[Breast reconstruction: a possible balance between oncological therapy, reconstructive methods and the patients].

BACKGROUND: Based on their experience of oncological surgery and wishing to respond to the patients' reconstructive requirements, the authors analyse the damage caused by medical therapy (chemo-hormone therapy and radiotherapy) in terms of reconstructive techniques; they aim to establish whether the tissues used in reconstruction interfere with the diagnosis and treatment of recidivations and to identify the best reconstructive strategy in relation to "timing"; lastly, they examine the possibility of realising a cosmetically improved breast. METHODS: A 2-year retrospective study was made during which 3 patients underwent immediate reconstruction using expanders (including 2 with bilateral reconstruction) and 1 patient underwent postradiotherapy differed reconstruction; all patients were followed up for a maximum of 4 years. The following surgical methods were used to improve cosmetic results: 1) conservation of the pectoralis minor which was turned sideways to create the muscular pocket; 2) costal and sternal disinsertion of the pectoralis major; 3) the implant was covered with the muscular pocket in the upper quadrants and with subcutaneous tissue in the lower quadrants; 4) realisation of a mammary groove; 5) immediate mastopexy of the surviving breast. All patients underwent intraoperative and postoperative polychemotherapy. RESULTS: At present (January 1997) none of the patients treated shows signs of locoregional recidivation or general metastases. Complications were observed in the form of subacute infection of the prosthetic flap exposing the expander and infection of the suture material used to reshape the breast in contralateral mastopexy in the patient undergoing reconstruction after radiotherapy. When evaluating the cosmetic results, scar diastasis varied in all patients. Smoothing of the scars, slight implant distortion observed echographically, grade 2 contraction of the periprosthetic capsule were assessed using Baker's scale and all patients were found to be grade I or II. In the light of these results and their personal experience, the authors then analyse, with reference to the literature, the effect of radiotherapy on reconstruction using tissular expansion, the effect of chemotherapy on reconstruction using expansion or autologous implants; the combined effect of radio and chemotherapy on reconstruction using autologous implants or tissues. Timing and the difficulty of diagnosis locoregional recidivation are also discussed. CONCLUSIONS: The authors fully agree with the need to carry out immediate reconstruction, when indicated (above all in bilateral reconstruction) using implants since it is simpler. Chemotherapy does not interfere with the expansion process whereas, if it is deemed necessary to use radiotherapy, it is certainly better to undertake reconstruction using autologous tissues. For special reconstruction methods (replacement of the expander, differed reconstruction with expander), greater use should be made of the day hospital, or better still office surgery.