Adherence to the evidence-based heart failure drug treatment: Are there sex-specific differences among new users?

BACKGROUND

The evidence-based heart failure (HF) drug treatment is made of a β-blocker and an angiotensin-converting enzyme inhibitor or an angiotensin II receptor blocker, or hydralazine + isosorbide dinitrate. Little is known about sex-based difference in adherence to the evidence-based HF drug treatment.

OBJECTIVES

To assess among new users of the evidence-based HF drug treatment, the association between sex and 1) persistence with the treatment 1 year after its initiation, 2) implementation of the treatment among those who persisted, and 3) overall adherence to treatment in the year following its initiation.

METHODS

A cohort study was conducted among new users of this treatment using Quebec medico-administrative data. Patients still on the evidence-based HF drug treatment one year after initiation were considered persistent. Among persistent users, those with ≥88% of days covered by the treatment were deemed to have adequately implemented it. Persistent patients who have adequately implemented the treatment were considered adherent. To measure the association between, on one hand sex, and on the other persistence, implementation and adherence, adjusted proportion ratios (APR) with their 95% confidence intervals (CI) were calculated.

RESULTS

Among 13,453 women, 72.1% were persistent, 72.2% adequately implemented the treatment, and 52.8% were adherent. Among the 14,614 men, these proportions were 73.6%, 67.9% and 50.1%, respectively. Men were less likely than women to be adherent to their treatment (APR: 0.96, 95% CI: 0.94-0.99).

CONCLUSION

Among individuals initiating an evidence-based multi-drug treatment for HF, men are less likely than women to be adherent to this treatment.

The impact of incident depression on medication adherence in patients with type 2 diabetes

BACKGROUND

Depression has been correlated with suboptimal adherence to antidiabetic drugs (ADs). Most studies on this topic were cross-sectional; thus, the directionality of this relationship could not be established. The objective of this study was to measure the association between incident depression and AD nonadherence among newly treated patients with diabetes.

METHODS

We performed a population-based cohort study among new AD users using the Quebec public health insurance data. To avoid immortal time bias, we carried out depression diagnosis-time distribution matching by assigning a date of depression diagnosis to individuals without depression. Nonadherence (i.e.,<90% of days covered by≥1 AD) during the year following depression diagnosis (real or assigned date) was the outcome. Multivariate logistic regression analyses that adjusted for baseline adherence and other confounders were used to estimate the adjusted effect of depression on AD nonadherence.

RESULTS

Between 2000 and 2006, we identified 3,106 new AD users with a subsequent diagnosis of depression and 70,633 without depression, of which 52% and 49% became non-adherent to AD treatment, respectively. Among patients with depression, 52.0% were considered AD non-adherent in the year after depression diagnosis compared with 49.0% of matched patients without depression. Depression was associated with AD nonadherence after accounting for baseline adherence and other confounders with an adjusted odds ratio of 1.24 (95% confidence interval: 1.13-1.37).

CONCLUSIONS

The results suggest that depression is an independent risk factor for AD nonadherence. Patients with type 2 diabetes and depression might benefit from adherence-enhancing interventions.

Comparative effectiveness of cardioprotective drugs in elderly individuals with type 2 diabetes

AIMS

Although many elderly individuals suffer from type 2 diabetes, the effectiveness of cardioprotective drugs in primary prevention of cardiovascular events in clinical practice in this population has rarely been evaluated. We aimed to assess the effectiveness of, (i) angiotensin converting enzyme inhibitors or angiotensin receptor blockers, (ii) statins, (iii) antiplatelet drugs and (iv) the combination of these three drugs, in the prevention of myocardial infarction (MI) and stroke in elderly individuals with type 2 diabetes.

METHODS

Using Quebec administrative databases, we conducted nested case-control analyses among a cohort of 17,384 individuals without a history of cardiovascular disease. Individuals were aged ≥ 66 years, newly treated with oral antidiabetes drugs and had not used any of the three above classes of cardioprotective drugs in the year before cohort entry. For each case (MI/stroke during follow-up), five controls were matched for age, year of cohort entry and sex. Use of each drug and of their combination was defined as current, past or no use. We calculated adjusted odds ratios (AOR) of MI/stroke.

RESULTS

We observed no reduction in the MI/stroke risk for users of ACEI/ARB nor for users of the three drugs combination. Longer exposure to statins was associated with a lower risk (AOR for every 30 days of therapy: 0.97; 95% CI: 0.96-0.99). By contrast, current use of antiplatelet drugs was associated with an increased risk of MI/stroke (1.40; 1.12-1.75).

CONCLUSION

The benefit of cardioprotective drugs in primary prevention was not clear in this cohort of elderly individuals with type 2 diabetes. A short duration of exposure to these drugs might explain the lack of benefit.

Insomnia and its relationship to health-care utilization, work absenteeism, productivity and accidents

BACKGROUND AND PURPOSE

To document and provide a micro analysis of the relationship between insomnia and health problems, health-care use, absenteeism, productivity and accidents.

PARTICIPANTS AND METHODS

A population-based sample of 953 French-speaking adults from Québec, Canada. Participants were categorized as having insomnia syndrome (SYND) or insomnia symptoms (SYMPT) or as good sleepers (GS). They completed questionnaires on sleep, health, use of health-care services and products, accidents, work absences and reduced work productivity. Data were also obtained from the Québec-government-administered health insurance board on selected variables (e.g., consultations with health-care professionals, diagnoses).

RESULTS

There were significantly more individuals in the SYND group relative to the GS group reporting at least one chronic health problem (83% vs. 53%; OR: 2.78) and who had consulted a health-care professional in the past year (81% vs. 60%; OR: 2.8). There were also higher proportions of individuals in the SYND group than in the GS group who had used prescription medications (57% vs. 30.7%; OR: 2.8), most notably to treat insomnia, mood and anxiety disorders, or who had used over-the-counter products (75.6% vs. 62.0%; OR: 1.8) and alcohol as a sleep aid (17.8% vs. 3.9%; OR: 4.6). In terms of daytime function, 25.0% of the SYND had been absent from work relative to 17.1% of GS (OR: 1.7), 40.6% reported having experienced reduced productivity compared to 12.3% of GS (OR: 4.8) and non-motor-vehicle accidents occurred at higher rates in the SYND group (12.5% vs. 6.4% for GS; OR: 2.4). No differences were found for hospitalisations or motor-vehicle accidents. Most of the associations remained significant even after controlling for psychiatric comorbidity. Rates for the SYMPT group were situated between SYND and GS on all major dependent variables. Furthermore, insomnia and fatigue were perceived as contributing significantly to accidents, absences and decreased work productivity, regardless of insomnia status.

CONCLUSIONS

This study indicates that insomnia is associated with significant morbidity in terms of health problems and health-care utilization, work absenteeism and reduced productivity, and risk of non-motor-vehicle accidents. Future studies should evaluate whether treating insomnia can reverse this morbidity.

Health-related quality of life in hypertension: impact of a pharmacy intervention programme

BACKGROUND AND OBJECTIVE

In a previous study, we observed that a pharmacy-based intervention programme decreased the blood pressure of hypertensive patients. The objective of the present study was to assess the effect of this pharmacy programme on the health-related quality of life (HRQOL) of individuals treated for hypertension.

METHODS

In a quasi-experimental cohort pilot study, we recruited 91 participants from nine pharmacies in the Quebec City area. We offered the intervention programme over a 9-month period to participants enrolled at four of the pharmacies. The other participants were not exposed to pharmaceutical services other than those usually given by their pharmacists. We used the SF-36 to evaluate HRQOL. Covariance analysis was used to test for significant differences of HRQOL scores between participants exposed and not exposed to the programme.

RESULTS AND DISCUSSION

When compared with the non-exposed participants, those receiving the intervention and with high income had an improvement in vitality score (P=0.05). On the contrary, low-income exposed participants did not show this benefit and had a decline in mental health score (P=0.01). Improvement in vitality is likely due to increased physical activity and to a reduction in systolic blood pressure in the high-income exposed group. The negative effect of the programme on the mental health of those exposed in the low-income group might be due to the fact that the programme was not effective in reducing blood pressure and may therefore have caused anxiety.

CONCLUSION

Pharmacists' interventions can have both a positive and negative impact on the HRQOL of individuals, treated with antihypertensive agents, depending on income level.

Persistence and discontinuation patterns of antihypertensive therapy among newly treated patients: a population-based study

The objective was to assess persistence with antihypertensive therapy (AHT) and discontinuation patterns in patients newly dispensed different antihypertensive drug classes in a natural Canadian population-based setting. Hypertensive patients initiating AHT monotherapy were included in this 3-year retrospective cohort study (N=21 326) using the Saskatchewan health-care databases. Persistence was defined as consistently refilling a new prescription for AHT within 90 days of a previous dispensing. New courses of AHT were also documented in nonpersistent patients. Kaplan-Meier and Cox regression analyses were used to compare persistence and new courses of therapy across initial drugs. Compared to the newer angiotensin II antagonists (AIIAs), the likelihood of discontinuing therapy over the 39-month study period was significantly higher for angiotensin-converting enzymes inhibitors (HR=1.29; 95% CI=1.16-1.43), calcium channel blockers (HR=1.42; 95% CI=1.27-1.60), beta blockers (HR=1.62; 95% CI=1.45-1.80) and diuretics (HR=1.92; 95% CI=1.73-2.14). In the year following treatment discontinuation, between 54 and 75% of patients initiated a second course of treatment. Patients initiated on an AIIA had a significantly higher likelihood of starting a new course of therapy after a first treatment discontinuation, compared to all other agents. In conclusion, hypertensive patients initiated on an AIIA not only had greater persistence to AHT but were also more likely to initiate a new course of AHT after discontinuation than those initiating treatment with other agents. Further studies are required that relate intermittent treatment behaviours to health outcomes and costs in hypertension.

Ambulatory use of inhaled beta(2)-agonists for the treatment of asthma in Quebec : a population-based utilization review

STUDY OBJECTIVES

To assess whether the utilization of inhaled short-acting beta(2)-agonists (ISAB) and inhaled long-acting beta(2)-agonists (ILAB) for the treatment of asthma was appropriate according to the 1996 Canadian Asthma Consensus Conference recommendations.

DESIGN

Population-based retrospective drug utilization review using pharmacists' billing data of the Prescription Drug Insurance Plan administered by the Quebec health insurance board. However, the database used did not contain complete patient clinical information to accurately assess severity of asthma.

SETTING

Province of Quebec, Canada.

PATIENTS

Persons who received at least one outpatient prescription of ISAB (age range, 5 to 45 years) or ILAB (age range, 12 to 45 years) for the treatment of asthma between August 1997 and April 1998.

MEASUREMENTS

Percentages of patients whose use was appropriate according to three criteria regarding the average daily dose of ISAB (criterion 1), the renewal interval of ILAB (criterion 2), and the concomitant daily use of corticosteroids for the expected length of utilization of ILAB (criterion 3).

RESULTS

Overall proportions of appropriate use according to criterion 1 were as follows: 75% (without inhaled corticosteroids [ICS]) and 84% and 43% (with one or more than one prescription of ICS, respectively). Appropriateness was slightly higher for female patients, younger patients (5 to 18 years old), and those treated by pediatricians. However, appropriateness was only 9% among patients who received at least two prescriptions of ISAB during the study period. The proportion of appropriate use was 19% according to criterion 2 and 15% according to criterion 3; there were few differences by gender or by age, but the appropriateness according to criterion 2 was somewhat higher for patients of respirologists.

CONCLUSION

Compared to the 1996 Canadian asthma consensus conference recommendations, ISAB are overused, ICS are underused, and ILAB are often used improperly. Close collaboration between health professionals and patients is essential to improve the pharmacotherapy of asthma.

Inter-provincial variation in government drug formularies

In Canada, coverage for ambulatory prescription drug expenditures is provided to some groups by provincial drug plans through a provincial formulary. Little is known about the drugs provincial formularies give access to. We report the variation in availability of new drug molecules (NDM) across provincial formularies. We identified 108 NDM approved in Canada between 1991 and 1998. From each drug plan bulletin or formulary, we abstracted names of NDM listed as per 15 January 1999. We compared the level of listing across provinces using kappa coefficients. In the Quebec, BC, Manitoba and Saskatchewan formularies, more than 70% of the NDM were listed. In four provinces, this proportion was lower than 50%. In general, the agreement between formularies was poor. There is a wide variation across provinces in terms of NDM listed in the formularies. This variation reflects inter-provincial differences in the way drugs are selected for coverage.

Tolerability of antihypertensive drugs in a community-based setting

BACKGROUND

Outside the experimental environment of clinical trials, the tolerability of angiotensin-converting enzyme inhibitors (ACEIs), calcium channel blockers (CCBs), and the angiotensin II antagonist losartan has not been compared.

OBJECTIVES

The purpose of this study was to estimate, in current clinical practice, the 3-month cumulative incidence of side effects among first-time users of losartan, ACEIs, and CCBs for hypertension.

METHODS

We conducted a prospective cohort study through a network of 173 pharmacies across Canada to identify patients with hypertension who were newly prescribed monotherapy with losartan, an ACEI, or a CCB. Individuals were interviewed by telephone 3 times over a 3-month period to determine perceived side effects of the antihypertensive medication prescribed. Data were analyzed using a multivariate logistic regression model.

RESULTS

Among the 663 eligible individuals, the 3-month cumulative incidence of perceived side effects was 52.5% (42/80), 60.2% (222/369), and 69.6% (149/214) for those treated with losartan, an ACEI, and a CCB, respectively. After adjustment for sex, age, level of education, number of symptoms perceived the week before entering the study, prior use of antihypertensive drugs, current use of any other drug, drug insurance coverage, and duration of hypertension, the odds of reporting a side effect were significantly higher among patients treated with an ACEI (odds ratio [OR] = 1.78: 95% CI, 1.02-3.12) or a CCB (OR = 2.65; 95% CI, 1.47-4.78) compared with patients treated with losartan.

CONCLUSIONS

In a community-based setting, we observed that losartan is better tolerated than ACEIs and CCBs. Given that the occurrence of side effects may contribute to lower adherence to drug treatment, the low incidence of side effects associated with losartan makes it an attractive antihypertensive drug choice.

Health-related quality-of-life measurement in hypertension. A review of randomised controlled drug trials

In hypertension, tolerability of drug treatment is important because individuals may see the use of antihypertensive medications as more troubling than their seemingly symptomless disease. This may result in noncompliance and ineffectual long term treatment. In the past 15 years, new antihypertensive medications have been marketed on the basis of the advantages they offer with regard to adverse effects and the unavoidable impact of such adverse effects on a person's quality of life. When related to health, quality of life refers to the physical, psychological and social dimensions of health that are influenced by a person's experiences, beliefs, expectations and perceptions. To measure this concept, many instruments, either generic or specific, may be used. The purpose of this study is to describe, by way of a critical review of the literature, the instruments that are most often used in the measurement of health-related quality of life (HR-QOL) in people using antihypertensive drug treatments. We carried out a search of the literature published in English in the period January 1966 to July 2000, looking for randomised controlled trials of antihypertensive drugs. Using the Medline database, we included 77 papers in our review. Our main finding suggests that HR-QOL changes associated with antihypertensive treatment are measured with many different instruments. In almost all studies, at least 1 instrument specific to a health dimension was used, whereas not many used a generic instrument only. The most commonly measured HR-QOL dimensions were cognitive function, symptomatic well-being, sexual function, psychological well-being, sleep dysfunction, social participation and general health perception. Since the choice of dimensions to measure depends not only on the disease but also on the drug, this review adds further evidence that a generic instrument as well as a preference measurement should be added to a specific instrument.

[International Prostate Symptom Scale. Evaluation of the usefulness of a French version]

OBJECTIVE

To evaluate the usefulness of a French-language version of the International Prostate Symptom Scale (I-PSS) by measuring, on this scale and on the quality of life index, the scores of patients with benign prostatic hyperplasia before and after prostate surgery.

METHOD

The questionnaire was completed by 14 men, mostly between 60 and 80 years old, 24 hours before surgery and 1 month and 3 months after surgery.

RESULTS

The French-language scale worked well. Scores changed from 19.1 before surgery to 7.5 3 months after surgery for prostate symptoms and from 8.5 to 4.5 for quality of life.

CONCLUSION

This version of the questionnaire is a valid tool for evaluating prostate symptoms reported by French-speaking people.

Appropriateness of omeprazole prescribing in Quebec's senior population

BACKGROUND

Prescribing omeprazole for the treatment of digestive disorders accounts for an important part of the costs in Quebec's drug benefit plan. In July 1993, the Quebec drug program listed omeprazole, with restriction, in its formulary. On January 1, 1994, this restriction was lifted; since then, omeprazole has been listed in the regular provincial formulary.

OBJECTIVE

To describe the appropriateness of initial omeprazole prescribing in the ambulatory senior population of Quebec in the 27 months after being listed without restriction.

SUBJECTS AND METHODS

A retrospective population-based cohort study was performed using prescription and medical services claims databases of the Quebec drug program. Data were extracted for elderly patients who received their first omeprazole prescription between July 1, 1994 and March 31, 1996.

RESULTS

Among the 47,140 first-time users of omeprazole identified, 7516 (15.9%) had had an endoscopy in the previous six months, 2308 (4.9%) were given an antimicrobial agent and omeprazole simultaneously, and 22,730 (48.2%) received omeprazole after prior use of an H2 receptor antagonist (H2RA) or a prokinetic drug. A total of 26,525 (56.3%) first-time users were prescribed omeprazole based on at least one of the three criteria listed above. Among these users, 729 (2.8%) received an H2RA concurrently with omeprazole. Altogether, 25,796 (54.7%) first-time users received omeprazole appropriately.

CONCLUSIONS

Although reimbursement for omeprazole prescriptions has not been restricted in Quebec since January 1, 1994, it was prescribed appropriately for elderly patients in the majority of cases studied.

[Accuracy of a self-administered questionnaire on the use of antibiotics]

BACKGROUND

To document the ambulatory use of drugs and the indications for that use, investigators often rely on self-administered questionnaires of questionable accuracy. The present study assessed the accuracy of a French Canadian self-administered questionnaire with regard to documenting current antibiotic drug use.

METHODS

The information independently obtained from physicians and pharmacists was compared with the information reported by 340 patients. Patients were asked to participate in the study by their pharmacist at the time that their prescribed antibiotic was dispensed. The proportion of agreement between the data sources was calculated with regard to antibiotic regimen characteristics and indications for use and the nature of the treated infection.

RESULTS

Self-reported information demonstrated a high level of agreement with data provided by physicians (k = 0.87) and pharmacists (k = 0.94), with regard to antibiotic names. Regarding the nature of the treated infection, the agreement between self-reported information and data obtained from physicians was substantial (k = 0.63). A total of 242 patients completed the questionnaire twice at two-week intervals. Test-retest reliability was high regarding both the antibiotic name (k = 0.72) and the nature of the treated infection (k = 0.86).

CONCLUSIONS

The self-administered questionnaire assessed in this study can reliably and accurately document the name of antibiotics used and the nature of the treated infections. Further work is needed to improve the accuracy of the questionnaire with regard to other components of antibiotics use.

Billing for cognitive services: understanding Québec pharmacists' behavior

BACKGROUND

There is growing evidence that pharmacists' interventions to solve drug-related problems are effective and cost-saving. Since 1978, under the Quebec provincial drug plan, payment for two cognitive services, the pharmaceutical opinion and the refusal to dispense a prescription, has been disbursed to community pharmacists. However, the number of claims for these services lags far behind expectations.

OBJECTIVE

To identify factors influencing Quebec community pharmacists in the billing for a pharmaceutical opinion or for a refusal to dispense.

METHODS

Questions on predisposing, enabling, and reinforcing factors potentially related to pharmacists' behavior were included in a self-administered questionnaire sent to all 3517 community pharmacists practicing in the province of Quebec during 1996. Using multivariate logistic regression, models were built to explain billing for an opinion and billing for a refusal.

RESULTS

According to our models, the typical pharmacist who billed for opinions or refusals in Quebec is <45 years of age, has attended a continuing education program on this topic, and believes that billing for interventions is important. This typical pharmacist handles a mean daily volume of 100-250 prescriptions, uses a decision-support computer program, and has sufficient technical staff assistance. This pharmacist believes that interventions can be billed rapidly and are consistently paid by the province's drug plan.

CONCLUSIONS

In order to increase the billing of pharmaceutical care in community pharmacies, tailored educational programs should be offered to pharmacists. There is also a need to improve working conditions in pharmacies.

Choice of initial antihypertensive medication and continuation of use

Three recent studies that have focused on the discontinuation of initial antihypertensive medications are reviewed. The studies reviewed indicate that newly prescribed antihypertensive medications are associated with high levels of discontinuation in the months following the initiation of treatment. After six months, less than 50% of patients are on initial treatment regardless of which of the following classes of medication has been prescribed: diuretics, beta-blockers, calcium antagonists or angiotensin-converting enzyme inhibitors. A higher proportion of patients on losartan than on angiotensin-converting enzyme inhibitors continue their initial treatment after 12 months. More research designed to assess the effectiveness of treatments in real life situations is needed. In particular, there is a need to clarify the role of side effects on continuation of initial treatment.

[Evaluation of the prescription quality: hospital databases]

Hospital databases can be used to evaluate drug prescription quality with the help of drug utilization review (DUR). A DUR appraises the appropriateness of prescribing by means of explicit criteria established in accordance with evidence-based data, and then suggests interventions designed to modify prescriber's practice. On the one hand, the capacity of the review to show the variations, and, on the other hand, the assessment of the impact of interventions implemented to correct those variations, depend on the quality of hospital databases. This article has two objectives: to identify the required data, both to carry out a DUR and to evaluate its outcomes, and to define the essential qualities of hospital databases.

[Validation of a French adaptation of the international prostatic symptom score]

OBJECTIVE

To evaluate the reliability and the validity of a French Canadian version of the International Prostatic Symptom Score.

DESIGN

Between November 23, 1993 and April 8, 1994, a self-administered questionnaire was submitted to a group of men on two occasions at an interval of at least one week. This questionnaire was composed of seven questions designed to score the severity of prostatic symptoms and two questions designed to score quality of life.

CONTEXT

Family medicine unit and prostatic cancer screening programme of the hormonal treatment clinic of the Laval University hospital centre.

PARTICIPANTS

Men between the ages of 50 and 80 years presenting for prostatic cancer screening or for a family medicine visit were invited to participate. A total of 207 men answered the questionnaire on the first occasion and all but two answered the questionnaire on the second occasion. MAIN ASSESSMENT CRITERIA: The internal consistency of the scale, its test-retest stability, the correlation between the prostatic symptom index of the scale and the quality of life index and the urine output were estimated.

RESULTS

The internal consistency of the scale has found to be good, with Cronbach's coefficient alpha equal to 0.82. Each question of the scale displayed a good test-retest stability, with coefficient Kappa varying between 0.41 and 0.66 according to the question. The correlation coefficient between the prostatic symptom index of the scale and the quality of life index was 0.75 (P < 0.001). An inverse linear relationship was observed between urine output and the prostatic symptom index, with a correlation coefficient of -0.289 (p < 0.001).

CONCLUSION

The psychometric qualities of the adapted scale, evaluated during the present study, are similar to the qualities of the original English language I-PSS scale. The present French version of the scale constitutes a reliable and valid tool to assess the severity of prostatic symptoms in the Quebec male population.

[Study on insomnia treatment by family physicians]

OBJECTIVES

To describe treatment of insomnia in general practice and to identify family physicians' training needs in this area.

DESIGN

Mail survey using Dillman's total design method.

PARTICIPANTS

A sampling of 484 general practitioners in the Quebec City area was done to provide roughly equal representation of six practice settings. The response rate was 65%; 295 of the 315 questionnaires returned were selected for analysis.

RESULTS

Most physicians reported treating insomnia with general advice and lifestyle changes; 25% reported prescribing hypnotics frequently; 56% reported they prescribed them occasionally. Although 58% often recommend relaxation techniques, only 8% taught these techniques to their patients. Other cognitive and behavioral approaches are rarely used. Most felt that training in treating insomnia should be offered.

CONCLUSION

Cognitive and behavioral approaches are very effective approaches are very effective nonpharmacological treatments for insomnia. General practitioners make little use of these treatments that could be easily integrated into clinical practice. Strategies for increasing their use discussed.

Medication Compliance in a Family Practice: Testimg a self-report questionnaire in a primary care setting

For the physician in a primary care setting, a self-report questionnaire on medication compliance can help to determine whether a lack of hypertension control is due to a drug-taking behavior problem or inadequate medication. Such a questionnaire can easily be implemented as a part of routine care and can help clinicians increase the efficiency of medical care dispensed to hypertensive patients.

Management of the remaining breast in breast reconstruction

Prophylactic subcutaneous mastectomy is performed only in high risk patients. In other cases, the breast is adapted if needed by conventional techniques. These are slightly modified to obtain a less conical shape of the breast and preserve the whole surface of the areola. In the majority of the cases the nipple-areolar complex will be used at a second stage as donor site for the reconstructed breast.