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A picture of breast reconstruction in Taiwan Sin-Daw Lin, MD Ming-Feng Hou, MD* Fu Ou-Yang, MD* Fang-Ming Chen, MD* Kaohsiung Medical University Hospital,

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Presentation on theme: "A picture of breast reconstruction in Taiwan Sin-Daw Lin, MD Ming-Feng Hou, MD* Fu Ou-Yang, MD* Fang-Ming Chen, MD* Kaohsiung Medical University Hospital,"— Presentation transcript:

1 A picture of breast reconstruction in Taiwan Sin-Daw Lin, MD Ming-Feng Hou, MD* Fu Ou-Yang, MD* Fang-Ming Chen, MD* Kaohsiung Medical University Hospital, Kaohsiung Medical University Department of Plastic Surgery and General Surgery* Kaohsiung, Taiwan

2 Features of the breast cancer in Taiwan   The most common cancer of female population   Incidence in 1991 14/10 5 population in 2008 53/10 5 population   new cases in 2000 4642 cases in 2008 8136 cases   The majority of patients are young women < 40 yrs old : 16% peak : 44-55 yr. old

3 行政院衛生署國民健康局【新聞稿】 2008 年 10 月 17 日公 佈 資料來源: 台灣:癌症登記 美國:美國癌症委員會癌症資料庫 Stage 0 & I : 55% vs 37% Stage distribution between Taiwan and U.S.A. (2005) Taiwan U.S.A. Stage Ⅱ & Ⅲ : 34% vs 56%

4 2006 - 2010; 12 Hospitals  Cases of breast reconstruction – 2487 cases  Cases of immediate reconstr. – 1986 cases (79.9%)  Cases of delayed reconstr. – 501 cases  reconstr. with autologous tissue – 1212 cases  reconstr. with prosthesis – 1275 cases

5 Factors influence the patients’ acceptance of breast reconstruction ( I )  Economic considerations In Taiwan, the National Health Insurance do not cover the breast reconstruction.In Taiwan, the National Health Insurance do not cover the breast reconstruction. 20% of mastectomy cases do not undergo reconstruction because of financial problem.20% of mastectomy cases do not undergo reconstruction because of financial problem.  Inadequate knowledge and misinformation may negatively affect p’t referral to plastic surgeons

6 Factors influence the patients’ acceptance of breast reconstruction ( II )  conservative attitude  the stage of the breast cancer  the age of the patient  the support from the family, esp. the husband

7 Reconstruction Rate (1997-2009,KMUH) * 2003 : SARS disaster

8 Age distribution (MRM only and TRAM flap reconstruction 1997-2009) MRM only : 1292 TRAM flap : 821 Reconstruct rate : average: 38.9% < 50yrs: 53.7% < 60yrs: 46.1% 0.1% 3.7% 25.8% 48.4% 19.2% 2.6% 0.2%

9 A Patient for Breast Reconstruction  a healthy, young or middle-aged woman < 40 yrs old : 16% peak : 44-55 yr. old  av. BMI value : 23.0 (15.3~38.5, 810 p’ts) (15.3~38.5, 810 p’ts)  p’t has an adequate abdominal subcutaneous fat and skin  a good candidate for either  a good candidate for either pedicled or free TRAM flap surgery pedicled or free TRAM flap surgery  self-paid for reconstruction

10 1.No significant difference of results was found between free and pedicle TRAM flaps. (Kroll et al, 1995; 237 cases) (Kroll et al, 1995; 237 cases) 2.Pedicled TRAM flap patients are more aesthetically satisfied than those with free TRAM flaps. (Alderman et al., 2000; Clough et al, 2001) (Alderman et al., 2000; Clough et al, 2001) 3.Most of the literatures have suggested that the pedicled and free tissue transfers are equal in relation to outcome, result, and cost. (Larson et al.,1999)

11  Despite the advent of microsurgery, advances in perforator-based flap design, and increasing procedural complexity, the pedicled TRAM flap is still one of the most common methods of autologous reconstruction performed today. (Buck DW 2 nd. & Fine NA. P.R.S. 2009)

12 1. Zones Ⅰ & Ⅲ are the main parts for the reconstruction 2. Only central part of the rectus muscles was dissected * major branches---in the central third of the m. in 90% of cases. (Milloy FG. 1960; Hartrampf CR. 1988) Hartrampf CR. 1988)

13 (Chang KP, Lin SD, et al. Ann Plast Surg. 2001) To reconstruct a symmetric breast 1. to weigh the flap with a spring scale during operation 2. the weight of the implanted flap =50-60% the wt. of dissected TRAM flap. Originally presented photo is removed

14 1. a major improvement in breast reconstruction over the past couple of decades 2. Since 2001, skin sparing mastectomy 3. preserved native skin envelop →color and texture match of the reconstructed br. →color and texture match of the reconstructed br. 4.to provide a 2-D pattern of the TRAM flap to create a 3-D shape of the reconstructed breast →to enhance the aesthetic results →to enhance the aesthetic results Skin sparing mastectomy - Toth and Lappert, 1991

15  The nipple-areolar complex seems to be the signature of the breast identity more than the volume or the shape which can be changed easily in esthetic surgery.  most important risk of preserving NAC → retroareolar or areolar relapse → retroareolar or areolar relapse  A frozen section histology was always taken in the retroareola region to be certain of its integrity.  Since 2004, NAC preservation - 251/481, 52.2% - 251/481, 52.2% Nipple-Sparing Mastectomy

16 Criteria for Nipple-Sparing Mastectomy AuthorsYear Tumor Size Distance from Nipple Others Laronga et al. 1999<2cmPeriphery Negative node status Gerber and Krause 2003>2cm <25% intraductal component, negative frozen section Crowe2004>1cm Very ptotic or large breasts excluded Sacchini2006<3.5cmNoncentral No neoadjuvant chemotherapy Wijayanayagam et al. 2008 No “large” tumor >2cm Preoperative MRI of nipple to evaluate tumor Hou2009>1cm Preoperative ultrasound of nipple to evaluate tumor, negative frozen section

17 Necrotic Complications of NAC preservation AuthorsyrNo. partial necrosis complete necrosis No.%No.% Kissin & Clark 198720210210 Verheyden et al. 199820105015 Crowe et al. 20044836.2-- Komorowski et al. 20063825.337.9 Sacchini20061922211-- Present ** 20112263214.262.6 p.s. different surgical technique ** periareolar incision; small areola 7; ptotically large br. 8.

18 Originally presented photos are removed

19 abdominal wall complications 1. DIEP, free TRAM not immue to the development of abd. bulging hernia & flap-related complications not immue to the development of abd. bulging hernia & flap-related complications (Kind GM. et al. Plast Reconstr Surg. 1997; Blondeel PN. et al. Br J Plast Surg. 1997; (Kind GM. et al. Plast Reconstr Surg. 1997; Blondeel PN. et al. Br J Plast Surg. 1997; Scevola S. et al. Ann Plast Surg. 2002; Nahabedian MY. & Manson PM. Plast Reconstr Surg. 2002; Petit JY. et al. Plast Reconstr Surg. 2003) Plast Reconstr Surg. 2002; Petit JY. et al. Plast Reconstr Surg. 2003) 2. no significant difference between pedicled TRAM, free TRAM, and/or DIEP flaps with regard to abd. wall morbidity (Kroll SS. et al. Plast Reconstr Surg. 1995; Kind GM. et al. Plast Reconstr Surg. 1997; (Kroll SS. et al. Plast Reconstr Surg. 1995; Kind GM. et al. Plast Reconstr Surg. 1997; Nahabedian MY. & Manson PM. Plast Reconstr Surg. 2002; Alderman AK. Plast Reconstr Surg. 2002) 3. The long-term clinical effect of rectus m. harvest is minimal and well tolerated. (Kind GM. et al. Plast Reconstr Surg. 1997; Petit JY. et al. Plast Reconstr Surg. 2003)

20 Advantages of immediate breast reconstruction 1. High acceptance rate 2. Psychological benefits - lessen the postoperative grief to the loss of the breast 3. One stage completion - reduce the overall cost, time and the 2nd anesthetic risk 4. Cosmetic benefits - better cosmetic results than those of the 2nd reconstructed one 5. Symmetric reconstruction - more easy to achieve a symmetric breast

21 Originally presented photos are removed

22 All Stage MRM+TRAM: 5 year overall survival rate: 92.6% (278 pts) MRM alone: 5 year overall survival rate: 82.8% (622 pts) Kaplan-Meier Survival Curve P<0.001

23 Stage III MRM+TRAM: 5 year overall survival rate: 85.7% (63 pts) MRM alone: 5 year overall survival rate: 60.4% (153 pts) Kaplan-Meier Survival Curve P<0.001p=0.001

24 Originally presented photos are removed

25 Material (Feb. 1997 – Aug. 2011, KMUH 、 KMHK 、 CCH) 1. br. reconstion with TRAM flap:945% 2. Immediate reconstruction: delayed reconstruction: bilateral reconstruction: with VLMA scar unmarried 921 24 61 117 94 97.5 2.5 6.5 12.7 9.9 3. ➀ since 2001 S.S.M. ➁ Nipple-areolar preserved: since 2004 - : 251/481 52.2 4. Operative time from 2 hrs 30min to 5 hrs 30min (average 3 hrs 20 min) 5. Hospitalization including MRM: 7 days

26 Complications of 921 immediate pedicled TRAM flaps reconstruction %  total loss of the flap : 00  partial loss of the flap : 80.8  postoperative infection of the flap : 101.0  removal of fat necrosis : 70.7  fat necrosis : 374.0  mild to moderate ischemic changes of native skin envelope : 363.9  skin graft of the native skin defect : 40.4  abdominal herniation : 50.5  necrosis of abd. wound : 101.0  necrosis of umbilical wound : 50.6  hyperextension injury of upper limb : 20.2

27 Satisfaction with the Reconstructed Breast ( %, 2000-2010, 636p’ts )

28 very satisfied + satisfied + neither satisfied nor dissatisfied : 97.6% to recommend this op. to other p’t : 92.9% Breast problem: size : 32 symmetry : 3 softness : 20 others : 25 (Lin et al., 2011) (Lin et al., 2011) very satisfied satisfied neither satisfied nor dissatisfied dissatisfied very dissatisfied No.43113852105636 %67.721.78.21.60.8100 Satisfaction with the Reconstructed Breast ( 2000-2010, 636p’ts )

29 Satisfaction with the Donor Abdominal Wound ( %, 2000-2010, 636p’ts )

30 Pierre-Auguste Renoir (French Impressionist Painter,1841-1919)

31 Thanks for your attention ! K.M.U. TW. Acknowledgement : Ming-Feng Hou Su-Shin Lee I-Feng Sun Yi-Chia Wu Chih-Hau Chang Chung-Sheng Lai Kao-Ping Chang Shu-Hung Huang Ching-Horng Lai Ping-Yen Tsai Ko-Kang Chen


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