EDITORIAL COMMENT
BREAST RECONSTRUCTION AFTER MASTECTOMY “Que prdfhre la femme? La vie ou sa feminitb?” WITH Gallic Qlan, Dr And& Picaud has thus crystallized the p ri n ci p a l i n d i ca ti o n fo r reconstruction of the breast after mastectomy. The loss of confidence in their femininity felt by many women after loss of a breast is often so profound t h d not only their lifestyle is altered for the worse, but psychiatric support may be sought. Dr James cites the recent Oxford study by Maguire to support this contention, and it is not an unreasonable estimate that 10% of women after m a s t e c t o m y are g e n u i n e l y i n need of reconstruction. Because the loss is immediate the need for reconstruction is immediate in these women. There exist, however, technical problems leading most plastic surgeons at present still to favour a delay of three to six months in patients with a good prognosis and up to three years in patients with a real possibilityof local recurrence, asstressed by Dr Leggett. Nine years ago in this Journal, Graham McKenzie and this Editor reported on delayed primary prosthetic insertion three to five days after radical mastectomy - stressing the psychological advantage of avoiding the castration complex which Maguire has shown to be strongest in the first postoperative year, the assessment of wound viability and infection, and of the personality of the patient, in particularthelikelihood of her need for contour reconstruction and of her probable acceptance or not of the limitations of present reconstructive procedures. We should not insist on immortality before we treat these patients, and if the psychological indications are present, there is little advantage in waiting any statutory period of one to five years. This early restoration of confidence by restoration of contour has only become possible since the mutilating Halsted mastectomy has been replaced by the pectoral-preserving Patey mastectomy and the availability of silicone prostheses. Thus one procedure suffices i n most patients. The pathological prognosis is probably less important when an early reconstruction is available to reduce
AUST. N.Z. J. SURG.VOL. 49-No.
5, OCTOBER, 1979
the psychological trauma of radical mastectomy. After all, if her first postoperative year may be her last, why not make it more livable? Prognosis depends above all else on the tumour itself, and Dr Furnival has dissected the factors in the tumour pathology which can be useful in assessing life expectancy after adequate mastectomy. Favourable factors include a well-defined noninvasive tumour, less than 2centimetres in diameter, without lymph node invasion, in a women over 35 years, and with a normal bone scintiscan two years after mastectomy. When reconstruction used to involve abdominal tubed pedicle migration in four stages or more, the life expectancy was clearly very important in deciding whetherto proceed. The programme is less restricting with silicone contour augmentation, even if skin needs to be added, since this can be effected by the use of large safe axial-pattern flaps and myocutaneous flaps described here by Dr McDougaH. While microvascular free flap transfer has been used, the introduction of sufficient soft tissue to allow adequate prosthetic augmentation is possible in most cases by these local flap techniques, and the microvascular facilities will be needed only rarely. Dr Robbins’s new compound myocutaneous flap carrying the bulk of rectus abdominis muscle may avoid the use of a prosthesis altogether. Hardening of the prosthesis by scar capsular contraction is inevitable, but it is less noticeable with subpectoral insertion of the prosthesis. The contoured extensions of a normal prosthesis have been shown by Dr Marshall to retain a satisfactory shape despite capsular contraction - and Dr Emmett has, by skilful siting of the dog ear, created a biological reconstruction at times rendering prosthetic insertion redundant. The opposite breast remains an unresolved dilemma. The risk of cancer in the opposite breast is variously estimated from 10% to20%, and there have been four approaches to those patients where no hope exists of augmenting the mastectomy side to achieve reasonable balance. First, one may ignore 501
HUESTON
EDITORIAL COMMENT
the difference, concentrate on the cleavage, and accept the need for continuing use of an external prosthesis. It is essential to mark the upper border of the normal breast i n a brassiere before the operation and aim, to match this level - accepting gross discrepancy without a brassiere. Second, one may introduce more skin to allow a larger implant for balance. Third, there is, as Dr Robinson indicates, a place for reduction of the opposite breast to match - often as a second operation in view of the difficulty of matching the implant on the operating table. The risk of cancer in the opposite breast should be explained to the patient, but many demand such balance. Finally, subcutaneous mastectomy and prosthetic insertion on the opposite breast at the same time or later reduce this anxiety about the opposite breast and make the essential subsequent follow-upeasier on 60th sides. The indications for this subcutaneous mastectomy along with a reliable technique t o obtain aesthetically satisfactory reconstruction are outlined in this number by Dr T. H. Ackland and his colleagues. A recent overseas article on post-mastectomy reconstruction spent eight times more page space on methods of nipple reconstruction than on the breast mound reconstruction. Conversely, in 15 years of post-mastectomy reconstruction I have
discussed nipple reconstruction with my patients and, like Dr Emmett, have found not one patient to feel it worth proceeding with. Assessing the results of other surgeons overseas has shown convincingly that labial grafts are too chocolate-coloured, and that sharing the opposite nipple is most acceptable but mutilating to the opposite breast, which often does not meet with the patient’sapproval. The use of the inguinal pigmented skin is a useful compromise where nothing is lost. Tattooing is rarely satisfactory, but a soft adhesive silicone nipple prosthesis can have a place in young women with breast loss. The storing of the nipple in the groin for replacement has been in vogue since it was introduced in 1971, but it carries the risk of retaining cancer or cancer-prone cells within the large ducts and metastases to the inguinal nodes have been reported. Post-mastectomy reconstruction presents another opportunity for constructive contributions to result from cooperation between general surgeons and a specialty. Care of the breast cancer remains firmly in the hands of the general surgeon, but the patient’s psychological stress can, in the 10% showing the need, be greatly reduced by reconstruction of the breast after mastectomy.
JOHNHUESTON
THE R.A.C.S. FOUNDATION At its June meeting Council formally decided to establish a Foundation by opening a special College account using funus already held for the promotion of educational activities. In accord with legal advice the Foundation will, in due course, probably be established as a separate legal entity, but always underthe control of Council. This is the beginning of what is hoped will become a major and continuing source of support for education, research and development . The objectives of the Foundation are broad, but of immense importance to the future welfare of the College and its Fellows. It should not be regarded as another Appeal, but as an ongoing mechanism to enable the College to enter its second fifty years with a financially secure and worthwhile policy directed towards more effective continuing education for all Fellows, the advancement of
502
surgical knowledge, and the provision of such physical and personnel resources as are necessary to achieve these aims. Of course, the College has always had these objectives, and due to the wisdom, foresight and energy of our forebears it has established training requirements, an examination system and a Diploma of Fellowship with the highest reputation. However, over the years knowledge has expanded and new requirements have evolved. There is an increasing and widely recognised need for all practising Fellows to keep abreast of new developments in knowledge and techniques. This need exists for all Surgeons, regardless of discipline, and the type and site of practice. As the accrediting body the College has a major responsibility to its Fellows and the community in this regard. Existing educational activities can be further developed and others might well be AUST.N.Z. J. SURG.VOL. 49-NO.
5, OCTOBER, 1979
BREAST RECONSTRUCTION AFTER MASTECTOMY “Que prdfhre la femme? La vie ou sa feminitb?” WITH Gallic Qlan, Dr And& Picaud has thus crystallized the p ri n ci p a l i n d i ca ti o n fo r reconstruction of the breast after mastectomy. The loss of confidence in their femininity felt by many women after loss of a breast is often so profound t h d not only their lifestyle is altered for the worse, but psychiatric support may be sought. Dr James cites the recent Oxford study by Maguire to support this contention, and it is not an unreasonable estimate that 10% of women after m a s t e c t o m y are g e n u i n e l y i n need of reconstruction. Because the loss is immediate the need for reconstruction is immediate in these women. There exist, however, technical problems leading most plastic surgeons at present still to favour a delay of three to six months in patients with a good prognosis and up to three years in patients with a real possibilityof local recurrence, asstressed by Dr Leggett. Nine years ago in this Journal, Graham McKenzie and this Editor reported on delayed primary prosthetic insertion three to five days after radical mastectomy - stressing the psychological advantage of avoiding the castration complex which Maguire has shown to be strongest in the first postoperative year, the assessment of wound viability and infection, and of the personality of the patient, in particularthelikelihood of her need for contour reconstruction and of her probable acceptance or not of the limitations of present reconstructive procedures. We should not insist on immortality before we treat these patients, and if the psychological indications are present, there is little advantage in waiting any statutory period of one to five years. This early restoration of confidence by restoration of contour has only become possible since the mutilating Halsted mastectomy has been replaced by the pectoral-preserving Patey mastectomy and the availability of silicone prostheses. Thus one procedure suffices i n most patients. The pathological prognosis is probably less important when an early reconstruction is available to reduce
AUST. N.Z. J. SURG.VOL. 49-No.
5, OCTOBER, 1979
the psychological trauma of radical mastectomy. After all, if her first postoperative year may be her last, why not make it more livable? Prognosis depends above all else on the tumour itself, and Dr Furnival has dissected the factors in the tumour pathology which can be useful in assessing life expectancy after adequate mastectomy. Favourable factors include a well-defined noninvasive tumour, less than 2centimetres in diameter, without lymph node invasion, in a women over 35 years, and with a normal bone scintiscan two years after mastectomy. When reconstruction used to involve abdominal tubed pedicle migration in four stages or more, the life expectancy was clearly very important in deciding whetherto proceed. The programme is less restricting with silicone contour augmentation, even if skin needs to be added, since this can be effected by the use of large safe axial-pattern flaps and myocutaneous flaps described here by Dr McDougaH. While microvascular free flap transfer has been used, the introduction of sufficient soft tissue to allow adequate prosthetic augmentation is possible in most cases by these local flap techniques, and the microvascular facilities will be needed only rarely. Dr Robbins’s new compound myocutaneous flap carrying the bulk of rectus abdominis muscle may avoid the use of a prosthesis altogether. Hardening of the prosthesis by scar capsular contraction is inevitable, but it is less noticeable with subpectoral insertion of the prosthesis. The contoured extensions of a normal prosthesis have been shown by Dr Marshall to retain a satisfactory shape despite capsular contraction - and Dr Emmett has, by skilful siting of the dog ear, created a biological reconstruction at times rendering prosthetic insertion redundant. The opposite breast remains an unresolved dilemma. The risk of cancer in the opposite breast is variously estimated from 10% to20%, and there have been four approaches to those patients where no hope exists of augmenting the mastectomy side to achieve reasonable balance. First, one may ignore 501
HUESTON
EDITORIAL COMMENT
the difference, concentrate on the cleavage, and accept the need for continuing use of an external prosthesis. It is essential to mark the upper border of the normal breast i n a brassiere before the operation and aim, to match this level - accepting gross discrepancy without a brassiere. Second, one may introduce more skin to allow a larger implant for balance. Third, there is, as Dr Robinson indicates, a place for reduction of the opposite breast to match - often as a second operation in view of the difficulty of matching the implant on the operating table. The risk of cancer in the opposite breast should be explained to the patient, but many demand such balance. Finally, subcutaneous mastectomy and prosthetic insertion on the opposite breast at the same time or later reduce this anxiety about the opposite breast and make the essential subsequent follow-upeasier on 60th sides. The indications for this subcutaneous mastectomy along with a reliable technique t o obtain aesthetically satisfactory reconstruction are outlined in this number by Dr T. H. Ackland and his colleagues. A recent overseas article on post-mastectomy reconstruction spent eight times more page space on methods of nipple reconstruction than on the breast mound reconstruction. Conversely, in 15 years of post-mastectomy reconstruction I have
discussed nipple reconstruction with my patients and, like Dr Emmett, have found not one patient to feel it worth proceeding with. Assessing the results of other surgeons overseas has shown convincingly that labial grafts are too chocolate-coloured, and that sharing the opposite nipple is most acceptable but mutilating to the opposite breast, which often does not meet with the patient’sapproval. The use of the inguinal pigmented skin is a useful compromise where nothing is lost. Tattooing is rarely satisfactory, but a soft adhesive silicone nipple prosthesis can have a place in young women with breast loss. The storing of the nipple in the groin for replacement has been in vogue since it was introduced in 1971, but it carries the risk of retaining cancer or cancer-prone cells within the large ducts and metastases to the inguinal nodes have been reported. Post-mastectomy reconstruction presents another opportunity for constructive contributions to result from cooperation between general surgeons and a specialty. Care of the breast cancer remains firmly in the hands of the general surgeon, but the patient’s psychological stress can, in the 10% showing the need, be greatly reduced by reconstruction of the breast after mastectomy.
JOHNHUESTON
THE R.A.C.S. FOUNDATION At its June meeting Council formally decided to establish a Foundation by opening a special College account using funus already held for the promotion of educational activities. In accord with legal advice the Foundation will, in due course, probably be established as a separate legal entity, but always underthe control of Council. This is the beginning of what is hoped will become a major and continuing source of support for education, research and development . The objectives of the Foundation are broad, but of immense importance to the future welfare of the College and its Fellows. It should not be regarded as another Appeal, but as an ongoing mechanism to enable the College to enter its second fifty years with a financially secure and worthwhile policy directed towards more effective continuing education for all Fellows, the advancement of
502
surgical knowledge, and the provision of such physical and personnel resources as are necessary to achieve these aims. Of course, the College has always had these objectives, and due to the wisdom, foresight and energy of our forebears it has established training requirements, an examination system and a Diploma of Fellowship with the highest reputation. However, over the years knowledge has expanded and new requirements have evolved. There is an increasing and widely recognised need for all practising Fellows to keep abreast of new developments in knowledge and techniques. This need exists for all Surgeons, regardless of discipline, and the type and site of practice. As the accrediting body the College has a major responsibility to its Fellows and the community in this regard. Existing educational activities can be further developed and others might well be AUST.N.Z. J. SURG.VOL. 49-NO.
5, OCTOBER, 1979
