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The Halsted mastectomy put American surgeons of the late 19th century ahead of competing general practitioners at home and the preeminent German surgeons abroad. It thus served economic and nationalistic drives in the nascent specialty of surgery. Such socioemotional forces-and not scientific principles-may explain why Halsted's expansion of the mastectomy to include the pectoral muscles became lastingly institutionalized.
We describe the effects of the breast reconstruction after radical mastectomy for cancer. The psychological advantages are compared to the post-mastectomy status in 102 patients.
Fifty subcutaneous mastectomy specimens, each of which were removed from a patient who had previously undergone radical or modified radical mastectomy of the contralateral breast for carcinoma, were age and date matched to a control group of patients with which carcinoma was not associated. The patients were evaluated with regard to specific types of epithelial proliferative lesions and other entities of fibrocystic disease without knowledge of their group membership. The results included a statistically significant dominance of certain epithelial hyperplasias in the study population and a lack of statistical significance in intergroup difference of some previously suspected lesions, such as sclerosing adenosis and gross cystic disease. It is concluded that the recognition of those forms of epitheliosis associated with carcinoma may help in the management of patients at high clinical risk for carcinoma of the breast.
The authors review all the breast diseases and tumours observed from 1972 through 1979 at the Division of Surgery, Hospital of Rapallo. On the basis of personal experience they discuss the possibility that, in the treatment of early breast cancer, a relatively conservative surgery (i.e. quadrantectomy), followed by postoperative radiotherapy and adjuvant chemotherapy in the N+ cases, give no worse results than standard radical mastectomy, in preventing local relapses and distant metastases, and therefore in conditioning both free-of-disease interval and survival of the patients, as many Authors in these last years have well shown either for quadrantectomy or other conservative procedures. This retrospective study particularly evaluates the results of 12 quadrantectomies performed in Stage I and II, compared to 8 Halsted radical mastectomies in the same Stages: all patients in the two groups survive free of disease (follow-up for the quadrantectomies from 6 to 41 months). Furthermore 4 cases of Stage III breast cancer are presented, 2 treated with Halsted procedure: in the first case the death occurred at 19 months, after the development of distant metastases, while in the second local relapses have been observed at 11 and 30 months; 2 patients were treated with quadrantectomy, as they didn't accepted a radical procedure: both survive free of disease at 17 and 23 months respectively.
A prospective randomised trial (534 patients, 1969-75) was designed to determine whether radical mastectomy conferred advantages over modified radical mastectomy for breast cancer in terms of total survival, local recurrence, distant metastasis, and disease-free interval. The results showed no significant difference in outcome as regards these variables between the two treatments.
Lymphoedema of the upper limb is the most serious and most crippling complication of mastectomy. An account is given of the factors possibly responsible, and a classification of the different forms is proposed. When fibrosis has set in, treatment is followed by very disappointing results, being at best able to bring about a partial, but transitory reduction in limb volume and consistency. Reference is also made to results obtained in 70 cases with two substances, 1-thyroxine and escine (somatoline), applied by massotherapy in postural drainage, ionophoresis, and pressotherapy, according to the requirements of each case. The results were distinctly satisfactory, though the outstanding fact was the maintenance of the response throughout many follow-up controls. It is felt, therefore, that somatoline can be usefully given in cyclic form, both in cases treated in an early stage, and also in all patients were lymphoedema is a likely risk after mastectomy.
The relationships of the breast cancer patient who has undergone mastectomy with her spouse and children can undergo many drastic changes. The data indicate that male partners who are more involved in decision making and hospital visitation are more supportive and cope better themselves. Nonviewing of the surgical site can be a joint psychological problem not confined to the female patients only. Children will tend to express their distress in indirect and potentially symptomatic ways. The symptoms may differ between preadolescents and adolescents. Adolescent girls may be at special risk when their mothers have undergone mastectomy; maternal envy and competitiveness may result in increased friction between mother and daughter.
A method for subcutaneous mastectomy and reconstruction is described. To the patients the results of this method are pleasing. A specific advantage of this method is, that only in 20, 15% of these cases in recent years, we used silicone prosthesis for augmentation. An analysis of 333 cases showed some frightening facts: in 9,26% an invasive carcinoma was found. Furthermore, in 4,44% a lobular carcinoma in situ was found. A preoperative diagnosis was made, only in four of these fourty patients. Therefore, it can be stated that - as reconstruction possibilities by plastic surgery standards are good - a generally restrictive point of view towards the indications to subcutaneous mastectomy should be given up.
The treatment of carcinoma of the breast, as with any other disease, may be considered optimal only when maximal rehabilitation has been achieved. Satisfactory restoration of contour is now possible in most patients after mastectomy. Reconstruction of 63 breasts in 50 patients has been performed. No attempt should be made to persuade a patient to undergo reconstruction. However, it would seem reasonable that patients who have undergone mastectomy might be informed of this possiblity and the reasonable results obtainable.
Recreation of normal breast anatomy and restoration of female body image after mastectomy for cancer are the goals of the reconstructive surgeon. Several recently refined techniques in plastic and reconstructive surgery have made the task of reforming the female breast easier while producing more predictable results. A blending of ideas has begun between the general surgeon performing the mastectomy and the plastic surgeon reconstructing the breast. Breast reconstruction in selection patients has become an accepted part of rehabilitation. It is the purpose of this paper to address the problems of breast cancer and patient selection for reconstruction and to outline the surgical techniques.
The most frequent problems after subcutaneous mastectomy involve capsule formation, inadequate resection of breast tissue, and a poor aesthetic result as a consequence of nipple-areolar ptosis. These problems can be largely avoided by the submuscular placement of implants and, in patients with moderate-to-severe ptosis, by performing concomitant mastopexy or skin tailoring. We believe that when properly performed for appropriate indications, subcutaneous mastectomy is a worthwhile procedure.
Subcutaneous mastectomy with axillary dissection plus breast reconstruction using latissimus dorsi myocutaneous flap (or latissimus dorsi muscle) was carried out for 8 patients with breast cancer. These consisted of 1 patient with non-invasive ductal carcinoma, 5 with stage I (4 invasive ductal carcinomas and 1 invasive lobular carcinoma) and 2 with stage II (1 invasive ductal carcinoma and 1 invasive lobular carcinoma). Cancer cells were recognized histopathologically in the resection margins of the small mammary gland resting under the nipple in only 1 case, and the remaining 7 cases underwent a curative resection. In the prognosis, 7 patients were disease-free and 1 showed a local recurrence. The patient with local recurrence showed no metastasis after the resection of the local lesion. The cosmetic results of this operation were excellent in all patients. This operation was effective both for these patients with breast cancer who did not want to undergo breast conserving surgery or modified radical mastectomy and for those who were excluded from the criteria of breast conserving surgery from the prognostic and cosmetic points of view.
A series of 133 patients treated for breast cancer with partial mastectomy and limited axillary dissection performed as a same day procedure is presented. For comparison purposes an additional 45 patients are presented who had the same operative procedure but stayed for 1 or more nights as an in-patient. Of those having the procedure on a same day basis complications included hematoma (0.8%), seroma (2.3%), infection (1.5%) and miscellaneous (0.8%). These results are similar to those for patients staying overnight. It is concluded that partial mastectomy and limited axillary dissection can be safely performed as a same day procedure with advantages to the patient of avoiding hospitalization, to the surgeon in avoiding excessive paperwork and in-hospital responsibilities, and to the third party insurers in reducing costs.
Post-mastectomy lymphedema of the upper limb, that can be noticed by 10 to 20 percent of patients with breast cancer, is usually related to some risk factors: use of radiotherapy on the axilla, obesity, venous outflow obstruction, delayed wound healing or infection. The most important contributing factor to postsurgical edema is the development of lymphangitis in the upper limb. Although literature contains numerous accounts on the use of pharmacological agents for the treatment of postmastectomy lymphedema, the results are not satisfactory in term of clinical response and side effects. In the present study we investigate tolerability and feasibility of the use of suledexide in patients, submitted to mastectomy for breast cancer, with an initial lymphedema of the limb omolateral to surgery or other risk factors for the development of a clinical remarkable lymphedema. Our results show that sulodexide is a very satisfactory therapy in term of lack of side effects and good compliance.
Recent Food and Drug Administration hearings on silicone gel implants have drawn attention to the paucity of information about women who seek reconstruction after mastectomy compared with those who do not. New analyses of data gathered in the early 1980s address this issue. Three groups of mastectomy patients were compared: 117 women who sought and obtained delayed reconstruction, 26 who sought but decided against delayed reconstruction, and a comparison group of 53 who were not seeking reconstruction. Results indicated that although younger and more knowledgeable about reconstruction, patients in the reconstruction group were similar to those in the comparison group. However, the women who sought but chose not to proceed with reconstruction appear to have been at greater risk for physical and emotional disappointment with the results of reconstruction, which suggests that poor candidates for reconstruction may select themselves out at the time of consultation.
Questionably viable skin flaps may be used as full thickness grafts after mastectomy. It is suggested that the procedure described can help reduce the incidence of flap necrosis after mastectomy and yield a more acceptable cosmetic result.
Reconstruction of the breasts after mastectomy remains controversial. The majority of patients who have undergone mastectomy can be encouraged to accept the disability with correct counselling and guidance from the surgeon. Occasionally, in the very highly selected case, however, the reconstructive procedures are required in order to restore the patient's body image.
The authors report their experience with immediate breast reconstruction following salvage mastectomy for local recurrence of invasive breast cancer after conservative treatment. From January 1987 to December 1992, among 91 immediate breast reconstructions, 41 were performed for this indication. The results and complications were analyzed for each of the three techniques used: simple prosthesis (n = 5), latissimus dorsi flap with prosthesis (n = 26), trans abdominalis musculocutaneous flap--TRAM flap (n = 10). Immediate flap reconstruction appears to be required in cases of either early or late local relapse since the skin has been irradiated and the mastectomy must be extensive. The transrectus abdominalis flap allows more extensive resection and gives better cosmetic results without the need for a prosthesis.