Puss-in-Corner Quilt Top

While visiting with my husband’s cousin Bud at their family reunion in early June, he recalled me “loaning” him a quilt to use in the hospital when he had his heart surgery years ago.  He recalled it cheering him up and helping with the recovery.  I offered to make him a quilt.  Here’s the quilt top which I have sent off to be quilted.  It is approximately 58 in X 78 in in size, machine pieced.

The pattern is called “puss-in-the-corner.”  Each block is 6 in square.  I used reds, oranges, and yellows to make it bright and cheerful.

Here is a detail photo of some of the fabrics.
Here is another.  I’ll share the finished quilt when it is quilted and the binding is done.

Raynaud’s Phenomenon of the Nipple

Updated 3/2017 -- photo and all links removed as many no longer active and it was easier than checking each one.

This article would have been off my radar had it not been for the interaction on twitter.

jeffreyleow RT @paulinechen: Camera Phones [patients taking pics] helps doctor make rare diagnosis http://3.ly/CXr (via @EllenRichter)

Granted I am not generally asked about nipple pain in pregnant women.  Those questions tend to go to folk like TBTAM or ER’s Mom. 
The article describes a case report of a 25 yo woman in her 2nd trimester with “frequent episodes of extreme bilateral nipple pain. A typical episode lasted between 5 and 15 minutes and was so painful as to bring her to tears.”

The article discusses Raynaud’s phenomenon of the nipple and share these photos (credit) taken with a camera phone with us.  The text with the photo:

Vasospasm of the arterioles manifesting as pallor (left), followed by cyanosis, and then erythema (centre). The right hand image shows the normal, asymptomatic, status.

As with Raynaud's of the hand (which I am more familiar with), the phenomenon tends to occur when the ambient temperature drops below a certain threshold that is specific to each individual.  Exposure to cold should be avoided, as is avoidance of caffeine, nasal vasoconstrictors, and tobacco.
Additional treatment for Raynaud’s of the nipple:

Women with persistent pain require immediate relief to continue breastfeeding successfully. Recommended treatment is 30 mg nifedipine of sustained-release once-daily formulation, and most women respond within two weeks.

REFERENCE
An Underdiagnosed Cause of Nipple Pain Presented on a Camera Phone; BMJ 2009;339:b2553; O L Holmen, B Backe
Vasospasm of the Nipple–a manifestation of Raynaud's phenomenon: case reports; BMJ 1997 314: 644; Laureen Lawlor-Smith and Carolyn Lawlor-Smith

No Call or Card

Today is my birthday. Birthday’s have always been quietly celebrated in my family. There were too many of us to get large or numerous gifts, so the day was made special in other ways. Mom made the cake or pie of your choice. As we grew up and left home, we sent cards and made phone calls to each other.

I won’t get my phone call or card from my mom this year. This makes me sadder than I’d like to admit.

I do have a coupon for a free serving of ice cream from Cold Stone Creamery. I plan on stopping by on my way home today as I try to celebrate today rather than grieve.

Shout Outs

Updated 3/2017-- all links removed as many no longer active and it was easier than checking each one.

 

Captain Atopic is this week's host of Grand Rounds. You can read it here.  He calls it the “Grand Rounds 5:45 - Le Tour de France Edition!”

Where Grand Rounds is the Grand Tour of Medical Blogging, the Grand tour of Cycling is undoubtedly Le Tour de France, which concluded on Sunday in Paris. After three weeks of cycling, nearly 3,500km at an average speed above 40km/h, the peleton will ride up Paris' Champs Elysee's to the finish. Throughout the race, certain riders and teams will have reached their goals, revealed their future potential and achieved great triumphs. This week's Grand Rounds features some sterling examples of writing, all capable of Stage Victories, and some, much more. Welcome to the Tour...

The latest edition of Change of Shift (Vol 4, No 2) is hosted by Ross at Nurse in Australia! You can find the schedule and the COS archives at Emergiblog. 

The beautiful sunshine coast in Queensland, Australia is where I call home, so I’ve themed this edition the Sunshine Coast Edition. So welcome, thanks again for visiting my corner of the world!

Close your eyes for a moment and take a deep breath of that coastal air, and get ready to invigorate yourselves with some great posts for this edition of change of shift

You can read Movin' Meat’s  interview of Dr. Nick Jouriles, President of ACEP, over at The Central Line.

• Interview with ACEP President Jouriles (Pt 1)
• Interview with ACEP President Dr Jouriles (Pt 2)

Several bloggers come to Dr Regina Benjamin’s defense.  I agree with them.  It is much more important to look at her impressive qualifications.

• Dr Rob – Stone Throwing
• KevinMD  -- We should not care about Regina Benjamin’s weight
• Emily Walke -- Critcism of Regina Benjamin's Weight Nothing But Sexism

I’d like to direct you to Buckeye Surgeon’s post “The Meaning of Life.”  Be sure you read the comments.

Our purpose, our meaning is driven by the concept of "life"--- making it better, richer, less intolerable. If we admit this, then we are obligated to define what we mean by "life", because that is the fulcrum upon which we operate. What is life? What is it exactly that we are trying to save, to alleviate, to improve?

H/T to @MedicalQuack who tweeted the following. 

Nice Mention of @GruntDoc in Houston Chronicle http://tinyurl.com/mvoymy

Interesting NPR interview of Michael Ruhlman on cooking and his new book, Ratio.

His new book, Ratio, is about learning basic ratios. For example: 3:2:1 — three parts flour, two parts fat (like butter) and one part water — makes a basic pie crust. Add a dash of salt, and it's a savory base for a quiche. Add some sugar, and you've got a shell for cherries, chocolate cream or fresh peaches.

Dr Rob is now doing podcast as the “House Call Doctor”  giving “quick and dirty tips” to help you take charge of your health.   You can find the list of his podcasts here.  Enjoy!     

Moles Should Not Be Treated by Lasers

Updated 3/2017 -- all links except those to my own posts were removed as many are no longer active and it was easier than checking each one.

 

H/T to DermDoc who treated this news article link.  The article is “Some Laser Treatments Could Put Health At Risk, Dermatologists Say.”

dermdoc  Medical Spas Removing Moles with Lasers <-- Dangerous. Melanoma looks like a mole. http://tinyurl.com/m2pqmo  3:13 PM Jul 20th from web

He then followed up with this tweet

dermdoc  Medi-Spas are spas. Never have a mole removed without being checked by a physician. @serious_skeptic @nanarcr  3:29 PM Jul 20th from web

I agree.  It can be difficult even for trained physicians to tell the difference between moles and melanoma.  Don’t allow spas to laser them.  If there is any question, the mole should be biopsied.  That doesn’t happen with “laser treatment.”

To further make this point, check out the slide show on Medscape (free subscription required)

Mole or Melanoma? Tell-Tale Signs in Benign Nevi and Malignant Melanoma: Slideshow  Can you spot the differences between benign and potentially malignant nevi? Would you be able to tell which require a biopsy?

Related Posts
Melanoma Review (February 25, 2008)
Skin Cancer—Melanoma (December 8, 2008)
Melanoma Skin Screening Is Important (April 29, 2009)
Skin Cancer -- Basal Cell Carcinoma  (December 3, 2008)
Skin Cancer – Squamous Cell Carcinoma  (December 4, 2008)

SurgeXperiences 302

Updated 3/2-17-- all links removed as many no longer active and it was easier than checking each one.

 

Once again I it brings me great joy to expose you to surgery (via blog posts rather than actual) and the many experiences that go along with it.   I hope you find them interesting. (this -- photo credit—makes me want to quilt it-- photo removed 3/2017)

Let’s begin with this one by a non-surgeon who finds scars as fascinating as I do.  Dr Charles’ post Cicatrix is much more elegant than I could ever write about scars, but captures my feeling wonderfully.  Each scar has a story attached to it.  We all have one scar in common – the umbilicus – which tells of our attachment to our mothers.

“It looks like it’s healing well.” I told her. I didn’t know if it would be appropriate or not, but I decided to say it anyway. “Your scar is a story. I hope you can own it. Don’t ever be ashamed by it. It’s a testament to your strength, a mark of your courage.”

Dr Charles was inspired by this article in the NYTimes “Our Scars Tell the Stories of Our Lives” by Dana Jennings, as was Tara Parker-Pope “The Power of Scars.”  The comments attached to Parker-Pope’s are a very interesting  discussion on scars and their stories.

…………………………………..

Moving on to the gratitude (or lack thereof) associated with the outcome of surgery, Bongi tells us about a patient with acalculous cholecystitis.

…….some time after this the neurosurgeon got a call from the family doctor from their home country. he was indignant. he wanted to know why the gallbladder had been removed in such a young male, a group that usually does not have gallbladder problems and that in the absence of gallstones. he felt it was totally unnecessary and demanded an explanation……..

……………………………………

QuietusLeo, the Sandman, tells us of true gratitude showed by a patient’s family in the form of a gift after taking care of a “12 year old boy needed ultrasound guided drainage of perforated appendicitis with abscess.”   The father sent a touching note along with the gift which you should go read.  The child (the patient) was less grateful, but we’ll chalk that up to his age.

I called the family to thank them for their generous gift. The son answered the phone. When I identified myself he said that I had done a poor job because he didn't see the James Bond movie. I apologized and assured him that it was much more important to be healthy again.

He then passed the phone to his father. I thanked him for the gift. He said it was only a small token of appreciation. I assured him that it was much more than that.

……………………………………………

Can you imagine the story that goes with this?! (photo removed 3/2017)  Check it out over at M.D.O.D. (photo credit)


T, Notes of an Anesthesoboist, back from her vacation in France tells us about a call to the ER -- “you know it’s bad when”

One day I was giving someone a lunch break and wheeling her patient to the O.R. with the circulating nurse when we heard over the P.A. system,

"Any available surgeon stat to the emergency room. Any available surgeon to E.R. stat."

That stopped us in our tracks for a second. The nurse and I exchanged a look.

"Sounds pretty bad," I said.

………………………………………..

Buckeye Surgeon talks about tough decisions as he gets ready to put in an access port for chemotherapy.

The other day I picked up the chart of a lady who needed a port and the first thing I noticed was that she was 92 years old. I must admit, my first thought was: what the hell are we doing here? She had metastatic breast cancer with lesions seen in her lungs and liver. I was all ready to march into the room and have an honest, heart to heart talk with the patient and the family about futile care and cost effectiveness etc etc.

But I composed myself. Every situation is different. I asked questions. I listened.

Bongi tells us about the difficulties of just walking away when nothing can be done surgically.   He doesn’t do as his “teacher” taught.  Go read the entire post.

"now why did i just walk away?" he asked. we all gave the usual blank stares. "because there is nothing we can do for her." he said with a chuckle. those of us who needed to be in his good books gave the obligatory half hearted laugh. i could just manage a smile that i think came out more as a grimace.

…………………………………………….

Orac, Respectful Insolence, writes about being faced with a different kind of tough decision in “iron surgeon?”  [first posted in July 2007 and reposted recently]

The other day, Sid Schwab, surgeon blogger extraordinaire, brought up a question that, I'm guessing, most nonsurgeons wonder about from time to time when contemplating how it is that we surgeons do what we do.

What about bathroom breaks?

…………….It happened to me only once, but it provided a serious dilemma. What do I do? I'm captain of the ship of the O.R., so to speak. The entire team depends on me. The patient depends on me.

And that's the key to making the correct decision……..

……………………………………………

From WhiteCoat’s Call Room -- What’s The Diagnosis #4 – this 13 year old boy will certainly have a story to go with his scar! 

Uveal Blues tells us about Better Vision, With a Telescope Inside the Eye for people with irreversible, advanced macular degeneration.  Check out the post for photos.

……………………………………….

Vijay, Scan Man’s Notes, gives us a quiz using “three x-rays”

A small mental exercise for medical bloggers.

See the following three portable (bedside) chest radiographs that were taken in an ICU setting. They are in sequence.

See if you can guess the story that they tell.

…………………………………………

What do you do when you can’t get good IV access?  Check out Dr Michelle Lin’s post  Sneak Peak "Trick of the Trade": IO line for failed IV access.  There’s even a video showing how to do the IO (intraosseous) access in adults.

Adult intraosseous needles are coming more into favor in the United States, although they have been part of standard practice in the military and Europe. Various commercial devices exist. The one we have at SF General is the EZ IO Needle. (I have no financial ties with the company.) Needle placement is surprisingly easy and takes less than 10 seconds, especially if you channel your inner Home Depot self in using the power drill.

……………………………………….

Orac does a much better job than I did discussing “Overdiagnosis of breast cancer due to mammography” and it’s implications.  It’s a must read for all of us.

M.D.O.D talks about a surgical tragedy in the recent news in two posts – here and here where he attempts to explain how the tragedy might have happened.

Surgeon hands intern trochar. Intern, stepping up on small stool puts all her weight behind it and hubs it. Descending aorta pierced, Surgeon apoplectic, blood fills abdomen, patient's legs get blue, Vascular Surgeon scared shitless, knows it's a hopeless case, tries to punt, no one receiving, then finally gets an accepting somewhere else. Rest of story plays out.

H/T to PSP (Plastic Surgery Practice) for the link to this news article from India --  Rare surgery helps re-implant foot's thumb to write with hand.  Technically the foot does not have a thumb, so it should read “rare surgery uses foot’s big toe to give right hand a thumb.”  Still it is a nice procedure.

H/T to Barbara, Medical  Quack, who shared an update on the  German Man with Double Arm Transplant.  You can see a video of the man here.

IntraopOrate was recently an ENT patient.  Here’s the first part, read her post for the outcome.

I've been having some unpleasant pressure in my right ear and a couple of episodes of vertigo over the last six days. Today I had an appointment with my ENT Dr. He entered the exam room, we shook hands, he looked at my throat, looked up my nose (but doc, it's my ear that troubles me!) looked in my right ear and while rolling across to look in my left ear, he said "We're gonna have to get that hair out of there."

Dr Alice, 3rd year surgical resident, talks about some of the “sand traps” attending set for residents.

Answering to one attending is difficult enough. Answering to three or four at the same time, about the same patients, is extremely tricky (I’m not going to try to explain the structure of this group of attendings……..

…………….

From twitter

• medpiano  RT @jonmikel: HUGE TUMOR: Radical right nephrectomy http://is.gd/1IjLH <<ENORME! (CT is image before and on wall behind)
• jeffreyleow RT @jonmikel: GIANT inguinal hernia: http://www.flickr.com/photo...
• jeffreyleow RT @ColumbiaSurgery: What You Must Know about Flesh Eating Bacteria and Superbugs from Dr. Oz. http://bit.ly/C7eRB

and for fun/education

• DrCris  I'm blue. Non-surgeons get to guess what procedure I have just done. http://twitpic.com/bavlb 
• DrCris  I like "smurf appendicectomy" but @twelveeyes hit the winner with sentinel node biopsy (for breast cancer)

MedPage Today reports that female surgeons report high job satisfaction.  I do love my work.

I agree with this news from fellow plastic surgeon, Dr Rob Oliver Jr -- Nip/Tuck gets "nipped" by FX - thank you God! 

And on that note, I wish you a wonderful day!  Enjoy the reading.   Remember if you would like to be the host  in the future, please contact Jeffrey who runs the show here.

Chasity’s Baby’s Quilt

My niece Chasity is pregnant with her first child.  She is due in December.  Chasity is my youngest brother’s first child.  We are all very happy for her and her husband.  And, yes, I’ve finished her baby quilt.

Using the same quilt block pattern and some of the same fabric as I used to make Steve and Lori's quilt, I machine pieced and quilted this one for Chasity.  It is 40 inches square.  She lives in west Texas so I went for a “cowboy” theme and hoped the red would work for a girl and the blue for a boy. 

Here is a closer view of one of the red blocks to show off the fabrics.  The red has cowboys riding broncos in it.

Here is a closer view of one of the blue blocks.  The blue fabric has cars and trucks in it.

Here is a view of the back which is a lovely yellow flora.  The quilting was done with gold colored thread in both the top and bobbin.

Bioactive Sutures

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

H/T to MedGadget who’s post introduced me to “bioactive sutures.”  What a great idea by the Johns Hopkins biomedical engineering students! 

……have demonstrated a practical way to embed a patient’s own adult stem cells in the surgical thread that doctors use to repair serious orthopedic injuries such as ruptured tendons. The goal, the students said, is to enhance healing and reduce the likelihood of re-injury without changing the surgical procedure itself.

The project team of 10 undergraduates focused on Achilles tendon injuries which require repair in approximately 46,000 people in the United States every year.   The surgery may fail in as many as 20%.  Recovery can take up to a year even with successful surgery.  If this new suture speeds healing and lowers failure rates – what potential! 

At the site of the injury, the stem cells are expected to reduce inflammation and release growth factor proteins that speed up the healing, enhancing the prospects for a full recovery and reducing the likelihood of re-injury. The team’s preliminary experiments in an animal model have yielded promising results, indicating that the stem cells attached to the sutures can survive the surgical process and retain the ability to turn into replacement tissue, such as tendon or cartilage……………

As envisioned by the company and the students, a doctor would withdraw bone marrow containing stem cells from a patient’s hip while the patient was under anesthesia. The stem cells would then be embedded in the novel suture through a quick and easily performed proprietary process. The surgeon would then stitch together the ruptured Achilles tendon or other injury in the conventional manner but using the sutures embedded with stem cells.

De Quervain Tenosynovitis

 Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

I love this problem though I’m sure I wouldn’t if I ever had it. It is one of those hand problems diagnosed by history and physical exam. The name can be a mouthful and is tricky to spell, but it is one that is treatable. Most often with a good outcome.

De Quervain tenosynovitis was first described in 1895 by a Swiss surgeon, Fritz de Quervain. He reported 5 cases of patients who had the now “classic” physical finding -- a tender, thickened first dorsal wrist compartment. Now this condition bears his name – De Quervain tenosynovitis.

De Quervain tenosynovitis is an entrapment tendinitis of the first dorsal compartment of the wrist. Even a small amount of swelling or inflammation of the tendons (abductor pollicis longus and extensor pollicis brevis) trying to slide through the non-elastic tunnel creates more irritation and inflammation. The involved tendons are used to move the thumb, so pain occurs with thumb motion.

De Quervain tenosynovitis is the second most common entrapment tendinitis of the hand/wrist. The most common is trigger finger (trigger digit) which is about 20 times more common. Frequently patients are mothers of infants aged 6-12 months who will have symptoms in both wrists.

Anyone with De Quervain tenosynovitis will note pain with thumb and wrist motion. These patients will also note tenderness and thickening at the radial styloid. Crepitation or actual triggering is rarely noted. Repetitive lifting/use is responsible for friction tendinitis. De Quervain tenosynovitis can also develop in individuals who have sustained a direct blow to the area of the first dorsal compartment.

Physical findings on examination will include local tenderness and swelling of the extensor retinaculum of the wrist over the first compartment. A positive Finkelstein sign confirms the diagnosis.

"Finkelstein sign” is done by tucking the thumb into the palm where it is held by the patient’s fingers. The examiner then gently deviates the wrist ulnarly. This creates a sharp increase in pain along the first dorsal compartment in any patient with De Quervain tenosynovitis.

The goal in treating de Quervain's tendinitis is to relieve the pain caused by irritation and swelling. Nonsurgical treatment should be tried first. If the tenosynovitis is associated with pregnancy, then the nonoperative treatment should be prolonged (4-6 months).

• Splints. Splints may be used to rest the thumb and wrist.
• Anti-inflammatory medication (NSAIDs). These medications can be taken by mouth or injected into that tendon compartment. They may help reduce the swelling and relieve the pain.
• Avoiding activities that cause pain and swelling. This may allow the symptoms to go away on their own.
• Corticosteroids. Injection of corticosteroids into the tendon sheath may help reduce swelling and pain.
• Surgery -- recommended if symptoms are severe or do not improve. The goal of surgery is to open the compartment (covering) to make more room for the irritated tendons.
  The procedure is usually done on an out-patient basis. The surgery typically involves identification and cutting of the tendon sheath segment under local anesthesia. Care must be taken to avoid cutting the sensory branch of the radial nerve. Patients commonly return to their normal activities within 2-3 weeks. The procedure has been reported to be successful in about 90% of the cases.

REFERENCES
De Quervain Tenosynovitis; eMedicine Article, Feb 17, 2009; Roy A Meals, MD
De Quervain's Tendinitis (De Quervain's Tendinosis) -- AAOS

Shout Outs

Updated 3/2017-- all links removed as many no longer active and it is easier than checking each one.

Doc Gurley is this week's host of Grand Rounds. You can read it here.

Welcome to Grand Rounds Vol. 5 No. 44.  A Grand Rounds full of plot twists, drama, melodrama and yes, death (this is a medical blog roundup after all).

Just for fun, I am going to group the submissions under acts whose real names you’ll have to guess (pick from: The Hunt Is Afoot, The Law Gets Involved, Death Arrives, Clues Are Discovered, The Plot Thickens, and All Is Revealed).

Suggestions/nominations for the acts’ titles can go in the comments and the people who get the closest to the right answers can wear their imaginary Sherlock Holmes deerstalkers with pride. The rest of us can instead wear our Doctor Watson designation (also with pride).

Here are some posts on the "Patients First” meeting Dr Val put together at the National Press Club this past Friday.  I hope I didn’t miss any.

• Congressman Paul Ryan’s Speech To Medical Bloggers At The National Press Club (Better Health)
• KevinMD Addresses Crowd At National Press Club About Primary Care Crisis (by KevinMD)
• My Comments At the National Press Club, Washington DC (by Dr Wes)  
• Washington Wrap-Up  (by Dr Wes)
• Someone Who Actually Knows How to Put Patients First (by DrRich)
• Washing Tons for Boggers (by Dr Rob)
• Patients First: Twitter Transcript (by Robin)
• Better Health in D.C.: the Panel, the Politics and the Ce-Ment Pond (by Kim)
• Reflections on health-care reform (by Dr Edwin Leap)

H/T to scanman who tweeted this:  “RT @precordialthump Trick of the Trade: IO line for failed IV access http://bit.ly/4qfUl Awesome post & video. Hats off to the volunteers!!!”  This link is to this article, Sneak Peak "Trick of the Trade": IO line for failed IV access, which has a very nice video showing IO (intraosseous access)

In the video below, 3 brave (a.k.a. crazy) volunteers get an IO drilled into their proximal tibia. Apparently, the insertion is only mildly painful and the infusion of fluids is actually the more painful part of the procedure. You might consider priming the IV tubing with 1% lidocaine to minimize pain in awake patients.

H/T to MedGadget for this:  For Tender Feet, Shoes Simulate Barefoot Running Safely.   I’d love to have a pair of these FiveFingers from Vibram.   Maybe I’ll ask for a pair for my upcoming birthday. 

Check out this cake from a former ophthalmologist turned pastry chef  -- Reaching New Heights.  You should check some of her others at her blog Charmaine’s Pastry Blog.

Dr Rob is now doing podcast as the “House Call Doctor”  giving “quick and dirty tips” to help you take charge of your health.   You can find the list of his podcasts here.  Enjoy!

       

This week Dr Anonymous will be taking July off. You might want to use this time to listen to some of the shows in his Archives.

The Impact of Partial Breast Reconstruction on Postoperative Cancer Surveillance – an Article Review

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

I wanted to share this article (1st reference below) with you.  I feel it is important as we continue to improve the treatment of breast cancer.  Our surgical treatments can change the surveillance.

The authors begin their article by pointing out breast conservation therapy has grown in popularity and scope.  In saving the majority of the breast tissue, some of the reconstructive procedures significantly alter the architecture of the breasts.  How does this affect surveillance postoperatively?  The article’s stated purpose was to look at this question.

The purpose of this review was to evaluate long-term postoperative cancer surveillance techniques in a group of patients with breast cancer who underwent partial breast reconstruction using reduction techniques. We were interested in determining whether mammographic screening remained a sensitive tool following oncoplastic reduction and whether the observed changes and diagnostic testing differed in this patient group.

We hypothesized that patients undergoing the reduction techniques might have additional qualitative mammographic changes compared with patients undergoing breast conservation therapy alone, with longer time to stability.

We further hypothesized that the mammographic changes and clinical concerns in the oncoplastic group would result in more diagnostic testing (mammograms, ultrasound, and magnetic resonance imaging) and in the need for additional tissue sampling events.

The authors did a retrospective look at charts of all patients who underwent partial breast reconstruction using reduction techniques (breast conservation therapy with reduction) at Emory University Hospital before 2004.   Their control group (breast conservation therapy alone) included women who underwent breast conservation therapy without reconstruction during the same time period.  Data points included follow-up and the number and type of breast-imaging techniques (mammogram, ultrasound, or magnetic resonance imaging).  They found 34 patients who met their criteria, 17 in each group. 

The average age in the control group was 61 years (range, 44 to 81 years).   Most in this group had diagnosis of either infiltrating ductal carcinoma or infiltrating ductal carcinoma and ductal carcinoma-in-situ. Four in this group had positive lymph nodes.  The average weight of the biopsy specimen was 71 gm.

The average age in the reconstructive group was 52 years (range, 38 to 72 years).  Two in this group had positive lymph nodes. The average weight of the biopsy specimen was 291 gm. 

Negative margins were established in all patients before radiation therapy. All patients underwent postoperative radiation therapy.  Average follow-up time was 5.9 years in the control group and 6.3 years in the study group.  The local recurrence rate in each group was 6 percent (one of 17). 

The available tools for postoperative cancer surveillance include (1) physical examination, (2) radiological imaging, and (3) tissue sampling. When local recurrence is detected, it is usually in the form of a mass, calcifications, or both.

Tumor recurrence is typically found at the lumpectomy bed (true recurrence), adjacent to it (marginal miss), or elsewhere in the treated breast.  The greatest emphasis on surveillance is in the first 5 years, as this is when the risk of recurrence is the highest; however, the risk does persist.

When breast reduction techniques are used in reconstruction, there is the potential for  additional scarring, epidermal inclusion cysts, and fat necrosis.  All these may make surveillance potentially more difficult.  In addition, breast reduction surgery displaced breast parenchyma from it’s original location. 

The authors make the point that currently there is no consensus regarding appropriate radiographic imaging protocols following oncoplastic procedures.

The main objectives are to (1) exclude residual disease, (2) rule out recurrence, (3) establish a new baseline, and (4) evaluate for metachronous disease, while minimizing misinterpretation.

Mammography following breast conservation therapy has been shown to be sensitive in about 55 to 68 percent of breast conservation patients.  Mendelson followed the mammographic changes over time following breast conservation, with the most frequent findings being skin thickening and breast edema in almost 100 percent of patients.

Other findings at 6 months after treatment include scarring and fibrosis (50 percent), fluid collections/seromas (40 percent), and dystrophic calcifications (10 percent). Skin thickening, edema, and seromas did tend to resolve with time and likely represent the changes associated with radiation dermatitis. These conditions will often peak at about 6 months after radiation therapy and resolve over 2 to 3 years in most patients.

The authors noted that it takes longer to achieve mamographic stabilization in the study group.

Since the 95 percent confidence interval for stability in the oncoplastic group was 20.5 to 30.7 months, we believe that, based on these data, biannual mammographic screening should be extended until the third postoperative year in patients who undergo partial breast reconstruction to confirm stability, and that it should be performed on an annual basis thereafter.

Accurate interpretation of postoperative images requires familiarity with these temporal changes following partial breast reconstruction. Establishing a new baseline is important and will avoid unnecessary biopsies, because many of the posttreatment mammographic findings can mimic radiographic signs of malignancy.

Even though the study is retrospective and small, it is heartening to see that with good radiologists who are aware of the surgical breast changes, surveillance and detection is possible.  Surgeons and patients can feel assured that the reconstruction procedure is not hampering follow up care.

REFERENCES

The Impact of Partial Breast Reconstruction Using Reduction Techniques on Postoperative Cancer Surveillance; Plast Reconstr Surg. July 2009 - Volume 124 - Issue 1 - pp 9-17; Losken, Albert M.D.; Schaefer, Timothy G. M.D.; Newell, Mary M.D.; Styblo, Toncred M. M.D.

Management Algorithm and Outcome Evaluation of Partial Mastectomy Defects Treated Using Reduction or Mastopexy Techniques;  Ann Plast Surg. 2007;3:235; Losken A, Styblo TM, Carlson GW, Jones G, Amerson B.

Critical Analysis of Reduction Mammaplasty Techniques in Combination with Conservative Breast Surgery for Early Breast Cancer Treatment;  Plast Reconstr Surg. 2006;117:1091-1103; Munhoz AM, Montag E, Arruda E, et al.

SurgeXperience 302 – Call for Submissions

Updated 3/2017 -- links removed as no longer active.
There is no host yet for  SurgeXperience 302 (July 26th) but don't let that keep you from making submissions.   The deadline for submissions is midnight on Friday, July 24th.  Be sure to submit your post via this form. 
SurgeXperiences is a blog carnival about surgical blogs. It is open to all (surgeon, nurse, anesthesia, patient, etc) who have a surgical blog or article to submit.   If you would like to be the host  in the future, please contact Jeffrey who runs the show here.
Here is the catalog of past SurgeXperiences editions for your reading pleasure.