الفهرس 
Anatomy of chest wall musclesOnly 14 pages are availabe for public view
 |  | from | 145 |  |  |
| | | from | 145 | | |
Abstract
During the last century, breast reconstruction after mastectomy has become an important part of comprehensive treatment for patients who have breast cancer. Breast reconstruction initially was created to reduce complications of mastectomy and to diminish chest wall deformities. Now, however, it is known that reconstruction also can improve the psychosocial well-being and quality of life of patients who have breast cancer. (Wilkins; et al., 2000).
Silicone breast implants were introduced in the early 1960s. (Cronin, 1963), but in 1992, the Food and Drug Administration (FDA) placed a moratorium on silicone implants due to concern regarding its safety of use in patients. Since then saline implants had been exclusively used in the United States, until recently. In November 2006, after an extensive scientific review revealed no significant risks, the FDA approved the use of silicone implants for breast reconstruction in women of all ages. Now that the silicone implant has been deemed safe, the FDA is requiring a 10 year follow-up to continue to monitor these implants as part of a post-approval study. (Food and Drug Administration; February 20, 2006)
The initial implant reconstructions were placed under the thin mastectomy skin flaps without prior expansion of the tissue, a practice that led to frequent complications such as skin loss. The introduction of the latissimus dorsi myocutaneous flap provided better soft tissue coverage over the implant and decreased postoperative complications. (Hollos, 1995).
Breast reconstruction with implants often requires the use of a tissue expander to create room for the implant before it can be placed as after mastectomy surgery there is less skin remains at the site of the breast than existed originally. For an implant to be comfortably placed, the surgeon first surgically inserts a balloon like tissue expander under the chest muscle. At weekly intervals - beginning two weeks after surgery - the surgeon injects saline solution into the tissue expander through a small valve located just below the surface of the patient‘s skin. Once the tissue expander has sufficiently stretched the skin, the surgeon replaces it with a breast implant. (Gamboa, 2006).
Immediate reconstruction is defined as reconstruction that starts at the same time as the mastectomy. This option can be an excellent one for women who have ductal carcinoma in situ and stage 1 or stage 2 disease. The advantages of immediate breast reconstruction are multiple. Women who have immediate reconstruction have less distress and better body image, self-esteem, and satisfaction, in general, than women who have delayed reconstruction. (Al-Ghazal: et al.,2000).
from an aesthetic standpoint, autogenous tissue reconstructions performed at the time of the mastectomy generally have produced a better aesthetic result than delayed procedures because the skin envelope is preserved. (Newman; et al., 1998).
The overall cost is less because fewer major operations are needed, the patient is anesthetized already, the defect does not have to be recreated, and the patient can recover from the mastectomy and the reconstruction simultaneously. (Khoo; et al.,1998).
Disadvantages of immediate reconstruction include the potential delay of adjuvant therapy should a postoperative complication such as delayed wound healing occur. Most studies, however, have not shown reconstruction to delay therapy. (Ramon; et al., 1997).
Another potential pitfall of immediate reconstruction is the partial loss of the mastectomy skin flaps, especially if the oncologic surgeon needs to create thin skin flaps. In addition, residual disease or close surgical margins may necessitate the use of postoperative radiation therapy, which can adversely affect the reconstruction. (Gamboa, 2006).
Relative contraindications to immediate reconstruction include advanced disease (stage 3 or higher), need for postoperative radiation (although this contraindication is controversial and varies by center), and medical comorbidities such as use of nicotine, morbid obesity, or cardiopulmonary disease. In addition, use of implants is a relative contraindication in women who have rheumatologic disorders. (Gamboa, 2006).
Delayed reconstruction, defined as a reconstructive procedure that starts after the mastectomy, can be started any time after the wound has healed and adjuvant therapy has been administered. Post radiation skin changes should have stabilized, and the hematologic effects of chemotherapy should have normalized before reconstruction is begun. Delayed reconstruction has its own advantages. First, all guess work regarding whether radiation therapy will be required is eliminated, so surgeons and patients can appraise to their reconstructive options more accurately. Second, studies have shown that delayed reconstructions have overall fewer complications than immediate reconstruction. Disadvantages of delayed reconstruction include prolonging the overall treatment of the patient, a poorer cosmetic result with autogenous tissue reconstruction because the skin envelope is not preserved, and potentially higher costs to the health care system. (Gamboa, 2006).