Breast reconstruction following mastectomy Stephen H Miller, MD, William P Graham 111, MD Janette Tepsich, RN, Nancy Taylor, RN Breast cancer is the most common malignancy affecting American women today. Each year approximately 90,000 new cases are diagnosed and treated in this country.' In the United States, the preferred treatment for operable carcinoma of the breast is the standard or modified radical mastectomy.2 Several prominent surgeons have advocated lesser operations for certain types of breast c a r ~ i n o m a It . ~ is not our intention to enter into the current debate as to which type of mastectomy should be performed for breast cancer. We believe this decision should rest primarily with the surgeon responsible for treating the patient. In our twentieth century society, the female breast has assumed a psychosocia1 significance far greater than its physiologic value. It is regarded by both sexes as a major symbol of femininity. Women faced with the prospect of undergoing mastectomy fear death from cancer but also fear that loss of their breast will make them less

feminine. It is not uncommon for women to delay and, in some instances, refuse treatment because of these fears. Following mastectomy, most women develop a psychological depression, which, in some, may be profound and long lasting. Although possibly cured of cancer, they are unable to adapt to the alteration of their physical appearance and psychological body image. The empathetic and experienced surgeon recognizes and anticipates these reactions. He allows the patient to express her fears and counsels her preoperatively. He should discuss the proposed operation and its consequences as well as possible alternative modes of therapy. While his primary concern must be to cure the patient, he cannot lose sight of the fact that the patient must live with the consequences of that aim. Preoperative plans should be made for physical and psychological rehabilitation after the mastectomy. Helpful to both physician and patient are volunteer postmastec-

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tomy patients, available on physician request, to guide and encourage patients pre and postoperatively. These volunteers can be contacted through local chapters of the American Cancer Society. Replacement of the missing breast is of great importance to the postmastectomy patient. The Reach for Recovery program, a national organization of postmastectomy patients, provides the new postmastectomy patient with a n individually sized prosthesis prior to departure from the hospital. If this service is unavailable, the patient can be fitted with a prosthesis at a surgical supply store or a major department store. The majority of women are satisfied with these prostheses and subsequently lead normal lives. A significant number of women, however, are unable to adapt psychologically following mastectomy. Although they appear normal when wearing a properly fitted brassiere and prosthesis under clothing, they are unable to incorporate the external prosthesis into their body image. They are distressed by the limited selection of clothing available to them. Many become reclusive, fearing dislodgment of the prosthesis with public disclosure of their deformity. This is especially true in the young and athletically inclined woman. For these psychological cripples, the possibility of breast reconstruction following mastectomy may represent a new lease on life. Surgeons in the past have been reluctant to consider breast reconstruction fearing that local recurrences might be hidden. The incidence of local recurrence following well-performed mastectomy should be less than ZO%.4 A t a recent symposium, several nationally prominent extirpative breast surgeons expressed the opinion that breast reconstruction 948

following adequate mastectomy would not increase the incidence of recurrence nor in all probability alter its diagnosis and treatment.5 Many techniques for reconstruction of the female breast using autogenous tissue have been reported.6 Most of these utilize pedicle flaps requiring several operative procedures and months or years to complete. The end result has rarely been satisfactory. It is also conceivable that placing large bulky flaps onto the chest wall may mask local recurrences. Other techniques for autogenous breast reconstruction utilize the opposite breast.' While requiring less time and fewer procedures than the pedicle flap method, it cannot be performed unless the opposite breast is large enough t o

Stephen H Miller, MD, is associate professor of surgery and associate chief, division of plastic surgery, Milton S Hershey Medical Center, Hershey, Pa. He is a graduate of the University of California at Los Angeles School of Medicine.

William P Graham 111,MD, is professor of surgery and chief, division of plastic surgery, Milton S Hershey Medical Center. A graduate of Princeton University, he received his MD from the University of Pennsylvania School of Medicine . Janette Tepsich, R N , is a staff nurse at the Milton S Hershey Medical Center. She is a graduate of the Albert Einstein Medical Center School of Nursing, Philadelphia. Nancy Taylor, R N , is a staff nurse in the operating room at Milton S Hershey Medical Center. She graduated from the Washington Hospital School of Nursing, Washington, Pa.

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ostmastectomy patients are requesting plastic surgery consultation.


be easily mobilized and transposed. An even greater objection to using the opposite breast is that in 10% to 15% of patients breast carcinoma is bilateral, and, therefore, one may be using a premalignant organ for reconstruction.8 Because of these factors and the technical difficulties involved, autogenous breast reconstruction is infrequently performed. With the development of the silicone breast prosthesis by Cronin and Gerow, a new method of breast reconstruction has become a ~ a i l a b l e .In~ creasing numbers of postmastectomy patients are now aware of this possibility and are requesting plastic surgical consultation. Unfortunately, many physicians and surgeons are unaware of the possibility of simple breast reconstruction and of how to increase the likelihood that their patients may be candidates for such a procedure. Technical maneuvers that may increase the possibility of breast reconstruction without risking the chance of cure should be known to all surgeons performing mastectomy. Transverse incisions heal better and faster than vertical or oblique incisions and still give adequate exposure for the mastectomy. Skin flaps should be cut as thickly as is consistent with a good cancer operation, yet assuring their complete survival. Redundant skin and soft tissue should not be need-

lessly sacrificed for they may be shifted prior to or during the insertion of an implant to assure that the latter is well covered by vascularized tissue and is not under tension. Closure of a mastectomy wound by skin graft, while useful at times, is rarely necessary in the standard or modified radical mastectomy. If cure can be achieved by moditied radical mastectomy leaving the pectoral muscles, breast reconstruction is far easier to perform and more likely to succeed. Routine postoperative radiotherapy is no longer advised for all breast carcinomas. It is a useful adjunct to mastectomy if cancer has been left behind aRer the resection, when there is extensive axillary node involvement, or with medial quadrant lesions. Radiation has a deleterious effect on the thin skin flaps left after a mastectomy as well as on the underlying lung.1° If a skin graft was used to close the defect or the patient had irradiation to the chest wall, new, well-vascularized tissue in the form of a composite flap must be transferred to replace the skin graft and/or irradiated area prior to considering breast reconstruction. Pedicle flaps from the ipsilateral flank or from a distant site such as the abdomen are available to replace the chest wall tissue. The opposite breast, while readily available, should not be used unless loss of the chest wall skin

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Fig 1. Artist’s interpretation of the defects present following a standard radical mastectomy. The subclavicular and axillaty fold defects are not present, and the skin does not adhere directly to the ribs following a modified radical mastectomy. (Photographs reprinted with permission of American Family Physician.)

and soR tissue results in an emergent life-threatening situation, which precludes the use of distant flaps. The ideal candidate for breast reconstruction is the patient who has undergone a curative resection for carcinoma of the breast and is dissatisfied with wearing an external breast prosthesis. The mastectomy wound should be well healed, the scar mature, and the flaps mobile. The skin of the chest wall should be well vascularized and undamaged by irradiation. Reconstruction is usually performed between 6 and 12 months postmastectomy, although in Australia it has been performed within a week of the mastectomy.ll Psychologically, the patient should demonstrate progressive adaptation to her disease and altered body image. Careful preoperative assessment should be made of the patient’s goals and expectations following reconstruc962

tion since a normal-appearing breast does not result. Aesthetically, the end result is merely a semblance of a breast. For this reason, we feel it is worthwhile to show our patients photographs of mediocre results to help them realistically appraise the procedure and its end result. Although absence of the breast is the major deformity following mastectomy, consideration may be given to the lack of tissue in the subclavicular and anterior axillary areas, which occurs after the standard radical mastectomy (Fig 1) but not following modified radical mastectomy. These soft tissue defects may be reconstructed by using autogenous dermalfat grafts or a silicone prosthesis.12 From a plaster of Paris chest wall moulage made by the physician, a silicone supply company can make a prefabricated customized prosthesis. The prosthesis can also be made to

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incorporate a prosthetic breast for implantation. It is also possible to make a silicone prosthesis for soft tissue defects by using room temperature vulcanizing silicone during the operative procedure. The disadvantage of this technique is the time required to make and cure the prosthesis; however, it is generally better fitting than a prefabricated one. Most patients who have had a standard radical mastectomy do not request soft tissue reconstruction, but want only to have a breast-like mound on the mastectomy side. Prior to undertaking breast reconstruction, we conservatively estimate the size of the implant needed. The estimate is based on the state of the local skin, presence or absence of pectoral muscles, and the body habitus of the patient. We then order a polyurethane-covered, inflatable, silicone gel breast implant from one of the manufacturers of silicone prostheses (Fig 2).

tion to raise as thick a flap as possible, especially under the old incision. Plication of soft tissue with reinforcing sutures underneath the old incision may be helpful. If the pectoral muscles are present, they are elevated so the implant can be placed behind them. The pocket should be large and easily accommodate the implant without any tension on the skin flaps. Hemostasis must be meticulous. Suction drainage is used, but prophylactic antibiotics are not. After closure of the skin and while carefully observing the color and capillary circulation within the flaps, small increments of 6% dextran are added through the valve of the prosthesis. If blanching or decreased capillary filling of the flaps is observed, dextran is withdrawn until the circulation improves. A soft bulky compression dressing is then applied and on the seventh postoperative day exchanged for a soft, wireless, wellfitting support brassiere. During the

Fig 2. The polyurethane-covered silicone prosthesis used for breast reconstruction.

The operation is performed under general anesthesia through an incision that avoids the previous mastectomy incision. Our preference is for a vertical axillary incision if an oblique or vertical incision was used for the mastectomy. If a transverse (Stewart-type) incision was used for the mastectomy, we prefer to use a new transverse incision inferior to the previous incision. Care must be taken during the dissec-

next several weeks, saline in 25 to 30 cc increments is added via percutaneous puncture of the valve of the prosthesis using a long #25 or #27 needle until the implant is filled to its capacity or the flaps appear to be in jeopardy. An areola nipple complex can be created a few months later by using one of several techniques. Local skin can be made to project above the

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Fig 3A. A modified mastectomy was performed on this 46-year-old female two years prior to this photograph.

Fig 38. This photograph was taken one year after reconstruction on the left side. The nipple-areolar complex was reconstructed with a split-thickness skin graft from the opposite breast and a reduction mammoplasty was performed on the right breast. Fig 4. Labia minora graft for nipple-areolar complex reconstruction.


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breast by using v-y advancement and a purse-string suture. Pigment may be added by tattooing the skin. Areola may be borrowed from the opposite breast in the form of a concentric fullthickness circle of skin, full-thickness pie-shaped wedge of skin, or splitthickness skin graft from the opposite areola nipple complex (Figs 3A, 3B). Finally, full-thickness grafts of buccal mucous membrane and labia minora have been used to create the nipple areola complex (Fig 4). Care must be taken not to expose the implant when adding these refinements. It is of interest that the majority of our patients have refused reconstruction of the nipple and areola, being satisfied with the breast mound alone (Figs 5A, 5B, 5 0 . Complications associated with prosthetic implantation after radical mastectomy are no different than those seen following augmentation mammoplasty. They are infection, hematoma, and, most commonly, skin necrosis. Their incidence is greater following standard radical mastectomy than in modified radical mastectomy due to the limitations of skin and soft tissue cover in the former. Careful patient selection and conservatism on the part of the surgeon are necessary to avoid a high incidence of complications and disappointed patients. Not infrequently the opposite breast is either ptotic or larger than the newly reconstructed breast mound. Serious consideration must then be given to balancing the two sides. In the past, we have recommended that these women have a reduction mammoplasty or ptosis procedure on the opposite breast. This may be prior to, following, or at the same time as implantation of the prosthesis for breast reconstruction. More recently, we have become concerned with the malignant

Fig 5A. A right radical mastectomy was performed on this 56-year-old female in


Fig 58. Seven months after implantation.

Fig 5c. Pafient brassiere.

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an unmodified

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potential of the opposite breast and in certain instances recommend that the patient undergo a subcutaneous mastectomy with immediate prosthetic reconstruction of this breast. Our technique for this procedure is similar to that described by others,13 but we prefer to use the polyurethane prosthesis for implantation. We feel that the end result with it is as good as with other implants. The main advantage of this prosthesis is that it can be filled to its capacity over several weeks time by percutaneous puncture of the valve to reduce the risk of skin necrosis. Summary. Each year in the United States, approximately 90,000 women undergo mastectomy for carcinoma of the breast. The majority of these women can be rehabilitated both psychologically and physically by the use of an external breast prosthesis. Some women, however, are unable to adapt to the loss of their breast and are severely handicapped in their roles as women. A technique of simple breast reconstruction using an implantable breast prosthesis of polyurethane-covered silicone is described. This implant has a self-sealing valve which can be filled by percutaneous injections of dextran. Refinements for the reconstructed breast are described. While the postoperative results are at best fair, patient acceptance has been extremely good in our experience. All of our patients have stated that they much prefer their new breast mound to the external prosthesis they formerly used to wear. 0 Notes 1. American Cancer Society. Ca-A Cancer Journal for Clinicians 26 (January/February 1976) 8. 2. Breast Cancer: Early and Late, a collection of papers presented at the Thirteenth Annual Clinical Conference on Cancer, 1968, at the University


of Texas M D Anderson Hospital and Tumor Institute, Houston, Yearbook, 1970. 3. G J Crile, “Results of simple mastectomy without irradiation in the treatment of operative stage I cancer of the breast,” Annals of Surgery 168 (1968) 330. 4. W L Donegan, C M Perez-Mesa, F R Watson, “A biostatistical study of locally recurrent breast carcinoma,” Surgery, Gynecology, and Obstetrics 122 (1966) 529. 5. Symposium on Neoplastic and Reconstructive Problems of the Female Breast, March 21-22, 1975, Rutgers Medical School, Greenbrook, NJ, sponsored by the Educational Foundation of the American Society of Plastic and Reconstructive Surgeons, Inc. 6. H Gillies, “Surgical replacement of the breast,“ Proceedings of the Royal Society of Medicine 52 (1959) 597; T Cholonsky, “Breast reconstruction after radical mastectomy: Formation of a missing nipple by everted navel,” Plastic and Reconstructive Surgery 38 (1966) 577. 7. J Alexander, L Block, “Breast reconstruction following radical mastectomy,” Plastic and Reconstructive Surgery 40 (1967) 175; R Pontes, ”Single stage reconstruction of the missing breast,” British Journal of Plastic Surgery 26 (1 973) 377. 8. J A Urban, “Bilaterality of cancer of the breast: Biopsy of the opposite breast,” Cancer 20 (1971) 1867. 9. T D Cronin, F J Gerow, “Augmentation mammoplasty: A new ‘natural feel’ prosthesis,” Excerpta Medical InternationalProceedings: Third lnternational Congress of Plastic Surgery (October 1966); R K Snyderman, R Guthrie, “Reconstruction of the female breast following radical mastectomy,“ Plastic and Reconstructive Surgery 47 (1971) 567. 10. B Fisher, et al, “Postoperative radiotherapy in the treatment of breast cancer: Results of the NSABP Clinical Trial,” Annals of Surgery 172 (1970) 711. 11. J Hueston, G McKenzie, “Breast reconstmction after radical mastectomy,” Australian and New Zealand Journal of Surgery 39 (1970) 367. 12. H Lipshutz, “Method for correction of the chest deformity after radical mastectomy,” in Symposium on Neoplastic and Reconstructive Problems of the Female Breast, R K Snyderman, ed. (St Louis: C V Mosby, 1973) 74. 13. C Horton, et al, “Simple mastectomy with immediate reconstruction,” Plastic and Reconstructive Surgery 53 (1974) 42.

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Breast reconstruction following mastectomy.

Breast reconstruction following mastectomy Stephen H Miller, MD, William P Graham 111, MD Janette Tepsich, RN, Nancy Taylor, RN Breast cancer is the m...
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