Postmastectomy Breast Reconstruction: Current Techniques
Alan R. Shons, MD, PhD, Gerard Mosiello, MD, DDS,
Department of Surgery at the H. Lee Moffitt Cancer Center & Research Institute at the University of South Florida, Tampa, Florida
[Cancer Control; JMCC 8(5):419-426, 2001. © 2001 Moffitt Cancer Center & Research Institute]
Background: The techniques of breast reconstruction have evolved and matured over the past 25 years. Recent studies have proven the benefit of breast reconstruction for breast cancer patients.
Methods: The authors reviewed the recent literature on the techniques of breast reconstruction and the effects of reconstruction on patients following surgery for breast cancer. The findings in recent studies are correlated with the experience of the authors.
Results: A better understanding has been gained regarding surgical techniques of breast reconstruction as well as the proper indications for the various methods. The criteria of patient benefit have been defined by recent long-term studies.
Conclusions: Breast reconstruction following mastectomy has been proven to be a safe and beneficial procedure.
In 2001, an estimated 192,200 patients will be diagnosed with breast cancer in the United States. In the next 20 years, the age incidence of breast cancer combined with the aging of the US population is expected to result in more than 400,000 new cases of breast cancer annually in the United States.
Over the past 20 years, the surgical techniques of breast conservation surgery have been refined and can now be used for nearly three quarters of all breast cancer patients. For patients who need to undergo a mastectomy for adequate surgical treatment of the breast cancer, a variety of reconstruction approaches are available that range from simple to complex.
We believe that breast cancer is unique among the several malignancies in that the treatment has a profound effect on how the patient feels about herself and how the world views her. The alteration of body form in the treatment of breast cancer affects the societal, professional, and intimate relationships of the patient. The preservation of a normal breast via breast preservation surgery for breast cancer or breast reconstruction following mastectomy for breast cancer has been proven to be valuable from a psychological viewpoint.
The patient with recently diagnosed breast cancer is confronted with an overwhelming amount of information from which she must make critical choices. The optimum surgical approach for the removal of the cancer should be recommended by the surgical oncologist. Overall patient survival and local recurrence rate are equivalent for mastectomy and lumpectomy in properly selected patients. Nevertheless, substantial regional and national differences exist in the use of lumpectomy or breast-conserving surgery. Lumpectomy rates of 10.2% in North Carolina in 1993, 43% in Vermont in 1989, 38% in the United States in 1992, 63.5% in Ontario in 1995, and 79% in United Kingdom in 1996 have been reported.
Breast reconstruction options should be available to the patient when a mastectomy approach is recommended. Depending on the experience of the surgical oncologist, the patient may not be informed of the options available for reconstruction in her community. In some cases, the patient must seek consultation with a reconstructive plastic surgeon on her own. A close working relationship between the surgical oncologist and a reconstructive surgeon is important for optimum management of the patient.
The mastectomy technique has changed dramatically in the past 50 years from the Halsted radical mastectomy, which sacrificed skin and muscle of the chest wall as well as the axillary anatomy. Today we know that the skin envelope of the breast can safely be preserved in the absence of direct tumor invasion. The breast tissue, the nipple areola complex, and the biopsy scar are included in the resected mastectomy specimen. In many cases, this can be achieved by performing the mastectomy through an obliquely oriented elliptical incision that encompasses the nipple areola complex and the adjacent biopsy scar.
If the diagnosis of cancer has been made by fine-needle aspiration or needle-core biopsy, the mastectomy can be accomplished through a periareolar incision in many patients.
Preservation of the infra-mammary fold as well as the skin envelope is critical for an optimum reconstruction. Earlier mastectomy techniques often involved sacrifice of the underlying tissues through the infra-mammary fold area and to the level of the costal margin. This inferior extension is unnecessary for clearance of the cancer. Preservation of the breast skin envelope permits an anatomic reconstruction using either autologous tissue or implants.
Several long-term studies have shown equivalent local recurrence rates for patients undergoing conventional mastectomy or skin-sparing mastectomy.[4,5]
The sentinel node approach to the axilla preserves the axillary lymphatic anatomy in the 70% of breast cancer patients who do not have axillary nodal metastases and in whom only the sentinel nodes are removed.
Preservation of the axillary anatomy essentially eliminates the risk of lymphedema and postmastectomy pain syndrome.
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