Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 12  |  Issue : 2  |  Page : 43-46

Initial experience in breast reconstruction with implants by general surgeons: A report of five cases


1 Department of Surgery, College of Medicine, University College Hospital, Ibadan, Nigeria
2 Department of Surgery, University College Hospital, Ibadan, Nigeria

Date of Web Publication17-Mar-2017

Correspondence Address:
Oludolapo Ola Afuwape
Department of Surgery, College of Medicine, University College Hospital, Ibadan
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0794-9316.202464

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  Abstract 

Context: This article presents a preliminary experience on implant breast reconstruction undertaken by the general surgeons in a tertiary hospital in Nigeria.
Aim: This article presents a preliminary experience on the implant breast reconstruction undertaken by the general surgeons in a tertiary hospital in Nigeria. It also discusses our challenges and limitations.
Patients and Methods: Five patients who consented to implant surgery in 5 years were reviewed retrospectively.
Results: Four of the five patients were satisfied with the outcome in the early postoperative period. There was one flap necrosis and one capsular contracture which developed a year after the procedure.
Conclusion: The practice of breast reconstruction in Nigeria is evolving, and demands will be made on general surgeons, especially in centers without reconstructive surgeons.

Keywords: Breast, implant, mastectomy


How to cite this article:
Afuwape OO, Ayandipo OO, Abdurrazzaaq AI. Initial experience in breast reconstruction with implants by general surgeons: A report of five cases. Nigerian J Plast Surg 2016;12:43-6

How to cite this URL:
Afuwape OO, Ayandipo OO, Abdurrazzaaq AI. Initial experience in breast reconstruction with implants by general surgeons: A report of five cases. Nigerian J Plast Surg [serial online] 2016 [cited 2017 Dec 14];12:43-6. Available from: http://www.njps.org/text.asp?2016/12/2/43/202464


  Introduction Top


Breast cancer is the most common malignancy in females [1] with an increasing incidence among the young women in developing countries.[2] Breast cancer surgery has significant physiological and physical impact on women. These include postmastectomy depression, poor self-esteem, and occasional attempts of suicide. Women who have had mastectomy have to deal not only with the physical changes but also with the feeling of loss of femininity and the fear of rejection by partners.[3] Treatment of breast cancer has evolved from radical mastectomy to less aggressive surgeries. Currently, breast conserving surgery with adjuvant radiotherapy is practiced with similar outcomes as mastectomy. In Africa, about two-thirds of patients with breast cancer present late when the role of surgery is minimal and the options at surgery are limited.[4] Breast reconstruction reduces the physical, psychological, and social sequels of mastectomy. In developing countries, breast cancer patients present late due to these fears. Consequently, immediate breast reconstruction with silicone prosthesis is rare. There are variable techniques of breast reconstruction with the common goal of restoration of the breast appearance to as normal as possible. Following the initial attempt on breast reconstruction in 1895 by Vincent Czerny [5] when he transferred a lipoma from the back to the mastectomy wound, many autologous breast reconstructions have evolved thereafter.[6] The use of implants for breast reconstruction was introduced in 1951 using polyvinyl alcohol sponge.[7] Silicone gel was introduced in 1963 by Thomas Cronin and Greenberg and Frank Gerow.[8] Since then, many improvements have been made on the silicone gel implant so as to reduce the occurrence of capsular contracture. Plastic surgeons have pioneered breast reconstruction in many centers, but general surgeons still have role to play.

This article aims at presenting preliminary experience on implant breast reconstruction undertaken by general surgeons in a tertiary hospital in Nigeria.


  Patients And Methods Top


This is a review of five patients who had immediate breast reconstruction with silicone implants following mastectomy for carcinoma of the breast between January 2010 and December 2014.

The selection criteria included patients with early-stage (stages 1 and 2) carcinoma of the breast who consented to the procedure. Exclusion criteria included advance stage of breast carcinoma, obesity, diabetes, and large breasts (i.e., estimated volume of above 500 cc). All the five patients consented to immediate breast reconstruction. The records of these patients who had breast reconstruction with implant following mastectomy were reviewed. All the patients had cytological/histological diagnosis of breast carcinoma. A textured silicone breast implant was used for one-stage immediate postmastectomy breast reconstruction. Prior to mastectomy, the appropriate size of the prosthesis was estimated using three parameters. The first was comparing the size of the breast with a 500 ml bag of infusion to estimate the volume of the breast while the second method involved the measurement of the diameter of the base of the breast on the anterior chest wall. The third parameter was the patient's brassiere size. These parameters were used to estimate the appropriate configuration of the proposed implant. Two patients with tumor size of diameter <2 cm located more than 6 cm from the nipple-areolar complex had nipple-sparing mastectomy while the rest had skin-sparing mastectomy with excision of the nipple-areolar complex. A lateral inframammary incision was used to raise the skin flap for nipple-sparing mastectomy. An elliptical circumareolar incision with a racquet with handle extension was used to excise the nipple–areolar complex and the biopsy site when required for skin-sparing mastectomy. The axillary dissection was through a separate incision in the axilla. All the patients had subcutaneous drains which was leftin situ for 4 days before removal. The downward migration of the implant was prevented by the application of adhesive tapes extending from the midline anteriorly to the scapula posteriorly.

Case presentation

Case 1

A 38-year-old woman presented to the surgical outpatient department with a 2-month history of a painless left breast lump. She had no features suggestive of metastasis. She was a premenopausal woman with a 2-year-old daughter. Examination revealed a mobile 2 cm diameter lump in the outer lower quadrant of the left breast. The cytology result was malignant. She had one palpable mobile axillary node in the left axilla. She had a subcutaneous nipple-sparing mastectomy. Axillary dissection was performed through a separate incision in the axilla. A 350 ml subcutaneous textured silicone breast implant was introduced under the breast skin flap. The skin was closed with 3/0 vicryl subcuticular sutures over a drain which was removed after 4 days. The histology report revealed invasive ductal carcinoma with tumor-free margins. The immunohistochemistry report was triple negative (estrogen receptor negative; progesterone receptor negative, and human epidermal growth factor receptor 2 [Her 2] negative). She was discharged home on the 8th postoperative day. She subsequently had radiotherapy to the chest wall and six courses of adjuvant chemotherapy. She has remained disease free for the past 4 years.

Case 2

B.A was a 39-year-old woman who was seen in the surgical outpatient clinic with a 4-month history of a painless left breast lump. She had no features of metastasis. The clinical examination at presentation revealed a healthy looking woman with a mobile breast lump of 1.5 cm diameter in the upper outer quadrant of the left breast. There was no demonstrable nipple involvement. There was no palpably enlarged lymph node. The cytology report was malignant. She had a subcutaneous nipple-sparing mastectomy with axillary dissection through a separate axillary incision. A 300 ml textured implant was introduced. The skin was closed with 3/0 subcuticular vicryl sutures over a drain which was removed on the 4th day. The histological report was invasive ductal carcinoma which was estrogen receptor positive but progesterone and Her 2 receptor negative. She was discharged home on the 9th postoperative day. She had adjuvant chemoradiation. She developed contracture of the skin over the implant [Figure 1], for which she needs to have a capsulotomy.
Figure 1: Contractures

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Case 3

O.M, a 45-year-old woman, was seen with a 6-month history of a painless right breast lump of 2 cm diameter which was histologically malignant. She had no features of metastasis. Examination at presentation revealed a 2 cm lump in the infra-areolar aspect of the right breast. She had two palpable mobile right axillary nodes. She had a skin-sparing mastectomy with excision of the nipple-areolar complex. A subpectoral implant was inserted. However, there was migration of the implant toward the right axilla and necrosis of the overlying skin which necessitated removing the implant and debriding the necrotic flap. The wound healed and she was discharged on the 14th day. She had adjuvant chemoradiation.

Case 4

A.A, a 51-year-old woman, was seen with clinical features of Paget's disease of the right breast. She had no palpably enlarged axillary nodes and no features of metastases. She had a subcutaneous mastectomy with excision of the nipple-areolar complex and a silicone implant reconstruction [Figure 2]. She had adjuvant chemotherapy and has remained disease free. She is been on follow-up on an outpatient basis for the past 2 years.
Figure 2: Skin-sparing mastectomy of the left breast with excision of nipple-areolar complex

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Case 5

F.A is a 50-year-old woman who was seen in the surgical outpatient department with a painless right breast lump. She had a positive family history of cancer. Examination revealed a 2 cm lump in the central region of the right breast. The histological diagnosis was invasive ductal cancer. She had two palpable axillary nodes in the right axilla. She requested for a bilateral mastectomy with bilateral implant, for which she had subcutaneous mastectomy with excision of the nipple-areolar complex [Figure 3]. She did well after bilateral subcutaneous implant reconstruction. She had adjuvant chemotherapy and radiotherapy. She has remained disease free to date.
Figure 3: Bilateral mastectomy with subcutaneous implant reconstruction

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  Results Top


The age range of the patients was 38–51 years. All of them had a diagnosis of an invasive ductal carcinoma. They all had simple mastectomy with axillary clearance. One patient had bilateral mastectomy. All the patients had immediate silicone gel implant reconstruction. Five of the implants were placed subcutaneously while one was subpectoral.

Complications observed included flap necrosis in one of the six procedures (16%). This necessitated debridement and removal of the implant. Contracture was observed in another patient (16%) a year after surgery [Figure 1]. All the patients had adjuvant radiotherapy after surgery. Three of these patients are still on follow-up while two have defaulted from clinical appointments. The follow-up period ranged from 1 year to 4 years.


  Discussion Top


Breast cancer is the most common female malignancy in Nigeria with a prevalence of 52 cases per 100,000 women per year.[9] Despite this high prevalence, breast reconstruction is not a frequent procedure in Nigeria. This may be attributed to the advanced stage of the disease at presentation, high cost of implants, and the lack of awareness of the patients.[10] Most breast reconstructions are performed by the plastic surgeons in many centers. General surgeons are more concerned with the outcome of the oncological treatment with minimal incidence of local recurrence. Consequently, some surgeons discourage patients from undergoing breast reconstruction following mastectomy.[11] Despite this concern, some general surgeons perform immediate breast reconstruction for their patients without recourse to plastic surgeons. A survey revealed that 31.3% of general surgeons who undertake breast surgeries perform breast reconstruction themselves.[12] In Nigeria, there is paucity of reports of breast reconstruction particularly from general surgeons. In this report, only six implant breast reconstructions were carried out by the general surgeons over a 5-year period in a unit where an average of 20–30 mastectomies are performed each year. This testifies to the infrequent practice of breast reconstruction.

Early complication (flap necrosis) observed in a patient could be explained as part of a learning curve and the infrequent nature of the surgery. Capsular contracture occurred in one of our patients (16%) a year after surgery. It is the most common complication of implant breast reconstruction occurring in 17.7% of women.[13] However, subsequently, thicker flaps were developed to prevent contractures in other patients. The number of cases done and the period of follow-up are not enough to make a valid conclusion of the complication rate. However, based on the breast reconstruction score chart (BREAST-Q reconstruction),[14] four patients were satisfied with the initial outcome [Figure 2] and [Figure 3]. One patient was unsatisfied with the immediate outcome of surgery. In the follow-up phase, one patient who was initially satisfied with the outcome became unsatisfied following the development of contracture of the overlying skin. All the patients had varying levels of paresthesia as a complication of tissue dissection.

Immediate postoperative breast reconstruction has a few challenges. These include the occasional difficulty in determining the appropriate implant size. The use of intraoperative sizers is ideal; however, this requires having implants of various sizes available intraoperatively which increases the cost of surgery. This was overcome by the technique of measuring the diameter of the base of the breast and brassiere cup size as described in the methodology. When there was doubt, we opted to purchase a smaller implant size and excise redundant skin.


  Conclusion Top


The practice of breast reconstruction in Nigeria is evolving, and demands will be made on general surgeons, especially in centers without reconstructive surgeons. The long-term cosmetic outcome and patients' satisfaction need to be determined in subsequent studies.

Acknowledgment

The author would like to thank the consultants in the Plastic and Reconstructive Department of University College Hospital, Ibadan, Nigeria.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
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2.
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Stavrou D, Weissman O, Polyniki A, Papageorgiou N, Haik J, Farber N, et al. Quality of life after breast cancer surgery with or without reconstruction. Eplasty 2009;9:e18.  Back to cited text no. 3
    
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Mabula JB, Mchembe MD, Chalya PL, Giiti G, Chandika AB, Rambau P, et al. Stage at diagnosis, clinicopathological and treatment patterns of breast cancer at Bugando Medical Centre in North-western Tanzania. Tanzan J Health Res 2012;14:269-79.  Back to cited text no. 4
    
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Uroskie TW, Colen LB. History of breast reconstruction. Semin Plast Surg 2004;18:65-9.  Back to cited text no. 5
    
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Peters W. The evolution of breast implants. Plast Surg 2002;10:223-36.  Back to cited text no. 7
    
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Cronin TD, Greenberg RL. Our experiences with the silastic gel breast prosthesis. Plast Reconstr Surg 1970;46:1-7.  Back to cited text no. 8
    
9.
Jedy-Agba E, Curado MP, Ogunbiyi O, Oga E, Fabowale T, Igbinoba F, et al. Cancer incidence in Nigeria: A report from population-based cancer registries. Cancer Epidemiol 2012;36:e271-8.  Back to cited text no. 9
    
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Olaitan P. Breast cancer management: A review of the role of plastic and reconstructive surgery. Niger J Plast Surg 2011;7:48-58.  Back to cited text no. 10
    
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Spyrou GE, Titley OG, Cerqueiro J, Fatah MF. A survey of general surgeons' attitudes towards breast reconstruction after mastectomy. Ann R Coll Surg Engl 1998;80:178-83.  Back to cited text no. 11
    
12.
Emiroğlu M, Sert İ, İnal A, Karaali C, Peker K, İlhan E, et al. The approach of general surgeons to oncoplastic and reconstructive breast surgery in Turkey: A survey of practice patterns. Balkan Med J 2014;31:307-12.  Back to cited text no. 12
    
13.
Kulmala I, McLaughlin JK, Pakkanen M, Lassila K, Holmich LR, Lipworth L, et al. Local complications after cosmetic breast implant surgery in Finland. Ann Plast Surg 2004;53:413-9.  Back to cited text no. 13
    
14.
Pusic AL, Klassen AF, Scott AM, Klok JA, Cordeiro PG, Cano SJ. Development of a new patient-reported outcome measure for breast surgery: The BREAST-Q. Plast Reconstr Surg 2009;124:345-53.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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