The surgical management of breast cancer has changed radically over the last years from the radical and extended radical procedures to the more conservative surgery and now to skin sparing mastectomy and immediate breast reconstruction. Provided that breast skin is not involved with or close to the tumor, skin sparing mastectomy can be done with removal of only the nipple areola complex and the tumor biopsy scar. The mastectomy is otherwise the same as the standard modified radical mastectomy with removal of all breast tissue and complete axillary nodal dissection. The inframammary fold should be left undisturbed. Preservation of uninvolved breast skin provides an ideal color and texture match of the reconstructed breast with the opposite one. It also aids the plastic surgeon in creating a normal breast shape by providing a properly shaped breast skin envelope, which the surgeon simply needs to fill. Immediate breast reconstruction has become the standard of care for women with breast cancer who need or elect to have a total mastectomy and who desire creation of a breast mound.
Skin sparing mastectomy with immediate reconstruction has become popular with patients because compared to delayed reconstruction, it improves the cosmetic result and reduces cost and anesthetic risk. In one stage, it completes most of the surgical treatment the patient will ever require for treatment of her breast cancer. It eliminates the need to live with the deformity caused by mastectomy and thereby contributes to a more positive body image. It does not increase the risk of local or regional recurrence and when properly performed, especially with autogenous tissue, it does not interfere with the adjuvant therapy.
The aim of this work was to study the oncologic appropriateness of SSM and the aesthetic results of IBR following SSM. In this study, 30 patients with early stage breast cancer were selected and were scheduled for skin sparing mastectomy and immediate breast reconstruction. All Patients in the study did skin sparing mastectomy and either pedicled TRAM flap or LD flap with implant breast reconstruction or sub pectoral implant alone. SSM was done for stage I in 7 cases (23.3%) and for stage II in 23 cases (76.7%) Types of SSM utilized included type I in 21 cases (70%) type II in 3 cases (10%) and type III in 4 cases (13.3%) and type IV 2 cases (6.7%).
Axillary lymph nodes were found to be negative for tumor metastases in 15 cases (50%) compared to positive nodes in 15 cases (50%). IBR was performed in all cases where 10 cases (33.3%) underwent pedicled TRAM flap reconstruction and 10 cases (33.3%) underwent pedicled LD flap with implant reconstruction and 10 cases (33.3%) underwent sub pectoral implant alone . Follow up period ranged from 1 year to 2 years.
The average age of pedicled TRAM flap group was(46.8) years, the LD flap with implant group was (38.3) years . and for sub pectoral implant group was(43.1)years .
The operative time averaged (7) hours for the TRAM flap group, (5.05) hours for the LD flap with implant group and (3.2) hour for sub pectoral implant group .
The mean blood loss was (975cc) in the TRAM flap group, was(520cc) in the LD flap with implant group and was (365cc) in sub pectoral implant group.
three patients (10%) received blood transfusion in the TRAM flap group compared to one patients (3.3%) in the LD flap with implant group
and no cases in sub pectoral implant group receive blood transfusion .
The hospital stay for the TRAM flap group ranged from 10 to 16 days with a mean of (12) days. The range for hospital stay for the LD flap with implant group was 6-12 day with a mean of (8) days and 4-7 days with a mean of (5)days for sub pectoral implant group. For TRAM flap there was no total flap loss. Early postoperative complication occurred in 5 patient including partial flap necrosis in 1 patients (10%), hematoma in 1 patient (10%) and infection in 1 patient (10%), fat necrosis in 2 patient (20%). Late complications included hernia in 1 case (10%) and Hypertrophic scar in 1 case (10%). In LD flap with implant group, seroma developed in 2 cases (20%), infection in 1 cases (10%) and capsular contracture in one case (10%) donor site Hypertrophic scar in 2 cases (20%).
In sub pectoral implant group, but nearly all are minor 7 cases has shoulder and anterior chest wall pain. One of the patient develop in addition capsular contracture 10% anther case develop infection not necessitate implant removal . The adjuvant therapy started on the usual time for the three groups. There was a delay in initiation of therapy in 3 cases following TRAM flap reconstruction due to partial flap necrosis and fat necrosis .
The aesthetic appearance of both groups was graded on a scale of I to IV. In TRAM flap group, excellent results obtained in 5 cases (50%), good results in 4 cases (40%) and fair results in 1 cases (10%).
In LD flap with implant group, excellent results was obtained in 4 cases (40%), good results in 4 cases (40%) and poor and fair results in 2 cases (20%).
In sub pectoral implant group, excellent result was obtained in 2 cases (20%) good result in 6 cases 60% fair and poor result in 2 cases 20%.
Local recurrence was observed in 1 case (3.3%) after follow up of 1.5 years and treated with multimodality therapy. Distant failure was observed in 1 case (3.3%) in the form hepatic metastasis.
Finally, this study was comparable to several other studies in the literature concerning SSM and IBR.
In summary, we believe that SSM with immediate breast reconstruction offers enhanced aesthetic results with safe technical outcomes with regard to early local recurrence rate that are comparable to those obtained after non SSM. However, the long term oncologic results of this procedure remain to be seen and therefore, additional long term follow up studies are needed .
|
