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Outcomes affect effective outcomes
Journal of Plastic, Reconstructive & Aesthetic Surgery (2006) 59, 1247e1256
SHORT REPORTS AND CORRESPONDENCE Reply to ‘Do basal cell carcinomas recur after complete conventional surgical excision? R.W. Griffiths, S.K. Suvarna, J. Stone BJPS (2005);58, 795e805’
We read the paper by Griffiths et al.1 with interest, and we were impressed by another high quality audit from this group. We would like to draw attention to the possibility of non-responder bias in not reporting recurrences or further BCC. Non-responder patients often have a different profile to those that do respond,2 and the difference can lead to significantly different clinical outcomes.3 In asking our clinical colleagues to provide feedback on our patients we need to bear in mind that repeated direct contact improves but does not give a total response,4 and late responders (which can equate with non-responders) are more likely to be more senior clinicians.5 Therefore we would urge a note of caution, even within clinical networks, of assuming a lack of response equates to no further problems occurring, especially with a lead time of several years for BCC recurrence.
References 1. Griffiths RW, Suvarna SK, Stone J. Do basal cell carcinomas recur after complete conventional surgical excision? Br J Plast Surg 2005;58:795e805. 2. Lahaut VM, Jansen HA, van de MD, et al. Non-response bias in a sample survey on alcohol consumption. Alcohol Alcohol 2002;37:256e60. 3. Barchielli A, Balzi D. Nine-year follow-up of a survey on smoking habits in Florence (Italy): higher mortality among non-responders. Int J Epidemiol 2002;31:1038e42. 4. Wensing M, Schattenberg G. Initial nonresponders had an increased response rate after repeated questionnaire mailings. J Clin Epidemiol 2005;58:959e61. 5. Barclay S, Todd C, Finlay I, et al. Not another questionnaire! Maximizing the response rate, predicting non-response and assessing non-response bias in postal questionnaire studies of GPs. Fam Pract 2002;19:105e11.
DOI of original article: 10.1016/j.bjps.2005.02.010.
D.L. Wallace W. Jaffe Plastic Surgery Unit, City General Hospital, Newcastle Road, Stoke on Trent ST4 6QG, UK E-mail address: [email protected] ª 2006 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2006.04.006
Outcomes affect effective outcomes I read with interest the report of Cole and Browne regarding a pilot study to assess performance measurements in reconstructive surgery.1 This paper comes from the Clinical Effectiveness Unit (CEU) of the Royal College of Surgeons of England. The CEU was established in 1998 and is an academic collaboration with the Health Services Research Unit of the London School of Hygiene and Tropical Medicine.2 The CEU has previously been associated with a review of patient-based outcome measures in Plastic Surgery. They concluded that the majority of Plastic Surgery research was fundamentally flawed and pledged to bring more ‘rigorous scientific standards’ to patient-based assessment and improve methodology in plastic surgery research generally.3 In view of these generally damning comments I was somewhat disappointed to read this new report which is both philosophically unconvincing and of questionable methodology. The argument previously developed was that patient-based outcome measures were important in plastic surgery so the choice of outcome measures in this report is rather surprising. To suggest that flap survival is directly related to outcome for the patient is, unfortunately, not a correct assumption. Conversely partial necrosis of a flap can still be associated with the desired limb salvage or reconstruction from the patient’s perspective. The proforma also fails to capture the re-admission revision which is highly relevant again from the patient’s point of view. Another, rather surprising feature is the arbitory cut off at 9 cm2. Such an exclusion is going to miss many highly challenging flaps in hand and head and neck
1248 reconstructions. Indeed this report rather reinforces the gulf between the ideals of the office bound academic and the realities facing the practicing surgeon and one can only wonder what Gillies and his contemporises would have made of what can best be described as the ‘Politicization of Plastic Surgery’! The failure rate of form filling, ‘ascertainment’, is over twice the failure rate of the reconstructive surgery that is being assessed and even the authors acknowledge that the power of analysis is such that it would take years to achieve any meaningful data if more realistic levels of unacceptable flap failure were used, i.e. >10%. The authors must, however, be congratulated in presenting honest data which serve to illustrate the conceptual and practical difficulties of assessing surgical performance by simple audit.
References 1. Cole RP, Browne JP. Towards performance measurement in reconstructive surgery: a multicentre pilot study of free and pedicled flap procedures. J Plast Reconstr Aesthet Surg 2006;59:257e62. 2. Clinical Effectiveness Unit.
Andrew Burd Department of Surgery and Plastic Surgery, The Chinese University of Hong Kong, Shatin, Prince of Wales Hospital, Hong Kong E-mail address: [email protected] ª 2006 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2006.04.005
A cost effective training tool for flexor tendon repair: Pig’s trotters Wright et al.1 have reported a model for flexor tendon repair using pig’s trotters. The usage of pig’s trotters has been part of the surgical curriculum for many years. All trainees must successfully complete the Basic Surgical Skills Course (BSS) by the Royal College of Surgeons of England, before appearing for the final Membership examination. The usage of pig’s trotters has been well described in the Trauma and Orthopaedics section of the BSS Participants Handbook and hands on experience is provided during the course. We acknowledge the author’s time and effort to promote this technique
Short reports and correspondence in their training curriculum, but one should not forget that this has been part of the Surgical Curriculum2 for the past 10 years.
References 1. Wright TC, Widdowson D, Khan M, et al. A cost-effective training tool for flexor tendon repair: Pig’s trotters. Journal of Plastic, Reconstructive & Aesthetic Surgery 2006;1:107e8. 2. The Royal College of Surgeons of England. Basic surgical skills: participant handbook. The Royal College of Surgeons of England; 1996. p. 38e9.
Amit Pabari P. Lim A. Linford P.M. Gilbert Plastic Surgery, McIndoe Burns Centre, Queen Victoria Hospital, Holtye Road, East Grinstead, West Sussex RH19 3DZ, United Kingdom E-mail address: [email protected] ª 2006 Published by Elsevier Ltd on behalf of The British Association of Plastic Surgeons. doi:10.1016/j.bjps.2006.03.063
Routine histological examination of the mastectomy scar at the time of breast reconstruction We read with interest the paper titled ‘Routine histological examination of the mastectomy scar at the time of breast reconstruction: important oncological surveillance?’ by Soldin et al.1 and the subsequent reply to that by Zambacos et al.2 We have audited our own experience on the above subject (January 2006) at the breast unit at Warwick Hospital and report our results on the subject. We identified 33 cases of delayed reconstructions over an eight-year period (1997e2005). Nineteen patients had their mastectomy scar analysed by routine H and E staining at the time of reconstruction. None of the 19 scars submitted for histological analysis showed any evidence of microscopic recurrence. More importantly, none of the patients from the group who did not have their scar analysed developed any local recurrence. We agree with Soldin et al. that the incidence of recurrence detected from the routine mastectomy scar analysis is very low and agree that histological examination of the mastectomy scar is of no benefit. Following our audit, we do not send mastectomy scars for routine histology at the time of delayed reconstruction.
SHORT REPORTS AND CORRESPONDENCE Reply to ‘Do basal cell carcinomas recur after complete conventional surgical excision? R.W. Griffiths, S.K. Suvarna, J. Stone BJPS (2005);58, 795e805’
We read the paper by Griffiths et al.1 with interest, and we were impressed by another high quality audit from this group. We would like to draw attention to the possibility of non-responder bias in not reporting recurrences or further BCC. Non-responder patients often have a different profile to those that do respond,2 and the difference can lead to significantly different clinical outcomes.3 In asking our clinical colleagues to provide feedback on our patients we need to bear in mind that repeated direct contact improves but does not give a total response,4 and late responders (which can equate with non-responders) are more likely to be more senior clinicians.5 Therefore we would urge a note of caution, even within clinical networks, of assuming a lack of response equates to no further problems occurring, especially with a lead time of several years for BCC recurrence.
References 1. Griffiths RW, Suvarna SK, Stone J. Do basal cell carcinomas recur after complete conventional surgical excision? Br J Plast Surg 2005;58:795e805. 2. Lahaut VM, Jansen HA, van de MD, et al. Non-response bias in a sample survey on alcohol consumption. Alcohol Alcohol 2002;37:256e60. 3. Barchielli A, Balzi D. Nine-year follow-up of a survey on smoking habits in Florence (Italy): higher mortality among non-responders. Int J Epidemiol 2002;31:1038e42. 4. Wensing M, Schattenberg G. Initial nonresponders had an increased response rate after repeated questionnaire mailings. J Clin Epidemiol 2005;58:959e61. 5. Barclay S, Todd C, Finlay I, et al. Not another questionnaire! Maximizing the response rate, predicting non-response and assessing non-response bias in postal questionnaire studies of GPs. Fam Pract 2002;19:105e11.
DOI of original article: 10.1016/j.bjps.2005.02.010.
D.L. Wallace W. Jaffe Plastic Surgery Unit, City General Hospital, Newcastle Road, Stoke on Trent ST4 6QG, UK E-mail address: [email protected] ª 2006 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2006.04.006
Outcomes affect effective outcomes I read with interest the report of Cole and Browne regarding a pilot study to assess performance measurements in reconstructive surgery.1 This paper comes from the Clinical Effectiveness Unit (CEU) of the Royal College of Surgeons of England. The CEU was established in 1998 and is an academic collaboration with the Health Services Research Unit of the London School of Hygiene and Tropical Medicine.2 The CEU has previously been associated with a review of patient-based outcome measures in Plastic Surgery. They concluded that the majority of Plastic Surgery research was fundamentally flawed and pledged to bring more ‘rigorous scientific standards’ to patient-based assessment and improve methodology in plastic surgery research generally.3 In view of these generally damning comments I was somewhat disappointed to read this new report which is both philosophically unconvincing and of questionable methodology. The argument previously developed was that patient-based outcome measures were important in plastic surgery so the choice of outcome measures in this report is rather surprising. To suggest that flap survival is directly related to outcome for the patient is, unfortunately, not a correct assumption. Conversely partial necrosis of a flap can still be associated with the desired limb salvage or reconstruction from the patient’s perspective. The proforma also fails to capture the re-admission revision which is highly relevant again from the patient’s point of view. Another, rather surprising feature is the arbitory cut off at 9 cm2. Such an exclusion is going to miss many highly challenging flaps in hand and head and neck
1248 reconstructions. Indeed this report rather reinforces the gulf between the ideals of the office bound academic and the realities facing the practicing surgeon and one can only wonder what Gillies and his contemporises would have made of what can best be described as the ‘Politicization of Plastic Surgery’! The failure rate of form filling, ‘ascertainment’, is over twice the failure rate of the reconstructive surgery that is being assessed and even the authors acknowledge that the power of analysis is such that it would take years to achieve any meaningful data if more realistic levels of unacceptable flap failure were used, i.e. >10%. The authors must, however, be congratulated in presenting honest data which serve to illustrate the conceptual and practical difficulties of assessing surgical performance by simple audit.
References 1. Cole RP, Browne JP. Towards performance measurement in reconstructive surgery: a multicentre pilot study of free and pedicled flap procedures. J Plast Reconstr Aesthet Surg 2006;59:257e62. 2. Clinical Effectiveness Unit.
Andrew Burd Department of Surgery and Plastic Surgery, The Chinese University of Hong Kong, Shatin, Prince of Wales Hospital, Hong Kong E-mail address: [email protected] ª 2006 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2006.04.005
A cost effective training tool for flexor tendon repair: Pig’s trotters Wright et al.1 have reported a model for flexor tendon repair using pig’s trotters. The usage of pig’s trotters has been part of the surgical curriculum for many years. All trainees must successfully complete the Basic Surgical Skills Course (BSS) by the Royal College of Surgeons of England, before appearing for the final Membership examination. The usage of pig’s trotters has been well described in the Trauma and Orthopaedics section of the BSS Participants Handbook and hands on experience is provided during the course. We acknowledge the author’s time and effort to promote this technique
Short reports and correspondence in their training curriculum, but one should not forget that this has been part of the Surgical Curriculum2 for the past 10 years.
References 1. Wright TC, Widdowson D, Khan M, et al. A cost-effective training tool for flexor tendon repair: Pig’s trotters. Journal of Plastic, Reconstructive & Aesthetic Surgery 2006;1:107e8. 2. The Royal College of Surgeons of England. Basic surgical skills: participant handbook. The Royal College of Surgeons of England; 1996. p. 38e9.
Amit Pabari P. Lim A. Linford P.M. Gilbert Plastic Surgery, McIndoe Burns Centre, Queen Victoria Hospital, Holtye Road, East Grinstead, West Sussex RH19 3DZ, United Kingdom E-mail address: [email protected] ª 2006 Published by Elsevier Ltd on behalf of The British Association of Plastic Surgeons. doi:10.1016/j.bjps.2006.03.063
Routine histological examination of the mastectomy scar at the time of breast reconstruction We read with interest the paper titled ‘Routine histological examination of the mastectomy scar at the time of breast reconstruction: important oncological surveillance?’ by Soldin et al.1 and the subsequent reply to that by Zambacos et al.2 We have audited our own experience on the above subject (January 2006) at the breast unit at Warwick Hospital and report our results on the subject. We identified 33 cases of delayed reconstructions over an eight-year period (1997e2005). Nineteen patients had their mastectomy scar analysed by routine H and E staining at the time of reconstruction. None of the 19 scars submitted for histological analysis showed any evidence of microscopic recurrence. More importantly, none of the patients from the group who did not have their scar analysed developed any local recurrence. We agree with Soldin et al. that the incidence of recurrence detected from the routine mastectomy scar analysis is very low and agree that histological examination of the mastectomy scar is of no benefit. Following our audit, we do not send mastectomy scars for routine histology at the time of delayed reconstruction.