|Year : 2016 | Volume
| Issue : 2 | Page : 39-45
Postmastectomy breast reconstruction at University of Benin Teaching Hospital, Benin City
Ferdinand Onwuemene Ijekeye1, Nnamdi Jude Nwashilli2
1 Department of Orthopaedics and Traumatology, Burns, Plastic and Reconstructive Surgery Unit, University of Benin Teaching Hospital, Benin City, Nigeria
2 Department of Surgery, General Surgery, University of Benin Teaching Hospital, Benin City, Nigeria
|Date of Web Publication||12-Jun-2017|
Nnamdi Jude Nwashilli
Department of Surgery, University of Benin Teaching Hospital, Benin City, Edo State
Source of Support: None, Conflict of Interest: None
Post-mastectomy breast reconstruction, though a desirable rehabilitation procedure has remained an uncommon procedure in most resource-limited environments. Most breast cancer patients in our environment undergo total mastectomy, however only a few of them seek or have access to breast reconstruction. Breast reconstruction has potential for improving the psychosocial wellbeing of a patient post-mastectomy. The availability of expertise for breast reconstruction and increased societal awareness will help maximize patients's benefit.We present a case series of five patients with breast cancer who had immediate postmastectomy breast reconstruction with autologous tissue with good outcome.
Keywords: Breast cancer, outcome, postmastectomy breast reconstruction
|How to cite this article:|
Ijekeye FO, Nwashilli NJ. Postmastectomy breast reconstruction at University of Benin Teaching Hospital, Benin City. Niger J Surg Sci 2016;26:39-45
| Introduction|| |
The treatment for malignant breast disease depends on the stage of the disease as well as on other available ancillary treatment such as chemotherapy, radiotherapy, hormonal therapy, and target therapy. Total mastectomy (modified radical mastectomy) or simple mastectomy with radiotherapy is indicated in early disease with the hope of possible cure while simple mastectomy is indicated in palliation of advanced disease. Total mastectomy leaves the patient with the psychological trauma consequent upon the loss of a functionally and cosmetically important body part – her breast.
Many patients with breast cancer undergo total mastectomy, but only few of them seek or have access to breast reconstruction. The most important consequence of total mastectomy is the psychosocial effect of the physical and esthetic deformity which can have negative effects on body image and on sexual function. Breast reconstruction restores body image, improves vitality, femininity, and sexuality, and positively affects the patients' sense of well-being and quality of life. The goal of breast reconstruction is to restore a natural-appearing breast mound that is symmetrical with the contralateral breast and to maintain the quality of life without affecting the prognosis or detection of recurrence of cancer., Nipple-areolar reconstruction completes the process.
It is desirable that a patient for breast reconstruction should be medically fit, well-motivated, with early disease, and of good socioeconomic status. However, in our practice, most patients present late with advanced disease and have spent scarce funds on ineffective treatment and consequently lack the necessary funds for additional surgery following mastectomy.
We present a case series of five patients out of 86 with breast cancer who had immediate postmastectomy breast reconstruction with autologous tissue with good outcome. The features and outcome of the patients are summarized in [Table 1].
|Table 1: Features and outcome of patients that had breast reconstruction|
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| Cases Report|| |
A 32-year-old female presented with a lump in her right breast of 9-month duration. Lump was painless and gradually increased in size. There was no lump in the left breast. There was no associated nipple discharge, breast ulcer, or fever. There was no family history of breast cancer, and she attained menarche at the age of 13. Physical examination showed a young woman, not pale, afebrile, anicteric, with neither pedal edema nor peripheral lymph node enlargement. Right breast examination revealed a 5 cm × 6 cm lump located in the upper outer quadrant. It had no differential warmth, nontender, firm, unattached to skin or underlying structure, and no axillary lymph node. The left breast was normal. The tumor, node, and metastasis (TNM) stage was T4N0Mx[Figure 1].
|Figure 1: Enlarged right breast from cancer before mastectomy and reconstruction (patient 1)|
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Breast ultrasound revealed a suspicious mass in the right breast. The chest X-ray was normal. A Tru-cut biopsy of the mass confirmed an invasive ductal carcinoma. The estrogen-progesterone receptor status was positive.
She had four courses of cyclophosphamide, adriamycin, and 5-fluorouracil (CAF) neoadjuvant chemotherapy. A total mastectomy with immediate latissimus dorsi breast reconstruction was carried out [Figure 2]. Additional two adjuvant courses of CAF chemotherapy regimen were administered. There was no postoperative complication, and she was very satisfied with the breast mound achieved. Hormonal treatment with tamoxifen was administered. She received radiotherapy afterward and presently being followed up in clinic.
|Figure 2: Postmastectomy and reconstruction of the right breast with latissimus dorsi flap (patient 1)|
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A 33-year-old female presented with a left breast lump of 10-month duration. Lump was painless, gradually increased in size and no lump in the right breast. There was no nipple discharge, ulcer, or fever. There was no family history of breast cancer. She attained menarche at the age of 15; her parity was 1 +1 (one pregnancy termination) and did not use oral contraceptives. Her first confinement was at the age of 26 and she breastfed for 1 year. Physical examination showed a young adult, not pale, afebrile, anicteric, with neither pedal edema nor peripheral lymph node enlargement. Breast examination showed a 2 cm × 3 cm lump located in the upper inner quadrant of the left breast without differential warmth, nontender, firm, unattached to skin or underlying structure, and no axillary lymphadenopathy. The right breast was normal.
Her hematocrit was 36.6% (Hb = 11.1 g/dl), total white blood cell count was 6200/mm, and platelet was 424,000/mm 3. An excision biopsy of the tumor confirmed invasive ductal carcinoma.
She had total mastectomy with immediate latissimus dorsi breast reconstruction [Figure 3]. Postoperatively, she had donor site seroma which was drained. She was satisfied with the breast mound achieved. Six adjuvant courses of CAF chemotherapy were administered. She received 50 Gy in 25 fractions of external beam radiotherapy to the left anterior chest wall and lymph drainage area. She defaulted from clinic follow-up.
|Figure 3: Side view showing left breast mound with symmetry in a patient that had latissimus dorsi flap breast reconstruction after total mastectomy|
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A 33-year-old female presented with a lump in her left breast of 1-year duration. Lump was initially small but gradually increased in size to involve the whole breast. There was associated breast ulcer but no nipple discharge or fever. She had no family history of breast cancer and attained menarche at the age of 12. She was parity 4 +0 and did not use oral contraceptives. Her first confinement was at the age of 22 and she breastfed all her children for at least 6 months. Physical examination showed a young woman, worried, not pale, afebrile, with no pedal edema. Left breast examination revealed a swollen breast with peau d'orange. There was a palpable firm mass in the upper outer quadrant, 8 cm × 8 cm in size, nontender, no differential warmth, and unattached to the skin or underlying structure with a 3 cm fixed axillary lymph node. There was an ulcer on the lower outer quadrant, 3 cm × 4 cm, tender, with sloughs, and everted edges. The right breast was normal. The TNM stage was T4bN2Mx. Tru-cut biopsy of the breast mass confirmed an invasive ductal carcinoma.
She had two courses of CAF neoadjuvant chemotherapy. A total mastectomy with immediate transverse rectus abdominis myocutaneous muscle (TRAM) flap breast reconstruction was carried out. Postoperatively, she had hematoma at donor site which was evacuated. A partial flap necrosis of the skin and subcutaneous tissue at the recipient site was debrided and the wound later healed. She was very satisfied with the breast mound achieved.
A 42-year-old female presented with a right breast lump of 8-month duration. Lump was painless, gradually increased in size, and no lump in the left breast. There was no nipple discharge, ulcer, or fever. There was no family history of breast cancer. She attained menarche at 14 years; parity was 5 +5 (five pregnancy terminations), used oral contraceptives for 8 years. Her first confinement was at the age of 28, and she breastfed all her children for at least a year. Physical examination revealed a middle-aged woman, not pale, afebrile, anicteric, with no pedal edema. Breast examination revealed a hard mass in the lower outer quadrant of the right breast, measuring 6 cm × 6 cm, nontender, no differential warmth, and unattached to skin or underlying structure with no axillary lymph node. The left breast was normal. The tumor stage was T3N0Mx[Figure 4].
|Figure 4: Pre-operative picture in a patient with right breast lump before total mastectomy and Latissimus dorsi reconstruction|
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Full blood count showed hematocrit of 37% (11.5 g/dl), total white blood cell count 9600/mm 3, and platelet count 164,000/mm 3. Chest X-ray and abdominal ultrasound were normal. Tru-cut biopsy of the breast mass confirmed an invasive ductal carcinoma. She had two courses of neoadjuvant chemotherapy and subsequently had total mastectomy with immediate latissimus dorsi breast reconstruction [Figure 5]. Postoperatively, she had seroma at the donor site which was drained. She was satisfied with the breast mound achieved. She had four adjuvant courses of CAF regimen to complete six courses. She had external beam radiotherapy to the right chest wall and lymph node drainage area afterward.
|Figure 5: Front view showing right breast mound with symmetry in another patient that had latissimus dorsi flap reconstruction after total mastectomy|
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A 45-year-old female presented with a right breast lump of 1-year duration. Lump was initially small and painless but gradually increased in size. She had no nipple discharge, breast ulcer, or fever. She attained menarche at age of 14 and had no family history of breast cancer. Physical examination revealed a middle-aged woman, not pale, afebrile, anicteric, with no pedal edema. Right breast had peau d'orange, a mass in the upper outer quadrant, firm, nontender, measured 6 cm × 6 cm, unattached to skin or underlying structure with a palpable axillary lymph node, 3 cm in size, firm and fixed to the underlying tissue. The left breast was normal. The TNM stage was T4aN2Mx.
Full blood count, electrolytes, urea and creatinine, random blood sugar, and urinalysis were within normal limits. Breast ultrasound demonstrated a mass measuring 5 cm × 6 cm with axillary lymphadenopathy. Chest X-ray was normal. Tru-cut biopsy of the breast mass confirmed an invasive ductal carcinoma.
She had two courses of CAF neoadjuvant chemotherapy. A total mastectomy with immediate TRAM breast reconstruction was carried out afterward [Figure 6]. Postoperatively, she had partial flap necrosis of skin and subcutaneous tissue at recipient site [Figure 7] which was trimmed and it gradually healed. She was very satisfied with the breast mound achieved. She had four adjuvant courses of CAF regimen to complete six courses and external beam radiotherapy over the right chest wall and lymphatic drainage area.
|Figure 6: Draped operation site showing open wound on the chest after right breast mastectomy and marked skin on the lower abdomen where transverse rectus abdominis myocutaneous muscle flap was harvested (patient 5)|
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|Figure 7: Postoperative picture showing right breast mound and the healed subumbilical transverse scar (patient 5)|
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| Discussion|| |
The goal of postmastectomy breast reconstruction is to recreate form and symmetry, thus improving the psychosocial well-being and quality of life of the patient. Breast reconstruction using latissimus dorsi flap without implant is fraught with asymmetry unlike reconstruction using TRAM flap. This was the situation in patients in this study. However, the patients had a small breast cup size (size A) and so the slight disparity between the breast and the reconstructed breast mound was negligible.
Wilkins et al. in a multicenter prospective cohort study of patients undergoing postmastectomy reconstruction concluded that immediate and delayed breast reconstructions provide substantial psychosocial benefits for patients who had mastectomy. This psychosocial benefit was similar to what we observed in our study. All the five cases in this study were satisfied with the reconstructed breast mound, level of symmetry achieved, as well as the donor and recipient site scars. Immediate reconstruction preserves anatomical structures such as the inframammary fold and maximizes the amount of native skin available for the reconstructive process, thereby maximizing the overall esthetic result. In addition, it preserves body image, femininity, and sexuality; lower cost of surgery compared to delayed reconstruction and significantly reduces postoperative emotional stress.
The best candidates for breast reconstruction are young, healthy patients with early stage breast disease. In the cases reported, the patients were young and relatively healthy though only one was in the early stage of breast disease. Ideally, breast reconstruction is recommended in early disease; however, in view of the positive psychological benefit derivable from breast reconstruction, even in late disease, patients who are desirous of breast reconstruction following mastectomy and are found to be medically fit for surgery should be availed the option of breast reconstruction. This psychological benefit was what informed reconstruction in the reported cases, and the patients were satisfied with the reconstructed breast mound. Moreover, breast reconstruction has no impact on the overall prognosis or survival of the patient as well as local tumor recurrence.
Breast reconstruction can be achieved through the use of autologous tissue, prosthesis (silicone breast implants), or a combination of both modalities. All the women in this study opted for autologous reconstruction without implants despite the knowledge of the risk of having a smaller volume in the reconstructed breast, especially in the latissimus dorsi group. The reason for this was the additional financial cost of purchasing the breast implant in addition to their disapproval of having a foreign body within their body tissues with its attendant risk of complications. Kaur et al. reported a similar preference of autologous latissimus dorsi flap in their study of 19 patients who had breast reconstruction in low-resource setting in India. The reasons adduced were that autologous tissue has more natural appearance with better esthetic result compared to implant-based reconstruction can withstand radiotherapy better and it is cost effective. Immediate breast reconstruction with autologous tissue creates a softer, more ptotic, and natural-appearing breast mound in a single procedure., However, its disadvantages include longer duration of anesthesia (5–10 h), more blood loss, longer recovery period, risk of necrosis of portions of the transferred fat and skin and donor site complications which include unsightly scars, abdominal weakness, abdominal bulge, or hernia.,
Hershman et al., in their study, reported that increasing age, Africans race, being married, rural location, and presence of comorbidities were associated with reduction in the rate of immediate reconstruction following mastectomy. However, the availability of health insurance, a large hospital with high patient turnover, and a high surgeon volume was associated with an increased odds ratio [OR] for immediate reconstruction. The five patients reported were all <50 years in age and thus relatively young with tertiary level of education though married. This probably influenced their desire for breast reconstruction to restore their body image and confidence in the public glare. Women who had undergone breast reconstruction are more likely to be younger, have partner, college educated, affluent, and Caucasian than those undergoing either mastectomy alone or lumpectomy.
Three patients had latissimus dorsi breast reconstruction while two had TRAM flap reconstruction in this study. Factors that can influence the type of breast reconstruction surgery a woman chooses includes the size and shape of the breast that is been replaced (breast cup size), the woman's age and health, availability of autologous tissue, and the location of the breast tumor. Breast cup size is determined by measuring the actual chest circumference at the inframammary line and the circumference at the level of highest projection of the breast nipple. A difference of 1 cm gives a cup size A; 2 cm gives cup size B; 3 cm gives cup size C; and so on. The breast cup size increases with increase in the number. The chosen autologous breast reconstruction techniques in our reported cases were generally guided by breast cup size, patients' choice for donor site, the use of implant for breast augmentation by patient, and surgeon's technical expertise. Breast cup size A (small-sized breast), less technical procedure compared to TRAM flap reconstruction, and patients' preference for site of scar to be at the back were the reasons for the choice of latissimus dorsi breast reconstruction. In the patients that had TRAM flap breast reconstruction, larger breast cup sizes (cup size B and C) to achieve symmetry, adequate abdominal fat pad, patients' desire for a flatter tummy, and patients who have completed childbearing guided the choice of TRAM flap technique.
Breast reconstruction does not impede standard oncologic treatment and does not delay detection of recurrence or alter the overall survival in breast cancer. There is now clear evidence that neither implant-based nor autologous tissue-based reconstruction has any effect on the incidence or detection of cancer recurrence.,, The reported cases had other modalities of treatment vis-a-vis chemotherapy and radiotherapy after breast reconstruction without any untoward effect over the reconstructed breast mound, and none of them developed local tumor recurrence.
Complications were more in the TRAM flap group than in the latissimus dorsi group in this study. They consisted of hematoma, seroma, partial flap necrosis of portions of the skin and fat, and breast volume loss which was similar to the complications reported by Nahabedian et al. All but one out of the five cases had postoperative complications. These complications can be attributed to the effect of chemotherapy as they all had neoadjuvant chemotherapy or probably due to technical fault by the surgeon. Decker et al. reported increased complications in patients treated with neoadjuvant chemotherapy who underwent mastectomies with immediate reconstruction although the trend was not statistically significant (OR = 1.58, 95% confidence interval = 0.98-2.58). However, meta-analysis studies , reported lower complication rates in patients treated with neoadjuvant chemotherapy after breast reconstruction. It is unclear why improved outcomes were observed in patients who received neoadjuvant. Selected patients for reconstruction were younger and had fewer comorbidities which could have contributed to fewer complications. In addition, the experience and operation skills of the surgeon are also very important factors that could influence early surgical complications.
| Conclusion|| |
Breast reconstruction remains a relatively uncommon procedure in our environment but retains the potential for improving the psychosocial well-being of patients. Young, medically fit, well-motivated patients with early disease should be encouraged to have breast reconstruction postmastectomy.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]