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A picture of breast reconstruction in Taiwan

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.

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A picture of breast reconstruction in Taiwan

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  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 14/105 population in 2008 53/105 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日公佈行政院衛生署國民健康局【新聞稿】2008年10月17日公佈 Stage distribution between Taiwan and U.S.A. (2005) Taiwan U.S.A. 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 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. • 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) • p’t has an adequate abdominal subcutaneous fat and skin  a good candidate for either pedicled or free TRAM flap surgery • self-paid for reconstruction

  10. No significant difference of results was found between free and pedicle TRAM flaps. (Kroll et al, 1995; 237 cases) Pedicled TRAM flap patients are more aesthetically satisfied than those with free TRAM flaps. (Alderman et al., 2000; Clough et al, 2001) 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 2nd. & Fine NA. P.R.S. 2009)

  12. Zones Ⅰ & Ⅲ are the main parts for the reconstruction • 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)

  13. Originally presented photo is removed 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. (Chang KP, Lin SD, et al. Ann Plast Surg. 2001)

  14. Skin sparing mastectomy－Tothand Lappert, 1991 • a major improvement in breast reconstruction over the past couple of decades • Since 2001, skin sparing mastectomy • preserved native skin envelop →color and texture match of the reconstructed br. • 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

  15. Nipple-Sparing Mastectomy • 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 • 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%

  16. Criteria for Nipple-Sparing Mastectomy

  17. Necrotic Complications of NAC preservation p.s. different surgical technique ** periareolar incision; small areola 7; ptotically large br. 8.

  18. Originally presented photos are removed

  19. abdominal wall complications • DIEP, free TRAM 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; Scevola S. et al. Ann Plast Surg. 2002; Nahabedian MY. & Manson PM. Plast Reconstr Surg. 2002; Petit JY. et al. Plast Reconstr Surg. 2003) • 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; Nahabedian MY. & Manson PM. Plast Reconstr Surg. 2002; Alderman AK. Plast Reconstr Surg. 2002) • 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 • High acceptance rate • Psychological benefits - lessen the postoperative grief to the loss of the breast • One stage completion - reduce the overall cost, time and the 2nd anesthetic risk • Cosmetic benefits - better cosmetic results than those of the 2nd reconstructed one • 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=0.001 P<0.001

  24. Originally presented photos are removed

  25. Material (Feb. 1997 – Aug. 2011,KMUH、KMHK、CCH)

  26. Complications of 921 immediate pedicled TRAM flaps reconstruction

  27. Satisfactionwith the Reconstructed Breast（ ％, 2000-2010, 636p’ts ）

  28. Satisfactionwith the Reconstructed Breast（ 2000-2010, 636p’ts ） 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)

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

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

  31. 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-HorngLai Ping-Yen Tsai Ko-Kang Chen Thanks for your attention！ K.M.U. TW.

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