54 HOSPITAL REVIEW: BREAST CANCER
A Focus On Advances In Breast Surgery: MMUH Breast Team Perspective Written by Professor Malcolm Kell, and Aoife Sartini-Bhreathnach Professor Malcolm Kell is Consultant Breast Surgeon in Breastcheck, Mater Misericordiae University Hospital and Mater Private, Dublin.
Aoife Sartini-Bhreathnach, Physician Associate PA-IC, Mater Misericordiae University Hospital
Professor Kell has special interest in oncoplastic, aesthetic and reconstructive breast surgery. He is widely published; current research focuses on optimising outcome after breast surgery.
Breast surgery is ever advancing in terms of surgical procedures through the introduction of new techniques and the revival and improvement of the old. This article focuses on some of the advances adapted by the Breast team in the Mater Misericordiae Hospital to date. Advances are continually made to improve surgical options for our patients in both breast reconstruction and breast conserving surgeries. This article will discuss the pre-pectoral implant reconstruction technique, a procedure that has made a resurgence in recent years and the introduction of magseed guided surgery to our unit; a new localisation method for impalpable Breast lesions. Alongside surgical advancements the team have also been supportive in advancing new roles within Irish healthcare, such as that of the Physician associate (PA). Physician Associate Role The role of the PA in Ireland is a rapidly developing professional group where worldwide there are over 110,000 PAs now employed in the US. PAs are trained in the medical model and work under the consultant’s supervision. Miss Sartini-Bhreathnach graduated with her MSc in Physician associate studies in 2019 as part of the second cohort of Physician Associate’s in Ireland. Eligibility for the MSc programme requires a relevant undergraduate degree and previous experience is desirable. Miss Sartini-Bhreathnach obtained her undergraduate in Biomedical Sciences in 2012
and prior to commencing the PA programme worked with a number of research groups. A career as a Physician Associate has given the opportunity to pioneer a new profession within healthcare and be directly involved in the management of patients under the medical model. Aoife has been working for the Breast team in the Mater hospital for almost two years to date where she works alongside the surgical team. The opportunities she has availed of have included: educational progression and learning. Aoife assists in surgical cases; reviews patients post operatively and at their clinical appointments. She has also had the opportunity to continue with new research endeavours. Advancements In Implant Based Breast Reconstruction Globally there is an increase in patients availing of breast reconstruction, following mastectomy, with 80-95% of reconstruction being implant based. Breast reconstruction can be performed with the use of autologous tissue to reconstruct the breast in procedures such as latissimus dorsi (LD) reconstruction. The addition of an implant can be common in these procedures and may be placed to enhance the aesthetic outcome. Reconstruction options can also include the sole use of the implant without autologous tissue. Implant based reconstruction of the breast cavity is a popular surgical procedure of which was traditionally performed as part of a two stage process. Firstly the mastectomy was performed
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followed by the insertion of a tissue expander. A second procedure was scheduled to remove and replace the expander with a permanent prosthesis. While this 2-stage process may still provide a suitable reconstruction option for a select cohort of patients,the majority of implant reconstructions performed by the breast team in the MMUH are direct-to-implant, one stage procedures. Historically the use of an implant to reconstruct the breast cavity has been in practice since the 1970’s where, at this time, the implant was mostly positioned in front of the pectoralis muscle. Positioning in this pre-pectoral position,following mastectomy, allows for the implant to be placed directly into the cavity in front of the pectoralis muscle where there is no manipulation of the pectoralis muscle. Post-operative complications were high, following pre-pectoral reconstruction, with complications such as flap necrosis, implant extrusion and overall implant loss. Due to this there was a natural progression away from the placement of the implant directly in front of the pectoralis muscle and towards a subpectoral positioning. Subpectoral implant reconstruction differs from the pre-pectoral procedure due to the manipulation of the pectoralis muscle. Following mastectomy, the inferior border of the pectoralis muscle is released and the implant is positioned under the muscle. Elevation of the pectoralis muscle provides tissue coverage to the superior aspect of the implant and an additional layer
between the implant and skin, all of which was absent in the prepectoral technique. There is wide acceptance of subpectoral implant reconstruction and to this day it is a popular surgical procedure amongst reconstructive breast surgeons. Revival of Pre-Pectoral Implant Reconstruction In more recent years however, there has been a surge in the use of pre-pectoral implant reconstruction, with many surgeons favouring this technique once more. Recent studies have reported positive outcomes when comparing the pre-pectoral technique to the subpectoral equivalent. The literature has reported an overall reduction in post-operative complications when compared to the subpectoral implant reconstruction technique. Aesthetic outcomes have also been favourable for the prepectoral technique, where an independent evaluation of pre versus subpectoral aesthetic outcomes reported that bilateral pre-pectoral implant procedures scored highest on a visual analog scale of aesthetic outcomes. Research continues to report a positive trend of reduced post-operative complications and a move towards this surgical procedure. The breast team in the MMUH have also progressed towards the pre-pectoral reconstruction procedure acknowledging the potential advancements it can provide to improved patient outcomes and breast reconstruction.
