This document discusses the relationship between evidence-based medicine and aesthetic plastic surgery. It provides definitions of evidence-based medicine and outlines its five primary components. The document then examines several examples of how evidence-based medicine has been applied to topics in aesthetic plastic surgery, including bariatric surgery outcomes, breast augmentation practices like antibiotic use and drain usage, and outcomes of facelifts with or without drain usage. It acknowledges that while plastic surgery literature often contains lower levels of evidence, the field should aim to both appreciate existing evidence and continue raising the overall level of evidence to best serve patients.
Let's Talk Research Annual Conference - 24th-25th September 2014 (Clare Mercer)NHSNWRD
"A 6 year study of mammographic compression force: practitioner variability within and between screening sites": Clare Mercer's presentation from the conference.
Let's Talk Research Annual Conference - 24th-25th September 2014 (Clare Mercer)NHSNWRD
"A 6 year study of mammographic compression force: practitioner variability within and between screening sites": Clare Mercer's presentation from the conference.
MGB is Great Look at the Data
MGB widespread persistent Confusion
Fear of Malnutrition
Need MGB Standardization Education Recognition of MGB Surgeons of Excellence
Comparison of Various Clinical Methods of Birth Weight Estimation in Term Pre...CrimsonPublishers-PRM
Comparison of Various Clinical Methods of Birth Weight Estimation in Term Pregnancy by Darshit G Prajapati in Perceptions in Reproductive Medicine_Crimson Publishers
Comparison of Various Clinical Methods of Birth Weight Estimation in Term Pre...CrimsonPublishers-PRM
Comparison of Various Clinical Methods of Birth Weight Estimation in Term Pregnancy by Darshit G Prajapati in Perceptions in Reproductive Medicine_Crimson Publishers
Exercise and cancer: How staying active can positively impact your health and...Inspire
In an hour-long webinar, nationally recognized exercise specialist Carol Michaels, MBA, ACE, ACSM discussed how maintaining an exercise program during cancer treatment and recovery can help patients to minimize treatment side effects, increase energy levels, and reduce stress, along with many other benefits. Inspire produced the educational webinar in partnership with the Bladder Cancer Advocacy Network, US TOO International, and ThyCa: Thyroid Cancer Survivors' Association.
This workshop is delivered by Dr. Daniel Santa Mina, a Registered Kinesiologist and Certified Exercise Physiologist with specialization in oncology. Dr. Daniel Santa Mina is a Scientist at the Princess Margaret Cancer Centre where he leads the Wellness and Exercise for Cancer Survivors Program (WE-Can) and an Assistant Professor in the Faculty of Kinesiology and Physical Education at the University of Toronto. His main areas of clinical-research focus are on the physiological, functional, and psychosocial effects of exercise for cancer survivors.
Audio and slides for this presentation are available on YouTube: http://youtu.be/ijBrsJCZQZs
Weidong Lu, MB, MPH, PhD, an oncology acupuncturist with Dana-Farber Cancer Institute's Leonard P. Zakim Center for Integrative Therapies, describes the the process of an acupuncture procedure, how it affects the body, and its benefits for breast cancer patients. This presentation was given at the Metastatic Breast Cancer Forum held at Dana-Farber on Oct. 5, 2013. The program was sponsored by EMBRACE (Ending Metastatic Breast Cancer for Everyone).
Audio and slides for this presentation are available on YouTube: http://youtu.be/UVRYzgFqVGM
Dana-Farber Nutritionist Hillary Wright presents on how to fight cancer with your fork. She discusses the importance of healthy eating, and dispels some of the common myths about certain foods and cancer.
Placental Elastography in Intrauterine Growth Restriction: A Case–control Studyasclepiuspdfs
Background: Intrauterine growth restriction (IUGR) is related to poor fetal outcome. Though, various tools are available for evaluation of IUGR they are notreliable inearly diagnosis of IUGR. Shear wave elastography (SWE) can be used to study the change in mechanical properties of various disease which can be a potential technique for early diagnosis of IUGR. Objective: The objective of the study was to compare the differences in SWE values of placentas between IUGR and normal pregnancies. Methodology: Normal second- and third-trimester pregnancies and IUGR pregnancies between 24 and 42 weeks period of gestation (POG), meeting the inclusion criteria were matched for age group and POG. SWE of placenta was performed in supine position during quiet respiration. The SWE of placenta was measured by placing the region of interest in relatively homogeneous area. The placental elasticity values obtained in pregnancies complicated by IUGR were compared with that of normal controls. Umbilical artery (UA) and fetal middle cerebral artery (MCA) Doppler findings were correlated with placental elasticity value of IUGR pregnancies.
MGB is Great Look at the Data
MGB widespread persistent Confusion
Fear of Malnutrition
Need MGB Standardization Education Recognition of MGB Surgeons of Excellence
Comparison of Various Clinical Methods of Birth Weight Estimation in Term Pre...CrimsonPublishers-PRM
Comparison of Various Clinical Methods of Birth Weight Estimation in Term Pregnancy by Darshit G Prajapati in Perceptions in Reproductive Medicine_Crimson Publishers
Comparison of Various Clinical Methods of Birth Weight Estimation in Term Pre...CrimsonPublishers-PRM
Comparison of Various Clinical Methods of Birth Weight Estimation in Term Pregnancy by Darshit G Prajapati in Perceptions in Reproductive Medicine_Crimson Publishers
Exercise and cancer: How staying active can positively impact your health and...Inspire
In an hour-long webinar, nationally recognized exercise specialist Carol Michaels, MBA, ACE, ACSM discussed how maintaining an exercise program during cancer treatment and recovery can help patients to minimize treatment side effects, increase energy levels, and reduce stress, along with many other benefits. Inspire produced the educational webinar in partnership with the Bladder Cancer Advocacy Network, US TOO International, and ThyCa: Thyroid Cancer Survivors' Association.
This workshop is delivered by Dr. Daniel Santa Mina, a Registered Kinesiologist and Certified Exercise Physiologist with specialization in oncology. Dr. Daniel Santa Mina is a Scientist at the Princess Margaret Cancer Centre where he leads the Wellness and Exercise for Cancer Survivors Program (WE-Can) and an Assistant Professor in the Faculty of Kinesiology and Physical Education at the University of Toronto. His main areas of clinical-research focus are on the physiological, functional, and psychosocial effects of exercise for cancer survivors.
Audio and slides for this presentation are available on YouTube: http://youtu.be/ijBrsJCZQZs
Weidong Lu, MB, MPH, PhD, an oncology acupuncturist with Dana-Farber Cancer Institute's Leonard P. Zakim Center for Integrative Therapies, describes the the process of an acupuncture procedure, how it affects the body, and its benefits for breast cancer patients. This presentation was given at the Metastatic Breast Cancer Forum held at Dana-Farber on Oct. 5, 2013. The program was sponsored by EMBRACE (Ending Metastatic Breast Cancer for Everyone).
Audio and slides for this presentation are available on YouTube: http://youtu.be/UVRYzgFqVGM
Dana-Farber Nutritionist Hillary Wright presents on how to fight cancer with your fork. She discusses the importance of healthy eating, and dispels some of the common myths about certain foods and cancer.
Placental Elastography in Intrauterine Growth Restriction: A Case–control Studyasclepiuspdfs
Background: Intrauterine growth restriction (IUGR) is related to poor fetal outcome. Though, various tools are available for evaluation of IUGR they are notreliable inearly diagnosis of IUGR. Shear wave elastography (SWE) can be used to study the change in mechanical properties of various disease which can be a potential technique for early diagnosis of IUGR. Objective: The objective of the study was to compare the differences in SWE values of placentas between IUGR and normal pregnancies. Methodology: Normal second- and third-trimester pregnancies and IUGR pregnancies between 24 and 42 weeks period of gestation (POG), meeting the inclusion criteria were matched for age group and POG. SWE of placenta was performed in supine position during quiet respiration. The SWE of placenta was measured by placing the region of interest in relatively homogeneous area. The placental elasticity values obtained in pregnancies complicated by IUGR were compared with that of normal controls. Umbilical artery (UA) and fetal middle cerebral artery (MCA) Doppler findings were correlated with placental elasticity value of IUGR pregnancies.
We report a case of acquired anterior thoracic lung herniation in a 63-year-old female. This painful herniation developed four years after uncomplicated video-assisted thoracic surgery for lung cancer resection and adjuvant radiation for concomitant breast cancer. The herniation site was remote from all prior incisions, and demonstrated intercostal muscle denervation and radiation fibrosis. The 8 cm x 10 cm chest wall defect was reconstructed with inlay PROCEED mesh and reinforced with a pedicled latissimus dorsi flap. Five months postoperatively the patient had complete resolution of symptoms, no evidence of herniation, and a stable wound.
Original StudyType of Breast Cancer Diagnosis, Screening,a.docxvannagoforth
Original Study
Type of Breast Cancer Diagnosis, Screening,
and Survival
Carla Cedolini,1 Serena Bertozzi,1 Ambrogio P. Londero,2 Sergio Bernardi,3,4
Luca Seriau,1 Serena Concina,1 Federico Cattin,1 Andrea Risaliti1
Abstract
Organized, invitational breast cancer screening in our population succeeded in detecting early-stage tumors,
which have been consequently treated more frequently with breast and axillary conservative surgery, com-
plementary breast irradiation, and eventual hormonal therapy. The diagnosis of invasive cancer with screening
in our population resulted in a survival gain at 5 years from the diagnosis.
Introduction: Breast cancer screening is known to reduce mortality. In the present study, we analyzed the prevalence
of breast cancers detected through screening, before and after introduction of an organized screening, and we
evaluated the overall survival of these patients in comparison with women with an extrascreening imaging-detected
breast cancer or those with palpable breast cancers. Materials and Methods: We collected data about all women
who underwent a breast operation for cancer in our department between 2001 and 2008, focusing on type of tumor
diagnosis, tumor characteristics, therapies administered, and patient outcome in terms of overall survival, and re-
currences. Data was analyzed by R (version 2.15.2), and P < .05 was considered significant. Results: Among the 2070
cases of invasive breast cancer we considered, 157 were detected by regional mammographic screening (group A),
843 by extrascreening breast imaging (group B: 507 by mammography and 336 by ultrasound), and 1070 by extra-
screening breast objective examination (group C). The 5-year overall survival in groups A, B, and C were, respectively,
99% (95% CI, 98%-100%), 98% (95% CI, 97%-99%), and 91% (95% CI, 90%-93%), with a significant difference
between the first 2 groups and the third (P < .05) and a trend between groups A and B (P ¼ .081). Conclusion: The
diagnosis of invasive breast cancer with screening in our population resulted in a survival gain at 5 years from the
diagnosis, but a longer follow-up is necessary to confirm this data.
Clinical Breast Cancer, Vol. 14, No. 4, 235-40 ª 2014 Elsevier Inc. All rights reserved.
Keywords: Breast cancer, Breast cancer screening, Invasive breast cancer, Mammographic screening, Overall survival
Introduction
Because of the detection of early-stage tumors, breast cancer
screening reduced breast cancer mortality in Europe by 25%-31%
in patients who were invited for screening and by 38%-48% in
those who were actually screened during the last decade of the
twentieth century and the first decade of the twenty-first.1 In our
region of Italy, an organized breast cancer screening was firstly intro-
duced in 2005, but despite the high compliance of invited women
1Clinic of Surgery
2Clinic of Obstetrics and Gynecology
University of Udine, Udine, Italy
3Department of Surgery, Ospedale Civile di Latisana, Udine, Italy
4 ...
How to have quality of life in Advanced ovarian malignancyRajesh Gajbhiye
Presentation given by Dr Rakhi Gajbhiye, Mauli Hospital Nagpur at MGIMS sewagram for an International conference on Womens Health Fatal Disorders Survival with Quality in collaboration with FOGSI.
This was the function to commemorate 100 th birth centenary of Dr Sushila
O número de cirurgias bariátricas aumentou dramaticamente nos últimos anos devido ao aumento taxas de obesidade nos Estados Unidos. Muitos desses procedimentos são em mulheres de em idade fértil, a perda de peso não só proporciona melhores resultados de saúde na gravidez, mas também apresenta desafios. Diretrizes são necessárias para mulheres em idade fértil considerando especialmente a gravidez e que desejam amamentar seus bebês.
Resultados de este estudo retrospectivo sugere que as mulheres pós-bariátricas grávidas se beneficiariam de consultas clínicas pré-natais para atender às necessidades suplementares. Consultas pré-natais com consultores de lactação e nutricionistas certificados podem contribuir com o estado nutricional e o aconselhamento da amamentação podem melhorar os resultados da amamentação para a díade. Encaminhamentos para nutricionistas e consultores de lactação
para dar continuidade à assistência durante todo o período fértil, incluindo a parte inicial do vida do bebê.
(Tradução livre de Marcus Renato de Carvalho)
Caren Stalburg, MD, MA presented to the 2016 annual Snow meeting of the Michigan Section of the American Congress of Obstetricians and Gynecologists (ACOG) about her program to train Michigan providers about the new Breast Density Notification Law (http://www.midensebreasts.org/).
Dr. Stalburg is Division Chief and Clinical Assistant Professor in the Division of Professional Education in the Department of Learning Health Sciences and Assistant Professor of Obstetrics and Gynecology in the University of Michigan Medical School.
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Breast surgery for Metastatic Breast Cancer : Cochrane Analysis Kundan Singh
Breast surgery plus systemic treatment may improve local PFS when compared to systemic treatment alone (HR 0.22, 95% CI 0.08 to 0.57; 2 studies; 607 women; I2 = 43%; low quality evidence)
The group receiving breast surgery plus systemic treatment probably had a shorter time
to distant PFS compared to the group receiving systemic treatment alone (HR 1.42, 95%CI 1.08 to 1.86; 1 study; 350 women; moderate-quality evidence)
5. Evidence Based Medicine
• the term itself sounds cold and too detached
for plastic surgery
• a specialty that necessarily involves close
interpersonal relationships with our patients,
each of whom has unique needs and desires
that do not seem amenable to a seemingly
homogenized statistical review
6. What is EBM?
“EBM is defined as the conscientious, explicit,
and judicious use of current best evidence,
combined with individual clinical expertise and
patient preferences and values, in making
decisions about the care of individual
patients”
– Swanson J, Schmitz D, Chung KC. How to practice evidence-
based medicine. Plast Reconstr Surg. 2010;126:286–294.
7. It has five primary components
1. Converting the need for information
e.g. about prevention, diagnosis, prognosis,
therapy or causation into an answerable
question.
8. It has five primary components
1. Converting the need for information
e.g. about prevention, diagnosis, prognosis,
therapy or causation into an answerable
question.
2. Tracking down the best evidence with
which to answer that question.
9. It has five primary components
3. Critically appraising that evidence for its:
-validity (closeness to the truth)
-impact (size of effect) and
-applicability (usefulness in our clinical
practice).
10. It has five primary components
4. Integrating the critical appraisal with our
clinical expertise and with our patient's
unique biology, values, and circumstances.
5. Evaluating our effectiveness and efficiency
in executing steps 1 through 4 and seeking
ways to improve for next time
11.
12. • Currently, most articles in the plastic surgery
literature are level 3, 4 or 5
• Articles with these levels of evidence are
indeed valuable
• Our intent as a society should not only be to
raise the overall level of evidence in the
plastic surgery literature BUT also practice it
14. Buchwald, H., Avidor, Y., Braunnald, E., et al. Bariatric surgery: A
systematic review and meta-analysis. J.A.M.A. 292: 1724, 2004
• Comprehensive review and meta-analysis
analyzed 136 bariatric surgery reports.
• This study reviewed 22,094 patients with a
mean age of 39 years (range, 16 to 64
years)
• Average body mass index of 46.9 (range,
32.3 to 68.8).
• The group was 72.6% female and 27.4%
male.
15. Buchwald, H., Avidor, Y., Braunnald, E., et al. Bariatric surgery: A
systematic review and meta-analysis. J.A.M.A. 292: 1724, 2004
• The authors concluded that co-
morbidities were improved by bariatric
surgery
– Lipid disorders improved in 70% of patients.
– Diabetes improved in 76.8% of patients.
– Hypertension improved in 78.5% of
patients.
– Obstructive sleep apnea improved in 85.7%
of patients.
16. • American Society for Bariatric Surgery, its
member surgeons performed:
– 28,800 weight loss operations in 1999
– 63,000 weight-loss operations in 2002,
– 140,000 weight-loss operations in 2004
• Mayo Foundation for Medical Education and Research.
Gastric bypass: Is this weight-loss surgery for you?
17. • American Society of Plastic Surgeons, nearly
56,000 body contouring procedures were
performed for massive weight loss patients in
2004 (140,000 weight loss operations)
18.
19.
20.
21.
22.
23. Implications of Weight Loss Method in Body Contouring
Outcomes:
Gusenoff, PRS 2009
499 patients (511 cases) were entered into a
prospective registry.
Diet and exercise patients were matched to
bariatric patients based on identical procedures
performed
All patients with a weight loss of greater than
50 lb were included
477 cases (93.3 percent) had bariatric
procedures
29 patients representing 34 cases (6.7 percent)
lost weight exclusively through diet and exercise
24. Implications of Weight Loss Method in Body Contouring Outcomes
Jeffrey A. Gusenoff, M.D. Devin Coon, B.A. J. Peter Rubin, M.D.
Plast. Reconstr. Surg. 123: 373, 2009
25. • Conclusion, that diet and exercise had:
– Higher absolute complication rates,
– Significantly higher infection rates (p = 0.03).
– When matched to 191 bariatric patients based on
procedures performed, had a higher complication
rate that did not reach significance (odds ratio,
1.5; p =0.28)
26. • Conclusion, that diet and exercise had:
– Higher absolute complication rates,
– Significantly higher infection rates (p = 0.03).
– When matched to 191 bariatric patients based on
procedures performed, had a higher complication
rate that did not reach significance (odds ratio,
1.5; p =0.28)
28. EBM and Breast Augmentation
– Khan (2009 Aesth Plastic surgery 34:42-47)
• 1628 patients (3256 breasts)
– Infection lowest in the group that received IV Ab at
induction and no post-op
– Nil statistical difference if given IV Ab at induction
and a course of post-op oral Ab
30. EBM and Breast Augmentation
• Location of incision?
– Weiner (2008 Aesth plastic surgery)
• 400 patient group, looking at capsule formation
• IMF incision 0.59% compared with 9.5% in periareolar
31. EBM and Breast Augmentation
• Compression garments post augmentation?
32. EBM and Breast Augmentation
• Nathan (Aesth plastic surgery 2001)
• 130 patients randomised to wearing post-op
compression garments or not
• NIL difference to bruising or haematoma
• Level 2
34. EBM and Breast Augmentation
• Drains
– Hipps (PRS 1978)
• Significantly reduced capsule formation when on low
suction
• But now thought outdated data
– Araco (Aesth plastic surgery 2007)
• 5 fold increase in infection
– Although level 1 or 2 doesn’t exist large body of clinical
data showing low capsular contractures rates when drains
not used
36. EBM and Breast Augmentation
• Pocket Irrigation
– Weiner ( PRS 2007)
• 50% betadine irrigation of pockets significantly lowered
capsule formation compared with saline
• No deflation of the implant device
– Adams (PRS 2001)
• In-vivo study using triple Ab solution (50000 unit
bacitracin, 1gm cefazolin, 80mg gent and 500mls saline)
– 3-4 decrease in capsule formation
37. EBM and Breast Augmentation
• Adams (PRS 2006)
• Prospective 6 year clinical study using above solution
compared with saline
• 1.8% vs 9.0% in augmentation group
• 9.5% vs 27.5% in reconstructive group
– Adams (Clinic Plastic Surgery 2009)
• Final solution with most broad spectrum cover is:
• 50mls betadine, 1gm cefazolin, 80mg gentamicin and
500mls saline
39. EBM and Breast Augmentation
Barnsley (PRS 2006) and Wong (PRS 2006)
Performed meta-analyses on effects of texturing on capsule
formation
Although many conflicting studies there is evidence that
when placed in subglandular position textured implants
produce less capsule formation than smooth
HOWEVER, this benefit is lost in the submuscular position
Level 1
Studies on types of implants, saline vs silicone, highly
cohesive vs less cohesive all have good results BUT
majority funded by manufacturer or the surgeons were
paid by them
41. EBM and Breast Augmentation and
Cancer
Silverstein (Cancer 1991)
presented a series of 20 women with breast ca who
had implants.
13 of these women had involved nodes. Suggested
implants had delayed diagnosis because silicone
obscured the breast tissue on mammography
Level 2
Xie (Int Journal of Cancer 2010)
Implants delayed the diagnosis of breast cancer but there was
no survival difference
Level 2
42. EBM and Breast Augmentation and
Cancer
Deapen: LA County (PRS 1997; 99:1346)
3182 women with implants (1953-1990) f/u for 18.7 yrs –
No evidence of delayed diagnosis or more advanced staging.
Augmentation in fact had 31 ca detected compared with expected
49 in general population
Level 2
Bryant & Brasher: Alberta, Canada (NEJM 1995; 332:1535)
10,835 women with implants (1973-1990)
no evidence for an increased risk of breast ca
Level 2
McLaughlin (J of National Cancer Inst 2006)
3486 patients followed up 9-37 years
Cancer rate was lower in the augmentation group but not statistically
significant
Level 2
43. EBM and Breast Augmentation and
Cancer
Jakub (PRS Dec 2004; 114(7), pp1737-1753)
4186 breast ca patients in Florida.
78 had prior augmentation.
If had augment:
More likely to present with a palpable mass - ?due to a smaller volume of
breast tissue which is pushed to the surface making examination easier.
Tumour size, nodal positivity, stage or prognosis was no different to the
non-augmented group.
Level 2
Hoshaw (PRS 2001; 107:1393)
Meta analysis of current literature.
Concluded that women with implants have no increased risk of breast cancer
nor is there a delay in diagnosis, an increased risk of of recurrence or
decreased survival.
Level 1
45. EBM Breast Reduction
• Cruz and Korchin (PRS 2004)
– Retrospective case series
– Control group of 149 women with a mean age of 27
who had children and were evaluated for breast
reduction
– Study group of 58 with mean age of 29 who had
children after breast reduction
– 61% control group vs 65% of study group were
successful at breast feeding (nil significant difference)
– 36% of control vs 28% of study group needed to
supplement breast feeding with formula
– Level 4
47. EBM Abdominoplasty
• Smoking:
– Manassa (2003 PRS)
• 1st to look at smoking and abdominoplasty
• 132 patients
• 49.7% vs 14.8% (p<0.01)
• Also related to number of cigarettes smoked over a
lifetime….with cut-off value of smoking and infection
being 8.5 pack years
• Relative risk 12-14 times
• Level 2
48. EBM Abdominoplasty
Antibiotics
Sevin (2007 JPRAS)
Prospective study of 200 patients
Nil Ab
Pre-op Ab only
Pre-op and post-op Ab
Significant increase in infection in no Ab group
Nil difference between the either Ab group
Level 2
Casear (2009 PRS)
300 patients with nil Ab with only 8% post-op infection rate requiring Ab
therefore advocated nil pre-op Ab
Level 4
50. EBM Facelift
• Jones (2007 PRS)
– Prospective randomised clinical trial on 50
consecutive patients
– Demonstrated a statistically significant
decrease in bruising as assessed by the
patient and the surgeon
– Level 2
• Tissue sealants?
– ????
51. “For surgeons who may accept average as
adequate, evidence-based medicine can be a
haven”
John Tebbetts PRS vol 128 (2) 596-597. 2011
52. “Surgical innovations have never in history derived
from level I or II evidence studies… Benchmarking to
average (even from an evidence level I or II study) and
excluding references to what is possible, regardless of
evidence level, guarantees mediocrity and suboptimal
outcomes for patients”
“Since when is best evidence (by evidence-based
medicine) better than evidence of what is best for
patients?”
– John Tebbetts PRS vol 128 (2) 596-597. 2011