Christopher Caddy - Academia.edu (original) (raw)

Papers by Christopher Caddy

Research paper thumbnail of Measuring the patient perspective on latissimus dorsi donor site outcomes following breast reconstruction

Journal of Plastic Reconstructive and Aesthetic Surgery, Mar 1, 2018

Measuring the patient perspective on latissimus dorsi donor site outcomes following breast recons... more Measuring the patient perspective on latissimus dorsi donor site outcomes following breast reconstruction.

Research paper thumbnail of Association between age and access to immediate breast reconstruction in women undergoing mastectomy for breast cancer

British Journal of Surgery, Feb 8, 2017

Background: National guidelines state that patients with breast cancer undergoing mastectomy in E... more Background: National guidelines state that patients with breast cancer undergoing mastectomy in England should be offered immediate breast reconstruction (IR), unless precluded by their fitness for surgery or the need for adjuvant therapies. Methods: A national study investigated factors that influenced clinicians' decision to offer IR, and collected data on case mix, operative procedures and reconstructive decision-making among women with breast cancer having mastectomy with or without IR in the English National Health Service between 1 January 2008 and 31 March 2009. Multivariable logistic regression was used to examine the relationship between whether or not women were offered IR and their characteristics (tumour burden, functional status, planned radiotherapy, planned chemotherapy, perioperative fitness, obesity, smoking status and age). Results: Of 13 225 women, 6458 (48.8 per cent) were offered IR. Among factors the guidelines highlighted as relevant to decision-making, the three most strongly associated with the likelihood of an offer were tumour burden, planned radiotherapy and performance status. Depending on the combination of their values, the probability of an IR offer ranged from 7.4 to 85.1 per cent. A regression model that included all available factors discriminated well between whether or not women were offered IR (c-statistic 0.773), but revealed that increasing age was associated with a fall in the probability of an IR offer beyond that expected from older patients' tumour and co-morbidity characteristics. Conclusion: Clinicians are broadly following guidance on the offer of IR, except with respect to patients' age.

Research paper thumbnail of Socioeconomic deprivation and inpatient complication rates following mastectomy and breast reconstruction surgery

British Journal of Surgery, Jun 15, 2015

Background: Socioeconomic deprivation is known to influence the presentation of patients with bre... more Background: Socioeconomic deprivation is known to influence the presentation of patients with breast cancer and their subsequent treatments, but its relationship with surgical outcomes has not been investigated. A national prospective cohort study was undertaken to examine the effect of deprivation on the outcomes of mastectomy with or without immediate breast reconstruction. Methods: Data were collected on patient case mix, operative procedures and inpatient complications following mastectomy with or without immediate breast reconstruction in the English National Health Service between 1 January 2008 and 31 March 2009. Multivariable logistic regression was used to examine the relationship between patients' level of (regional) deprivation and the likelihood of local (mastectomy site, flap, flap donor and implant) and distant or systemic complications, after adjusting for potential confounding factors. Results: Of 13 689 patients who had a mastectomy, 2849 (20⋅8 per cent) underwent immediate reconstruction. In total, 1819 women (13⋅3 per cent) experienced inpatient complications. The proportion with complications increased from 11⋅2 per cent among the least deprived quintile (Q1) to 16⋅1 per cent in the most deprived (Q5). Complication rates were higher among smokers, the obese and those with poorer performance status, but were not affected by age, tumour type or Nottingham Prognostic Index. Adjustment for patient-related factors only marginally reduced the association between deprivation and complication incidence, to 11⋅4 per cent in Q1 and 15⋅4 per cent in Q5. Further adjustment for length of hospital stay, hospital case volume and immediate reconstruction rate had minimal effect. Conclusion: Rates of postoperative complications after mastectomy and breast reconstruction surgery were higher among women from more deprived backgrounds.

Research paper thumbnail of Surgical Determinants of Patient-Reported Outcomes following Postmastectomy Reconstruction in Women with Breast Cancer

Plastic and Reconstructive Surgery, May 1, 2017

Background: This national prospective cohort study compared the patient-reported outcomes of brea... more Background: This national prospective cohort study compared the patient-reported outcomes of breast cancer patients having post-mastectomy autologous reconstruction to those who had breast implants, in terms of aesthetic appearance, levels of psychological, physical and sexual well-being and overall satisfaction. Methods: Of 5,063 women who underwent immediate (IR; n=3,349) or delayed (DR; n=1,714) reconstruction between 1 January 2008 and 31 March 2009 in England, 2,923 women who consented were sent validated, procedure-specific 18-month follow up questionnaires. Outcome scale scores ranged from 0 (poor) to 100 (excellent); multiple linear regression was used to adjust scores for patient and treatment characteristics. Results: 2,289 women (78%) returned completed questionnaires (1,528 IR, 761 DR). For IR, mean overall satisfaction scores for the various techniques ranged from 67 to 85 (median 67 to 93). For DR, mean overall satisfaction scores ranged from 70 to 85 (median 75 to 100). For both groups, similar gradients were observed for the other outcome scales across techniques. Reconstruction using patients' own tissues tended to have higher mean adjusted scores compared with those techniques using implants alone (p<0.0001 for aesthetic appearance, psychological well-being, sexual well-being, and satisfaction with outcomes for IR and DR groups). Conclusion: Women who underwent autologous reconstruction tended to report greater satisfaction than those who had an implant reconstruction. These results can inform patients of the anticipated outcomes of their selected surgery but further research is required to confirm whether autologous reconstruction is superior in general.

Research paper thumbnail of The association between complications and quality of life after mastectomy and breast reconstruction for breast cancer

Cancer, May 17, 2017

Precis: Surgical complications are associated with little or no long-term impairment in quality o... more Precis: Surgical complications are associated with little or no long-term impairment in quality of life in breast cancer patients undergoing mastectomy without reconstruction, or delayed reconstruction. The association is much larger for flap-related complications suffered during immediate reconstruction. Background: Medical treatment for breast cancer is associated with substantial toxicity and patient burden. There is less known about the impact of surgical complications. Understanding this impact would provide important information for patients when considering surgical options. Methods: Between 2008 and 2009, the UK National Mastectomy and Breast Reconstruction Audit recorded surgical complications for a prospective cohort of 17,844 women treated for breast cancer at 270 hospitals. 6,405 of these women were surveyed about their quality of life 18 months after surgery. Breast appearance, emotional well-being and physical wellbeing were quantified on 0-100 point scales. Linear multiple regression models were used to compare the scores of patients who had complications to those who did not, while controlling for a range of baseline prognostic factors. Results: The overall complication rate was 10.2%. Complications were associated with little or no impairment in women undergoing mastectomy without reconstruction, or delayed reconstruction. The association was much larger for flap-related complications suffered during immediate reconstruction. The breast appearance (adjusted mean difference =-23.8; 95% CI,-31.0 to-16.6) and emotional well-being (adjusted mean difference =-14.0; 95% CI,-22.0 to-6.0) scores of these patients were much lower than any other patient group. Implant-related complications were not associated with lower quality of life in any surgical group. Conclusions: There is a strong case for prospectively collecting flap complication rates at the surgeon and surgical unit level, and allowing patients to access this data when they make choices about their breast cancer surgery.

Research paper thumbnail of Patients’ satisfaction with the reconstructive options provided to them measured 18 months after mastectomy surgery for breast cancer

European Journal of Cancer Care, Nov 10, 2020

INTRODUCTION Mastectomy patients' satisfaction with reconstructive options has not been exami... more INTRODUCTION Mastectomy patients' satisfaction with reconstructive options has not been examined. METHODS A national study measured 18-month satisfaction with reconstructive options and collected case-mix and reconstructive offer and uptake data on breast cancer patients having mastectomy with or without immediate reconstruction (IR) in England between January 2008 and March 2009. Multivariable logistic regression examined the relationship between satisfaction, age, IR offer and uptake, and clinical suitability. RESULTS Of 4796 patients, 1889 were not offered IR, 1489 declined an offer and 1418 underwent it. Women not offered IR were more likely older, obese or smokers and had higher ASA grades, ECOG scores, tumour burdens and adjuvant chemotherapy and radiotherapy likelihoods (9% of lowest suitability group offered IR; 81% in highest suitability group). 83.7% were satisfied with their reconstructive options, varying significantly by IR offer and uptake (76.1% for those not offered IR; 85.8% for those who declined IR; 91.7% following IR). Older women and women deemed more suitable for IR were more often satisfied (p-values <0.001). CONCLUSIONS Satisfaction varied by offer and uptake status, age and suitability score. Clinicians should target equity for women deemed unsuitable by exploring their needs and desired outcomes, standardising operative fitness assessments and utilising shared decision-making aids.

Research paper thumbnail of Findings of a national comparative audit of mastectomy and breast reconstruction surgery in England

Journal of Plastic Reconstructive and Aesthetic Surgery, Oct 1, 2014

This paper summarises the findings of a national audit of mastectomy and breast reconstruction su... more This paper summarises the findings of a national audit of mastectomy and breast reconstruction surgery carried out in England. It describes patterns of treatment, and the clinical and patient-reported quality of life outcomes associated with these types of procedure. Design: Prospective cohort study. Setting: All 150 National Health Service hospital groups (NHS trusts) in England that provided mastectomy or breast reconstruction surgery, along with six NHS trusts in Wales and Scotland and 114 independent hospitals.

Research paper thumbnail of The National Mastectomy and Reconstruction Audit as a driver for local service improvement. Improving peri-operative pain control in breast surgery

Ejso, May 1, 2012

, only patients responding with a 1 or 2 for all of the items within a subscale were classified a... more , only patients responding with a 1 or 2 for all of the items within a subscale were classified as satisfied for the subscale. Results: A total of 47 reconstructive procedures (29 immediate and 18 delayed) were done between April 2007 and Dec 2010. The study population consisted of 30 LD and 17 Sub-pectoral implant reconstructions during this period. 28 out of 47 (60%) patient satisfaction questionnaires were returned. Conclusion: Most patients were satisfied with their breast reconstructions and would recommend this procedure to others. However it is important to assess the reasons for the need to wear a prosthetic shell in 20% of patients.

Research paper thumbnail of Breast Cancer in Reduction Mammoplasty specimens: 10-year experience

Research paper thumbnail of Burns in patients with impaired sensibility of the hands—a case of osteomyelitis in a neglected thumb burn

Research paper thumbnail of Interpleural analgesia in breast reconstruction

Scandinavian journal of plastic and reconstructive surgery and hand surgery, 2008

To investigate the safety and efficacy of interpleural analgesia for postoperative pain control i... more To investigate the safety and efficacy of interpleural analgesia for postoperative pain control in patients having breast reconstruction we did a retrospective audit of 114 women who had had their breasts reconstructed by the same team. A group of 22 women given morphine postoperatively acted as a historical control. Ninety-two women were given continuous postoperative interpleural bupivacaine with free access to morphine. We recorded complications, morphine consumption, postoperative pain, nausea and vomiting scores, and duration of hospital stay. There was one episode of air entrapment. Morphine consumption was significantly reduced in the interpleural group (p&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.000). Pain scores were similar in all groups (p=0.11). Nausea and vomiting scores were significantly lower in the interpleural group (p=0.04) and hospital stay was shorter in the interpleural group but not significantly so (p&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.9). We conclude that interpleural analgesia improves the quality of postoperative care in breast reconstruction with latissimus dorsi flaps.

Research paper thumbnail of A new method for the assessment of suturing ability

PubMed, Dec 1, 1997

A new method for the formal assessment of surgical ability in simple wound closure is presented. ... more A new method for the formal assessment of surgical ability in simple wound closure is presented. Suture tension and accuracy of placement are measured indirectly in a standardized rig using Lyofoam as a skin substitute. This method has been used to assess a group of seven junior hospital doctors before and after instruction in a workshop setting. Formal instruction reduced suture tension by an average of 30.3% for the group as a whole (P < 0.01). Standard deviation in inter-suture distance was reduced by an average of 39.4% (P < 0.05), suggesting increased accuracy of suture placement following teaching. On the basis of this study, it appears that those involved in suturing wounds would benefit from postgraduate instruction in workshop setting early in their career.

Research paper thumbnail of An atraumatic technique for harvesting cancellous bone for secondary alveolar bone grafting in cleft palate

British Journal of Plastic Surgery, Oct 1, 1985

Secondary alveolar bone grafting in cleft palate patients has been popularised by the Oslo group.... more Secondary alveolar bone grafting in cleft palate patients has been popularised by the Oslo group. Harvesting of the bone graft has been carried out by techniques developed initially for crania-facial surgery. This paper describes a more refined technique applicable to the requirements of alveolar bone grafting. The Craig bone biopsy set is used to trephine cores of autogenous particulate marrow and cancellous bone from the iliac bone. The method was tested in a cadaver and then applied in 10 clinical cases. The aesthetic and functional results of this technique proved to be superior to the conventional approach.

Research paper thumbnail of An anatomic review of the delay phenomenon: II. Clinical applications

PubMed, Mar 1, 1992

This paper applies the anatomic concepts and data obtained from our animal experimental studies o... more This paper applies the anatomic concepts and data obtained from our animal experimental studies of the delay phenomenon to a series of clinical cases. Similar clinical results were obtained to those seen in Part I of our study when skin flaps were raised with and without a delay, when a tissue expander was used, and when the delay technique was extended to musculocutaneous flaps. In each instance, the cutaneous perforators were identified with the Doppler probe to facilitate the delay of specific vessels rather than dividing those at random. Intraoperative arteriograms and venograms reveal that the choke arteries dilate and the anatomically unfavorable valved vein segments become regurgitant. The end result is the observation that at least one additional anatomic vascular territory can be added to the length of a flap with safety following a surgical delay.

Research paper thumbnail of An anatomic review of the delay phenomenon: I. Experimental studies

PubMed, Mar 1, 1992

A number of experiments were conducted to study the anatomic changes in a flap following a surgic... more A number of experiments were conducted to study the anatomic changes in a flap following a surgical delay using the Doppler probe to add precision to the technique. After scanning the integument of a series of anesthetized animals with the probe, each was sacrificed; a total-body arterial injection was performed with a lead oxide mixture, the integument and deep tissues were radiographed separately, and the results were correlated and compared with our previous human studies. The dog was selected from the range of animals examined, and the arterial networks of a number of skin and muscle flaps were studied with and without a surgical delay. The study included the use of a tissue expander. Results revealed that an adjacent cutaneous perforator could be captured with safety on the artery at the base of an undelayed flap; that the survival length of that flap was related to the distance between perforators; that the necrosis line of the flap usually appeared in the zone of choke vessels connecting adjacent territories; that a surgical delay results in a dilatation of existing vessels with maximal effect in the zone of choke arteries; that the most effective delay was obtained by elevating the flap in stages from the base, leaving detachment of the tip until last; that tissue expansion is a form of surgical delay, with particular emphasis on vessel hypertrophy; and that similar changes occur when a muscle is delayed. The clinical applications of this investigation are presented in Part II of this anatomic review of the delay phenomenon.

Research paper thumbnail of Abstract P6-03-02: Breast Reduction Mammoplasty and Incidence of Occult Carcinoma. A 10 Year Experience

Background: The aim of this study was to report the incidence of cancer in reduction mammoplasty ... more Background: The aim of this study was to report the incidence of cancer in reduction mammoplasty specimens and suggest alternative pragmatic cost-effective way of identifying and treating patients with carcinoma. Methods: All patients who underwent breast reduction surgery at Northern General Hospital over a 10-year period were identified from a prospective database. The histopathology reports and case records of all patients with significant abnormalities were analysed. All breast reduction specimens were sliced at 1 cm intervals and examined macroscopically. At least 3 blocks per breast were examined microscopically in addition to sampling of any grossly abnormal tissue. Results: Between October 1999 and April 2010, 1,588 patients underwent reduction mammoplasty. The median age of patients was 38 years (range 16-75 years). Indications for surgery were macromastia in 1,194 (75.2%), congenital asymmetry in 182 (11.5%) and contralateral symmetry procedure post breast cancer surgery in 178 (11.2%). 9 specimens showed atypical hyperplasia (0.57%). 5 cancers were detected (0.31%). 4 of the 5 patients had normal mammograms 1-3 years before the reduction operation (not done in 1). Of these cancers, 4 were invasive (3 invasive lobular, 1 invasive ductal) (0.25%) (mean invasive tumour size 9 mm (SD 7.4)) and 1 was DCIS (4mm) (0.06%). A lump was felt macroscopically by the pathologist in 2 of the 4 patients with invasive cancer. The median age of patients with invasive cancer was 56 years (range 47-68 years). Patient found to have DCIS did not undergo further surgery while those with invasive disease underwent mastectomy (3) and axillary nodal staging (4). None of the patients with benign/normal post-reduction breast imaging had residual breast cancer on histology. Conclusion: The incidence of occult carcinoma in reduction mammoplasty specimens is less than 0.5%. Pre-operative mammogram is not useful as 4 of the 5 patients with cancer had a normal mammogram 1-3 years before surgery and invasive lobular cancers are often not detected on mammogram. Mastectomy may be avoided in patients with no residual breast disease on post-reduction imaging. Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P6-03-02.

Research paper thumbnail of Response to “In Defense of the International Collaboration of Breast Registry Activities (ICOBRA)”

Aesthetic Surgery Journal, Apr 6, 2016

Research paper thumbnail of Breast Implant Registries: The Problem with Ambition

Aesthetic Surgery Journal, Nov 3, 2015

Research paper thumbnail of A rare case of SCC in a young patient with incontinentia pigmenti

Journal of Plastic Reconstructive and Aesthetic Surgery, Aug 1, 2008

Research paper thumbnail of Breast Reconstruction

Springer eBooks, Dec 4, 2009

ABSTRACT Surgeons are invited to discuss breast reconstruction with all breast cancer patients (I... more ABSTRACT Surgeons are invited to discuss breast reconstruction with all breast cancer patients (Improving Outcomes in Breast Cancer - Manual Update 2002). In practice, this counseling and decision-making process is not solely surgeon- and patient-based, but is frequently complemented by the breast care nurse and other members of the multidisciplinary team. The intention is that this recommendation should apply equally to the older patient as to the younger. This chapter presents what is relevant to this older group of patients and how this may affect our practice. For the purposes of this chapter, and keeping in line with the literature discussed below, older or elderly patients are defined as those over 60 years of age. The literature specifically relating to issues regarding breast reconstruction in the elderly patient is sparse. Previous studies have addressed changes in body image, patient preferences, technical aspects and risks of surgery, and outcomes, but no prospective study has been undertaken to follow a group of patients through the journey with comparison to their younger counterparts. Randomized controlled trials are difficult in this group where patients make an active choice whether to have a reconstruction and, if so, the type of reconstruction.

Research paper thumbnail of Measuring the patient perspective on latissimus dorsi donor site outcomes following breast reconstruction

Journal of Plastic Reconstructive and Aesthetic Surgery, Mar 1, 2018

Measuring the patient perspective on latissimus dorsi donor site outcomes following breast recons... more Measuring the patient perspective on latissimus dorsi donor site outcomes following breast reconstruction.

Research paper thumbnail of Association between age and access to immediate breast reconstruction in women undergoing mastectomy for breast cancer

British Journal of Surgery, Feb 8, 2017

Background: National guidelines state that patients with breast cancer undergoing mastectomy in E... more Background: National guidelines state that patients with breast cancer undergoing mastectomy in England should be offered immediate breast reconstruction (IR), unless precluded by their fitness for surgery or the need for adjuvant therapies. Methods: A national study investigated factors that influenced clinicians' decision to offer IR, and collected data on case mix, operative procedures and reconstructive decision-making among women with breast cancer having mastectomy with or without IR in the English National Health Service between 1 January 2008 and 31 March 2009. Multivariable logistic regression was used to examine the relationship between whether or not women were offered IR and their characteristics (tumour burden, functional status, planned radiotherapy, planned chemotherapy, perioperative fitness, obesity, smoking status and age). Results: Of 13 225 women, 6458 (48.8 per cent) were offered IR. Among factors the guidelines highlighted as relevant to decision-making, the three most strongly associated with the likelihood of an offer were tumour burden, planned radiotherapy and performance status. Depending on the combination of their values, the probability of an IR offer ranged from 7.4 to 85.1 per cent. A regression model that included all available factors discriminated well between whether or not women were offered IR (c-statistic 0.773), but revealed that increasing age was associated with a fall in the probability of an IR offer beyond that expected from older patients' tumour and co-morbidity characteristics. Conclusion: Clinicians are broadly following guidance on the offer of IR, except with respect to patients' age.

Research paper thumbnail of Socioeconomic deprivation and inpatient complication rates following mastectomy and breast reconstruction surgery

British Journal of Surgery, Jun 15, 2015

Background: Socioeconomic deprivation is known to influence the presentation of patients with bre... more Background: Socioeconomic deprivation is known to influence the presentation of patients with breast cancer and their subsequent treatments, but its relationship with surgical outcomes has not been investigated. A national prospective cohort study was undertaken to examine the effect of deprivation on the outcomes of mastectomy with or without immediate breast reconstruction. Methods: Data were collected on patient case mix, operative procedures and inpatient complications following mastectomy with or without immediate breast reconstruction in the English National Health Service between 1 January 2008 and 31 March 2009. Multivariable logistic regression was used to examine the relationship between patients' level of (regional) deprivation and the likelihood of local (mastectomy site, flap, flap donor and implant) and distant or systemic complications, after adjusting for potential confounding factors. Results: Of 13 689 patients who had a mastectomy, 2849 (20⋅8 per cent) underwent immediate reconstruction. In total, 1819 women (13⋅3 per cent) experienced inpatient complications. The proportion with complications increased from 11⋅2 per cent among the least deprived quintile (Q1) to 16⋅1 per cent in the most deprived (Q5). Complication rates were higher among smokers, the obese and those with poorer performance status, but were not affected by age, tumour type or Nottingham Prognostic Index. Adjustment for patient-related factors only marginally reduced the association between deprivation and complication incidence, to 11⋅4 per cent in Q1 and 15⋅4 per cent in Q5. Further adjustment for length of hospital stay, hospital case volume and immediate reconstruction rate had minimal effect. Conclusion: Rates of postoperative complications after mastectomy and breast reconstruction surgery were higher among women from more deprived backgrounds.

Research paper thumbnail of Surgical Determinants of Patient-Reported Outcomes following Postmastectomy Reconstruction in Women with Breast Cancer

Plastic and Reconstructive Surgery, May 1, 2017

Background: This national prospective cohort study compared the patient-reported outcomes of brea... more Background: This national prospective cohort study compared the patient-reported outcomes of breast cancer patients having post-mastectomy autologous reconstruction to those who had breast implants, in terms of aesthetic appearance, levels of psychological, physical and sexual well-being and overall satisfaction. Methods: Of 5,063 women who underwent immediate (IR; n=3,349) or delayed (DR; n=1,714) reconstruction between 1 January 2008 and 31 March 2009 in England, 2,923 women who consented were sent validated, procedure-specific 18-month follow up questionnaires. Outcome scale scores ranged from 0 (poor) to 100 (excellent); multiple linear regression was used to adjust scores for patient and treatment characteristics. Results: 2,289 women (78%) returned completed questionnaires (1,528 IR, 761 DR). For IR, mean overall satisfaction scores for the various techniques ranged from 67 to 85 (median 67 to 93). For DR, mean overall satisfaction scores ranged from 70 to 85 (median 75 to 100). For both groups, similar gradients were observed for the other outcome scales across techniques. Reconstruction using patients' own tissues tended to have higher mean adjusted scores compared with those techniques using implants alone (p<0.0001 for aesthetic appearance, psychological well-being, sexual well-being, and satisfaction with outcomes for IR and DR groups). Conclusion: Women who underwent autologous reconstruction tended to report greater satisfaction than those who had an implant reconstruction. These results can inform patients of the anticipated outcomes of their selected surgery but further research is required to confirm whether autologous reconstruction is superior in general.

Research paper thumbnail of The association between complications and quality of life after mastectomy and breast reconstruction for breast cancer

Cancer, May 17, 2017

Precis: Surgical complications are associated with little or no long-term impairment in quality o... more Precis: Surgical complications are associated with little or no long-term impairment in quality of life in breast cancer patients undergoing mastectomy without reconstruction, or delayed reconstruction. The association is much larger for flap-related complications suffered during immediate reconstruction. Background: Medical treatment for breast cancer is associated with substantial toxicity and patient burden. There is less known about the impact of surgical complications. Understanding this impact would provide important information for patients when considering surgical options. Methods: Between 2008 and 2009, the UK National Mastectomy and Breast Reconstruction Audit recorded surgical complications for a prospective cohort of 17,844 women treated for breast cancer at 270 hospitals. 6,405 of these women were surveyed about their quality of life 18 months after surgery. Breast appearance, emotional well-being and physical wellbeing were quantified on 0-100 point scales. Linear multiple regression models were used to compare the scores of patients who had complications to those who did not, while controlling for a range of baseline prognostic factors. Results: The overall complication rate was 10.2%. Complications were associated with little or no impairment in women undergoing mastectomy without reconstruction, or delayed reconstruction. The association was much larger for flap-related complications suffered during immediate reconstruction. The breast appearance (adjusted mean difference =-23.8; 95% CI,-31.0 to-16.6) and emotional well-being (adjusted mean difference =-14.0; 95% CI,-22.0 to-6.0) scores of these patients were much lower than any other patient group. Implant-related complications were not associated with lower quality of life in any surgical group. Conclusions: There is a strong case for prospectively collecting flap complication rates at the surgeon and surgical unit level, and allowing patients to access this data when they make choices about their breast cancer surgery.

Research paper thumbnail of Patients’ satisfaction with the reconstructive options provided to them measured 18 months after mastectomy surgery for breast cancer

European Journal of Cancer Care, Nov 10, 2020

INTRODUCTION Mastectomy patients' satisfaction with reconstructive options has not been exami... more INTRODUCTION Mastectomy patients' satisfaction with reconstructive options has not been examined. METHODS A national study measured 18-month satisfaction with reconstructive options and collected case-mix and reconstructive offer and uptake data on breast cancer patients having mastectomy with or without immediate reconstruction (IR) in England between January 2008 and March 2009. Multivariable logistic regression examined the relationship between satisfaction, age, IR offer and uptake, and clinical suitability. RESULTS Of 4796 patients, 1889 were not offered IR, 1489 declined an offer and 1418 underwent it. Women not offered IR were more likely older, obese or smokers and had higher ASA grades, ECOG scores, tumour burdens and adjuvant chemotherapy and radiotherapy likelihoods (9% of lowest suitability group offered IR; 81% in highest suitability group). 83.7% were satisfied with their reconstructive options, varying significantly by IR offer and uptake (76.1% for those not offered IR; 85.8% for those who declined IR; 91.7% following IR). Older women and women deemed more suitable for IR were more often satisfied (p-values <0.001). CONCLUSIONS Satisfaction varied by offer and uptake status, age and suitability score. Clinicians should target equity for women deemed unsuitable by exploring their needs and desired outcomes, standardising operative fitness assessments and utilising shared decision-making aids.

Research paper thumbnail of Findings of a national comparative audit of mastectomy and breast reconstruction surgery in England

Journal of Plastic Reconstructive and Aesthetic Surgery, Oct 1, 2014

This paper summarises the findings of a national audit of mastectomy and breast reconstruction su... more This paper summarises the findings of a national audit of mastectomy and breast reconstruction surgery carried out in England. It describes patterns of treatment, and the clinical and patient-reported quality of life outcomes associated with these types of procedure. Design: Prospective cohort study. Setting: All 150 National Health Service hospital groups (NHS trusts) in England that provided mastectomy or breast reconstruction surgery, along with six NHS trusts in Wales and Scotland and 114 independent hospitals.

Research paper thumbnail of The National Mastectomy and Reconstruction Audit as a driver for local service improvement. Improving peri-operative pain control in breast surgery

Ejso, May 1, 2012

, only patients responding with a 1 or 2 for all of the items within a subscale were classified a... more , only patients responding with a 1 or 2 for all of the items within a subscale were classified as satisfied for the subscale. Results: A total of 47 reconstructive procedures (29 immediate and 18 delayed) were done between April 2007 and Dec 2010. The study population consisted of 30 LD and 17 Sub-pectoral implant reconstructions during this period. 28 out of 47 (60%) patient satisfaction questionnaires were returned. Conclusion: Most patients were satisfied with their breast reconstructions and would recommend this procedure to others. However it is important to assess the reasons for the need to wear a prosthetic shell in 20% of patients.

Research paper thumbnail of Breast Cancer in Reduction Mammoplasty specimens: 10-year experience

Research paper thumbnail of Burns in patients with impaired sensibility of the hands—a case of osteomyelitis in a neglected thumb burn

Research paper thumbnail of Interpleural analgesia in breast reconstruction

Scandinavian journal of plastic and reconstructive surgery and hand surgery, 2008

To investigate the safety and efficacy of interpleural analgesia for postoperative pain control i... more To investigate the safety and efficacy of interpleural analgesia for postoperative pain control in patients having breast reconstruction we did a retrospective audit of 114 women who had had their breasts reconstructed by the same team. A group of 22 women given morphine postoperatively acted as a historical control. Ninety-two women were given continuous postoperative interpleural bupivacaine with free access to morphine. We recorded complications, morphine consumption, postoperative pain, nausea and vomiting scores, and duration of hospital stay. There was one episode of air entrapment. Morphine consumption was significantly reduced in the interpleural group (p&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.000). Pain scores were similar in all groups (p=0.11). Nausea and vomiting scores were significantly lower in the interpleural group (p=0.04) and hospital stay was shorter in the interpleural group but not significantly so (p&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.9). We conclude that interpleural analgesia improves the quality of postoperative care in breast reconstruction with latissimus dorsi flaps.

Research paper thumbnail of A new method for the assessment of suturing ability

PubMed, Dec 1, 1997

A new method for the formal assessment of surgical ability in simple wound closure is presented. ... more A new method for the formal assessment of surgical ability in simple wound closure is presented. Suture tension and accuracy of placement are measured indirectly in a standardized rig using Lyofoam as a skin substitute. This method has been used to assess a group of seven junior hospital doctors before and after instruction in a workshop setting. Formal instruction reduced suture tension by an average of 30.3% for the group as a whole (P < 0.01). Standard deviation in inter-suture distance was reduced by an average of 39.4% (P < 0.05), suggesting increased accuracy of suture placement following teaching. On the basis of this study, it appears that those involved in suturing wounds would benefit from postgraduate instruction in workshop setting early in their career.

Research paper thumbnail of An atraumatic technique for harvesting cancellous bone for secondary alveolar bone grafting in cleft palate

British Journal of Plastic Surgery, Oct 1, 1985

Secondary alveolar bone grafting in cleft palate patients has been popularised by the Oslo group.... more Secondary alveolar bone grafting in cleft palate patients has been popularised by the Oslo group. Harvesting of the bone graft has been carried out by techniques developed initially for crania-facial surgery. This paper describes a more refined technique applicable to the requirements of alveolar bone grafting. The Craig bone biopsy set is used to trephine cores of autogenous particulate marrow and cancellous bone from the iliac bone. The method was tested in a cadaver and then applied in 10 clinical cases. The aesthetic and functional results of this technique proved to be superior to the conventional approach.

Research paper thumbnail of An anatomic review of the delay phenomenon: II. Clinical applications

PubMed, Mar 1, 1992

This paper applies the anatomic concepts and data obtained from our animal experimental studies o... more This paper applies the anatomic concepts and data obtained from our animal experimental studies of the delay phenomenon to a series of clinical cases. Similar clinical results were obtained to those seen in Part I of our study when skin flaps were raised with and without a delay, when a tissue expander was used, and when the delay technique was extended to musculocutaneous flaps. In each instance, the cutaneous perforators were identified with the Doppler probe to facilitate the delay of specific vessels rather than dividing those at random. Intraoperative arteriograms and venograms reveal that the choke arteries dilate and the anatomically unfavorable valved vein segments become regurgitant. The end result is the observation that at least one additional anatomic vascular territory can be added to the length of a flap with safety following a surgical delay.

Research paper thumbnail of An anatomic review of the delay phenomenon: I. Experimental studies

PubMed, Mar 1, 1992

A number of experiments were conducted to study the anatomic changes in a flap following a surgic... more A number of experiments were conducted to study the anatomic changes in a flap following a surgical delay using the Doppler probe to add precision to the technique. After scanning the integument of a series of anesthetized animals with the probe, each was sacrificed; a total-body arterial injection was performed with a lead oxide mixture, the integument and deep tissues were radiographed separately, and the results were correlated and compared with our previous human studies. The dog was selected from the range of animals examined, and the arterial networks of a number of skin and muscle flaps were studied with and without a surgical delay. The study included the use of a tissue expander. Results revealed that an adjacent cutaneous perforator could be captured with safety on the artery at the base of an undelayed flap; that the survival length of that flap was related to the distance between perforators; that the necrosis line of the flap usually appeared in the zone of choke vessels connecting adjacent territories; that a surgical delay results in a dilatation of existing vessels with maximal effect in the zone of choke arteries; that the most effective delay was obtained by elevating the flap in stages from the base, leaving detachment of the tip until last; that tissue expansion is a form of surgical delay, with particular emphasis on vessel hypertrophy; and that similar changes occur when a muscle is delayed. The clinical applications of this investigation are presented in Part II of this anatomic review of the delay phenomenon.

Research paper thumbnail of Abstract P6-03-02: Breast Reduction Mammoplasty and Incidence of Occult Carcinoma. A 10 Year Experience

Background: The aim of this study was to report the incidence of cancer in reduction mammoplasty ... more Background: The aim of this study was to report the incidence of cancer in reduction mammoplasty specimens and suggest alternative pragmatic cost-effective way of identifying and treating patients with carcinoma. Methods: All patients who underwent breast reduction surgery at Northern General Hospital over a 10-year period were identified from a prospective database. The histopathology reports and case records of all patients with significant abnormalities were analysed. All breast reduction specimens were sliced at 1 cm intervals and examined macroscopically. At least 3 blocks per breast were examined microscopically in addition to sampling of any grossly abnormal tissue. Results: Between October 1999 and April 2010, 1,588 patients underwent reduction mammoplasty. The median age of patients was 38 years (range 16-75 years). Indications for surgery were macromastia in 1,194 (75.2%), congenital asymmetry in 182 (11.5%) and contralateral symmetry procedure post breast cancer surgery in 178 (11.2%). 9 specimens showed atypical hyperplasia (0.57%). 5 cancers were detected (0.31%). 4 of the 5 patients had normal mammograms 1-3 years before the reduction operation (not done in 1). Of these cancers, 4 were invasive (3 invasive lobular, 1 invasive ductal) (0.25%) (mean invasive tumour size 9 mm (SD 7.4)) and 1 was DCIS (4mm) (0.06%). A lump was felt macroscopically by the pathologist in 2 of the 4 patients with invasive cancer. The median age of patients with invasive cancer was 56 years (range 47-68 years). Patient found to have DCIS did not undergo further surgery while those with invasive disease underwent mastectomy (3) and axillary nodal staging (4). None of the patients with benign/normal post-reduction breast imaging had residual breast cancer on histology. Conclusion: The incidence of occult carcinoma in reduction mammoplasty specimens is less than 0.5%. Pre-operative mammogram is not useful as 4 of the 5 patients with cancer had a normal mammogram 1-3 years before surgery and invasive lobular cancers are often not detected on mammogram. Mastectomy may be avoided in patients with no residual breast disease on post-reduction imaging. Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P6-03-02.

Research paper thumbnail of Response to “In Defense of the International Collaboration of Breast Registry Activities (ICOBRA)”

Aesthetic Surgery Journal, Apr 6, 2016

Research paper thumbnail of Breast Implant Registries: The Problem with Ambition

Aesthetic Surgery Journal, Nov 3, 2015

Research paper thumbnail of A rare case of SCC in a young patient with incontinentia pigmenti

Journal of Plastic Reconstructive and Aesthetic Surgery, Aug 1, 2008

Research paper thumbnail of Breast Reconstruction

Springer eBooks, Dec 4, 2009

ABSTRACT Surgeons are invited to discuss breast reconstruction with all breast cancer patients (I... more ABSTRACT Surgeons are invited to discuss breast reconstruction with all breast cancer patients (Improving Outcomes in Breast Cancer - Manual Update 2002). In practice, this counseling and decision-making process is not solely surgeon- and patient-based, but is frequently complemented by the breast care nurse and other members of the multidisciplinary team. The intention is that this recommendation should apply equally to the older patient as to the younger. This chapter presents what is relevant to this older group of patients and how this may affect our practice. For the purposes of this chapter, and keeping in line with the literature discussed below, older or elderly patients are defined as those over 60 years of age. The literature specifically relating to issues regarding breast reconstruction in the elderly patient is sparse. Previous studies have addressed changes in body image, patient preferences, technical aspects and risks of surgery, and outcomes, but no prospective study has been undertaken to follow a group of patients through the journey with comparison to their younger counterparts. Randomized controlled trials are difficult in this group where patients make an active choice whether to have a reconstruction and, if so, the type of reconstruction.