Sunday, 23 May 2010

Breast Surgery

Breast Surgery involves surgical procedures to remove lesions (breast cancer or benign lesions) and procedures to modify the shape and contour or to reconstruct it after removal due to cancer.

Breast lesions should be first investigated by a general surgeon and a radiologist, followed by a histopathologist, once a biopsy specimen of the breast lesion is taken.

The treatment of breast cancer is best done by a general surgeon, specializing in breast oncology. The treatment of breast cancer involves the combination of 3 modalities: surgery, chemotherapy & radiotherapy.

After the completion of breast cancer treatment, follows breast reconstructive surgery. The reconstruction is best done by a Plastic & Reconstructive surgeon specializing in breast reconstructive surgery. The reconstruction is done in 2 ways:

-preformed silicone implants are used now days. Modern silicone implants have a thick capsule & roughened surface to prevent rupture & migration or displacement. Despite rumours, large statistical analyses have shown no association between silicone and cancer and/or connective tissue diseases.

2. Autologus tissue
-a person's own fatty tissue is harvested to reconstruct a breast mound. It is only for the shape or looks and there is no functional significance of this reconstructed breast. The surgery may take a longer time than when inserting an implant. Donor site morbidity may be unacceptable to some patients.

Other surgical procedures on the breast incudes:

1. Lumpectomy (removal of a lump within the breast)

2. Mastectomy (removal of the entire breast tissue)
3. Radical Mastectomy (extensive removal of breast as well as other nearby tissues and all the lymphnodes drainning the breast)

4. Breast reduction (reducing the size of the breast by partial mastectomy)

5. Mastopexy (breast lift or lifting a ptotic or dropping breast to make it pointed))

An Example of Wide Excisional Biopsy or Lumpectomy:

A punch biopsy or narrowed lumpectomy may disperse the tumor from the nidus (center) & accelerate tumor growth & infiltration to surrounding, normal tissues. It may be safer to do a wide, excisional biopsy through a 'peri-areolar' & axillary incision, to hide the scars.

*'Peri-areolar' incision/approach

*Lumpectomy with good margin

*Examination of specimen


*After 1 Month

Dr. Mol has learnt the art of breast surgery from Japan's number one breast reconstructive surgeon, Dr. Nohira Kunihiko (Director, Soshundo Plastic Surgery Clinic, Sapporo, Japan).
Further Notes on Silicon, Silicone & Autologus tissue
Let me clear some aspects of the above topic. Silicones are widely used medically. In the field of plastic surgery (cosmetic or aesthetic or esthetic surgery), they are used as:
1. Breast implant
2. Facial implants (chin, nasal etc.)
3. Fillers (injected straight under the skin to modify the contour)
4. Dressing (compression sheets applied straight onto scars to prevent
and/or treat hypertrophic scars & keloids)

Before going further, lets define some terms:

Silicon:Silicon (Si) is a metal in the same column as carbon in the periodic table. It is the most abundant element on earth and does not occur naturally in its pure metallic state.

Silica (SiO2) in its crystalline form is common sand or quartz.

Silicate:Negatively charged (anionic) form of silica eg. [Si2O7]6" or other compunds of Silicon eg. fluorosilicate (SiF6)2-. In one form it attracts water molecules (hydroscopic) so it is placed in containers of dried food as a white, small packet, labelled 'do not eat' to keep them dry.

Silicone: (R2SiO)n, where R=organic groups such as methyl, ethyl, and phenyl.The class of substances known as silicones are polymers of silicon and oxygen. There are as many forms of silicone. Dimethylsiloxane=(C2H6OSi)n where n is typically >4, is the building block for most medical-grade silicone products, including breast implants. It can be made extremely pure and modified into products with a multitude of characteristics (various viscosities to hardness).

Why use silicone?

Because it is easier for the surgeon. They come in ready-made sizes, shapes & textures so it is easy & quick to apply or insert.

What are the problems?

It is a common rumor that silicone is associated with certain illnesses, including breast cancer and connective tissue disorders (also referred to as autoimmune diseases such as lupus, scleroderma, and rheumatoid arthritis).

Large scientific trials have disproved such rumors:

1. Eherenfeld M., Shoenfeld Y, Bar-Meir E. Silicone gel breast implants and connective tissue disease--a comprehensive review. Autoimmunity, June 2003, vol.36 no.4, pp.193-197(5)

However, there are a group of few, unfortunate individuals who display some kind of unfavourable results. The causes could be divided into 3 groups:

1. The surgeon (not skilled enough or human error during placement)
-hematoma, Infection, skin necrosis etc.

2. The material: (modern versions of silicone are tough, well textured, shaped & easily integrates with surrounding tissue).
-rupture (when they rupture, the fluid silicone escapes the firm capsule into the surrounding tissue & may calcify & become as hard as a rock)
-migration (moves around & may lodge in an undesired location/position) etc.

3. The individual-Chronic inflammatory reaction which leads to 'capsular contracture', displacement of the implant to nearby structure or protrusion through the skin. Not only this but it may be associated with other symptoms such as pain, irritation etc. The individual tends to blame all other medical problems, at that time to the silicone (personally, I think it is a kind physical & psychological rejection of the foreign substance).

Individuals who suffer from such problems are really shocked & they make alot of 'noise' using the media, such as this website:

If there are no 'rejection' then the silicone implant may last/stay 20 or more years some say a life time. But it is hard to predict which patient will undergo 'rejection' & which will not.

Autologus tissue can be used to replaced all such procedures done using silicone implants, however the problems are:

1. Time consuming (takes too long & may be tiresome to harvest the tissue eg. when using autologus abdominal fat & skin as a 'flap' to reconstruct the breast, it takes about 6-7 hours for 1 breast)

2. Donor site morbidity (pain, scar, loss of muscle function etc.)

3. General anaesthetic problems (most silicone implants are inserted with mild sedation & local anaesthesia in the form of 'tumescent' meaning diluted local anaesthesia to increase the volume or coverage and minimize systemic complications).
4. Surgical complications (blood loss, wound infection, hernia formation at donor site etc.)

For the time being, the use of silicone is increasing, especially in the developed world.

I hope I've cleared some doubts regarding silicone implants.

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