breast cancer.  I have small, more dense than fatty breast, but have always had normal mammograms.  I have never had any lesions which needed biopsy.

For an individual woman with a strong family history of breast cancer (especially genetically proven, BRCA1 and BRCA2) and a person history of breast cancer (ie right mastectomy for lobular carcinoma), then it is easy to say “Yes, a prophylactic left mastectomy would be worth it for you.”

In between these two examples is the gray area, and this article doesn’t necessarily make the gray area any clearer.

There is plenty of evidence that prophylactic mastectomy lowers the risk of breast cancer in the high–risk population in at least 95%.

The authors of the June 2011 Aesthetic Plastic Surgery Journal article performed a retrospective study by reviewing the records of all their patients (n=52) who underwent prophylactic mastectomy within a 25-year period to look at the aesthetic and long-term oncologic outcomes, complications, and patient satisfaction.

Of the 52 patients, 40 had the surgery on one side only (contralateral prophylactic mastectomy) and 12 had bilateral (bilateral prophylactic mastectomy), giving a total of 64 prophylactic mastectomies.

Of the 52 patients/ 64 mastectomies, there was 1 (1.56%) case of unexpected breast cancer in the mastectomy specimens.

Two thirds (42/64) were subcutaneous prophylactic mastectomies and the other third (22/64) were simple total prophylactic mastectomies.

Most of their patients chose to have reconstruction with implants (58/64 = 90.62%) while the other 6 (9.37)  chose to use autologous tissue --  5 (7.81%) received latissimus dorsi flaps with implants and 1 (1.56%) had a TRAM flap.

The complications included 4 (6.25%) breasts that developed capsular contracture, 2 (3.12%) cases of hematoma, and 1 (1.56%) infection.

More than 90% of the patients reported being either highly (39/52) or partially satisfied  (10/52).  Only 3/52 reported being unsatisfied. The authors report an overall aesthetic index of 8.8.

There were no deaths among their patients, nor any new development of breast cancer during the time period.

Related posts
Women Don’t Regret Prophylactic Mastectomy (May 5, 2011)

Prophylactic Mastectomy (January 28, 2009)

Advances in Nipple-Sparing Mastectomy – an article review (April 27, 2011)

Are Patients Making Good Decisions About Breast Reconstruction? (February 28, 2011)

REFERENCE

Prophylactic Mastectomy: Is It Worth It?; Jose Abel de la Peña-Salcedo, Miguel Angel Soto-Miranda, Jose Fernando Lopez-Salguero; Aesthetic Plastic Surgery, Volume 35 (3), June 2011;  DOI: 10.1007/s00266-011-9769-x

American Cancer Society:  What are the risk factors for breast cancer?

Impact of Obesity on Breast Surgery Complications – article review

 Updated 3/2017-- all links (except to my own posts) removed as many no longer active.

Obesity is an ever increasing presence in today’s world.  Thirty-four percent of U.S. adults are now estimated to be obese (BMI>30), up from just 15% three decades ago.

Obesity increases the risk of complications in many medical/surgical situations which has pushed some Ob-Gyns in Florida to refuse to care for pregnant women over a certain weight.

Martin A. Makary, MD and colleagues designed a study to measure the impact on complication rates in obese patients presenting for a set of elective breast procedures.

The PRS journal article referenced below has been published online ahead of print and looks at the impact obesity has on breast surgery complication.

The researchers used claims data from seven Blue Cross and Blue Shield Plans covering individuals with employer-provided coverage and residing in Hawaii, Iowa, Michigan, North Carolina, Pennsylvania, Tennessee, and South Dakota to identify a cohort of obese patients and a non-obese control group who underwent elective breast procedures covered by insurance between 2002-2006.

Criteria for the patient  to be included:
Enrolled in the insurance plan for at least one month before and after surgery

Have a paid claim for breast augmentation, breast reduction, breast lift (mastopexy), or breast reconstruction during the period between 2002-2006

Have either 1) a BMI of 30 kg/m2 or greater, 2) a diagnosis of obesity (using ICD 278.x or V85.x code closest to the date of surgery), or 3) at least one comorbidity associated with obesity (diabetes, hypertension, metabolic syndrome, obstructive sleep apnea, hyperlipidemia, or gallbladder disease) within one year of undergoing the breast procedure

There were 2,403 patients (mean age 42.1 yrs)  in the obese group who were compared to a non-obese control group of 5,597 patients (mean age 48.4 yrs).  Breast reduction was the most commonly performed procedure in the obese and control groups (80.7% vs 63.8%), followed by breast reconstruction (10.3% vs 24.2%), augmentation (4.0% vs 8.9%), and mastopexy with or without augmentation (5.0% vs 3.2%).

Overall, 18.3% of obese patients had a complication compared to only 2.2% in the control group (p<0.001). After adjusting for other variables, the researchers found obesity status increased the odds of experiencing a complication by 11.8 times.

Among the obese patients, at least one complication was observed in 50.5% of patients undergoing breast augmentation (vs. 4.4% of controls), 24.1% undergoing mastopexy (vs. 11.4%), 38.9% mastopexy with augmentation (vs. 5.6%), 29.4% of reconstruction (vs. 1.8%), and 14.6% of breast reduction patients (vs. 1.7%).

The differences between the two groups were most pronounced
in complications such as inflammation (OR=22.2), infection (OR=13.4), pain (OR=11.7), the development of seroma (OR=11.4) and hematoma (OR=10.9).

Obesity status  increased the odds of experiencing a complication (OR = 10.1, adjusted 11.8).  Diabetes (OR = 1.37, adjusted 1.16) and a history of prior chest wall irradiation (adjusted OR = 1.4) were associated with a higher odds of complication.

Hypertension, COPD, a history of neoadjuvant chemotherapy and undergoing a bilateral procedure were not significantly associated with the development of complications.

Makary and colleagues write in their discussion (bold emphasis is mine):

Our data demonstrate that obesity is a major risk factor for complications following elective breast procedures. In light of current trends towards pay-for-performance-based reimbursement, although obesity is currently not accounted for in quality metrics, based on our study, it increases the odds of experiencing any complication within a 30-day postoperative period by 11.8 times. This is in marked contrast to previous studies, which showed either no significant difference in complications between
obese and non-obese patients undergoing elective breast surgery, or just a slight increase.

Although pay-for-performance strives to reward healthcare providers for meeting certain performance measures for quality and efficiency, there is no guarantee that the measures being used accurately reflect the quality of surgical care being provided. For example, the current assumption behind pay-for-performance is that high-quality care reduces surgical
complications.  Our results suggest that variations seen in the rate of complications may be, in part, related to the characteristics of the population--in this case, body habitus. These complications could even occur despite adherence to process measures such as administering appropriate antibiotic prophylaxis. Thus, any measure of quality should consider the effect of obesity on these measures.

REFERENCES
The Impact of Obesity on Breast Surgery Complications; Chen, Catherine L.; Shore, Andrew D.; Johns, Roger; Clark, Jeanne M.; Manahan, Michele; Makary, Martin A.; Plastic & Reconstructive Surgery., POST ACCEPTANCE, 9 June 2011; doi: 10.1097/PRS.0b013e3182284c05