Immediate breast reconstruction with implants in breast cancer patients

Abstract

Breast cancer is the most common form of cancer among Swedish women. The incidence has increased since the beginning of the 1970s. Simultaneously the age-standardized mortality has been relatively constant, which is probably explained by earlier tumour detection as a result of improved diagnostic methods and treatment advances. Most patients have surgery and additional therapy such as radiation, chemotherapy and/or endocrine therapy. For those subjected to mastectomy, a breast reconstruction may be performed either at the time of mastectomy - immediate reconstruction, or at a later date - delayed reconstruction. The standard technique for immediate reconstruction at our reconstructive centre is the use of permanent adjustable prostheses placed under the pectoral muscle. This has been shown to be an oncologically safe procedure with no increased risk of relapse of cancer among the patients.

The overall aim of the present thesis was to attain increased knowledge about the outcome of immediate breast reconstruction with implants. Such knowledge would be guiding in the care of the patients. The perspectives were those of surgical technique, quality of life and breast sensibility.

A long-term follow-up study from a technical aspect recorded several characteristics of the surgical treatment and the patient care. Among the 249 patients operated on between 1990 and 1996, 32 (13 %) had local complications of which eighteen (7 %) lost their prostheses due to infection. Six of these patients lost their prostheses as late as 1-2.5 years after the reconstruction. Three patients had systemic complications.

Improvements in quality of life, one of the major goals in breast reconstructive surgery, were surveyed by use of the Medical Outcome Study 36-item Short Form (SF-36) completed by 76 patients consecutively treated between 1998 and 2001. Preoperative scores for emotional well-being and physical role functioning were lower than in a Swedish reference population, while after 12 months the scores in all domains had improved and were comparable with those in the reference population. The most common reasons for immediate reconstruction were the desire to avoid wearing an external prosthesis and the wish to feel whole again. The women reported great satisfaction with the general outcome of reconstruction and moderate satisfaction with the aesthetic outcome. The major determinant of aesthetic contentment was completion of the reconstructive procedure.

Cutaneous breast sensibility was evaluated retrospectively three to six years after immediate reconstruction and prospectively before surgery and two years after. Von Frey filaments and Termotest® were used to assess the sensibility to touch, cold, warmth and heat pain. In both studies all the examined modalities were significantly impaired although some individual sensibility threshold values were comparable with controls. Most affected was the area above the areola. Breast sensibility in patients given postoperative radiotherapy did not differ from the sensibility in those without radiotherapy. Subjectively, the patients reported reduced overall sensibility in the reconstructed breast compared to control. Nearly all patients stated that the reconstructed breast felt different from the other breast; nevertheless two thirds reported that the reconstructed breast felt like a real breast.

In conclusion, immediate breast reconstruction with submuscular implants following mastectomy is associated with a low frequency of systemic and local complications although implants may be lost years after surgery. The women experience an improvement in health-related quality of life over the first postoperative year, reaching levels comparable with the normal population. The reasons for reconstruction are both practical and emotional. The overall cutaneous breast sensibility is significantly impaired which is in accordance with the patients subjective experience, although the majority reports that the reconstructed breast feels like a real breast, a main purpose of breast reconstruction.