Recent Updates in Breast Reconstruction After Mastectomy

Abstract

Breast cancer is the most common neoplasm in women accounting for about 26% of all cancer cases diagnosed annually. It is over all the second leading cause of cancer death. However breast cancer is the leading cause of cancer death in women below 65 years.

Early diagnosis can partially be achieved through rapid access referral, accurate triple assessment and multidisciplinary management of potential breast cancer patients. All patients presenting with breast symptoms should undergo triple assessment, this involves history taking and examination, followed by breast imaging and pathological assessment.

Diagnostic investigations for breast cancer may be: Non-Invasive as mammography, screen film mammography, digital mammography, ultrasonography, positrone emission tomography and magnetic resonance imagingor Invasive as ductography, fine needle aspiration cytology, excisional biopsy and frozen section.

Once a diagnosis of early breast cancer has been established, surgical treatment needs to proceed, with either breast conservation or mastectomy. The possibility of axillary metastatic involvement should also be addressed. Once the surgical treatment is complete, patients should be referred to radiation oncologists and medical oncologists to finalize planning of definitive adjuvant therapy if appropriate.

Breast conservation involves resection of the primary breast cancer with a margin of normal appearing breast tissue, adjuvant radiation therapy, and assessment of regional lymph node status.

Breast conservation surgery (BCS) combined with postoperative radiotherapy has become the preferred locoregional treatment for the majority of patients with early-stage breast cancer, with no statistically significant differences in the survival rate or in the incidence of the development of new cancers between women treated with mastectomy and those treated with breast conservation therapy.

In addition to being equivalent to mastectomy in terms of oncologic safety. BCT appear to offer advantages over mastectomy with regard to quality of life and aesthetic outcomes. BCT allows for preservation of breast shape and skin as well as preservation of sensation and provides an overall psychological advantage associated with breast preservation.

Oncoplastic surgery defines the appropriate adequate surgery to extirpate a cancer in the breast to achieve locoregional control combined with partial or total reconstruction as well as immediate or delayed reconstruction with access to a full range of techniques to correct excision defects, contralateral breast symmetrization and reconstruction of the nipple - areola complex (NAC), when needed.

OPS is the "third pathway" between standard BCS and mastectomy. It proposes a specific solution for different scenarios and helps improve breast conservation outcomes to avoid complications and obtain the best oncologic and cosmetic results.

OPS divided into two levels based on excision volume and the complexity of the reshaping technique. For resections less than 20% of the breast volume (level I OPS), a step-by-step approach allows easy reshaping of the breast. For larger resections (level II OPS), a mammoplasty technique is required. Three elements can be used for patient selection and for determination of the appropriate OPS technique: excision volume, tumor location, and glandular density.

Contraindications for oncoplastic surgery are generally defined by contraindications for BCT. These include multicentric disease, inflammatory carcinoma, and progressive disease after neoadjuvant therapy and patients' wishes.

Oncoplastic surgery approach involves reconstruction of resected defects either by volume replacement or by volume displacement. Both techniques are adaptations of conventional method of breast reconstruction and or breast reduction technique mammoplasty techniques.

Volume displacement procedures include local glandular or dermoglandular flaps which are mobilized and transposed into the resection defect. This leads to a net loss in breast volume and the potential need for a simultaneous contralateral reduction to achieve symmetry. The resection of the tumor can be combined with a range of mammoplasty techniques including Inferior pedicle techniques, Superior pedicle techniques, S-shape oblique reduction mammoplasty, Batwing technique, Round block techniques and Grisotti flaps.