Effects of the Zhikang capsule on healing of the flap after radical breast cancer surgery.

This study aimed to investigate the effect and mechanism of trauma flap healing promoted by the Zhikang capsule after radical breast cancer surgery. The enrolled breast cancer patients were randomly divided into two groups: treatment and observation. The patients in the treatment group were treated with the Zhikang capsule in addition to the conventional dressing changes, while patients in the observation group underwent only the regular dressing changes. Serum samples of 98 breast cancer patients (with complete clinical data) who underwent modified radical mastectomy were collected and analyzed for expressions of transforming growth factor beta (TGF-ß) and basic fibroblast growth factor (bFGF). The drainage fluid amount and tissue necrosis rate were found to be lower in the treatment group than in the observation group. Moreover, bFGF expression in peripheral blood was higher in the treatment group than in the observation group. However, no significant difference was found between the two groups in the expression of TGF-ß in peripheral blood. In conclusion, Zhikang capsule is effective in promoting flap healing after radical breast cancer surgery, and the increase of bFGF expression in peripheral blood may be the underlying mechanism.

[Breast reconstruction following amputation for cancer].

BACKGROUND/AIM: Today, breast reconstruction is a widely accepted method in the treatment of breast cancer after modified radical mastectomy. Reconstruction methods are associated with an acceptable number of complications and reconstruction favourably impacts quality of life. The aim of the study was to present our experience in breast reconstruction. METHODS: We presented here a four-year experience with 84 patients with breast reconstruction after modified radical mastectomy. RESULTS: Implant reconstructions were most common, 44 (52.3%), with primary reconstruction in 31 (70.4%) and secondary in 13 (29.5%) women. Lattisimus dorsi flap (LDF) and implant were utilized in 32 (38%) of the patients, with primary reconstruction in 24 (75%) and secondary in 8 (25%) women. Transversal rectus abdominis myocutaneous (TRAM) flap was rarely used -- just in 8 (9.5%) patients and only for secondary breast reconstruction. Postoperatively, some early complications such as hematoma, seroma, infections and partial flap necrosis were observed in 10 (11.9%) patients. Late complications, such as implant rejection, hypertrophic scarring and hernias at the flap elevation site, were noted in 10 (11.9%) cases. Implant loss occurred in 5 (5.9%) cases. All the complications were successfully managed, and patients rated their reconstruction as follows: excellent, 49 (59%) cases; very good, 20 (24%), and good, 14 (16.8%). In one case, disease progression was observed 6 months after the primary breast reconstruction. CONCLUSION: Breast reconstruction is an acceptable method in the treatment of breast cancer in patients in the need for or with already performed mastectomy. The choice of reconstruction approach depends on the breast volume, patient's wish and experience of surgical team. Our results suggest the advantage of breast reconstruction with LDF with implant, since the technique is safe, complications relatively rare and easily manageable, and the results are excellent or very good in each woman.

Decreased muscle strength following management of breast cancer.

PURPOSE: To assess whether muscle strength, power and endurance at the affected shoulder were reduced in women treated for breast cancer. Secondly, we assessed whether muscle performance was explained by management or other symptoms. METHODS: Participants were 40 women (mean +/- SD: 56.7 +/- 11.6 yr) who had completed all treatments for breast cancer at least 6 m previously. We measured dynamic concentric strength at one repetition maximum (1RM), endurance at 90% 1RM, and power through a range of 40-100% 1RM for shoulder protractors, extensors and retractors. Strength and endurance, but not power, were measured for shoulder flexors. Additionally, maximal grip strength, passive shoulder range of motion and arm circumference were measured. Self-reported symptoms were recorded using a questionnaire. RESULTS: Shoulder protractors (p = 0.011), retractors (p = 0.007), and extensors (p = 0.009), but not flexors, were significantly weaker on the affected side compared to the unaffected side. Muscle power and endurance at the shoulder and grip strength were not impaired. Inter-limb differences in muscle strength were not explained by the surgical and medical management of the cancer. Self-reported weakness correlated poorly with our measures of muscle strength. CONCLUSIONS: Long-term weakness occurs about the shoulder secondary to treatment for breast cancer. Strategies to prevent weakness need to be considered.

[Breast reconstruction by DIEP free flap: a 30 cases experience]. / Reconstruction mammaire par lambeau libre DIEP : à propos de 30 cas.

PURPOSE: The purpose of this study was to analyse the surgical procedure and the complications in case of breast reconstruction by deep inferior epigastric perforator flap (DIEP). MATERIALS AND METHODS: This retrospective study concerns 30 cases performed between 2001 and 2005. The reconstruction was delayed (73%), immediate (3%) or realised after failed attempt to reconstruct the breast with implant or flap (27%). We studied perforator selection, operative time, total flap loss, partial flap loss, and postoperative complications. RESULTS: Flap was raised with one pedicle in 22 cases and with two pedicles in eight cases. The recipient vessels were the axillary vessels (70%), circumflex scapular vessels (27%), and the thoracodorsal vessels (1%). Mean operating time was 6h 17min for the one-pedicle flaps and 8h 43min for the double-pedicle flaps. We noted two total flap necrosis, four partial flap necrosis, one deep venous thrombosis and one pulmonary embolism. Postoperative abdominal hernia or bulge never occurred. CONCLUSION: Although the use of DIEP flap reduces morbidity of the harvest, long operative time and thrombosis complications cause significant morbidity. Therefore we only use the DIEP flap when other procedures cannot be performed.

A fisioterapia na disfunção motora do membro superior pós-mastectomia radical modificada / The physiotherapy on upper lim disfunction following modified radical mastectomy

Objetivo: Avaliar a importância da fisioterapia como tratamento a ser utilizado no restabelecimento da função membro superior homolateral em pacientes submetidas à mastectomia radical modificada. Método: Utilizando-se modelo estatístico de estudo de coortes, os autores analisaram 20 pacientes atendidas no Hospital Ofir Loyola submetidas à mastectomia radical modificada do tipo Madden, no período de março a julho de 2003. Dois grupos foram selecionados para o estudo. O Grupo Tratado (GT) com 10 pacientes que realizaram fisioterapia como tratamento adjuvante; Grupo Controle (GC), 10 pacientes sem fisioterapia associada. Avaliadas a amplitude de movimentos e a força muscular no membro homolateral à cirurgia. Utilizou-se o Risk Ratio e nível de significância com p<0, 05. Resultados: A fisioterapia foi efetiva em reduzir a limitação da amplitude nos seguintes movimentos: flexão e abdução de ombro (p=0,005 e p=0,032),.fllexão de cotovelo e punho (p=0,010 e p=0,0l0) com melhora da ~a muscular na flexão e abdução de ombro (p=0,025 ep=0,025) e extensão de punho (p=0,010). Conclusão: A fisioterapia constitui-se numa importante terapia adjuvante na melhora da função motora do membro superior homolateral em pacientes submetidas à mastectomia para tratamento do câncer de mama

Phantom breast pain as a source of functional loss.

Although physicians are aware of phantom limb pain, which can occur in up to 85% of patients who undergo amputation, and its potential effect on functional status, the presence of phantom pain after amputation of other body parts such as the breast and its effect on function may be less appreciated. We report the case of a 63-yr-old woman with multiple sclerosis who underwent a modified radical mastectomy for left intraductal breast carcinoma. After her mastectomy, she required a brief course of inpatient rehabilitation and was discharged from rehabilitation independent, with feeding, dressing, hygiene, and transfers. Two months after her mastectomy, she had difficulty with these tasks because of phantom breast pain. Accurate diagnosis of her pain and successful treatment resulted in a return to premorbid functional status.

Recovery of upper limb function after axillary dissection.

BACKGROUND AND OBJECTIVES: After surgery for breast cancer, data on the long-term impairment of upper limb activities of daily living (ADL) are scarce. The purpose of this study was to investigate the short- and long-term recovery of upper limb ADL function after surgery for breast cancer. METHODS: Seventy-six patients, who underwent either a breast-conserving procedure with axillary dissection (BCP, n = 45) or a modified radical mastectomy (MRM, n = 31), were included. The patients were assessed on the fourth postoperative day, after 3 weeks, and after 3 months. Shoulder mobility, arm circumference, and upper limb ADL (score from 1 to 7) were evaluated. RESULTS: In the early postoperative phase, a considerable decrease in shoulder mobility and the ability to perform upper limb ADL were observed. After 3 months, MRM patients had more limitations in shoulder mobility than BCP patients (shoulder flexion: 150 degrees vs. 126 degrees, respectively, P = 0.0001). In addition, upper limb ADL was still significantly impaired: MRM patients suffered from greater functional disabilities than BCP patients, ADL score 2.7 and 1.8, respectively (P = 0.037). Patients with axillary radiation experienced greater disability of shoulder mobility and ADL. CONCLUSIONS: Three months after surgery for breast cancer, impaired shoulder mobility, and ADL persisted in a substantial number of patients. Type of surgery and axillary irradiation contributed significantly to upper limb recovery. This observation warrants considering continuation of physiotherapy aiming to improve restoration of upper limb function.

Immediate breast reconstruction-impact on radiation management.

Breast reconstruction is an option for women undergoing modified radical mastectomy due to a diagnosis of breast cancer. In certain patients, breast reconstruction is performed by insertion of a temporary tissue expander prior to the placement of permanent breast implants. Some of these patients, following mastectomy, may require chest wall irradiation to prevent loco regional relapse. The compatibility of radiation and tissue expanders placed in the chest wall is of major concern to the radiation oncologist. Clinically undetectable changes can occur in the tissue expander during the course of radiation therapy. This can lead to radiation treatment set-up changes, variation in tissue expansion resulting in unwanted cosmesis, and deviation from the prescribed radiation dose leading to over and/or under dosing of tumor burden. At Howard University hospital, a CT scan was utilized to evaluate the status of the temporary tissue expander during radiation treatment to enable us to prevent radiation treatment related complications resulting from dosimetric discrepancies. CT images of the tissue expander were obtained through the course of treatment. To avoid a 'geographic miss' the amount of fluid injected into the tissue expander was kept constant following patient's satisfaction with the size of the breast mound. The CT scans allowed better visualization of the prosthesis and its relation to the surrounding tumor bed. This technique ensured that anatomical changes occurring during radiation treatment, if any, were minimized. Repeated dosimetry evaluations showed no changes to the prescribed dose distribution. A CT of the reconstructed breast provides an important quality control. Further studies with greater number of patients are required for confirming this impact on radiation treatment.

Shoulder movement after breast cancer surgery: results of a randomised controlled study of postoperative physiotherapy.

Breast screening programmes have facilitated more conservative approaches to the surgical and radiotherapy management of women diagnosed with breast cancer. This study investigated changes in shoulder movement after surgery for primary, operable breast cancer to determine the effect of elective physiotherapy intervention. Sixty-five women were randomly assigned to either the treatment (TG) or control group (CG) and assessments were completed preoperatively, at day 5 and at 1 month, 3, 6, 12 and 24 months postoperatively. The CG only received an exercise instruction booklet in comparison to the TG who received the Physiotherapy Management Care Plan (PMCP). Analyses of variance revealed that abduction returned to preoperative levels more quickly in the TG than in the CG. The TG women had 14 degrees more abduction at 3 months and 7 degrees at 24 months. Functional recovery at 1 month was greater in those randomised to the TG, with a dominant operated arm (OA) or receiving breast-conserving surgery. However, it was not possible to predict recovery over the 2 years postoperatively on the basis of an individual woman's recovery at 1 month postoperatively. The eventual recovery of abduction or flexion range of movement was not related to the dominance of the OA nor to the surgical procedure performed. The PMCP provided in the early postoperative period is effective in facilitating and maintaining the recovery of shoulder movement over the first 2 years after breast cancer surgery.

Development of the inframammary fold and ptosis in breast reconstruction with textured tissue expanders.

Tissue expansion has become the most important method for postmastectomy breast reconstruction. However, well-defined inframammary fold and ptosis are difficult to achieve with this technique. This study was performed to evaluate the inframammary fold and ptosis achieved in breast reconstruction using a textured tissue expander, later replaced by a textured implant. In ten postmastectomy patients, a textured tissue expander was inserted into a submuscular pocket. Every two to three weeks the volume of the expander was increased by about 30%. About three months after the last filling, the expander was removed and replaced with a permanent textured, gel-filled implant. The profile of the reconstructed breast was recorded before and after the tissue expansion, as well as before and after the change of the implant. The results showed that the inframammary fold did not move significantly upwards or downwards during the expansion period when a textured tissue expander was used. Waiting three months after the last inflation of the expander before replacing it with the permanent implant resulted in a more ptotic breast mound. Usually, however, no real ptosis was achieved, meaning that the angle between the lower part of the breast and the lower chest wall was more than 90 degrees. These findings indicate that a textured expander could help create a pronounced inframammary fold, but without ptosis. A three-month waiting period before inserting the permanent implant may improve the development of an inframammary fold.

[The early results of autogenous plastic reconstruction of the breast using the TRAM and LDM methods in patients with breast carcinoma. Transverse rectus abdominis muscle. Latissimus dorsi muscle]. / Ranni rezultati ot plastichna avtogenna rekonstruktsiia na mlechnata zhleza s izpolzvane na TRAM i LDM metodi pri bolni s kartsinom na mlechnata zhleza.

It is the purpose of the study to assess the early results of TRAM (transversus rectus abdominis musculocutaneous flap) and LDM (latissimus dorsi musculocutaneous flap) techniques used in mammary gland reconstruction following mastectomy in breast carcinoma patients. Over a two-year period (Nov 1995 through Nov 1997), nineteen patients presenting breast carcinoma undergo treatment. In ten immediate reconstruction of the breast is undertaken, and in nine the operation is deferred for varying periods of time. TRAM technique is used in 18 cases, and LDM--in one. The mean postoperative follow-up period is 12 months (range 1 to 24 months). Evaluation of results is done with a reference to local relapses and distant metastases, cosmetic outcome of the reconstruction and complications. There is conclusive evidence that in a considerable number of patients autogenous mammary gland reconstruction is practicable as totally complying with the oncologic tenet concerning life style improvement in this high-risk contingent of patients.

A comparison of morbidity from bilateral, unipedicled and unilateral, unipedicled TRAM flap breast reconstructions.

A large series of women who had undergone bilateral, pedicled TRAM flap reconstructions were compared with women who had had unilateral, unipedicled TRAM flap procedures to determine whether a bilateral TRAM flap breast reconstruction had significant additional morbidity. The records of all women who underwent either a bilateral or unilateral pedicled TRAM flap breast reconstruction through the Emory Clinic from 1987 to 1994 (n = 257) were retrospectively analyzed with respect to general, breast (fat necrosis, flap loss, and cellulitis), and abdominal (hernia, skin loss, and cellulitis) complications. By using logistic regression, risk factors for these complications were determined. The incidence of fat necrosis and partial flap loss was not significantly different among bilateral patients compared with patients with unilateral TRAM reconstructions (10.0 percent versus 12.6 percent, p = 0.64 and 3.8 percent versus 5.5 percent, p = 0.74, respectively). The rate of hernia formation in the bilateral TRAM flap patients (5.4 percent) was similar to that of unilateral patients (3.9 percent, p = 0.80). Significant factors for any complication in both patient populations included obesity, smoking, and prior irradiation. The type of breast reconstruction was not a significant factor for any breast or donor-site complication. A bilateral TRAM reconstruction showed a weak association with general complications. Review of the Emory Clinic experience with unilateral and bilateral pedicled TRAM flap reconstructions from 1987 to 1994 was able to detect no significant additional rate of complications for bilateral pedicled TRAM flap breast reconstructions compared with unilateral unipedicled TRAM flap procedures.

Serum creatine kinase in fasciocutaneous and musculocutaneous flap surgery.

The pre- and postoperative serum levels of creatine kinase (CK) were analyzed in 56 patients operated with three different breast reconstructive procedures. Thirteen patients were operated with the lateral thoracodorsal flap (LTD), 23 by the latissimus dorsi flap (LD), and 20 by the pedicled transverse rectus abdominis musculocutaneous (TRAM) flap. Nineteen patients in the LD and TRAM groups had received postmastectomy radiotherapy. The operations caused a significant rise in the serum levels of CK, and the highest levels were found on the first postoperative day: LTD, 5.4 microkat per liter; LD, 8.1 microkat per liter; and TRAM, 7.3 microkat per liter. There was no significant difference in CK levels between the groups. The irradiated patients did not show increased CK levels when compared with nonirradiated patients.

Feasibility of postmastectomy radiation therapy after TRAM flap breast reconstruction.

BACKGROUND: Postoperative radiotherapy (PORT) has been shown to decrease locoregional failure rates in high-risk breast cancer patients following modified radical mastectomy. However, there had not been a study evaluating the effect of PORT in patients after transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction. Therefore, we evaluated flap viability, cosmetic results, and locoregional recurrence in patients who underwent TRAM flap reconstruction and PORT. METHODS: The charts of patients who had undergone modified radical mastectomy with TRAM flap reconstruction and PORT at our institution were reviewed. Patients were examined in the clinic and interviewed by telephone to evaluate their perceptions of the cosmetic result. RESULTS: PORT was delivered to 19 patients with TRAM flaps (3 pedicled and 16 free flaps) between 1988 and 1994. There were no TRAM flap losses as a result of either surgical or radiotherapy complications. Two patients developed fat necrosis, one with a pedicled and one with a free TRAM flap. Patients with pedicled TRAM flaps noted more volume loss in the breast after radiation therapy. Eighty-four percent of patients felt their overall cosmetic result was excellent or good; only one patient reported a poor cosmetic result. Local control was achieved in three of the four patients who received PORT for local recurrence. There was only one local recurrence among the 14 patients who received PORT because they were at high risk of local recurrence. CONCLUSIONS: These results suggest that PORT can be given safely to high-risk patients following TRAM flap breast reconstruction with excellent cosmetic results and good locoregional control.

Delayed shoulder exercises in reducing seroma frequency after modified radical mastectomy: a prospective randomized study.

BACKGROUND: Seromas and impaired shoulder function are well-known complications after modified radical mastectomy for breast cancer. Early postoperative physiotherapy is a common treatment to avoid shoulder dysfunction. The aim of this study was to evaluate if the frequency of postoperative seromas could be reduced, without increasing shoulder dysfunction, by delayed postoperative shoulder exercises. METHODS: In a prospective study 163 patients with breast cancer undergoing modified radical mastectomy were randomized to physiotherapy starting on postoperative day 1 or day 7. Patients were seen by the surgeons and the physiotherapists during hospital stay and in the outpatient department. Seromas and other complications were registered by the surgeons. The physiotherapists instructed the patients pre- and postoperatively and assessed shoulder function. RESULTS: There was a significantly higher incidence of postoperative seromas in the group of patients that started physiotherapy postoperative day 1 (38%) compared to the group that started physiotherapy postoperative day 7 (22%) (p < 0.05). There was no significant difference between the groups in the late outcome of shoulder function. CONCLUSION: The incidence of seromas after modified radical mastectomy for breast cancer is reduced by delaying shoulder exercises one week postoperatively. Earlier postoperative physiotherapy is not necessary to avoid impaired shoulder function.

Breast reconstruction by expansion and advancement of the upper abdominal flap.

Inspired by successful reconstruction obtained using the Lewis-Ryan lower thoracic advancement flap to rebuild missing breast, we have adapted that extremely simple technique to prior serial expansions, in order to create more natural mounds, better defined submammary folds, and when possible, some grade of ptosis, without additional, new scarring. The procedure is introduced and compared to other such flaps as the TRAM and the latissimus dorsii. In our series, 30 patients were evaluated according to the quality of the final results, and the most frequent complication are pointed out and discussed.

[Psychosocial acceptance of surgical interventions of the breast in oncological gynecology]. / Psychosoziale Akzeptanz mammachirurgischer Eingriffe in der Gynäko-Onkologie.

In a retrospective analysis of 197/600 women (33%) treated for primary breast cancer at the Department of Obstetrics and Gynecology at the University of Münster (1984 to 1994) the psycho-social acceptance of mastectomy vs. breast conservative treatment (BET) was evaluated. Mean age was 59 years (range, 31-87 yrs.). BET was performed in 58% (n = 114), modified radical mastectomy (MRM) in 42% (n = 83). Reconstructive surgery after MRM was performed in 40% (n = 33) either as primary procedure in 39% (n = 14) or as secondary procedure in 61% (n = 20). In addition to somatic patterns, features of pre- and postoperative coping, individual psycho-social burden, cosmetic results, contentment of treatment, social rehabilitation and quality of life were evaluated. Performance status and quality of human relations are discussed. In terms of psycho-social acceptance the results of BET are in general not superior to MRM at a mean follow-up of six years. Coping and postoperative quality of life are almost similar within the two groups. Although the alteration of body image after BET is less compared to MRM, the psychologic burden of postoperative radiotherapy and the fear of local recurrence are experienced worst compared to all other features analyzed after BET.

Patients' psychological and cosmetic experience after immediate breast reconstruction.

Immediate breast reconstruction was introduced in 1990 at the Karolinska Hospital. A semistructured interview with 20 patients operated on between 1991 and 1994 was undertaken to evaluate patients' degrees of satisfaction regarding pre-operative information, the need for psychological support and the opinion about the cosmetic outcome. During the pre-operative period, 18 patients felt that they were engaged in the decision-making whereas two patients felt that the surgeon alone was responsible for the decision. Regarding pre-operative information given, 7/20 were satisfied, 5/20 were mostly satisfied, 5/20 were unsatisfied and 3/20 had no opinion. During the early post-operative period (<3 months), five patients felt anxiety or depression and 10 patients felt a need of additional psychological support. Within 6 weeks 19/20 patients returned to their occupational level. During the late post-operative period (>3 months), 19/20 patients were generally satisfied with the reconstructive procedure. Eight patients thought the final result exceeded their initial expectations and 11/17 accepted the new breast as an integrated part of their body. The results confirm that immediate breast reconstruction plays an important role in the surgical management of breast cancer. The need for pre-operative information and continuous psychological support in terms of an empathetic behaviour cannot be underestimated.