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Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."
Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011
Dr. Shankar P.R.
"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."
Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011 Anuradha
Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.
Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020
Original article / research
Full Version
Modified Lateral Intercostal Artery Perforator Flap in Immediate Partial Breast Reconstruction for Breast Cancer: A Retrospective Cohort Study
Correspondence Address :
Dr. Suhaildeen Kajamohideen,
Assistant Professor, Department of Surgical Oncology, Sri Ramachandra Medical College and Research Institute, Chennai-600116, Tamil Nadu, India.
E-mail: suhaildrdeen@gmail.com
Introduction: The primary surgical options for treating breast cancer involve mastectomy or Breast Conservative Surgery (BCS), which may or may not include reconstruction procedures. BCS helps achieve complete tumour excision with an acceptable cosmetic result. Contour deformities and asymmetry are associated with tissue excision in the lateral aspect of the breast. To address this issue, various techniques of volume replacement, such as the modified Lateral Intercostal Artery Perforator (LICAP) flap, can be performed.
Aim: To demonstrate the outcomes of a modified LICAP flap when a muscle flap is not available or desired.
Materials and Methods: A retrospective cohort study was conducted, reviewing all modified LICAP flaps performed for breast tumours in Department of Surgical Oncology, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India, a tertiary-level cancer centre, from June 2018 to August 2020. Patient demographics, surgical details, histopathology reports, and postoperative complications were collected.
Results: Ten patients underwent modified LICAP flaps over a two-year period. All patients had pT2 tumours with margin-negative resection, and the mean resection volume of the specimen was 370 cm3. Intraoperative patient repositioning was not necessary during the modified LICAP flap procedure. One patient experienced marginal wound necrosis, which was managed conservatively. No patients had scars extending beyond the posterior axillary line, and axillary dissection was performed without a separate incision.
Conclusion: The present study demonstrates the advantages of using a modified LICAP flap for breast reconstruction. The modified LICAP flap can be considered as an option for tumours located in the outer aspect of the breast, providing good access to the breast as well as the axilla, with an aesthetically acceptable scar.
Breast conservation, Carcinoma breast, Mastectomy
Modified radical mastectomy with or without reconstruction or BCS are the main treatment options for breast cancer. With a better understanding and implementation of oncoplastic techniques, the complexity of these BCS and reconstruction procedures is increasing. BCS has comparable survival rates to mastectomy when paired with adjuvant radiotherapy. Tumour factors, patient body habitus, co-morbidities, and patient wishes are taken into consideration when offering BCS as a treatment option (1).
Standard oncoplastic techniques involve volume displacement, resulting in a significant difference in the size of the breast, sometimes requiring contralateral reduction mammoplasty to achieve symmetry. In patients who initially have nearly symmetrical breasts preoperatively, volume replacement techniques can be performed instead of volume displacement techniques to maintain symmetry. The evolution of volume replacement oncoplastic techniques has progressed from musculocutaneous to fasciocutaneous flaps, and currently involves the use of perforator-based flaps composed solely of skin and subcutaneous tissue. The LICAP flap, as described by Hamdi M et al., stands out as an excellent method of volume replacement technique, relying on perforating arteries originating within the costal segment of the intercostal arteries (2).
The original LICAP flap described by Hamdi M et al., had two limitations. There was a need to reposition the patient to harvest the flap, and the scar extended from the lateral mammary fold to a point 5 cm behind the posterior axillary line, making the scar quite visible (2). To address these limitations, the LICAP technique was modified, and this article assesses the surgical technique, patient and tumour characteristics, and any postoperative complications of breast reconstruction using a modified LICAP flap.
A retrospective cohort study was conducted, reviewing all patients who underwent the modified LICAP flap procedure along with BCS from June 2018 to August 2020 at Department of Surgical Oncology, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India, a tertiary-level cancer centre.
Study Procedure
The patients were identified from a prospectively maintained database. The LICAP flap procedure had been performed on breast tumours in the upper and outer quadrants. Patient demographics, details of surgery, histopathology results, and any postoperative complications following the modified LICAP flap were collected and tabulated.
Surgical anatomy: The lateral chest roll, extending laterally from the breast, comprises both the skin and adipose tissue situated alongside the inframammary crease. To reconstruct the breast mound without an implant, a large chest fold can provide adequate tissue. Even when a distinct lateral fold is not clearly defined, it is still possible to harvest the flap since there is some a degree of excess skin in the upper back. The LICAP flap is based on the skin and subcutaneous pedicle containing analogous perforators, which are present more laterally in the inframammary fold. There are usually 2 to 5 lateral intercostal perforator arteries located within a range of 6 to 8 cm from the midaxillary line, based on the dissection studies conducted by Hamdi M et al., (2),(3),(4). The portion of the fold present within 6 to 8 cm of the midaxillary line represents the flap pedicle, which can be rotated 180°. A single perforator bundle measuring more than 0.5 cm in diameter is sufficient to provide blood supply to the flap, as indicated by Hamdi M et al., based on cadaver dissections. In 90% of the dissections, lateral intercostal perforators were found 2.67 to 3.49 cm from the anterior border of the latissimus dorsi muscle (3),(5).
Surgical technique: Prior to surgery, preoperative marking is performed to identify external landmarks, including the mid-axillary line, the lateral edge of the latissimus dorsi muscle, the inframammary fold, and its extension as the lateral chest fold. The anterior part of the incision is a continuation of the inframammary crease along the lateral aspect of the breast. Based on the redundancy of the lateral skin fold, another line is drawn elliptically in a posterior direction along the midaxillary line, completing the outline of the flap. This design ensures that the pedicle consistently includes cutaneous perforators from the intercostal vessels (Table/Fig 1),(Table/Fig 2) (2),(3),(4). The flap’s skin is de-epithelialised.
The skin flap is raised along the anterior border of the flap, and a wide local excision of the breast primary is performed. From the superior border of the flap, axillary dissection is completed, providing excellent access to both the breast and axilla. Clips are placed for marking within the cavity of the wide local excision. Once the dissection is complete, the flap is rotated 180 degrees to fill the defect and concealed within the skin envelope to provide a vascularised volume. The flap is supported with deep dermal and subcuticular sutures in its new location before closing the wound with a suction drain (Table/Fig 2).
Ten patients underwent BCS and modified LICAP flap between June 2018 and August 2020. The patient characteristics are summarised in (Table/Fig 3). All patients underwent preoperative multidisciplinary tumour board discussions. They all had a biopsy-proven breast carcinoma before surgery and were scheduled for initial surgery.
Out of the 10 patients, seven had tumour located in the upper outer quadrant, two had tumours in the upper quadrants at the 12 o’clock position, and one had a tumour in the lower outer quadrant. Seven patients had luminal B tumour biology, two had basal-like subtype, and one had Her-2 enriched tumour.
All patients had a pathological T stage of pT2, and the size of the excised tumour ranged from 2 cm to 4 cm (median size 2.9 cm), with clear margins. Axillary dissection and modified LICAP flap were performed in the same sitting. Five patients had pN0 nodal status, four had pN1a, and one had pN3a nodal staging. The volume of the breast specimen ranged from 140 cm3 to 600 cm3 (median 370 cm3).
The median postoperative stay was 48 hours, and the average duration of surgery was 120 minutes. None of the patients required perioperative blood transfusion. All patients were taught shoulder exercises and advised to continue them at home.
There were no perioperative mortalities. The drains were removed by the 10th day (range 8-14 days). No postoperative seroma infections were reported. One patient developed wound marginal necrosis and required debridement and resuturing. All patients underwent adjuvant chemotherapy and sequential radiotherapy and are currently on regular follow-up. The median duration of follow-up was 18 months, ranging from 6 to 30 months.
The primary goal of BCS is to achieve complete cancer removal with clear margins while also obtaining a favourable aesthetic outcome. Several factors influence the outcome and risk of complications, including the ratio of excised tissue volume to breast volume, tumour location, density of the glandular breast tissue, and the condition of the skin covering the area (1),(6),(7).
In traditional BCS for a large tumours in the upper outer quadrant, there is a potential risk of the nipple-areola complex experiencing deviation, which becomes more noticeable following radiotherapy, leading to contour deformity or depression in the breast parenchyma. Balancing the oncological requirement for wider excision with the patient’s desire for a pleasing aesthetic outcome can pose a significant challenge in standard BCS. These irregularities and imbalances in breast appearance have been documented as contributing factors to negative body image and reduced quality of life (8),(9),(10).
Oncoplastic breast surgery integrates the principles of both oncology and reconstructive surgery to achieve optimal results that are both oncologically sound and aesthetically pleasing. Oncoplastic procedures enable the removal of larger tumours relative to breast size, reduce the occurrence of positive margins, and the need for redo surgeries, while maintaining and improving the shape, symmetry, and cosmetic appeal of the breast (11).
To address these aesthetic problems, oncoplastic techniques with or without contralateral reduction procedures have been developed (12). In a retrospective review by Wijesinghe K et al., oncoplastic breast surgeries were shown to have wider surgical margins, decreased need for re-excision, better aesthetic outcomes, and similar operative times and complication rates (13). The LICAP flap, a perforator-based flap, has been added to the armamentarium of oncoplastic breast surgeries. The modified LICAP flap, initially described by Meybodi F et al., (3), offers several advantages over the traditional LICAP flap, including the elimination of the need for intraoperative patient repositioning and the achievement of a cosmetically pleasing scar. These perforator flaps do not alter the inframammary fold, and there is no need for skeletonisation of the perforator pedicle. In comparison to Meybodi F et al., the present flap was fashioned close to the anterior axillary line, resulting in a scar hidden by the breast and not extending into the axilla (Table/Fig 4) (3). Even in patients with tumours close to the upper inner quadrant at the 12 o’clock position, adequate exposure was provided by the incision for wide excision. The de-epithelialised skin placed under the skin flap contributes to the uniformity of the reconstruction, and the resultant scar is along the anterior axillary line. The volume replacement technique also enables BCS in patients with a large tumour volume to breast volume ratio. The modified LICAP technique is particularly suitable for women who wish to maintain their breast shape and size and who have excess tissue lateral to the breast and skin laxity.
Limitation(s)
The study has certain limitations, including its small sample size, which necessitates further assessment of patient satisfaction when comparing it with volume displacement oncoplastic techniques.
The volume replacement technique, such as the modified LICAP flap, provides immediate reconstruction of defects in the lateral aspect of the breast following BCS. The Modified LICAP flap also allows excellent exposure of the axilla and avoids the need for intraoperative patient repositioning, while also offering an aesthetically acceptable scar.
DOI: 10.7860/JCDR/2023/63829.18678
Date of Submission: Feb 28, 2023
Date of Peer Review: Apr 27, 2023
Date of Acceptance: Sep 24, 2023
Date of Publishing: Nov 01, 2023
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes
PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Mar 14, 2023
• Manual Googling: May 12, 2023
• iThenticate Software: Sep 20, 2023 (20%)
ETYMOLOGY: Author Origin
EMENDATIONS: 7
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