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A procedure is described for reduction mammaplasty, mastopexy, and prophylactic mastectomy, which utilizes an inferiorly based flap. This flap is either dermal or dermal-glandular. It is coupled with a superior-based derme of performance, and reproducible pleasing appearance have been attained.
We present a series of 267 patients who have had bilateral prophylactic subcutaneous mastectomies with immediate submuscular reconstruction. Seventy-one of these patients had a simultaneous surgical skin reduction (mastopexy). All 276 patients have both of their implants currently in place and have achieved very satisfactory functional and aesthetic results, as judged by both the patient and the surgeon. We believe the essentials to obtaining a satisfactory result are thorough preoperative evaluation, creation of adequate muscle cover to include always a large triangle of the serratus anterior with the pectoralis and rectus abdominis muscles, proper use of skin taping in patients not undergoing a surgical mastopexy to allow adhesion of the nipple-areola complex in the proper position and shape, and careful postoperative muscle therapy.
Patient selection for prophylactic mastectomy should be based on an individual assessment of risk factors. These should be correlated with the patient's age, the difficulty of clinical examination, and, in the case of a previous breast cancer, its prognosis. Only then can the patient and her surgeon make an intelligent decision regarding management.
A case is presented of a young woman after radical mastectomy and skin graft to demonstrate that a skin graft can provide adequate cover for reconstructing the breast with a silicone implant.
Immediate reconstruction of a breast removed for treatment of carcinoma can be accomplished without altering the cancer-ablative surgical procedure. The theoretical possibility that reconstruction might compromise the cure rate has tempered enthusiasm for this approach. To test this issue, the relapse-free survival of 101 patients who underwent breast reconstruction in the immediate postmastectomy period was compared with that of 377 patients with breast cancer who underwent mastectomy without immediate reconstruction. This comparison was accomplished using multivariable statistical techniques to correct for baseline inequalities between the patient groups. After adjustment for the relevant prognostic factors, no significant difference remained between the two groups. We conclude that immediate reconstruction has no discernible adverse influence on the natural history of surgically treated breast carcinoma.
This case illustrates an unusual mastectomy patient in whom the standard alternatives for breast reconstruction were not available. A deep inferior epigastric transverse abdominal free flap was successfully employed. The abundance of tissue provided by this technique enabled reconstruction of a large breast to match the contralateral side.
A combined pectus excavatum and bilateral mastectomy deformity was corrected with a deepithelialized, buried, transverse abdominal myocutaneous flap and second stage custom-made silicone implants. The shape of pectus excavatum makes it particularly amenable to correction with the transverse abdominal myocutaneous flap.
Severe gynecomastia with excessive skin is difficult to treat by only periareolar excision or suction-assisted lipectomy or both. In these patients, total mastectomy and free nipple grafting may be the best option. Placement of the nipple, however, has been arbitrary. With use of 20 "aesthetically perfect" men as models, standard nipple distances were identified. The average sternal notch-to-nipple measurement was 21 cm. In addition, two consistent ratios were identified. The nipple plane was located 0.33 times the distance from the sternal notch to the pubis, and the internipple distance was 0.23 times the chest circumference. With use of preoperatively obtained measurements of the sternal notch to pubis and chest circumference, accurate nipple placement can be accomplished.
Breast reconstruction after mastectomy is chosen by approximately 10 percent of Australian women. Younger women are more likely to have this surgical procedure. This suggests that there may be many factors determining this choice. Sixty-four women who wore an external postmastectomy breast prosthesis and 31 women who had postmastectomy breast reconstruction participated in the present study. The purpose was to gain a greater understanding through semi-structured interviews of why women who had breast reconstruction chose this alternative and why women who wore the external postmastectomy breast prosthesis elected not to have reconstruction. The study also ascertained how difficult it was for the women in both groups to decide their particular breast restoration alternative. The most frequently endorsed reasons for not having breast reconstruction in the prosthesis group included: (1) not essential for physical well being, (2) not essential for emotional well being, (3) not having enough information about the procedure, and (4) not wanting anything unnatural in the body. When each member of the group was asked to identify a major reason for not having reconstruction, two predominant issues emerged: (1) fearing complications and (2) perceiving themselves as being too old for the procedure. Twelve percent of the prosthesis group experienced difficulty in making the decision not to have reconstruction. Three factors accounted for this difficulty: (1) the lack of family support, (2) the inability to have a specific type of reconstruction, and (3) the perception that friends and acquaintances saw the surgery as cosmetic. The most frequently reported reasons given by the reconstruction group for having reconstruction included: (1) to get rid of the external breast prosthesis, (2) to be able to wear many different types of clothing, (3) to regain femininity, and (4) to feel whole again. The least influential factors were to improve marital and sexual relations. The major reason cited most often by this group was to feel whole again. None of the women in the reconstruction group experienced any difficulty when deciding their method of breast restoration. What factors are taken into consideration by women when they decide either to have or not to have reconstruction need to be understood by physicians. This knowledge will assist them in conveying appropriate information regarding alternatives and will help them deal with the women's concerns and/or misconceptions.
Recurrence patterns were analyzed in 323 patients treated by radical mastectomy, 219 of whom received postoperative irradiation. Thirty-five patients with inner quadrant lesions and negative axillary nodes received postoperative regional node irradiation; 33 of these 35 patients are alive without recurrence from 2 to 22 years later. Six of 219 patients receiving postoperative regional lymph node irradiation developed recurrence in the treated area. In patients with positive axillary nodes, 27% of all recurrence developed initially in the chest wall region, and an additional 10% of patients developed distant metastases in addition to chest wall recurrence. The high incidence of chest wall recurrence in patients with four or more positive nodes, and in patients with two or three positive nodes and primary lesions over 3 cm in diameter who did not receive chest wall irradiation, suggests that the maximal benefit from postoperative irradiation would not be realized in prospective, randomized studies without the use of chest wall irradiation postoperatively in these categories of patients.
The omental pedicle graft is a technic developed to replace tissues removed by classic radical mastectomies in preparation for constructing a new breast. The graft and the reconstruction may be done in one stage. The advantages of the technic are (1) the tissue is readily available, (2) it can be done in one or two stages, and (3) it provides improved esthetic results. During the past eight years, I have used this technic for breast reconstruction in 24 cases.
We describe a new breast implant that greatly facilitates immediate breast reconstruction after mastectomy. Through a detachable filling reservoir, the implant can be filled with saline by percutaneous injection; this allows the empty implant to be placed in position and filled only after viability of the flaps is assured. Because filling can be controlled, the fear of skin flap necrosis or wound breakdown is eliminated. Furthermore, the chest wall skin can be expanded, thus avoiding the use of distant flaps.
PURPOSE: Risk-reducing surgery is an important option for women with BRCA1 and BRCA2 mutations. There are reports in the literature that insurance reimbursement for these procedures varies greatly. Because health insurance coverage significantly affects medical decision-making, current information regarding reimbursement practices of third-party payers is needed. METHODS: Retrospective study of hospital billing records of 38 women with documented BRCA1 or BRCA2 mutations who underwent either a risk-reducing mastectomy or a risk-reducing oophorectomy between March 1, 1997, and July 30, 2000. RESULTS: Complete billing and reimbursement information was available for 35 women undergoing a total of 39 risk-reducing surgeries. A total of 38 of 39 (97%) risk-reducing surgeries were covered in full, less applicable coinsurance and deductibles. The rate of insurance reimbursement did not vary with type of insurance, personal history of cancer, or type of procedure. CONCLUSION: Insurance carriers reimbursed the vast majority of BRCA mutation carriers undergoing risk-reducing surgery.
A retrospective review of the treatment of 15 breast cancer patients who received postoperative radiotherapy after a mastectomy and transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction was undertaken to determine the effects of postoperative irradiation on flap viability and cosmesis. Fourteen patients had pedicle TRAM flaps, and one patient had a free TRAM flap. Surgical complications, acute and chronic side effects of radiotherapy, and cosmetic outcome were evaluated. The median interval between the TRAM flap procedure and radiotherapy was 7 months. The median total radiation dose was 60 Gy. All patients underwent three-dimensional radiotherapy treatment planning to determine the optimal dose distribution. Mild erythema developed in 9 patients (60%), moderate erythema developed in 2 (13%), and severe erythema developed in 1 (7%). Dry desquamation developed in 6 patients (40%), whereas moist desquamation developed in none. At median follow-up of 26.4 months, only 2 (13%) of the 15 patients had fat necrosis within the TRAM flap that was not present before radiotherapy. Fourteen patients (93%) retained their flap, and 13 patients (87%) rated their cosmetic outcome as "good" to "excellent." We conclude that TRAM flaps can be irradiated with few complications and acceptable cosmetic results.
This study assesses the incidence and outcome of skin-sparing mastectomy (SSM) flap complications after breast reconstruction. The authors performed a retrospective review of 37 consecutive patients undergoing SSM and immediate breast reconstruction, focusing on preoperative demographics, management of complications, and early outcome. Univariate analysis comparing patients with and without complications was performed using Student's t-test and chi-square analysis. From July 2000 to December 2001, 37 patients (mean age 48.1, range 24-71 y) underwent SSM and breast reconstruction (unilateral 20, bilateral 17) via TRAM flaps (n = 18), latissimus flaps (n = 13), and expander/implants (n = 6). SSM flap complications occurred in nine patients (24.3%) and included mild (n = 2), moderate (n = 5), and severe (n = 2) skin loss, resulting in four cases of dehiscence, five reoperations, and no delay in postoperative adjuvant therapy (required in six patients). Previous irradiation (n = 5, p = 0.045) and diabetes (n = 3, p = 0.001) were associated with SSM flap complications, but age, smoking, previous breast cancer, and type of reconstruction were not. Patients with SSM flap loss had a higher body mass index (BMI) than those without complications (30.0 vs. 24.3; p = 0.025). Skin flap complications after SSM and breast reconstruction are not uncommon but did not delay the initiation of adjuvant chemotherapy or radiotherapy, despite the need for reoperation. Patients with elevated BMI, diabetes, and previous irradiation may be at increased risk for SSM flap complications.
The value of multiple frequency bioelectric impedence analysis (MFBIA) in the monitoring and management of post-mastectomy lymphoedema of the arm was evaluated in 15 patients and controls. The technique was found to produce quantitative agreement with a clinical diagnosis of lymphoedema and with the currently-used measure (limb volume calculated from circumferential measurements) of limb size. The significance of this finding lies in MFBIA being diagnostically informative: it indicates when an observed change in limb volume is directly, albeit theoretically, attributable to accumulation of extracellular fluid. MFBIA potentially offers the means for earlier definitive diagnosis and more-accurate monitoring of extracellular fluid changes during and after treatment.
A 61-year-old woman developed an angiosarcoma in the irradiated chest wall 2 1/2 and 4 years after mastectomy for a carcinoma of breast. The two sets of tumours were morphologically distinct and differed immunohistochemically. The short interval between post-operative irradiation and presentation of the angiosarcoma is unusual. The case is discussed in relation to others of allied type.
An example of post-mastectomy angiosarcoma was studied by electron microscopy to determine its histogenesis. Unequivocal evidence of endothelial differentiation was found in well and poorly differentiated areas. Positive staining for factor VIII related antigen and negative staining for epithelial membrane antigen further confirmed that the tumour was a true angiosarcoma rather than a peculiar form of carcinomatous metastasis.