Postmastectomy Reconstruction CHARLES E. HORTON, M.D.,* FRANCIS E. ROSATO, M.D.,t FRANK A. SCHULER, III, M.D.,f JOHN McCRAW, M.D.§
Reconstructive surgery following mastectomy has had an increased acceptability with improved techniques and prostheses. Plastic reconstructive procedures following prophylactic mastectomy were performed in 104 patients and following mastectomy for cancer in 88 patients. Capsular contractions have not occurred with the use of a subpectoral pocket and detection of recurrent cancer is not hampered by the materials now used.
R ECONSTRUCTION of the female breast following mastectomy is now receiving serious attention. Factors responsible for this include the development of better reconstructive techniques,4 the availability of improved prosthetics and the demonstration that there are no adverse effects of such procedures on host resistance to tumor.5 The large number of women in high risk groups who undergo prophylactic mastectomy and the number of younger patients undergoing mastectomy for cancer have come to expect such additional measures. Finally, the general acceptance of the modified radical mastectomy with preservation of the pectoral muscles has permitted a much better approach to breast contouring. We present our experience in postmastectomy breast reconstruction acquired during the last six years. The patients are considered for presentation and discussion in three major categories (Table 1).
Prophylactic Mastectomy Multiple factors have been identified as predictive of a high risk for developing breast cancer (Table 2). A family history of previous breast cancer is particularly important; the chances of developing breast cancer are increased three- to eight-fold depending on the pattern of family involvement.' In this setting we feel it critically important to remove all breast tissuesubcutaneous mastectomy cannot accomplish this.3 Further, the nipple must be dissected of all breast and * Professor and Chairman, Department of Plastic Surgery. t Professor and Chairman, Department of Surgery. t Associate Instructor, Department of Plastic Surgery. § Assistant Professor, Department of Plastic Surgery. Submitted for publication: March 25, 1978.
From the Departments of Surgery and Plastic Surgery, Eastern Virginia Medical School, Norfolk, Virginia
ductal tissue, including that which extends into the nipple papilla. Our technique, described below, satisfies these requirements. Methods
General Surgical Technique A transverse incision is made through the breast skin around the nipple and areola, extending from the anterior axillary line to the circular nipple incision and 2.0-3.0 cm medially. The nipple is excised and given to the plastic surgeon to thin while the total mastectomy is completed. The skin flaps are dissected moderately thin, making certain to remove all identifiable breast tissue with the specimen. The skin flap dissection is carried medially to the sternal area, superiorly to the clavicle, laterally and superiorly into the axilla to expose the tail of the breast, and inferiorly to below the inframammary line. If more exposure is required, both ends of the skin incision may be lengthened. Breast removal is started by dissecting medially and inferiorly to reach the pectoralis fascia, where a plane of separation is easily created. A careful search is made around the periphery of the dissection to identify and remove all elements of breast tissue that may have been left in the wound. While the general surgeon commences a similar procedure on the opposite breast, the plastic surgeon can begin reconstructive efforts. Plastic Surgical Technique An incision is made at the lateral border of the pectoralis major at a level where it overlays the pectoralis minor high in the axilla. By blunt dissection, the pectoralis major can be lifted from the chest wall to produce a pocket which extends below the inframammary line, laterally beneath the anterior serratus
0003-4932/78/1200/0773 $00.75 © J. B. Lippincott Company
773
HORTON AND OTHERS
774 TABLE 1. Patient Classification
TABLE 2. Risk Factors for Breast Cancer
No. of Patients Prophylactic mastectomy & reconstruction Immediate postmastectomy & reconstruction Delayed postmastectomy & reconstruction
Family history Florid cystic disease Previous multiple biopsies Mastodynia Contralateral antecedent breast cancer
104 6
52
fascia, superiorly to the desired height of the position of the implant and medially to the sternum. In rare instances, the pectoralis muscle must be cut at the sternal insertion to provide lateral transfer of the muscle to cover the implant (Fig. 1). A well-designed and executed surgical dissection of the pocket will provide a space bounded on all sides by adequate tissue sufficient to prevent motion and displacement of the prosthesis. A medium-sized suction catheter is brought from within this cavity through the inframammary skin for suction drainage. An appropriate sized implant (165-210 cc) is selected according to the size of the patient. We prefer to use polyurethane foam covered gelfilled prostheses, which will not migrate easily because of the external covering. The implant is placed within the pocket, after positioning the patient's arms at her sides, and the opening into the pocket is closed. Skin closure is accomplished by either denuding the edge of the inferior flap to form a vascularized dermal flap for cushioning of the implant, or by direct tailoring and apposition of skin edges. We prefer the dermal flap, which provides more cusioning and substance over the prosthesis. The denuded dermal flap edge is sutured to the pectoralis muscle in a few areas to position it properly, and the upper flap is brought down as far inferiorly as possible to produce a low scar. The superior flap is then sutured to the epithelial edge of the inferior flap (Fig. 2).
Undermining and detachment of Pectoralis Major M. I.", 'IJ
Ann. Surg. a December 1978
The general surgeon has completed the opposite side by this time and the plastic surgeon now repeats the reconstructive efforts on the other side to effect bilateral symmetrical breast mounds. Ordinarily, the middle portion of the nipple is excised to remove all ductal elements from the graft. When both nipple/areolar tissue specimens (previously removed and saved) have been thinned properly, the correct position for the nipples must be determined. The anesthesiologist can assist in accurately determining correct nipple position by making certain prior to general anesthesia that the table will tilt so that the anesthetized patient can be placed in a semi-sitting position. With the anesthetized patient semi-sitting, the plastic surgeon can identify both breast mounds and calculate the exact central nipple position. Preoperative measurements are of some value; the nipple should ordinarily be 15.0-21.0 cm from the sternal notch, depei,ding on the stature of the patient. Predetermined measurements are not as accurate as intraoperative markings in the semisitting position. The patient is returned to a reclining position and appropriately sized round areas are denuded of epithelium at the sites where the nipple-areolar complexes have been marked. The grafts are sutured with interrupted 5-0 sutures with a tie-over bolster type dressing. No breast dressings are used; the suction drains are removed on the third or fourth postoperative day when drainage is minimal. If vascularity of the breast flap is in question, it is best to determine this prior to developing the inferior
Prosthesis Placement
-Pectoralis Maj. M.
-Prosthesis Serratus Ant.
FIG. 1. Diagram of subpectoral pocket. Medial detachment is usually not necessary. The serratus fascia must be preserved.
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POSTMASTECTOMY RECONSTRUCTION
775
Nipple graft placement
FIG. 2. Diagram of denuded dermal flap. The skin may be closed without the dermal flap.
dermal flap. If the upper flap is not viable in a certain portion, this skin should be excised and the lower flap (if viable) used for coverage. This would reduce the amount of skin available for the dermal flap. Viability of the breast flaps can best be assessed by circulation return and color of the skin and by the use of intravenous fluorescein dye and ultraviolet light. If a portion of flap does not fluoresce, we excise it, and use viable tissue for closure. Results Prophylactic mastectomy was performed in 104 patients; 191 breasts have been reconstructed. The indications important in deciding for such mastectomy are given in Table 3. The follow-up period has varied from one month to 10 years with an average follow-up of 3.1 years. In the first 31 patients the prostheses were not placed subpectorally and two implants were lost. In both instances this loss resulted from small areas of skin breakdown with exposure of the prostheses. In the remaining 73 patients, with the prosthesis placed subpectorally, no prostheses have been lost, even in those situations where a modest skin loss has occurred. With subpectoral placement there has been no pain and TABLE 3. Indications for Prophylactic Mastectomy
Carcinoma opposite breast Florid adenosis Giant Fibroadenomata Incomplete subcutaneous mastectomy Multiple above including family history
No. Patient
%
11 28 4
10 27 4
7
7
54 104
52
FIGS. 3a and b. Prophylactic Mastectomy-(a, top) before and (b, bottom) after. Note that with arms elevated there is neither distortion nor migration of prostheses.
no limitation of muscular motion. All implants placed subpectorally have remained soft and have not been distorted in shape by pectoralis pressure. The transverse skin scars remain conspicuous for a considerable time, but fade appreciably after 12 months. No early or late spherical contractures have been noted. Severe mastodynia from cystic disease, present in ten patients, was completely controlled. No breast disease has developed or been diagnosed after our series of total mastectomies. We have sampled the margins of resection at the time of prophylactic mastectomy in 12 patients and found no residual breast tissue. This is in contrast to the biopsies after subcutaneous mastectomy, which revealed breast tissue beneath the nipple and around the periphery in all cases.2 A patient who underwent this procedure is shown before and after the operation (Fig. 3). Reconstruction Following Mastectomy for Cancer The techniques employed are basically the same except that the general surgeon employs a modified
776
HORTON AND OTHERS
Ann. Surg. * December 1978
FIG. 5. Chest film in patient with bilateral silicone-gel prostheses.
FIGS. 4a-c. Postmastectomy Reconstruction-(a, top) preoperative, (b, center) flap, and (c, bottom) delayed prosthesis.
radical mastectomy. Obviously, the patient must fulfill the usual criteria for such an operation. The prostheses can be put in place immediately in this type of situation. If extensive skin is involved, or the pectoral muscle has been invaded and must be removed, then the reconstruction may have to be staged to allow healing of properly placed skin or skin and muscle flaps. Figure 4 shows such a patient who required a skin flap for coverage and finally a delayed placement of a prosthesis.
Special attention must be given the nipple-areolar area in this setting. The chance of the areola or nipple being involved with tumor is only 2.0% when the nipple is clinically normal, the tumor is outside the areolar margins and the primary tumor is less than 2.0 cm in diameter; otherwise, the chance of areola or nipple involvement approaches 12%. In any case, the nipple area is thoroughly "thinned" and frozen section diagnosis obtained before replacing the nipple grafts; in larger tumors which extend into the subareolar area the nipples are not replaced and standard methods are used for nipple reconstruction. We have operated upon 58 patients for reconstruction following mastectomy for cancer. Twenty-seven patients underwent Halsted's radical mastectomy, while 31 had a modified (Patey) procedure. The interval between mastectomy and reconstruction varied up to 12 years, averaging three years. Usually the remaining breast was removed by the previously described total mastectomy since it is a high risk organ; additionally, the symmetry and cosmetic effect is much improved where bilateral reconstruction is undertaken. Two of the 58 patients have developed recurrence. A mean of
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POSTMASTECTOMY RECONSTRUCTION
2.8 operations were required to attain the final reconstruction. Theoretical objections to this approach are frequently raised. We do not feel it interferes with early detection of recurrence, since the prosthesis is placed deep to the pectoral muscle and overlying changes should be readily detectable. Underlying bone changes should be as readily recognized by either bone scan or rib films. Pulmonary metastases, or any lung changes, are in no way obscured by the prostheses (Fig. 5). We have now completed animal experiments to validate the concept that the prostheses in no way divert or weaken host tumor immunity.5
Discussion
While the end result of prophylactic mastectomy is not as cosmetically desirable as the normal breast, this technique is believed to be preferable to either the total mastectomy without reconstruction or to the subcutaneous mastectomy. It can offer to the concerned, high risk breast cancer patient an adequate breast mound with an areolar complex, and the security that a conscientious general surgeon has removed all identifiable breast tissue. The complication rate of this operation is markedly less than that of the usual subcutaneous mastectomy reported in the literature. The capsular contractions which occur late in subcutaneous mastectomy causing distortion and firm, noncompressible, unnaturally shaped breasts over the long-term, make the total mastectomy with subpectoral implant reconstruction the preferred procedure. Time alone will tell whether this will prove to be an effective operation to prevent breast cancer. At the present, we can state that it is at least as effective as the simple mastectomy, which has been used for years as a
777
prophylactic procedure. The standard subcutaneous mastectomy, leaving considerable remnants of breast tissue in the patient cannot make this claim. When breast cancer is present the reconstructive procedure can follow a standard mastectomy. The axillary dissection and even subsequently proven positive lymph nodes are no contraindication-they simply alert the surgeon to the greater risk of recurrence. The extent of skin dissection or the need to sacrifice the pectoralis muscles are the major situations necessitating a flap coverage of the mastectomy wound and delayed prosthetic placement. Similarly constituted prostheses used elsewhere in the body after malignancy have had no detrimental effects. Our own studies, to be reported elsewhere, show no impairment of lymphocyte immune functions in a rat model where prostheses were placed after breast tumor excision.2 Enthusiastic attempts to restore patients cosmetically should now be viewed as part of the total approach to patient rehabilitation. Techniques and material now available make this possible. Physician awareness of these procedures, as well as their limitations are mandated by increasing patient demands for more acceptable results following mastectomy. References 1. Anderson, D.: Genetic Study of Breast Cancer: Identification of a High Risk Group. Cancer, 4:34, 1091, 1974. 2. Goldwyn, R. M.: Subcutaneous Mastectomy. N. Engi. J. Med., 297:503, 1977. 3. Peacock, E.: Biologic Basis for Management of Benign Disease of the Breast. Plast. Reconstr. Surg., 55:14, 1975. 4. Rosato, F. E., Fink, P. J., Horton, C. E. and Payne, R. L.: Immediate Postmastectomy Reconstruction. J. Surg. Oncol., 8:277, 1976. 5. Schyler, F. A., Rosato, F. E., Horton, C. E. and Miller, E.: Silicone Prostheses and Anti-Tumor Immunity. Plast. Reconstr. Surg., 61:762, 1978.
Reconstructive surgery following mastectomy has had an increased acceptability with improved techniques and prostheses. Plastic reconstructive procedures following prophylactic mastectomy were performed in 104 patients and following mastectomy for cancer in 88 patients. Capsular contractions have not occurred with the use of a subpectoral pocket and detection of recurrent cancer is not hampered by the materials now used.
R ECONSTRUCTION of the female breast following mastectomy is now receiving serious attention. Factors responsible for this include the development of better reconstructive techniques,4 the availability of improved prosthetics and the demonstration that there are no adverse effects of such procedures on host resistance to tumor.5 The large number of women in high risk groups who undergo prophylactic mastectomy and the number of younger patients undergoing mastectomy for cancer have come to expect such additional measures. Finally, the general acceptance of the modified radical mastectomy with preservation of the pectoral muscles has permitted a much better approach to breast contouring. We present our experience in postmastectomy breast reconstruction acquired during the last six years. The patients are considered for presentation and discussion in three major categories (Table 1).
Prophylactic Mastectomy Multiple factors have been identified as predictive of a high risk for developing breast cancer (Table 2). A family history of previous breast cancer is particularly important; the chances of developing breast cancer are increased three- to eight-fold depending on the pattern of family involvement.' In this setting we feel it critically important to remove all breast tissuesubcutaneous mastectomy cannot accomplish this.3 Further, the nipple must be dissected of all breast and * Professor and Chairman, Department of Plastic Surgery. t Professor and Chairman, Department of Surgery. t Associate Instructor, Department of Plastic Surgery. § Assistant Professor, Department of Plastic Surgery. Submitted for publication: March 25, 1978.
From the Departments of Surgery and Plastic Surgery, Eastern Virginia Medical School, Norfolk, Virginia
ductal tissue, including that which extends into the nipple papilla. Our technique, described below, satisfies these requirements. Methods
General Surgical Technique A transverse incision is made through the breast skin around the nipple and areola, extending from the anterior axillary line to the circular nipple incision and 2.0-3.0 cm medially. The nipple is excised and given to the plastic surgeon to thin while the total mastectomy is completed. The skin flaps are dissected moderately thin, making certain to remove all identifiable breast tissue with the specimen. The skin flap dissection is carried medially to the sternal area, superiorly to the clavicle, laterally and superiorly into the axilla to expose the tail of the breast, and inferiorly to below the inframammary line. If more exposure is required, both ends of the skin incision may be lengthened. Breast removal is started by dissecting medially and inferiorly to reach the pectoralis fascia, where a plane of separation is easily created. A careful search is made around the periphery of the dissection to identify and remove all elements of breast tissue that may have been left in the wound. While the general surgeon commences a similar procedure on the opposite breast, the plastic surgeon can begin reconstructive efforts. Plastic Surgical Technique An incision is made at the lateral border of the pectoralis major at a level where it overlays the pectoralis minor high in the axilla. By blunt dissection, the pectoralis major can be lifted from the chest wall to produce a pocket which extends below the inframammary line, laterally beneath the anterior serratus
0003-4932/78/1200/0773 $00.75 © J. B. Lippincott Company
773
HORTON AND OTHERS
774 TABLE 1. Patient Classification
TABLE 2. Risk Factors for Breast Cancer
No. of Patients Prophylactic mastectomy & reconstruction Immediate postmastectomy & reconstruction Delayed postmastectomy & reconstruction
Family history Florid cystic disease Previous multiple biopsies Mastodynia Contralateral antecedent breast cancer
104 6
52
fascia, superiorly to the desired height of the position of the implant and medially to the sternum. In rare instances, the pectoralis muscle must be cut at the sternal insertion to provide lateral transfer of the muscle to cover the implant (Fig. 1). A well-designed and executed surgical dissection of the pocket will provide a space bounded on all sides by adequate tissue sufficient to prevent motion and displacement of the prosthesis. A medium-sized suction catheter is brought from within this cavity through the inframammary skin for suction drainage. An appropriate sized implant (165-210 cc) is selected according to the size of the patient. We prefer to use polyurethane foam covered gelfilled prostheses, which will not migrate easily because of the external covering. The implant is placed within the pocket, after positioning the patient's arms at her sides, and the opening into the pocket is closed. Skin closure is accomplished by either denuding the edge of the inferior flap to form a vascularized dermal flap for cushioning of the implant, or by direct tailoring and apposition of skin edges. We prefer the dermal flap, which provides more cusioning and substance over the prosthesis. The denuded dermal flap edge is sutured to the pectoralis muscle in a few areas to position it properly, and the upper flap is brought down as far inferiorly as possible to produce a low scar. The superior flap is then sutured to the epithelial edge of the inferior flap (Fig. 2).
Undermining and detachment of Pectoralis Major M. I.", 'IJ
Ann. Surg. a December 1978
The general surgeon has completed the opposite side by this time and the plastic surgeon now repeats the reconstructive efforts on the other side to effect bilateral symmetrical breast mounds. Ordinarily, the middle portion of the nipple is excised to remove all ductal elements from the graft. When both nipple/areolar tissue specimens (previously removed and saved) have been thinned properly, the correct position for the nipples must be determined. The anesthesiologist can assist in accurately determining correct nipple position by making certain prior to general anesthesia that the table will tilt so that the anesthetized patient can be placed in a semi-sitting position. With the anesthetized patient semi-sitting, the plastic surgeon can identify both breast mounds and calculate the exact central nipple position. Preoperative measurements are of some value; the nipple should ordinarily be 15.0-21.0 cm from the sternal notch, depei,ding on the stature of the patient. Predetermined measurements are not as accurate as intraoperative markings in the semisitting position. The patient is returned to a reclining position and appropriately sized round areas are denuded of epithelium at the sites where the nipple-areolar complexes have been marked. The grafts are sutured with interrupted 5-0 sutures with a tie-over bolster type dressing. No breast dressings are used; the suction drains are removed on the third or fourth postoperative day when drainage is minimal. If vascularity of the breast flap is in question, it is best to determine this prior to developing the inferior
Prosthesis Placement
-Pectoralis Maj. M.
-Prosthesis Serratus Ant.
FIG. 1. Diagram of subpectoral pocket. Medial detachment is usually not necessary. The serratus fascia must be preserved.
Vol. 188 . NO. 6
POSTMASTECTOMY RECONSTRUCTION
775
Nipple graft placement
FIG. 2. Diagram of denuded dermal flap. The skin may be closed without the dermal flap.
dermal flap. If the upper flap is not viable in a certain portion, this skin should be excised and the lower flap (if viable) used for coverage. This would reduce the amount of skin available for the dermal flap. Viability of the breast flaps can best be assessed by circulation return and color of the skin and by the use of intravenous fluorescein dye and ultraviolet light. If a portion of flap does not fluoresce, we excise it, and use viable tissue for closure. Results Prophylactic mastectomy was performed in 104 patients; 191 breasts have been reconstructed. The indications important in deciding for such mastectomy are given in Table 3. The follow-up period has varied from one month to 10 years with an average follow-up of 3.1 years. In the first 31 patients the prostheses were not placed subpectorally and two implants were lost. In both instances this loss resulted from small areas of skin breakdown with exposure of the prostheses. In the remaining 73 patients, with the prosthesis placed subpectorally, no prostheses have been lost, even in those situations where a modest skin loss has occurred. With subpectoral placement there has been no pain and TABLE 3. Indications for Prophylactic Mastectomy
Carcinoma opposite breast Florid adenosis Giant Fibroadenomata Incomplete subcutaneous mastectomy Multiple above including family history
No. Patient
%
11 28 4
10 27 4
7
7
54 104
52
FIGS. 3a and b. Prophylactic Mastectomy-(a, top) before and (b, bottom) after. Note that with arms elevated there is neither distortion nor migration of prostheses.
no limitation of muscular motion. All implants placed subpectorally have remained soft and have not been distorted in shape by pectoralis pressure. The transverse skin scars remain conspicuous for a considerable time, but fade appreciably after 12 months. No early or late spherical contractures have been noted. Severe mastodynia from cystic disease, present in ten patients, was completely controlled. No breast disease has developed or been diagnosed after our series of total mastectomies. We have sampled the margins of resection at the time of prophylactic mastectomy in 12 patients and found no residual breast tissue. This is in contrast to the biopsies after subcutaneous mastectomy, which revealed breast tissue beneath the nipple and around the periphery in all cases.2 A patient who underwent this procedure is shown before and after the operation (Fig. 3). Reconstruction Following Mastectomy for Cancer The techniques employed are basically the same except that the general surgeon employs a modified
776
HORTON AND OTHERS
Ann. Surg. * December 1978
FIG. 5. Chest film in patient with bilateral silicone-gel prostheses.
FIGS. 4a-c. Postmastectomy Reconstruction-(a, top) preoperative, (b, center) flap, and (c, bottom) delayed prosthesis.
radical mastectomy. Obviously, the patient must fulfill the usual criteria for such an operation. The prostheses can be put in place immediately in this type of situation. If extensive skin is involved, or the pectoral muscle has been invaded and must be removed, then the reconstruction may have to be staged to allow healing of properly placed skin or skin and muscle flaps. Figure 4 shows such a patient who required a skin flap for coverage and finally a delayed placement of a prosthesis.
Special attention must be given the nipple-areolar area in this setting. The chance of the areola or nipple being involved with tumor is only 2.0% when the nipple is clinically normal, the tumor is outside the areolar margins and the primary tumor is less than 2.0 cm in diameter; otherwise, the chance of areola or nipple involvement approaches 12%. In any case, the nipple area is thoroughly "thinned" and frozen section diagnosis obtained before replacing the nipple grafts; in larger tumors which extend into the subareolar area the nipples are not replaced and standard methods are used for nipple reconstruction. We have operated upon 58 patients for reconstruction following mastectomy for cancer. Twenty-seven patients underwent Halsted's radical mastectomy, while 31 had a modified (Patey) procedure. The interval between mastectomy and reconstruction varied up to 12 years, averaging three years. Usually the remaining breast was removed by the previously described total mastectomy since it is a high risk organ; additionally, the symmetry and cosmetic effect is much improved where bilateral reconstruction is undertaken. Two of the 58 patients have developed recurrence. A mean of
Vol. 188 . No. 6
POSTMASTECTOMY RECONSTRUCTION
2.8 operations were required to attain the final reconstruction. Theoretical objections to this approach are frequently raised. We do not feel it interferes with early detection of recurrence, since the prosthesis is placed deep to the pectoral muscle and overlying changes should be readily detectable. Underlying bone changes should be as readily recognized by either bone scan or rib films. Pulmonary metastases, or any lung changes, are in no way obscured by the prostheses (Fig. 5). We have now completed animal experiments to validate the concept that the prostheses in no way divert or weaken host tumor immunity.5
Discussion
While the end result of prophylactic mastectomy is not as cosmetically desirable as the normal breast, this technique is believed to be preferable to either the total mastectomy without reconstruction or to the subcutaneous mastectomy. It can offer to the concerned, high risk breast cancer patient an adequate breast mound with an areolar complex, and the security that a conscientious general surgeon has removed all identifiable breast tissue. The complication rate of this operation is markedly less than that of the usual subcutaneous mastectomy reported in the literature. The capsular contractions which occur late in subcutaneous mastectomy causing distortion and firm, noncompressible, unnaturally shaped breasts over the long-term, make the total mastectomy with subpectoral implant reconstruction the preferred procedure. Time alone will tell whether this will prove to be an effective operation to prevent breast cancer. At the present, we can state that it is at least as effective as the simple mastectomy, which has been used for years as a
777
prophylactic procedure. The standard subcutaneous mastectomy, leaving considerable remnants of breast tissue in the patient cannot make this claim. When breast cancer is present the reconstructive procedure can follow a standard mastectomy. The axillary dissection and even subsequently proven positive lymph nodes are no contraindication-they simply alert the surgeon to the greater risk of recurrence. The extent of skin dissection or the need to sacrifice the pectoralis muscles are the major situations necessitating a flap coverage of the mastectomy wound and delayed prosthetic placement. Similarly constituted prostheses used elsewhere in the body after malignancy have had no detrimental effects. Our own studies, to be reported elsewhere, show no impairment of lymphocyte immune functions in a rat model where prostheses were placed after breast tumor excision.2 Enthusiastic attempts to restore patients cosmetically should now be viewed as part of the total approach to patient rehabilitation. Techniques and material now available make this possible. Physician awareness of these procedures, as well as their limitations are mandated by increasing patient demands for more acceptable results following mastectomy. References 1. Anderson, D.: Genetic Study of Breast Cancer: Identification of a High Risk Group. Cancer, 4:34, 1091, 1974. 2. Goldwyn, R. M.: Subcutaneous Mastectomy. N. Engi. J. Med., 297:503, 1977. 3. Peacock, E.: Biologic Basis for Management of Benign Disease of the Breast. Plast. Reconstr. Surg., 55:14, 1975. 4. Rosato, F. E., Fink, P. J., Horton, C. E. and Payne, R. L.: Immediate Postmastectomy Reconstruction. J. Surg. Oncol., 8:277, 1976. 5. Schyler, F. A., Rosato, F. E., Horton, C. E. and Miller, E.: Silicone Prostheses and Anti-Tumor Immunity. Plast. Reconstr. Surg., 61:762, 1978.
