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PubMed1985

A 6-year experience with immediate reconstruction after mastectomy for cancer.

A 6-year retrospective review is presented of 185 patients who underwent immediate reconstruction of the breast at the same operation as mastectomy for carcinoma. The patients were treated at two institutions under similar protocols of patient selection, surgical technique, and postoperative care. A detailed evaluation is presented from both the oncologic and surgical points of view. The data support the conclusion that immediate reconstruction of the breast does not alter survival or cancer recurrence rates and does not interfere with the treatment of primary or secondary disease. A low incidence of significant surgical complications is also detailed. Combined with previous reports answering psychological concerns about this mode and timing of reconstruction, this review offers significant reassurance about the overall safety of immediate reconstruction. The authors therefore recommend immediate reconstruction of the breast as a safe treatment option for the woman facing mastectomy.

Adult↗
PubMed1987

An improved technique for immediate retropectoral reconstruction after subcutaneous mastectomy.

Subcutaneous mastectomy is becoming an operation of choice in certain cases of premalignant and other breast pathology. We describe a technique for simultaneous subcutaneous mastectomy and retropectoral implantation of a silicone prosthesis. Gentle blunt prepectoral, retromammary dissection is performed through an axillary incision as far inferiorly as the inframammary fold, where a fibrous bridge between the anterior surface of the pectoralis major muscle and the skin prevents dissection any lower. Through the same incision, the retropectoral space is dissected to about 5 cm below the inframammary fold. A second incision is made in the inframammary fold to join the retromammary plane of the first dissection. The gland is then dissected subcutaneously and removed through the inframammary incision. A silicone implant is introduced retropectorally through the axillary incision, thus avoiding splitting the pectoralis major. Satisfactory results have been obtained in 23 bilateral and 14 unilateral cases; it is important that the dissection be performed carefully in order to prevent the implant from riding up too high in its musculoaponeurotic sling.

Breast↗
PubMed1994

Can breast reconstruction with gel-filled silicone implants increase the risk of death and second primary cancer in patients treated by mastectomy for breast cancer?

An increased risk of cancer and autoimmune disease associated with gel-filled silicone implants has been suggested recently, but these possible detrimental effects have not been adequately studied in patients with breast cancer. In order to evaluate these effects, we have studied 146 patients with breast cancer treated by mastectomy at the Gustave Roussy Cancer Institute between 1965 and 1983 and who received a gel-filled silicone implant for immediate or delayed breast reconstruction between 1976 and 1984. These patients were compared with 146 matched controls with breast cancer who were treated in the same center by mastectomy without breast reconstruction and were matched for age at diagnosis (within 10 years), year of diagnosis (within 3 years), stage, histologic type of the tumor, histopathologic grade, and nodal status. The relative risks of death, relapse, and second primary cancer were estimated by means of the Cox proportional hazards model stratified on age at diagnosis. The risks of distant metastasis and death due to breast cancer were significantly lower in the breast reconstruction group than in the control group. The risks of local recurrence, second breast cancer, and second primary cancer in another site than the breast were not significantly different between the two groups of patients. Our results do not support the hypothesis of a detrimental effect of gel-filled silicone implants either in the course of breast cancer or in the risk of death due to other diseases.

Breast Neoplasms↗
PubMed1998

Aesthetic refinement in breast reconstruction: complete skin-sparing mastectomy with autogenous tissue transfer.

Aesthetic results in breast reconstruction are often compromised either by prominent scars or by the presence of an island of skin that differs in color and texture from the native breast skin. Complete skin-sparing mastectomy is a technique by which breast scars can be largely eliminated and the need for a visible skin island avoided. A circumareolar incision is used for mastectomy with a separate axillary incision if needed. Autogenous tissue is used to fill the skin envelope, and a disk of skin temporarily replaces the areola. Twenty-eight patients treated by this method were reviewed retrospectively. Prerequisites included a favorable biopsy scar location and a suitable tissue donor site. The mean patient age was 42.5 years, and the majority were reconstructed with TRAM flaps (92 percent). There was no evidence of increased morbidity or any instance of local recurrence during a follow-up period, which averaged 25.7 months. Aesthetic results were judged excellent in 12 patients, good in 11 patients, and fair in 5 patients. Insufficient tissue volume, shape asymmetry, and areolar position asymmetry were the most common factors that detracted from the quality of the results. Advantages of this method, besides the prospect of an ideal aesthetic result, include easier flap insetting and simplified subsequent revision procedures. Disadvantages include the requirement of a skilled ablative surgeon and incompatibility with conventional expander/implant methods of reconstruction.

Abdominal Muscles↗
PubMed1999

An approach to the repair of partial mastectomy defects.

In many cases, breast deformity caused by partial mastectomy can be reduced or corrected by plastic surgery. Partial breast reconstruction is best performed immediately after the partial mastectomy using an approach determined by the size of the breast and the defect. Small defects in large breasts usually need no reconstruction. For larger defects in large breasts, breast reshaping (similar to reduction mammaplasty) combined with a contralateral breast reduction is usually the best option. For medium-sized or smaller breasts with small to moderate-sized defects, local flaps from the subaxillary region are very useful. If the defect is too large for correction with local tissue, a latissimus dorsi myocutaneous flap is usually the best choice. Using these techniques, patients can achieve aesthetically better outcomes from breast-conservation therapy, even when larger tumors are being treated or when wider margins are taken to reduce the risk of tumor recurrence. By working together with an oncologic surgeon and facilitating the removal of larger tumors, the plastic surgeon can widen the indications for both breast-conservation therapy and breast reconstruction at the same time.

Breast↗
PubMed1978

Subcutaneous mastectomy with delayed subpectoral augmentation.

National survival statistics for breast cancer victims are basically the same today as they have been for the last 50 years. Less than 60% survive five years after diagnosis, and they frequently must accept mutilating results of treatment. To improve this bleak picture, our efforts should be directed toward prevention. One aspect of prevention would be to identify the breasts most likely to develop malignancies and remove the breast tissue with planned restoration of contour. Subcutaneous mastectomy and immediate insertion of Silastic gel prostheses has not met with the desired results either medically or esthetically. The complications with this procedure are numerous, and there is an unnatural "cystic" appearance on the chest wall with a thin skin covering through which the prostheses can be palpated. We advocate subcutaneous mastectomy with appropriate fixation of the nipples and areolae on the pectoral muscle and fascia, followed several months later by subpectoral augmentation. This two-staged procedure has proved to be a reliable one with few serious complications. It is hoped it will play a significant role not only in reducing the mortality associated with breast cancer but also in lessening the undesirable psychologic impact of the loss of breasts.

Breast Diseases↗
PubMed1983

Breast reconstruction after mastectomy.

Radical mastectomy inflicts emotional as well as physical scars, and preoperative interviews with the reconstructive surgeon can help to ameliorate some anxiety. There is no evidence of risk to the patient from reconstruction of the breast. Reconstruction is best deferred for four to six months after mastectomy for several oncologic and psychologic reasons. Careful selection of patients is paramount. Reconstruction involves the correction of several functional and structural deficits. The end result has been enhanced by the silicone breast implant and the myocutaneous flap. Although the final result is usually not a cosmetic triumph, the reconstruction may serve to enhance the patient's self-image.

Age Factors↗
PubMed2007

Breast reconstruction following mastectomy for breast cancer: the decisions of sexual minority women.

BACKGROUND: Prior research on decision-making for reconstructive surgery after mastectomy has not addressed the specific considerations of sexual minority women (women who partner with women, and lesbian or bisexual identified women). The purpose of this study is to explore which issues sexual minority women considered when making decisions on reconstructive surgery and to understand the influence and perspectives of these women's most important support persons. METHODS: Study participants were recruited through targeted community-based sampling. The authors conducted individual semistructured interviews with 15 sexual minority women who had been treated with mastectomy after breast cancer diagnosis and 12 support persons who were identified by these women as their most important source of support. Using qualitative data analysis software, transcribed interviews were analyzed. Through constant comparison methods, themes related to the decision on and experiences and satisfaction with reconstructive choice were identified from the narrative data. RESULTS: The considerations of women who decided for or against reconstruction are rooted in a value system and body image shaped by their sexual minority identity. Women who chose reconstruction experienced difficulties and regrets, whereas women without reconstruction adjusted well after time. Partners of sexual minority women matched the level of satisfaction with reconstructive choice achieved by the women themselves. CONCLUSION: Providers who treat sexual minority women might benefit from knowing about issues important to this population to provide more comprehensive care.

Bisexuality↗
PubMed2005

Radiation-induced angiosarcoma after mastectomy and TRAM flap breast reconstruction.

Radiation-induced angiosarcoma of the breast is being reported with increasing frequency as a result of the increased use of radiation therapy in conjunction with breast conservation surgery. However, this entity has not been well documented in patients undergoing mastectomy. The authors present a case of angiosarcoma occurring in a patient 6 years after undergoing mastectomy for invasive duct carcinoma with immediate transverse rectus abdominis musculocutaneous flap reconstruction followed by postoperative radiation therapy. The diagnosis of angiosarcoma was made by skin biopsy performed by the patient's reconstructive surgeon on routine follow-up examination. This is the first reported case of postradiation angiosarcoma occurring in a postmastectomy breast reconstructed with autogenous tissue and it is unusual in that the cancer invaded the musculocutaneous flap. Diagnosis and management recommendations for radiation-induced angiosarcoma are discussed.

Adult↗
PubMed2005

The conjoined sternalis-pectoralis muscle flap in immediate tissue expander reconstruction after mastectomy.

The sternalis muscle is an accessory muscle of the anterior chest wall. This is a rare anatomic variant reported in approximately 8% of the population, with variation among races. While several anatomic studies of the sternalis muscle exist, nothing in the literature addresses the implications of this muscle on reconstruction of the breast after mastectomy. Based on several encounters of this muscle variant by the senior author over a 15-year period, we offer a strategy and rationale for dealing with this rare, but known, anatomic variant during immediate tissue expander reconstruction of the breast after mastectomy. First is the importance of recognizing the presence of a sternalis muscle, which may present in a variety of configurations. We offer our technique of conjoined sternalis-pectoralis muscle flap during tissue expander reconstruction of the breast. This allows for the creation of a larger, more properly placed submuscular pocket with adequate muscle coverage of the tissue expander. Our experience illustrates that the reconstructive surgeon must be familiar with the sternalis muscle and be prepared to adapt his or her technique for tissue expander placement when faced with this accessory muscle.

Adult↗
PubMed2003

Axillary lymph node status, but not tumor size, predicts locoregional recurrence and overall survival after mastectomy for breast cancer.

OBJECTIVE: To assess the significance of axillary lymph node status and tumor size for predicting locoregional recurrence (LRR) and overall survival after mastectomy for breast cancer and to discuss the utility of postmastectomy radiation therapy. SUMMARY BACKGROUND DATA: Patients with locally advanced breast cancer require multimodality treatment combining chemotherapy (and/or hormonal therapy), surgery, and radiation. Randomized trials have demonstrated that postmastectomy radiation reduces LRR, but no overall survival benefit has been established. METHODS: Criteria for accrual to the Alabama Breast Cancer Project (1975-1978) were female gender and T2-3 breast cancer with M0 status. Patients underwent a radical or a modified radical mastectomy. Node-positive patients received adjuvant cyclophosphamide, methotrexate, and fluorouracil chemotherapy or adjuvant melphalan. Patients were evaluated for LRR and overall survival based on the number of positive axillary lymph nodes and (in N0 patients) pathologic tumor size. Significance was determined using chi-square analysis. Survival curves were generated using the Kaplan-Meier method and were compared by log-rank analysis. RESULTS: After median follow-up of 15 years, neither type of surgery nor chemotherapy was shown to affect locoregional disease-free or overall survival. LRR rates were higher and overall survival rates were lower in patients with nodal involvement, while tumor size was not shown to significantly affect these rates. CONCLUSIONS: Patients with axillary lymph node metastases may benefit from postmastectomy radiation, but the use of postmastectomy radiation in N0 patients is not supported when it is based on tumor size alone.

Adult↗
PubMedDate not supplied

Delayed nipple-sparing modified subcutaneous mastectomy: rationale and technique.

The problem of nipple-areola complex (NAC) preservation during mastectomy is a very intriguing and stimulating issue. In fact, in order to perform an oncologically safe operation, no mammary tissue (enclosed in the main galactophoric ducts) should remain; on the other hand, without the blood supply coming from the breast gland, NAC viability is greatly impaired because the surrounding vascular dermal network is not developed enough to support its metabolic requirements. We suggest therefore a two-step surgical procedure. The first step, on an outpatient basis with local tumescent anesthesia, is a mini-invasive cutting and coagulating procedure. It addresses the autonomization of the vascular supply to the NAC by detaching the galactophore stalk from the nipple and coagulating the deep vascular plexus. The second step, under general anesthesia and again with tumescent technique, removes the breast within its capsule, with careful checks of any remnant and adequate approach to the axilla. A subpectoralis prosthesis completes the procedure. In our view, this technique is electively suitable for prophylactic mastectomy, but also for stage I breast cancer, 2.5 cm from the NAC and 1.5 cm from the skin and pectoralis fascia, and it is very safe, simple, and effective.

Adult↗
PubMedDate not supplied

Total mastectomy under local anesthesia: the tumescent technique.

The management of breast cancer in elderly women is controversial. Breast cancer in this age group tends to be biologically less aggressive and is highly responsive to hormonal intervention. The risk of dying of other causes often exceeds the risk of cancer recurrence. For these reasons, older patients tend to be treated less aggressively. One large study of elderly women with breast cancer found that half of the patients were undertreated. Four patients (mean age 72 years, range 61-95 years) underwent a unilateral total mastectomy for cancer under local anesthesia using the tumescent technique of infiltrating dilute lidocaine with epinephrine (25 ml of 1% lidocaine [250 mg] and 1 ml of 1:1000 epinephrine [1 mg] to 1 L of Ringers lactate) via an infusion pump. Three of the patients had estrogen receptor (ER)-negative tumors and one patient had tumor progression despite switching from tamoxifen to anastrozole. All four patients were class IV as defined by the American Society of Anesthesiology (ASA). There was no morbidity related to the surgery in the form of hematoma, wound infection, or skin flap necrosis. The patients were discharged 1-4 days after surgery. The anesthesia was adequate in all four cases and there was no deviation from the described technique. The mean operative time was 35 minutes (range 24-46 minutes). The tumescent technique is a safe, effective method for performing a total mastectomy in patients who would not be considered candidates for general anesthesia.

Aged↗
PubMed2004

Evaluation of a local anaesthesia regimen following mastectomy.

Breast surgery can be emotionally distressing and physically painful. Acute pain following surgery is often related mainly to the axillary surgery and is aggravated by arm and shoulder movement. We conducted a prospective double-blind, randomised, placebo-controlled trial to determine the influence of local anaesthetic irrigation of axillary wound drains on postoperative pain during the first 24 h following a modified Patey mastectomy (mastectomy with complete axillary node clearance). The treatment group received bupivacaine irrigation through the axillary wound drain 4-hourly for 24 h postoperatively. Controls received irrigation with normal saline. Morphine via a patient controlled analgesia pump was used for postoperative analgesia. Morphine consumption, visual analogue and verbal rating pain scores were recorded. There were no statistical differences in morphine requirements or pain scores between the two groups, nor were there differences in anti-emetic or supplemental analgesic consumption. Bupivacaine irrigation used in this manner does not appear to offer an effective contribution to postoperative analgesia.

Adult↗
PubMed2005

Analgesic efficacy of diclofenac in combination with morphine and paracetamol after mastectomy and immediate breast reconstruction.

BACKGROUND: Breast cancer treatment with mastectomy and immediate breast reconstruction (IBR) is associated with intense pain in the primary post-operative period. The present prospective, placebo-controlled and double-blind study aimed to evaluate the analgesic efficacy of diclofenac, a non-steroid anti-inflammatory drug (NSAID), in combination with paracetamol and opioids. This was done by 64-h assessment of post-operative pain intensity, opioid consumption, blood loss, nausea and tiredness. METHODS: Fifty women selected for mastectomy and IBR with submuscular implants with or without axillary lymph node dissection (ALND) were randomized to receive diclofenac 50 mg x 3 or placebo rectally in addition to oral paracetamol and intravenous opioids delivered using a patient-controlled analgesia (PCA) technique. RESULTS: During the first 20 h post-surgery, patients who received diclofenac experienced significantly less pain when resting than those who received placebo. When moving, a non-significant estimated difference in pain in favour of diclofenac was also noted. Opioid consumption during the first 6 h post-operatively was 34% less with diclofenac than with placebo. Means (SD) were 16.9 (10.3) mg and 25.6 (10.2) mg, respectively (P = 0.007). After 64 h, the difference was no longer statistically significant. Post-operative bleeding was significantly higher with diclofenac than with placebo (P < 0.01). Nausea and tiredness did not differ between the groups. CONCLUSIONS: The addition of NSAID to paracetamol and opioid-PCA reduced opioid consumption and improved pain relief during the first 20 h at rest but was not convincingly effective during mobilization. Post-operative blood loss was higher with diclofenac.

Acetaminophen↗
PubMed1979

Subcutaneous mastectomy: indications and technique.

For a certain group of patients, carefully selected by criteria which are here discussed, subcutaneous mastectomy offers a real prospect of minimizing the risk of breast cancer developing. It will also relieve pain in most of those for whom it has become intolerable and will usually provide the patient with both comfort and peace of mind. Performed by the technique described, subcutaneous mastectomy can now produce an aesthetically pleasing result. Regular review of all patients is, however, mandatory.

Breast↗
PubMed1998

Evidence of effectiveness of clinical audit in improving histopathology reporting standards of mastectomy specimens.

AIM: To assess the effectiveness of clinical audit in improving standards in histopathological reporting of mastectomy specimens. METHODS: Reports on mastectomy specimens containing tumour issued by non-specialist histopathologists in 1990, 1992, 1994, and 1996 were scored for their information content. There were 10 reports evaluated from each year. Before 1990 no reporting guidelines had been formulated within the department. The audits in 1992 and 1994 were performed after agreed written guidelines (including the establishment of six essential pieces of information), and in 1996 the specimens were reported using a proforma. RESULTS: There was a significant increase in information after the introduction of written guidelines but there was a reduction in information over time. In 1990 none of the 10 reports included all six pieces of mandatory information; in 1992 four of the reports contained all mandatory information; in 1994 only one report contained all mandatory information. The introduction of a proforma for reporting resulted in further significant improvement with all 10 reports in 1996 containing all mandatory information. CONCLUSIONS: Successive rounds of audit increases the standard of reporting in histopathology. There is a need for continuing monitoring of standards as these may deteriorate over time. Reporting complex specimens on a proforma has a significant beneficial effect on information content.

Breast Neoplasms↗
PubMed1993

Breast cancer recurrence after mastectomy: diagnosis with mammography and US.

The authors reviewed mammograms and/or ultrasound (US) scans of 76 lesions (67 patients) suspected of being recurrent breast cancer. All patients had previously undergone mastectomy. Sixty-one cases were malignant disease and 15 were benign. Mammography and US were complementary to clinical examination in evaluating palpable lesions at the mastectomy site. Both imaging methods revealed nonpalpable recurrences. The sensitivity of US was 91%, whereas the sensitivities of clinical examination and mammography were 79% and 45%, respectively. US was the best imaging method for evaluating tumors in the chest wall far from the scar and in the axilla, as these could not be visualized on mammograms. Most recurrent cancers were seen as circumscribed masses at mammography and as hypoechoic lesions at US. Hyperechoic recurrences could not be differentiated from benign lesions. The value of early detection of recurrences with imaging methods remains to be seen.

Breast Neoplasms↗