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Innovations in post mastectomy surgery: A deep dive

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What options are there for survivors considering reconstruction surgery? Dr. Raffi Gurunian, MD from Cleveland Clinic Abu Dhabi, shares his insights on progressive procedures.

While 31st October marked the last day of global breast cancer awareness month, championing awareness and encouraging precautionary measures continues for oncologists.

Coping through a breast cancer diagnosis is life-altering, with the journey towards recovery being a process. Treatments and procedures may be overwhelming; therefore a multidisciplinary approach that helps patients navigate through options post-mastectomy is vital.

Dr. Raffi Gurunian, MD from Cleveland Clinic Abu Dhabi, breaks down the relationship between reconstructive plastic surgeons and surgical oncologists, and how it creates successful postoperative outcomes:

Initial steps

The initial diagnostic workup is conducted by the surgical oncologist to evaluate the patient. In Cleveland Clinic Abu Dhabi, we implement a multidisciplinary approach, and our breast cancer team includes medical oncologists, radiation oncologists, plastic surgeons.

When patients consult with surgical oncologists, they are referred to a plastic surgeon to discuss reconstructive options for the replacement of the tissue. It is extremely important to have a cohesive team with the breast surgeons working shoulder to shoulder as a successful reconstruction surgery relies on a good mastectomy, which is the removal of the entire breast tissue.

Therefore, if you have a skilled surgical oncologist paying attention to the finer details and performing a successful mastectomy, the planes and tissues are viable, which makes for a perfect foundation for the plastic surgeon to work on.

Again, it is very critical, both theoretically and, practically, that we work very closely with breast surgeons, and they do work closely with us as well to obtain the best possible outcome for an individual patient.

Personalised pre-operative evaluation for successful outcomes  

Once we receive referrals from breast surgeons, we evaluate patient history and conduct a physical examination. Some patients may have comorbidities therefore it is crucial to identify the problems prior to the surgery. In some cases, unfortunately, there are patients who would not be good candidates for reconstructive surgery.

After evaluation, there are two ways of reconstructing the breast. One is implant-based reconstruction and the other is autologous tissue, which means that we harvest tissue from the patient to reconstruct their breasts.

Preoperative assessment and discussion with the patient as well as the family members are critical to a successful outcome. It is an in-depth, personalised approach during which we communicate with the patient and develop a definitive plan for them.

Innovation

In recent years, for implant-based reconstruction, we have started performing pre-pectoral breast reconstruction. In this procedure, we place the implant above the muscle, combined with a synthetic skin substitute, and create a pocket for the breast implant to sit on the muscle.

The standard for many years was subpectoral, in which the implant was placed beneath the muscle.

Although still performed in some practices, our experience demonstrated that these types of procedures are associated with patient discomfort post-surgery. There are some spasms, animation deformity recalls due to the implant being placed under the muscle, which means patients would feel displacement as they move the muscle.

Therefore, in recent years we have transitioned from subpectoral to pre pectoral which elevates patient comfort after surgery and prevents animation deformity. It also gave us a better ability in pain management.

Again, there will be certain cases where you would still have to do partially submuscular procedure, based on the viability of the tissue. However, in my practice around 90 per cent of the time, I am opting to do pre-pectoral reconstruction if I'm using an implant reconstruction.

In breast mount reconstruction, the first step is to eliminate cancer, and then provide the volume and reasonable shape. The surgeon then proceeds with revisions, such as nipple reconstruction until the patient is satisfied with the outcome.

Again, the size matching procedures on the other side could be a breast lift, breast reduction, also reduction, and augmentation, depending on the size and other elements of the reconstructive breast.

In lymphedema prevention surgery, immediately after the lymph nodes are cleaned up in the axilla, some patients may, unfortunately, encounter the metastatic disease in the lymph nodes. The breast surgeon would remove the lymph nodes.

After this procedure, plastic surgeons use the lymphatic vessels, draining the arm, and we hook them up to the remaining vessels in the veins, in the armpit immediately.  

This is for the prevention of upper arm swelling, what we call lymphedema. This is another, very detailed technology because it uses high-power microscopes and delicate instruments to reach lymphatic vessels that are 0.3 millimeters against 0.3 millimeters wide.

Connecting those vessels to the veins and things is a highly delicate procedure and although not a new procedure, it is becoming prevalent now in preventing the lymphedema occurrence in patients undergoing lymph node dissection, for cancer.

Patient eligibility

Certain patients benefit from a direct implant, which means after their mastectomy we immediately come in and place an implant into the breast pockets, provided that the skin envelope is healthy and mastectomy flaps viable.

This technique is mostly applicable in patients undergoing either preventive or what we call a prophylactic mastectomy.

In a nipple-sparing mastectomy, you can preserve the nipple based on the location of cancer. If performing a preventive surgery, direct implantation can be made into the breast pocket.

Now, if we're performing a skin-sparing mastectomy, which means that you're removing the nipple and part of the areola, we would perfume a tissue expander placement, until we can exchange it for a permanent implant.

Some patients may require post-mastectomy radiation for further treatment, and until the radiation is complete, you do not want to do any definitive reconstruction. This could be a reconstruction with the implant or the patient's own tissue.

Again, knowing that some of those patients would require post-mastectomy radiation, you don't want to burn any bridges. Because radiation comes in and it changes the skin envelope, causing issues such as burning of tissue creating scar tissue, poor outcomes, and failure of the implant as well.

So, therefore, in these patients, the situation is temporised, by placing a temporary device called the tissue expander. Navigating the patient throughout their treatment is key, which could be chemotherapy or follow-up chemotherapy with radiation.

Until after the radiation is complete, no further steps should be taken, except potentially expanding the tissue expander.

After completion of radiation, which is roughly three to six months, we take those patients back to the operating room to exchange their tissue expanders for a permanent implant.

This is a two-stage procedure, which gives surgeons the ability to revise the surgery and do touch-ups, such as size match with the contralateral other side, if only the patient has undergone a single, unilateral mastectomy.

TAGS: Oncology
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