Removal of fibroadenoma of the breast augmentation and breast implants. Analysis of the possibility of simultaneous and delayed execution of these operations


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Abstract

Introduction. Fibroadenomas (FA) are the most common benign breast neoplasms that are diagnosed in 25% of women. Dissatisfaction with the size of the breast and the desire to increase it occurs in 40%. For this reason, in the practice of a plastic surgeon, there are cases when the patient wants to remove fibroadenomas (FA) and increase the size of the breast. In this situation, there are two options for managing the patient- the simultaneous execution of two operations and the delayed one.
Aim. To evaluate the possibility of simultaneous FA removal and augmentation mammoplasty, to analyze possible complications and methods of their correction.
Materials and methods. We have analyzed the experience of simultaneous interventions of FA removal and augmentation mammoplasty on the example of 10 cases performed in the period from 2014-2019, as well as FA removal after implant placement-3 cases.
Results. Performing a simultaneous operation has advantages due to the minimization of injuries (the ability to perform from a single access - submammary or periareolar), reducing psychological stress and better cosmetic effect. Two patients had postoperative complications in the form of capsular contracture, manifested in the asymmetry of the mammary glands, corrected by performing capsulotomy and forming a new submammary fold. When performing invasive diagnostic tests and surgical intervention in three patients after endoprosthesis augmentation mammoplasty, extreme caution was required due to the risk of violating the integrity of the implant. It was found that the incision of the posterior leaf of the MJ capsule with a large number of removed neoplasms in the postoperative period leads to the development of breast asymmetry. The fact of FA recurrence was also confirmed (2 patients), who subsequently underwent repeated surgical intervention.
Conclusion. Performing simultaneous operations for benign breast tumors can be surely practiced by plastic surgeons, including as one of the options for simultaneous treatment of breast FA and augmentation mammoplasty. The occurrence of FA in the long-term period after breast augmentation surgery is associated with difficulties in diagnostics (mammography and fine needle aspiration biopsy under the control of ultrasound), as well as in the course of surgery itself, due to the presence of the implant and the risk of violation of its integrity.

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Introduction.

In modern plastic surgery, one of the most popular and frequently performed operations is augmentation mammoplasty. Dissatisfaction with the shape and size of the breast, its asymmetry, and postpartum changes in the mammary glands are most often reasons for patients to contact a plastic surgeon. An increase in the number of such operations leads to the emergence of various variations of this surgical intervention, in particular, the performance of single-stage augmentation mammoplasty in patients with breast fibroadenomas [12].

Fibroadenomas (FA) are the most common benign breast neoplasms consisting of fibrous and epithelial components [1-4]. These kinds of tumors  have 25% of women, and patients in the age group up to 30 years are susceptible to FA .Malignant transformation of FA occurs with a frequency of 0.12–3%, leaf-shaped FA with a node size of more than 2 cm-75% [3, 5]. Leaf-shaped FA, characterized by a rapid rate of increase, a tendency to relapse and the risk of malignancy depending on the degree of differentiation [4, 6]. The indication for removal is the size of the FA more than 1 cm, FA increasing in size, and there is a need for resection of the FA with an indentation, due to the detection of many small formations around the resected FA.

The etiology of the development of these formations is unknown, but the correlation of size with the state of a woman's hormonal background has been revealed. Hyperestrogeny plays a key role in it. Thus, FA undergoes changes during the menstrual cycle, during pregnancy, and regresses after menopause [2, 5, 7].

Detection of FA occurs more often during self-examination of the patient or occurs as a finding during ultrasound examination of the mammary glands, mammography. Benign formation is usually painless, but in the premenstrual period, discomfort may occur [2].The triple assessment includes physical examination, imaging such as ultrasound and MRI of the mammary glands, as well as cytological examination (fine needle aspiration biopsy (TIAB), has a very high accuracy in the diagnosis of benign breast diseases [1, 8]. Thus, FA is palpated as a mobile smooth tumor with clear borders [1, 4, 9]. On tomography, a rounded, lobed volume formation is determined, lower or equal in density to the surrounding parenchyma, with possible calcification of the "popcorn" type[2, 3]. Ultrasound picture of fibroadenoma in the form of a homogeneous hypoechoic structure[4].

Simultaneous augmentation breast reconstruction in FA is rarely discussed in publications if the tumor is not classified as giant and its removal does not lead to pronounced asymmetry [6].

In the postoperative period, dynamic monitoring and examination is necessary to detect complications and possible recurrence of fibroadenomas.

The risk of FA after augmentation mammoplasty is present in patients with initial risk factors (hyperestrogenia and hyperproliferation of the ductal and lobular epithelium of the mammary glands) [11]. It should be noted that in recent years, organ-preserving operations on the mammary gland have become more widespread, including in cases of malignant neoplasms, with a good long-term result in compliance with the medical examination of this category of patients.

After augmentation mammoplasty, there may be some difficulties in diagnosing neoplasms. This is because tumors can be hidden by an implant that compresses the surrounding breast tissue. Therefore, for the purpose of accurate visualization, in addition to physical examination methods, routine ultrasound and MRI with contrast are shown [5, 12, 13].

 

A series of scientific studies aimed at identifying breast cancer patients has led to the conclusion that augmented and non-augmented patients were diagnosed at a similar stage and had a comparable prognosis [16]. This is because while implants can interfere with mammography, they appear to make it easier to detect palpable breast cancer during physical examination. Some manipulations in the breast area involve the risk of violating the integrity of the implant capsule. So, TIAB should be performed using a needle, placing it parallel to the implant, in order to avoid violating the integrity of the endoprosthesis. Damage can also occur when the FA is removed, so the operation must be performed very delicately and carefully.[12]

Aim: to evaluate the possibility of simultaneous FA removal and augmentation mammoplasty, to analyze possible complications and methods of their correction.

Materials and methods. This article presents a retrospective analysis of the histories of 13 patients aged 26 to 38 years. All patients underwent General clinical examination, breast ultrasound, preoperative TIAB with mandatory cytological examination of the obtained material. This volume of diagnostic measures makes it possible to make a diagnosis with a high probability, without resorting to the most invasive diagnostic interventions, such as tissue and cor biopsies [15]. At the same time, we chose simultaneous augmentation mammoplasty with simultaneous removal of breast formation when the patient is dissatisfied with the initial breast size in order to reduce the number of surgical interventions, minimize trauma and reduce psychological stress. Augmentation mammoplasty was performed using silicone implants. Sebbin: Classic, Profile High, Textured (12 patients) and Mentor Round, Profile High, Moderate velvet (1 patient).

The incisions were performed periarelarly (3/13) or submammar (10/13), the advantage was given to the submammar incision in view of less trauma and good access to almost all parts of the breast, with the exception of the upper pole. The volume of intervention was performed in the form of a sector resection of the breast, followed by the installation of the implant retro-sectorally with the formation of a pocket in two planes of the dualplane type. It should be noted that during the formation of the future pocket for the implant, we get good access to the back surface of the breast tissue, which allows us to remove the neoplasm of almost any localization without making an additional incision on the skin. In the event of difficulties with the positioning of the location of the fibroadenomas due to their small size, during surgery, we used intraoperative ultrasound.

It was mandatory for the surgical preparation to be sent for routine histological examination. In one case, an Express study was required due to intraoperative cancer alertness.

 

In 3 cases out of 13 after previously performed endoprosthetics in patients P., 35 years old, G., 48 years old, A., 30 years old. Before surgery, ultrasound and TIAB were performed with the necessary precautions. In these cases, an incision was made on the old postoperative scar with excision of the latter for cosmetic purposes, but the formation was complicated due to the presence of a scar capsule around the implant and in the retroareolar region.

Two 30 years old  patient A. (ph. 1), had a  delayed correction of breast asymmetry. After Central sector resection with simultaneous implant placement, lymphorrhea was observed due to the location of the FA directly under the areola and the interest of the ducts in this area. Long-term lymphorrhea caused the formation of capsular contracture and the appearance of pronounced MJ asymmetry (Fig. 2). After 7 months, a delayed correction was performed with capsulotomy and the formation of a new submammary fold with a good long-term result (Fig. 3).

 

Ph . 1. Patient A. 30 years old, before surgery

Ph . 2. Patient A. 30 years, after 7 months (capsular contracture on the right)

Ph . 3. Patient A. 30 years old, after 8 months (delayed correction was performed)

Patient S., 28 years old (ph . 4), with multiple fibroadenomas of the MJ, 2 formations in the right MJ and 5 formations in the left MJ were removed. During the operation, the posterior leaf of the MJ capsule was cut on the left breast. This led to the fact that in the postoperative period there was a redistribution of the left breast tissue on the implant and a displacement of the submammary fold caudally, resulting in an asymmetry of the MJ (ph. 5). Correction of the asymmetry was delayed due to the patient's pregnancy.

Ph . 4. Patient S., 28 years old, before surgery

 

 

Ph . 5. Patient S., 28 years old, after 6 months (pronounced asymmetry)

Patient S., 28 years old, in the long-term period, during the control of ultrasound data, the re-formation of small FA was determined, which required performing a sectoral resection.

Patient M., 38 years old, with a burdened family history (C-r MJ in the mother), increased risk of MJ and ovarian cancer according to molecular genetic research, had a bilateral subcutaneous mastectomy with the preservation of SAC.

In one of the observations, patient A., 31 years old, revealed a multiple recurrence of FA after a series of sectoral resections. Thus, in 2014, a sectoral resection of the right MJ was performed. histological examination of the operating material revealed fibrocystic breast disease with masoplasia and foci of sclerosing adenosis, as well as FA of mixed structure against the background of non-proliferative fibrocystic disease. In the long-term postoperative period in 2016, ultrasound revealed a relapse of FA, which required repeated sectoral resection simultaneously with endoprosthesis of the mammary glands on both sides with submammar access implants. In 2019, ultrasound again revealed signs of FA of the right breast, which in

In the remaining 4 patients, the preoperative preparation, intraoperative picture, and postoperative period were uneventful.

Conclusion. For patients with fibroadenomas of MJ, confirmed by Cytology data, and who want to increase or change the shape of the breast, simultaneous interventions are the best option. A single-stage operation has a full place in the practice of a plastic surgeon, subject to preoperative verification of FA and the possibility of dynamic observation in the early and long-term postoperative period with subsequent correction of complications.. The choice of the method and scope of the operation must take place with the mandatory participation of the patient in the course of the conversation with legal confirmation on paper. In the postoperative period, it is possible to develop breast asymmetry associated with the development of capsule contracture or with dissection of the posterior leaf of the MJ capsule, which require further correction. After simultaneous surgery, dynamic diagnostics may have some difficulties, which are caused by impaired visualization of breast tissue due to the presence of a breast endoprosthesis.

When analyzing the long-term postoperative period, we can conclude that simultaneous FA removal and augmentation mammoplasty have good results. The positive aspects of simultaneous operations include the use of one access for cosmetic purposes, reducing the number of hospitalizations (1), and psychological stress due to the limited number of operations.

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Conflict of interest

The authors declare that there are no obvious or potential conflicts of interest associated with the publication of this article.

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About the authors

Viktoriia Dzhuganova

First Moscow state medical University named after I. M. Sechenov

Author for correspondence.
Email: viktorijadzhuganova@gmail.com
ORCID iD: 0000-0002-5957-1364

5th year student

Russian Federation, ул. Трубецкая, д.8, Москва, 119991, Российская Федерация

Valery V. NOVOMLINSKY

Clinical hospital "Russian Railways-Medicine" Voronezh

Email: dorbl@mail.ru

M.D., Professor, chief physician

Russian Federation, пер. Здоровья, д. 2, Воронеж, 394024, Российская Федерация

Andrey Petrovich Sokolov

Clinical hospital "Russian Railways-Medicine" Voronezh

Email: pechsvet@yandex.ru

Ph.D., head of the surgical Department No2

Russian Federation, пер. Здоровья, д. 2, Воронеж, 394024, Российская Федерация

Pavel Alekseevich Lynov

Clinical hospital "Russian Railways-Medicine" Voronezh

Email: Linov@mail.ru

head of the plastic Department

Russian Federation, пер. Здоровья, д. 2, Воронеж, 394024, Российская Федерация

Margarita Gennedievna Sokolova

Clinical hospital "Russian Railways-Medicine" Voronezh

Email: author@vestnik-surgery.com

surgeon of the surgical Department No

Russian Federation, пер. Здоровья, д. 2, Воронеж, 394024, Российская Федерация

Anton Petrovich Ostroushko

N.N. Burdenko Voronezh State Medical University

Email: antonostroushko@yandex.ru

Ph.D., associate Professor of the Department of General surgery of N. N. Burdenko Voronezh state medical University

Russian Federation, Voronezh, Russian Federation

Azariy Falesovich Kutsuradis

N. N. Burdenko Voronezh state medical University

Email: Azariykutsuradis@yandex.ru

6th year student

Russian Federation, ул. Студенческая, д. 10, Воронеж, 394036, Российская Федерация

Arina Vladimirovna Chugunova

First Moscow state medical University named after I. M. Sechenov

Email: Chugunova.av@yandex.ru

5th year student

Russian Federation, ул. Трубецкая, д.8, Москва, 119991, Российская Федерация

Anastasia Yurievna Laptiyova

N.N. Burdenko Voronezh State Medical University

Email: laptievaa@mail.ru

postgraduate student of the Department of General Surgery

Russian Federation, Voronezh, Russian Federation

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Copyright (c) 2021 Dzhuganova V., NOVOMLINSKY V.V., Sokolov A.P., Lynov P.A., Sokolova M.G., Ostroushko A.P., Kutsuradis A.F., Chugunova A.V., Laptiyova A.Y.

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