Specialist Profile Wang Ximei, M.D., Deputy Director of the Department of Plastic Surgery, The First Affiliated Hospital of Zhengzhou University, Member of the Craniomaxillofacial Repair Society of the Chinese Medical Association and Deputy Director of the Plastic Surgery Society of Henan Province, Graduated from Henan Medical College in 1984 and joined the Plastic Surgery Department of The First Affiliated Hospital of Zhengzhou University with honors. In 2009, he was sponsored by the Department of Health of Henan Province to work as a visiting professor in the plastic surgery department of the University of Virginia Medical Center in the U.S. In 2009~2010, he was sponsored by the Department of Health of Henan Province to go to the U.S. for one year to observe breast cancer surgery in the plastic surgery department of the University of Virginia Medical Center. He observed more than 500 cases of breast reconstruction after breast cancer surgery in the Plastic Surgery Department of the University of Virginia Medical Center, and discussed all aspects of breast reconstruction after mastectomy. Ximei Wang, Plastic Surgery Department, Zhengzhou University First Affiliated Hospital Breast reconstruction allows my friend to live happily after breast cancer surgery Expert Experience:Breast reconstruction should be understood by Chinese patients In the United States, breast reconstruction is a routine procedure after mastectomy. Talking about breast reconstruction after breast cancer surgery, Wang Ximei recalled her Chinese friend in Chicago who found a breast lump during a physical examination and was diagnosed with breast cancer, when she told her American doctor what she wanted according to the Chinese idea: “I want to remove my breast, I want to live!” The doctor laughed: “We must remove your tumor, but we will also give you back a breast so you can live happily ever after!” Because her breast cancer was detected early, she had reconstructive surgery while the tumor was removed. She communicated with Wang Ximei throughout her treatment, and afterwards she lamented, “Looking at the two sides of her breast, which are almost the same as the original, is like a nightmare, but now the nightmare is over and the physical and psychological wounds have been healed. I can’t imagine what life would have been like if I didn’t have reconstruction and only had one breast!” Breast cancer has now become the number one killer of women, with about 1.2 million women diagnosed with the disease each year worldwide, and the incidence of the disease ranks first among female tumors in both developed and developing countries. The incidence of breast cancer is surging year by year in all countries, and China is no exception. In the past decade, the incidence of breast cancer among urban women has increased by 20-30%, and there is a trend of further growth and low age, breast cancer has been regarded as the biggest killer of modern women. Breast cancer is known as a cancer of affluence, and in the United States, the incidence is particularly high, with one breast cancer patient for every eight to nine people. Breast reconstruction has become part of the routine systemic treatment after breast cancer surgery in the United States, and some states even have legislation requiring breast reconstruction in appropriate cases after mastectomy, or else it is illegal for the surgeon doing the surgery. In our country, the treatment of breast cancer has changed a lot in the last 10 years. Early detection, early diagnosis and early treatment of breast cancer have improved the cure rate, and many breast cancer patients are in good health after surgery, but complete removal, or the more the cut, the safer it is the consensus of patients and even doctors. Surgical removal of one or both breasts causes serious physical and mental trauma and pain to patients. How to make up for this defect and improve the survival quality of breast cancer patients after surgery, so that patients can not only recover their complete body but also have a healthy psychology, breast reconstruction is a better way to solve this problem, and it has been clinically verified for decades and has indeed achieved more satisfactory results. China is late to carry out this technology, but in recent years, with the increase of early cases and patients’ awareness of improving the quality of life, it has been commonly carried out in Shanghai, Beijing and other major cities. Without breasts, rather than life – breast reconstruction benefits patients’ physical and psychological recovery When it comes to the Chinese and Western differences in attention to breasts, Wang Ximei talked about this incident. “I met a 49-year-old patient whose whole family came when she went for her breast cancer treatment plan, not to discuss the surgical plan, but to advise her and help her choose a breast prosthesis. Her husband, mother, and daughter all came, believing that it was already part of the disease. Her husband was carefully selecting the size and shape of the implants, gross or glossy, and weighing them, saying flirtatiously that it was no different from the real thing. After having one implant, she was happy with the side made by the implant, but was not satisfied with the sagging of the natural breast on the other side, so she had another surgery to have that other side reduced and reshaped.” “Breasts are part of my life, no less than even the face for women, so without them, I would rather not have life.” She told Wang Ximei. The peak age of breast cancer incidence in China is 10 years earlier than that in western countries, 40 to 50 years old, an age when individuals play an important role in their career, family and society. When diagnosed with breast cancer, patients not only have to bear the threat of possible life-threatening cancer, but also the heavy blow of losing one breast due to breast cancer treatment, which even endangers the stability of family and marriage. Breast cancer treatment causes great physical and psychological damage to the patient due to mastectomy. Numerous studies have shown that breast cancer treatment with breast preservation and mastectomy with breast reconstruction can improve the psychological damage caused by the physical destruction of the patient’s body due to mastectomy. Breast reconstruction is a part of breast cancer treatment, not just a cosmetic issue. Statistics in 1995 showed that the percentage of patients who needed mastectomy for breast cancer to receive breast reconstruction was about 30% in the United States, but it has increased to 60%-70% over the years. Compared with western countries, there is a huge gap in breast cancer treatment and breast reconstruction in China, which is inseparable from the difference of Chinese and western concepts. Chinese people generally believe that it does not matter whether they have breasts or not, while American patients clearly state that they would rather not live without breasts. It has been observed that immediate breast reconstruction is more beneficial to patients’ psychological health than delayed breast reconstruction. It is understood that American patients’ motivations for requesting breast reconstruction include: making their bodies whole, restoring a sense of femininity, ease of dressing, not wanting to wear external prostheses, and restoring self-confidence for physical activity. Opponents, on the other hand, believe that they are too old, fear complications from surgery, and worry about the impact of reconstruction on cancer treatment. Although the benefits of breast reconstruction after mastectomy for breast cancer are undeniable, implementation in China is a rather long process. Breast reconstruction after mastectomy in the United States is covered by health insurance, while health insurance in Henan Province covers only 10 percent. Not only can they be reconstructed but they can be made just like before – breast reconstruction is feasible Lucy’s breast cancer was discovered the year before. Before the surgery, her husband expressed his hope that she could recreate a breast that was the same as before, so the doctor picked the largest 800 ml implant according to Lucy’s plump figure, but after doing it for a while, the Lucys found the doctor again and said: “The implant is not big enough, it is not the same as before.” So, the doctor operated a second time and added another 300 ml implant to her. By the time Janine turned to her doctor, her breast cancer had metastasized in her armpit, and she had the second stage of breast reconstruction surgery, or implantation, done at the same time as chemotherapy. “The doctors judged that my proximal metastases were fine and could be done, and I trusted them.” She faced this surgery with courage and openness. “Breast reconstruction has no effect on the treatment of breast cancer and does not induce breast cancer, but it needs a professional doctor to judge whether it can be done or not.” Wang Ximei emphasized. Skin-preserving mastectomy was proposed in 1991, with the main purpose of instantly reconstructing the breast using artificial breast implants or autologous tissue to obtain a better breast shape. The concern with skin-preserving mastectomy is whether the procedure affects local recurrence of tumors, distant metastases, patient survival, and whether it increases surgical complications. Multiple studies have demonstrated that the procedure is safe and does not increase local recurrence, distant metastasis, or affect patient survival compared to non-skin-preserving conventional mastectomy. 539 cases of skin-preserving mastectomy have been investigated with a local recurrence rate of 5.5% at 65 months of follow-up. Another group of 177 cases with 118 months of follow-up showed a local recurrence rate of 5.6%, which was not significantly different from the recurrence rate of conventional non-skin-preserving radical mastectomy. In addition, the rate of flap necrosis was 10.7% in the skin-preserving mastectomy group compared with 11.2% in the non-skin-preserving mastectomy group, which is not much different. In conclusion, properly selected skin-preserving mastectomy combined with immediate breast reconstruction can result in reconstructed breasts with more natural skin color, softer texture, and less scarring, with better surgical cosmetic results. In addition, surgery does not increase tumor recurrence or metastasis, nor does it require delaying other treatments. Although breast reconstruction should be an integral part of breast cancer treatment, not all patients are suitable for immediate breast reconstruction. Firstly, the patient’s desire to have breast reconstruction is the most important deciding factor. Secondly, the patient’s systemic condition should be considered, such as whether the patient has significant systemic diseases: chronic obstructive pulmonary disease, severe cardiovascular disease, hypertension, diabetes, etc. In terms of oncological considerations, immediate breast reconstruction is mainly suitable for patients with stage I and II breast cancer. In addition, preoperative clinical or ultrasound examination is required to clarify the absence of lymph node metastasis in these patients. It has also been reported that immediate breast reconstruction for locally advanced cancer did not increase tumor recurrence and affect treatment compared with patients who did not undergo reconstruction. They concluded that immediate breast reconstruction is feasible for patients with locally advanced cancer, but patients with distant metastases are absolute contraindications to breast reconstruction. Sculpting and slimming in one fell swoop – a variety of breast reconstruction methods Jo, a fat breast cancer patient, wanted the option of breast reconstruction with a flap from her abdomen, and after talking with her surgeon, she was equipped to do so. After the surgery, not only were her breasts reshaped, but her previously bulging belly was also flattened. The result was like liposuction, with both body contouring and plastic surgery, and Joe was very happy. “The surgical methods are breast implant breast reconstruction, autologous tissue breast reconstruction or a combination of both. The specific method chosen for each patient needs to be determined by the patient’s own conditions, the patient’s wishes, and the technical conditions the surgeon has.” Wang Ximei reminded that. 1. Breast implant breast reconstruction Breast implant breast reconstruction refers to the surgical removal of breast cancer and the reconstruction of the removed breast by implanting an implant under the pectoralis major muscle or under the skin flap. Since the use of silicone breast implants for breast augmentation in 1963, breast implants have been gradually used for breast reconstruction. Breast implants are available in silicone, saline implants. According to the shape and surface condition, they are divided into different types such as round, teardrop, glossy and frosted surface. Breast reconstruction with prosthesis is mainly suitable for: (1) patients with medium or smaller volume and no obvious sagging degree breast; (2) those who have not had radiotherapy in the past or do not need radiotherapy after surgery; (3) those who are not suitable or do not want to receive other surgical breast reconstruction; (4) those who have bilateral breast reconstruction. 2. Autologous tissue breast reconstruction Autologous tissue breast reconstruction can obtain natural, somewhat sagging, soft, and radiation-tolerant breasts. Autologous tissue can be derived from the back, abdomen, buttocks, thighs, and the greater omentum. Depending on the blood supply of the flap, it can be divided into tipped flaps and free flaps. The most widely used flaps are the latissimus dorsi muscle flap and the transverse rectus abdominis muscle flap. 1) The latissimus dorsi muscle flap breast reconstruction surgery is suitable for: (1) those who do not have enough skin after mastectomy, do not have enough lower abdominal tissue for breast reconstruction or are medically unsuitable for TRAM (transverse rectus abdominis muscle flap) breast reconstruction. (2) Patients who have undergone previous breast radiation therapy for mastectomy. (3) For smaller breasts the expanded latissimus dorsi muscle flap technique can be used for total autologous tissue breast reconstruction. During surgery, the entire latissimus dorsi muscle is separated from the corresponding subcutaneous fat, and the excess skin can be removed and implanted under the flap of the breast after mastectomy to reshape the reconstructed breast to increase the size of the breast. It should be noted that sufficient subcutaneous tissue should be preserved during the separation of the dorsal flap to prevent necrosis of the donor flap. 2) Transverse rectus abdominis muscle flap breast reconstruction Currently it is the most widely used autologous tissue flap for breast reconstruction, but the surgical technique is demanding and requires microvascular anastomosis techniques. It also takes a long time to perform and has a few percent chance of failure. The TRAM flap can be used in patients with previous radiation therapy or tight chest skin because it provides a larger volume of more adequate autologous tissue that can tolerate postoperative radiation therapy. It is the recommended procedure for breast reconstruction with autologous tissue, and is even called the “gold standard procedure”. However, it is not recommended for women who smoke, have diabetes, hypertension, collagenous tissue disease, and a history of multiple abdominal surgeries.