| Izah Azahari |
RAJA Isteri Pengiran Anak Saleha (RIPAS) Hospital currently provides comprehensive services in the areas of breast cancer surgery for resection, plastic surgery for reconstruction, oncology (chemotherapy and radio therapy) for disease control and other occupational therapy for rehabilitation.
Dr Chan Koo Guan from the Department of Maxillofacial & Plastic Reconstructive Surgery of RIPAS Hospital discussed this yesterday in his presentation on ‘Oncoplastic Breast Surgery In Brunei Darussalam’ at the Centrepoint Hotel.
The presentation was delivered at the Brunei Cancer Centre’s ‘Breast Cancer Symposium 2014 Multidisciplinary Meet.’
In his presentation, Dr Chan noted that mastectomy patients should have the option of breast reconstruction, a subject which should not be taboo. Better awareness will allow patients to seek consultation for breast reconstruction at the early stages of treatment.
Breast cancer is the most common form of cancer in women worldwide. It is estimated that one in eight women will suffer breast cancer, representing 81 per cent of women aged below 60, and 45 per cent of women aged under 50.
Early detection and subsequent treatment is key to long-term survival. A mastectomy is still the gold standard surgical treatment for most operable breast cancers. Moreover, there is a strong trend in breast-conserving surgery (especially in the early stage of the disease) but it can often result in breast deformity and asymmetry.
Prior to August 2011, there was no breast reconstructive surgery offered in Brunei with the only option being external prosthesis for mastectomy patients.
Dr Chan explained, the external prosthesis was often uncomfortable for patients and would result in rashes under the prosthesis, in addition to being difficult to maintain in place and that it does not feel like part of the woman’s own body.
He pointed out that in more advanced countries like the USA, the take up of reconstruction has increased from about five per cent in the 90s to as high as 50 per cent at present. However, in the Brunei context, it stands merely at 1.3 per cent as it has only recently been provided as an option.
“The single greatest predictor as to whether a woman undergoes breast reconstruction was the mentioning of reconstruction by the surgeon in the initial consultation,” Dr Chan said.
The reasons for this, in his personal view, is because a lot of women opt not to have surgery as they do not want the additional burden (of surgery), they may think of it as cosmetic surgery, that it is unnecessary or because they are unclear (on religious grounds). Additionally, they may also not be suitable candidates due to medical or oncological reasons, or that they may have not been told that it is possible.
Dr Chan later discussed why breast cancer sufferers should undergo reconstruction.
Reconstruction helps restore body image by creating a breast mound of good shape, volume, size and texture – matching what is fitting for the patient’s body habitus and age; brings better self-esteem and is a durable reconstruction as it is comfortable, hassle-free, low maintenance and has low replacement rate.
Moreover, reconstruction aims to set realistic aesthetic expectations, where it will appear normal when in clothes, does not affect cancer survival outcome and has a life-long follow up to detect cancer recurrence.
There are three common mastectomy reconstruction techniques involved. The first is prosthetics which is purely implant-based. It is best for bilateral reconstruction in non-irradiated chest that includes a tissue expander and definitive breast implants. Symmetry is guaranteed.
The second technique is a hybrid-prosthetic with autologous (which means own body) tissue. The Latissimus Dorsimyocutaneous (skin and muscle in Latin) flap with implant for patients who have gone through radiotherapy but want prosthetic reconstruction or inadequate autologous tissue, or for salvaging failed surgeries of reconstruction using the Transverse Rectus Abdominis Myocutaneous (TRAM) flap, which is the third technique. This is purely autologous, using muscles and fats with blood vessels, or a Deep Inferior Epigastric Perforator (DIEP) flap that uses purely fats and skin with blood vessels.
Dr Chan explained that additional surgery may be required to achieve the desired symmetry in terms of size, shape and ptosis, where they will have to match the normal breast, conduct a reduction or mastopexy (lift), touch up surgery for scar revision, dog ears correction for donor site, liposuction or lipo-filling of reconstructed breast to correct minor size or contour discrepancies, or rectify complications such as bulge or hernia in abdominal donor site.
To date, RIPAS Hospital has had seven patients, which makes up the 1.3 per cent of breast cancer patients aged below 60 who have undergone breast reconstruction. There have been no failures thus far and the average length of hospital stay is between six to 14 days.
One patient had a persistent abdominal donor site bulge and seroma and required surgery to rectify the problem. Although all patients had some degree of hypertrophic scarring, it settled with time and all were extremely satisfied with the results.
Oncoplastic Breast Surgery involves the removal of the breast cancer in combination with reconstruction of the resultant defect to achieve the most favourable cosmetic outcome with optimal control in the treatment of breast cancer.
Bad cosmetic result following breast-conserving surgery ends in concave deformity, skin puckering, poor scars, nipple-areolar displacement, misshapen breast and poor symmetry.