Rheumatoid arthritis (RA) is a type of chronic debilitating inflammatory arthritis that usually affects small joints of hands and feet. If not treated adequately, RA may cause severe pain and joint damage leading to permanent joint deformity.

How common is RA
Worldwide, the prevalence of RA is estimated to be 0.24% of the population (Global Burden of Disease 2010 Study). In US and European countries, RA has a higher prevalence (0.5%- 1.0% of the population). In South-east Asia, the prevalence of RA was reported to be 0.40% (J Glob Health 2015). RA is found twice as common in women compared with men and more commonly found between 30-50 years old.

What causes RA
RA is an autoimmune disease. To date, the exact cause of RA is not able to be identified. Researchers believe the occurrence of RA is multifactorial. A positive family history, genetic factor, smoking, obesity, physical inactivity, age and female sex have been reported to increase the risk of RA.

Presentations and symptoms of RA
Commonly, RA patient will experience stiffness of hands/ feet or affected joints for more than an hour during early mornings. Joint pain and swelling are common. Joints involvement are usually symmetrical on both sides and joint distributions are polyarticular in nature. Apart from joint symptoms, patient may suffer from dry eye, dry mouth, lethargy, weight loss, nodules on skin, lung fibrosis or skin ulcer.

Diagnosis and investigations
Diagnosis of RA is made based on patient’s history, physical examination, blood and imaging tests. Physical examination may reveal boggy joint swelling and joint tenderness on palpation. Patient may have deformities such as radial/ ulnar deviation of the wrist, wrist subluxation, ‘boutonniere deformity’ (hyperextension of the distal inter-phalangeal joint and flexion of the proximal inter-phalangeal joint), or ‘swan-neck’ deformity (hyperextension of the proximal inter-phalangeal joint and flexion of the distal inter-phalangeal joint).

Blood test for specific autoantibodies associated with RA are rheumatoid factor (RF) and anti-cyclic citrullinated peptide antibody (ACPA). A positive RF or ACPA may indicate a more severe/ aggressive disease. Inflammatory markers such as erythrocyte sedimentation rate (ESR) or c-reactive protein (CRP) may be elevated in active disease.

Imaging such as x-ray and ultrasonography of the affected joints may help to detect joint inflammation or erosion on the bones. Musculoskeletal ultrasound is widely used in rheumatology outpatient clinic as a diagnostic tool because ultrasound is more sensitive to detect early arthritis. Ultrasound is a non expensive, non-invasive safe procedure that does not use radiation when compared to other imaging modalities.

Differential diagnoses of RA
Other than RA, the differential diagnoses of chronic inflammatory polyarthritis are: –
– Gouty arthritis- polyarticular
– Psoriatic arthropathy
– Generalized erosive osteoarthritis
– Arthritis related to connective tissue disease such as systemic lupus erythematosus (SLE)

Treatment
Treatment of RA should be initiated as soon as the diagnosis of RA to preserve joint function and prevent joint deformity. The mainstay treatment of RA is disease modifying anti-rheumatic drugs (DMARDs). Example of commonly used conventional DMARDs are methotrexate, leflunomide, sulfasalazine and hydroxychloroquine. Biologic therapy or small molecule targeted therapy are also an option to treat severe RA whom have failed conventional DMARDs. Non-steroidal anti-inflammatory drugs (NSAIDs) and corticosteroids may be used as an add-on therapy to reduce joint inflammation.

Non-pharmacological treatment is also important as part of RA treatment. Physiotherapy or occupational therapy may help in maintaining joint activity, strength and joint protection.

Complication of RA
Untreated RA may cause severe disabling joint deformity. Apart from joint complication, RA may cause premature cardiovascular disease, lung fibrosis, osteopenia or osteoporosis, dry eyes and mouth, increased risk of cancer such as lymphoma.

What should I do if suspected to have RA
If you have symptoms of arthritis, please consult your doctor. If investigations and further management are required, referral to Rheumatologist is warranted.

Dr Lim Chong Hong is a Consultant Rheumatologist & Physician in Loh Guan Lye Specialists Centre, Penang. He has vast experience in diagnosing and treating various rheumatic diseases/connective tissue diseases such as rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, gout, degenerative joint diseases and systemic lupus erythematosus (SLE).

by Chng Tian Ying,
Head Sports Trainer – RMIT University

When it comes to the management and rehabilitation of soft tissue injuries, there is much complexity involved. What is a soft tissue injury? Soft tissue injuries commonly involve sudden trauma or overuse to muscles, ligaments, or tendons. These injuries often occur during sports and exercise activities but can also be sustained in a situation such as from a misstep when walking, and in many more different scenarios. 

The most common traditional first aid protocols for soft tissue injuries were the mnemonics R.I.C.E. (Rest, Ice, Compression, Elevation), P.R.I.C.E. (Protection, Rest, Ice, Compression, Elevation) or P.O.L.I.C.E. (Protection, Optimal Loading, Ice, Compression, Elevation). 

These methods highlight the acute management of soft tissue injuries but do not cover the sub-acute and chronic stages of these injuries. In 2019, Blaise Dubois and Jean-Francois Esculier proposed a new protocol: P.E.A.C.E and L.O.V.E. 

The PEACE and LOVE protocol is a new comprehensive guide that covers all stages of injury. It also emphasises the importance of patient education and the biopsychosocial model. 

Current research has shown that an individual’s experience of pain is influenced by the complex interactions between their biological, psychological, and social factors; Thus, it is essential that they receive equal attention to optimise the individual’s recovery process. 

This protocol is split into two parts. PEACE is used as immediate care in the acute stage (1-3 days) after injury, and LOVE as ongoing management in the subsequent phases of injury. 

In the past, movement and exercise after injury have been frowned upon because of the fear of re-injury, but recent research has suggested that introducing easy and gentle movement during the early stages of injury can be beneficial. It can help with blood flow, joint mobilisation, and decreased fear to get back into activity later. It has been suggested that movement is safe as long as it does not exceed a 4/10 pain, does not worsen the existing condition, and is not done excessively. 

You may be wondering why ice has not been suggested in this protocol as one familiar scene that has been seen repeatedly, especially in the sporting community, is the use of ice during the early stages of a soft tissue injury. 

The PEACE and LOVE protocol holds a controversial opinion towards the use of ice. Despite ice being widely used, there is no high-quality evidence to back up the efficacy of it. It has been suggested that although it can help relief pain, it could also potentially disrupt the inflammatory process and delay healing, as inflammation is the body’s natural response to heal and repair damaged tissue. The avoidance of anti-inflammatories is also suggested for a similar reason. 

With the continual advancement of research comes new knowledge; therefore, leading to the constant evolvement of treatment and rehabilitation strategies. This article is a brief introduction to the PEACE and LOVE protocol, and more details can be found online. 

With that being said, if you do experience a soft tissue injury in future, don’t forget to treat them with PEACE and LOVE!

by Dr Hayden Pooke,
Chairman of the Sports Chiropractic Council Malaysia (SCCM)

The formation of Malaysia’s National Chiropractic Sports Council (NCSC), the Sports Chiropractic Council Malaysia (SCCM) was announced by the Association of Chiropractic Malaysia (ACM) at the beginning of 2020 and it was officially recognised by the International Federation of Sports Chiropractic (FICS) in 2021.

According to the SCCM Chairman and Sports Chiropractor, Dr Hayden Pooke, the SCCM’s membership increased from 13 to 47 members in 2021 and he hopes that the trend continues as the Malaysian Sporting Sector begins to open up and travel restrictions are reduced.

Before the Covid 19 national lockdown, the SCCM was involved in their first ever event in the Zurich PGAM Junior Invitational Tournament in 2020, invited by the Professional Golf Association of Malaysia.

Despite ongoing challenges from Covid-19, the SCCM is currently collaborating with Malaysian Sports Associations and plans to provide Sports Chiropractic care for athletes at as many events as possible in 2022.

SCCM is also poised to conduct, with FICS, their first International Certificate in Sports Chiropractic (ICSC) “hands-on” seminar in the third quarter of 2022 in Malaysia. The SCCM is also proud to announce that one of their student members Kong Hong Lian was awarded one of the FICS Student Scholarships for 2022, a first for any Malaysian Chiropractic Student.

Apart from producing world class Sports Chiropractors by completing the FICS highly acclaimed ICSC and giving its members the opportunity to represent FICS Sports Chiropractic delegations at international sports events treating world class athletes, SCCM also pledges to do everything it takes to bring Sports Chiropractic treatment to the local Malaysian sporting scene, servicing and educating athletes at all levels of competition.

by Dr Tan Boon Cheong – MBBS (MU), MS Ortho (MU)

I believe some of us have come across stem cells treatment in certain diseases. In orthopaedic, stem cells have been used to treat osteoarthritis, for example knee osteoarthritis, etc. Much has been said and heard about stem cells treatment but I believe the knowledge of the general population on stem cells treatment is still superficial. Thus, it is better for everyone to learn a little more about it.

Stem cells are undifferentiated cells with the ability and potential to self-renew and proliferate, producing more differentiated or specialised cells in the process. Stem cells can be obtained from several sources; they have several types, namely embryonic stem cells, perinatal stem cells, induced pluripotent stem cells, adult stem cells(Mesenchymal, hematopoietic and epithelial) and immune stem cells.

With the advancement and research development of stem cells technology, stem cells therapy has been able to expand its therapeutic function. Stem cells have been used as a cell source to reconstruct or rebuild living tissue. In the field of immunotherapy, stem cells have been used as an immune modulator for autoimmune diseases. Furthermore, it can also act as progenitor cells for immunotherapy, allowing the development of cellular technology for anti-cancer, anti-virus and enhancement of body immune system. Because of its potential to self-renew and proliferate, stem cells is also used as a therapeutic agent for degenerative diseases related to aging and frailty, and it has been developed into drugs for treatment of chronic and resilient illnesses. With recent advancements, stem cells therapy has been introduced into the treatment of autism and it has shown promising results.

After several decades and continuous research, stem cells therapy will become a game changer for the future in medicine. The capabilities of stem cells are growing everyday although there are still many obstacles to overcome. It is undeniable that stem cells play a huge role in regenerative medicine and transplantology, but because the technology that produces stem cells is expensive, only few could afford it. With the establishment of more regulated stem cells laboratories, I believe stem cells therapy could be more affordable to everyone that requires it.

by Dr Tan Kenny – Consultant Neurologist & Physician 

(Subspecialty in Parkinson’s Disease & Movement Disorders)

Having sudden facial or limb weakness and numbness?
Sudden slurred speech or drooling?
Sudden blurred vision?
Is that a concern?
What is going on with your body?

Stroke is preventable and treatable. It is important to recognise early stroke symptoms and BE FAST to act during the golden hour so that immediate emergency stroke treatment can be initiated to reduce brain injury.

Stroke occurs when there is reduced blood supply to the brain. In general, stroke can be classified based on the etiology of reduced blood supply, i.e. ischemic (blockage) and hemorrhagic (bleed). Ischemic stroke is the most common type of stroke. Symptoms suggestive of stroke include sudden poor balance, visual problems, face or limb weakness or numbness, speech difficulty. An easy acronym to remember is BE FAST (Balance Difficulties, Eyesight Changes, Face Weakness, Arm Weakness, Speech Difficulties, Time to call for help).

Around 2 million brain cells die every minute during acute stroke, increasing the risk of permanent brain damage, disability or death. Thus, it is pertinent to identify stroke early so that the necessary medical treatment can be implemented.

Upon reaching the hospital, the neurologist will initiate emergency stroke assessment to establish the diagnosis of ischemic stroke before initiating acute stroke treatment. One such treatment is thrombolytic therapy, i.e., administration of a ‘clot buster’ medication to dissolve blood clots that have blocked the arteries in the brain causing stroke, in the hopes of breaking the clot to reperfuse and return blood flow to the affected brain cells. To be effective, the therapy needs to be initiated as soon as possible within the golden hour (4.5 hours from the onset of symptoms), before permanent irreversible damage has occurred.

For ischemic stroke patients who arrive beyond the treatment window period (>4.5 hours) and not suitable for acute thrombolytic therapy, appropriate investigations and medical treatment to stabilise patient will be initiated i.e. blood thinners, blood pressure and blood sugar control. The first three months after a stroke are the most important for recovery as patients will see the most improvement. Thus, besides providing best medical treatment, patient will require neuro-rehabilitation i.e. physiotherapy, occupational therapy and speech therapy.

Stroke can be debilitating but the bright side is it can be prevented and may be attributed to modifiable and non-modifiable risk factors

In Malaysia, hypertension was the most common risk factor followed by diabetes mellitus. Modifiable risk factors are the focus of primary prevention and they include the following risk factors:

a) Lifestyle, i.e., smoking, unhealthy diet, lack of physical activity.

b) Metabolic, i.e., hypertension, diabetes, high cholesterol, obesity (measured by high body mass index or BMI)

c) Environmental, i.e., stress, air pollution.

Many are not aware that stroke can recur. The recurrence rates are 3-4% in the first month and 12% in the first year after a stroke. This emphasises the importance of secondary stroke prevention, and this may involve medical interventions including anti-platelet therapy, anti-hypertensive treatment, cholesterol and blood sugar control. Besides compliance to medication, lifestyle modification plays a vital role.

It is recommended to maintain an active lifestyle by exercising 30 mins daily or at least 150 mins per week, stop smoking, avoid heavy alcohol drinking and healthy diet. Mediterranean diet (low glycemic with high intake of vegetables) supplemented with nuts, diet high in fruits and leafy green vegetables are beneficial. It is also recommended to follow the Dietary Approaches to Stop Hypertension (DASH diet) to reduce blood pressure, emphasising on high consumption of fruits, vegetables, whole grains, low-fat dairy foods, legumes and nuts, and low intake of sodium, sweetened beverages, and red and processed meat.

In Malaysia, there is still lack of awareness in regards to recognition of stroke symptoms and the significance of time-sensitive stroke treatment. As a result, delay in early intervention may lead to prolonged hospital stay and increase of stroke-related morbidities and mortality. BE FAST to ensure better outcome as time loss is brain loss in acute stroke. Stroke strikes fast, so should you.

By Dr. Lim Ban Keong, D.V.M (UPM)，GM of Rhone Ma Holdings Bhd

The ruminant industry in Malaysia only started taking off over the last ten years with many participants being small farmers. To help them out, we plan to share our combined expertise and technological knowhows for dairy farming and milk production with other farmers and other interested parties,”  – said Dr. Lim Ban Keong

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There’s nothing better than a splash of milk in your morning coffee for the important nutrients for our body. However, sometimes consuming milk and milk products might result in tummy problems. If that happens, it’s time to try A2 milk.

Tummy problems from milk may not necessarily be due to lactose intolerance or trouble digesting lactose sugar in milk. Recent research suggests that a less-known protein, A1, may be one of the culprits. A1 produces a protein fragment known as Beta-casomorphin-7 (BCM-7) during digestion which triggers tummy discomfort and symptoms similar to those with lactose intolerance.

There are 2 kinds of proteins in milk: A1 and A2. While most cows’ milk contains both, A2A2 cows produce only A2 protein, which results in A2 milk.

Rhone Ma Holdings Berhad, a homegrown end-to-end animal health solutions provider, introduces the A2 milk to the local market through its acquisition of 49% interests each in three livestock companies in February 2020. The Group has teamed up with One Lazuli Sdn. Bhd., Nor Lazuli Nutrition Sdn. Bhd. and Nor Livestock Farm Sdn. Bhd. in order to expand into the dairy farming business.

As a first step, the Group and its partners injected RM3 million capital in Nor Livestock Farm Sdn. Bhd. who operates a 6-acre dairy farm in Batang Kali, Selangor which currently house more than 160 A2A2 Holstein cattle. The Group expects to further expand the herd to 500 heads as they are expecting around 90 more female cows to be born in a few months’ time. In addition, they are also planning to import another batch of 100 impregnated cows in 2021. The farm’s milk production currently averages 12,000 litres/month and soon the farm is expected to produce approximately 65,000 litres/month. 

The Group’s shift into the ruminant sector is part and parcel of its responsibilities as a key industry player to further develop the local ruminant industry. Rhone Ma, a proponent of the Total Solutions Programme (TSP) which allows customers the flexibility to customise the animal health services and animal health products to form their desired animal health solution, has pledged to work together with local dairy farmers to support them and establish more dairy farms in the country in line with the government’s heed to stimulate the industry. 

“The ruminant industry in Malaysia only started taking off over the last ten years with many participants being small farmers. To help them out, we plan to share our combined expertise and technological knowhows for dairy farming and milk production with other farmers and other interested parties,” said Dr. Lim Ban Keong, Managing Director of Rhone Ma Holdings Berhad.

“This will also include advocating the use of Milk Boosta the premium cattle feed that was specially formulated to induce energy for maximum milk production for cattle in a tropical climate. The combination of Milk Boosta and Alfalfa Hay and some kind of supplements also helps to reduce heat stress,” added Qasem Alhasan, Managing Director of Nor Livestock Farm Sdn. Bhd.

With the establishment of more farms, the Group will not only be able to encourage their peers to thrive in the industry but also address the issue of fresh milk insufficiency in Malaysia head on. On top of that, as consumers become more health conscious and discerning in their food consumption, the Group and its partners envisage a big future for fresh A2 milk in the local market.

Bryan Lin Boon Diann
Chief Executive Officer of Sunway Medical Centre

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2020 has brought upon a new wave of change to people everywhere – from wearing a face mask in public areas, social distancing, practising good personal hygiene at all times to working and studying at home. 

Likewise, the hospital landscape has altered due to the unprecedented arrival of the COVID-19 pandemic. Today, patients can meet their doctors from the comforts of their homes through virtual clinics, evolving the way hospitals operate as digitisation becomes the norm. 

The pandemic has effectively changed the way businesses are run and for healthcare institutions like Sunway Medical Centre, we need to be innovative. We were the first tertiary hospital to establish the telemedicine service at the start of the pandemic, and this is one of the ways that has transformed the way we support care outside of our facility. 

We have made healthcare more accessible by extending services such as medicine delivery, nursing care, diabetes care, wound care, physiotherapy and phlebotomy to homes through our personalised, mobile healthcare services and home nursing under Sunway Home Healthcare (formerly known as SunMed@Home). 

We have also set up a Telemedicine Command Centre which facilitates referrals for patients with medical emergencies to the hospital. This will provide better patient experience journey and peace of mind during their times of need. This project is likely the first in the country and will be another game changer in the clinical landscape.

The ultimate goal is to improve patient value, and the only way the healthcare industry will achieve this is by digitalising healthcare, leveraging on artificial intelligence, telemedicine, Internet of Things (IoT) and other digital platforms to propel it to the next level. Robotics and automation will also be vital in improving overall service delivery and customer experience while enabling more personalised medical care. 

We need to demonstrate greater value in the healthcare system in this challenging time while continuing to care for patients requiring multispeciality and multidisciplinary care services and/or complex technologies. 

Setting up new and advanced quarternary service offerings like bone marrow transplant, renal transplant and paediatric cardiac surgery has also set Sunway Medical Centre apart in the market. The hospital is also focused on Women & Children Services and Acute Services to ensure that communities are well taken care of. 

As the industry grows, the requirement for highly-skilled, professional talent will also increase. 

Healthcare providers like us will need to continue developing a sustainable talent pipeline, while strengthening the existing talent pool with strategic hires, retention initiatives and continued employee training and development.

While diseases will never be completely eliminated, through science, data and technology, we will be able to identify it earlier, intervene proactively and better understand its progression to help consumers more effectively and actively sustain their wellbeing. 

Personalised medicine will progress and as researchers find out more about the particular genetic makeup of diseases, we will be able to give specific drugs to target it. And by 2030, healthcare will be centred on patients empowered to prevent diseases rather than seek treatment. They will receive personalised health solutions in ways that are integrated seamlessly into their daily lives. 

In short, healthcare providers need to change accordingly in order to forge ahead. As the rate of change in healthcare is accelerating, healthcare providers must harness the forces of driving transformation and use them to its advantage and in this case, growth, innovation and diversification. 

by Dr Mecherl Lim 

MD (MA) Naturopath (ND), Holistic Kinesiology

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In 2006, researchers Dr Sue Shepherd & Professor Peter Gibson from Monash Uni, linked several highly fermentable but poorly absorbed short chain carbohydrates and polyols to symptoms associated with IBS, including wind & diarrhoea, as well as to the increased intestinal permeability associated with Crohn’s disease.

These fermentable aligo-di-and monosaccharides and polyols are now known collectively as FODMAPs.  They comprise oligosaccharides (fructans and galactans), disaccharides (lactose), monosaccharides (fructose) and polyols, which is the technical word for sweetener.  In the 2006 study, 74 per cent of patients with IBS and fructose/fructan diet such as the FODMAP diet.

HOW DOES THE LOW-FODMAP DIET WORK?

Research shows that FODMAPS in meals are poorly absorbed in the small intestine and increase the delivery of water to the colon-suggesting the catalyst for diarrhoea in some people.  Breath test show that eating a low-FODMAP diet reduces hydrogen production (in both healthy volunteers and patients with IBS), linking the short chain carbohydrates with bloating, abdominal distension and pain and excessive flutulence. 

Since the first study, research has consistently tied global restriction of FODMAPs (rather than restriction of individual components) with reduced symptoms of IBS.  In a challenge trial (in which participants restricted fructose/fructans-containing foods and then restored the foods to the diet) showed a return of symptoms after the foods were reintroduced.

In those with Crohn’s  disease, sweeteners such as sorbitol, maltitol and isomalt are absorbed, but the digestibility of the other nutrients in the foods is reduced because these polyols cause an osmotic load, meaning that more water remains in the intestine, leading to watery stool.

FODMAP group had reduced bloating, 87 per cent enjoyed less flatulence and 85 per cent experience a reduction in abdominal pain.

The researchers concluded that the low-FODMAP diet is more effective than standard dietary guidelines for symptom control of IBS.

FODMAPS AFFECT HEALTHY PEOPLE TOO

It’s interesting to note the research has also uncovered information about how FODMAPS are digested by healthy participants.  We know, for example, that fructans (polymers of fructose found in asparagus, leeks, garlic, onions and onions and wheat) and galacto-oligosaccharides (lactose from cows milk) are always fermented by intestinal flora, and cause wind production and flatulence in healthy people too.  The effects are merely worsened in those with hypersensitivity and motility disorders as found in IBS.

READY TO TRY IT

The low FOD-MAP diet eliminates sugars that can’t be fully  digested and absorbed in the small intestine.  When following this diet, journal ling is critical.  Be sure to keep accurate records of what you eat, when and how your body responds.

After following the diet until all of your symptoms have disappeared, the goal is to reintroduce foods to determine whether they are a trigger for your symptoms.  When doing so, add one food back at a time and wait 72 hours to determine that symptoms haven’t re-appeared before moving on to the next food. 

This way of eating is not as restrictive as some other prescription diets, but if you are interested in following it, you are wise to get nutritional guidance from an expert so you are sure to get all of your health-supportive nutrients.  You may have to use vitamin and mineral supplementation to be sure to meet nutrient requirements, particularly in the elimination and re-challenge phases. 

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Visit : http://www.drmecherlherbs.com

Email : drmecherherbs@gmail.com

FACEBOOK : drmecherlherbs for further enquiries.

By Dr Teoh Mei Shi (Consultant Breast, Endocrine & General Surgeon)  & Dr Wong Thai Er (Consultant Plastic and Reconstructive Surgeon)

Dr Teoh Mei Shi is a Breast, Endocrine and General Surgeon. Dr Wong Thai Er is a Plastic and Reconstructive Surgeon. Both are consultants at Loh Guan Lye Specialists Centre. As a team they work together to treat the cancer and help reconstruct the breast to give patients a more positive outlook in their recovery from cancer.

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Over the last few decades, surgical treatment of breast cancer has undergone a paradigm shift from radical mastectomy that involves removal of whole breast and large portion of muscle underlying the breast tissue to breast conserving surgery and now oncoplastic breast reconstructive surgery. Concomitant advances in chemotherapy and radiotherapy have played major role in this shift.

Oncoplastic breast reconstructive surgery involves the oncological removal of breast cancer combined with reconstructive plastic surgery techniques to rebuild or reshape the breast for an aesthetically pleasing final outcome. The combined reconstructive surgery can be carried out immediately at the time of breast cancer surgery or as delayed procedure performed months or years later. The current practice of Breast Reconstruction results in single hospitalization saving time and cost with shorter time away from work. Moreover immediate breast reconstruction certainly helps them to regain confidence with positive outlook. 

Multidisciplinary discussion between patient, oncologist, breast surgeon and reconstructive surgeon is pertinent to decide the best approach for each patient for appropriate oncological treatment for breast cancer followed by appropriate breast reconstruction. 

Choice of Oncoplastic breast reconstructive surgery will depend on 

• stage and subtypes of breast cancer 

• breast size and volume

• adequate autologous tissue for reconstruction

• patient’s choice and expectation

• location of the breast tumor

• tumor response to neoadjuvant treatment 

Types of oncoplastic breast surgery

• Breast conserving surgery with volume replacement and volume displacement techniques

• Nipple-sparing / Skin-sparing mastectomy with autogenous tissue reconstruction eg Back tissue / Tummy tissue

• Nipple-sparing / Skin-sparing mastectomy with Implant reconstruction 

There are many options for breast reconstruction following surgery for breast tumour. As such, these options have to be discussed with the patients and the most appropriate option is then chosen and tailored for them. Many factors need to be taken into consideration during the discussion as these factors would affect not only the outcome of the reconstruction, but also the adjuvant therapies (radiotherapy and chemotherapy)

The options for reconstruction are:

• External prosthesis

• Silicone implant

• Fat injection

• Autogenous tissue flap reconstruction

External prostheses are made of foam-like material into well-designed breast-shaped prostheses, to be placed inside the inner wear. They are suitable for those who had undergone breast tumour surgery and do not want any reconstructive surgery at all. 

Commonly used for breast augmentation, silicone implants, can be used for breast reconstruction in selected cases. They come in various sizes and shapes, to be inserted after breast surgery. It is suitable for those who will not require chemotherapy and radiotherapy as both these therapies can affect the outcome and enhance the complications and risks associated with silicone implants.

Fat injection involves harvesting fat from either the tummy or the thigh and injected into chest. This technique requires multiple sittings of harvesting and injection to achieve the desired size as some of the injected fat shrinks after each sitting, thus can significantly elevate cost with this technique. This technique is also suitable for those who will not require chemotherapy and radiotherapy as both these therapies can affect can affect fat cell survival and the outcome.

Autogenous tissue flap reconstruction is still the gold standard in breast reconstruction. It involves harvesting the patients’ own tissue together with the underlying muscle and blood supply and the flap is then repositioned into the chest. Tissues commonly harvested are usually from the tummy (TRAM flap) or the back (LD flap). As these tissues have their own good blood supply, they have been well documented to facilitate healing, making it more robust and reducing complications and risks associated with radiotherapy and chemotherapy. Hence this method is strongly advisable for those patients who had undergone or going for chemotherapy and radiotherapy. For patients with advanced large breast tumour, this technique is also helpful for closure of chest wound and in preparation for chemotherapy and radiotherapy.

CONCLUSION

Breast cancer patients are now enjoying a longer lifespan due to better understanding of tumour biology with more advanced treatment options. By removal of the breast tumour coupled with choice of breast reconstruction, we aspire the survivors not only will enjoy a longer and better quality of life, but also live with restored confidence and esteem in their ongoing and future endeavours.