RECONSTRUCTION AFTER MASTECTOMY

Although reconstruction after mastectomy offers an opportunity for cos metic rehabilitation that should make mastectomy more acceptable and c ontribute to overall rehabilitation, the procedure is relatively under utilized. The best cosmetic results usually come from breast conservat ion rather than from mastectomy and subsequent reconstruction, and mos t small (T0-T2) cancers can be treated by means of breast-conserving m easures, The surgeon who is performing the mastectomy plays a key role in explaining reconstruction to the patient and encouraging her to co nsider the process. Surgeons and patient-related factors contribute to under-utilization. Physician assessment of the results of reconstruct ion, particularly with use of implants, tends to be less favorable tha n that of the patient. Surgeons may overemphasize the inadequacies of the results and patients may be overwhelmed by the diagnosis and array of decisions that must be made. Immediate reconstruction poses Little risk of treatment delay or limitation. Reconstruction after mastectom y does not interfere with follow-up for recurrence, Choices for recons truction have been limited by the withdrawal of silicone implants from the market. The availability of reconstruction has encouraged the ina ppropriate use of mastectomy for low risk disease. Prophylactic mastec tomies and reconstruction should be performed for appropriate indicati ons. To be effective, prophylactic mastectomy must include the nipple areolar complex. The availability of genetic testing to define very hi gh risk groups brings into question the adequacy of protection offered by this procedure. Whereas prophylaxis in humans for premalignant mas topathy appears to be nearly complete, mastectomy appears to offer lit tle protection in a rodent carcinogen model. The effectiveness of mast ectomy for prophylaxis in a genetically high risk human population is unknown.