Breast Cancer - Arab Medical Association Against Cancer

Surgery 135The safety of gel-filled silicone prosthesis has recently been brought into question, despite theirworldwide use for more than 30 years in breast augmentation or reconstruction. An increased risk ofcancer and autoimmune disease has been suggested. In order to evaluate these effects, we have studied146 patients with breast cancer treated by mastectomy at the Gustave Roussy Cancer Institute between1965 and 1983 and who received a gel-filled silicone prosthesis for immediate or delayed breastreconstruction between 1976 and 1984. These patients were compared with 146 matched controls withbreast cancer that were treated in the same center by mastectomy without breast reconstruction and werematched for age at diagnosis (within 10 years), year of diagnosis (within 3 years), stage, histologic type ofthe tumor, histopathologic grade, and nodal status. The relative risks of death, relapse, and secondprimary cancer were estimated by means of the Cox proportional hazard model stratified on age atdiagnosis.The risks of distant metastasis and death due to breast cancer were significantly lower in the breastreconstruction group than in the control group. The risks of local recurrence, second breast cancer andsecond primary cancer in another site than the breast were not significantly different between the twogroups of patients. These results do not support the hypothesis of detrimental effect of gel-filled siliconeprosthesis in the course of breast cancer (Table 16.3).In respect of autoimmune disease, the literature showed about a hundred cases around the world ofassociation between silicone use (prosthesis or silicone injection) and autoimmune disease. These ratesseem very low in comparison to the total of silicone prosthesis use in the world. However, a valuablestatistical study is difficult to apply with such a low incidence of the autoimmune disease. Nowadays,epidemiologic studies have shown that autoimmune disease cannot be related to prosthesis implantationin most cases and most countrieCapsular contracture is another common problem observed when using an implant. Five to 20%contracture rates are published in the literature. Textured prosthesis seem to give a lower rate of capsularcontracture than smooth envelope.Surgical proceduresWhen a conservative treatment is not recommended, a mastectomy with prosthetic immediate breastreconstruction is the first choice in our experience. This is the simplest procedure and requires theminimum hospital stay. The use of myocutaneous flaps is necessary when the local thoracic or generalconditions do not allow the use of simple implant or when such simple reconstruction risks to end up witha poor cosmetic result.Delayed Breast Reconstruction Using ProsthesisThis technique was the outset of the breast reconstruction. It was proposed, in the past, for mastectomisedpatients after a certain delay free of disease. This delay was decreased progressively down to severalmonths and nowadays the immediate breast reconstruction is more frequent than the delayed in our series.This technique is indicated is cases presenting with adequate skin and muscle coverage after mastectomy.A good cosmetic result can be obtained in cases of small nonptotic breasts. It can also be used in thewoman with larger ptotic breast, but symmetry can only be achieved with reduction or pexy of the otherbreast (photos l and 2). The contraindications are pectoralis muscle damage, tight skin closure and specialattention should be given to previous thoracic wall radiotherapy.The reconstruction is performed through an incision along the mastectomy scar then the pectoralis majoris undermined. A pocket is created behind this muscle medially and behind the serratus anterior musclelaterally and a definite prosthesis is inserted after drainage. When the skin is well vascularized, it is possiblesometimes to insert the prosthesis subpectoral in the inner part and subcutaneously in the outer part.