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Goal is to restore a breast mound, to maintain quality of life and not impair prognosis or detection of breast cancer recurrence.
In 2008 the American Society of Plastic Surgery reported 79,458 postmastectomy breast reconstructions, 29.7% of these procedures autologous tissue procedures.
Reconstruction rate after mastectomy varies widely from 27% to 65%.
Can restore body-self image, femininity, sense of well being, sexuality, and quality of life.
Patients undergoing the procedure are more likely to be younger, to be college educated, to have a partner, to be affluent, to be white, than patients treated with mastectomy alone or lumpectomy (Rowland).
Women seeking early procedures have higher rates of psychosocial impairment and functional disability than those undergoing delayed reconstruction.
70% of procedures are implant based reconstructions and the remainder are forms of autogenous tissue based reconstruction.
Key advantage of immediate surgical reconstruction after mastectomy is superior aesthetic results, with less scarring and more natural breast shape since the breast skin can be preserved during the mastectomy.
Immediate reconstruction can offset psychological and physical consequences of mastectomy and is technically easy to perform than delayed reconstruction die to decrease scarring and preservation of the breast contours.
Implant-based breast reconstruction is the most commonly perform reconstructive procedure worldwide.
Traditionally, a two-stage procedure is performed, involving the initial placement of the tissue expander in this subpectoral pocket, sequential expansions with saline until the desired volume is achieved and replacement of the expander with a fixed-volume implant.
Immediate autologous reconstruction for patients that potentially require postmastectomy radiation therapy is to be discouraged because of the increased need for revision, higher rate of fat necrosis and loss of volume of transplanted tissue in irradiated patients.
Compared with non-irradiated implants, irradiated implants have been associated with a greater risk of infection, capsule formation, and reconstruction.
Irradiated autologous flaps have a greater rate of fibrosis or shrinkage, volume loss, and fat necrosis than nonirradiated autologous flap reconstruction.
Post mastectomy radiotherapy has been shown to be associated with inferior patient satisfaction.
Biological and synthetic meshes revolutionized the technique as the mesh is sutured between the lower edge of the pectoralis muscle and the chest wall to create a larger subpectoral pocket that can accommodate a fixed-volume implant at the time of the initial surgery.
The above approach facilitates a single-stage direct-to-implant reconstruction without the need for a second procedure with a substantial associated benefits for the patient.
The mesh can improve cosmetic outcomes by allowing improved lower pole projection and creating a more natural looking ptotic result.
The rates of immediate reconstruction has steadily increased over recent years,
with only 15% of the women who Underwent immediate reconstruction in 2011, and this number has increased to about 40% in 2018.
In node positive mastectomy patients discouragement from pursuing immediate breast reconstruction occurs because some plastic surgeons are unwilling to except the risk of potential irreversible damage to the reconstructed breast by postmastectomy radiation.
In the one-stage procedure the permanent implant is either inserted in an entirely pre-pectoral position, or the upper part of the implant is covered partially by the major pectoral muscle, while the lower part is covered by supportive material.
Immediate reconstruction allows improved breast shape as it allows more complete use of the skin envelope.
Immediate reconstruction associated with psychological advantages initially with improved body image.
For immediate reconstructive procedure completed in one stage combines a permanent implant with less obtrusive of scars, restoring the breast shape without delay.
Immediate reconstruction is not associated with an increased risk of local-regional recurrence after mastectomy.
Patients with reconstruction and implant do not need subsequent mammography since no breast tissue remains.
In a retrospective study of 577 patients treated with wide local excision, simple mastectomy or breast reconstruction the degree of satisfaction was 91%, 73%, and 80%, respectively, with decreased sexual attractivemenss 18%, 68/% and 25%, anxiety 38%, 69% and 55%, and depression 7%, 10%, and 2% (Al-Ghazal).
Smaller prospective studies do not show significant differences with reconstruction, indicating that benefits of the procedure are dependent on the individual circumstances and preference of patients.
Generally, consists of 2 stages: restoration of the breast mound and reconstruction of the nipple-areola complex.
Reconstruction of the breast mound can be accomplished by the use of implants or autogenous tissue.
The type of technique used for reconstruction of the mound dependenet on a number of factors including the size and shape of the breast before surgery, the location of the cancer, the availability of tissue surrounding the breast and at other sites, the age of the patient, the presence of comorbid medical problems, the type of adjuvant therapy planned after the surgery nd the patient’s preference.
The nipple areola complex reconstruction is usually completed once the breast mound is completed and administration of any adjuvant therapy is completed.
Options for implant based reconsruction include standard immediate reconstruction, two-stage reconstruction with a tissue expander followed by implantation, or reconstruction with implant and autogenous tissue.
In the two stage reconstruction a tissue expander is placed in the submuscular position under the pectoralis major and serratus anterior muscles at the time of mastectomy, and postoperatively the tissue expander is serially inflated with saline during outpatient visits.
After 6-8 weeks the expansions are complete and the tissues adjust to the new positions for 1-2 additional months, when the exchange is made of the expander with the final implant, usually as an outpatient.
The two stage technique is presently the most common approach to implant reconstruction.
Single stage implant reconstructionis are esthetically less successful as two stage reconstructions and in many cases a revision is required-this technique not used for the majority of cases of implant reconstructions.
Contralateral breast surgery may be performed to maximize breast symmetry, and can be done at the time of unilateral reconstruction or at a second stage.
An association between breast implants and the development of an anaplastic large cell lymphoma.