Breast Reconstruction after Mastectomy

Transcription

1 Breast Reconstruction after Mastectomy 1 Noor Jawad Al-Juwayed, 2 Raed Fahad Abdullah Al-Otibi Abstract: Background: Most women reported in many studies the improvements in important areas of life, and quality of life in terms of "social functioning" and "mental health" increased significantly after the reconstruction. The latissimus dorsi flap and TRAM flap scored significantly higher as compared with the lateral thoracodorsal flap for similarity with the contralateral breast and reduced problems in social situations. Objective: To determine the safety and efficacy of autologous fat grafting and other procedures for post mastectomy, and evaluate other plastic surgical procedures in breast reconstruction after mastectomy, also to introduce the most common techniques in breast reconstruction surgeries following mastectomy. Methods: we conducted our literature search for similar previous studies mainly in Medline (PubMed), the studies were included which are concerning the breast reconstruction especially after mastectomy. Results: The latissimus dorsi flap and TRAM flap scored significantly higher as compared with the lateral thoracodorsal flap for similarity with the contralateral breast and diminished issues in social circumstances. No contrasts in the middle of illuminated and nonirradiated patients were found. All techniques were considered to create great corrective results and changes in patient-characterized issue zones of life and personal satisfaction. No negative impacts were recorded. Thus, irrespective of method, breast reconstruction is a valuable tool for the mastectomized woman to cope with problems in everyday life. Conclusion: Breast reconstruction is an option for patients following a unilateral or bilateral mastectomy, or after breast conservation therapy that has had a less than ideal cosmetic result. Breast reconstruction provides psychological, social, emotional, and functional improvements, including improved psychological health, selfesteem, sexuality, and body image. Patients who choose breast reconstruction are presented with complex decisions, including the type and timing of reconstruction. Keywords: TRAM flap, Breast reconstruction, latissimus dorsi flap. 1. INTRODUCTION Breast reconstruction performed at the season of mastectomy is currently generally acknowledged as sheltered and compelling. Albeit a few studies have shown the mental advantages on a patients having breast reconstruction, the Canadian Clinical Practice Guidelines for the Care and Treatment of Breast Cancer (1998) make no reference to breast reconstruction. With the end goal ladies should settle on an educated decision, the choice of quick breast reconstruction ought to be talked about by the specialist before mastectomy. Ladies come to UBC Hospital for deferred breast reconstruction from all locales of BC. A large portion of these ladies state they were not educated about the alternative of prompt breast reconstruction preceding their mastectomy. The motivation behind this study was to decide, to begin with, what choices are introduced by specialists and general experts to ladies who require mastectomy, and second, whether people in general knows about the alternative of prompt breast reconstruction. Breast reconstruction choices at present incorporate remaking the breast utilizing a breast insert, commonly taking after a time of tissue development (alloplastic reconstruction) or by reproducing the breast utilizing the patient's own particular tissues, giving she has a suitable benefactor site (autogenous reconstruction TRAM fold from the midriff or latissimus dorsi fold from the back). These strategies should be possible at the season of mastectomy or whenever from that point, giving the patient's general wellbeing is suitable. Skin-saving mastectomy is a noteworthy point of preference over postponed reconstruction when a patient picks autogenous quick breast reconstruction, in light of the fact that it saves most of the characteristic skin brassiere and along these lines decreases obvious breast scars while advancing breast shape. In the lion's share of cancer the main skin that should be uprooted as a major aspect of the mastectomy is the areola areolar mind boggling and any biopsy scars. The Page 189

2 conventional circular mastectomy entry point is done to take into account an in fact simple and exhaustive evacuation of the fundamental breast. A few studies with acceptably long haul follow-up have demonstrated no expanded danger of neighborhood repeat with skin-saving strategies. The advantages of quick breast reconstruction incorporate enhanced mental prosperity, enhanced stylish results, and decreased expense. Determination of prompt reconstruction patients is done in discussion with the patient's surgical oncologist, therapeutic oncologist, and reconstructive specialist. Despite the fact that the known requirement for adjuvant chemotherapy or radiotherapy is not a contraindication to prompt reconstruction, it includes a potential extra many-sided quality and might improve the patient suited for one sort of reconstruction than another. The main burden of quick reconstruction is that a few patients hope to hold their common breast; in light of the fact that they have never lived with a mastectomy deformation, they might be less fulfilled than patients who have deferred reconstruction. Breast reconstruction after mastectomy has been viewed as an imperative stride in the recovery of breast cancer patients assuming a noteworthy part in the interdisciplinary treatment for the malady. Different techniques have been depicted in writing. They essentially incorporate tissue expanders, changeless inserts notwithstanding different types of autologous breast reconstruction. Autologous types of reconstruction are as of late increasing significant enthusiasm for this patient gathering. Breast reconstruction with autogenous tissues is known not a considerably more characteristic, sturdy and enduring choice for patients. The latissimus dorsi (LD) fold was initially depicted in the seventies for breast reconstruction. It has following turned into a typical practice to expand the volume of the standard LD by the expansion of a breast insert to make up for the little volume gave by the traditional fold. Despite the fact that the system is speedy and simple with a tastefully satisfying result, negative sequelae connected with breast embeds, for example, capsular contracture, insert removal and break can at present conceivably happen. The rate of capsular contracture has been variably reported in the writing and extends from 20 to 40% in a few studies. To stay away from the expansion of an insert to the LD fold, endeavors have been made to build the volume of the fold with autogenous tissues. The pedicled TRAM (transverse rectus abdominis muscle) fold is the favored strategy for autologous breast reconstruction by numerous specialists, especially in the USA. In reality, better tasteful results have been acquired by the free microvascular TRAM fold and all the more as of late, the DIEP perforator fold (profound sub-par epigastric supply route fold) making them the highest quality level in autologous breast reconstruction. The thoracodorsal vessels are kept in place amid axillary dismemberment while in deferred reconstruction, the trustworthiness of the thoracodorsal vascular framework ought to be checked from past surgical records. To be sure, a well-working Latissimus Dorsi muscle as controlled by preoperative clinical examination is normally suggestive of an in place thoracodorsal neurovascular group. The augmented LD (Latissimus dorsi) fold is another choice in autologous breast reconstruction. In any case, it has been occasionally reported and consigned to a second alternative in breast reconstruction in perspective of the astounding results and the considerable achievement in the most recent too many years of alternate techniques specified previously. By and by, pedicled and free TRAM or DIEP folds might be contraindicated or not favored by a few patients. For sure, the mind boggling execution of microvascular systems may not yet be conceivable in all focuses. Objectives: To determine the safety and efficacy of autologous fat grafting and other procedures of breast reconstruction following mastectomy, to support also the belief that breast reconstruction prevents appropriate surveillance for recurrence of disease, or that it affects disease-free survival or mortality, and to evaluate the safety of different procedures. But the main purpose of this study is to introduce the most common techniques in breast reconstruction surgeries following mastectomy. Also to determine whether immediate breast reconstruction affected the psychosocial morbidity of mastectomy. 2. METHODOLOGY A literature search and systemic review was carried out on Databases including MEDLINE (PubMed), EMBASE, Cochrane Database of Systematic Reviews and Database of Abstracts of Reviews search was performed for studies published up to Studies were selected depending on reconstruction breast surgery following mastectomy, using the terms breast reconstruction, mastectomy, reconstructive surgery, breast surgery, breast implants, transverse rectus adominis myocutaneous (TRAM) flap, autologous fat grafting. All studies were included about reconstruction surgeries of breast after mastectomy. Page 190

3 3. RESULTS Reconstruction with the latissimus dorsi myocutaneous flap produces a breast with ptosis and projection while maintaining the natural consistency and feel of normal tissue. This flap provides ample bulk for reconstruction due to the large surface of the muscle. In many patients, the flap can be used without the use of an implant, restoring volumes of up to 1.5 L in large patients or with the use of modified techniques. During latissimus dorsi flap reconstruction surgery, an incision is made in your back near your shoulder blade. Then, an oval section of skin, fat, blood vessels, and muscle is slid through a tunnel under the skin under your arm to your chest and formed into a breast shape. The blood vessels are left attached to their original blood supply in your back. If any blood vessels do have to be cut, they are matched to blood vessels in your chest and carefully reattached under a microscope. left: Latissimus dorsi muscle, right: Latissimus dorsi flap moved to chest area to rebuild breast. (Singletary SE, et al, 1996) Skin-sparing mastectomy is a major advantage over delayed reconstruction when a patient chooses autogenous quick breast reconstruction since it safeguards most of the normal skin brassiere and in this manner decreases unmistakable breast scars while streamlining breast shape. In the lion's share of disease the main skin that should be evacuated as a major aspect of the mastectomy is the nipple areolar perplexing and any biopsy scars. The conventional curved mastectomy cut is done to take into account an actually easy and thorough removal of the underlying breast. Several studies with acceptably long-term follow-up have shown no increased risk of local recurrence with skinsparing techniques. implant based reconstruction immediately after mastectomy, a plastic surgeon must discuss all reasonable alternatives with a patient to enable the patient to make an informed decision and give truly informed consent. Unfortunately, there are few high quality instruments for measuring women s assessment of the outcome of reconstructive surgery, and the studies in this area are generally substantially flawed In particular, though several studies suggest that patients undergoing different reconstructive procedures have roughly similar degrees of satisfaction,24,35 this area needs more research, particularly for specific patient subgroups (e.g., those undergoing radiation therapy). Also, at least one study found that patients views of the results of reconstructive surgery change over time.35 Hence, practitioners need to be very cautious in comparing patients long term satisfaction with different reconstructive approaches or with immediate reconstruction compared to no reconstruction after mastectomy. Few studies have attempted to examine the views of women and their providers concerning what information is critical to the decision about reconstructive surgery. There are sometimes substantial differences between what each sees as most important. For example, in one study patients and providers most every now and again chose the same two top objectives of reconstructive surgery: to minimize the quantity of operations and to look common in garments. Then again, patients put more prominent significance on staying away from a prosthesis than suppliers did (33% versus 0%) and were less worried about looking characteristic without garments (24% versus 40%). Surgical judgment in the setting of quick implant based breast reconstruction is of fundamental importance. Eventually, it is the plastic specialist's obligation to survey the majority of the variables. In counsel with the patient and different individuals from the multidisciplinary group, the plastic specialist ought to add to a surgical arrangement predictable both with wishes of the patient and the evident dangers of the methodology. It is just through full and capable examination with the patient that these troublesome and nuanced contras can be communicated. During the informed consent process, patients must be made aware that an attempt at immediate implant based reconstruction carries with it substantially increased risks of complications. Such a discussion should be documented in accordance with informed consent protocols. Page 191

4 4. CONCLUSION Breast reconstruction after mastectomy has evolved over the last century to be an integral component in the therapy for patients with breast malignancy. Breast reconstruction initially was intended to diminish postmastectomy complexities and to right mid-section divider deformation, however its quality has been perceived to reach out past this restricted perspective of utilization. The objectives for patients experiencing reconstruction are to amend the anatomic defect and to restore form and breast symmetry. The surgical options for breast reconstruction involve the use of endoprostheses (implants), autogenous tissue transfers, or a combination of both. REFERENCES [1] Rowland JH, Desmond KA, Meyerowitz BE, et al. Role of breast reconstructive surgery in physical and emotional outcomes among breast cancer survivors. J Natl Cancer Inst 2000; 92:1422. [2] Dean C, Chetty U, Forrest AP. Effects of immediate breast reconstruction on psychosocial morbidity after mastectomy. Lancet 1983; 1:459. [3] Al-Ghazal SK, Fallowfield L, and Blamey RW Comparison of psychological aspects [4] and patient satisfaction following breast conserving surgery, simple mastectomy and breast reconstruction. Eur. J. Cancer 36 (15): [5] Metcalfe KA, Semple J, Quan ML, Vadaparampil ST, Holloway C, Brown M, Bower B, Sun [6] P, and Narod SA Changes in Psychosocial Functioning 1 Year after Mastectomy Alone, Delayed Breast Reconstruction, or Immediate Breast Reconstruction. Ann. Surg. Oncol. 2011, June 15. [7] D'Souza N, Darmanin G, and Fedorowicz Z Immediate versus delayed reconstruction [8] following surgery for breast cancer. Cochrane. Database. Syst. Rev. 7: CD [9] Al-Ghazal SK, Sully L, Fallowfield L, and Blamey RW The psychological impact of [10] immediate rather than delayed breast reconstruction. Eur. J. Surg. Oncol. 26 (1): [11] Slavin SA, Love SM, Goldwyn RM. Recurrent breast cancer following immediate reconstruction with myocutaneous flaps. Plast Reconstr Surg 1994; 93:1191. [12] Macadam SA, Ho AL, Lennox PA, Pusic AL. Patient-reported satisfaction and health-related quality of life following breast reconstruction: a comparison of shaped cohesive gel and round cohesive gel implant recipients. Plast Reconstr Surg 2013; 131:431. [13] Teimourian B, Adham MN. Survey of patients' responses to breast reconstruction. Ann Plast Surg 1982; 9:321. [14] Anderson SG, Rodin J, Ariyan S. Treatment considerations in postmastectomy reconstruction: their relative importance and relationship to patient satisfaction. Ann Plast Surg 1994; 33:263. [15] Cederna PS, Yates WR, Chang P, et al. Postmastectomy reconstruction: comparative analysis of the psychosocial, functional, and cosmetic effects of transverse rectus abdominis musculocutaneous flap versus breast implant reconstruction. Ann Plast Surg 1995; 35:458. [16] Stevens LA, McGrath MH, Druss RG, et al. The psychological impact of immediate breast reconstruction for women with early breast cancer. Plast Reconstr Surg 1984; 73:619. [17] Schain WS. Breast reconstruction. Update of psychosocial and pragmatic concerns. Cancer 1991; 68:1170. [18] Brandberg Y, Malm M, Blomqvist L. A prospective and randomized study, "SVEA," comparing effects of three methods for delayed breast reconstruction on quality of life, patient-defined problem areas of life, and cosmetic result. Plast Reconstr Surg 2000; 105:66. [19] Morrow M, Mujahid M, Lantz PM, et al. Correlates of breast reconstruction: results from a population-based study. Cancer 2005; 104:2340. [20] Carlson GW, Losken A, Moore B, Thornton J, Elliott M, Bolitho G, and Denson DD Page 192

5 [21] Results of immediate breast reconstruction after skin-sparing mastectomy. Ann. [22] Plast. Surg. 46 (3): [23] Meretoja T, Suominen E. Demand for plastic surgical operations after primary breast cancer surgery. Scand J Surg 2005; 94:211. [24] Joslyn SA. Patterns of care for immediate and early delayed breast reconstruction following mastectomy. Plast Reconstr Surg 2005; 115:1289. [25] Alderman AK, McMahon L Jr, Wilkins EG. The national utilization of immediate and early delayed breast reconstruction and the effect of sociodemographic factors. Plast Reconstr Surg 2003; 111:695. [26] Alderman AK, Wei Y, Birkmeyer JD. Use of breast reconstruction after mastectomy following the Women's Health and Cancer Rights Act. JAMA 2006; 295:387. [27] Tran NV, Chang DW, Gupta A, Kroll SS, and Robb GL Comparison of immediate and [28] delayed free TRAM flap breast reconstruction in patients receiving postmastectomy [29] radiation therapy. Plast. Reconstr. Surg. 108 (1): [30] Alderman AK, Hawley ST, Waljee J, et al. Correlates of referral practices of general surgeons to plastic surgeons for mastectomy reconstruction. Cancer 2007; 109:1715. [31] Lee CN, Belkora J, Chang Y, et al. Are patients making high-quality decisions about breast reconstruction after mastectomy? [outcomes article]. Plast Reconstr Surg 2011; 127:18. [32] Cemal Y, Albornoz CR, Disa JJ, et al. A paradigm shift in U.S. breast reconstruction: Part 2. The influence of changing mastectomy patterns on reconstructive rate and method. Plast Reconstr Surg 2013; 131:320e. [33] Losken A, Hamdi M. Partial breast reconstruction: current perspectives. Plast Reconstr Surg 2009; 124:722. [34] Losken A, Pinell-White X, Hart AM, et al. The oncoplastic reduction approach to breast conservation therapy: benefits for margin control. Aesthet Surg J 2014; 34:1185. [35] Horiguchi J, Iino JHY, Takei H, Koibuchi Y, Iijima K, Ikeda F, Ochiai R, Uchida K, Yoshida [36] M, Yokoe T, and Morishita Y A comparative study of subcutaneous [37] mastectomy with radical mastectomy. Anticancer Res. 21 (4B): [38] Barnett GR, Gianoutsos MP. The latissimus dorsi added fat flap for natural tissue breast reconstruction: Report of 15 Cases. Plast Reconstr Surg. 1996;97: [39] Gendy RK, Able JA, Rainsbury RM. Impact of skin-sparing mastectomy with immediate reconstruction and breastsparing reconstruction with miniflaps on the outcomes of oncoplastic breast surgery. Br J Surg 2003; 90:433. [40] Fischer JP, Fox JP, Nelson JA, et al. A Longitudinal Assessment of Outcomes and Healthcare Resource Utilization After Immediate Breast Reconstruction-Comparing Implant- and Autologous-based Breast Reconstruction. Ann Surg 2015; 262:692. [41] Trabulsy PP, Anthony JP, Mathes SJ. Changing trends in postmastectomy breast reconstruction: A 13-year experience. Plast Reconstr Surg. 1994;93: [42] Beasley ME. The pedicled TRAM as preference for immediate autogenous tissue breast reconstruction. Clin Plast Surg. 1994;21: [43] Kroll SS, Schusterman MA, Reece GP, Miller MJ, Smith B. Breast reconstruction with myocutaneous flaps in previously irradiated patients. Plast Reconstr Surg. 1994;93: Page 193