A-17 Primary breast reconstruction with an implant

In this presentation we would like to discuss a common form of breast reconstruction after a loss of breast during surgical therapy of breast cancer. This technique is a primary immediate reconstruction, which has been a routine procedure worldwide, however in the Czech Republic it has still been a method associated with myths and prejudice.

In cooperation with Dr. Amy Degnim from Mayo Clinic, Rochester, Minnesotta, USA is pointed out the standard for therapy of breast cancer. This procedure, i.e. immediate breast reconstruction in breast cancer is based on multiple review articles published in literature, last of which is a meta analysis published by Gienim in the journal Breast in 2000.

Our work suggests that while observing oncological radicality, it is possible to very effectively reconstruct the breast with synthetic material even in our conditions. This method is beneficial for “health” but also psychical well-being of the oncology patient, but finally it provides benefits to the whole system, by avoiding further hospitalizations and surgical procedures during secondary reconstructions.

Similarly to all surgical procedures, the most important is the preoperative planning. In case of breast cancer is this planning performed within a multidisciplinary team - an oncoboard. Cooperation with mammary radiology diagnostics specialist, oncologist and surgeon, plastic surgeon (worldwide known as oncoplastic surgeon) is requited together with the psychical tolerance and cooperation of the patient at the top.

As indication criteria were selected mainly extensive DCIS, NST carcinomas and ILC carcinomas not suitable for breast conserving surgery (BCS) due to unsuitable ratio of the size of the tumor and size of the breast. At the beginning of our efforts to accept this method we have chosen still rather strict criteria, which do not consider adjuvant radiotherapy and we do not indicate it in case of chemoneoadjuvant therapy or if we admit a possibility of adjuvant chemotherapy. This method is certainly limited for such carcinomas that are not locally advanced, i.e. only for carcinomas which do not grow to skin, chest wall or erysipeloid carcinomas (it means for early stage carcinomas).

The incision for mastectomy is chosen mostly as a lazy S around areola (modified ellipse), possibly a tennis racquet shape. In case of larger breasts, we have used an inverted T incision that was very beneficial. At our workplace we perform single stage immediate reconstruction, i.e. directly with an implant. For reconstruction is used almost solely an anatomical implant, always under the muscle. The method of two stage reconstruction that is used worldwide including the Mayo Clinic, was simplified and we had to adjust it to the system of health insurance in the Czech republic initially and for now we keep it due to low number of complications and good cosmetic results (oncological radicality is always the same).

The advantages of primary reconstruction include psychical well-being of the patient and reduced number of operations. The disadvantage is non-realistic expectation by the patient, possible delay of adjuvant therapy in case of a “surprise” in final pathology. Delay could also be due to complicated healing after modified radical mastectomy or skin sparing mastectomy without implant reconstruction.

The main pitfall of introduction of this method to practice in the Czech Republic is the specificity of therapy of breast cancer, i.e. multidisciplinary approach. This requires cooperation with a plastic surgeon, or better with a plastic surgeon trained in oncosurgical problems of breast cancer, or with an oncosurgeon with plastic-surgical training, workplace of nuclear medicine and Complex oncological center. This approach centralizes the care to three centers in the Czech Republic.

The goal of this presentation is a review of indications, techniques and results of this method from the point of multispecialty cooperation and insight to the breast cancer as a systemic disease, when surgical therapy is “only a small tiny” piece in a puzzle in the treatment of breast cancer without the need to cause mutilation of the patient with this therapy. In conclusion we always emphasize oncological radicality, which must of course be on the first place. (Fig. 17.1, 17.2.)