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ORIGINAL ARTICLE
Year : 2022 | Volume
: 18
| Issue : 7 | Page : 1988-1993
Study on short-term cosmetic effects and quality of life after breast cancer modified radical mastectomy combined with one-stage prosthesis implantation
Hongxia Yan, Peng Gao, Xiangyi Kong, Jianjian Wei, Yi Fang, Jing Wang
Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
Correspondence Address:
Jing Wang
Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021
China
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/jcrt.jcrt_1217_21
Background: This study investigated the reconstruction effect of skin-preserving breast cancer modified radical mastectomy combined with one-stage breast prosthesis implantation in female patients to analyze relevant factors and observe the effect of prosthesis reconstruction on short-term breast satisfaction, psycho-social functions, and quality of life (QOL) in patients with breast cancer after the operation.
Methods: Patients were divided into two groups based on the reconstruction effect (an excellent effect group and a good and general effect group). Patients' short-term cosmetic effect on the breast after breast cancer modified radical mastectomy combined with one-stage breast prosthesis implantation was prospectively followed up to analyze influencing factors. At post-operative 6 months, the breast satisfaction dimension, psycho-social dimension, upper limb breast health dimension, and surgical satisfaction dimension in the prosthesis reconstruction module in the BREAST-Q scale were used for follow-up evaluation.
Results: The excellent rate of prosthesis reconstruction was 91.3%. A significant correlation was observed among the reconstruction effect, implant volume, and number of children born by the patient (P < 0.05). The correlation with age, BMI (body mass index), operation time, nipple and areola retention, operation method, and incision was not statistically significant (P > 0.05). At post-operative 6 months, the Breast-Q score was significantly different in the overall breast satisfaction dimension and outcome satisfaction dimension between the two groups (P < 0.05).
Conclusion: Breast cancer modified radical mastectomy combined with one-stage breast prosthesis implantation can not only fulfill patients' physical aesthetic needs but also positively affect their psychosocial behavior to improve post-operative QOL.
Keywords: Breast cancer modified radical mastectomy, breast-Q score, cosmetic effect, one-stage breast prosthesis implantation
Authors Hongxia Yan, Peng Gao, Xiangyi Kong contributed equally to this article.
> Introduction
Breast cancer is a common malignant tumor in women, occurring more frequently in younger women annually.[1],[2] Although radical mastectomy is currently a commonly used treatment, either radical mastectomy or partial mastectomy in breast-conserving surgery causes loss of the breast and changes in appearance, which lead to significant trauma and psychological impact in women. However, the survival of patients is constantly increasing because of the gradual improvement of therapies for breast cancer. In treating breast cancer, physicians should also consider the impact of quality of life (QOL) and breast loss on patients' psychology. Breast reconstruction reserving the skin, nipple, and areola after radical mastectomy is an important method to immediately satisfy patients' physical problems in breast surgery. Currently, breast reconstruction based on prosthesis is a primary reconstruction method[3],[4] because of its advantages such as a simple procedure,[5],[6] a reliable curative effect, few complications, rapid postoperative recovery, and a good cosmetic effect.[7] In addition, one-stage prosthesis implantation immediately after mastectomy restores the appearance of the breast, relieves the psychological and social pressure, and improves the QOL of the patient.
With the continuous advancement of surgical techniques, surgeons are focusing more on understanding patient-reported outcomes (PROs) and patient satisfaction following breast reconstruction. Currently, there is extensive research on the breast reconstruction effect and post-operative QOL in foreign countries for domestic patients whose breast dimensions, aesthetic concepts, and cultural adaptability are different from those of foreign patients. However, there is still a lack of research on the reconstruction effect and follow-up of QOL of patients immediately after radical mastectomy for breast cancer. Therefore, in this study, patients were prospectively followed up using the Breast-Q scale to provide further guidance for breast surgeons and patients with breast cancer.
> Subjects and MethodsThis study was approved by the National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences, and Peking Union Medical College institutional review board. All subjects provided written informed consent for participating in this study.
Inclusion and exclusion criteria
Inclusion Criteria:
The patient has a strong desire for breast reconstruction;Breast cancer has been confirmed by pre-operative or intra-operative pathology;The patient has no operative contraindication and no significant prolapse in the contralateral breast;There is no adhesion between the tumor and chest muscle and skin;The skin on the affected side is intact.Exclusion Criteria:
Patients who had received delayed prosthesis implantation;Patients who had received latissimus dorsi skin flap graft and prosthesis implantation;Patients who had received prosthesis implantation on both sides;Patients who had refused for follow-up and failed to cooperate with this study.Therapies
Patients' intention to undergo breast reconstruction was learned about. The clinical classification of breast cancer and the status of axillary lymph nodes were evaluated for patients with reconstruction intention. Patients' breast morphology was screened to ensure that there were no problems such as nipple depression and excessive droop that seriously affected the post-operative appearance and quality. The base width and height of the breast were measured for patients screened out to determine the size and type of the implant.
Patients underwent radical mastectomy combined with one-stage breast prosthesis implantation under general anesthesia. During surgery, all regulations for hygienic prosthetic surgery were followed meticulously to reduce the possibility of bacterial contamination. Patients with no cefazolin allergy received one prophylactic dose of an antibiotic 30 min before surgical incision and two doses in the 24 h after surgery. The specific procedures were as follows: the operative incision depended on the location of the tumor, whether there was local scar removal before the operation, and the cosmetic effect. Different incisions were made as decided by the operator. A radial incision along the nipple and areola or a transverse incision was made along the anterior folds of the axilla. The incision was approximately 10–15 cm long. The skin was cut to free the subcutaneous gland. The thickness of the skin peeled was approximately 0.3–0.5 cm to the mid-line on the inner side, to the outer margin of the latissimus dorsi on the outer side, and to the subclavian 1.5 cm on the upside and costal arch on the downside. Removal of the fascia pectoralis was decided by the tumor. The gland was removed from the axillary sentinel lymph nodes and sent for frozen pathology. Axillary lymph node dissection (ALND) was decided based on the pathological results. The distal resection margin of the nipple and areola was removed and sent for frozen pathology. The nipple and areola were reserved for patients with a negative result but removed for those with a positive result. The prosthesis was implanted as follows: the posterior space between the pectoralis major and part of the serratus anterior was freed to the original superior border of the breast on the upside, to the mid-axillary line on the outer side, to the sub-mammary fold of the breast on the downside, and to the lateral margin of the collarbone on the inner side. The inferior margin of the pectoralis major was detached, and the prosthesis was implanted below the pectoralis major. Biological or synthetic meshes were implanted to the inferior margin and lateral border of the pectoralis major. The mesh can directly support the implant so that the skin can avoid the negative consequence of the internal pressure of the implant. It is also believed that it achieves a good-looking breast in the cosmetic outcome. Negative pressure drainage tubes were placed on the side of the sternum and in the axilla and were extracted from the anterior axillary incision. The skin was sutured, and pressure dressing was performed. The drains remained in place for at least 7 days until the output was <20 mL in 24 h.
On the first day after the operation, the dressing was changed and the blood supply in the flap and nipple was observed. The pressure bra was changed, and patients were given instructions about wearing it. The bra should be worn day and night during the first 6 weeks, after which it should be worn during the day and perhaps removed at night until 6 months after the operation.
Methods and indicators
The pre-operative plate of the BREAST-Q scale was used to evaluate patients with prosthesis reconstruction intention before the operation. The operation method and peri-operative management followed the standard treatment management procedures of our department. Relevant patients were followed up for 6 months after the breast reconstruction effect. Meanwhile, positive and lateral photographs of both breasts were taken. Two breast surgeons evaluated the breast shape according to the photographs taken during the follow-up visit to evaluate and grade the reconstruction effect. Regarding the evaluation criteria for the appearance and shape of the reconstructed breast, in this study, the Harris[8] evaluation criterion was used, and the reconstructed breasts were divided into four grades. “Excellent” implied that the reconstructed breast was similar to the breast on the healthy side in size and position and that patients were very satisfied; “good” implied that there was not much difference in size and position between the reconstructed breast and the breast on the healthy side, there was no significant difference after dressing, and patients were fairly satisfied; “general” implied that the two breasts were significantly asymmetrical and different even after dressing and that patients were unsatisfied; and “poor” implied that the reconstructed breast was seriously deformed.
BREAST-Q evaluation is a self-rating scale for patients and has excellent reliability and validity in evaluating the health-related QOL and satisfaction of patients who have received breast surgery.[9] As the dimensions of BREAST-Q can be used independently, clinical researchers can choose according to their own needs, reducing unnecessary information collection.[10] Therefore, in this study, two health-related QOL dimensions (mental health, including physical health of the breast and the upper limb) and two satisfaction dimensions (breast satisfaction and surgical outcome satisfaction) in this module were selected for the recovery phase of 6 months after the operation to evaluate patient's satisfaction with the breast reconstructed with prosthesis and the operation, symptoms of the upper arm and breast, and the effect of prosthesis reconstruction on their psychosocial behavior. The Q score of the BREAST-Q scoring system converted the performance in each dimension into an independent score between 0 and 100. The higher the score, the higher the health-related QOL or satisfaction in the corresponding dimension.[11]
Patients were divided into two groups based on the reconstruction effect (an excellent effect group and a good and general effect group). The basic information and evaluation before and after the reconstruction were compared between the two groups. The factors influencing the cosmetic effect of prosthesis reconstruction and the relevant dimensions influencing patients' satisfaction with prosthesis reconstruction were evaluated.
Statistical methods
Data were processed and analyzed using the software SPSS 25.0. Descriptive statistics were conducted on measurement data using mean and standard deviation. One sample t-test and independent samples t-test were performed for comparison between two groups. Incidence was used for descriptive statistics of enumeration data. The Chi-square test and Fisher's test were used for comparison between two groups. Differences were considered to be statistically significant at P < 0.05.
> ResultsGeneral data of patients
A total of 80 female patients were included in this study. All were pathologically diagnosed with breast cancer and were aged 26–59 (mean 42.30 ± 6.69) years. One patient had diabetes, and four had hypertension. Other general data are shown in [Table 1].
Effect evaluation and incidence of complications after prosthesis reconstruction
According to the Harris reconstruction standard, the reconstruction effect in this study was as follows: excellent 58 patients (72.5%) and good 15 patients (18.8%), with an excellent and good rate of 73 (91.3%) patients and a general rate of 6 (7.5%) patients. One patient (1.3%) had the prosthesis removed after the operation because of prosthesis rejection, which was evaluated as poor.
Regarding post-operative complications, five patients had limb swelling (6.3%) within 1 week after the operation; the swelling was alleviated the next morning by the timely guidance of nursing measures such as functional exercise. Three patients had subcutaneous hydrops (3.8%); the wound healed completely after surgical dressing change and suction of hydrops one to two times. Two patients had poor skin healing (2.5%). The skin healed after re-debridement and re-suture. One patient had capsular contracture (1.3%). One patient had poor healing because of prosthesis rejection (1.3%); the prosthesis was removed 50 days after the operation. Other patients had no complications, such as infection, necrosis of flap, displacement of prosthesis, and lymphedema of the affected limb, within 6 months after the operation.
Appearance effect of prosthesis and correlation analysis
Patients were divided into two groups based on the reconstruction effect (an excellent effect group and a good and general effect group). Fisher's exact test revealed a significant correlation between the reconstruction effect and number of children born (P < 0.05). No significant correlation was observed between the reconstruction effect and operation method, incision type, marital status, and whether the nipple and the areola were reserved, and the difference showed no statistical significance (P > 0.05). Quantitative analysis revealed a statistical difference in the reconstruction effect and implant volume between the two groups (P < 0.05). Age, BMI, incision length, number of lymph nodes dissected, duration of operation, and intra-operative amount of bleeding showed no significant differences between the two groups (P > 0.05; [Table 2]).
Table 2: Analysis of factors related to the effect of prosthesis reconstructionBreast-Q self-rating scale for patients
There was no statistical difference in overall satisfaction with the breast in our study (63.46 ± 14.88) and a previous large-scale study involving 1200 patients (58 ± 18) (P > 0.05).[12] Moreover, the psycho-social health dimension between our study (79.74 ± 17.61) and the previous study (71 ± 18) showed no statistical differerence (P > 0.05). Comparison of the sample groups revealed no statistical difference between patients with an excellent reconstruction effect and other patients before the operation (P > 0.05). At post-operative 6 months, the BREAST-Q self-rating scale revealed a statistical difference in the breast satisfaction dimension and outcome satisfaction dimension (P < 0.05). The psycho-social dimension and upper limb breast health dimension showed no statistical difference (P > 0.05; [Table 3]). Based on surgical outcome satisfaction, the results of 38 patients (47.5%) were similar to the expected results, and those of 39 patients (48.7%) were generally consistent with the expected results. However, 70 patients (87.5%) strongly agreed that reconstruction was better than no breast, but one patient (1.3%) expressed regret for receiving the operation. Moreover, 26 patients (32.5%) mentioned that the cosmetic effect could be further improved by micro-plastic surgery.
> DiscussionAnalysis of the overall short-term effect of the prosthesis
Prosthesis implantation and breast reconstruction immediately after breast cancer surgery improve the appearance of the breast and reduce the psychological trauma of the patient based on tumor removal and improvement in the survival rate of the patient. Therefore, post-operative breast aesthetics is also an important indicator of a successful operation.[13],[14] The excellent and good rate of breast reconstruction in patients in this study was 91.3%. There was no statistical difference in the breast satisfaction score between BREAST-Q self-rating scale for patients and the international large-scale study. Today, an increasing number of surgeons in China are observing that the QOL, body image, and psychosocial well-being are critically important to women after mastectomy. The BREAST-Q, which was introduced in 2009, has been widely used to evaluate PROs after breast reconstruction and can detect small clinically meaningful differences between individual patients and groups.
Regarding the factors that influence the reconstruction effect, breast size and symmetry are vital components of cosmetic evaluation after breast reconstruction. This study revealed a significant difference between the reconstruction effect and number of children born and the prosthesis volume between the two groups. After mastectomy, the prosthesis replaced the volume of the original breast and was placed in the posterior space of the pectoralis major. Because of its limited capacity, it is difficult for women with large cup sizes to obtain satisfactory outcomes. The greater the number of children born and the longer the lactation period, the more relaxed and the more saggy the breast. However, the reconstructed breast is rounder and more upright, and thus, the asymmetry is more obvious, affecting the cosmetic outcome. The results of this study were consistent with those reported by Wu Jiong,[15] who mentioned that patients with small- or medium-sized breasts without obvious sagging are more suitable for implant reconstruction. However, further studies are required to determine the breast size for which a more aesthetic effect can be obtained by reconstruction.
In addition to the results described in this study, an apparent problem with prosthesis is also a major cause of the poor appearance of the reconstructed breast because the anterior axillary filling is poor, resulting in depression in the external upper part of the breast. However, this study revealed no significant difference between the effect of prosthesis reconstruction and the number of sentinel lymph nodes, as well as whether ALND was performed. In addition to appearance satisfaction, the feedback on the patient's hand feeling is a vital factor. Irrespective of whether the appearance reconstruction is satisfactory, most patients stated that the hand feeling was hard, and some of them could feel a protrusion at a certain outer edge of the breast. This is the primary reason why patients believe that the reconstructed breast cannot integrate with its own tissues. Hence, it is necessary to further analyze more data in this regard concerning the type of prosthesis, surgical and reconstruction techniques, and incision locations. A longer follow-up visit is also necessary to observe how well the prosthesis integrates with the patient's tissues over time.
Effect of prosthesis on patients in the psycho-social dimension
The purpose of breast reconstruction is to restore the morphology and psychosocial function of the breast and reconstruct a satisfactory breast for patients.[16],[17] Therefore, it is important to measure the success of breast reconstruction in the psychosocial health dimension. This study demonstrated that there was no statistical difference in the psycho-social dimension between the two groups. Regardless of whether the shape was satisfactory, 87.5% of patients agreed that the reconstruction was better than no breast and had a positive attitude toward prosthesis reconstruction, which could increase their confidence. Prosthesis reconstruction had a positive impact on the psycho-social level of patients with breast cancer.[18]
In the reconstruction satisfaction survey, the results of 38 patients (47.5%) were similar to the expected results, and those of 39 patients (48.7%) were generally consistent with the expected results. According to patients, it is difficult to understand the exact effect of the reconstruction because of the lack of systematic knowledge support from aspects such as appearance and hand feeling. Without being cognitively and mentally prepared and because different people have different perceptions of beauty, some negative effects are imposed on psychological activity, especially in the case of complications or poor recovery. For patients with a poor shape reconstruction effect, it is important to focus more on their psychological state and emotional response, and the medical personnel should provide timely attention and support to such patients.
During the follow-up visit, although prosthesis reconstruction exerted a positive effect on patients' psychology, most patients stated that no difference could be noticed after dressing. Further analysis showed that there were still some patients who did not dare to look at their breasts and touch the reconstructed breasts. Therefore, the mirror image cognition of patients with the prosthesis to their appearance needs to be completed through further psychological intervention to complete the patients' self-identification and improve their QOL.
Effect of prosthesis reconstruction on patients' breast symptoms
This study revealed no statistical difference in the symptoms of the upper limbs and breasts of patients with the prosthesis, irrespective of the appearance effect of the reconstruction. The symptoms reported by some patients were primarily weakness of the upper limbs and movement of the arms. This may be related to the poor recovery of the affected limbs at home during the rehabilitation period. More research data are required to support whether this is related to the severance of the lower margin of the pectoralis major. The breast symptoms were primarily tightness and the feeling of being pulled in the breast, as well as the short-term tingling sensation that occurred occasionally; however, these feelings did not affect the patients' sleep and rest. The patients in this study did not suffer from persistent and severe pain in the upper limbs, ribs, breasts, and back.
Limitations of study and prospects
First, the follow-up period in this study was 6 months post-operatively. During this period, patients did not undergo radiotherapy. Thus, the effect of radiotherapy on the prosthesis cannot be evaluated. Second, the sample size of the included patients was relatively small, which might have caused statistical differences when comparing PROs. Third, as the patients were under continuous treatment and most patients had not resumed sexual life, this factor was not evaluated in this study. Furthermore, in terms of the comfort level of innerwear, because patients continued to wear shapewear that prevented the prosthesis from shifting after the operation, which caused a feeling of tightness and discomfort as a whole, it was difficult to evaluate the comfort level in ordinary innerwear in patients with the prosthesis.
Author contribution
Conceptualization, Hongxia Yan, Xiangyi Kong; Data Collection, Hongxia Yan, Jianjian Wei; Methodology, Hongxia Yan, Peng Gao, Xiangyi Kong; Supervision, Yi Fang, Jing Wang; Writing, Hongxia Yan, Xiangyi Kong. All authors have read and agreed to the published version of the manuscript.
Data availability
The data that support the findings of this study are available from the corresponding author upon reasonable request.
What does this paper contribute to the wider global clinical community?
Today, there is extensive research on the breast reconstruction effect and post-operative QOL in foreign countries for domestic patients whose breast dimensions, aesthetic concepts, and cultural adaptability are different from those of foreign patients. However, there is still a lack of studies on the reconstruction effect and follow-up of QOL of patients immediately after radical mastectomy for breast cancer. Therefore, in this study, patients were prospectively followed up using the Breast-Q scale to provide further guidance for breast surgeons and patients with breast cancer.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
This work was supported by the Natural Science Foundation of China (No. 81872160), the Beijing Municipal Natural Science Foundation (Key Project) (No. 7191009), the Beijing Municipal Natural Science Foundation (No. 7204293), the Special Research Fund for Central Universities, Peking Union Medical College (No. 3332019053), the Beijing Hope Run Special Fund of Cancer Foundation of China (No. LC2019B03), the Beijing Hope Run Special Fund of Cancer Foundation of China (No. LC2019L07), and the Golden Bridge Project Seed Fund of Beijing Association for Science and Technology (No. ZZ20004).
Conflicts of interest
There are no conflicts of interest
> References
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