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Mastectomy and Reconstruction

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Aliza Cicerone

on 14 March 2013

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Transcript of Mastectomy and Reconstruction

Mastectomy and Reconstruction

Prior radiation therapy to the affected breast
2 or more areas of cancer in the same breast that are too far apart to be removed through 1 surgical incision
Initial lumpectomy along with re-excisions has not completely removed the tumor
Serious connective tissue diseases such as scleroderma
Pregnant women
Tumor larger than 5 cm (2 inches) that does not decrease in size with neoadjuvant chemotherapy
Tumor that is large relative to breast size
BRCA1 or BRCA2 postive for prophylactic removal of the breasts
Male breast cancer patients TYPES OF MASTECTOMY

Simple/Total Mastectomy

The surgeon removes the entire breast tissue but does not remove the muscle tissue under the breast
May be combined with a sentinel lymph node biopsy in any case of an early invasive cancer and in some cases of ductal carcinoma in-situ when a mastectomy is chosen as the treatment option TYPES OF MASTECTOMY

Simple/Total Mastectomy: Traditional

Most commonly performed mastectomy
The surgeon removes an ellipse of skin that includes the skin of the nipple/areolar complex
Without immediate reconstruction, the end result is a flat chest with a scar about 8 inches in length, usually oriented transversely TYPES OF MASTECTOMY

Simple/Total Mastectomy: Skin-sparing

In addition to the breast tissue, the only skin removed is that of the nipple and areola, usually through a circular incision around the areola
Ideal for patients undergoing prophylactic mastectomy TYPES OF MASTECTOMY

Simple/Total Mastectomy: Nipple-sparing

The surgeon makes an incision around the nipple but leaves the areola intact
The nipple and areola are left in place while the breast tissue under them is removed
Indicated for women who have a small early stage cancer near the outer part of the breast, with no signs of cancer in the skin or near the nipple
Possible adjuvant radiation to the nipple to reduce the risk of recurrence TYPES OF MASTECTOMY

Simple/Total Mastectomy: Total skin-sparing

The surgeon removes the breast tissue but leaves all the skin, including the nipple and areola
The incision may be in the outer part of the breast, in the inframammary fold, or around the areola TYPES OF MASTECTOMY

Simple/Total Mastectomy

4 types:
Total skin-sparing TYPES OF MASTECTOMY

Modified Radical Mastectomy

Simple/total mastectomy, including the skin of the nipple and the areola
Includes an axillary lymph node dissection using a 6- to 8-inch incision
Immediate or delayed breast reconstruction TYPES OF MASTECTOMY

Radical Mastectomy (aka Halstead Mastectomy)

Removal of the entire breast tissue, axillary lymph nodes, and chest wall muscles
Common in the past (1895-1970s), but rarely performed now COMPLICATIONS AND ADVERSE EFFECTS

Risks specifically related to mastectomy in general are numbness and necrosis of the breast skin

Risks specifically related to axillary lymph nodes dissection are lymphedema and possible injury to the axillary nerves COMPLICATIONS AND ADVERSE EFFECTS

Stewart-Treves Syndrome

Angiosarcoma arising within chronic postmastectomy lymphedema was reported in 1948 by Stewart and Treves
The lymphedematous limb is an immunologically vulnerable area, susceptible to the development of neoplasms and infections
This condition has a very poor prognosis, with an overall survival rate of 10 to 30%
Approximately 400 cases of Stewart-Treves syndrome are reported in the world literature BREAST RECONSTRUCTION


Immediate Breast Reconstruction
Performed at the same time as the mastectomy
Chest tissues are not damaged by radiation therapy or scarring
Better cosmetic outcome
Fewer surgeries

Delayed Breast Reconstruction
A better choice for women who need radiation post-mastectomy TYPES OF RECONSTRUCTION

Implant procedures

The most common is a saline-filled implant
Silicone gel-filled implants are another option, but not used as often presently
One-stage immediate breast reconstruction may be done at the same time as mastectomy
Two-stage reconstruction or two-stage delayed reconstruction is done if the skin and chest wall tissues are tight and flat TYPES OF RECONSTRUCTION

Tissue flap procedures: TRAM (transverse rectus abdominis muscle) flap

Uses tissue and muscle from the the lower abdominal wall
The tissue from this area alone is often enough to shape the breast, and an implant may not be needed
The skin, fat, blood vessels, and at least one abdominal muscle are moved from the abdomen to the chest TYPES OF RECONSTRUCTION

Tissue flap procedures: Latissimus Dorsi flap

The flap is made up of skin, fat, muscle, and blood vessels
It is tunneled under the skin to the front of the chest
This creates a pocket for an implant, which can be used for added fullness to the reconstructed breast
Though not common, some women may have weakness in their back, shoulder, or arm after this surgery TYPES OF RECONSTRUCTION

Tissue flap procedures: DIEP (deep inferior epigastric artery perforator) flap

A newer type of flap procedure
Uses fat and skin from the same area as in the TRAM flap, but does not use the muscle to form the breast mound

Uses a free flap with microsurgery TYPES OF RECONSTRUCTION

Tissue flap procedures: SGAP (superior gluteal artery perforator) flap

Newer surgery that uses tissue from the buttocks, including the gluteal muscle, to create the breast shape
An option for women who cannot or do not wish to use the abdominal sites due to thinness, incisions, failed tummy flap, or other reasons

Optional and usually the final phase of breast reconstruction
Outpatient procedure with local anesthesia performed about 3 to 4 months after surgery
Tissue used to rebuild the nipple and areola is taken from the newly created breast, opposite nipple, ear, eyelid, groin, upper inner thigh, or buttocks
A tattoo may be used to match the color of the nipple of the other breast and to create the areola
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