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CORRESPONDENCE
Year : 2019  |  Volume : 15  |  Issue : 5  |  Page : 1181-1185

Rehabilitation of unilateral mastectomy using a hollow breast prosthesis: A clinical case report


1 Department of Prosthodontics, A J Institute of Dental Sciences, Mangalore, Karnataka, India
2 Department of Radiation Oncology, A.J. Hospital and Research Centre, Mangalore, Karnataka, India

Date of Web Publication4-Oct-2019

Correspondence Address:
Blessy Susan Bangera
Department of Prosthodontics, A J Institute of Dental Sciences, Kuntikanha, Mangalore - 575 004, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcrt.JCRT_91_17

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 > Abstract 


The incidence of breast carcinoma is reportedly the second highest among all carcinomas in Indian women. Depending on the extent of resection, age, general health, and economic condition of the patient, various methods of breast reconstruction using surgery have been reported with success and a superior cosmesis. When the patient is unwilling to opt for surgical reconstruction due to various constraints, an alternative technique must be employed. In such cases, nonsurgical prosthetic reconstruction using maxillofacial silicones is considered the only viable option. This prevents the need for a second surgery and rehabilitates the patient during the decision-making phase for considering a delayed reconstructive surgery. The prosthesis mimics the natural texture, feel, weight, and appearance as its natural counterpart enabling the patient to go about her routine social activities. This case report illustrates an indigenous method of rehabilitation of a unilateral mastectomy case using hollow breast form/prosthesis.

Keywords: Breast Prosthesis, hollow prosthesis, Mastectomy, Maxillofacial silicones


How to cite this article:
Shenoy VK, Bangera BS, Pinto VM, Upadhya MK, Shenoy KK, Rent E. Rehabilitation of unilateral mastectomy using a hollow breast prosthesis: A clinical case report. J Can Res Ther 2019;15:1181-5

How to cite this URL:
Shenoy VK, Bangera BS, Pinto VM, Upadhya MK, Shenoy KK, Rent E. Rehabilitation of unilateral mastectomy using a hollow breast prosthesis: A clinical case report. J Can Res Ther [serial online] 2019 [cited 2019 Nov 22];15:1181-5. Available from: http://www.cancerjournal.net/text.asp?2019/15/5/1181/244485




 > Introduction Top


Mastectomy as a result of carcinoma in women results in a massive impact on the patient's psychology and anatomical appearance. Surgical reconstruction with graft material and silicon inserts have been widely and successfully used depending on the extent of resection and feasibility of graft placement.[1],[2] Breast augmentation is performed either by enlargement mammoplasty or augmentation mammoplasty with prosthesis or with flaps to increase the size of the breast for cosmetic reasons, postcancer resection or due to genetic deformity. Breast implants commonly used are saline filled silicone shells and Polypropylene or soy oil inserts.[2],[3] They have consistently shown high success rates and superior aesthetics. In selected cases, this may not be a viable option due to economic constraints and the patient's unwillingness for a second surgery. When surgical reconstructive procedures are not an option due to multiple surgical failures or patient's disagreement toward a second surgery, an epithesis may be designed using silicon, reproducing the anatomy, and enhancing the cosmetic effect of the affected area.[4] This article reports an indigenous technique of fabricating a breast prosthesis using silicones in a patient who underwent unilateral mastectomy.


 > Case Report Top


A 45-year-old female patient reported to the department of radiotherapy and oncology complaining of a lump in the right breast since few years that had increased in size since the past 8 months. She also complained of localized pain in the area. Bilateral sonomammogram revealed 2 × 1.5 hypoechoic area suggestive of an abscess. The right axilla showed a few enlarged lymph nodes of size 1–1.5 cm. Bilateral radio mammography revealed dense opacities in the right breast. Preoperative trucut biopsy was done showing features of lobular carcinoma. Histopathological evaluation revealed infiltrating lobular carcinoma of the right breast T3N2Mx stage IIIA, with 4 out of 11 nodes showing metastasis. Tumor size was 1.5 cm × 1.5 cm × 1.5 cm. However, the disease had indeterminate focality. Tumor was 0.1 cm away from margin in inferior, superior, and lateral margin.

Positron-emission tomography-computed tomography scan showed metabolic activity in a 7.5 cm × 4.9 cm × 2.8 cm heterogeneously enhancing lesion in the lateral quadrant of the right breast with multiple satellite nodules. Metabolically active right level IV cervical, S/C, right axillary and deep pectoral lymphadenopathy was found, with no pulmonary or hepatic metastases. There was no pulmonary or hepatic metastases. The patient was hence diagnosed with invasive lobular carcinoma of the breast of size 1.5 cm × 1.5 cm × 1.5 cm with indeterminate focality. There is a definitive response to presurgical therapy in invasive carcinoma but no definitive response to presurgical therapy in metastatic carcinoma. The patient received 4 cycles of A - doxorubicin (Adriamycin), C - cyclophosphamide (AC) regimen of chemotherapy before surgery. The patient had to be treated with neoadjuvant chemotherapy as there was visceral disease at Level IV cervical node. She had a good response to neoadjuvant chemotherapy and was amenable for surgery. Hence, the surgery was done.

She underwent right modified mastectomy with axillary clearance. The disease was not static as there was near total remission of disease posttreatment. She also received 4 cycles of docetaxel post surgically. Her radiotherapy comprised of 50 gy at 25 fractionations over 5 weeks to the chest wall, axilla, and supraclavicular area. Once she healed, the patient was presented with various treatment options such as silicone implants, augmentation grafting procedures, and external artificial silicone prosthesis. She was unwilling to undergo another surgical procedure and hence opted for the external silicone prosthesis.

The patient was hence referred to the Department of prosthodontics for consultation regarding an external breast prosthesis. Physical examination revealed a well-healed surgical site [Figure 1]. A moulage of the patient's normal breast was made with the patient seated in the upright position using alginate impression material (DPI, Mumbai) carried in a receptacle/tray that was fashioned out of the positioning stent used in radiotherapy. This mesh form thermoplastic material (Head and neck Positioning Device, intensity-modulated radiotherapy Reinforced Style 27, Type- S, Disposable, HN and S, 3.2 mm, CIVCO Radiotherapy) was cut in the required shape and molded in a hot water bath. The patient's chest was wiped with Betadine and then covered with a cloth of approximately 6 mm thickness so as to provide space for the impression material. Once cooled, the mesh form was adapted to the patient's chest area and allowed to harden [Figure 2]. Once the tray was set, the alginate was mixed according to the manufacturer's recommendations and was carried in the thermoplastic tray and was seated on the patient's chest area [Figure 3]. The set impression was retrieved and poured in dental stone (Kalstone, Kalabhai, Mumbai) to obtain the master cast. The undercuts on the cast (areolar area and the inferior aspect of the breast) were blocked out using condensation silicone impression material (Speedex, Coltene, USA) [Figure 4]. The master cast was invested in dental stone, so as to obtain a two-piece mold using an enamel tray. Indices were cut along the borders of the mold, so as to enable accurate repositioning of the counterpart of the mold. Once the first pour was set, a separating medium was applied, and the second half of the mold was poured using dental stone. Once set, the two halves of the mold were separated and inspected [Figure 5]. The master cast was now trimmed all over the tissue surface area to a depth of approximately 5 mm which was to be the thickness of the final hollow breast prosthesis. Molten Modeling wax (DPI, Mumbai) was poured into the mold space evenly to obtain a smooth wax pattern of the normal breast devoid of voids. After each wax addition, the counterpart of the mold was seated to make sure that the wax pattern was made of uniform thickness [Figure 6].
Figure 1: Patient with Unilateral mastectomy

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Figure 2: Impression tray made of thermoplastic material, in an upright position

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Figure 3: Impression of the left breast made with irreversible hydrocolloid

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Figure 4: Cast of the left breast, invested in dental stone. Block out of the nipple area, and inferior portion is done with condensation silicone putty, with indices keyed along the borders

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Figure 5: Second pour over the blocked outcast resulting in a two-piece mold

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Figure 6: Scraping of the cast and pouring the wax pattern producing a hollowed wax form

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The wax pattern was tried on the patient to evaluate the anatomy, size, and precise positioning in relation to the normal breast [Figure 7]. The trial was found satisfactory.
Figure 7: Wax pattern tried on the patient

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The final prosthesis was designed to be hollow to reduce the weight and also increase the flexibility. Medical grade room temperature vulcanizing silicone material A-2186 Platinum room-temperature-vulcanizing Silicone elastomer (Factor II, Lakeside AZ, USA) consisting of part A and B was mixed in the ratio of 10:1 respectively and incorporated with intrinsic colors (Principality Ltd.) to match the shade of the patient's skin. Packing of the silicone material into the mold was carried out by incremental layering. The areolar area was packed with silicone incorporated with a darker shade as compared to the rest of the prosthesis. The material was allowed to set for 24 h inside the two-piece mold at room temperature.

The final prosthesis was retrieved and trimmed at the borders. After the surface was finished, three slots were incorporated in the prosthesis to secure elastic bands to retain the prosthesis [Figure 8]. She could wear a bra comfortably over the prosthesis.
Figure 8: Hollow breast prosthesis made with silicone, fastened with elastic straps

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The finished prosthesis, which weighed 100 g was tried on the patient [Figure 9] and provided weight symmetry with the normal breast. She was educated regarding the care and maintenance of the prosthesis. The patient expressed her satisfaction concerning the aesthetic outcome, comfort, and ease of use of the prosthesis. She is on regular follow-up since 1 year and is found to be doing well.
Figure 9: Frontal and lateral views of breast prosthesis

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 > Discussion Top


Postcancer surgery, breast augmentation, and breast reconstructive surgeries are widely suggested. Breast reconstructive surgery may be done using various breast implants and tissue flap procedures which may be immediate (as the same time as the mastectomy) or delayed.[2],[5],[6],[7] Breast augmentation is done using breast implants, which may be single lumen, double lumen, subglandular, and subpectoral. These surgeries have been performed with high success rates and supreme cosmesis; however, few complications may result. Some patients due to psychological stress of dealing with cancer, do not want any more surgery than what was absolutely required and hence tend to opt for noninvasive approach as a part of rehabilitation.[8],[9],[10],[11] The current types of breast prostheses available are adhesive and conventional. Adhesive prostheses are attached to the woman's skin with an adhesive strip, whereas conventional prostheses are worn inside the bra. Adhesive prostheses are available as contact breast forms which adhere directly to the chest wall, with or without adhesive tape. The main advantage with adhesive prostheses is that they are perceived by the patient as a part of their bodies. However, some patients prefer a conventional external prosthesis as it has a greater ease of application and lesser local irritation. The nonsilicone prostheses (made of foam) are cheaper than the silicone prostheses.[12] In this case, the patient was presented with the treatment option of a mastectomy bra with artificial padding and an adhesive prosthesis and she chose to go for an external breast prosthesis. As indicated by the American Cancer Society, a breast form or prosthesis is an artificial body part worn inside a bra or attached to the body to simulate the natural breast. It may be a definitive option for patients who do not consider reconstructive surgery or it may be a temporary form of treatment to a patient who might have a reconstruction later.[1],[3],[9],[11],[13] The materials used for fabrication of the prosthesis are tissue friendly and economical and commonly used in the fabrication of maxillofacial prosthesis.[14],[15],[16],[17] The total cost of the prosthesis was INR 12,000. Since this prosthesis was hollow, and its weight was similar to the left breast, there would be lesser potential for neck and shoulder pain. The risk of prosthesis dislodgment would be reduced as the prosthesis was fitted with straps. Cleaning the prosthesis with mild soap and water and drying with a soft towel and avoidance of contact with sharp objects was the care/maintenance schedule.

There is a need to provide information to women about breast prostheses and the options available to them. Introducing the topic early in the cancer journey is important, but having a more in-depth conversation about wearing a prosthesis will need to be based on the individual's readiness for it.[18],[19]

The thermoplastic material used to fashion the tray for impression making was reusable, economical, and easily molded to required shape. The mesh from thermoplastic material used as patient positioning stent for radiotherapy was used to record the impression. This material may be used for recording extraoral impressions especially for fabrication of large prosthesis and its further use in the field of maxillofacial prosthodontics may be considered in future. The hollow breast prosthesis designed in this case offered a natural appearance, feel and weight of the normal tissue. It helped balance the upper body and correctly anchored the bra, avoiding it from riding up. It could also be removed and worn at patient's will. She could wear her bra and clothing comfortably over the prosthesis. The decision to keep the prosthesis hollow was made to reduce its weight and also keep it flexible enough to fit inside the bra. A breast prosthesis will need to be replaced every 2 years. The patient expressed her satisfaction with respect to appearance, feel and comfort in wearing the prosthesis.


 > Conclusion Top


This case report describes the prosthetic rehabilitation of a patient who underwent unilateral mastectomy with a hollow breast prosthesis. As she was unwilling to undergo additional reconstructive surgical procedures, she opted to go for an external artificial prosthesis. The prosthesis was fabricated out of maxillofacial silicone materials that were economical, easy to manipulate and biocompatible. The prosthesis could fit easily in the bra and was flexible, lightweight, and reproduced the anatomical form and contours of the natural breast.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 > References Top

1.
American Society of Plastic Surgeons. Breast Reconstruction. 2017; Suppl :15-6.  Back to cited text no. 1
    
2.
Ananthakrishnan P, Lucas A. Options and considerations in the timing of breast reconstruction after mastectomy. Cleve Clin J Med 2008;75 Suppl 1:S30-3.  Back to cited text no. 2
    
3.
Djohan R, Gage E, Bernard S. Breast reconstruction options following mastectomy. Cleve Clin J Med 2008;75 Suppl 1:S17-23.  Back to cited text no. 3
    
4.
Sperli A, Bersou A, Freitas JO, Michalany N. Complications in breast augmentation. Rev Soc Bras Cir Plast 2000;15:33-46.  Back to cited text no. 4
    
5.
Andrades P, Fix RJ, Danilla S, Howell RE 3rd, Campbell WJ, De la Torre J, et al. Ischemic complications in pedicle, free, and muscle sparing transverse rectus abdominis myocutaneous flaps for breast reconstruction. Ann Plast Surg 2008;60:562-7.  Back to cited text no. 5
    
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Resnick B, Belcher AE. Breast reconstruction. Options, answers, and support for patients making a difficult personal decision. Am J Nurs 2002;102:26-33.  Back to cited text no. 6
    
7.
Spear SL, Parikh PM, Reisin E, Menon NG. Acellular dermis-assisted breast reconstruction. Aesthetic Plast Surg 2008;32:418-25.  Back to cited text no. 7
    
8.
Weiland GB, Monreal FJ, Zamora OB, Ruiz PJ, Laborda EG, Zapata AL. Imaging findings and complications following breast implant reconstruction. European Society of Radiology-Electronic Presentation Online System. 10.1594/ecr2013/C-0139.  Back to cited text no. 8
    
9.
Breast Reconstruction: A Supplement to Plastic Surgery News 2017;14-21. Available from: https://view.imirus.com/1006/document/12752. [Last accessed on 2018 Aug 02].  Back to cited text no. 9
    
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Hölmich LR, Vejborg I, Conrad C, Sletting S, McLaughlin JK. The diagnosis of breast implant rupture: MRI findings compared with findings at explantation. Eur J Radiol 2005;53:213-25.  Back to cited text no. 10
    
11.
Venkataraman S, Hines N, Slanetz PJ. Challenges in mammography: Part 2, multimodality review of breast augmentation – Imaging findings and complications. AJR Am J Roentgenol 2011;197:W1031-45.  Back to cited text no. 11
    
12.
Thijs-Boer FM, Thijs JT, van de Wiel HB. Conventional or adhesive external breast prosthesis? A prospective study of the patients' preference after mastectomy. Cancer Nurs 2001;24:227-30.  Back to cited text no. 12
    
13.
American Cancer Society. Cancer Facts and Figures; 2014. Atlanta, Ga. Available from: http://www. Cancer.org/Research/CancerFactsFigures/CancerFactsFigures/cancer-facts-figures-2014. [Last accessed on 2014 Dec 04].  Back to cited text no. 13
    
14.
Marunick MT, Harrison R, Beumer J 3rd. Prosthodontic rehabilitation of midfacial defects. J Prosthet Dent 1985;54:553-60.  Back to cited text no. 14
    
15.
Rodrigues S, Shenoy VK, Shenoy K. Prosthetic rehabilitation of a patient after partial rhinectomy: A clinical report. J Prosthet Dent 2005;93:125-8.  Back to cited text no. 15
    
16.
Aydin C, Karakoca S, Yilmaz H. Implant-retained digital prostheses with custom-designed attachments: A clinical report. J Prosthet Dent 2007;97:191-5.  Back to cited text no. 16
    
17.
Gallagher P, Buckmaster A, O'Carroll S, Kiernan G, Geraghty J. External breast prostheses in post-mastectomy care: Women's qualitative accounts. Eur J Cancer Care (Engl) 2010;19:61-71.  Back to cited text no. 17
    
18.
Andersen MR, Bowen DJ, Morea J, Stein K, Baker F. Frequent search for sense by long-term breast cancer survivors associated with reduced HRQOL. Women Health 2008;47:19-37.  Back to cited text no. 18
    
19.
Glaus SW, Carlson GW. Long-term role of external breast prostheses after total mastectomy. Breast J 2009;15:385-93.  Back to cited text no. 19
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]



 

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