الفهرس 
MastectomyOnly 14 pages are availabe for public view
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Abstract
B
reast cancer is the commonest cancer among women. The female breast is a potent symbol of maternity and femininity. For many years after a mastectomy, many women experience psychological distress and feel that her everyday life has been disputed (Kate el al., 2009).
Treatment of the breast carcinoma will largely depend upon the clinical stage of the disease at the time of presentation including not only the classical TNM staging but also often other tumor characteristics such as tumor grading. Added to that the development of diagnosis, Imaging (Mammography, Ultrasonography and breast MRI); Invasive diagnostic technique (Fine needle biopsy, core needle biopsy, Incisional biopsy and Excisional biopsy) and different protocols to learn the women self-examination (Kate el al., 2009).
The treatment of breast cancer over the past 90 years was traditionally performed by radical mastectomy, described by Halsted in 1894, which resulted in severe deformities, which were difficulty to reconstruct. Form the 1970s. Patey’s mastectomy (modified radical mastectomy) followed by simple mastectomy became the treatment of choice. These operations resulted in less severe deformities but still required reconstruction to be cosmetically acceptable (Kate el al., 2009).
The surgical treatment of patients with breast cancer involves either breast conserving surgery or mastectomy, both of which can result in considerable asymmetry of the breasts. Breast reconstruction offers restoration of breast symmetry to such women, Breast reconstruction has become an important aspect of breast cancer management. The patient needs to be aware that the reconstructed breasts will neither feel nor function like a normal breast but may help in restoring body image and confidence (Ahmed et al., 2005).
Breast reconstruction after mastectomy aims to replace lost bulk and in many cases a skin deficit. Although normal skin can of substantial expansion, skin that has been irradiated, for example, as part of breast conservation therapy will have permanently. This means that attempts to expand it will produce shiny thinned tissue that may eventually necroses or may push the chest wall inwards. Hence, in extensive skin loss as part of mastectomy or prior irradiation, it is necessary to import pliable skin good blood supply, usually derived from underlying muscle, and so myocutaneous flaps are used. To obtain the necessary bulk, either a synthetic inert implant or autologous tissue is used (Spear and Spittler, 2011).
Reconstructive techniques can be divided into:
1. Non-Autologous methods that use breast implants.
2. Autologous methods in which the patient’s own tissues are used.
3. A combination of Autologous and non-Autologous methods.
The patient’s choice will depend on the available options in the breast unit where she is being treated, which in turn will depend on the experience and attitude of the breast surgeon. If it is likely that the patient will need post-operative radiotherapy, an autologous flap rather than an implant-based reconstruction will need used to avoid problems of capsular contracture. Lastly, it should be remembered that it is the woman’s perception of the cosmetic outcome that matters, and inferior aesthetic results form breast-conserving surgery may be more acceptable than good post-mastectomy reconstruction with loss of sensation. It must be emphasized that reconstructive surgery is an aesthetic procedure and should not in any way compromise the oncological principles of breast cancer treatment (Fentiman and Hamed, 2006).
Breast reconstruction using implants is the simplest and most common method used today in the United States (Roberta et al., 2007).
Autologous reconstruction relies on the transfer of flaps to the transfer of flaps to the anterior chest wall (pedicled flaps) or as (free flaps), in which tissue is isolated, transferred, and its blood vessels anastomosed to recipient blood vessels by micorsurgical techniques. The reconstructed breast may be made from the flaps, or from the flaps plus a breast implant. Operating time is generally longer with free flaps (Reece and Kroll, 2008).
There are several and commonly used flaps:
1) Latissimus dorsi myocutaneous flap (LDF)
2) Transverse rectus abdominis myocutaneous flap (TRAM flap), either pedicled or free.
3) Deep and superficial inferior epigastric arteries flap.
4) Other types of free flaps like superior and inferior gluteal flaps and lateral transverse thigh flaps.
While free TRAM or DIEP flaps are still the most common techniques for autologous breast reconstruction (Schemer et al., 2008). there are also other flaps, which are suitable for patients who are not candidates for a TRAM/DIEP flap like the LD flap with the following advantages:
1. It is a robust flap that can be used to reconstruct small to moderate sized breasts.
2. The flap is an excellent option for almost any reconstructive situation 3. It can be used with ease in cases of immediate or delayed reconstruction.
3. It is a particularly attractive option for patients in need of bilateral reconstruction
4. In patients who may not have enough volume for a bilateral transverse rectus abdominis musculocutaneous (TRAM) flap and who want more of an expander/implant reconstruction, the bilateral latissimus flap option can be an excellent.
5. It is also a very useful flap for reconstruction of the partial mastectomy defect or autogenous salvage in cases of significant fat necrosis after TRAM flap reconstruction.
6. At times, in patients with relatively small opposite breasts, it can be used as a completely autogenous flap, obviating the need for an implant. In these latter circumstances. The ”volume-added” strategy becomes a particularly attractive option for increasing the available soft-tissue bulk provided by the flap (Luce and Hammond, 2005).
7. The LD flap is often reserved for patients in whom TRAM reconstruction is contraindicated. This subset of patients includes extremely thin patients in whom the infraumbilical soft tissues is limited and patients who previously have undergone abdominoplasty or other abdominal operations or who have abdominal scars that may entail compromise of the rectus abdominis pedicle. Relative to TRAM reconstruction, the LD is more resistant to the effects of impaired wound healing posed by smoking and diabetes. Additionally, LD reconstruction does not compromise the abdominal wall, which may be of issue in patients desiring future pregnancy (Kim et al., 2007).
3. Timing of the breast reconstruction
Carcinoma in situ, Stag I and early stag II; immediate breast reconstruction is good option.
For the locally advanced patients delayed breast reconstruction is considered.
4. Complications must be discussed with the patient:
Bleeding, bruising, infection and necrosis (whither breast or donor site)
Complete failure of the reconstructed breast or the donor site
5. The impact of the operation on the course of Radiotherapy and the delayed in chemotherapy treatment especially locally advanced patients which discussed in details in this study.
Although breast reconstruction does not alleviate the patient’s fear of disease, it markedly, improves the patient self-image, feeling of wholeness and body symmetry (Bostwick et al., 2004).
Today, plastic surgery can be performed immediately without adverse effects on the cancer treatment; however, it cannot be performed without a meticulous preoperative evaluation of the cancer status and the physical conditions of the patient by the plastic and general surgeon’s concomitantly. The patient should be involved in the discussion and well informed about the surgery, which is proposed especially in what concerns the possibility of complications or failures (Petit et al., 2011).