Breast Surgery: a Problem of Beauty Or Health? Benditte-Klepetko, H.C

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Download date: 10 Feb 2019 Breast Surgery Breast Surgery

A Problem of Beauty or Health? A Problem or Health? of Beauty Heike Benditte-Klepetko Heike Benditte-Klepetko Breast Surgery – A Problem of Beauty or Health?

Heike Benditte-Klepetko This thesis was ﬁnancially supported by the University of Amsterdam.

Benditte-Klepetko, Heike Christina Breast Surgery – A Problem of Beauty or Health?

Thesis Universiteit van Amsterdam – with summary in Dutch ISBN: 978-94-6169-518-5

Layout: Optima Graﬁsche Communicatie, Rotterdam, The Netherlands Printed by Optima Graﬁsche Communicatie, Rotterdam, The Netherlands Cover: Nana, Niki de Saint Phalle (1930–2002)

Copyright: H.C. Benditte-Klepetko, 2014 No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior admission of the author. Breast Surgery A Problem of Beauty or Health?

ACADEMISCH PROEFSCHRIFT

ter verkrijging van de graad van doctor aan de Universiteit van Amsterdam op gezag van de Rector Magniﬁcus Prof. Mr. H.M. de Jong ten overstaan van een door het college voor promoties ingestelde commissie, in het openbaar te verdedigen in de Aula der Universiteit

op 21 Mei 2014

door Heike Christina Benditte-Klepetko

geboren te Langenhagen, Duitsland Promotiecommissie promotores: Prof. Dr. C.M.A.M. van der Horst Prof. Dr. M. Deutinger overige leden: Prof. Dr. M. Maas Prof. Dr. J.C.J.M. de Haes Prof. Dr. J.H.G. Klinkenbijl Dr. L.A.E. Woerdeman Dr. H.A.H. Winters

Faculteit Geneeskunde Aan mijn kinderen

Contents

Chapter I Introduction and aim of this thesis 9

Chapter II Hypertrophy of the breast: a problem of beauty or 37 health?

Chapter III Crucial aspects of smoking and wound healing 51

Chapter IV Psychosocial aspects in breast surgery 63

Chapter V Functional and ultrasound evaluation of donor site 77 morbidity after TRAM-ﬂap for breast reconstruction

Chapter VI Patient satisfaction after different techniques of breast 91 reconstruction

Chapter VII Correlation between MRI results and intraoperative 105 ﬁndings in silicone breast implants: the role of the linguine sign

Chapter VIII General discussion and conclusions 119

Chapter IX Summary 129

Chapter X Samenvatting in het Nederlands 135

Acknowledgment 141

Curriculum Vitae 145

Chapter I

Introduction and aims of this thesis

Introduction and aims of this thesis 11

Introduction

The female breast in culture and art Throughout the ages, the female body has been revered as a work of art and beauty and as a source of life, from which all people are born. The breast is one of the most predominant features of a woman and stands out as a symbol of womanliness and livelihood1. The way how the breast is viewed throughout history is a direct reflection of the views of women of time and life. In European pre-historic societies, sculptures of female figures with pronounced or highly exaggerated breasts were common, symbolising fruitfulness and nourishment. A typical example is the so called Venus of Willendorf2, one of many Paleolithic Venus figurines with ample hips and bosom (fig.1).

Artefacts such as bowls, rock carvings and sacred statues with breasts have been recorded from 15,000 BC up to late antiquity all across Europe, North Africa and the Middle East.

In Ancient Greece there were several cults worshipping the “Kourotrophus”3, the sucking mother, represented by goddesses such as Hera and Artemis. Neverthe- less, the worship of deities symbolised by the female breast in Greece became less common during the ﬁrst millennium. Classic Greek society praised masculinity and repressed femininity. Woman in art were covered or portrayed in postures that were intended to express shyness or modesty4. A popular legend at the time was that of the Amazons, a tribe of ﬁerce female warriors who socialised with men only for procreation and even removed one breast to become better warriors (the

Figure 1: Venus of Willendorf 12 Chapter I

idea being that the right breast would interfere with the operation of a bow and arrow)5.

With the rise of Christianity, the breasts and the flesh in general were discouraged from being exposed. Medieval Christian stories focus on the breast milk of the Virgin Mary as being the most holy and miraculous of fluids4. It was not until the fourteenth century and the Renaissance that this began to change. As people became more frivolous, clothing became more revealing, and the neckline lowered to show cleavage6. In the seventeenth century, the breast once again became the predominant center of female attractiveness, being a symbol of power and wealth6. After the French Revolution an outpour of emotional awaking occurred and inde- pendence and freedom of expression lead to a decade of naturalism where breasts became symbols for emotion and naturalism4. This symbolism is well documented in the famous painting of Eugene Delacroix (“La Liberte guidant le peuple” from 1830), in which “Liberty” is symbolised by a bare-breasted robust woman holding the “La Tricolore” (fig 2)7.

When this Romanticism calmed down the proper display of the breasts and waists through corsets became an important part of fashion society4. Nevertheless, due

Figure 2: “La Liberte guidant le people”, Eugene Delacroix 1830 Introduction and aims of this thesis 13 to the physical restrictions of women by corsets, there was a growing opposition to this phenomenon at the turn of the century.

During World War I women’s roles in the work force increased. In 1919 women acquired the right to vote in the United States and there was a growing belief that women were able to do almost anything a man could do. Therefore breasts as a sign of femininity were bided down to emphasise the less gender based roles in the society4. After the chaos of World War II, people again looked for stability and fertility. Therefore the female breasts once again became popular as a symbol for prosperity. During the rise of motion pictures big breasts were viewed as symbol of sexuality in contrast to small breasts, which were associated with upper class sophistication and wit.

Based on this a period of rebellion started in the 1960’s and 70’s. One of the best- known aspects of the early Women’s Liberation Movement those days was the “bra burning”8, a form of liberation to make men face up to the reality of the breast by freeing it from it’s fantasy underpinnings. This symbolic act was meant as a serious criticism of the modern beauty culture, of valuing women for their looks instead of their whole self. When the hippie era calmed down, perfection of the body became an ideal, which was reﬂected by its frequent use in advertising. Large breasts came back in fashion and woman started to use breast implants to enlarge their breasts6. Nowadays large breasts emphasise gender differences, femininity and womanhood, reﬂected by a constantly increasing of number of aesthetic breast surgeries.

Meaning of the breast As history reflects, the cultural significance of the breast revolves around its use as a symbol both of fertility and sexual pleasure. Many women regard breasts as an important female secondary sex characteristics, and a factor in the sexual attractiveness of a woman9. For Freud, the breast was the first erogenous zone, from which a child should move on to the anal and genital stages of it’s developing sexuality. The baby’s complete satisfaction at it’s mother’s breast led to an identification with the mother, after which the baby needed to develop a sense of itself as a separate being. In adult life, a person therefore longs for the perfect pleasure of the breast, which has been taken away10. Beside this analytic point of view, the media is obsessed with portraying the “perfect body”: being thin and having perfectly shaped breasts. Women seeking to 14 Chapter I

reach this ideal are at risk of feeling uncomfortable to the extend of suffering from low self esteem and therefore disturbed body image. This might induce an impairment in psychological well being, social life and disturbed relationships resulting in a decreased quality of life11.

Disorders of the breast Anomalies 1. Polythelia/Athelia Accessory nipples appear along the natural mammary lines between the axilla and the groin. In contrast in case of athelia the nipples are imperfect or incompletely developed. This developmental breast abnormality affects slightly less than 2% of women and less than 1% of men around the world. The absence of the nipple- areola complex is often associated with other anomalies12,13,14.

2. Polymastia/Amastia Polymastia is a so called accessory breast, supernumerary breasts or mammae er- raticae12,13. Athelia as well as amastia might be associated with congenital anhidrotic ectodermal dysplasia, additional musculoskeletal abnormalities or dermoid cysts15. In 1841, Poland described a congenital deﬁciency of the Pectoralis Major and Minor muscles associated with syndactyly. This syndrome is a spectrum, often involving chest wall and breast deformity as well16.

3. Gynecomastia Gynecomastia is a benign enlargement of male breast glandular tissue. At least a third of males are affected at some time during their lifetime. Idiopathic causes exceed other aetiologies and relate to an imbalance in the ratio of oestrogen to androgen tissue levels or end-organ responsiveness to these hormones17.

4. Breast Hypertrophy The hypertrophy of the breast is an abnormal enlargement of the mammary tissue. There are many varieties including gigantomastia18, virginal breast hypertrophy19, juvenile gigantomastia20,21 and secondary breast hypertrophy22,23. There are a variety of hypertrophic conditions, which can affect women at various times in their lives. Hypertrophy can affect both breasts equally or only one breast causing asymmetry issues. The condition usually produces psychological and physical effects including: antisocial behaviour, introversion, lack of conﬁdence, insecurity, fear, anxiety, depression, suicidal thoughts, chronic fatigue and mal-posture as well as back pain; among others24-26. No deﬁnition exists what size or weight of a female breast is necessary to declare it to be hypertrophic27. Introduction and aims of this thesis 15

5. Breast Hypoplasia Micromastia is the post-pubertal underdevelopment of a woman’s breast tissue. Just as it is impossible to deﬁne ‘normal’ breast size, there is no objective deﬁni- tion of hypoplasia of the breast. It might be a congenital defect, related to trauma or it may be a more subjective aesthetic description. Self perceived micromastia involves a discrepancy between a person’s body image, and her internalised images of appropriate or desirable breast size and shape28.

6. Asymmetrical breasts Breast asymmetry occurs due to developmental differences29, congenital deformities, trauma or surgery

7. Tuberous breasts The tuberous breast deformity is described as a result from aplasia of one or more quadrants of the breast as well as skin shortage and herniation of breast tissue through the nipple-areola complex30.

Benign breast masses The most common benign breast conditions include ﬁbrocystic breasts, benign breast tumors, and breast inﬂammation. Depending on the type of benign breast condition and the patient’s medical situation, treatment may or may not be necessary.

1. Fibrocystic disease This mammary dysplasia is not a disease, but rather, it describes a variety of changes in the glandular and stromal tissues of the breast. Symptoms of fibrocystic breasts include cysts, fibrosis, lumpiness, areas of thickening, tenderness, or breast pain. Due to the thickening of the tissue fibrocystic conditions can sometimes make breast cancer more difficult to detect with mammography. According to the American Cancer Society, fibrocystic breasts affect at least half of all women and therefore, is the most common cause of breast lumps in women between 30 and 50 years old31.

2. Simple cysts Simple breasts cysts are accumulations of ﬂuid in the breast, which might cause discomfort, and in this case might need ﬁne needle aspiration31.

3. Galactoceles Galactoceles are milk-ﬁlled cysts that can occur in women who are pregnant or lactating32. 16 Chapter I

4. Fibroadenomas Fibroadenomas are one of the most common breast lumps in young women under the age of 30. Treatment may include careful monitoring to detect changes or surgical removal33.

5. Phylloides tumors Phylloides tumors are breast tumors with an overgrowth in ﬁbro-connective tissue, which are much less common than ﬁbroadenomas. On very rare occasions, they may be malignant. Therefore they need to be removed with one inch margin of surrounding breast tissue33.

6. Intraductal papillomas Intraductal papillomas are non-cancerous wart-like growths with a branching that has grown inside the breast. They often involve the large milk ducts near the nipple, causing bloody nipple discharge. Papillomas are diagnosed by galactograms and should be removed surgically34.

7. Granular cell tumors Rarely detected tumors in the breast, which require surgically removal along with a surrounding margin of breast tissue35.

8. Duct ectasia Duct ectasia, widening and hardening of the duct, is characterised by a thick green or black nipple discharge, typically affecting women in their forties and ﬁfties. The nipple and surrounding tissue may be red and tender. Duct ectasia is a benign condition but can sometimes be mistaken as cancer if a hard lump develops around the abnormal duct. Opalescent (clear) nipple discharge is often due to duct ectasia or cyst. Often, duct ectasia does not need treatment, or improves with the application of heat or antibiotic drugs. Occasionally, the affected duct is surgically removed by an incision at the border of the areola (the pigmented region around the nipple)36..

9. Fat necrosis Fat necrosis, a benign condition where fatty breast tissue swells or becomes tender, can occur spontaneously or as the result of an injury to the breast. Usually symptoms of fat necrosis subside within a month, however the affected area may be sometimes replaced with ﬁrm scar tissue. According to the American Cancer Society, some areas of fat necrosis can have a different response to injury. Instead of forming scar tissue an oily cyst might be formed37. Introduction and aims of this thesis 17

10. Mastitis Mastitis most commonly affects women while breastfeeding and is treated with antibiotics. If an abscess occurs surgical drainage is needed38. All these benign breast masses may require surgical removal and therefore may result in a disﬁgurement of the breast with subsequent impairment in aesthetic appearance. Regarding the importance of the breasts appearance for women’s body image and self-esteem women might look for plastic surgery corrections.

Breast Cancer Epidemiology Worldwide, breast cancer is the most common invasive cancer in women. Breast cancer compromises 22.9% of all invasive cancers in women. The number of cases worldwide has signiﬁcantly increased since the 1970s, a phenomenon partly attributed to modern lifestyles39. In 2008, breast cancer caused 458,503 deaths worldwide (13.7% of cancer deaths in women and 6.0% of all cancer deaths for men and women combined)40. Breast cancer is more than 100 times more common in women than in men. The lifetime risk for breast cancer in the United States is given as about 1 in 8 (12%) of women by age 95, with a 1 in 35 (3%) chance of dying from breast cancer41.

Table 1: Breast Cancer Incidence Europe 200643 18 Chapter I

The same numbers are given for the UK according to the data of the UK cancer research institute42. Prognosis and survival rate varies greatly depending on cancer type, staging and treatment. Five-year relative survival rates vary from 98% to 23%, with an overall survival rate of 85%40. According to the American Cancer Society, more than 230,000 women will be diagnosed with breast cancer annually in the United States, and more than 39,000 will die from the disease each year43. The highest incidence of breast cancer worldwide is found in Western Europe (85 per 100,000 females) with the highest incident in The Netherlands (121 per 100,000 females in 2006, table 1)42.

Treatment of breast cancer Depending on type and stage of the tumor, six types of standard treatment of breast cancer are being used: 1. Surgery 2. Sentinel lymph node biopsie and/or axillary dissection 3. Radiation therapy 4. Chemotherapy 5. Hormone therapy 6. Targeted therapy (i.e. monoclonal antibodies)

According to tumor stage and breast size, breast-conserving therapy like lumpec- tomies or partial resections of the breast followed by irradiation as well as mastectomies, are the gold standard in surgical therapy of breast cancer. About two thirds of women diagnosed with breast cancer will undergo breast conserving treatment and one third will elect to undergo mastectomy44.

These interventions may result in alteration of the breast’s shape and aesthetic appearance or even loss of the breast. The functional deﬁcits that occur as a consequence of mastectomy include the inability to breastfeed and loss of sensation of the chest. Loss of the breast mound alters the patient’s personal appearance and can make wearing some types of clothing problematic. The use of external prothesis to address these issues can be inconvenient and uncomfortable, particu- larly for a woman with large breasts. However, the most important consequence of mastectomy is the psychosocial effect of the physical and aesthetic deformity, which can include anxiety, depression and negative effects on body image and on sexual function45. Therefore reconstructive surgery, to remodel the breast, became an important part in treatment of breast cancer patients9,46,47. Introduction and aims of this thesis 19

Figure 3: “Beauty out of damage”, Matuschka 199349

An exception of dealing with the disﬁgurement was the art-work of the model and artist Matuschka in the early 90s. Her self-portrait “beauty out of damage”, showing herself after amputation of one breast, made the cover of the New York Times magazine in 1993 and subsequently won many prizes all around the world – for creating awareness of a “hidden” problem (ﬁg 3)48.

History of breast surgery Reduction mammaplasty In comparison with other surgical procedures concerning the breast, the history of reduction mammaplasty is relatively short. Hans Schaller, the so-called “barber” of Augsburg, is considered to be the first surgeon to have performed a reduction mammaplasty by breast amputation in 1561. The patient was a maid whose “breasts assumed such great proportions that she could not support them, neither standing up nor being seated”. Undoubtedly, his intentions were purely functional to relieve her physical symptoms without any further aesthetic considerations50. After general anaesthesia was discovered in the 19th century, the indications for breast reduction became more numerous. Till now the most common motivation for breast reduction surgery is to alleviate back and shoulder problems, neck pain and a whole range of other health and emotional problems caused by overlarge breasts. Difficulty in breathing, poor posture and chronic inflammations in the submammary fold are disorders among others that can be minimised or eliminated26. However, the growing acceptance of cosmetic and corrective plastic surgery to obtain a bal- 20 Chapter I

anced and more proportional body has greatly increased the popularity of breast reduction surgery. Women seeking breast reduction might have no physical needs but the desire to change their aesthetic appearance. Therefore, the medical necessity and, as a consequence the insurance coverage, are questioned by insurers as well as the general public26.

Breast augmentation In 1895, surgeon Vincenz Czerny performed the first reported breast implant emplacement when he used the patient’s autologous adipose tissue, harvested from a benign lipoma, to repair the asymmetry of the breast from which he had removed a tumor51. In 1899 Robert Gersuny experimented with paraffin injections, with disastrous results. Many other filling materials were tried with the same fatal results until 1961, when American plastic surgeons Thomas Cronin and Frank Gerow developed the first silicone breast implant. In due course, the first augmentation mammoplasty was performed in 196252. Since then, further development took place to increase the safety of breast implants. Nevertheless, in the early 1990s, breast implants became the subject of heated controversy as reports of women claiming their implants had seriously damaged their health became widely publicised in the media. As a consequence the FDA issued a ban on the use of silicone-gel filled implants for cosmetic aug- mentation53 after stating there was “inadequate information to demonstrate that breast implants were safe and effective”. During this controversy saline filled breast implants continued to be generally available for both breast reconstruction and augmentation. In the late 1990s, many studies reported no evidence of saline-filled and silicone- gel filled breast implant devices causing systemic health problems; that their use posed no new health or safety risks, and that local complications were “the primary safety issue with silicone breast implants”. They distinguished between routine and local medical complications like capsular contracture and systemic health concerns.”54,55 Due to this the FDA lifted its restrictions conditional upon accepting FDA monitoring under study conditions53. In other countries, like the UK and Spain, the ban was lifted in 1992 and 1996 respectively56. Since then, the number of breast augmentations or breast reconstructions using silicone breast implants increases continuously and finally silicone gel implants got re-approved by the FDA in 200656. Introduction and aims of this thesis 21

But, the next implant scandal emerged soon: after receiving reports of potential problems with PIP implants since 2002, The Medicine and Healthcare Products Regulatory Agency (MHRA) in the United Kingdom issued a Medical Device Alert through a press release for clinicians in March 2010, not to use the Poly Implant Pro- thèse (PIP) implant due to a higher rate of failure and local signs than other implants based on a non-medical grade silicone being used as filler in these substandard implants57. This safety scare over PIP has again generated heated discussion about cosmetic surgery, private and public responsibilities, and device regulation58, being the center of global media attention. The European Union’s Scientific Committee on Emerging and Newly Identified Health Risks (SCENIHR) was asked to enlighten the question of potential health risks of PIP breast implants and concluded the following; “In the case of PIP implants, when the limited available clinical information is taken together with the findings from tests of the physical and chemical properties of the shell and silicone, and of the in vivo irritancy test, some concerns are raised about the safety of PIP breast implants as the possibility for health effects cannot be ruled out.”59 As a result PIP implants were recalled in France and other countries. Subsequent studies not only reaffirmed PIP’s rupture prevalence to be higher than other brands of breast implants, but also recorded the media’s beneficial effect in improving the recall60. As a result the need of quality in control for prosthetic material gained importance even more. Effective quality control needs to keep in step with scientific progress as well as technical specifications. Currently obligatory implant registries are being implemented as a tool for bio-monitoring of breast implants, which increases transparency and quality control60.

As an alternative, techniques of transferring fat using liposuction and lipofilling have evolved and are being developed to augment and reconstruct the breast over the past 25 years61. In that time the technique has been criticised as it can lead to the fat dying, leaving cysts in the breast or calcification, which can be seen on mammograms and, it was thought, mimic cancer62-64. This was suspected to compromise breast cancer detection and therefore the American Association of Plastic and Reconstructive Surgery banned this technique in 198765. Only recently refinements in techniques and improved understanding of the science behind fat transfer have lead to more predictable results66. Autologous fat grafting has subsequently become a routine procedure: Its value and indications seem to expand continuously66-68. 22 Chapter I

The breast augmentation patient is usually seeking aesthetic improvement, while accepting the potential side effects associated with breast augmentation69. Their personality proﬁle indicates psychological distress about their personal appearance and their body70, with a high incidence of body dysmorphic disorders amongst this population71.

Breast cancer The earliest reference to the surgical treatment of breast cancer can be found in the “Edwin Smith Surgical Papyrus”, which originates in Egypt between 3000 and 2500 b.c.72. Throughout ancient times there was considerable controversy surrounding the surgical treatment of breast cancer. Hippocrates for instance questioned in 400 b.c. if patients with breast cancer might not live longer without excision of the tumor73. Not until the rise of surgery in the 16th century European surgeons began to develop different procedures in the surgical treatment of breast cancer. Jean Louis Petit (1674-1750), Director of the French Surgical Academy, is accredited with developing the first unified concept. Petit suggest that “the lymphatic gland should be removed” and “the mammary gland should not be cut into”74. In 1774 the French surgeon Bernard Peyrilhe advocated radical operative surgery. He first formulated this surgical concept, which is now widely connected to the name of the American surgeon William Stewart Halsted (1852-1922). This concept of radical resection has remained influential till now73. Halsted was influenced by the findings of the German pathologist Rudolf Virchow, who noted the invasive anatomy of breast cancer in the mid nineteenth century75. Following Virchow’s findings not only the tumor-containing breast, but also the underlying pectoral muscle and its ipsilateral axillary lymph nodes had to be removed en bloc76. After World War II, simple mastectomy and high-voltage radiotherapy was advocated to treat primary breast cancer. McWhriter was one of the first authors who published about the effectiveness of radiotherapy after mastectomy, laying the foundations for the use of radiotherapy in modern breast-conserving surgery77. In this context, the effect of Halsted’s radical procedures was questioned again: several large randomised prospective trials tried to answer this question. One of the most important trials was conducted by Veronesi et al. They were able to show that the local recurrence rate was higher after breast conserving therapy when compared to mastectomies, but this had no influence on the overall survival rate78. Nowadays the treatment of breast cancer is dependent on the stage of the tumor (TNM classification) and includes surgery (either breast conserving surgery or mastectomy), sentinel lymph node extirpation/axillary dissection, radiotherapy, Introduction and aims of this thesis 23 chemotherapy, hormone therapy and targeted therapy. Further studies are continuously undertaken to improve the outcome of breast cancer therapy79.

Breast reconstruction Recently, there has been an increased emphasis on improving quality of life for those afflicted by breast cancer. Breast reconstruction became an important tool to reduce the psychological trauma associated with disfigurement of the breast as mentioned above9,46,47,80. Therefore, the goal of reconstruction is to restore a breast mound and to maintain the quality of life without affecting the prognosis of recurrence of cancer81-83. The first attempt at a true breast reconstruction was in 1895. As mentioned above, Vincent Czerny, a professor of surgery in Heidelberg, is generally credited with the first autogenous breast reconstruction by transplanting a fist-sized lipoma from the patient’s flank into the breast51. In 1906, the Italian surgeon Tanzini had difficulty closing large wounds after the radical mastectomy. He developed a pedicled flap of skin and underlying Latissimus Dorsi muscle, which was transferred to the mastectomy defect, therefore becoming the first surgeon to use a musculo-cutaneous flap in breast reconstruction. However, due to Halsted’s hypothesis of the negative influence of breast reconstruction on the disease, his technique was soon to be forgotten84. Some of the techniques for breast reconstruction used during the first half of the 20th century included bisecting the opposite breast and using half as a pedicle for breast reconstruction. Sir Harold Gilles used a tubed abdominal flap method, which he developed in 1919, to perform his first breast reconstruction in 194284,85. Several others followed with excellent reconstructions, but the limiting factor became the need for several staged operations over a minimum of 6 months. These extensive procedures required multiple delays and transfers and often resulted in many significant scars. Frequently, the flaps would fail, and disappoint- ing results kept these flaps from gaining larger popularity. Neither the surgeon nor patient could recommend these early “reconstructions” to anybody. In the decades that followed, the Germans continued to lead the way. Hohler and Bohmert86 performed two-stage reconstructions utilising the thoraco-epigastric flap followed by insertion of prosthesis for routine mastectomies.

Implant reconstruction After Cronin and Gerow introduced silicone gel implants for breast reconstruction in the 1960’s, delayed reconstruction by inserting the implants became the typical method for many years52. In 1971 Snyderman and Guthrie were the ﬁrst to report on the use of a silicone breast implant placed under the remaining chest 24 Chapter I

wall skin immediately following a mastectomy84,87. This kind of breast reconstruction was limited by the deficit of skin resulting from radical mastectomies. Therefore Radovan introduced the use of tissue expansion in 198288. The disadvantage of this procedure is, that the tissue expander has to be removed and replaced by a silicone implant, which made further surgery needed. For this reason Becker developed a dual-chamber expander that had a silicone gel outer lumen with an inflatable inner saline lumen. This technique eliminated the need for a second-stage operation. Despite the difficulties to expand skin and reach a symmetric result, the longterm experience showed several drawbacks. The aesthetic appearance changed by time and long term problems with the implants, like deflation, capsular contracture or rupture occurred and made further surgery necessary89. This forced a rekindled interest in autogenous breast reconstruction.

Autologous reconstruction The first modern description of an autogenous reconstruction of the breast came toward the end of the 1970s. Several authors reintroduced and popularised the use of the Latissimus Dorsi musculocutaneous flap for breast reconstruction in one stage90-93. Due to the limited volume of the Latissimus Dorsi musculocutaneous flap it was - and still often is - used in combination with an implant to reach an appropriate volume. As an alternative though, Hokin and Sifverskiold94 introduced an extended Latissimus Dorsi flap without implant in 1987.

Even though the Latissimus Dorsi flap led to satisfactory results, its donor site left large scars with a tendency to contract and was linked to a risk of seroma forma- tion94. Attempts were therefore made to improve breast reconstruction techniques. Holmstrom performed the first abdominal muscle free flap for breast reconstruction in 1979101 and Robins subsequently described a vertically oriented skin-muscle flap with the Rectus Abdominis muscle pedicled on the epigastric superior vessels. This allowed for transplantation of larger tissue volumes to recreate a breast mound95. This technique was improved upon by Hartrampf et al.96,97 who introduced a Trans- versely oriented Rectus Abdominis Myocutaneous (TRAM) island flap, which was still pedicled on the superior epigastric vessels. This provided a more aesthetic result, as its direction enabled to close the donorsite like in an abdominoplasty. Despite disadvantages like an increased risk of abdominal wall herniation due to weakness of the abdominal scar and abdominal discomfort, this flap became the “workhorse” for breast reconstruction for many years98. Another disadvantage of the pedicled TRAM-flap was the high tissue-to-blood supply ratio, which was tried to overcome by using the deep inferior epigastric vessels, being the primary source of circulation to the Rectus Abdominis muscle99. Using the TRAM-flap as a free flap Introduction and aims of this thesis 25 based on the deep inferior epigastric vessels the blood supply proved to be more reliable with subsequent less tissue necrosis100. Despite improvement in flap survival, the donor-site morbidity remained a problem, even though just a small part of the muscle had to be sacrificed. To overcome this problem, a new technique of harvesting the abdominal tissue was suggested by Koshima102. He isolated the skin and subcutaneous tissue from the abdomen based upon vessels that perforate the Rectus Abdominal muscle without sacrifice of the muscle. As an evolution and refinement of breast reconstruction, this flap (Deep-Inferior— Epigastric-Artery-Perforator flap/ DIEAP-flap) was first used by Allen103 in 1994. The reduction of risk of abdominal wall herniation or bulging was combined with a unsurpassed freedom of design to give a sufficiently aesthetic as well as long last- ing result104,105. Since then, the microsurgical breast reconstruction techniques using perforator flaps have evolved into becoming the state of the art in reconstructive breast surgery after mastectomy.

As a result of this perforator flap concept, all over the body tissue can be taken, for instance not only from the abdomen, but also from the gluteal area (SGAP-flap106) or the upper legs (TMG-flap107). Preserving underlying muscles lessens postoperative discomfort making the recovery easier and shorter, and also enables the patient to maintain muscle strength long term.

Despite various techniques of breast reconstruction with autologous tissue or prosthesis, adipocyte tissue has been used more frequently in recent times108,109. The indications for lipofilling in breastreconstruction are postlumpectomy deformity, postmastectomy deformity, secondary breast reconstruction after flap or prosthesis reconstruction. In combination with vacuum assisted pre-expansion Khouri110 et al reported in 2009 about satisfying results in secondary breast reconstructions without previous flap or implant surgery.

The diversity of options for breast reconstruction enables surgeons as well as patients to ﬁnd the individual treatment for the patients need.

Number of surgical procedures The importance of breast surgery is reﬂected by the number of surgical procedures per year. According to the American Society of Plastic Surgeons, breast augmentation is the most frequently performed aesthetic procedure111, with 296,000 surgeries performed in 2010. Breast reconstruction is also under the ﬁve top reconstructive procedures in 2010 with 93,000 procedures a year. These numbers are constantly 26 Chapter I

Table 2: 2010 Top ﬁve cosmetic surgical procedures in the United States106

Table 3: 2010 Top ﬁve reconstructive procedures in the United States111

Table 4: 2010 Numbers of Reconstructive procedures in the United States111

increasing over the course of the last years111. Among breast reconstructions, those with implants are the most performed procedures in 2010. These numbers are shown in table 2, 3 and 4. Introduction and aims of this thesis 27

Financial impact In 2010 American women spent $992.432.214 on breast augmentations and another $49.589.719 on implant removals (table 5)111. Costs for breast surgery with a medical indication, like malformations or after breast cancer, are covered by health insurance. A breast reconstruction costs about $7.000 on average in the United States. This adds up to a total of around $650.000.000 per year in the U.S.. With an average of $7.500 per breast reduction the overall costs per year in the U.S. are $620.000.000111. These numbers show the high socioeconomic impact of breast surgery. Unfortunately, from other countries outside the United States, there are no reliable data available. Breast reduction is generally considered to be a reconstructive procedure and may be covered by the health insurance when it is performed to relieve medical symptoms. Although reduction mammoplasty is defined as being reconstructive in nature112, the general public and many medical professionals consider reduction mammoplasty to be more a cosmetic than a functional operation. As a result, insurers do not accept that symptomatic macromastia is a significant health burden. Un- fortunately, denials of insurance coverage and policy exclusions for breast reduction are becoming increasingly common in Europe as well as in the United States,113,114 and the justification for outright rejection of funding is often unknown115. Although previously published longitudinal studies showed that reduction mammoplasty will reliably provide the desired improvement in all symptoms and in the quality of a woman’s life24-26, discussion is ongoing about whether reduction mammoplasty is a cosmetic or reconstructive procedure.

Table 5: 2010 Average surgeons fee per type of cosmetic procedure in the United States111 28 Chapter I

Definition of Beauty Beauty is a characteristic of a person, animal, place, object, or idea that provides a perceptual experience of pleasure, meaning, or satisfaction. An “ideal beauty” is an entity, which is admired or possesses features widely attributed to beauty in a particular culture, for perfection. In its most profound sense, beauty may engender a salient experience of positive reflection about the meaning of one’s own exis- tence116. The characterisation of a person as “beautiful”, whether on an individual basis or by community consensus, is often based on some combination of inner beauty, which includes psychological factors such as personality, intelligence, grace, polite- ness, charisma, integrity, congruence and elegance, and outer beauty which includes physical attributes which are valued on a subjective basis. Bodily beauty can be defined as the deeply pleasurable experience of someone else’s or one’s body. The origins of interest in bodily beauty were explained by Sigmund Freud, the founder of modern psychology, as being sexual drives: through a transformation, sexual attraction is moved away from the primary sexual characteristics (reproduc- tive organs) and instead to the secondary sexual characteristics (e.g. women’s more rounded forms and breasts)117. Therefore many women regard breasts as an important female secondary sex characteristic, and a factor in the sexual attractiveness and a woman’s beauty. Beauty presents a standard of comparison, and it can cause resentment and dissatisfaction when not achieved. People who do not fit the “beauty ideal” may be ostracised within their communities109. The media play an important role in constantly presenting a specific “beauty ideal”. This perpetration of beauty standards has an immense effect on women’s body image and self esteem. Due to the resulting body image dissatisfaction more and more women are seeking plastic surgery to influence their beauty and therefore body image and self esteem.

Definition of Health According to the WHO110 “Health is a state of complete physical, mental, and social well being and not merely the absence of disease or infirmity”. In case of breast cancer the impairment of health is without doubt. The patients face a potentially life-threatening disease on one hand, on the other hand they have to deal with a resulting disfigurement of their body. Both, their physical, as well as their mental health are impaired. In other disfigurements of the breast, like hypertrophy of the breast or congenital deformities, the influence on physical health is less clear, while the disturbance of mental health by impairment of body image and self-esteem is more likely. Introduction and aims of this thesis 29

Figure 4: The factors inﬂuenced by breast surgery

The question if the indication for breast surgery is of medical or more mental nature is important regarding the insurance coverage of the costs. Medical insur- ances exclude cosmetic procedures from coverage even though they might have an impact on the patients mental health. While breast augmentations for aesthetic reasons are purely cosmetic, the corrections of i. e. congenital deformities or breast hypertrophy26 are being discussed. Another aspect of breast surgery is, that it might also have a negative impact on health. All kinds of surgery have a risk of complications, which might impair the physical as well as the mental health. In contrary a mental health disorder like body dysmorphic disorder might cause a disturbed self-perception. In this case surgery would not cure the disease but might even increase the underlying problem (ﬁg. 4)119

Aims and outline oft this thesis Breast surgery might result in improvement of physical and mental health of women. However, in contrary it might also impair physical and mental health due to complications or negative side effects. Therefore the aim of the study was to illuminate different factors inﬂuencing the impact of breast surgery on women with regards to health and beauty.

Summary of the main questions of this thesis 1. What is the impact of breast weight on the psychological and physical morbidity of women? 2. What are the complications after reduction mammoplasty and how much is this inﬂuenced by the smoking habit of the patients? 3. What is the impact of breast reconstruction on mental health and social well being of the patients? 30 Chapter I

4. Does breast reconstruction by use of autologous tissue from the abdomen impair patient’s physical health? 5. Does the choice of breast reconstruction make a difference on postoperative patient satisfaction or physical and mental health? 6. What is the role of MRI in implant rupture detection? Introduction and aims of this thesis 31

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90. Schneider WJ, Hill HL, Brown RG. Latissimus dorsi myocutaneous flap for breast reconstruction. Br J Plast Surg 30(4): 277-81 91. Mühlbauer W, Olbrisch R. The latissimus dorsi myicutaneous flap for breast reconstruction. Chit Plast (Berlin) 4: 27; 1977 92. McCraw JB, Dibbel DG, Carraway JH. Clinical definition of independent myocutaneous vascular territories. Plast reconstr Surg 60: 341-352; 1977 93. Bostwick J, Schlefan M. The latissimus dorsi musculocutaenous flap: a one stage breast reconstruction. Clin Plast Surg 7: 71-78; 1980 94. Hokin JA, Silfverskiold KL. Breast reconstruction without an implant: results and complications using an extended latissimus dorsi flap. Plast Reconstr Surg 79(1): 58-66; 1987 95. Robbins TH. Rectus abdominis myocutaneous flap for breast reconstruction. Aus N Z Surg 29(5): 527-30; 1979 96. Hartrampf CR, Scheflan M, Black PW. Breast reconstruction with a transverse abdominal island flap. Plast Reconstr Surg 69: 216-225; 1982 97. Hartrampf CR. Breast reconstruction with a transverse abdominal island flap. A retrospective evaluation of 335 patients. Perspect Plast Surg 1: 123; 1987 98. Benditte-Klepetko H, Sommer O, Weiss G, Czembirek H, Deutinger M. Functional and ultrasound evaluation of donor site morbidity after TRAM flap for breast reconstruction. Microsurgery 24(3): 174-81; 2004 99. Bunkis J, Walton RL, Mathes SJ, Krizek TJ, Vasconez LO. Experience with the transcerse lower rectus abdominis operation for breast reconstruction. Plast Reconstr Surg 72(6):819- 29; 1983 100. Schusterman MA, Kroll SS, Miller MJ, Reece GP, Baldwin BJ, Robb GL, Altmyer CS, Ames FC, Singletary SE, et al. The free transverse rectus abdominis musculocutaneous flap for breast reconstruction: one center’s experience with 211 consecutive cases. Ann Plast Surg 32(3): 234-41; 1994; discussion 241-2 101. Holmström H. The free abdominoplasty flap and its use in breast reconstruction. An experi- mentalstudy and case report. Scan J Plast Reconstr Surg 13(3): 423-27; 1979 102. Koshima I, Soeda S. Inferior epigastric artery skin flaps without rectus abdominis muscle. Br J Plast Surg 42(6): 654-8; 1989 103. Allen RJ, Treece P. Deep inferior epigastric perforator flap for breast reconstruction. Ann Plast Surg 32(1): 23-8; 1994 104. Blondeel PN. One hundred free DIEP flap breast reconstructions: a personal experience. Br J Plast Surg 5282): 104-11; 1999 105. Blondeel PN, Hijawi J, Depypere H, Roche N, Van Landuyt K. Shaping the breast in aesthetic and reconstructive breast surgery: an easy three-step principle. Plast Reconstr Surg 123(2): 455-62; 2009 106. Blondeel PN, Van Landuyt K, Hamdi M, Monstrey SJ. Soft tissue reconstruction with the superior gluteal artery perforator flap. Clin Plast Surg 30(3): 371-82; 2003 107. Schoeller T, Huemer GM, Wechselberger G. The transverse musculocutaneous gracilis flap for breast reconstruction: guidelines for flap and patient selection. Plast Reconstr Surg 122(1): 29-38; 2008 108. Missana MC, Laurent I, Barreau L, Balleyguier C. Autologous fat transfer in reconstructive breast surgery: Indications, technique and results. Eur J Surg Oncol 33: 685-690; 2007 109. Chan CW, McCulley SJ, Macmillan RD. Autologous fat transfer: A review of the literature with a focus on breast cancer surgery. J Plast Reconstr Aesthet Surg 61: 1438-1448; 2008 36 Chapter I

110. Khouri R, Del Vecchio D. Breast reconstruction and augmentation using pre-expansion and autologous fat transplantation. Clin Plast Surg 36(2): 269-80; 2009 111. http://www.plasticsurgery.org/News-and-Resources/Statistics.html accessed October 2011 112. Young VL, Watson ME. Breast reduction. In: Sarwer DB, et al. Psychological aspects of reconstructive and cosmetic plastic surgery. Philadelphia: Lipincott; Williams & Wilkins; 2006 113. Krieger LM, Lesavoy MA. Managed care’s methods for determining coverage of plastic surgical procedures: The example of reduction mammoplasty. Plast reconstr Surg 107: 1234; 2001 114. Horlock N, Cole RP, Rossi AR. The selection of patients for breast reduction: Should health commissions have a say? Br J Plastic Surg 52: 118; 1999 115. Jones SA, Bain JR.review of data describing outcomes that are used to assess changes in quality of life after reduction mammoplasty. Plast Reconstr Surg 108: 62; 2001 116. http://en.wikipedia.org/wiki/Beauty accessed October 2011 117. http://www.answers.com/topic/beauty accessed October 2011 118. https: //apps.who.int/aboutwho/en/deﬁnition.html accessed October 2011 119. Klesmer J. Mortality in Swedish women with cosmetic breast implants: body dysmorphic disorder should be considered. BMJ 326(7401): 1266-7; 2003 Chapter II

Hypertrophy of the breast: a problem of beauty or health?

Heike Ch. Benditte-Klepetko1 Valerie Schickl1 Tatjana Paternostro2 Monika Rakos2 Thomas Helbich3 Siegfried Trattnig3 Michael Schemper4

Maria Deutinger1

1Department of Plastic and Reconstructive Surgery | Krankenanstalt Rudolfstiftung 2Department of Rehabilitation | Medical University of Vienna 3Department of Radiology | Medical University of Vienna 4Institute of Computer Sciences | Medical University of Vienna Vienna, Austria

Journal of Women’s Health 16(7):1062-9, 2007

Hypertrophy of the breast: a problem of beauty or health? 39

Introduction

The most common symptoms of women suffering from breast hypertrophy are mal-posture, painful shoulder grooves, submammary intertrigo and back pain1-8. Furthermore different authors reported upper extremity neurologic symptoms caused by excessive breast size, like ulnar nerve paresthesias9, hand numbness10 and carpal tunnel syndrome11. These findings may result from brachial plexus compression between the coracoid process of the scapula and the rib cage as forward depression of the shoulders tilts the coracoid downward11. Starley et al.12 reported reduction of lung function, suggesting that a heavy breast mass leads to decreased chest wall compliance. In addition to these physical symptoms, macromastia has cosmetic and psychological components. The breast plays an important role in female self-confidence. Therefore breast hypertrophy is associated with heightened body image dissatisfaction. Patients may have decreased self-confidence due to difficulties while exer- cising, problems finding properly fitting clothes or impaired personal relationships and social life1-8. A detailed overview of the literature was given recently by Young and Watson13. They conclude, that the majority of women with macromastia pursue breast reduction surgery to relieve the physical symptoms, which also interfere with the ability to keep up daily life activities. But Young and Watson also point out that especially young women may be more strongly motivated to have surgery because of psychosocial concerns, although they suffer from physical problems. Young women tend to adopt strategies to camouflage their breasts and the emotional and social repercussions of abnormally large breasts in adolescence may resonate throughout adulthood. As Young and Watson discuss, complaints about physical symptoms are more often voiced by older women, perhaps because of the accumulated years of carrying heavy weight on the chest, which can place unnatural loading on the upper body14. Because of this complex health burden for women with breast hypertrophy, reduction mammoplasty is considered reconstructive in nature13 and is the most common operation on the female breast in plastic surgery today. With a rate of up to 9.5 in 100,000 women15 it ranks among the top five reconstructive procedures16. In 2006, 104.000 breast reduction procedures were performed in the United States by board-certified plastic surgeons17. On the other hand, cosmetic surgery procedures have increased at a dramatic rate16, since the enigma of beauty is epitomised in our culture. But, cosmetic surgery is excluded from service contracts. Selective access policies are designed to restrict expenditure on certain procedures, and non-urgent plastic surgical cases, 40 Chapter II

such as breast reduction, have become targets. Beside the fact that the official definition of reconstructive surgery by the American Society of Plastic Surgeons considers reduction mammoplasty to be reconstructive in nature13, the general public and many medical professionals consider reduction mammoplasty to be more a cosmetic than a functional operation. As a result, insurers do not accept that symptomatic macromastia is a significant health burden. Unfortunately, denials of insurance coverage and policy exclusions for breast reduction are becoming increasingly common in Europe as well as in the United States15,18,19 and the justification for outright rejection of funding is often unknown20. Although previously published longitudinal studies showed that reduction mammoplasty will reliably provide the desired improvement of all symptoms and improvement in the quality of a women’s life1-8,13, a continuous discussion is ongoing about whether reduction mammoplasty is a cosmetic or reconstructive procedure.

To elucidate this question the aim of our study was to demonstrate using reliable measurements the inﬂuence of breast weight on the physical and psychological morbidity of women.

Materials and Methods

Study design and population We performed a cohort study of 50 women with various breast sizes, a mean age of 28 years (range: 20 – 40 years, SD: 4.94) and a body mass index (BMI) less than 25 (mean: 21.9, SD: 2.16). The women were recruited from nurses of our department, medical students and women consulting our outpatient clinic for breast reduction surgery as well as other reasons. A balanced representation of individuals with respect to Cup-size (A-C vs. D) and age (20-29 years vs. 30 – 40 years) was achieved. In order to reduce the confounding effect of overweight, the body mass index had to be less than 25 according to the 1998 National Heart, Lung and Blood Insti- tute criteria21 (normal < 25 kg/m2, overweight 25 – 29,9 kg/m2, obese > 30 kg/m2). Also women with traumatic or other known spine diseases were excluded from the study.

All women were Caucasian, well educated (at least 12 years of education) and employed. All women were asked for participation without payment. The women with hypertrophic breasts were speciﬁcally told that the responses given in this study were conﬁdential and would not impact on their treatment, thus eliminating any possible confounding motive in their responses. Hypertrophy of the breast: a problem of beauty or health? 41

Local ethics committee approval was obtained and all women had to give informed consent to participate under the guidelines of the local ethics committee.

The following data were obtained: breast volume, magnet resonance imaging of the spine, physical examination and interview as described below.

Volumetric measurement of the breast A speciﬁc device based on the principle of water displacement was constructed by technicians of the department of Biomedical Engineering and Physics of the Medical University of Vienna. The amount of displaced water was weighted and multiplied by a breast tissue speciﬁc factor (mass density of breast tissue = 940 kg/m3)22. The validity and reliability of this method was demonstrated in previous studies. For statistical analysis the weight of both breasts was added.

Magnetic Resonance Imaging (MRI) of the spine Degenerative changes in the cervical and thoracic discs were studied by MRI and evaluated by loss of signal characteristics, posterior and anterior disc protrusion, narrowing of the disc space and foraminal stenosis. We examined the alignment for deviations in the frontal and sagittal plain. For MRI a 1.5 T scanner (Magnetom Vision, Siemens, Erlangen, Germany) with a phased array spine coil was used. We obtained localiser sequences in the coronal plane for planning the sagittal and axial sequences. The following sequences were applied: sagittal T1-FSE (TR/TE: 700/12ms; Turbofactor: 3), sagittal T2-FSE (TR/TE: 4700/112ms; Turbofactor: 15). For both sequences the matrix size was 390x512 mm, Field of view: 360x480 and the slice thickness 2mm. Additionally, an axial FISP- 3D sequence (TR/TE/Flip-ankle: 40/15/5°) was performed. For this sequence the matrix size was 128x256 mm, the ﬁeld of view: 200 and the slice thickness 2 mm. For statistical analyses pathological ﬁndings were graded as 1 and 0, for degenerative and no changes, respectively. The assessments were made blindly by two independent, experienced radiologists.

Functional evaluation of the spine To evaluate the functional status of the spine a grading system was used, based on the assessment of posture, mobility of the cervical spine, muscular dis-balance and musculoskeletal pain. According to the speciﬁc symptoms described for women with high breast weight14,15 it was looked for the presence of scoliosis, the presence of deviated head position, the presence of shoulder protraction in habitual or cor- rected sitting position, the shortening of the pectoralis muscles, the strength of the abdominal muscles and back extensor muscles. The mobility of the cervical spine 42 Chapter II

Table 1. “spine score”: grading system for the functional status of the spine, maximal total score =12

was measured by a hand goniometer according to the neutral-zero method and the muscle strength of the abdominal wall and the back extensors was obtained using Janda’s23 and Kendall’s24 standardised grading scale (table 1). Scoliosis, spine deviation in the sagittal plane and head posture were assessed in standing position. A spine deviation was scored as 1, no deviation as 0. A correct head posture was assumed if the meatus acusticus externus was in ligne with the hip joint axis. Any deviation to the front was regarded as deviation of the correct head position and was scored as 1, no deviation as 0. Shoulder protraction was assessed in sitting position. Shoulder position was described as being protracted (score 1) or normal (score 0). For measurements of the length of the pectoralis muscle the woman was lying supine, elevating the arms over the head. Shortening was assumed when the arms did not reach the table and scored as 1. Normal length was considered 0. Cervical spine mobility was assessed for the sitting patient. Restricted cervical spine mobility was scored as 1, unrestricted as 0. For muscle strength assessment of the abdominal wall the woman was lying supine, strength was assessed according to Janda’s grading system from 1 to 5 (grade 5 stands for normal strength and grade 1 for highly reduced strength). For the spine score in our study grade 5 was scored as 0 and grade 1 as 4. For muscle strength assessment of the back extensors according to Kendall’s strength grades were scored from 2 (highly reduced strength) to 0 (normal strength). Maximum score was 12. The higher the score, the higher was the functional impairment of the spine. All measurements were performed by a single physical therapist. Hypertrophy of the breast: a problem of beauty or health? 43

Pain intensity A visual analogue scale (VAS) was used to quantify pain intensity. This scale consists of a 10-cm line with each centimeter numbered 0 to 10. At the left (0), the words “no pain” are typed, and at the right (10), the words “worst possible pain” are typed. The patient is asked to mark on the scale an estimation of their current level of pain25.

Assessment of depressive symptoms All women completed the Beck Depression Inventory26 (BDI). The Beck Depression Inventory deﬁnes 3 grades of depressive symptoms by a scoring system: 1. no depression (score 11) 2. mild depression (score 12–17) 3. severe depression (score 18)

Statistical analyses The effects of age, breast weight and BMI on pathologic findings in the MRI were quantified and tested for significance by means of multiple logistic regression analysis. Associations of BDI and spine-score values with other patient characteristics were quantified and tested for significance by Spearman correlation coefficients. Partial Spearman correlations served to eliminate the effect of BMI and age on correlations of BDI and spine-score values with breast weight. All statistical analyses utilised programs of SAS (SAS Institute, Cary, NC, USA).

Results

Breast weight measurement A median total breast weight of both breasts of 1666 g was found (range: 418 – 3628 g). The correlation of breast weight to the bra-cup size is shown in ﬁgure 1. Concerning the deﬁnition for breast hypertrophy, as reported in the literature by cup size D or larger, the corresponding breast weight for the smallest cup size D was 1741 g.

The mean BMI of all women was 21,8 kg/ m2 (range: 17-25 kg/m2). Table 2 shows that the breast weight is correlated with the MRI-score, the spine score, pain, BDI, age and BMI. Adjustment of these correlations by age and BMI did neither substantially modify correlations or p-values. 44 Chapter II

Figure 1. Breast weight of all individuals included in the population according to bra size

Table 2. Upper triangle: Spearman Correlations of all variables considered, lower triangle: Partial Spearman Correlations of the variables considered, adjusted for age and BMI

MRI of the cervical and thoracic spine In 16 out of 50 women a pathologic MRI result was found. In 1 woman a disc- protrusion beyond the margin of the vertebral bodies was seen. 8 women had a disc-protrusion within the anterior margin of the vertebral bodies. In 10 women other degenerative abnormalities were found.

For the MRI-score we observed a statistically significant correlation with breast weight, spine-score, pain BDI and BMI. Between MRI-score and age no significant correlation was detected. After adjustment of these correlations by age and BMI the correlation of MRI-score and BDI is not significant anymore, which might show the influence of BMI on these parameter (Table 3). Hypertrophy of the breast: a problem of beauty or health? 45

Table 3. Effect of the three most important factors for degenerative spine disorders classiﬁed by MRI according to multiple logistic regression.

Multiple logistic regression analysis (using breast weight, age and BMI as predictors) gave evidence that the independent effect of breast weight on pathologic ﬁndings in the MRI is conﬁrmed (p=0.02), as is the effect of age (p=0.03). In addition to age and breast weight, the body-mass-index was of no predictive relevance (Table 2).

For each additional 10 years the relative risk to develop a degenerative spine disorder increases 5.7 fold and for each additional kg of breast weight 2.7 fold. The resulting probabilities for degenerative spine disorders are summarised in table 2 and the effect of breast weight by age are plotted in ﬁgure 3.

Spine Score In the whole cohort the mean score of functional impairment of the spine was 2.62 (range: 0 – 9). The statistical analysis of the data by the spearman correlation coefficient “r” showed a significant correlation between the spine score and the BMI as well as the breast weight, the MRI-score, the BDI and the pain defined by the visual

Figure 2a & 2b. Degenerative morphological changes (2a) and a prolapse of an intervertebral disc (2b) shown by MRI in women with breast hypertrophy. 46 Chapter II

analogue scale VAS, which does not change after adjustment for age and BMI. In our selected group no signiﬁcant correlation was found between the spine score and age (Table 3).

Back pain The mean cumulative visual analogue scale score for all participants was 3.02 (range, 0-10). The unadjusted spearman correlation coefﬁcient “r” showed signiﬁcant correlation between pain and breast weight, MRI-score, Spine-score, BDI and BMI. These correlations are not changed by adjustment for age and BMI (Table 3).

Beck Depression Scale 11 out of 50 women showed symptoms of a mild or severe depression analogue to the Beck Depression Inventory. 6 out of 11 had signs of a mild (score 12-17), 5 out of 11 of a severe (score >/= 18) depression (mean: 7.37, SD: 8.39). The statistical analysis by the spearman correlation coefficient showed a significant correlation of the score of depressive symptoms and all other measured parameters beside age. Adjusted for age and BMI there was no further significant correlation found between the value of depressive symptoms and the MRI score (Table 3).

Discussion

This cohort study demonstrates the impact of breast weight on the morbidity of 20 – 40 year old women. In particular, the results of pathologic ﬁndings in the MRI show conclusively the increased risk of developing a spine disorder in women with heavy breasts. The risk has been shown to be related to the patients’ age27, but additionally the risk is 2,7 times higher per kilogram of increased breast weight. As an example, the corresponding probability of developing a spine disorder for a 25-year-old woman with 800 g breast weight (cup size B) is 8%; for 25-year-old woman with 2800 g breast weight (cup size D) it is 44%. Compared to this the risk for a 35-year-old woman with 800 g breast weight is 34% and for a 35-year-old woman with 2800 g breast weight it is 82 % (ﬁg. 3). By using standardised muscle and posture testing we have shown the morpho- logic changes caused by increased breast weight and a validated pain scoring demonstrated the high level of pain in woman with heavy breasts. Our results, similar to those published by Chao et al.7 illustrated the functional disability in patients with macromastia. Hypertrophy of the breast: a problem of beauty or health? 47

Figure 3. Estimated probabilities for degenerative spine disorders (as diagnosed by MRI), effect of breast weight and age. Line 1: 800gr/25 years old: risk 8%; 800gr/35 years old: risk 34%. Line 2: 2800gr/25 years old: risk 44%; 2800gr/35 years old: risk 82%.

Additionally, the psychological impairment caused by increased breast weight was demonstrated by the high incidence of depressive symptoms in heavy breasted women by means of the Beck Depression Inventory. Our data show that body weight as measured by Body Mass Index also has an impact on development of spine disorders, mal-posture and depressive symptoms. A correlation between obesity and depressive symptoms had been previously de- scribed28. Therefore we suggest that weight reduction might support risk reduction. However, it is notable that Glatt et al.1 found that symptom relief and improved body image occurred after breast reduction independently of preoperative body weight. In addition, there is a high prevalence of obesity in patients seeking breast reduction and these women also beneﬁt from breast reduction surgery, as reported by Collins et al.29.

Weight seemed to have an influence on all parameters, but by excluding obese women from this study and adjusting the analysis of the effect of breast weight on BMI, the confounding effect of weight was avoided. As a result our cohort might be not representative for the typical population of women seeking breast reduction, but by focusing on the effect of breast weight, it was necessary to exclude obese women from the study. For the same reason, women older than 40 years were excluded from the study, since age has a well known impact on spine pathology. As our data show an effect of age on pathologic findings in the MRI even in women younger than 40, we believe older women might benefit from reduction mammoplasty. A further study of a larger number of women, including obese women and women older than 40, would allow this issue to be proved statistically. 48 Chapter II

Limitations of our study include the small sample size, as well as the predomi- nantly afﬂuent Caucasian population that comprises the study cohort. Further study of a more racially and economically diverse population may be warranted.

Thus far no definite breast weight has been defined at which reduction mammoplasty is necessarily indicated to prevent a subsequent morphological or psychological disease. Apart from those insurance companies that do not cover the procedure at all, most companies reimburse the cost of a resection involving more than 500 g tissue per breast. Kerrigan et al.30 stated that a woman with cup-size D or larger would benefit from breast reduction surgery. Our data show that the minimum breast weight of a breast with cup-size D is approximately 900 g per side compared to approximately 380 g in a breast with cup-size B. Therefore, we suggest that 500 g is a reasonable weight of tissue to remove in women with Cup size D or larger. Nevertheless, we emphasise that declaring a minimum of 500 g resection-weight per breast to differentiate between cosmetic and reconstructive indications might be disadvantageous to very small and slim women. For this reason Schnur et al.31 as well as Kompatscher et al.32 calculated scales of individual specimen weight limits for a reconstructive indication in breast reduction operations adapted to the individual patients body proportions. As stated by Collins et al.29 it makes more sense to use the physical symptoms of the patients as the criteria for insurance coverage instead of the amount of removed tissue. The question arises if nonsurgical interventions could be an alternative to reduction mammaplasty. To answer this question Collins et al.29 performed a prospective study comparing a surgical intervention group with a group including women with hypertrophic breasts and a control group of women with cup-size < D. In this study, conservative measures such as weight loss, physical therapy, special brassieres and medications did not provide sufficient and permanent relief of symptoms in patients with macromastia.

Conclusions

These data give the objective evidence that breast weight has an inﬂuence on the physical and psychological morbidity of women, and therefore challenges the basis for resource allocation decisions with regard to breast reduction surgery. The results should guide insurance companies to establish a uniform and appropriate selection procedure that ensures equitable access. Hypertrophy of the breast: a problem of beauty or health? 49

References

1. Glatt BS, Sarwer DB, O’Hava DE, Hamori Ch, Bucky LP and LaRossa D: A retrospective study of changes in physical symptoms and body image after reduction mammaplasty. PRS 103/1: 76-82,1999 2. Gonzales F, Walton RL, Shafer B, Matory WE, Borah GL: Reduction mammaplasty improves symptoms of macromastia. Plast Reconstr Surg 91: 1270-1275, 1993 3. Blomqvist L, Eriksson A, Brandberg Y: Reduction mammaplasty provides long-term improvement in health status and quality of life. Plast Reconstr Surg 106: 991,2000 4. Mizgala CL, MacKenzie KM: Breast reduction outcome study. Ann Plast Surg 44: 125-134, 2000 5. Boschert MT, Barone CM, Puckett CL: Outcome analysis of reduction mammaplasty. Plast Reconstr Surg 98: 451, 1996 6. Schnur PL, Schnur DP, Petty PM, Hanson TJ, Weaver AL: Reduction mammaplasty an outcome study. Plast Reconstr Surg 100/4: 875, 1997 7. Chao JD, Memmel HC, Redding JF, Egan L, Odom L, Casas LA: Reduction mammaplasty is a functional operation improving quality of life in symptomatic women: A prospective, single-center breast reduction outcome study. Plast Reconstr Surg 110(7): 1644-1652, 2002 8. Miller AP, Zacher JB, Berggren RB, Falcone RE, Monk J: Breast reduction for symptomatic macromastia: Can objective predictors for operative success be identiﬁed? Plast Reconstr Surg 95: 77-83, 1995 9. Kaye BL: Neurologic changes with excessively large breasts. South Med J 65: 177, 1972 10. Brown DM, Young VL: Reduction mammaplasty for macromastia. Aesthetic Plast Surg 17: 211, 1993 11. Pernia LR, Daniel NR, Leeper JD, Miller HL: Carpal tunnel syndrome in women undergoing reduction mammaplasty. Plast Reconstr Surg 105: 1314-1319, 2000 12. Starley IF, Bryden DC, Tagari S, Mohammed P, Jones BP: An investigation into changes in lung function and the subjective medical beneﬁts from breast reduction surgery. Br J Plast Surg 51: 531-534, 1998 13. Young VL, Watson ME: Breast Reduction in Sarwer DB et al “Psychological Aspects of Reconstructive and Cosmetic Plastic Surgery”, 2006, Lipincott Williams & Wilkins, ISBN 0781753627. 14. Letterman G, Schurter M: The effects of mammary hypertrophy on the skeletal system. Ann Plast Surg 5: 425, 1980 15. Klassen A, Fitzpatrick R, Jenkinson C, Goodacre T: Should breast reduction surgery be rationed? A comparison of the health status of patients before and after treatment: postal questionnaire survey. British Med J 313: 454-457, 1996 16. Rohrich RJ: The increasing popularity of cosmetic surgery procedures: a look at statistics in plastic surgery. PRS 106/6: 1363-1365, 2000 17. American Society of Plastic surgeons. 2006. Procedural Statistics: American Society of Plastic Surgeons Web Site, available at http://www.plasticsurgery.org. Accessed April, 2007. 18. Krieger LM, Lesavoy MA: Managed care’s methods for determinig coverage of plastic surgery procedures: The example of reduction mammaplasty. Plast Reconstr Surg 107: 1234, 2001 19. Horlock N, Cole RP, Rossi AR: The selection of patients for breast reduction: Should health commissions have a say? Br J Plastic Surg 52: 118-121, 1999 50 Chapter II

20. Jones SA, Bain JR: Review of data describing outcomes that are used to asses changes in Quality of life after reduction mammaplasty. Plast Reconstr Surg 108: 62, 2001 21. National Institutes of Health, National Heart, Lung, and Blood Institute. Clinical guidelines on the identiﬁcation, evaluation, and treatment of overweight and obesity in adults--the evidence report. Obes Res 6 (suppl 2): 51-209, 1998 22. Photon, Electron and Neutron Interaction Data for Body Tissues, ICRU Report 46, 1992; ISBN 0-913394-41-6 23. Janda V.: Muskelfunktionsdiagnostik 2nd Ed. Berlin: Volk- und Gesundheit 1986. 24. Kendall F, ed. Muscles: Function and Testing. 4th ed. Baltimore: WiliamsWilkins 1993 25. Price DD, McGrath PA, Raﬁi A and Buckingham B: The validation of the Visual Analog Scale as ratio scale measures for chronic and experimental pain. Pain 37: 295, 1983 26. Beck AT, Ward CH, Mendelson M et al. An Inventory for measuring depression. Arch. Gen- eral Psychiatry 4: 561-571, 1961 27. Matsumoto M, Fujimura Y, Suzuki N, et al.: MRI of cervical intervertebral discs in asymptomatic subjects. J Bone Joint Surg (Br) 80-B: 19-24, 1998 28. Herva A, Laitinen J, Miettunen J et al.: Obesity and depression: results from the longitudinal Nothern Finland 1966 Birth Cohort Study. Int J Obes 2006 Mar; 30(3): 520-7. 29. Collins ED, Kerrigan CL, Kim M et al.: The effectiveness of surgical and nonsurgical interventions in relieving the symptoms of macromastia. Plast Reconstr Surg 109: 1556-1565, 2002 30. Kerrigan CL, Collins ED, Striplin D et al.: The health burden of breast Hypertrophy. Plast Reconstr Surg 108: 1591-1599, 2001 31. Schnur PL: Reduction mammplasty – the Schnur sliding scale revisited. Ann Plast Surg 27: 232-237, 1999 32. Kompatscher P, von Planta A, Seifert B, Beer GM: A body mass index related scale for reconstructive breast reduction. Eur J Plast Surg 26: 202-206, 2003 Chapter III

Crucial aspects of smoking in wound healing after breast reduction surgery

Rolf Bartsch1 Gabriel Weiss1 Kurt Patocka2 Maria Deutinger1 Heike Benditte-Klepetko1

1Department of Plastic and Reconstructive Surgery | Krankenanstalt Rudolfstiftung 2Department of Pulmology | Hospital Hietzing Vienna, Austria

Journal of Plastic Reconstructive and Aesthetic Surgery 60(9):1045-9,2007

Crucial aspects of smoking in wound healing after breast reduction surgery 53

Introduction

Cigarette smoking affects multiple organ systems. Besides an increased risk of various neoplastic, cardiac1- cerebral-, peripheral vascular and pulmonary diseases, smokers are more likely to have poor surgical outcome in general2-4. For a long time plastic and reconstructive surgeons have been blaming tobacco smoking for jeopardy of physiological wound healing and surgical outcome. In 1974, Sarin first demonstrated a 43% reduction in the blood flow of digits of normal volunteers, after smoking of a single cigarette5,6. Since 1977, when Mosely and Finseth first reported impaired wound healing of a wound of a smoker’s hand as well as a slow down of wound healing in ears of nicotine injected rabbits7, the literature has seen many cases and studies of delayed and impaired wound healing8-10.

However, recommendations for smokers before surgery vary greatly. Some surgeons refuse to perform aesthetic or elective reconstructive surgery on individuals who use tobacco products10. Cigarette smoke contains more than 4000 toxic compounds11, of which nicotine is the toxin of greatest interest. Carbon monoxide and hydrogen cyanide are the two most common toxic gases.

Nicotine has several effects on wound healing. First, it causes a reduced prolifera- tion of red blood cells, ﬁbroblasts, and macrophages thus resulting in decreased tissue oxygenation and subsequent scar formation. Second, nicotine has been associated with increased platelet adhesiveness causing microclots and decreased microperfusion12,13. Nicotine also reduces levels of prostacyclin, one of the most important physiological vasodilatators14. Through these mechanisms, nicotine leads to tissue ischemia. Due to its 200 times higher binding-afﬁnity to haemoglobin carbon monoxide induces formation of methemoglobin and decreases levels of oxygen available for tissue perfusion. Hydrogen cyanide inhibits the enzyme systems of major pathways of the oxidative metabolism and oxygen transport at the cellular level15.

All these processes in summary are responsible for poor surgical outcome in smokers. However, most of the hypoxic effects of smoking last no longer than 24 h after the last cigarette13,16. Exception is the afﬁnity of carbon monoxide to haemoglobin, which may last up to 48 h17. A single cigarette can initiate skin vasoconstriction for about 90 min18.

We evaluated the effect of smoking cessation after surgery on wound healing. 54 Chapter III

Patients and methods

Patients In our prospective study we compared 25 nonsmoking patients and 25 smoking patients who were undergoing breast reduction in our unit between 2000 and 2003. We excluded patients suffering from systemic, immunologic, metabolic or hematologic disease to avoid the confounding effect on wound healing. All patients were informed preoperatively about the proposed negative impact of smoking and smoking cessation was recommended.

In 50 female patients, 25 smokers (mean age 39.4 years) and 25 nonsmokers (mean age 41.7 years), 93 breasts were reduced at our institution by two experienced plastic surgeons. In the group of the smokers 3 unilateral and 22 bilateral reductions were performed, in the group of the non-smoking women 4 patients received a unilateral and 21 patients a bilateral breast reduction. By chance the patients of the two groups were comparable by age and resection weight (table 1).

Table 1. Demographics of the study group

The median reduction weight in nonsmokers was 534 g for each breast (lower quar- tile 180/upper 700). Smokers showed a median reduction weight of 512 g per side (195/ 900). There was no signiﬁcant difference between the two groups concerning reduction weight (p = 0.76: Mann Whitney U Test). All patients received thrombosis prophylaxis starting 24 h before surgery until the 10th postoperative day (Lovenox 40 mg s.c. once per day). Crucial aspects of smoking in wound healing after breast reduction surgery 55

Methods

Surgical procedure Reduction mammaplasties were performed as central pedicle ﬂap (Eren) or medial pedicle ﬂap (Hall Findlay) techniques. The closure technique concerning breast- reduction is standardized in our instutution. All surgeons used 4-0 Vicryl sutures for subcutaneous wound closure and 4-0 monocryl sutures for skin closure and did close both sides personally. Steristrips were used for additional dressing. We used one drain for each breast and removed them two days postoperative. No prophy- lactic antibiotics were used intraoperatively.

Wound healing Regular wound healing was deﬁned as presence of a stable and dry wound without inﬂammation or skin necrosis thus no longer requiring any dressing. Impaired wound healing was assessed as absence of the above criteria and the requirement of a wound dressing after the 10th postoperative day. The two operating surgeons assessed the surgical outcome and decided if further dressing was required after the 10th postoperative day. They did not know which patients were planned to be included in the presented study.

Cotinine measurements To get objective data of the nicotine levels in smokers and nonsmokers, we measured urinary cotinine levels. Cotinine is a metabolite of nicotine, which is found in blood, urine and saliva. Cotinine has a half-life of nineteen hours. We determined urinary cotinine with a Cotinine-Urine ELISA-Test (DRG Cotinine MTPL EIA). The Urine samples were drawn preoperatively and on the fourth day after surgery.

Statistical analysis Since data were not normally distributed (D’Agostino Pearson test), statistical analysis were performed using Mann Whitney U-test and Sign-test for independent or dependent data, as appropriate. For graphic comparison of the non-normally distributed data, we used box and whiskers plot presentation comprising median, 25th and 75th percentiles as well as outliers.

Results Surgical procedure In 12 nonsmoking patients and 14 smoking patients the Eren technique was performed, the Hall Findlay technique was used in 13 nonsmoking and 11 smoking patients. 56 Chapter III

Wound healing Ten smoking patients showed impaired wound healing compared to only four patients of the non-smokers. Frequencies between groups were compared by one tailed Fisher test p = 0.057 (Fig. 1). We monitored the following wound healing problems: minor hematoma, minor wound dehiscence and partial infections. In the nonsmokers group two patients operated by the Hall-Findlay technique showed wound-healing complications, compared to two patient operated by the Eren-technique. The group of smokers showed equal number of wound-healing complications - ﬁve in each group - in both groups of surgical techniques. Because of overall minor wound infections, no additional use of antibiotics and no further inpatient treatment was necessary. There was no need to perform any revision because of hematoma.

Figure 1. Incidence of impaired wound-healing in nonsmokers [NS] and smokers [S]

Cotinine measurements The median preoperative cotinine level of smokers (S right 310 bar) was 1964 (783/3963) ng/ml, whereas preoperative cotinine level of nonsmokers (NS left bar) was 18 ng/ml (7/37) p < 0.0001. Continine levels signiﬁcantly decreased in both groups after a ﬁve day period. Smokers (S right bar) presented a median level of 432 ng/ml (148/1695) and nonsmokers (NS right bar) 15 ng/ml (4/34) p < 0.0001 Mann-Whitney-U-test (Fig. 2). Smokers with regular wound healing (left bar ‘0’) presented a median preoperative cotinine level of 1614 ng/ml (294/4000), whereas smokers with impaired wound healing (left bar ‘1’) had a median preoperative cotinine level of 2117 ng/ml (883/3951) p = 0.68. Postoperatively smokers with regular wound healing (right bar ‘0’) showed a decrease to 389 ng/ml (23/2141), and smokers with impaired wound healing (right bar ‘1’) showed decreased levels of 485 ng/ml (345/935) p = 0.60. Crucial aspects of smoking in wound healing after breast reduction surgery 57

Figure 2. Urinary cotinine levels in [ng/cc] pre (left) – and post (right boxes)-operatively in smokers and nonsmokers.

Cotinine levels between smokers with and without impaired wound healing showed a statistically signiﬁcant difference between preoperative and postoperative values (p < 0.05) (Fig. 3). There was no signiﬁcant difference seen between the two groups comparing the parameters age as well as reduction weight (table 2).

Figure 3 Urinary cotinine levels of smokers without (S0) and with (S1) impaired wound-healing, left bars showing preoperative cotinine levels and right bars postoperative levels. 58 Chapter III

Table 2. Differences between smokers with impaired and with regular wound healing

Discussion

Many clinicians have presented their negative experience with smoking patients4,19-23. A few experimental studies describe the negative impact of smoking on wound24 and bone healing25,26. These effects are attributed to nicotine and the numerous other contents of cigarette smoke. Van Adrichem et al. proved that smoking of cigarettes jeopardises survival of free vascularised flaps in rats due to vasospasms in the flap pedicle that may not necessarily lead to complete flap necrosis27. There is no consensus among plastic surgeons as to how long a patient should refrain from smoking before surgery.

Gill et al.28 showed an overall significantly higher incidence of breast complications with smoking (p = 0.0043). Smoking also caused a higher incidence of donor-site complications (p = 0.0033) and a higher incidence of fat necrosis (p = 0.0226), but no statistically significant correlation with partial flap loss and venous occlusion. O’Grady et al.29 described a trend for wound dehiscence, delayed healing and fat necrosis in large inferior pedicle reduction mammaplasties, although there was no statistically significant difference. Smokers were four times as likely to develop fat necrosis than nonsmokers. Finally there was no increase of complication rates among smokers with large reductions as opposed to smaller reductions. Padubidri et al.30 reports an overall complication rate in smokers of 439 39%, compared with 25% in ex-smokers and 26 in non-smokers (p = 0.002), who underwent breast reconstruction. Complications were significantly more frequent in smokers. From his point of view breast reconstruction should be done with caution in smokers. Smokers undergoing reconstruction should be strongly urged to stop smoking at least three weeks before surgery. Crucial aspects of smoking in wound healing after breast reduction surgery 59

Glassman et al.31 presented comparable results: patients who quit smoking after spinal fusion surgery for longer than six months had a lower non-union rate (17%) than smokers (27%), but still a higher rate than nonsmokers (14%). It was postoperative rather than preoperative smoking cessation that resulted in improved outcome. Akoz et al.19 reported a case of abdominoplasty with wound healing by secondary intention, because the patient was smoking immediately in the first postoperative days and a second case of a patient, undergoing breast reconstruction with a pedicled TRAM flap, who stopped smoking two years before surgery and started to smoke again the second postoperative day. Manassa et al.32 studied the effects of smoking in 132 patients who had undergone abdominoplasty. Smokers reported consuming, on average, 18 cigarettes per day. The rate of wound problems showed a statistical difference between smokers and nonsmoker (p < 0.01). 48 % of the smokers showed wound healing problems before hospital discharge versus 18% of the nonsmokers. Smokers should be informed about their possible higher risk of wound healing problems. Former studies have shown that either active smoking (smoking a cigarette) or passive smoking (exposure to environmental tobacco smoke, ETS) has undoubtedly harmful effects on the cardio-vascular system33. By measuring urinary cotinine it is also possible to correlate the nicotine levels in indoor air and the urinary cotinine to creatinine ratio of the passive smokers34. Urinary cotinine levels are significantly higher in individuals exposed to ETS than non-exposed humans35 as seen in our study. Cotinine concentrations between smokers and nonsmokers differ by factor 10 to 10036. The reduction of urinary cotinine levels in nonsmokers can be explained through the non-smoking environment in hospital. Usually nonsmokers are exposed to ETS, as outline above.

The present study can be seen as a pilot project to evaluate the impressive importance of smoking cessation in general and shows a tendency that even in smokers postoperative cessation of smoking appears to reduce complications in wound healing. To assess the beneﬁt of only postoperative smoking cessation, further patients need to be included. Smokers may maintain their normal smoking habits until hospitalisation and some refrain from smoking in the ﬁrst postoperative days. The group of female smokers who did not develop any wound healing problems presented with lower cotinine levels before surgery and stayed more abstinent after surgery compared to the group of smokers who developed wound healing problems.

According to the results of our pilot project we conclude that each smoking patient scheduled for breast reduction surgery should be explicitly informed on the 60 Chapter III

beneﬁcial effects of smoking cessation. If the patient is unable to quit smoking preoperatively she should be aware that even postoperative tobacco abstinence has a positive impact on the wound healing process. Crucial aspects of smoking in wound healing after breast reduction surgery 61

References

1. Rotenberg KS, Miller RP, Adir J. Pharmacokinetics of nicotine in rats after single-cigarette smoke inhalation. J Pharm Sci 1980; 69: 1087. 2. Moller AM, Pedersen T, Villebro N, et al.. Effect of smoking on early complications afterelec- tive orthopaedic surgery. Br J Bone Joint Surg 2003; 85: 178. 3. Adams CL, Keating JF, Court-Brown CM. Cigarette smoking and open tibial fractures. Injury 2001; 32: 61. 4. Ishikawa SN, Murphy GA, Richardson EG. The effect of cigarette smoking on hindfoot fu- sions. Foot Ankle Int 2002; 23: 996. 5. Sarin CL. Effects of smoking ondigital blood flow velocity. JAMA 1974; 229: 1327. 6. Mosely LH, Finseth F. Cigarette smoking: impairment of digital blood flow and wound healing in the hand. Hand 1977; 9: 97. 7. Mosely LH, Finseth F, Goody M. Nicotine and its effects on wound healing. Plast Reconstr Surg 1978; 61: 570. 8. Sorensen LT, Hemmingsen UB, Kirkeby LT, et al. Smoking is a risk factor for incisional hernia. Arch Surg 2005; 140: 119. 9. Reus 3rd WF, Colen LB, Straker DJ. Tabacco smoking and complications in elective microsurgery. Plast Reconstr Surg 1992; 89: 490 10. Krueger JK, Rohrich RJ. Clearing the smoke: the scientific rationale for tobacco abstention with plastic surgery. Plast Reconstr Surg 2001; 108: 1063. 11. Krupski WC. The perephereal consequences of smoking. Ann Vasc Surg 1991; 5: 291. 12. Reus WF, Roboson MC, Zachary L, et al. Acute effects of tabacco smoking on blood flow in the cutaneous microcirculation. Br J Plast Surg 1984; 37: 213. 13. Van Adrichem LN, Hovius SE, Van Strik R, et al. Acute effect of cigarette smoking on microcirculation of the thumb. Br J Plast Surg 1992; 45: 9. 14. Nadler JL, Velasco JS, Horton R. Cigarette smoking inhibits prostacycline formation. Lancet 1983; 1(8336): 1248. 15. Silverstein P. Smoking and wound healing. Am J Med 1992; 93: 564 22S. 16. Jensen JA, Goodson WH, Hopf HW, et al. Cigarette smoking decreases tissue oxygen. Arch Surg 1991; 126: 1131 17. Padubidri AN, Yetman R, Browne E, et al. Complications of 568 postmastectomy breast reconstructions in smokers, exsmokers, and nonsmokers. Plast Reconstr Surg 2001;107: 342. 18. Smith JB, Fenske NA. Cutaneous manifestations and consequences of smoking (see com- ments). J Am Acad Dermatol 1996; 334: 717. 19. Akoz T, Akan M, Yildirim S. If you continue to smoke, we may have a problem: smoking’s effects on plastic suigery. Aesthetic Plast Surg 2002; 26: 477. 20. Chang LD, Buncke G, Slezak S, et al. Cigarette smoking, plastic surgery, and microsurgery. J Reconstr Microsurg 1996; 12: 467. 21. Hardesty RA, West SS, Schmidt S. Preoperative cessation of cigarette smoking and its relationship to flap survival. In: Proceeding of the annual meeting of the American Society of Plastic Surgeons, Virginia, May 1990. 22. W-Dahl A, Toksvig-Larsen S. Cigarette smoking delays bone healing: a prospective study of 200 patients operated on by the hemicallotasis technique. Acta Orthop Scand 2004; 75:347. 62 Chapter III

23. Nkazawa A, Shigeta M, Ozasa K. Smoking cigarettes of low nicotine yield does not reduce nicotine intake as expected: a study of nicotine dependency in Japanese males. BMC Public Health 2004; 4: 28. 24. Nolan J, Jenkins RA, Kurikara K, et al. The acute effects of cigarette smoke exposure on experimental skin flaps. Plast Reconstr Surg 1985; 75: 544. 25. Silcox DH, Daftari T, Boden SD, et al. The effect of nicotine onspinal fusion. Spine 1995;20: 1549. 26. Ueng SW, Lee MY, Li AF, et al. Effect of intermittent cigarette smoke inhalation on tibial lengthening: experimental study on rabbits. J Trauma 1997; 42: 231. 27. Van Adrichem LN, Hoegen R, Hovius SE, et al. The effect of cigarette smoking on the survival of free vascularized and pedicled epigastric flaps in the rat. Plast Reconstr Surg 1996; 97: 86. 28. Gill PS, Hunt JP, Allen RJ. A 10-year retrospective review of 758 DIEP flaps for breast reconstruction. Plast Reconstr Surg 2004; 113: 1153. 29. O’Grady KF, Thoma A, Dal Cin A. A comparison of complication rates in large and small inferior pedicle reduction mammaplasty. Plast Reconstr Surg 2005; 115: 736. 30. Padubidri AN, Yetmann R, Zins J. Complications of postmastectomy breast reconstructions in smokers, ex-smokers and nonsmokers. Plast Reconstr Surg 2001; 107: 342. 31. Glassman SD, Anagnost SC, Parker A, et al. The effect of cigarette smoking and smoking cessation on spinal fusion. Spine; 2000: 08. 32. Manassa EH, Hertl CH, Olbrisch RR. Wound healing problems in Smokers and nonsmokers after 132 abdominoplasties. Plast Reconstr Surg 2003; 111: 2082. 33. Leone A. Relationship between cigarette smoking and other coronary risk factors in arthero- sclerosis: risk of cardiovascular disease and preventive measures. Curr Pharm Des 2003; 7. 34. Kim H, Lim Y, Lee S, et al.. Relationship between environmental tobacco smoke and urinary cotinine levels in passive smokers at their residence. J Expo Anal Environ Epidemiol 2004; 14(Suppl. 1): S65. 35. Boyaci H, Duman C, Basyigit I, et al. Determination of environmental tobacco smoke in primary school children with urine cotinine measurements. Tuberk Toraks 2004; 52: 231. 36. Heinrich J, Holscher B, Seiwert M, et al. Nicotine and cotinine in adults’ urine: the German environmental survey 1998. J Expo Anal Environ Epidemiol 2005; 15: 74. Chapter IV

Psychosocial aspects of breast reconstruction

Heike Benditte-Klepetko1 Rupert Koller2 Jolanta Ptak-Butta1 Maria Deutinger1

1Department of Plastic and Reconstructive Surgery | Hospital Hietzing 2Department of Plastic and Reconstructive Surgery | Medical University Vienna Vienna, Austria

Geburtshilfe und Frauenheilkunde 63:37-42, 2003

Psychosocial aspects of breast reconstruction 65

Einleitung

Die weibliche Brust hat in unserer Gesellschaft eine besondere Bedeutung. Levy und Schain1 nannten in einem 1988 erschienen Buch unsere Zeit eine „Mammo- zentrische Epoche“. Im Spiegel von Kunst und Literatur hat die weibliche Brust eine wichtige ästhetische und symbolische Bedeutung2. So steht die weibliche Brust für die Fähigkeit der Frau, Kinder gebären und ernähren zu können, zwischenmensch- lich und partnerschaftlich für die Fähigkeit, Männer „anzuziehen“ und letztlich binden zu können1.

In diesem Kontext ist die weibliche Brust eine Quelle weiblicher Identiﬁkation und Selbstwertgefühls. Die Brust ist also ein wichtiges Merkmal der Weiblichkeit in der Gesellschaft, dessen Mechanismen nicht zuletzt in der Werbung Verwendung ﬁnden3.

Welche Auswirkungen hat die Brustkrebserkrankung für die Frau? Primär steht die Bedrohung der Krebserkrankung selbst im Vordergrund: die Angst vor Rezidiv und Tod, die Einschränkung körperlicher Funktionen und der Leistungsfähigkeit4.

Auf der Basis der speziellen Bedeutung der Brust kommt es allerdings noch auf einer anderen Ebene zu Bedrohungen: die persönlichen „Ich-Ideale“ der Frau bezüglich Körpergefühl und Weiblichkeit werden massiv gestört und damit das Selbstbild verändert. Dieser gesellschaftliche Makel kann je nach Persönlichkeitsstruktur zu sozialer Isolation führen, sowohl im weiteren gesellschaftlichen, als auch im engen privaten, partnerschaftlichen Bereich. Hier können auch sexuelle Störungen die Folge sein3-8.

Ziel der vorliegenden Studie war es, den Einﬂuss der unterschiedlichen Zeitpunkte der Rekonstruktion auf die psychosozialen Auswirkungen der Patientinnen zu ob- jektivieren.

Patientinnen und Methode

Insgesamt wurden 125 Patientinnen, die zwischen 1991 und 2000 eine Brustrekon- struktion erhalten hatten, angeschrieben. Von diesen 125 Patientinnen konnten 40 untersucht und in einem persönlichen Gespräch befragt werden. Unvollständig aus- gefüllte retournierte Fragebogen ohne zusätzliches persönliches Interview wurden in der Datenanalyse nicht berücksichtigt. 66 Chapter IV

Hiervon waren 20 Patientinnen sofort und 20 Patientinnen spät rekonstruiert worden. Von den spät rekonstruierten Patientinnen hatten 15 Patientinnen eine Eigengeweberekonstruktion (TRAM- (9) oder M. Latissimus Dorsi Lappenplastik (10)) erhalten. 5 Patientinnen wurden mittels eines Implantates rekonstruiert. In der Gruppe der sofort rekonstruierten Patientinnen fanden sich 18 Eigen- gewebere- konstruktionen und 2 Implantatrekonstruktionen. Alle Patientinnen waren einseitig rekonstruiert worden.

Das durchschnittliche Alter der spät rekonstruierten Patientinnen zum Zeitpunkt der Ablatio betrug durchschnittlich 44,5 Jahre (34-71 Jahre). Diese Patientinnen waren zum Zeitpunkt der Rekonstruktion durchschnittlich 46,5 Jahre alt (36-72 Jahre). Daraus ergibt sich, dass die Spätrekonstruktion im Durchschnitt 1,9 Jahre (0,5-6 Jahre) nach der Brustentfernung erfolgt war.

Anhand eines Fragebogens, der den oben genannten Patientinnen zugesandt wurde, wurden die psychosozialen Auswirkungen von Ablatio bzw. Rekonstruktion retrospektiv untersucht. Dieser Fragebogen enthielt Fragen zur Anamnese sowie zur Erfassung des zeitlichen Verlaufes von der Diagnose bis zur Rekonstruktion. Schwerpunkte des Fragebogens bezogen sich auf das weibliche Selbstbild, das Gesellschaftsleben, auf Partnerschaft und Sexualität sowie auf die Arbeitssituation. Die Auswirkungen auf das soziale Verhalten der Patientinnen und die Auswir- kungen von Ablatio und Rekonstruktion wurden hinsichtlich verschiedener Aspekte überprüft und beziehen sich auf die Beeinträchtigung der eigenen Attraktivität, des Verhaltens im Bekanntenkreis, der Teilnahme an sozialen Aktivitäten, der Beeinträchtigung in der Kleidungswahl sowie der Frequenz von Sauna- oder Frei- badbesuchen. Es stand der retrospektive Vergleich des Zustandes vor Ablatio, in der Zeit zwischen Ablatio und Rekonstruktion, beziehungsweise in der Zeit nach der rekonstruktion im Vordergrund. Die Gruppe der spät rekonstruierten Patientinnen wurde den sofort rekonstruierten Patientinnen gegenübergestellt.

Zur Beurteilung der Beeinträchtigung diente eine Skala von 1-6, wobei 1 für gar keine und 6 für eine sehr starke Einschränkung stand. Zu jedem der geschilderten Aspekte wurden mehrere offene Fragen gestellt, z.B. im Bereich der Partnerschaft wurden sowohl die Unterstützung durch den Partner, das Wohlbeﬁnden in der Part- nerschaft, das eigene Interesse bzw. das des Partners sowie letztlich die Änderung der familiären Situation erhoben. Um beurteilen zu können, ob die Patientinnen Informationen hinsichtlich der Rekonstruktionsmöglichkeiten erhalten hatten und zu welchem Zeitpunkt dies Psychosocial aspects of breast reconstruction 67 erfolgte, wurden den Patienten Fragen zur Aufklärung, die diesbezüglich erfolgt war, gestellt. Letztlich wurden die Patientinnen hinsichtlich Einwänden zum Vorgehen befragt und ob sie die rekonstruktion wieder durchführen lassen würden. In weiterer Folge wurden die Patientinnen zu einer Untersuchung einbestellt, bei welcher das Rekonstruktionsergebnis hinsichtlich des Erscheinungsbildes der rekonstruierten Brust im Vergleich zur gesunden Seite quantiﬁziert wurde. Dabei wurden Größe, Form, Projektion und Sensibilität herangezogen. Auch diente das persönliche Gespräch mit der Patientin dazu, offene Punkte des Fragebogens zu klären.

Ergebnisse

Weibliches Selbstbild Für die Gruppe der spät rekonstruierten Patientinnen zeigt sich, dass sich alle Patientinnen in der Zeit zwischen Ablatio und rekonstruktion stark beeinträchtigt fühlten. Außer bei 2 Patientinnen verminderte sich diese Beeinträchtigung nach der Rekonstruktion stark. In der Gruppe der sofort rekonstruierten Patientinnen gaben nach der Rekon - struk tion 3 Patientinnen eine starke Einschränkung im weiblichen Selbstbild aufgrund eines schlechten kosmetischen Ergebnisses an (Abb. 1)

Abb. 1. Einschränkung im weiblichen Selbstbild (1=gar nicht, 9=sehr stark) 68 Chapter IV

Gesellschaftsleben 1. Nach der Ablatio fühlten sich alle 20 spät rekonstruierten Patientinnen in ihrer Attraktivität stark eingeschränkt. Nach der Rekonstruktion reduzierte sich die Anzahl auf 8 Patientinnen, die sich schwach eingeschränkt fühlten. Damit entspricht dies dem Anteil der Patientinnen, die nach der Sofortrekonstruktion eine schwache Einschränkung empfanden. 2. Auch in Bezug auf die Beeinträchtigung, die die Patientinnen im Bekannten- kreis angaben, zeigt sich, dass sich durch die die Rekonstruktion die Zahl der Patientinnen, die eine Beiinträchtigung angaben, reduzierte. So empfanden 7 Patientinnen eine starke und 7 Patientinnen eine schwache Einschränkung des Verhaltens im Bekanntenkreis nach Ablatio. Dies reduziert sich auf 3 Patientin- nen, die nach der Spätrekonstruktion noch eine starke Einschränkung angaben, sowie 2 Patientinnen, bei denen eine schwache Einschrämkung verblieb. In der Gruppe der sofort rekonstruierten Patientinnen bewerteten 3 ihre Einschränkung im Bekanntenkreis als schwach, eine Patientin fühlte sich stark eingeschränkt. 3. Auf die Frage nach der Frequenz der Teilnahme an sozialen Aktivitäten wie z. B. Teilnahme an Fetivitäten oder Vereinsmitgliedschaften gaben 11 von 20 Patien- tinnen für die Zeit zwischen Ablatio und Rekonstruktion eine Beeinträchtigung an. Diese Zahl reduzierte sich nach der Operation auf 2 Patientinnen. Im Kollek- tiv der sofort rekonstruierten Patientinnen gab eine Patientin diesbezüglich eine Beeinträchtigung an.

Abb. 2. Psychosoziale Beeinträchtigung Psychosocial aspects of breast reconstruction 69

4. Eine Beeinträchtigung in der Wahl der Kleidung gaben 6 spät rekonstruierte Patientinnen nach der Ablatio mit stark an, 3 Patientinnen empfanden eine schwache Einschränkung. Nach der Rekonstruktion verblieben 4 Patientinnen, die sich schwach eingeschränkt fühlten. 3 Patientinnen äußerten eine schwache Beeinträchtigung des Modeverhaltens. 5. 17 von 20 der Spätrekonstruierten reduzierten die Frequenz von Sauna- oder Freubadbesuchen nach der Ablatio. Sowohl nach Spät- als auch nach Sofort- rekonstruktion verblieben in jeder der verglichenen Gruppen jeweils 3 von 20 Patientinnen, die eine Einschränkung bezüglich der Sauna-oder Freibadbesuche angaben (Abb. 2)

Partnerschaft/Sexualität 1. Spätrekonstruktion: 8 Patientinnen gaben an, dass sich ihre Partnerbeziehung nach der Ablatio verschlechterte. Bei 3 dieser Patientinnen blieb die Verschlechterung bestehen und es kam zur Trennung bzw. Scheidung. Bei den restlichen Patientinnen nor- malisierte sich die Partnerschaft nach der Rekonstruktion, bei 2 verbesserte sie sich. 2. Sofortrekonstruktion: Für eine Patientin verschlechterte sich die Partnerschaft nach der Operation, 2 Patientinnen empfanden eine Verbesserung. 17 von 20 Patientinnen sahen ihre Beziehung unverändert.

Tab. 1. Beeinträchtigung von Partnerschaft und Sexualität 70 Chapter IV

Das eigene Interesse an Sexualität reduzierte sich postoperativ bei 4 Frauen, 3 Frauen stellten eine Reduktion des sexuellen Interesses des Partners fest.

Arbeitssituation Bei 11 der spät rekonstruierten Patientinnen und 15 der sofort rekonstruierten Patientinnen änderte sich postoperativ das Arbeitsverhältnis nicht. Besonders ist darauf hinzuweisen, dass 5 von 20 spät rekonstruierten Patientin- nen aufgrund des lange währenden Krankenstandes, bedingt durch die onkologi- sche Therapie mit anschließender neuerlicher Operation zur Brustrekonstruktion, arbeitslos wurden, hingegen keine der sofort rekonstruierten Patientinnen. Nach Sofortrekonstruktion befand sich 1 Patientin zum Zeitpunkt der Untersu- chung ein halbes Jahr nach der Rekonstruktion aufgrund von Folgetherapien noch im Krankenstand. Für 2 spät und 3 sofort rekonstruierte Patientinnen kam es zu einer Reduktion der Arbeitszeit, 2 spät und eine sofort rekonstruierte Patientin gingen in Frühpension (Tab. 2).

Tab. 2. Beeinträchtigung der Arbeitssituation

Patientenaufklärung 1. Spätrekonstruktion - 14 von 20 Patientinnen fühlten sich sowohl vor als auch nach der Operation gut beraten. 3 Patientinnen glaubten, nach der Rekonstruktion schlecht, 3 glaubten mittelmäßig beraten worden zu sein. - Nur 3 Patientinnen waren durch Eigeninitiative vor der Ablatio über die Mög- lichkeit einer Rekonstruktion informiert worden. - Alle Patientinnen hätten retrospektiv eine Sofortrekonstruktion bevorzugt. Psychosocial aspects of breast reconstruction 71

2. Sofortrekonstruktion - Bis auf eine Patientin, die eine Lappenteilnekrose erlitten hatte, fühlten sich alle Patientinnen sowohl vor als auch nach der Operation gut beraten. - 13 Patientinnen wurden vom Gynäkologen über die Möglichkeit einer Sofortre- konstruktion aufgeklärt, 6 Patientinnen durch den Chirurgen, und eine Patientin durch Eigeninitiative. - Außer einer Patientin mit postoperativer Lappenproblematik würden sich alle Patientinnen neuerlich demselben Vorgehen unterziehen.

Diskussion

Zusammenfassend ist aus den erhobenen Daten abzulesen, dass die psychosoziale Belastung für die Patientinnen in der Zeit zwischen Mastektomie und Rekonstrukti- on sehr hoch und zum Teil mit langfristigen Folgen verbunden ist.

Seit 1970 von Hueston und McKenzie11 die erste Sofortrekonstruktion einer Brust durchgeführt wurde, beschäftigen sich verschiedene Studiengruppen mit den Vor- und Nachteilen der verschiedenen Zeitpunkte der Rekonstruktion.

Grundlage der Überlegungen zu psychosozialen Vorteilen für die Patientinnen muss hier die medizinische Sicherheit der Methode sein. Verschiedene Studien konnten zeigen, dass die Sofortrekonstruktion keine Auswirkungen auf Überlebens- und Rezidivraten hat und keine Verzögerung weiterer Therapien oder Diagnostik nach sich zieht12,13.

Auf dieser Basis sollte die Entscheidung für einen bestimmten Zeitpunkt der Rekonstruktion von den individuellen Gegebenheiten der Patientin der Patientin abhängig sein.

Die Beweggründe für die Patientin, eine Rekosntruktion durchführen zu lassen, sind ausführlich in der Literatur beschrieben14. Durch die allgegenwärtige Erinnerung an die Krebserkrankung nach Mastektomie, werden die Patientinnen repetitiv an ihre Erkrankung erinnert. Dadurch werden die Patientinnen im täglichen Leben auf ihre Erkrankung fokussiert und die negative psychologische Reaktion verstärkt. Die negativen Auswirkungen auf alltägliche Aktivitäten zeigen unsere Daten.

Durch eine Rekonstruktion kann dieses Trauma verringert werden. In einer 1983 von C. Dean15 im Lancet veröffentlichten prospektiven, kontrollierten, randomi- 72 Chapter IV

sierten Studie konnte nachgewiesen werden, dass die psychiatrische Morbidität 3 Monate nach Mastektomie durch eine sofortige Rekonstruktion signiﬁkant gesenkt werden kann. Dies entspricht den von uns erhobenen Daten. Al-Ghazal et al.16 beschreiben sogar einen letztlich insgesamt verbesserten psychologischen Status von Patientinnen nach Sofortrekonstruktion im Vergleich zu Patientinnen nach Spätrekonstruktion. Dieses Ergebnis kann durch unsere Daten unterstützt werden, wenn man die erhöhte Inzidenz von Arbeitslosigkeit oper Scheidungen in der Grup- pe der spätrekonstruierten Patientinnen betrachtet. Ebenso entsprechen unsere Ergebnisse denen einer von Schain14 publizierten Studie, die beschreibt, dass der größte Unterschied der psychosozialen Morbidität darin zu sehen ist, wie es den Patientinnen in der Zeit zwischen Mastektomie und Rekonstruktion ergeht.

Allerdings argumentiert auch D.K. Wellisch in einer weiteren Arbeit17, dass die Patientinnen nach Sofortrekonstruktion die rekonstruierte Brust besser in ihr Körperbild aufnehmen können18. An dieser Stelle sollte das Argument diskutiert werden, dass Frauen erst nach der Erfahrung mit der Deformität einer amputierten Brust gelebt zu haben, das rekonstruktive Ergebnis positiv sehen können. Sowohl unsere als auch die Ergebnisse vorangegangener Studie widerlegen diese Theorie, da die Patientenzufriedenheit sowohl nach Sofort- als auch nach Spätrekonstruktion mindestens als gleichwertig anzusehen ist.

Neben diesen positiven Aspekten der Brustrekonstruktion sei nicht zu übersehen, dass ein Teil der Patientinnen nach Mastektomie sich nicht für eine Rekonstruktion entscheiden. Gründe hierfür sind z. B. Angst vor neuerlichen Operationen vor allem bei hohem Alter der Patientin oder Nebenerkrankungen. Auch die Sorge vor einem möglicherweise unbefriedigenden kosmetischen Resultat lässt Patientinnen von einer Rekonstruktion Abstand nehmen. Letztlich bestimmt das Ausmaß des Leidensdruckes wie z. B. auch beschriebener sexueller Dysfunktion oder Probleme im täglichen Umgang mit einer externen Prothese die Entscheidung für eine Re- konstruktion. Befürchtungen der Patientinnen bezüglich einer erschwerten Diagnostik oder er- höhter Rezidivrate können nach den oben genannten Erkenntnissen abgeschwächt werden12,13. Letztlich ist also vor allem die Information der Patientinnen von entscheidender Bedeutung, welches Procedere, auch im Hinblick auf die Möglichkeit einer brus- terhaltenden onkoplastischen Therapie19, im individuellen Fall beschritten wird. In einer Arbeit von S. Rosenqvist20 wird das Wissen der Patientin über die Möglichkeit einer Sofortrekonstruktion als ausschlaggebender Faktor für die Entscheidung der Patientin beschrieben. Wir konnten dies auch in unserer Studie bestätigen. Psychosocial aspects of breast reconstruction 73

Schlussfolgerung

Ziel sollte also sein, beruhend auf dem Wissen über die psychosoziale Problematik von Frauen mit Brustkrebs, den Patientinnen durch sufﬁziente Information zu einer Entscheidungsautonomie zu verhelfen. Diese kann dazu beitragen, eine spätere psychische Morbidität zu senken21. Ebenso werden die Patientinnen selektiert, die sich bewusst gegen eine Brustrekonstruktion entscheiden22. Zu berücksichtigen ist dabei, dass die Patientinnen sich zum Zeitpunkt der Diagnosestellung in einer psychischen Krise beﬁnden. Umso wichtiger erscheint das Wissen über die spezielle psychosoziale Problematik. Die von uns erhobenen Daten und die anderer vorausgegangener Studien sollten eine Patientenführung erleichtern, ebenso wie eine interdisziplinäre Zusammenarbeit von Gynäkologen, Chirurgen, Radiologen und Plastischen Chirurgen. 74 Chapter IV

Literatur

1. Levy SM, Schain WS Psychologic response to breast cancer: direct and indirect contributors to treatment outcome. In: Lippman ME et al (eds.) Diagnosis and Management of Breast Cancer. Philadelphia: W.B. Saunders, 1988: 439-456 2. Kirchhoff H. Die künstlerische Darstellung der weiblichen Brust als Attribut der Weiblichkeit und Fruchtbarkeit als auch als Spende der Lebenskraft und der Weisheit. Geburtsh Frauen- heilk 1990; 50: 234-243 3. Münstedt K, Milch W, Reimer Ch. Epikutane Brustprothetik nach Ablatio mammae. Geburtsh Frauenheilk 1996; 56: 8-12 4. Schain WS, Jacobs E, Wellisch DK. Psychological issues in breast reconstruction: Intrapsy- chic, interpersonal and practical concerns. Clin Plast Surg 1984; 11: 237 5. Maguire P, Selby P. Assessing quality of life in cancer patients. Br J Cancer 1989; 60: 437-440 6. Schover LR, Yetman RJ, Tuason LJ, Meisler E, Esselstyn CB, Hermann RE, Grundfest- Broniatowski S, Dowden RV. Partial mastectomy and breast reconstruction. A comparison of their effects on psychosocial adjustment, body image, and sexuality. Cancer 1995; 75: 54-63 7. Hawighorst-Knapstein S. Fusshoeller C, Franz C, Seufert R, Schönefuß G. Perioperative Aufklärung und Lebensqualität bei onkologischen Patientinnen. Geburtsh Frauenheilk 2002; 62: 5-8 8. Brandenburg U, Leeners B, Schulte-Werfers H, Krahl D, Rath W. Sexualität – ein Tabu in der Gynäkologie? Eine Analyse der Interaktion zwischen sexuellen und gynäkologischen Problemen. Geburtsh Frauenheilk 2002; 62(Suppl 1): 1-4 9. Voigt M, Andree C, Galla TJ, Borges J, Stark GB. The free TRAM-flap as a standard procedure for breast reconstruction. Geburtsh Frauenheilk 2001; 61: 384-390 10. Fersis N, Relakis K, Bastert G, Wallwiener D. Autologe Brustrekonstruktion mittels M. latissimus dorsi Lappen: Analyse der ästhetischen Resultate und der Komplikationen nach Anwendung der „fleur-de-lis“-Technik. Geburtsh Frauenheilk 2000; 60: 625-629 11. Hueston JT, McKenzie G. Breast reconstruction after radical mastectomy. Aust N Z J Surg 1970; 39: 367 12. Eberlein TJ, Crespo LD, Smith BL, Hergrueter CA, Douville L, Eriksson E. Prospective evaluation of immediate reconstruction after mastectomy. Ann Surg 1993; 218: 29-36 13. Noone RB, Murphy JB, Spear SL, Little JW. A 6-year experience with immediate reconstruction after mastectomy for cancer. Plast Reconstr Surg 1985; 76: 258-269 14. Schain WS, Wellisch DK, Pasnau RO, Landsverk J. The sooner the better: a study of psychological factors in woman undergoing immediate versus delayed breast reconstruction. Am J Psychiatry 1985; 142: 40-46 15. Dean C, Chetty U, Forest APM. Effects of immediate breast reconstruction on psychological morbidity after mastectomy. Lancet 1983; 26: 459-463 16. Al-Ghazal SK, Sully L, Fallowfield L, Blamey RW. The psychological of immediate rather than delayed breast reconstruction. Eur J Surg Oncol 2000; 26: 17-19 17. Wellisch DK, Schain WS, Noone RB, Little JW. Psychological correlates of immediate versus delayed reconstruction of the breast. Plast Reconstr Surg 1985; 76: 713-718 18. Luce EA. Breast reconstruction after mastectomy. South Med J 1983; 76: 190-193 19. Rowland JH, Desmond KA, Meyerowitz BE, Berlin TR, Wyatt GE, Ganz PA. Role of breast reconstructive surgery in physical and emotional outcomes among breast cancer survivors. J Natl Cancer Inst 2000; 92: 1375-1376 Psychosocial aspects of breast reconstruction 75

20. Rosenqvist S, Sandelin K, Wickman M. Patients’ psychological and cosmetic experience after immediate breast reconstruction. Eur J Surg Oncol 1996; 22: 262-266 21. Neiss M, Strittmatter HJ. Does reconstructive breast surgery and brest-conserving therapy improve the quality of life? Onkol 1997; 20: 118-121 22. Rowland JH, Dioso J, Holland JC, Chaglassian T, Kinne D. Breast reconstruction after mastectomy: who seeks, who refuses it? Plast Reconstr Surg 1995; 95: 812-822

Chapter V

Functional and ultrasound evaluation of donor-site morbidity after TRAM-ﬂap for breast reconstruction

Heike Benditte-Klepetko1 Oliver Sommer2 Gabriel Weiss1 Helmut Czembirek2 Maria Deutinger1

1Department of Plastic and Reconstructive Surgery | Hospital Rudolfstiftung 2Department of Radiology | Hospital Hietzing Vienna, Austria

Microsurgery 24(3):174-81, 2004

Functional and ultrasound evaluation of donor-site morbidity after TRAM-ﬂap for breast reconstruction 79

Introduction

Since the original description by Carl R. Hartrampf jr. in 19821 the TRAM-flap has become a well established method for breast reconstruction. The aesthetic result by autologous breast reconstruction is superior to that by implant reconstruction. Nevertheless the main disadvantage is the potential risk for creating weakness of the abdominal wall2. Despite technical improvement of harvesting by minimising the amount of muscle resection3,4 and sufficient abdominal wall closure5, until now the risk still remains. Therefore the integrity of the abdominal wall has to be evaluated in follow up examinations. In different recent studies clinical examinations6-12 and dynamometry8,11,12 as well as CT-scans11,12 and MRI was performed. For morphological evaluation of the muscle function however, an imaging method has to be used which is able to proof functional properties of the remaining muscle. Methods like dynamometry or CT-scan are not always available in the clinical practice or even very expensive. Compared to methods used before, ultrasound imaging is an easily available method, visualising not only static images but also movements of the muscle. Therefore this study was undertaken in order to verify if ultrasound imaging is a reasonable method to examine muscle movements after TRAM-flap procedures in addition to clinical examination.

Patients

22 patients have been evaluated. In 8 patients 11 DIEP-flaps (3 bilateral, 5 unilateral reconstructions), in 11 patients 11 unilateral free TRAM-flaps and in 3 patients 3 unilateral pedicled TRAM-flaps have been used for breast reconstruction. The patients were examined 12-72 month (mean 32 month) after surgery. The mean age of patients after DIEP-flap reconstruction was 50,4 years (39-60 years) and the mean follow up period was 27 month postoperatively (10-47 month). In patients after free TRAM-flap the mean age was 53 years (37-62 years) and the follow up period was 32 month (10-72 month). The mean age of patients after pedicled TRAM-flap reconstruction was 45,3 years (43-53 years) and the follow up period was 35 month (13-55 month).

Methods

1. Ultrasound imaging of the abdominal wall was performed in longitudinal as well as in cross sections (Siemens Elegra, Erlangen Germany, multifrequent, 13 Mhz, 80 Chapter V

“Siescape”). The diameter of the remaining muscle was measured 2 cm below the rib bow, at the level of the umbilicus and at the level of the skin scar. For exact measurements the diameter was deﬁned between the inner layers of the Rectus muscle sheets. In case of unilateral breast reconstruction the operated side was compared to the non-operated contra-lateral side. 2. In order to evaluate the contractility of the remaining rectus muscle, the patients were asked to do straight curl-ups while ultrasound monitoring of muscle movements. Muscle contractility as well as muscle diameter was graded into four degrees from 0-3. 3 described the highest score with unchanged muscle diameter and normal muscle contractility. Score 2 was deﬁned as reduced muscle diameter with remaining muscle contractility, Score 1 as remaining muscle tissue with reduced diameter and without movements, Score 0 described Scar tissue without contractibility. 3. Clinically the functional testing was performed by the well-known method of Janda13. 4. The abdominal wall was examined for bulging or hernia formation by a plastic surgeon. 5. Additionally the patients answered a six-scale (0 = no impairment, 5 = very strong impairment) self-designed questionnaire concerning the impairment of daily living and pain.

Results

1. Even in the longitudinal as in the cross section the Rectus Abdominis muscle is visible. Figures 1-5 show the ultrasound images of a patient after unilateral breast reconstruction by unilateral free TRAM-flap. At the level of the scar the reduced muscle amount after harvesting of a muscle sparing TRAM-flap is shown. The mean diameter of the Rectus Abdominis muscle after bilateral DIEP- flap harvesting was 8.0 mm at the level 2 cm below the rib bow, 5.9 mm at the umbilical level and 5.1 mm at the level of the scar. In unilateral harvested flaps the operated side was compared to the non-operated contra-lateral side as described. In free TRAM-flaps the mean diameter at the level 2 cm below the rib bow was 8.1 mm compared to 8.5 mm at the non-operated side. At the umbilical level the mean diameter at the side of the muscle harvesting was 5.3 compared to 9,1 mm, at the level of the scar the mean diameter was 2.9 mm compared to 8.7 mm at the contralateral side. The measurements showed the following diameters for the unilateral pedicled TRAM-flaps: 2 cm below the rib bow the mean muscle diameter was 8.3 versus 8.0 mm at the non-operated Functional and ultrasound evaluation of donor-site morbidity after TRAM-flap for breast reconstruction 81

Figure 1. Longitudinal section of the Rectus Abdominis muscle after free TRAM harvesting

Figure 2. Longitudinal section of the Rectus Abdominis muscle without harvesting

Figure 3. Cross section 2 cm below the ribcage after unilateral TRAM-ﬂap harvesting

Figure 4. Cross section at the umbilicus after unilateral TRAM-ﬂap harvesting 82 Chapter V

Figure 5. Cross section at the level of the scar after unilateral TRAM-ﬂap harvesting

Table 1. Criteria for scoring muscle power (Modiﬁed from Janda1)

Table 2. Mean muscle diameters at 2 cm below the rib cage, at the level of the umbilicus and at the level of the scar in different types of ﬂaps Functional and ultrasound evaluation of donor-site morbidity after TRAM-ﬂap for breast reconstruction 83

Table 3. Intra-individual comparison of muscle diameters: bilateral DIEP-ﬂap

Table 4. Intra-individual comparison of muscle diameters: unilateral DIEP-ﬂap

side, at the umbilical level it was 5.4 mm at the operated side compared to 7.1 mm and at the level of the scar the mean diameter was 3.3 compared to 6.4 mm. The intra-individual comparison of the mean muscle diameters is shown in table 1-4. 2. In figures 6 and 7 the ultrasound images of the Rectus Abdominis muscle is shown while relaxation and contraction. Even in the static images the difference in muscle diameter are shown. During examination even the movements of the muscle tissue can be shown. Two of three bilateral DIEP-flaps showed degree 2 of muscle contractility, 1 reached a score of 1. 1 out of 5 unilateral DIEP-flaps reached a score of 0, 1 out of 5 reached a Score of 1, 2 out of 5 showed degree 2 and 1 out of 5 showed degree 3 of muscle contractibility. Two out of eleven unilateral free TRAM-flaps reached score 0, 3 out of 6 showed score 1 and 6 out of 11 unilateral TRAM-flaps showed degree 2. 1 out of 3 patients after unilateral pedicled TRAM-flap showed a score of 0 and 2 out of 3 patients score 1 (table 5). 84 Chapter V

Figure 6. Diameter of Rectus Abdominis muscle in relaxed position

Figure 7. Diameter of Rectus Abdominis muscle during contraction

3. In the clinical evaluation by Janda 2 of 3 patients after bilateral DIEP-flap reached a score of 5 and 1 patient score 3. After unilateral DIEP-flap 3 of 5 patients reached a Janda score 5, in 2/5 patients a score of 4 was found. Four of eleven patients after unilateral free TRAM-flap showed a Janda score 5, 5/11 patients Janda 4, 1/11 patients Janda 3 and 1/11 patients Janda 2. All 3 patients after unilateral pedicled TRAM-flap reached Janda score 5. Functional and ultrasound evaluation of donor-site morbidity after TRAM-flap for breast reconstruction 85

Table 5a. Intra-individual comparison of muscle diameters: unilateral free TRAM-ﬂap

Table 5b. Intra-individual comparison of muscle diameters: unilateral free TRAM-ﬂap

4. In 2 of 3 patients after bilateral DIEP-flap a bulging of the abdominal were found. 1 patient after unilateral DIEP flap had a hernia formation and one showed a bulging. Six of eleven patients after unilateral free TRAM-flap received a abdominal bulging and 1 of 3 patients after unilateral pedicled TRAM-flap. 5. One of three patients after bilateral DIEP-flap reported a severe impairment in daily live activity and 1/3 patients a moderate impairment. After unilateral DIEP-flap 3 of 5 patients rated their impairment at 0 and 1/5 patients specified their impairment as moderate, 1/5 patients as severe. 6 of 11 patients after unilateral free TRAM-flap harvesting had no impairment in daily life activity, 2/11 86 Chapter V

had a moderate and 3/11 patients a severe impairment. 1 of 3 patients after unilateral pedicled TRAM-flap reported a moderate impairment. 2/3 patients after bilateral DIEP-flap, 1% patients after unilateral DIEP-flap, 3/11 patients after unilateral free TRAM-flap and 2/3 patients after unilateral pedicled TRAM- flap reported to have pain.

Table 6. Intra-individual comparison of muscle diameters: unilateral pedicled TRAM-ﬂap

Table 7. Contractility of remaining Rectus Abdominis Muscle*

*Score: 0, no remaining muscle tissue 1, Reduced muscle diameter, no contractility 2. Reduced muscle diameter, remaining contractility 3. Muscle diameter not reduced, remaining contractility Functional and ultrasound evaluation of donor-site morbidity after TRAM-ﬂap for breast reconstruction 87

Table 8. Correlation between subjective impairment in daily life, activity, pain, Janda scores and findings Impairment in daily Pain (yes/no) Janda (0-5) Contractility (0-3) life activity (0-5) a) bilateral DIEP-flaps Patient 1 3 yes 5 1 Patient 2 5 yes 3 2 Patient 3 0 no 5 2 b) unilateral DIEP-flaps Patient 1 0 no 5 2 Patient 2 5 yes 4 0 Patient 3 0 no 4 1 Patient 4 0 no 5 2 Patient 5 3 no 5 3 c) unilateral TRAM-flaps Patient 1 4 no 4 1 Patient 2 4 yes 2 0 Patient 3 5 yes 4 1 Patient 4 0 no 5 0 Patient 5 0 no 4 2 Patient 6 0 no 5 2 Patient 7 0 no 5 2 Patient 8 2 yes 4 2 Patient 9 0 no 5 2 Patient 10 0 no 4 2 Patient 11 3 no 3 1 d) unilateral pedicled TRAM-flaps Patient 1 0 no 5 1 Patient 2 3 yes 5 0 Patient 3 0 yes 5 1

Discussion

Functional testing of the abdominal wall as well as CT scans or MRI for evaluation of the remaining Rectus muscle are reported in literature6-12. As there is a clear need for reduction of costs in medical treatment we looked for a more cost effective evaluation method compared to CT scan or MRI. Functional ultrasound imaging of the donor site in order to evaluate the remaining Rectus Abdominis muscle is not yet reported in the literature. Our experience showed that ultrasound evaluation could show not just static images like MRI or CT-Scans, but even the movements of the tissue while contraction. 88 Chapter V

In clinical examination 12 patients reached Janda 5 including all patients after pedicled TRAM-flap although no muscle contractility was left after pedicled flaps. Janda 4 (4/22) and Janda 5 (15/22) was reached mainly after unilateral free TRAM and DIEP-flaps. These findings are comparable with literature reports where permanent muscle damage is described also after muscle sparing techniques of TRAM and DIEP-flaps2,5,7,9. Due to reports in literature the importance of careful abdominal wall closure and the influence of age on Janda functional testing is stressed5,8,9-11,14. Therefore not just the way of harvesting is important to the postoperative abdominal wall function. The results of function of the abdominal wall have although to be interpreted in the context of age of the patients as well as stability of the abdominal wall by the way of abdominal wall closure after flap harvesting.

No impairment in daily life activity was found in 12 out of 22 patients. The other patients were rated from score 2 to 5 of impairment whereas no more than one or two patients were gathered in each group. Muscle contractility due to grade 2 and 3 could be detected in 11 patients. Absent muscle contractility (degree 0 and 1) was found among all kinds of harvested ﬂaps. In this context the question rises up, if the function of the abdominal wall and the impairment of daily life can be inﬂuenced by muscle training, if remaining muscle tissue with poor contractility is shown by Ultrasound evaluation. Further studies are necessary to answer this question.

Ultrasound imaging can show contractility and movements of the remaining muscle. Therefore we consider ultrasound investigations to be superior to CT scan or MRI concerning functional evaluation and cost effectiveness. Functional and ultrasound evaluation of donor-site morbidity after TRAM-ﬂap for breast reconstruction 89

References

1. Hartrampf CR, Scheflan M and Black PW: Breast reconstruction following mastectomy with a transverse abdominal island flap. Plast. Reconstr. Surg. 69: 216; 1982 2. Lejour M, Dome M: Abdominal wall function after rectus abdominis transfer. Plast. Reconstr. Surg. 87: 1054-68; 1991 3. Koshima I, Moriguchi T, Soeda S, Tanaka H, Umeda D: Free thin paraumbilical perforator- based flaps. Ann. Plast. Surg. 29: 12-17; 1992 4. Allen RJ, Treece P: Deep inferior epigastric perforator flap for breast reconstruction. Ann. Plast. Surg. 32: 32-38; 1994 5. Hartrampf C. R. jr.: Abdominal wall competence in transverse abdominal island flap operations. Ann. Plast. Surg. 12,2: 139-146; 1984 6. Amez ZM, Khan U, Pogoretec D, Planinsek F: Rational selection of flaps from the abdomen in breast reconstruction to reduce donor site morbidity. Br. J. Plast. Surg. 52: 351-354; 1999 7. Blondeel P. N.: One hundred free DIEP-flap breats reconstructions: a personel experience. Br. J. Plast. Surg. 52: 104-111; 1999 8. Hamdi M, Weiler-Mithoff E, Webster M: Deep inferior epigastric perforator flap in breast reconstruction: Experience with the first 50 flaps. Plast. Reconstr. Surg. 103(1): 86-95; 1999 9. Futter CM, Webster MHC, Hagen S, Mitchell SL: A retrospective comparison of abdominal muscle strength following breast reconstruction with a free TRAM or DIEP flap. Br. J. Plast. Surg. 53: 578-583; 2000 10. Kroll SS, Marchello M: Comparison of strategies for preventing abdominal-wall weakness after TRAM flap breast reconstruction. Plast. Reconstr. Surg. 89 (6): 1045-1051; 1992 11. Blondeel PN, Vanderstraeten GG, Monstrey SJ, Van Landuyt K, et al.: The donor site morbidity of free DIEP-flaps and free TRAM flaps for breast reconstruction. Br. J. Plast. Surg. 50: 322-30; 1997 12. Blondeel PhN, Boeckx WD: Refinements in free flap breast reconstruction: the free bilateral deep inferior epigastric perforator flap anastomosed to the internal mammary artery. Br. J. Plast. Surg. 47: 495-501; 1994 13. Janda V.: Muskelfunktionsdiagnostik 2nd Ed. Berlin: Volk- und Gesundheit 1986 14. Zauner-Dungl A, Resch KL, Herzceg E, Piza-Katzer H: Funktionelle Defizite nach Entnahme des M. rectus abdominis. Handchirurgie Mikrochir Plast Chir 27: 83-88; 1995

Chapter VI

Analysis of Patient Satisfaction and Donor- Site Morbidity after Different Types of Breast Reconstruction Satisfaction in Breast Reconstruction

H.Ch. Benditte-Klepetko, MD1,2, F. Lutgendorff, MD, PhD2, T. KästenbauerMSc3, M. Deutinger MD4, CMAM van der Horst, MD, PhD2

1Department of Plastic and Reconstructive Surgery, Erasmus Medical Center, Rotterdam, the Netherlands, 2Department of Plastic and Reconstructive Surgery, Amsterdam Medical Center, Amsterdam, the Netherlands, 3Science Consulting & Clinical Monitoring Institution, Vienna, Austria, 4Department of Plastic and Reconstructive Surgery, Hospital Rudolfstiftung, Vienna, Austria

Analysis of Patient Satisfaction and Donor-Site Morbidity 93

Introduction

One in eight women in the United States will be faced with the diagnosis of breast cancer at some point in her life (1). Roughly one third of these women will elect to undergo mastectomy (2). And while mortality of breast cancer is decreasing due to advances in treatment strategies, incidence is steadily rising, resulting in exponen- tial increase of breast cancer survivors (1). A large percentage of these women are unhappy with the cosmetic outcome (3) of whom many are faced with the decision whether to undergo breast reconstruction. Mastectomy defects can leave deep scars both physically and mentally and there is a large body of evidence indicating improvement of self-esteem and mental health following breast reconstruction (4). However, decision-making is complicated by a multitude of options and a wide range from implant to different autologous reconstruction alternatives. As information from health care professionals is most valued for decision-making (5), outcomes research is essential to provide patients with concrete and reliable information to assist in their decision-making. Although patient satisfaction is important in all surgical disciplines, it is of pivotal importance in post-mastectomy reconstruction as its over-riding goal is to satisfy patients with respect to improvement in quality of life (QoL). As many factors besides clinical outcomes can influence patient satisfaction, both clinical outcomes and patient reported outcomes should be rigorously assessed in studies that attempt to evaluate surgical success. There is clear evidence showing that unrecognized or unfulfilled expectations regarding surgical outcomes are directly related with poor patient satisfaction and greatly influences patient’s perception of the surgical result (6, 7). On contrary, it is difficult to come by clear data regarding impact of various breast reconstruction alternatives on patient satisfaction and QoL. And these data are of grave importance to communicate to the patient in order to create realistic expectations regarding surgical outcomes (8-11). Therefore, the objective of the study herein was to evaluate patient satisfaction and donorsite morbidity in a large sample population in five common types of breast reconstruction: expander/implant, Latissimus Dorsi myocutaneous (LD)-flap, LD-flap in combination with an implant, free Transverse Rectus Abdominis Musculocutaneous (TRAM)-flap, and Deep Inferior Epigastric Perforator (DIEP)-flap. 94 Chapter VI

Material and Methods

Study design and population Patients who underwent either immediate or delayed breast reconstruction between May 2000 and October 2006 were identified from a prospective database for breast surgery patients at Hospital Rudolfstiftung, Vienna, Austria. Five different types of breast reconstruction were included in the study, i.e. expander/implant, LD-flap, LD-flap in combination with an implant, TRAM-flap, and DIEP-flap. Both unilateral and bilateral breast reconstructions were included. All surgeries were performed at the Department of Plastic and Reconstructive Surgery, Hospital Rudolfstiftung, Vienna, Austria. Patients with reconstruction for other reasons than cancer and severe comorbidities (>ASA III) were excluded from the study. The study followed the Helsinki Declaration and was approved by the Local Ethics Committee of the Medical University of Vienna. All patients gave their informed consent to participate under the guidelines of the local ethics committee. The following data were obtained: patient satisfaction using a self designed questionnaire, SF-36 and complication rate.

Assessment of patient satisfaction The women were send a study specific questionnaire and invited for a follow-up visit. Questionnaires were mailed along with self-addressed postage paid return envelopes. To maximize response rates, non-responders were mailed a reminder after 2 months. Only survey results from patients who had completed their reconstruction were included and only patients who completed QoL questionnaires were selected in the analysis. Patients were asked to score postoperative pain on a five-point scale from ‘absent’ to ‘very severe’. Also, self-reported recovery time to preoperative status was scored. In addition, patients were asked to rate their impairment in daily life and their impairment during physical exercise on a five-point scale ranging from ‘no impairment’ to ‘severe impairment’. Furthermore, patients were asked whether they were satisfied with the overall result. In responds to this question patients could choose from 3 different answers: ‘not satisfied’, ‘satisfied’ and ‘fully satisfied’. Patients who were not fully satisfied were asked to explain the reason for their incomplete satisfaction. Finally patients were asked whether they would undergo the same procedure again. This study specific questionnaire was developed based on questionnaires previously used to assess surgical procedures of the breast, including EORTC QLQ BR-23 (12) and FACT-B (13). General QoL was assessed using the validated questionnaire, Short-From 36-item health survey (SF-36) (14). This questionnaire consists of eight scaled scores, which Analysis of Patient Satisfaction and Donor-Site Morbidity 95 are weighted sums of the items in their sections. These eight scales can be divided into two clusters. Firstly, Physical Health in which physical functioning, physical role functioning, bodily pain and general health are scored. Secondly, Mental Health in which vitality, social functioning, emotional role functioning and mental health are being assessed. Additional data regarding complications were extracted from the database and clinical evaluation during the follow-up visit. Complications were categorized as being minor or major. Minor complication included clinical signs of infection, abdominal bulging/hernia, limited necrosis of the breast and delayed wound healing which was defined as prolonged healing time requiring dressing changes assisted by health personnel. Major complications comprised necrosis of most of the flap, total flap failure, and capsular contracture.

Statistical analysis Statistical analysis was performed using GraphPad Prism version 5.0 (GraphPad Software, Inc., La Jolla, CA, USA). For continuous variables, P-values were derived from ANOVA for comparing mean values between groups. When comparing two groups Student’s t-test were used. For categorical variables, P-values were derived from chi-square test for inde- pendence. P-values for variables that were calculated from a score are computed by a Kruskal-Wallis test. Values are given as mean (SEM). Statistical signiﬁcant was considered for values of p < 0.05. To calculate the odds ratio of independent risk factors for patient satisfaction, a stepwise logistic regression analysis was done. Following variables were used for the model: type of surgery, post-surgical complications, revisions, quality of daily life, and SF-36 score. Independent variables were included into the model at a level of p<0.05 and excluded at p>0.1.

Results

A total of 257 patients underwent breast reconstruction between May 2000 and October 2006. Of these woman 13 underwent a bilateral reconstruction summing up to a total of 270 breasts. Of these 257 patients, 126 returned the questionnaire and attended the follow-up visit, resulting in an overall response rate of 49.0%. Amongst the responders were 17 implant-based reconstructions (9 implant reconstructions and 8 with expanders), 69 LD-flaps (5 with and 64 without implants), 22 free TRAM-flaps, and 18 DIEP-flaps (table 1). The response rate was highest in the LD+implant group and the DIEP group, whereas patients reconstructed with 96 Chapter VI

Table 1. Characteristics Responders vs. Non-responders Responders Non-responders p† n=126 n=131 Reconstruction type p=0.14 Implant 17 (13.5%) 22 (16.8%) LD+implant 5 (4.0%) 2 (1.5%) LD 64 (50.8%) 77 (58.8%) TRAM 22 (17.5%) 22 (16.8%) DIEP 18 (14.3%) 8 (6.1%) Age, y (range) 51.6 (33-82) 53.1 (35-81) p=0.48 Laterality p=0.40 Unilateral 118 (93.7%) 126 (96.2%) Bilateral 8 (6.3%) 5 (3.8%) Follow-up, m (range) 38.4 (6-77) 35.0 (10-83) p=0.42 Complications p=0.84 Major Complications 5 (4.0%) 7 (5.3%) Minor Complications 19 (15.1%) 18 (13.7%)

implants had the lowest response rate. However these differences were not statistically signiﬁcant (p=0.14, table 2). A minimal response rate of 43.6% was obtained in all categories. Both responders and non-responders showed similar baseline characteristics regarding age and time since surgery. Average (range) age of the group that responded the survey was 51.6 (33-82) year. The average follow-up was 38.4 (6-77) months. All women were Caucasian, well educated and employed. Amongst responders, when baseline characteristics were speciﬁed per reconstruction type, it showed that all groups were of a similar average age and were on average assessed the same time after their surgery (table 2). Immediate reconstructions were more

Table 2. Baseline Characteristics per Reconstruction Type of Survey Responders Implant LD+implant LD TRAM DIEP p‡ n=17 n=5 n=64 n=22 n=18 Response rate 43.6% 71.4% 45.4% 50.0% 69.2% p=0.14 (Responders/ (17/39) (5/7) (64/141) (22/44) (18/26) total surveyed) Age y (range) 51.4 (33-82) 47.9 (40-61) 52.7 (34-74) 55.7 (37-69) 50.2 (38-78) p=0.45 Timing p=0.04a Immediate 8 (47.1%) 0 (0.0%) 26 (40.6%) 4 (18.2%) 3 (16.7%) Delayed 9 (52.9%) 5 (100.0%) 38 (59.4%) 18 (81.8%) 15 (83.3%) Laterality Unilateral 14 (82.4%) 5 (100.0%) 63 (98.4%) 21 (95.5%) 16 (88.9%) p=0.05b Bilateral 3 (17.6%) 0 (0.0%) 1 (1.6%) 1 (4.5%) 3 (11.1%) Follow-up p=0.36 m (range) 33.3 (6-76) 33.3 (8-57) 40.5 (6-86) 49.7 (13 –77) 40.4 (6–70) Recurrence rate 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) p=1.0 ‡ Bold type indicates statistical signiﬁcance. aTRAM and DIEP vs. Implant. bImplant vs. LD Analysis of Patient Satisfaction and Donor-Site Morbidity 97 frequently performed amongst implant and LD patients (p=0.04). Furthermore, implant based and DIEP-ﬂap reconstructions were more frequently performed in a bilateral fashion as compared to other groups (p=0.05). The follow-up time was similar in all groups.

Complications The overall complication rate of all 257 women in the study was 19.1% of which 14.4% was categorized as minor and 4.7% as major complications. When comparing responders to non-responders both minor and major complications occurred at a similar rate (p=0.84) (table 1). Amongst survey responders, 24 complications were scored, resulting in a complication rate of 19.0%. There are no statistical differences regarding complication rate between the groups (p=0.66, table 3). For obvious reasons capsular contracture did not occur in the autologous reconstruction groups. Flap failure and partial necrosis of the flap did not occur in implant-based groups. Revisions rates were similar in all groups (p=0.53). When comparing TRAM to DIEP, total flap loss occurred at a similar rate, however there was a higher need for reoperation in the TRAM group (18.2 vs. 11.2%), although this difference did not reach significance (p>0.05). Only in the TRAM group 1 patient suffered from bulging. When comparing implant- based reconstruction types to autologous reconstruction types, the post-operative infection rate is similar, however the need for reoperation is relatively higher in implant-based reconstruction types (13.6 vs. 9.6%), though not significantly different (p>0.05).

Table 3. Complications Implant LD+implant LD TRAM DIEP n=17 n=5 n=64 n=22 n=18 Flap failure - - 0 (0.0%) 1 (4.5%) 1 (5.6%) Partial Necrosis - - 2 (3.1%) 0 (0.0%) 0 (0.0%) Infection 1 (5.9%) 1 (20.0%) 8 (12.5%) 3 (13.6%) 0 (0.0%) Hematoma 0 (0.0%) 0 (0.0%) 2 (3.1%) 0 (0.0%) 1 (5.6%) Herniation - - - 1 (4.5%) 0 (0.0%) Capsular 2 (11.8%) 1 (20.0%) - - - Contracture Revision 2 (11.8%) 1 (20.0%) 4 (6.3%) 4 (18.2%) 2 (11.2%)

Patient Satisfaction The questionnaire revealed that there were no statistical differences between the different reconstruction types regarding postoperative pain score and the recovery time to pre-operative status (p=0.07 and p=0.06, respectively, table 4). Also the 98 Chapter VI

Table 4. Survey Results per Reconstruction Type Implant LD+implant LD TRAM DIEP p†‡ n=17 n=5 n=64 n=22 n=18 Post-operative Pain 2.35 1.00 1.81 1.77 0.83 p=0.07 (SEM) (0.52) (0.63) (0.19) (0.30) (0.19) Recovery time, w 9.47 6.40 10.03 10.09 8.11 p=0.06 (SEM) (3.17) (1.47) (0.98) (0.95) (0.90) Impairment on Daily 1.06 1.60 1.05 0.86 1.1 p= 0.68 Life (SEM) (0.31) (0.51) (0.16) (0.26) (0.37) Impairment on Physical 0.82 1.40 0.92 1.46 1.17 p= 0.27 Activity (SEM) (0.32) (0.51) (0.18) (0.29) (0.39) Satisfaction Not Satisfied 2 (11.8%) 0 (0.0%) 10 (15.6%) 0 (0.0%) 3 (16.7%) p=0.007a Satisfied 11 (64.7%) 2 (40.0%) 23 (35.9%) 4 (18.2%) 3 (16.7%) Fully Satisfied 4 (23.5%) 3 (60.0%) 31 (48.4%) 18 (81.8%) 12 (66.7%) Recommendation Yes 16 (94.1%) 4 (80.0%) 51 (79.7%) 20 (90.9%) 15 (83.3%) p=0.55 No 1 (5.9%) 1 (20.0%) 13 (20.3%) 2 (9.1%) 3 (16.7%) ‡ Bold type indicates statistical significance. aDIEP and TRAM vs. Implant

answers regarding impairment on daily life and on physical activity revealed no differences between the groups. In contrast, responses to the question regarding general satisfaction revealed that women who underwent a reconstruction with a DIEP-flap were significantly more satisfied with the overall result as compared to patients from the implant group (p=0.007). Also, TRAM and DIEP patients answered more frequent that they were ‘fully satisfied’ as compared to patients from implant-based groups (p=0.004). Finally, the results of the questionnaire showed that the majority of the patients from all groups would recommend the same type of reconstruction to a close relative or family member. This result was irrespective of the undergone reconstruction type. In addition, general QoL as assessed by SF-36 was similar amongst the groups (table 5). Accordingly, when analyzed per section, no differences between the groups were found in the section describing physical health (i.e. physical function-

Table 5. Quality of Life as surveyed by SF-36 per Reconstruction Type Implant LD+implant LD TRAM DIEP p† n=17 n=5 n=64 n=22 n=18 Physical Health 69.9% 64.8% 64.7% 68.2% 64.3% p= 0.75 (SEM) (5.4) (8.8) (2.4) (3.6) (3.3) Mental Health 77.9% 66.0% 74.8% 67.8% 70.0% p=0.80 (SEM) (6.5) (20.0) (4.4) (6.2) (7.0) Total 73.9% 65.3% 70.6% 68.1% 68.7% p=0.46 (SEM) (1.8) (7.6) (1.5) (2.9) (2.1) Analysis of Patient Satisfaction and Donor-Site Morbidity 99 ing, physical role functioning, bodily pain and general health). Also, when assessing mental health related items (i.e. vitality, social functioning, emotional role functioning and mental health), no differences were found between the different reconstruction types.

Factors in Satisfaction Multivariate analyses were used to assess the effects of different variables on patient satisfaction. To find variables that may affect satisfaction we performed univariate analysis using the study population as a whole. Variables included in the satisfaction analysis were overall complication rate, revision rate, reconstruction type, ‘impairment on daily life’ and QoL as measured by total SF-36 scores. This combined multivariate model, showed significance regarding effects on general satisfaction (p=0.029). However, when excluding ‘impairment on daily life’ from this model, no statistical significant effect was found regarding satisfaction. In contrary, when including ‘impairment on daily life’, but excluding SF-36 scores, levels of correlation with satisfaction increased. We then performed stepwise logistic regression to ensure that only those variables significantly influencing general satisfaction were included in the final logistic regression analysis. After multiple eliminations, the only factor that continued to play a significant role in general satisfaction was ‘impairment on daily life’. Patients who reported a greater impairment on daily life had decreased odds of being satisfied (OR 0.6, 95% CI 0.40-0.91, p=0.017). Both reconstruction type, and complication rate and revision rate failed to show a statistical significant correlation with general satisfaction levels.

Discussion

This study assessed long-term patient satisfaction in 126 post-mastectomy patients with ﬁve different types of breast reconstruction. Our results indicate that, in contrary to operation type, complication rate and revision rate, only ‘impairment on daily life’ was independently correlated with patient satisfaction. As body image and physical integrity is of pivotal importance in QoL, it is of no surprise that there is a vast body of evidence showing the devastating effects of breast cancer and cancer-related mastectomy on QoL (15-17). Breast reconstruction has been shown to signiﬁcantly ameliorate this burden on mental well-being and body image (18-19). However there still is controversy over factors being involved in patient satisfaction after breast reconstruction. In our study, the overall major complication rate of 4.0% is within range of what is reported in literature (20-22). Several studies that assessed correlations between 100 Chapter VI

patient satisfaction and complications have shown a lack of correlation between the two (21-22). In line with these previous studies, when analyzing our data by logistic regression, complication rate did not show to be an independent factor in patient satisfaction. Contradictory, recent work by Colakoglu et al. (20) shows that patients having a complication from breast reconstruction were about 60 percent more likely to be aesthetically dissatisfied than those without a complication. This discrepancy could be explained by the difference in follow-up, which was on average 23.3 months in Colakoglu’s study vs. 38.4 months in our study. It has been well documented that post-reconstruction satisfaction rates decline over time (23). Therefore, when analyzing long-term patients satisfaction, it might be increasingly more difficult to show differences in satisfaction. Even though reconstruction type and its effect on patient satisfaction had been an extensively studied topic (24). There is no general consensus on how the type of reconstruction being performed correlates with patient satisfaction. However, an increasing body of evidence is elucidating certain aspects of this topic. There is a general consensus suggesting that autologous reconstructions results in significantly increased patient satisfaction when compared to implant-based reconstructions (11, 25). This is in line with our findings showing that women who underwent an autologous reconstruction were significantly more ‘fully satisfied’ as compared to women undergoing a reconstruction solely using an implant. However this did not show in QoL scores nor did this reflect whether women would recommend their chosen procedure to other women. Moreover, there was no significant correlation between patient satisfaction and type of reconstruction. When comparing patient satisfaction of LD patients to patients who underwent an abdominal based reconstruction, our data failed to show significant differences regarding general satisfaction and QoL scores. This is similar to data reported by Spear et al. (10), showing no difference in patient satisfaction in a population of 79 breast reconstruction patients of which 13 LD-based reconstructions. Also, Brand- berg et al. (27) showed in a prospective randomized trial no correlation between satisfaction and type of reconstruction in 75 patients (pedicled TRAM vs. LD-flap vs. lateral thoracodorsal flap). Conversely, there are data indicating a significant difference in patient satisfaction between LD and abdominal-based reconstructions (21). However, in this study the majority of LD patients was reconstructed also utilizing an implant (90 with vs. 26 without). As patients who underwent an LD+implant based reconstruction can have complications from the autologous tissue as well as from the implant, these satisfaction levels might resemble implant based satisfaction levels. This possibly explains the found difference in patient satisfaction in their study. Previous studies examining outcomes of abdominal flap reconstruction have analyzed differences in abdominal wall function, donor site morbidity, hospital stay, and Analysis of Patient Satisfaction and Donor-Site Morbidity 101 complication rate. Few data, however, can be found on patient satisfaction comparing abdominal based reconstructions. In a recent study by Momoh et al. (28) 120 DIEP patients were compared to 114 pedicled TRAM patients. Authors were able to show a significant difference in general satisfaction in favor of DIEP. However, when assessing aesthetical satisfaction in the aforementioned study, no significant differences were found. Conversely, our data show no differences between free TRAM and DIEP reconstructions regarding general satisfaction or QoL. Although free and pedicled TRAM-flaps showed similar satisfaction scores in a previous study (26), differences might rely in the fact that our study was a head to head comparison of free TRAM vs. DIEP instead of pedicled TRAM vs. DIEP. On the other hand, greater impairment in abdominal wall function in TRAM as compared to DIEP patients has been described in previous literature (29). Therefore, a questionnaire with more specific questions addressing abdominal donor site morbidity might have resulted in a difference in patient satisfaction between TRAM and DIEP reconstructions. A number of limitations to the study herein ought to be addressed. Firstly, for obvious ethical reasons patients cannot be randomized for reconstruction type. Therefore, one unavoidable limitation is selection bias. Another inherent limitation in questionnaire-based studies is responder bias. Although, in baseline responders were in all characteristics and complication rates comparable to non-responders, it is still possible that highly satisfied or highly dissatisfied patients were more willing to respond to the questionnaire. Also, our data need to be replicated by a valid and reliable, surgery specific patient reported outcome measure, such as BREAST-Q (30). Unfortunately, as the BREAST-Q was only available in English at the start of the study, this questionnaire could not be employed in this German speaking patient population. In conclusion, the study herein indicates that neither complication rate, nor operation type are independent predictors of patient satisfaction. The fact that only ‘impairment in daily life’ correlated with satisfaction reflects that patient satisfaction is very much determined by subjective patient experiences of every day living. However, in order to be able to improve outcome and specifically satisfaction, future studies focusing on elucidating pre-operative factors affecting those post-operative daily experiences are needed. Perhaps research fields such as patient education (31), patient expectations, and personality characteristics deserve thorough attention in the context of breast reconstruction. In the end, it is our responsibility to guide patients through the decision making process regarding their individual needs. 102 Chapter VI

References

1. De Angelis R, Tavilla A, Verdecchia A, et al. Breast cancer survivors in the United States: geographic variability and time trends, 2005-2015. Cancer 115: 1954-1966, 2009. 2. Barlow WE, Taplin SH, Yoshida CK, et al. Cost comparison of mastectomy versus breast- conserving therapy for early-stage breast cancer. J Natl Cancer Inst 93: 447-455, 2001. 3. Wang J, Kollias J, Boult M, et al. Patterns of surgical treatment for women with breast cancer in relation to age. Breast J 16: 60-65, 2010. 4. Cordeiro PG. Breast reconstruction after surgery for breast cancer. N Engl J Med 359: 1590- 1601, 2008. 5. Wolf L. The information needs of women who have undergone breast reconstruction. Part I: decision-making and sources of information. Eur J Oncol Nurs 8: 211-223, 2004. 6. Stambough JL. Matching patient and physician expectations in spine surgery leads to improved outcomes. Spine J 1: 234, 2001. 7. Eisler T, Svensson O, Tengstrom A, et al. Patient expectation and satisfaction in revision total hip arthroplasty. J Arthroplasty 17: 457-462, 2002. 8. Yueh JH, Slavin SA, Adesiyun T, et al. Patient satisfaction in postmastectomy breast reconstruction: a comparative evaluation of DIEP, TRAM, latissimus flap, and implant techniques. Plast Reconstr Surg 125: 1585-1595, 2010. 9. Kalaaji A, Bruheim M. Quality of life after breast reconstruction: comparison of three methods. Scand J Plast Reconstr Surg Hand Surg 44: 140-145, 2010. 10. Spear SL, Newman MK, Bedford MS, et al. A retrospective analysis of outcomes using three common methods for immediate breast reconstruction. Plast Reconstr Surg 122: 340-347, 2008. 11. Saulis AS, Mustoe TA, Fine NA. A retrospective analysis of patient satisfaction with immediate postmastectomy breast reconstruction: comparison of three common procedures. Plast Reconstr Surg 119: 1669-1676; discussion 1677-1668, 2007. 12. Sprangers MA, Groenvold M, Arraras JI, et al. The European Organization for Research and Treatment of Cancer breast cancer-specific quality-of-life questionnaire module: first results from a three-country field study. J Clin Oncol 14: 2756-2768, 1996. 13. Brady MJ, Cella DF, Mo F, et al. Reliability and validity of the Functional Assessment of Cancer Therapy-Breast quality-of-life instrument. J Clin Oncol 15: 974-986, 1997. 14. Ware JE Jr., Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Concep- tual framework and item selection. Med Care 30: 473-483, 1992. 15. Al-Ghazal SK, Fallowfield L, Blamey RW. Does cosmetic outcome from treatment of primary breast cancer influence psychosocial morbidity? Eur J Surg Oncol 25: 571-573, 1999. 16. Montazeri A, Vahdaninia M, Harirchi I, et al. Quality of life in patients with breast cancer before and after diagnosis: an eighteen months follow-up study. BMC Cancer 8: 330, 2008. 17. Elder EE, Brandberg Y, Bjorklund T, et al. Quality of life and patient satisfaction in breast cancer patients after immediate breast reconstruction: a prospective study. Breast 14: 201- 208, 2005. 18. Roth RS, Lowery JC, Davis J, et al. Psychological factors predict patient satisfaction with postmastectomy breast reconstruction. Plast Reconstr Surg 119: 2008-2015; discussion 2016-2007, 2007. 19. Colakoglu S, Khansa I, Curtis MS, et al. Impact of complications on patient satisfaction in breast reconstruction. Plast Reconstr Surg 127: 1428-1436, 2011. Analysis of Patient Satisfaction and Donor-Site Morbidity 103

20. Ramon Y, Ullmann Y, Moscona R, et al. Aesthetic results and patient satisfaction with immediate breast reconstruction using tissue expansion: a follow-up study. Plast Reconstr Surg 99: 686-691, 1997. 21. Krueger EA, Wilkins EG, Strawderman M, et al. Complications and patient satisfaction following expander/implant breast reconstruction with and without radiotherapy. Int J Radiat Oncol Biol Phys 49: 713-721, 2001. 22. Hu ES, Pusic AL, Waljee JF, et al. Patient-reported aesthetic satisfaction with breast reconstruction during the long-term survivorship Period. Plast Reconstr Surg 124: 1-8, 2009. 23. Serletti JM, Fosnot J, Nelson JA, et al. Breast reconstruction after breast cancer. Plast Reconstr Surg 127: 124e-135e, 2011. 24. Alderman AK, Wilkins EG, Lowery JC, et al. Determinants of patient satisfaction in postmastectomy breast reconstruction. Plast Reconstr Surg 106: 769-776, 2000. 25. Brandberg Y, Malm M, Blomqvist L. A prospective and randomized study, “SVEA,” comparing effects of three methods for delayed breast reconstruction on quality of life, patient-defined problem areas of life, and cosmetic result. Plast Reconstr Surg 105: 66-74; discussion 75-66, 2000. 26. Benditte-Klepetko H, Sommer O, Steinbach R, et al. Clinical and ultrasound evaluation of donor site morbidity after tram-flap for breast reconstruction. Microsurgery 24: 174-181, 2004. 27. Momoh AO, Colakoglu S, Westvik TS, et al. Analysis of Complications and Patient Satisfac- tion in Pedicled Transverse Rectus Abdominis Myocutaneous and Deep Inferior Epigastric Perforator Flap Breast Reconstruction. Ann Plast Surg, 2011. 28. Pusic AL, Klassen AF, Scott AM, et al. Development of a new patient-reported outcome measure for breast surgery: the BREAST-Q. Plast Reconstr Surg 124: 345-353, 2009. 29. Spector D, Mayer DK, Knafl K, et al. Not what I expected: informational needs of women undergoing breast surgery. Plast Surg Nurs 30: 70-74; quiz 75-76, 2010.

Chapter VII

Correlation between MRI results and intraoperative ﬁndings in silicone breast implants

Nicole Lindenblatt MD1, Karem El Rabadi MD2, Thomas Helbich MD2, Heinrich Czembirek MD3, Maria Deutinger MD4,Heike Benditte-Klepetko MD5

1Division of Plastic and Hand Surgery, Department of Surgery, University Hospital Zurich, Zurich, Switzerland. 2Department of Radiology, Universitiy of Vienna, Vienna, Austria 3Department of Radiology, Hospital Wiener Privatklinik, Vienna, Austria 4Department of Plastic and Reconstructie Surgery, Hospital Rudolfstiftung, Vienna, Austria 5Department of Plastic and Reconstructive Surgery, Erasmus Medical Center, Rotterdam, The Netherlands

Correlation between MRI results and intraoperative ﬁndings in silicone breast implants 107

Introduction

The total number of patients with breast implants worldwide is estimated to be between 5 and 10 million by the U.S. Food and Drug Administration.1 Approxi- mately 250,000 to 340,000 people in the United States receive breast implants each year.2 The most frequent long-term complications of implant placement include capsular contracture and implant rupture. Rupture is deﬁned as a disruption of the implant shell, including focal rupture to large tears and may be the result of trauma, deterioration of implant shell with time, or manufacturing defects. Plastic surgeons are responsible for dealing with questions about potential negative health effects in case of undetected implant rupture. Therefore implant integrity and silent implant ruptures are important issues. In addition it has been questioned repetitively whether women with ruptured implants may be at risk for immunologic reactions due to the exposed free silicone entailing systemic diseases.3,4 Several imaging methods, including mammography, ultrasonography, computer tomography and magnetic resonance imaging (MRI) have been used to assess the integrity of breast implants. In previous studies MRI has proven to be superior in detection of breast implant rupture compared to other methods.5-8 Because progress in detection of rupture has not been accompanied by knowledge of the frequency and severity of complications associated with rupture, there still is discussion about the appropriate way to deal with presumed implant ruptures detected on MRI exams in symptomatic and asymptomatic patients. In case of false positive MRI diagnosis, i.e. examen positive for implant rupture without correlation at time of explantation, the potential for unnecessary surgical interventions is a cause of concern. On the other hand, false negative MRI results, i.e. failure to detect an actually present implant rupture may expose the patient to potential negative sequelae of extracapsular implant rupture and silicone migration. Therefore it was the aim of the presented study to investigate the congruence of MRI results and intraoperative ﬁndings in the diagnosis of breast implant rupture in both symptomatic and asymptomatic patients. Furthermore we aimed at simulating potential causes for the appearance of false implant rupture signs by experimental implant dissection.

Materials and Methods

Patients 50 consecutive patients with 85 silicone gel ﬁlled breast implants consulting the outpatient clinic from July 2001 until April 2003, were included into the study. 108 Chapter VII

Of those 50 patients, 25 previously underwent implantation of silicone gel-ﬁlled breast prostheses for reconstructive and 25 for cosmetic reasons. All patients with cosmetic breast augmentation had bilateral breast implants, while patients after breast reconstruction had unilateral implants. The mean age of the patients was 51 years (range 21–72 years) with a mean duration of implant presence of 3.8 years (range 0.2-28 years). In all patients a clinical examination was performed followed by MRI of the breasts.

Clinical examination All patients received a standardized clinical breast exam by a physician. As clinical symptoms of potential implant rupture the appearance of visible folds, shape change or volume reduction of the implant, capsular contracture and pain were deﬁned as criteria (Fig. 1 A and B).

Figure 1. Patient presenting with clinical symptoms indicated by (A) visible rippling and form change of the implant and (B) capsular contracture Grade 4.

MRI All MR-scans were performed on a 1.0T MR Scanner (Gyroscan, T10-NT, Philips Medical System, Eindhoven, The Netherlands) using a dedicated breast coil in prone position. The imaging protocol consisted of 5 sequences including a T2- weighted turbo-spin-echo sequence in axial and sagittal plane, a 3-dimensional T2- weighted fast-field-echo in sagittal plane, a T1-weigthed turbo-spin-echo sequence in sagittal plane and an 3-dimensional T1-weigthed fast-field-echo sequence. Both T1- and T2-weighted fast-field-echo sequences used water suppression for better visualization of silicone. MR images were read and interpreted before surgery by two independent experienced radiologists. Signs for intracapsular rupture of the implant were the keyhole and the linguine sign. The keyhole sign (also known as Correlation between MRI results and intraoperative findings in silicone breast implants 109

Figure 2. (A) MRI image of the keyhole or inverted teardrop sign indicating intracapsular free silicone trapped in a fold of the implant shell (B). MRI image of the linguine sign caused by a collapsed rupture of the implant shell, which then floats within the liquid silicone gel (C). For comparison not pathological complex radial folds of the implant in the MRI by outer compression of an intact silicone gel-filled breast implant. inverted teardrop sign) results from extraprothetic silicone gel trapped in an invagi- nation of the implant shell after interruption of the envelope (Fig. 2A). It represents an uncollapsed rupture in which the silicone shell still covers the viscous core of the implant. On the other hand the linguine sign is represented by multiple curvilinear low signal intensity lines seen within the high signal intensity silicone gel (Fig. 2B). The curvilinear lines represent the collapsed implant shell floating within the silicone gel surrounded by the fibrous capsule.9 In contrast to this are radial folds of the implant usually seen during MRI, which are of no pathological value (Fig. 2C).

Intraoperative diagnosis For intraoperative diagnosis we removed the implants within their fibrous capsule to prevent iatrogenic damage of the implant shell. The implant capsule was then opened carefully. Criteria to determine an implant rupture at time of explantation were a ruptured implant shell with silicone leakage and/or subsequent calcifica- tions of the fibrous capsule. In case of a false positive MRI result we additionally performed ultrasound imaging of the harvested implant.

Experimental simulation of implant rupture signs By outer compression of a new unused implant we produced complex radial folds in the MRI to analyse the source of a false positive keyhole sign. Additionally we separated the different shell layers of new silicone gel ﬁlled breast implants by microsurgical preparation to analyse the potential underlying cause of a false positive linguine sign. The implants then were examined by MRI to verify their imaging. 110 Chapter VII

Results

Clinical examination 19 out of 50 (38%) patients displayed at least one of clinical symptom at time of examination. Out of these 19 patients 17 patients were operated with the suspicion of implant rupture.

MRI The MRI results showed signs of rupture in 17 out of 50 patients (34%) and in 22 out of 85 implants (26%). 10 out of these 17 patients (59%) with presumed implant rupture did not exhibit any clinical symptoms, while 7 patients (41%) showed clinical signs of implant rupture. In 22 implants with signs of implant rupture, 12 implants (55%) were symptomatic, while 10 implants (45%) were asymptomatic (Fig. 3A). Of these 22 implants 19 implants were diagnosed with linguine signs and 3 with keyhole signs in the MRI as signs for implant rupture (Fig. 3B). 8 out of 19 (42%) implants with linguine signs and 2 out of 3 (67%) implants showing the keyhole sign had been asymptomatic.

Figure 3. Results of the MRI screening of 50 consecutive patients: (A) 22 out of 85 implants exhibited signs of rupture, while 63 did not. In patients with positive MRI 55% were symptomatic, while 11% in patients with negative MRI were. (B) In the MRI most implants were judged to exhibit the linguine sign, of those 61% were symptomatic.

Intraoperative diagnosis Of the 17 patients with a positive MRI exam, 12 patients underwent surgical removal of the implants. The remaining 5 patients were all asymptomatic and refused to undergo surgery. Alltogether 17 implants were removed. Intraoperatively in 7 out of 17 (41%) explanted breast implants the suspected rupture was confirmed. Of these 7 patients 4 (57%) had been symptomatic. In 10 out of 17 patients (59%) no implant rupture was identified during the operation. Of these 10 patient 9 patients (90%) Correlation between MRI results and intraoperative findings in silicone breast implants 111

Figure 4. Intraoperative ﬁndings after implant removal of 17 of 22 implants with a positive MRI result. had been symptomatic before (Fig. 4). In the ultrasound imaging of the harvested implants we found signs of interrupted inner layers of the implant shell despite the integrity of the outer shell (Fig. 5 A-C).

Figure 5. Ultrasound imaging: (A) Three separate shell layers can be identiﬁed in an intact silicone gel breast implant. (B) Silicone gel found in between the dissolving shell layers of a harvested implant with positive linguine sign in the MRI. (C) Broken inner shell layer ﬂoating in the intraluminal silicone gel of an implant with linguine sign in the MRI.

Experimental simulation of implant rupture signs Fig. 2C shows the MRI of an unused intact silicone gel-filled breast implant, which has been compressed during MRI exam. The simulated complex radial folds are difficult to differentiate from the keyhole sign. As seen in the ultrasound imaging of a new un-ruptured implant (Fig. 5A) the shell consists of 3 different layers. In implants with positive linguine sign in the MRI we found alterations in this shell structure with silicone gel in between these layers (Fig. 5B). In one case we were able to find the broken inner layer floating in the silicone gel (Fig. 5C). In order to experimentally simulate the linguine sign an intact unused silicone-gel filled breast implant was dissected by a clean cut of the shell. Then the different layers of the implant were dissected and the shell then closed again with sutures 112 Chapter VII

Figure 6. (A) Microsurgical separation of the different shell layers and (B) suture of the outer layer (C) Low signal intensity line in the high signal intensity silicone gel seen in MRI after microsurgical separation of the shell layers mimicking the linguine sign.

(Fig. 6 A and B). The MRI of the microsurgical prepared implant showed a low signal intensity line in the high signal intensity silicone gel mimicking the linguine sign (Fig. 6C).

Discussion

Ever since the introduction of silicone gel breast implants in the early 1960s plastic surgeons have been faced with the short and long-term consequences. Among the various sequelae of breast implant placement capsular contracture, asymmetry and implant malposition are the most frequent.11 However, the possibility of implant rupture and potential leakage of silicone into the body has been of continuous interest. In 2010, of the nearly 300,000 breast augmentations and 93,000 breast reconstructions performed in the United States, 51% and 59%, respectively, were performed with silicone implants.11 It can be assumed that these numbers are con- siderably higher in other western countries, in which no temporary ban on the use of silicone implants was in effect. Rupture of silicone implants was reported in 8% in asymptomatic women12 and in about 33% in symptomatic women.13-15 Typically symptoms are defined as the presence of new onset of pain, capsular contracture, form changes of the implant and breast asymmetry. Implant rupture in asymptomatic patients usually is suspected during routine screening imaging.2 The risk for implant rupture raises with the age of the implant. A rupture prevalence of 30% at implant age of 5 years, 50 % at 10 years, and 70% at 17 years have been reported.15 The median age of implant at rupture has been estimated to be 10.8 years.12,16 The clinical diagnosis of implant rupture in general is difficult considering the mani- foldness of potential clinical rupture signs. The sensitivity of physical examination of Correlation between MRI results and intraoperative findings in silicone breast implants 113 the breast only for implant rupture was shown to be as low as 30%17 Therefore MRI has evolved to become the number one imaging tool to discover both intra- and extracapsular implant rupture over the last 10 years. Mammography and computer tomography have been abandoned due to specific drawbacks, like risk of implant damage and radiation exposure.2 Ultrasound imaging may be the future. However, ultrasound imaging is very operator-dependent and the detection of intracapsular rupture largely relies on the experience of the examiner.18 In light of this it was the aim of the presented study to investigate the ability of MRI screening in 50 consecutive patients to accurately detect implant rupture. However, due to the fact, that only 12 out of 17 symptomatic women underwent implant removal, and not all women examined by MRI, statistical variables like sensitivity and specifity were not defined. The explantatiopn of all implants, e.g. also in asymptomatic women with a negative MRI screening would not have been clinically feasible. We found a strikingly low correlation between supposed implant rupture in the MRI exam and the intraoperative implant condition. A positive MRI finding was congruent with an implant rupture only in 41% of the cases, while the MRI result was false positive in 59% of implants. Moreover, of the above mentioned 59% intact implants, 90% had been symptomatic. This clearly demonstrates, that there was no coherence between clinical symptoms and actual presence of implant rupture in the study population. However, MRI still is assumed to be the best imaging modality available to diagnose implant rupture, with a reported sensitivity and specificity of more than 90 percent.5,9,17,19 Implant rupture basically is divided into two categories: extracapsular rupture referring to free silicone outside the fibrous capsular formed by the body around the implant, and intracapsular rupture in which the silicon gel is still contained within the fibrous capsule.9 80-90% percent ruptures are intracapsular ruptures.5,20 The most recent so-called third generation silicone gel implants, which were introduced in the late 1980s, consist of a cohesive viscous silicone gel encap- sulated in a silicone shell. The older second generation silicone gel breast implants that were implanted before the late 1980s, consist of a shell filled with less viscous silicone gel. Based on the fact that the composition of implant core is different, each implant generation exhibits specific MRI findings for detection of an implant rupture. The second generation of silicone gel implants tends to give the image of the classic collapsed implant shell floating in the more liquid silicone core creating the linguine sign. On the contrary the third generation of silicone gel implants consiting of a more cohesive silicone gel typically shows an uncollapsed rupture creating the keyhole sign. Therefore third generation implants will rarely depict the totally collapsed implant shell creating the linguine sign.9,21 114 Chapter VII

In the presented study patients in average had the implant in place for 3.8 years with a range from 0.2 to 28 years. This means that the large majority of patients had implants belonging to the third generation and were implanted in the 1990s, even though a small number of patients may have carried second generation implants. Overall in 18 implants the linguine sign was diagnosed in the MRI and in only 2 implants the keyhole sign. Based on the above mentioned assumptions it is highly likely that most changes of the breast implant inner structure that were interpreted as linguine sign indicating the silicone shell floating in the liquid gel, were actually artifacts caused by tears in the more cohesive gel of the third generation implants. The implant shell itself in these cases was intact. By ultrasound we were able to show tears in the viscous silicone gel. In an attempt to mimick possible artifacts during breast MRI, we compressed an intact silicone implant yielding deep folds in the MRI, which could be misjudged as keyhole signs. Secondly the microdissection of the implant shell from the cohesive silicon core in a third generation implant lead to the appearance of curvedlinear lines similar to the linguine sign in the MRI exam. Therefore many in MRI diagnosed linguine signs actually may merely be tears within the highly-cohesive gel of third generation implants without rupture of the implant shell. These findings should be taken into consideration by radiologists occupied with breast implant rupture diagnostic today. The linguine sign even today often is judged as a typical sign for intracapsular rupture ignoring the fact that most implants likely belong to the third generation, which will rarely exhibit this particular sign of rupture. A microscopic silicone leakage through an intact implant shell is referred to as gel bleed.5,22 The majority of gel bleeds cannot be detected by magnetic resonance imaging. If a larger amount of gel bleed collects in a radial fold of the implant, the keyhole sign can develop. In a study performed by Chung et al. in asymptomatic women and a low prevalence of rupture (8%), the predictive value of a positive test was low for both ultrasound (19%) and magnetic resonance imaging (20 %). On the other hand, in symptomatic women, with a prevalence of 33 percent, the predictive value of a positive test was higher for both ultrasound (68%) and magnetic resonance imaging (81 %).2 This means that these modalities are better in detecting implant ruptures in a study population exhibiting a high incidence and do not perform well as pure screening modalities. Therefore, in the general population of women having silicone breast implants and in which the prevalence of implant rupture is significantly lower, the positive predictive value of magnetic resonance imaging is too low to make it suitable as a screening method.23 This again is supported by the results of our study. In symptomatic implants the MRI was able to accurately identify implant rupture in 55% of the cases, while it was able to do this in the asymptomatic group in only 11% of the cases. Correlation between MRI results and intraoperative findings in silicone breast implants 115

Any unnecessary explantation of a breast implant can result in considerable aesthetic impairment and potential perioperative and anesthesia-related complications. Moreover, it is to be avoided from an economic point of view. The national average for surgeon/physician fees in 2010 for breast augmentation was $3351 and for removal it was $2288 in 2010.11 After the US Food an Drug Administration (FDA) repermitted the use of silicone gel filled breast implants in 2006, they recommended yearly MRI screening in all women carrying silicone breast implants to rule out asymptomatic ruptures.23 However, the consequences of silent silicone implant rupture have been shown to be minimal in a prospective study in 271 women with cosmetic breast implants.24 In this study the majority of the women with implant rupture had no visible magnetic resonance imaging changes of their ruptured implants over a time period of 2 years. In 11% of implants the authors observed progression of silicone migration, either as a conversion from intracapsular into extracapsular rupture, as progression of extracapsular silicone or as increasing herniation of the silicone within the fibrous capsule. However, in most cases, these changes were minor. In the same study no increase in levels of autoantibodies during the study period in either study group was seen. From their results the authors concluded that rupture is a “relatively harmless condition, which only rarely progresses and gives rise to notable symptoms”.24 Song et al. studied the diagnostic accuracy of MRI examinations regarding breast implant rupture. They found that most studies using MRI and ultrasound examined symptomatic subjects and therefore had 14- fold higher diagnostic accuracy to studies using an asymptomatic sample.25 This undelines the lack of proof that routine screening of patients with breast implants will results in proper detection of implant ruptures. Likewise McCarthy et al. stress this aspect in their evaluation of the suitability of MRI screening to provide health benefits to women with breast implants.26 The consequences of the two types of implant rupture have to be considered when making decisions. In asymptomatic patients with an implant rupture, the integrity of the implant shell becomes impaired yet there are no symptoms experienced by the patient and no obvious shape changes of the breast or the implant. In contrast to this, in patients with a symptomatic rupture silicone gel leaks from the implant shell into the intracapsular and/or extracapsular space, which results in a change in breast appearance and/or the development of silicone granulomas or axillary lymphadenopathy.26-28 Concludingly, sole reliance on MRI findings in asymptomatic patients most likely will result in a larger number of unnecessarily explanted implants. On the other hand pure clinical examination will be limited in acurately and definitely confirming or ruling out a potential implant rupture. Therefore the decision to re-operate a patient has to be made carefully and in agreement with the patient after all advan- 116 Chapter VII

tages and disavantages as well as risks of such a procedure have been weighted up. The tolerance level of each individual patient for insecurity regarding a potentially silently ruptured silicone implant within the body also should be taken into account. If the patient decides against the explantation close clinical and radiological examinations of the breast should be performed to detect possible progression of a silicone leak. Correlation between MRI results and intraoperative ﬁndings in silicone breast implants 117

References

1. U.S. Food and Drug Administration. FDA approves siliconegel-filled breast implants after in-depth evaluation. Available at: http://www.fda.gov/NewsEvents/Newsroom/ Press. An- nouncements/2006/ucm108790.htm. Accessed November 2, 2011. 2. Chung KC, Malay S, Shauver MJ, Kim HM. Economic analysis of screening strategies for rupture of silicone gel breast implants. Plast Reconstr Surg. 2012; 130: 225-37. 3. Press RI, Peebles CL, Kumagai Y, Ochs RL, Tan EM. Antinuclear autoantibodies in women with silicone breast implants. Lancet. 1992; 340: 1304-7. 4. Holmich LR, Lipworth L, McLaughlin JK, Friis S. Breast implant rupture and connective tissue disease: a review of the literature. Plast Reconstr Surg. 2007; 120 (7 Suppl 1): 62S-69S. 5. Gorczyca DP. MR imaging of breast implants. Magn Reson Imaging Clin N Am. 1994;2: 659-72. 6. Ikeda DM, Borofsky HB, Herfkens RJ, Sawyer-Glover AM, Birdwell RL, Glover GH. Silicone breast implant rupture: Pitfalls of magnetic resonance imaging and relative efficacies of magnetic resonance, mammography, and ultrasound. Plast Reconstr Surg. 1999;104: 2054-62. 7. Caskey CI, Berg WA, Hamper UM, Sheth S, Chang BW, Anderson ND. Imaging spectrum of extracapsular silicone: Correlation of US, MR imaging, mammographic, and histopathologic findings. Radiographics. 1999; 19 Spec No: S39-51. 8. Cher DJ, Conwell JA, Mandel JS. MRI for detecting silicone breast implant rupture: Meta- analysis and implications. Ann Plast Surg. 2001; 47: 367-80. 9. Gorczyca DP, Gorczyca SM, Gorczyca KL. The diagnosis of silicone breast implant rupture. Plast Reconstr Surg. 2007; 120 (7 Suppl 1): 49S-61S. 10. Hvilsom GB, Holmich LR, Henriksen TF, Lipworth L, McLaughlin JK, Friis S. Local complications after cosmetic breast augmentation: results from the Danish Registry for Plastic Surgery of the Breast. Plast Surg Nurs. 2010; 30: 172-9. 11. American Society of Plastic Surgeons. National clearinghouseof plastic surgery procedural statistics. Available at: http://www.plasticsurgery.org/news-and-resources/statistics.html. Accessed October 20, 2011. 12. Heden P, Nava MB, van Tetering JP, et al. Prevalence of rupture in Inamed silicone breast implants. Plast Reconstr Surg. 2006; 118: 303-8. 13. Goodman CM, Cohen V, Thornby J, Netscher D. The life span of silicone gel breast implants and a comparison of mammography, ultrasonography, and magnetic resonance imaging in detecting implant rupture: A meta-analysis. Ann Plast Surg. 1998; 41: 577-85. 14. Kessler DA. The basis of the FDA’s decision on breast implants. N Engl J Med. 1992;326: 1713-5. 15. Netscher DT, Weizer G, Malone RS, Walker LE, Thornby J, Patten BM. Diagnostic value of clinical examination and various imaging techniques for breast implant rupture as determined in 81 patients having implant removal. South Med J. 1996; 89: 397-404. 16. Marotta JS, Widenhouse CW, Habal MB, Goldberg EP. Silicone gel breast implant failure and frequency of additional surgeries: Analysis of 35 studies reporting examination of more than 8,000 explants. J Biomed Mater Res. 1999; 48: 354-64. 17. Holmich LR, Fryzek JP, Kjøller K, et al. The diagnosis of silicone breast-implant rupture: clinical findings compared with findings at magnetic resonance imaging. Ann Plast Surg. 2005; 54: 583-9. 118 Chapter VII

18. Azavedo E, Bone B. Imaging breasts with silicone implants. Eur Radiol. 1999; 9: 349-55. 19. Everson LI, Parantainen H, Detlie T, et al. Diagnosis of breast implant rupture: imaging findings and relative efficacies of imaging techniques. AJR Am J Roentgenol. 1994; 163: 57-60. 20. Gorczyca DP, DeBruhl ND, Mund DF, Bassett LW. Linguine sign at MR imaging: Does it represent the collapsed silicone implant shell? Radiology. 1994; 191: 576-7. 21. Collis N, Sharpe DT. Silicone gel-filled breast implant integrity: A retrospective review of 478 consecutively explanted implants. Plast. Reconstr. Surg. 2000; 105: 1979-85 22. .Middleton MS, McNamara MP, eds. Breast Implant Imaging, Philadelphia: Lippincott Wil- liams & Wilkins; 2003. 23. Anaplastic Large Cell Lymphoma (ALCL) In Women with Breast Implants: Preliminary FDA Findings and Analyses. Center for Devices and Radiological Health U.S. Food and Drug Administration, 2011 24. Holmich LR, Vejborg IM, Conrad C, et al. Untreated silicone breast implant rupture. Plast Reconstr Surg. 2004; 114: 204-14. 25. Song JW, Kim HM, Bellfi LT, Chung KC. The effect of study design biases on the diagnostic accuracy of magnetic resonance imaging for detecting silicone breast implant ruptures: A meta-analysis. Plast Reconstr Surg. 2011; 127: 1029-44. 26. McCarthy CM, Pusic AL, Kerrigan CL. Silicone breast implants and magnetic resonance imaging screening for rupture: do U.S. Food and Drug Administration recommendations reflect an evidence-based practice approach to patient care? Plast Reconstr Surg. 2008;121: 1127-34. 27. Teuber SS, Reilly DA, Howell L, Oide C, Gershwin ME.Severe migratory granulomatous reactions to silicone gel in 3 patients. J Rheumatol. 1999; 26: 699-704. 28. Brown SL, Pennello G, Berg WA, Soo MS, Middleton MS.Silicone gel breast implant rupture, extracapsular silicone, and health status in a population of women. J Rheumatol. 2001; 28: 996-1003. Chapter VIII

General discussion and conclusions

General discussion and conclusions 121

General discussion

The complexity of care surrounding women seeking breast surgery, like the wide variety of surgical modalities, or the accompaning socioeconomic aspects, lead to the diverse investigations presented here, in an attempt to understand the inﬂu- ence of breast surgery on beauty and health of women.

Hypertrophy of the breast

Psychological and functional impairment in breast hypertrophy The motivation of women to undergo reduction mammaplasty is usually based on both physical as well as psychological reasons. As reported in many previous studies, macromastia is, in fact, the cause of an array of physical symptoms: such as back, neck and shoulder pain, due to posture alteration from the downward pull of heavy breasts, or pressure grooves from the bra straps, Mastodynia, difficulties in sports, maceration and intertrigo in the infra- mammary region also appear in the long list of problems related to hypertrophy of the breasts1. Psychological symptoms such as self consciousness, social embarass- ment, difficulty in finding fitting clothes, and low self esteem also play a role. Although previously published longitudinal studies showed that reduction mammaplasty will reliable provide improvement of all symptoms2,3,4, medical directors of health insurance companies are not convinced that this procedure is of medical benefit for the patients. Therefore, the aim of our study was to demonstrate the influence of breasts weight on the physical morbidity of women5. In our cohort study 50 women with various breast sizes underwent breast volume measurement, magnet resonance imaging of the spine, physical examination of the spine, and completed different questionnaires with regard to depression and pain. The results showed, that the risk of developing a spine disorder is 2,7 fold higher per kilogram of increased breast weight. Morphological changes of the spine as well as pain levels increased parallel with progressive breast weight.5 Assuming the hypothesis that reduction mammoplasty would be able to reduce these symptoms, Foreman et al.6 showed in 2009 that reduction mammoplasty can decrease the biomechanical stress on the spine. In addition to these physical findings, the psychological impairment was demonstrated by the high prevalence of depressive symptoms in women with heavy breasts. In a recently published study, Saariniemi et al.7 were able to prove that breast reduction did significantly reduce the prevalence of depressive symptoms in these women. 122 Chapter VIII

These data provide objective evidence that breast weight has an inﬂuence on the physical morbidity of women and, therefore, challenge the basis for resource allocation decisions with regard to breast reduction5.

Risk factors in reduction mammoplasty Breast surgery does not only have beneﬁcial effects on women’s health. Like any kind of surgery, breast surgery might lead to complications, which could result in an impairment of health for the patient. Typical complications in reduction mammaplasty are infections and wound healing problems. Certain preoperative conditions, such as obesity, can increase the risk of such complications8. However, the use of a target BMI as exclusion criterium should be treated with caution, as our previous study showed that BMI has a negative inﬂuence on spine disorders and prevalence of depression itself, which could be improved by breast reduction surgery5,8

The negative influence of tobacco smoking on physiological wound healing and surgical outcome is widely recognised in all fields of surgery9. Based on this, the aim of our study was to evaluate the effect of smoking cessation on wound healing after breast reduction surgery10. Previous results of other study groups regarding the influence of smoking on wound healing11-13 were reconfirmed for reduction mammoplasty in our study. Smokers were shown to have more postoperative wound healing problems than non-smokers. In addition, we found a tendency that even in smokers a postoperative cessation of smoking appeared to reduce complications in wound healing. We concluded that each smoking patient should not only explicitly be informed about the negative effects of smoking and urged to stop smoking at least 3 weeks before surgery12, but also be informed about the reduction of these negative effects due to postoperative tobacco abstinence10. In summary, it has to be stated that patients can influence the surgical outcome themselves and preoperative reduction of risk-factors like smoking or obesity can prevent women from impairment in health after surgery.

Breast reconstruction

Psychosocial aspects of breast reconstruction The high psychosocial impairment of patients with breast cancer and related ab- lative surgery has been described extensively in several studies14,15. To overcome General discussion and conclusions 123 this problem reconstructive surgery became an integrated part in the treatment of breast cancer patients16,17. However, the question arose whether reconstructive surgery should be performed immediately or delayed? To enlighten this question we performed a study of 40 patients to determine psychosocial differences between those who underwent immediate (n=20) or delayed (n=20) breast reconstruction. A survey was done which questionned social behaviour, relationships, self-esteem, employment and satisfaction with the time of reconstruction as well as preoperative information. All patients with delayed breast reconstruction had a high range of impairment in body image and social activities in the period between mastectomy and breast reconstruction. This impairment was reduced after breast reconstruction in 17 out of 20 patients. Just one of 20 patients undergoing immediate breast reconstruction reported a high impairment in body image and social activities. After reconstruction there were no significant differences between both groups concerning social activities and body image. Five out of 20 delayed reconstructed patients lost their job and two out of 20 got divorced. Compared to this none of the immediate reconstructed patients were rendered unemployed or divorced. 18 out of 20 patients with delayed reconstruction would have preferred immediate breast reconstruction but did not get the information about the possibility before surgery. All immediately reconstructed patients would again decide to have an immediate reconstruction18. From these results we concluded that immediate breast reconstruction potentially avoids a period of time caracterised by high psychosocial impairment for the patient18. Several other studies have supported this conclusion19-21. Therefore, the information about the possibility of breast reconstruction should be given at the time of breast cancer diagnosis. In contrary to the assumed psychological benefits of breast reconstruction, recently published data show that differences in psychological distress disappeared one year after surgery among women regardless of reconstruction or timing of reconstruction22,23. Metcalfe et al.22 stated that psychological functioning at 1-year post-surgery was not different between women with mastectomy alone, with mastectomy and immediate reconstruction or delayed reconstruction. Harcourt at al.23 concluded that breast reconstruction does not necessarily offer psychological benefits when compared to treatment by mastectomy only. The Cochrane review on immediate versus delayed breast reconstruction published by D’Souza N. et al.24 represents a meta analysis on this topic. They saw a lack in reliable data due to missing randomized control trials, methodological flaws and a high risk of bias. 124 Chapter VIII

However, based on the limited data they surveyed, they concluded there was evidence that immediate reconstruction reduced psychiatric morbidity reported at three months post-operatively when compared to delayed reconstruction.24 Further research should aim to provide reliable evidence for people to be able to make well founded decisions as to the best and most appropriate timing of breast reconstruction following surgery for breast cancer.

Functional morbidity after breast reconstruction

Using autologous tissue for breast reconstruction subsequently results in creating a donor site defect. Even without complications this might lead to a functional impairment for the patient. Tissue acquired from the abdominal wall for instance has the risk of creating weakness or even herniation25,26. Despite technical improvements in harvesting by minimizing the amount of muscle resection27-29 and meticulous closure of the abdominal wall30, until now this risk remains unsolved. Most studies that focused on the comparison of different harvesting techniques (TRAM/DIEP/SIEA), were based on subjective measurements29-31 or static imaging by CT-Scans32 or MRI. These imaging tools are expensive and often not easily available, and furthermore not ideal for evaluating the abdominal muscles. In order to perform a morphological evaluation of muscle function one needs an imaging method, which is able to visualise functional properties of the remaining muscle. Ultrasound imaging offers this possibility: its an easily available and cost-effective method, which visualises not only static, but also movements of the muscle. In our study we were able to show that ultrasound imaging fullfills the requirements needed to evaluate muscle function by showing contractility and movements of the remaining muscles33. We observed no statistically significant differences correlating the ultrasound results with the clinical data on abdominal wall function in our patients (power/ contractility/pain). However, as a descriptive result we found contracting muscles together with impairment in abdominal wall function according to Janda. The question arises whether the function of the abdominal wall and the impairment in daily life could be influenced by muscle-training. Based on this method, further studies are needed to answer this question33. General discussion and conclusions 125

Patient satisfaction after breast reconstruction

Breast reconstruction has been shown to improve quality of life (QoL). However, long-term patient satisfaction is largely unknown. Our aim was to evaluate patient satisfaction and donorsite morbidity in five types of breast reconstruction. A prospectively collected database of all breast surgery patients at Hospital Rudolfstiftung, Vienna, Austria was searched for five types of breast reconstruction (2000-2006): implant, latissimus dorsi (LD)-flap, LD-flap with implant, free transverse rectus abdominis musculocutaneous (TRAM)-flap, and deep inferior epigastric perforator (DIEP)-flap. Patients were sent a study specific questionnaire to assess satisfaction. SF-36 was used to analyze (QoL) and complication data were retrieved from the database and assessed during a follow-up visit. There were 257 patients identified of whom 126 responded to the survey (17 implant, 5 LD+implant, 64 LD-, 22 TRAM- and 18 DIEP-reconstructions). No statistical differences were found in complication or reoperation rates. DIEP-flap patients were significantly more satisfied compared to patients from the implant group (p=0.007). However there was no significant difference regarding QoL scores amongst the groups. After logistic regression analysis only ‘impairment on daily life’ showed to be independently correlated with patient satisfaction. This in contrary to operation type and complication rate, which both did not correlate with patient satisfaction. Our results indicate that neither operation type nor complication rate or revision rate independently correlated with patient satisfaction. Therefore to further improve patient satisfaction, future research should be focused on other pre-operative factors, like patient education, expectations, and personality characteristics.

Correlation between MRI results and intraoperative ﬁndings in silicone breast implants: the role of the linguine sign

Much of the interest in implant safety has focused on the issue of implant leak and rupture. Silicone gel implants gradually undergo gel bleed and many rupture without being detected by the patient or the physician. This has been the main reason why magnetic resonance imaging (MRI) of the augmented or reconstructed breast is advocated. The aim of the presented study was to investigate the accuracy of MRI in diagnosis of implant rupture. 50 consecutive patients with 85 silicone gel implants, were included into the study. The mean age of the patients was 51 years (range 21–72 years) with a mean followup of 3.8 years after implantation (range 1-28 years). All patients underwent clinical examination and subsequent breast MRI. 126 Chapter VIII

19 out of 50 patients suffered from clinical symptoms potentially related to implant rupture. Actual implant rupture was diagnosed intraoperatively by the operating surgeon. Intraoperative results were compared to the preoperative ﬁndings. In 17 women 22 implant ruptures were diagnosed by MRI (out of 85 implants (26%). 17 implants were removed surgically. In 7 out of these 17 removed implants (41%) the intraoperative diagnosis corresponded with the positive MRI result. How- ever, only 57% of these patients were symptomatic. In 10 out of 17 implants (59%) no rupture was found intraoperatively, even though 90% of these implants were symptomatic. In the ultrasound imaging of the harvested implants we found signs of interrupted inner layers of the implant shell despite the integrity of the outer shell. By microsurgical separation of the different layers of the implant shell of a new implant, we were able to reproduce these same signs of implant rupture in the MRI. In conclusion our results show that the rupture of only inner layers of the implant shell with integrity of the outer shell might lead to a misdiagnosis of implant rupture by MRI. Therefore our results question the indication of implant removal based only on MRI results. The correlation with clinical symptoms and the speciﬁc wish of the patients should be guiding in the decision whether or not to remove a breast- implant. General discussion and conclusions 127

References

1. Rogliani M, Gentile P, Labardi L, Dinfrancesco A, Cervelli V. Improvement of physical and psychological symptoms after breast reduction. J Plast Recosntr Aesthet Surg 62: 1647-9; 2009 2. Saariniemi KM, Kuokkanen HO, Tukiainen EJ. The outcome of reduction mammoplasty remains stable at 2-5 years’ follow-up: a prospective study. J Plast Reconstr Aesthet Surg 64: 573-576; 2011 3. Neto MS, Dematte MF, Freire M, Garcia EB, Quaresma M, Ferreira LM. Self-esteem and functional capacity outcomes following reduction mammaplasty. Aesthet Surg J 28:417-420; 2008 4. Mello AA, Domingos NAM, Miyazaki MC. Improvement in quality of life and self-esteem after breast reduction surgery. Aesthet Plast Surg 34: 59-64; 2010 5. Benditte-Klepetko H, Leisser V, Paternostro-Sluga T, Rakos M, Trattnig S, Helbich Th, Schemper M, Deutinger M. Hypertrophy of the breast – a problem of beauty or health? H women’s health 16(7): 1062-9; 2007 6. Foreman KB, Dibble LE, Droge J, Carson R, Rockwell WB. The impact of breast reduction surgery on low-back compressive forces and fuction in individuals with macromastia. Plast Reconstr Surg 124(5): 1393-9; 2009 7. Saariniemi KM, Joukamaa M, Raitasalo R, Kuokkanen HO. Breast reduction alleviates depression and anxiety and restores self-esteem: A prospective randomised clinical trial. Scan J Plast Reconstr Surg Hand Surg 43: 320-324; 2009 8. Shah R, Al-Ajam Y, Stott D, Kang N. Obesity in mammaplasty: a study of complications following breast reduction. J Plast Reconstr Aesthet Surg 64(4): 508-14; 2011 9. Mosely LH, Finseth F. Nicotine and its effects on wound healing. Plast Recosntr Surg 140: 119; 2005 10. Bartsch R, Weiss G, Kästenbauer Th, Patocka K, Deutinger M, Benditte-Klepetko H. Crucial aspects of smoking in wound healing after breast reduction surgery. J Plast Reconstr Aesthet Surg 60(9): 1045-9. Epub 2007 Mar 9; 2007 11. O’Grady KF, Thoma A, Dal CLin A. A comparison of complication rates in large and small inferior pedicle reduction mammaplasty. Plast Reconstr Surg 115: 736; 2005 12. Padubidri AN, Yetmann R, Zins J. Complications of postmastectomy breast reconstruction in smokers, ex-smokers and non-smokers. Plast Reconstr Surg 107: 342; 2001 13. Gill PS, Hunt JP, Allen RJ. A 10-year retrospective review of 758 DIEP-ﬂaps for breast reconstruction. Plast Reconstr Surg 113: 1153; 2004 14. Levy SM, Schain WS. Psychologic response to breast cancer: direct and indirect contributors to treatment outcome. In: Lippman ME et al. (eds). Diagnosis and Management of breast cancer. Philadelphia; WB Saunders: 439-456; 1988 15. Schain WS, Jacobs E, Wellisch DK. Psychosocial issues in breast reconstruction: intrapsychic, interpersonal and practical concerns. Clin Plast Surg 11: 237; 1984 16. Luce EA. Breast reconstruction after mastectomy. South Med J 76: 190-3; 1983 17. Rowland JH, Desmond KA, Meyerowitz BE, Belin TR, Wyatt GE, Ganz PA. Role of breast reconstructive surgery in physical and emotional outcomes among breast cancer survivors. J Natl Cancer Inst 92: 1375-76; 2000 18. Benditte-Klepetko H, Koller R, Ptak-Butta, Deutinger M. Psychosoziale Aspekte der Brus- trekonstruction. Geburtsh Frauenheilk 63: 37-42; 2003 128 Chapter VIII

19. Al-Ghazal SK, Sully L, Fallowfield L, Blamey RW. The psychological impact of immediate rather than delayed breast reconstruction. Eur J Surg Oncol 26: 17-19; 2000 20. Schain WS, Wellisch DK, Pasnau RO, Landsverk J. The sooner the better: a study of psychological factors in women undergoing immediate versus delayed breast reconstruction. Am J Psychiatry 142: 40-46; 1985 21. Wellisch DK, Schain WS, Noone RB, Little JW. Psychosocial correlates of immediate versus delayed reconstruction of the breast. Plast Reconstr Surg 76: 713-718; 1985 22. Metcalfe KA, Semple J, Quan ML, Vadaparampil ST, Holloway C, Brown M, Bower B, Sun P, Narod SA. Changes in psychosocial functioning 1 year after mastectomy alone, delayed breast reconstruction, or immediate breast reconstruction. Ann Surg Oncol published online 15.6.2011: DOI 10.1245/s10434-011-1828-7 23. Hartcourt DM, Rumsey NJ, Ambler NR, Cawthorn SJ, Reid CD, Maddox PR, Kenealy JM, Rainsbury RM, Umpleby HC. The psychological effect of mastectomy with or without breast reconstruction: a prospective multicenter study. Plast Reconstr Surg 111(3): 1060-8; 2003 24. D’Souza N, Darmanin G, Fedorowicz Z. Immediate versus delayed reconstruction following surgery for breast cancer (review). The Cochrane Library 9: 1-23; 2011 25. Lejour M, Dome M. Abdominal wall function after rectus abdominis transfer. Plast Reconstr Surg 87: 1054-1068; 1991 26. Hartrampf CR Jr. Abdominal wall competence in transverse abdominal island flap operations. Ann Plast Surg 12: 139-146; 1984 27. Koshima I, Moriguchi T, Soeda S, Tanaka H, Umeda D. Free thin paraumbilical perforator based flaps. Ann Plast Surg 29: 12-17; 1992 28. Allen RJ, Treece P. Deep inferior epigastric perforator flap for breast reconstruction. Ann Plast Surg 32: 32-38; 1994 29. Amez ZM, Khan U, Pogoretec D, Planinsek F. Rational selection of flaps from the abdomen in breast reconstruction to reduce donor site morbidity. Br J Plast Surg 52: 351-354; 1999 30. Wan DC, Tseng CY, Anderson-Dam J, Dalio AJ, Crisera CA, Festekjian JH. Inclusion of mesh in donor site repair of free TRAM and muscle sparing free TRAM flaps yields rates of abdominal complications comparable to those of DIEP flap reconstruction. Plast Reconstr Surg 126: 367-374; 2010 31. Futter CM, Webster MHC, Hagen S, Mitchell SL. A retrospective comparison of abdominal muscle strength following breast reconstruction with TRAM or DIEP flap. BR J Plast Surg 53: 578-583; 2000 32. Blondeel PN, Vanderstraeten GG, Monstrey SJ, Van Landuyt K, et al. The donor site morbidity of free DIEP-flaps and free TRAM flaps for breast reconstruction. Br J Plast Surg 50: 322-330; 1997 33. Benditte-Klepetko H, Sommer O, Steinbach R, Czembirek H. Clinical and ultrasound evaluation of donor site morbidity after tram-flap for breast reconstruction. Microsurgery 24(3): 174-81; 2004 Chapter IX

Summary

Summary 131

Because its meaningfulness for women, the female breast plays a special role in surgical treatment. The diversity in breast surgery and its wide spread impact on women’s mental and physical health has lead to this thesis. The research was planned with the intent to get a better understanding of the inﬂuencing factors in breast surgery. Several aspects have thus been investigated in the previous chapters. They are summarised below:

Chapter II

Psychological and functional impairment in breast hypertrophy A cohort study of 50 women with various breast sizes was undertaken. By magnet resonance imaging of the spine, physical examination and the use of a validated questionnaire it was proven that breast weight has an inﬂuence on development of disorders of the spine as well as on the prevalence of depressions among women. These data should challenge the basis for resource allocation decisions with regard to breast reduction.

Chapter III

Risk factors in reduction mammaplasty Complication rates after surgery are based on various factors. In this study we hy- pothesized a negative impact of smoking on wound healing after breast reduction surgery. This was proven and furthermore, we were able to show a trend, that even postoperative smoking cessation decreases the negative impact of smoking.

Chapter IV

Psychosocial aspects in breast reconstruction The main aim of reconstructive breast surgery is to lower the distress for women facing breast cancer and mastectomy. Beside showing the positive psychosocial effect of breast reconstruction, another aim of our study was to enlighten the question if breast reconstruction should preferably performed immediately or as an delayed procedure. According to our data immediate breast reconstruction potentially avoids a phase of high psychosocial impairment for the patients and as a consequence the information about the possibility of breast reconstruction should be given at the time of 132 Chapter IX

breast cancer diagnosis. However, recent meta-analysis doubt the reliability of our and other studies regarding this topic, due to methodically ﬂaws. The aim for the future should be to recruit reliable data in trials taking the confounding parameters into account.

Chapter V

Morbidity after breast reconstruction The donor-site defect after harvesting tissue from the abdomen goes along with the risk for impairment in abdominal wall function and herniation. The measurements of abdominal wall weakness were restricted due to the used methods. In our study we evaluated the reliability of functional ultrasound of the Rectus Abdominis muscle to measure abdominal wall weakness. Functional ultrasound seems to be a cost effective, easy available and reproduc- ible method to visualise muscle function.

Chapter VI

Patient satisfaction after breast reconstruction Nowadays a patient searching for breast reconstruction has a choice between many different techniques. Since the main aim of breast reconstruction is to restore psychological well-being for the patient, the aim of our study was to investigate the inﬂuence of the technique being used for breast reconstruction in correlation to the patient satisfaction. The results indicate that neither operation type nor complication rate nor revision rate independently correlated with patient satisfaction. Therefore other pre-operative factors like expectations, and personality characteristics should be centre of further investigations to improve patient satisfaction after breast reconstruction.

Chapter VII

Correlation between MRI results and intraoperative ﬁndings in silicone breast implants: the role of the linguine sign Implant rupture remains a risk factor after breast augmentation or reconstructive surgery. The health issue of an implant rupture still is uncertain. Therefore diagnosis of implant rupture and its consequences is essential in postoperative management Summary 133 of patients carrying breast implants. In this process MRI seemed to be crucial in detecting breast implant rupture. For this reason the reliability and sensitivity of MRI in diagnosis of implant rupture in our patients was evaluated. Due to a low sensitivity and reliability being seen in our results the structure of breast implants was analysed microscopically as well as by ultrasound. This showed, that alterations in the implant shell might mimic implant rupture without subsequent clinical consequences. Therefore the use of MRI versus ultrasound as a standard screening method for breast implant detection should be questioned and further investigated.

Breast Surgery - a problem of beauty or health?

In conclusion the sum of the investigations enlighten that breast surgery is not a question of beauty OR health, but more a question of beauty AND health.

Due to impairment in physical or mental health women undergo breast surgery. On the other hand breast surgery might have a negative inﬂuence on both, physical and mental health. A subjective perception of impaired beauty might lead to reduced mental health and subsequently women seeking breast surgery. In case of cancer, the disease, and therefore disturbed physical health results in an impairment of beauty. One should be aware that a mental health disease like a body dismorphic disorder might cause a disturbed self perception and should be considered as a contradiction for breast surgery.

Chapter X

Samenvatting in het Nederlands

Samenvatting in het Nederlands 137

Gezien haar belang voor vrouwen neem neemt de vrouwelijke borst een speciale positie in binnen de chirurgie. De diversiteit in mammachirurgie en haar grote impact op het geestelijk en lichamelijk welbevinden hebben geleid tot dit promotie- onderzoek, met als doel een beter begrip te krijgen van de factoren die bepalend zijn binnen deze vorm van chirurgie. Daartoe werden verschillende onderdelen onderzocht. Ze kunnen als volgt worden samengevat:

Hoofdstuk II

Psychologische en functionele beperkingen in borst hypertroﬁe. Dit betrof een cohort studie van 50 vrouwen van verschillende borstomvang. Door middel van een gevalideerde vragenlijst, een lichamelijk onderzoek en een MRI onderzoek kon worden bewezen dat het gewicht van de mammae van invloed is op zowel het ontstaan van afwijkingen van de wervelkolom als op de prevalentie van depressies bij vrouwen. Deze uitkomsten spelen een belangrijke rol in de discussie over de vergoedingen rondom borstverkleiningen.

Hoofdstuk III

Risico factoren in borstverkleining Complicatie risico’s na chirurgie zijn gerelateerd aan verschillende factoren. In deze studie werd een negatieve invloed van roken op de wondgenezing na borstverkleining verondersteld en bewezen. Daarbij werd tevens een trend gezien dat het stop- pen met roken na een ingreep de negatieve invloed van het roken verminderde.

Hoofdstuk IV

Psychologische aspecten van borst reconstructie Reconstructieve borst chirurgie helpt de stress te verminderen bij vrouwen met borstkanker die een borst operatie te wachten staat. Doel van deze studie was het onderzoeken van het effect van een borstreconstructie op het psychosociale welbevinden van vrouwen met borstkanker. Ook werd hierin het effect van directe versus uitgestelde reconstructie op het welbevinden meegenomen. Onze analyse toonde aan dat het direct uitvoeren van een borstreconstructie in potentie een periode van zware psychosociale onrust zou kunnen voorkomen. Als gevolg hiervan werd geadviseerd de mogelijkheden van directe reconstructie 138 Chapter X

te bespreken met vrouwen ten tijde van het gesprek waarin de diagnose wordt medegedeeld. Recente meta-analyse trok bovenstaande conclusies echter in twijfel op basis van methodologische bezwaren. Prospectief gerandomiseerd onderzoek zal daarom verricht moeten worden om bovenstaande conclusies verder te onderbouwen.

Hoofdstuk V

Morbiditeit na borstreconstructie Voorkeurslocatie voor het oogsten van weefsel voor een borst reconstructie is de buikwand. Een dergelijke ingreep gaat gepaard met een afname van buikwand functie en een verhoogd risico op herniatie. Dit onderzoek richtte zich op de betrouwbaarheid van de functionele echografie in het vaststellen van Rectus Abdo- minus spier zwakte als uiting van afgenomen buikwand functie. Functionele echografie bleek een kost efficiënte, makkelijk beschikbare en goed reproduceerbare methode te zijn om deze spierfunctie te kwantificeren.

Hoofdstuk VI

Patient tevredenheid na borst reconstructie Tegenwoordig hebben patiënten die een borst reconstructie wensen de keuze uit meerdere technieken. Het voornaamste doel van zo’n reconstructie is het herstel is van de psychologische balans van de patiënt. Daarom werd in deze studie met name gekeken naar de invloed van de gebruikte operatie techniek op de patiënt tevredenheid. Hieruit werd geconcludeerd dat er geen correlatie bestond tussen patiënt tevredenheid enerzijds en de operatie techniek, het complicatie percentage of het revisie percentage aan de andere kant. De relatie tot andere preoperatieve factoren, zoals het verwachtingspatroon of karakter eigenschappen, zouden meegenomen moeten worden in toekomstig onderzoek om patiënt tevredenheid na borst reconstructie te verbeteren. Samenvatting in het Nederlands 139

Hoofdstuk VII

Correlatie tussen MRI observaties en intraoperatieve bevindingen bij silicone borst prothesen. Ruptuur van een borst implantaat is een risico factor, zowel na borst vergroting als na reconstructie. De relevantie van zo’n ruptuur voor de gezondheid van de patiënt is nog steeds onduidelijk. Het controleren op een ruptuur blijft daarom van groot belang in de follow-up na borst implantatie. In dit proces neemt de MRI een cruciale plaats in. In deze studie werd daarom de betrouwbaarheid van dit MRI onderzoek bij implantaat rupturen onderzocht. Als gevolg van de lage sensitiviteit en specificiteit die hierbij werd gevonden, werd vervolgens een echografische en microscopische analyse van de structuur van de implantaten uitgevoerd. Er werd aangetoond dat veranderingen in de omhulsel van een implantaat zich konden presenteren als ware het een ruptuur zonder klinische gevolgen. De keuze voor MRI versus echografie als screenings methode voor borst implantaten is daarmee nog geen gelopen race en zal verder onderzocht moeten worden.

Borst chirurgie – een probleem van schoonheid of gezondheid?

Geconcludeerd kan worden dat borst chirurgie bij maligniteit niet zozeer een vraag is van schoonheid of gezondheid, maar meer van schoonheid en gezondheid.

140 Chapter X

Een combinatie van zowel lichamelijke als psychosociale beperkingen vormen de indicatie voor het verrichten borst chirurgie. De ingreep op zich kan echter ook een negatieve invloed hebben op deze beide aspecten van de gezondheid. Zo kan een subjectieve afname van schoonheid leiden tot psychosociale klachten, die reden kunnen zijn om een borst reconstructie te wensen. Ook geeft de ziekte zelf, met haar verstorende fysieke effect, al vaak een verminderd gevoel van schoonheid. Op- gemerkt moet worden dat eventueel onderliggend aanwezige psychopathologie, zoals “body dysmorphic disorder” ook een verstoord zelfbeeld tot gevolg hebben. Zo’n gedragsafwijking wordt als contra-indicatie gezien voor borstchirurgie. Acknowledgment

“Knowledge is in the end based on Acknowledgements”

Ludwig Wittgenstein

Acknowledgment 143

Since many years, in many different countries, many people helped me ﬁnishing this thesis – by inspiring me, supporting me, guiding me, believing in me … I would like to express my gratitude to all of you that feel addressed by this. I feel blessed.

Johanna and Maris: I am aware of the price the two of you paid for my ambition – thank you!

Mum and Dad, Ingo: what ever I did – thank you for always covering my back

Jacques: thank you for 1+1=on(c)e

Curriculum Vitae

Curriculum Vitae 147

Heike Klepetko was born on February 2nd 1972 in Langenhagen, Germany. After school in her hometown she started Medical School in Hannover, Germany. During Medical School she worked as an intensive care nurse on the transplant department and found out about her fascination for surgery. Aiming to become a surgeon she visited several departments around the world and started her research career at the Medical University in Vienna where she finished Medical School in 1996. The same year her son Maris was born, before she started training in Plastic and Reconstructive Surgery at the Medical University Vienna. After birth of her daughter Johanna in 1998 she finished her training at the Depart- ment for Plastic and Reconstructive Surgery in the Hospital Rudolfstiftung, Vienna, where Maria Deutinger, her former co-worker at the Medical University Vienna became head of the department. During her professional career, she travelled a lot to many different places in the world to learn special techniques in plastic Surgery. Her special interest was always breast surgery, microsurgery and surgery of the face. After finishing her training in 2004 she stayed at the department of Plastic and Reconstructive Surgery in the Hospital Rudolfstiftung in Vienna and took part in building up one of the first certified breast centers in Austria. In 2006 her private clinic in Vienna was opened. Beside this she had a teaching position at the Institute of Anatomy at the Medical University in Vienna until 2010. Due to changes in life she started working at the Academisch Medisch Centrum in Amsterdam in 2010 where she was able to finish her thesis. Since 2011 she continued her career at the Erasmus Medisch Centrum in Rotterdam.

Heike Klepetko werd geboren op 2 Februari 1972 in Langenhagen, Duitsland. Na haar schooltijd ging ze medicijnen studeren in Hannover. Tijdens haar studie werkte ze als intensive care verpleegkundige op de transplantatie afdeling en raakte gefas- cineerd door de chirurgie. Met als doel chirurg te worden, reisde ze langs diverse ziekenhuizen over de hele wereld, om uiteindelijk in 1996 in Wenen haar medicijnen studie af te maken. In hetzelfde jaar dat haar zoon Maris werd geboren, begon ze haar plastisch chirurgische opleiding aan de Medische Universiteit van Wenen. Nadat ook haar dochter Hanna geboren werd in 1998, sloot ze haar opleiding af bij de afdeling plastische en reconstructive chirurgie van het Rudolfstiftung Ziekenhuis, waar Maria Deutinger (haar voormalige college in het Universiteits ziekenhuis) hoofd van de afdeling werd. Tijdens haar professionele carierre reisde ze naar veschillende locaties in de wereld om zich speciﬁeke chirurgische technieken eigen te maken. Haar interesse lag 148 Curriculum Vitae

daarbij altijd bij de mamma chirurgie, de microchirurgie en de chirurgie van het aangezicht. Na haar opleiding begon ze als staﬂid in het ziekenhuis van de Rudolfstiftung en stond daar aan de basis van een van de eerste erkende borstchirurgie centra in Oos- tenrijk. In 2006 volgde daarop de opening van haar eigen privekliniek. Daarnaast had ze ook een onderwijsaanstelling bij het anatomie instituut van de Medische Faculteit in Wenen (tot 2010). Door een verandering in levensomstandigheden begon ze in 2010 als staﬂid in het Amsterdam Medisch Centrum, waar ze de kans kreeg om haar promotie af te maken. In 2011 maakte ze de overgang naar het Erasmus Medisch Centrum in Rotterdam.