Deferred breast reconstruction – soul surgery?

Overview

The loss or mutilation of a breast as a result of the surgical treatment of neoplastic disease always represents a negative impact on a woman’s psyche and negatively influences the quality of the woman’s remaining life. The goal of our work was to implement deferred breast reconstruction into routine practice and the objectification of the influence of reconstruction on bodily integrity, quality of life, and the feeling of satisfaction in women. Women in remission from neoplastic disease after a radical mastectomy were indicated for breast reconstruction. Between January 2002 and December 2011 deferred breast reconstruction was carried out 174x on 163 women, with an average age of 49.2 and an age range of 29 – 67 years. The most frequently used reconstruction method was a simple gel augmentation of the breast or a Becker expander/implant – 51 (29.3%) and 37 (21.3%), or in combination with a lateral thoracodorsal flap (31; 17.8% and 47; 27%); reconstruction using a free DIEP flap was carried out 7x (4%). Complications occurred in 19 operations (10.9%) with a dominance of inflammation and pericapsular fibrosis, in a subjective analysis, satisfaction with the results prevailed, along with an increased quality of life after reconstruction.

A growing number of deferred breast reconstructions, women’s satisfaction with the results, the positive influence of renewed bodily integrity on the feeling of life satisfaction and the quality of life have elevated breast reconstructions to a qualitatively higher level.

Key words:
Becker expander/implant, nipple-areola complex, lateral thoracodorsal flap, DIEP.

Introduction

Neoplastic breast disease in conjunction with their mutilation or loss is a medical and a socioeconomic problem. A woman experiencing serious stress can not be considered, within the meaning of the WHO definition, as healthy even if the neoplastic disease has been shown to be in long-term remission; from this point of view we regard breast reconstruction as a regular part of the treatment of neoplastic disease. As a result of pressure placed on breast reconstruction by sick women, the intensive development of reconstruction methods occurred. Moments of breakthrough took place with the creation of silicone implants (Cronin, 1963) the Becker expander/implant (1984) and the development of microsurgery. At present we have at our disposal a whole range of reconstruction methods and approaches which can be chosen in accordance with the current situation.

The goal of our work was to, in the indicated cases, increase the quality of life of sick women and to incorporate this modus operandi into the treatment protocol and routine practice in such a way so that it is commonly available and is established in the awareness of specialists and laymen alike, and to find out the differences in the quality of life of the women which have undergone deferred breast reconstruction and the group of women who have not undergone reconstruction.

Achievement of the project goals was conditional on the team-work within the framework of the mammological center and interdisciplinary approach of the Surgical clinic, the Plastic Surgery Department, RTO, clinics displaying the methods of the Plzeň University Hospital, The Šikluv pathological-anatomical LF institution in Plzeň, UK, and Prague and the expert consultation within the framework of plastic reconstruction surgery.

Materials and Procedures

174 deferred breast reconstructions were included in our sample, which were carried out between January 2002 and December 2011 on 163 women overall; 152 women (93.3%) underwent unilateral reconstruction, 11 (6.7%) bilateral concurrently. Tab.1. During the course of the monitored period a significant growth in the number of reconstructive operations carried out occurred.

The average age of the women operated on was 49.2 years old in the range of 29 - 67 years with a median age of 48 years old. The greatest incidence was shown in the 5^th decade of life (41 – 50 years old) – 57 (35 %), then the 6^th decade (51 – 60 years old) – 52 (31.9 %), the other decades showed a lesser incidence – 4^th decade  (31 – 40) – 46 (28.2 %) , 7^th decade (61 – 70) – 7 (4.3 %), 3^rd decade (21 – 30) – 1 (0.6 %). Tab 2

In 164 (94.3 %) of the preceding mastectomies, the causality was neoplastic, in 8 (4.6 %) it concerned the benign illness of the breasts and in 2 (1.1%) it concerned prevention. Tab. 3

3 reconstructions (1.7%) were carried out less than a year after mastectomy, the majority – 110 (63.2%) with an interval of 1 – 4 years, the others- 61 (35.1%) with an interval greater than 4 years; the shortest interval was 8 months, the longest 20 years. Tab. 4

Reconstruction by way of augmentation using silicone gel breast implants was carried out 51x (29.3%), augmentation with BEI  37x (21.3%); a combination of   TDLF and reconstruction by means of augmentation using gel breast implants was performed 31x (17,8%), while TDLF and BEI augmentation was carried out  47x (27 %). A combination of a musculocutaneous flap from the m. latissimus dorsi and augmentation by way of a gel breast implant 1x (0.6 %), and a DIEP microsurgical skin graft 7x (4 %). Tab. 5

The basic conditions for the indication of reconstruction operations were the realistic wishes and expectations of patients and the unambiguously positive results of the oncological examination, as well as adequate overall health state. The method of reconstruction was established after consideration of the above stated moments and local anatomical conditions. Emphasis was placed on minimizing the strain on the patients. In the case of augmentation round as well as anatomic silicone gel implants, brands CUI and Laboratoires Eurosilicone, were used. In the case of Becker expander/implants, Siltex Becker 25 Cohesive I, Becker 50 Cohesive I and Siltex Becker Contour Profile Becker 35 Cohesive II were used.  

Subsequent interventions were carried out on the reconstructed breasts (reconstruction of the NAC, scar correction, flap correction etc.) as well as the contralateral breast (reduction, breast lift) For the reconstruction of the areola, tattooing was primarily used, or autotransplantation by way of a skin graft from the contralateral areola, for the reconstruction of the nipple autotransplantation with a part of the contralateral nipple, or the usual methods of local flaps (star flap, wrap around flap, two-step purse string)

The final subjective analysis of patients concerned ascertaining their satisfaction with the results of the reconstruction itself, the willingness, if necessary, to undergo the process of reconstruction again, the feeling of life satisfaction (not closely defined), and a qualitative change in the areas of socioeconomics, and psychosexuality, in relationships with partners, level of self-confidence and in life style. The data was obtained through personal interviews, brief, clearly structured questions were placed, for evaluation, 5 and 3 degree scales were used (degree 1 = the best). In all cases of subjective evaluation, special emphasis was placed on ensuring that a disturbing comparison with the pre-illness state did not occur.

The women underwent supervised care for 12 months after completing reconstruction, during which the final evaluation was also carried out and the women were subsequently handed over to the care of an oncologist.

Results

The main evaluating criteria for a successful reconstruction is, according to our belief, the degree of a woman’s satisfaction with her own results of the reconstruction, the degree of feeling a  non-closely defined feeling of subjective life satisfaction, and the degree of improvement of quality of life in the selected areas. All the below mentioned evaluations, related to the subjective quality of life were compared with the pre-reconstructive state.

Complete satisfaction with the results was reported by 120 women (73.6%), prevailing satisfaction 36 (22.1 %), the results were evaluated as good by 1 (0.6 %) patients with prevailing dissatisfaction were reported by 6 women (3.7 %); pronounced dissatisfaction was not reported. To the question whether the women would undergo reconstruction again if necessary, 148 answered “YES” (90.8%) “NO” 4 women (2.5%) and “I DON”T KNOW” 11 (6.7%) women overall. Tab. 6

A feeling of non-specified life “satisfaction” was reported by 89 (54.6%) women “prevailing satisfaction” 64 (39.3%) life satisfaction as “good” 9 (5.5%), “sufficient” 1 (0.6%) of women. We didn’t meet with an insufficient degree of or the absence of the feeling of life satisfaction.

The individual quality of life and their changes were monitored in 6 chosen areas, evaluated with the help of three degree scales and compared with the period before the actual reconstruction, so then in the period between the mastectomy and the reconstruction. In the socioeconomic area, a majority of women did not report any changes – 119 (73.0%), approximately the same number reported improvement 23 (14.1%) and worsening 21 (12.9%) socioeconomic level, which could however be influenced by long-term work disability, or loss of employment etc. A positive influence of reconstruction was monitored in the psychosexual area – 112 (70.6%) of women reported improvement, 46 (28.2%) did not report any change and only 2 (1.2%) reported a worsening. The quality of relationships with partners was not at all significantly affected by the completion of reconstruction. 146 (89.6%) of women evaluated them as unchanged, only 7 (4.3%) as improved and 10 (6.1%) reported an unambiguous worsening. Both evaluating parameters – socioeconomic level and relationships with partners are influenced by a wide range of complex factors, often intangible, besides others also their quality in the pre-illness state. Self-confidence is very positively influenced by renewed bodily integrity. 151 (92.7%) of women reported its improvement, 9 (5.5%) did not observe a change in self-confidence and only 3 (1.8%) a worsening. It is possible to meet with a similar situation in self-assessment, where 122 (74.8%) of women reported an improvement and only 41 (25.2%) did not observe a change. We did not meet with a worsening of self-assessment in the sample.

Life style was not significantly influenced by reconstruction. The greatest number 153 (93.9%) evaluated it as unchanged, only 9 (5.5%) as improved and only 1 (0.6) woman reported a worsening quality of life style. Tab.8

The monitored sample reported a relatively low frequency of complications. 19 (10.9%) local complications were discovered. Abscesses around the implant requiring explantation were discovered 2x (1.2%), likewise as with abscesses in the wound – 2 (1.2%), clinically significant necrosis around the flap was discovered 3x (1.7%), however explantation was only required 1x, pericapsular fibrosis grade III on the Baker scale 4x (2,3%), chronic idiopathic pain in a reconstructed breast 1x (0.6%). Total complications were not recorded. Tab. 9

Extremely low mortality was recorded for a one year period – 1 (0.6%), and it occurred 8 months after breast reconstruction. We did not observe any formation of local metastasis disease. Tab.10

154 women (94.5) underwent accessory operations which most of all concerned correction of asymmetries in breast shape and size and breast lift, or reduction of the contralateral breast with the simultaneous reconstruction of the NAC – 131 (80.4%), the other 23 woman gave preference to the isolated reconstruction of the NAC, or correction of asymmetries. Tab.11

Discussion

Carcinoma of the breast is the disease of civilization in the developed countries of the world with the most frequent incidence of malignant tumors in women, with a year-over-year growth of 1 – 2 %. (1–4). In light of the fact that breasts are a significant secondary sexual symbol, reconstruction has become a logical part of the treatment concept. According to our conviction, the main goal of breast reconstruction must be an increased quality of life of women in comparison with life after a radical mastectomy, restoration of the feeling of bodily comprehensiveness and integrity and the minimization or elimination of stress arising out of the previous mutilation or loss of a breast. About this point, consensus related to the problems of breast reconstruction usually ends. Right from the question of whether or not to reconstruct the breast immediately or deferred, there will be discussion, the same as with the selection of the conditions of indication, reconstruction methods etc. (5) With the realization of the complexity of the problems, to solve the task we joined together in an interdisciplinary and team approach, we have experienced that it is not possible to solve the problems satisfactorily in a another way.

The fundamental question is at which point breasts can be safely reconstructed (6 – 7). The previous time interval of more than 2 years is today already too long according to the evolved opinion, and in agreement with most work places, we believe that it is possible to consent to reconstruction at the moment when it is no longer limited by treatment, it is not encumbered by some reason of the supervised care and the patient is in overall good condition (8). Even though it is possible to discuss the possibility of breast reconstruction before possible radiotherapy (9,10), we prefer to carry out breast reconstruction after its completion. However it is not beneficial to uselessly wait too long because of the stress caused from bodily mutilation, which often empowers stress induced from neoplastic anamnesis. This stress can even have fatal consequences (11), which only points out the complexity of the problem.

The reported improvement in quality of life in the psychosexual area, in the sphere of self-confidence, underlines this and emphasizes the effects of deprivation of patients from their own reconstruction (12, 13). We recommend comparing the data with the period between the mastectomy and reconstruction, and not at all with the pre-illness period, which would not make evaluation simple, and which would be complicated by a range of side factors, often intangible.

Collecting and evaluating the data which helps evaluate sensitive areas such as the feeling of life satisfaction, and sensing qualitative changes in self-confidence and so on. It is an open question to what extent it is possible to verify the acquired data and especially to evaluate it. It concerns an area of dynamic changes, therefore we always relate the evaluation to the given moment which was put out of the dispensatory, when it is already possible to assume a certain degree of stabilization.  

Presently we have a wide spectrum of reconstruction methods which by their number give evidence to the complexity of the problem. Reconstruction methods are not methods competing with each other, rather a connected spectrum of possibilities from which it is possible to choose depending on the current situation, the given subjective wishes of the patient, anatomical proportions, the overall medical condition etc. (14, 15). The selection of a suitable reconstruction method must however always be unambiguous (16) it therefore also often becomes the subject of expert discussions (17). With regard to the mentioned constantly growing incidence of neoplastic disease in women’s breasts and the resulting growing number of reconstruction operations the economic question is also coming to the forefront (18).

In our conception, we give, if it is possible, unambiguous preference to the methods which have the shortest period of time of operation and which have the lowest risks, for these reasons we have given preference to simple gel implant augmentation, or BEI everywhere where there is a sufficient amount of high-quality tissue, bodily constitution, and the subjective imagination of the patient regarding the target breast size allowed. In the case of gel breast implants or BEI, we used round and anatomic implants to the same extent, however we did not record significant differences in the shape of the reconstructed breasts (19,20), a more significant influence on the resulting shape we ascribe to the volume of the implants. Everywhere where simple augmentation with a gel breast implant appeared to be a less suitable solution, but the situation still did not require the combination of an implant and a flap, BEI were used (21,22). Our experience confirms their benefits, even in spite of a lower willingness on the part of women, in comparison with gel breast implants. An explanation of this phenomenon can be a greater awareness among women of gel breast implants, known to them from esthetic procedures, or the necessity of percutaneously filling the implant and its gradual expansion. However, we consider BEI as a very beneficial solution, especially when there were no recordings in our grouping of any ruptures or spontaneous deflations of implants, complications arising out of the filling port, or a higher occurrence of pericapsular fibrosis (23).

In situations where absolutely insufficient quality of tissue in the breast region was discovered, or where the region exhibited considerable post-actinic therapeutic changes, or the patient insisted on a large volume of the reconstructed breast, refused the use of implants as an exogenous material, or refused another, less invasive method without a more detailed explanation of the reason, DIEP flap microsurgical transfers were used (24). The advantages of this solution is the possibility of reconstructing the breast with the patient’s own tissue in the low-quality terrain, naturalness and the adequate volume of the reconstructed breast while minimizing the loss of functionality of the muscle layer of the anterior abdominal wall. It is also the last possibility of how to reconstruct the breast in the case of previously unsuccessful reconstructions using microsurgical approaches, or in the case of unsatisfactory cosmetic results of a previous reconstruction (25). Between the two above mentioned groups of reconstruction techniques are found methods which provide a compromise solution. We consider the most advantageous of these to be the TDLF flap and implant, or BEI (26) or a musculocutaneous flap from the m. latissimus dorsi and an implant or BEI. A musculocutaneous flap from the m. latissimus dorsi is a source of a high-quality tissue block, which seems to be relatively resistant to actinic therapy and therefore presents the consideration of which solution is more beneficial or technically demanding, DIEP, or a simple flap with the m. latissimus dorsi which could be an alternative for breast reconstruction even before finishing treatment (9, 27).

The earlier, frequently mentioned and used unilateral or bilateral TRAM, which also represents a certain compromise between microsurgical reconstruction and interventions with the help of implants (28). The difficulty of the operation, the weakening of the muscle layer of the anterior abdominal wall, morbidity of the areola locality are however such significant disadvantages that the usability of this method is, in our opinion,  limited.

Subsequent interventions such as reduction and lifting of the contralateral breast, scar correction, or reconstruction of the NAC are tasked to optimize and complete the reconstruction results and achieve the most natural appearance and satisfaction with the results (29,30).

Conclusion

During the course of the ten year period from January 2002 and December 2011, deferred breast reconstruction became an integral part of the treatment protocol of the mammological center of the Plzeň University Hospital. In this way the treatment of neoplastic disease of the mammary glands was expanded by an important qualitative element, whereby the evaluation of the influence of the reconstruction operation on the quality of life and the mental state of patients found an unambiguously positive influence.

The renewal of bodily integrity positively influenced in first order the feeling of life satisfaction, evaluation of the quality of life in the areas of psychosexual, level of self-confidence and self-assessment. It is possible to state that with little strain, low incidence of complications and acceptable economic expenses, the treatment of serious neoplastic disease dramatically improved in quality.

List of abbreviations:

Becker expander/implant (BEI), nipple-areola complex (NAC), lateral thoracodorsal flap (TDLF),  DIEP (deep inferior epigastric artery perforator flap).

Correspondence Address:

Tomáš Kydlíček MD,

Department of Plastic Surgery, Plzeň Univeristy Hospital,

Alej Svobody  80, 304 60, Czech Republic

kydlicek@fnplzen.cz