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Reconstructive Breast Surgery
Because the breast plays such an important part in self-image of many women, a perceived abnormality may lead to a request for mammoplasty (plastic surgery of the breast in which size, shape,or position is altered). Variations in the size of the breasts are a common reason for women to seek information about recon-structive breast surgery. Reduction mammoplasty is performed to reduce the size of the breast, whereas augmentation mammo-plasty is performed to increase the size of the breast. Other women desire surgery to reconstruct their breasts after mastectomy. There are several different procedures used for this type of reconstruc-tive surgery. In addition, some women choose to undergo pro-phylactic (risk-reducing) mastectomy if they are at high risk for breast cancer. This type of mastectomy is included in this discus-sion because it is considered elective.
Reduction mammoplasty is usually performed on women who have breast hypertrophy (excessively large breasts). If the enlarge-ment occurs early in life, it is called virginal breast hypertrophy. The condition is usually bilateral but may affect just one breast. Hypertrophy in later life almost always affects both breasts.
Tenderness, diffuse pain, and fatigue are common complaints of women with hypertrophy. Premenstrual tenderness and pain are marked. The weight of the enlarged breasts causes a dragging sensation in the shoulder, and support is commonly futile, despite use of the most supportive bra. Many women have deep grooves in their shoulders from the weight borne by bra straps. Poor pos-ture, discomfort, and embarrassment when wearing bathing suits and participating in athletic events may limit the woman’s social life. As a result, insecurity may develop from poor self-image.
After a surgical or plastic surgery consultation, a reduction mammoplasty may be performed under general anesthesia. One approach is an incision in the skin of the anterior breast in the shape of a keyhole or an anchor if a large amount of tissue needs to be removed. Another approach is through an incision around the areola complex. The surgeon then removes the excess tissue and transplants the nipple to a new location. Skin edges are ap-proximated with sutures, and the nipple is secured with sutures. Drains are placed in the incision, where they remain for 1 to 2 days. Simple gauze dressings are applied, without pressure.
After mammoplasty, the usual postoperative care is indicated. Patients are ambulatory fairly quickly and typically describe their surgery as nontraumatic, possibly because of the relief they experience. Hypertrophy does not recur, but if the patient gains weight, the breasts may enlarge. The newly transplanted nipple most likely becomes covered with a scab. As the nipple regains a new blood supply, the scab falls off, and the appearance approx-imates normal. Lactation may be impossible after this type of surgery, although half of women who have this surgery can breast-feed successfully. Sensory changes, such as numbness, are normal after this surgery but resolve after several months, although di-minished sensation in the nipples can persist. Postoperatively, the woman may feel a mixture of euphoria, relief, sorrow over loss of a body part, and anxiety over these feelings. Providing reassur-ance is an important nursing measure.
Augmentation mammoplasty is requested frequently by women desiring larger or fuller breasts. It is performed through an inci-sion along the undermargin of the breast, in the axilla, or at the border of the areola. The breast is then elevated, and a pocket is formed between the breast and the chest wall into which various types of synthetic materials are inserted to enlarge and uplift the breast. The subpectoral approach is preferred because it interferes less with clinical breast examinations or mammography than do subglandular implants. These procedures may be performed on an outpatient basis with local anesthesia. Infection, an immediate complication that can occur, may require removal of the im-plant. A delayed complication, which usually occurs years after the surgery, is a capsular contracture (scar formation around the implant); further surgery may be needed to correct this problem.
Saline implants are typically used for augmentation mammog-raphy. Silicone implants were used in the past; however, because of the reported systemic complications associated with their use, they have been removed from the market. They are now available only to women enrolled in controlled clinical trials designed to study spe-cific safety questions. Long-term risks associated with their use are also being studied. Women with breast implants need to be aware that accurate mammograms are more difficult, and they should seek radiologists at specialized breast centers who are familiar with read-ing mammograms of women who have breast implants.
When a woman undergoes a mastectomy (either total or mod-ified radical) for the treatment of breast cancer, she may desire to have immediate reconstruction at the time of surgery, or de-layed reconstruction may be an option at a later point after all treatments have been completed. About 75% of women with breast cancer undergoing mastectomy elect immediate recon-struction. A consultation with the surgeon may assist women in deciding whether reconstruction is something that they desire at the time of surgery. It is important for women to understand that reconstruction does not interfere with the treatment of their breast cancer, and they should also understand that although a good cosmetic result can be obtained, the reconstructed breast will never be what they once had. Another key point for women to understand is that reconstruction is a three-stage process that occurs over a period of months: the first is creation of the breast mound, the second is achieving symmetry with the contralateral breast, and the third is creation of the nipple–areola complex (described later). Women who undergo reconstruction with re-alistic expectations tend to be more pleased with the cosmetic result. Also, women who have mastectomy with immediate reconstruction may demonstrate a more positive adjustment afterward.
The choice of the surgical procedure is based on the patient’s wishes, the condition of the overlying skin and underlying muscle, and any previous scars that may be present, because they may limit possible reconstructive options. Another important factor is any secondary medical conditions that may affect the healing process (eg, hypertension, diabetes mellitus, tobacco use, or obesity).
One method of reconstruction is the tissue expander with per-manent implant (Fig. 48-7). After the surgeon has completedthe mastectomy, the plastic surgeon creates a pocket inside the pectoralis muscle and inserts a partially filled Silastic expander and a drainage device. Then, over a period of weeks, the patient comes to the office for injections of additional saline into the ex-pander through a port that is under the skin; this temporary ex-pander stretches the skin and muscle. When the implant is fully expanded (usually one third larger than the other breast to create a natural crease and droop to match the contralateral breast), the patient has the temporary implant exchanged for a permanent implant. This is usually performed as outpatient surgery. It may be done 4 to 6 months later to allow the tissue to soften and be-come more pliable before the permanent implant is inserted.
Postoperative care is similar to that of the patient undergoing breast surgery, although more discomfort can be expected due to the additional surgery. Nausea may take longer to clear because there was a greater period under general anesthesia. Patients re-ceive instruction just as any other surgical breast cancer patient would, but usually they are not allowed to shower until the drain is removed.
Another method of reconstruction is using the patient’s own tis-sue and transferring it to the mastectomy site. These flap surgeries can use the transverse rectus abdominis myocutaneous flap (TRAM flap) (Fig. 48-8), gluteal muscle, or latissimus dorsi mus-cle (Fig. 48-9). The plastic surgeon transfers the muscle flap with attached circulatory structures, skin, and fatty tissue, rotates it to the operative site, and molds it to create a mound that simulates the breast.
These procedures are far more extensive and involve greater operative time (about 8 to 10 hours total time for the mas-tectomy and reconstruction) and duration of general anesthesia than does the tissue expander procedure. The risk for potential complications is greater (infection, bleeding, flap necrosis), but the benefits are a more natural-looking breast and avoidance of synthetic material. The recovery period is greater, and activity re-strictions are different due to the cut muscles.
The TRAM flap is the most commonly used tissue transfer procedure, and postoperative care involves drain management and monitoring the operative site for changes in circulation. During the immediate postoperative period, patients are more limited in their activity and are at greater risk for respiratory complications, so pulmonary hygiene is essential. Measures to re-duce tension on the incisions include elevating the head of the bed by 30 degrees and flexing the patient’s knees to reduce ten-sion on the abdominal incision. Antiemetic agents are adminis-tered to control nausea and vomiting, and analgesic medications are administered to reduce pain and discomfort. Assessing circu-lation by observing the color and temperature of the newly con-structed breast area is an important nursing function. Mottling or an obvious decrease in skin temperature is reported to the sur-geon immediately. Excessive drainage should also be reported.
During ambulation, the patient usually protects the surgical incision by splinting. Gradually, she will achieve a more upright position. The patient is instructed to avoid tight and underwire bras until the surgeon indicates that no injury will result. Elevat-ing the arms above the shoulder and lifting more than 5 pounds of weight are avoided for 1 month after surgery to avoid stress on the incision.
After the breast mound has been created and the site has healed, some women choose to have a nipple–areola reconstruction. This consists of minor surgical procedures carried out either in the physician’s office or as outpatient surgery. A nipple is created using a skin graft from the inner thigh or labia because this skin has darker pigmentation than the skin on the reconstructed breast. After the nipple graft has healed, the areolar complex is usually completed with micropigmentation (tattooing). The surgeon can usually match the reconstructed nipple–areola complex with that of the contralateral breast for an acceptable cosmetic result.
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