Evaluating the results of surgical treatment of wound defects and cicatricial deformities of the breast and chest

Introduction

Patient satisfaction and health-related quality of life are becoming important outcomes for assessing the success of breast and chest reconstructive procedures. Patient evaluation of the results of surgical treatment of breast and/or chest lesions is particularly important, as the main goals are patient satisfaction, psychosocial outcomes, physical functioning, and perception of aesthetic outcome [1]. Evaluation criteria for the results of reconstructive interventions influence the development of certain standards for making decisions regarding scientifically based tactics and methods of surgical interventions.

In Ukraine, there are still no evidence-based standards for evaluating the results of surgical treatment of patients with wound defects and cicatricial deformities of the breast and chest. Most surgeons rely on their own criteria or untested random scales to determine treatment outcomes. Currently, there is an urgent need to develop a reliable, simple method for assessing the functional and aesthetic results of treatment in this category of patients, which will have clinical, educational, and prognostic significance.

Currently, the Patient and Observer Scar Assessment Scale (POSAS) is widely used to assess scars. However, the scale has some limitations and is used to assess linear scars and contains separate elements of scar tissue characteristics. The basic structure of the scale with adaptation to our needs was used in the study.

To obtain important and reliable information on the quality of life and patient satisfaction with breast reconstruction procedures, an international assessment scale, the BREAST-Q Version 2.0^© questionnaire, was created in 2009 [2].

The BREAST-Q is a patient-reported outcome assessment tool that can be used to quantify the impact and effectiveness of breast surgery, including a questionnaire dedicated to reconstruction [1, 3]. Meta-analysis also confirmed the value of the BREAST-Q for measuring patient satisfaction and health-related quality of life after oncoplastic surgery [4, 5].

However, the BREAST-Q assessment scale has some limitations. It considers aspects of treatment in adult patients and does not take into account the pediatric population, and does not include reconstructive interventions for such severe pathologies as wound defects and scar deformities, especially after major burns of the breast and chest. In this study, we adapted certain modules of the reconstruction assessment scale to the topic of our study.

The goal is to develop a method for assessing the results of surgical treatment of patients with wound defects and cicatricial deformations of the mammary glands and chest.

Material and methods of the research

The study included patients with cicatricial deformities and wound defects of the mammary glands and chest with reconstructive interventions using various methods of flap formation and transplantation. The results of the analysis of the patient’s clinical characteristics who underwent breast and/or chest reconstruction demonstrate important aspects in the context of a comparative review of the methods used.

For patients under 18 years of age, preoperative and postoperative evaluation was performed by parents (guardians).

The study used a modified working scale, which was developed based on the BREAST-Q Version 2.0^© questionnaire, as well as the POSAS.

The paper considers the criteria for assessing post-burn breast deformities based on: subjective assessment of doctors (observers), anthropometric measurements, photo assessment during treatment. The survey process using the modified working scale involved several stages — before surgery and after reconstruction.

The modified work scale included both physician (obser­ver) and patient (parent/guardian) ratings in its component. In turn, each component had a rank 1 rating form, a rank 2 ra­ting form, and satisfaction rating scores.

Grade 1 rating forms for the patient or parent rating scale included:

Overall level of assessment, which includes satisfaction with appearance and ability to hide the defect.

Psychosocial well-being. This form reflects the mental and social well-being of patients, their emotional reactions, social adaptation, and self-perception.

Breast satisfaction. This form shows the patients’ overall satisfaction with the shape, volume, and appearance of the reconstructed breasts, as well as the presence of deformities in the donor sites.

Physical well-being. This form assesses the physical comfort and functioning of the chest after reconstruction and the site after the reconstruction where flaps were formed, including pain, discomfort, and limitation of movement.

Assessment of the impact of treatment, including the absence or progression of deformity (Table 1).

Table 1. Patient/parent rating scale

Grade 1 rating forms for the physician rating scale included:

The shape of the breast. The preservation of the shape or its underdevelopment is assessed.

Deficit of breast volume. The relative deficit is determined depending on the degree of damage and the method of restoration.

The assessment factor indicates displacement of the breast by the scars surrounding it.

Scar lesions of breast segments. The distribution of scar masses in areas of the breast and the possibility of their elimination are assessed.

Condition of scars. Both postoperative scars and scars located in the chest areas are evaluated (Table 2).

Table 2. Physician rating scale

Breast volume assessment is one of the most important information indicators during breast reconstructive procedures [6].

In addition, assessment of breast symmetry is very important for adequate selection of surgical interventions. The following methods of breast assessment are described in the literature: ultrasound, mammography, CT, MRI, Grossman-Roudner method using disks of different diameters, anthropometric measurements using anatomical landmarks, water displacement method, molding method using thermoplastic materials [7].

However, the use of anthropometric measurements is considered a reliable, cheap, fast, and reproducible method [6].

Anthropometric measurements of the breasts were performed using the BREAST-V system. According to this, the lowest point of the inframammary fold was determined at the intersection of lines drawn from the middle of the clavicle through the nipple and below and a horizontal line drawn from the midline of the sternum.

The authors argue that the larger the size of the lo­wer pole of the gland, the larger its volume [6]. Therefore, as the volume of the breast increases, the distance from the projection point of the inframammary fold to the nipple and the distance from the projection points of the inframammary folds of the breast become larger [6].

To determine breast symmetry, the lines from the jugular notch to the nipple were used, as well as the medial dimension from the mid-chest line to the nipple and the lateral dimension from the lateral fold of the gland to the nipple.

Anthropometric measurements of the volume and position of the breasts in girls were determined by anatomical landmarks of the chest. The anatomical location of the breasts in the upper parts is at the level of the 3rd rib, the lower — at the level of the 6th rib, the medial — the edge of the sternum and the lateral — the anterior axillary line. The position of the nipple areolar complex was determined at the intersection of the midclavicular line and the 5th rib.

This concept formed the basis of anthropometric measurements of the breasts in the pre- and postoperative periods, as well as in subsequent observations as the patient grew.

The segmentation of the breasts and adjacent areas was based on the anatomical landmarks of A.B. Nebril [10]. We divided the breasts and adjacent areas of the chest and upper abdominal wall into 10 segments [11].

Clinical observations

Patient A., received boiling water burn at the age of 3. Scar deformity of the 4th type, with damage of the 1–5th segment of the left breast, 7.9 segments on the left and 8 segments (Fig. 1A). The patient underwent excision of scars and reconstruction with a stretched flap from the 6th segment, with displacement and circular plastic surgery of the NAC (Fig. 1B). Fig. 1C shows the long-term postoperative result with normal development of the breast. When assessing according to the developed scale, the patient’s parents gave 18 points before the operation, 11 points in the early postoperative period, and the long-term result was 11 points. The doctor gave 17 points in the preoperative period, 9 points in the early postoperative period, and 9 points in the long-term result. The data indicate a positive assessment of the surgical intervention by both the patient and the doctor. However, despite the good result, postoperative correction is still necessary.

Figure 1. Results of treatment of patient A.: A — before surgery, B — early postoperative period, C — late postoperative period

Patient B., received boiling water burn at the age of 1 year. Scar deformity type 4, with damage of the 1–5 segments of the left breast, segments 7.9 on the left and segment 8 (Fig. 2A). The patient underwent excision of scars and plastic surgery with a stretched flap from the 6th segment, with displacement and circular plastic surgery of the NAC (Fig. 2B). Fig. 2C shows the long-term postoperative result with normal development of the breast. When assessing according to the developed scale, the patient’s parents gave her 18 points before the operation, 11 points in the early postoperative period, and 10 points in the long-term result. The doctor gave her 18 points in the preoperative period, 9 points in the early postoperative period, and 8 points in the long-term result. Given the positive assessment of the surgical intervention by both the patient and the doctor, the patient plans to correct the scar-changed areas adjacent to the reconstructed areas.

Figure 2. Results of treatment of patient В.: A — before surgery, B — early postoperative period, C — late postoperative period

Discussion

In recent decades, standardized measures of treatment outcomes have become increasingly important. First, the application of evidence-based medicine requires that the field of research evaluate the effectiveness of new and existing treatments. Therefore, no clinical trial can exist without appropriate outcome measurement tools that allow the results of the trial to be determined in a reliable and valid manner. These outcome measurement tools are vital in research settings, and indispensable in everyday clinical practice for monitoring scarring in individual patients [8].

Although an objective assessment by the treating physician can accurately determine the patient’s degree of health, the patient’s subjective perception and expectations are also important and can influence the assessment of the outcome.

In breast reconstructive surgery, a clear system of standardization of changes that occur in the patient’s body and locally at the site of the lesion during the development of scars is necessary. Such an assessment is necessary to work out the treatment tactics in each specific period of time, including reconstructive surgical methods, pharmacological agents and physiotherapeutic procedures. This is especially true for trauma in childhood, which must be taken into account in the process of child development.

The ideal tool for assessing scar changes should be non-invasive, painless, easy to obtain and reproduce [12].

The most commonly used scar assessment method is the Vancouver Scar Scale, which is based on four indicators: vascularization, pigmentation, thickness, and plasticity. However, it lacks clinical information from the patient’s (parent’s) perspective.

Other methods are also used, including computerized imaging, 3D digital analysis [13], etc. However, these methods are complex, require specific equipment, and trained personnel, which limits the ease of examination.

One of the most suitable assessments of post-burn scars is the POSAS scale, which includes both physician (observer) and patient (parent) assessment. However, the POSAS scale is designed to assess post-burn scars in general, which is not very suitable for assessing post-burn deformities of the breast, since this is an organ that, when damaged, causes both anatomical, functional, and cosmetic changes, as well as general, psychosomatic, and social changes.

In our work, a scale for assessing post-burn scar deformities of the MH using anthropometric measurements is proposed, which allows for flexible assessment of scar characteristics that vary over a large surface area with the involvement of adjacent tissues. These measurements help to correctly and realistically inform the patient about the postoperative result.

Patients have recently received more information and are increasingly participating in decision-making regarding treatment options and information regarding the expected prognosis of the treatment outcome [8].

As a prototype of the rating scale in our own adaptation, to capture and quantify the main domains of both objective research (physician) and the patient himself or his parents, we took the concept of patient satisfaction as a basis.

Objective assessment is carried out by the patient himself according to criteria that cannot be taken into account by the researcher, which include: satisfaction with appearance and the ability to hide the defect, mental and social well-being of patients, their emotional reactions, social adaptation and self-perception, general satisfaction of patients with the shape, volume and appearance of the reconstructed breasts, as well as the presence of deformations of donor sites, physical comfort and functioning of the chest after reconstruction and the site after the formation of flaps for reconstruction, including pain, discomfort and restriction of movement.

Indicators such as patient satisfaction and health-related quality of life are becoming important factors in assessing the success of surgical treatment of breast injuries [1, 9].

Conclusion

The proposed scale for assessing the results of surgical treatment of patients with wound defects and cicatricial deformities of the breast and thorax makes it possible to carry out a standardized assessment of various reconstructive interventions on the mammary glands or chest, both from the patient’s and the performer’s side.

References

Received/Надійшла до редакції: 16.01.2025
Accepted/Прийнято до друку: 20.01.2025