With the increase in early detection of breast cancer due to the advances in diagnostic methods such as ultrasonography, computed tomography (CT), and MRI, the known incidence of breast cancer in Korean women after uterine cancer and stomach cancer has increased. Due to this, mastectomies are frequently performed, and thus, more breast reconstruction procedures are also carried out. It has been shown in numerous patients that breast reconstructive surgery provides significant help in overcoming cancer [1
]. Breast reconstruction can be broadly classified into immediate breast reconstruction and delayed breast reconstruction according to the reconstruction period. Immediate breast reconstruction has the advantage of preventing fear and mental suffering from the changes in the body after mastectomy because the patient does not see the results of the mastectomy. It also has the advantages of better cosmetic results due to the absence of scars and the non-exposure of blood vessels upon mastectomy as well as decreasing the medical costs by reducing the number of surgeries through simultaneously performing the mastectomy and breast reconstruction. Immediate breast reconstruction, however, also has drawbacks such as the uncertainty of the progress of the treatment after the mastectomy, and the psychological burden of the surgeon who has to reduce the time for shaping the reconstructed breast due to the need to perform the reconstructive surgery during the mastectomy [6
On the other hand, delayed breast reconstruction provides time for physical recovery after mastectomy, and makes it easier to verify the complete recovery by observing the progress of the breast cancer treatment. It has the disadvantages, however, of requiring more frequent surgeries and requiring breast reconstruction using autologous tissue due to the extreme lack of flexibility because of the cicatricial contracture.
Additionally, according to Wellisch et al. [7
], 60% of patients who have undergone delayed breast reconstruction have shown a mentally hypersensitive reaction that included obsessive-compulsive reaction, hypersensitivity in personal relations, depression, hostility, paranoia, and rage. Even in this study, 12 (75%) of the 16 patients who underwent delayed breast reconstruction showed mentally hypersensitive reactions, though there were differences in the severity of their reactions after surgery. However, only 21 (10%) of the 204 patients who underwent immediate breast reconstruction complained of a sense of loss or depression after the surgery. Therefore, immediate breast reconstruction can also be deemed superior with regard to these mental impacts. Hence, despite the advantages of delayed breast reconstruction, the number of cases of immediate breast reconstruction is increasing due to its cosmetic, mental, and economic advantages.
Numerous studies have shown that breast reconstruction using autologous tissue has resulted in a lower incidence of complications after postoperative adjunctive therapy and superior cosmetic results compared to breast reconstruction using a prosthesis [2
]; moreover, in the authors' hospital, a method that employs autologous tissue was used when performing breast reconstruction. Among the autoplasty methods, reconstructive surgery using LD pedicled flap or TRAM flap was performed. The LD pedicled flap was used extensively for local excisions and when the breast on the opposite side was not too large. The reconstruction with TRAM flap was used after total mastectomy and when the breast on the tendon side was relatively big. Up to the present, approximately 200 random clinical trials have been performed for postoperative adjuvant therapy, among which many of these studies carried out follow-up observations of patients for over 20 years and have come up with a definite conclusion on the treatment results. Unlike in the past, not only has adjuvant therapy after mastectomy been mostly performed in the recent stage, but also in the initial stages; and it has been developed because it prevents locoregional recurrence of breast cancer and enhances the average survival rate [8
]. Despite these advantages, however, it may cause various complications such as delayed healing, skin necrosis, discoloration, fat necrosis, flap necrosis, flap contraction, flap contracture, flap deformation, flap hardening, infection, and inflammation.
According to a recently announced thesis, a group that had received adjuvant therapy after immediate breast reconstruction using autologous tissue had a high incidence of complications, but its patient satisfaction did not significantly differ from that of the group that had not received adjuvant therapy. Moreover, the incidence of complications in the group that received adjuvant therapy after immediate breast reconstruction using autologous tissue was slightly higher than that in the group that had undergone delayed breast reconstruction, but the first group showed superior results in patient satisfaction [4
]. Similar results were achieved in this study. There was no incidence of complications in the group that did not undergo adjuvant therapy, and it scored 3.25 points in patient satisfaction. In the group that underwent adjuvant therapy after immediate breast reconstruction, complications occurred in 21 (11.4%) of the total of 183 patients, and the score for patient satisfaction was 3.11 points. In the group of patients who underwent delayed breast reconstruction, the patient satisfaction score was 3.15 points.
The analysis of the results of this study showed that the group that had undergone adjuvant therapy after immediate breast reconstruction had a high incidence of complications, which did not significantly differ, however, from that of the patient group that did not undergo adjuvant therapy. Moreover, the former group showed no incidence of major complications related to flaps, and among these, even most of the complications that occurred were observed to have disappeared within 6 months after adjuvant therapy. From the perspective of patient satisfaction, there was no significant difference (P>0.05) compared to the group that did not receive adjuvant therapy and the group that underwent delayed breast reconstruction.
Such findings might have resulted from the technological advances in radiotherapy and the development of surgical methods.
The development of the medical linear accelerator in the 1950s, the performance of 3D therapy design, and irradiation using computers since the late 1990s have reduced the side effects of radiation and have made it possible to perform more effective radiotherapy by irradiating more precisely, that is, only irradiating the cancerous tissue. Moreover, 5,040-6,040 cGy of irradiation is divided and irradiated in 28 to 33 smaller doses. This method, which is effective against tumors and minimally damages the flaps, can also reduce radiation-induced side effects of the flaps due.
According to numerous studies, various complications may arise depending on the length of time after the irradiation. In the initial stages of the disease, these possible complications include breast edema, fat necrosis, calcification, radiation-induced tuberculosis, and pleural effusion; and in the intermediate stages, breast fibrosis, contraction of the mammary glands, difficulty in breastfeeding, fracture of the irradiated area, pulmonary fibrosis, and pericardial disease. In the latter stages, cardiac disorder or a radiation-induced malignant tumor may occur [10
]. Viewing the effects of radiotherapy from the perspective that it reduces the locoregional recurrence of a postoperative primary tumor and further improves the survival rate, it will become a meaningless medical procedure if it does not help enhance the final survival rate due to the occurrence of various complications after radiotherapy. Therefore, the exposure dose of 5,040-6,040 cGy investigated by the authors is the dose that can minimize complications while reducing the locoregional recurrence of the postoperative primary site, and it is the exposure dose that can effectively improve the final survival rate. Because contact radiography using photon and electron beams, and 3D therapy technology that performs more precise and accurate irradiation while searching for the target, are now being developed, more effective radiotherapy will be performed in the future. Even surgical procedures will become more effective due to technological advances such as those that cause minimal damage to the flaps and the flap pedicle. In addition to the gradual development of radiotherapy and surgical methods, efforts should be made to ensure further flap stabilization and more satisfactory patient results even after the performance of adjuvant therapy following immediate breast reconstruction.
In sum, 183 patients who underwent adjuvant therapy after breast reconstruction using autologous tissue at the authors' hospital showed no significant difference in complications, in contrast to the patient group that did not undergo adjuvant therapy after immediate breast reconstruction; and the patients who underwent adjuvant therapy showed no incidence of major complications related to flaps. Even among the complications that arose, most were observed to have disappeared. Furthermore, the authors report that the immediate breast reconstruction using autologous tissue ensured flap stability and yielded good patient satisfaction results even after postoperative chemotherapy and radiotherapy. It also showed that immediate reconstruction is safe and useful for patients who need postoperative adjuvant therapy.