Implant-Based Breast Reconstruction


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  • In 2010, 80 percent of women in the United States chose permanent implant-based reconstruction rather than autologous tissue for breast defect reconstruction.
  • recommendations regarding postmastectomyradiation therapy are often based on pathologic analysis of the mastectomy specimen,the need for postmastectomy radiationtherapy is not always known at the time of mastectomy at the time of mastectomy andsentinel lymph node biopsy whether lymph node micrometastases are present.49 In addition,the increasing use of fine-needle aspirationand stereotactic core biopsy techniques, insteadof open excisional biopsy techniques, to makethe diagnosis of breast cancer has limited theability to accurately assess the amount of invasivetumor within the breast parenchyma until aftermastectomy and review of the permanent sections.
  • Implant-Based Breast Reconstruction

    1. 1. CRITICAL QUESTIONS -REFINEMENTS IN IMPLANT BASED BREAST RECONSTRUCTION Stamatis Sapountzis M.D Division of Plastic Surgery China Medical University HospitalDepartment of Plastic and Reconstructive Surgery Seoul National University Hospital
    2. 2. Goals of Breast Reconstruction Provide permanent breast contour Make the breasts look balanced Avoid the need for external prosthesis Re-establish normalcy and confidence
    3. 3. Breast Reconstruction Implant Based Autologous Tissue Implant + Autologous Tissue
    4. 4. 80 % of Women in 2010received Implant- Based Breast Reconstruction
    5. 5. Plastic and Reconstructive Surgery • December 2009 The 70% of women Plastic Surgeon prefer Implant Based Reconstruction for themselves
    6. 6. Immediate Vs Delayed Breastreconstruction – Benefits &Risks
    7. 7. •Better aesthetic result •Lower complication rate•Better psychological effect •Less optimal result•Lower cost •High percentage of anxiety,•Higher risk of complications depression and impairmentindependently the method of their sexual attractivenessof reconstruction •Higher cost (2 operations, hospital stays)
    8. 8. Comparison Immediate- Delayed Reconstruction to the same patientPreoperative with previous right Result of delayed right breastmastectomy reconstruction and immediate left breast reconstruction with bilateral deep inferior epigastric perforator (DIEP) flaps shown 21 months postoperatively
    9. 9. 80 % of breast reconstructions are immediate
    10. 10. What is the effect ofradiation on Implant based breast reconstruction?
    11. 11. The objective of this meta -analysis is to examine:whether patients requiring post-mastectomyradiotherapy should have an immediate or delayedreconstructionwhether a prosthesis or autologous reconstruction isassociated with the optimum outcome in terms ofpostoperative morbidity
    12. 12. conclusion Post-mastectomy radiation, irrespective of the method of reconstruction, increases the incidence of postoperative complications; however, this study demonstrates that an autologous flap offers a more favorable outcome in terms of morbidity than expander/implant reconstruction
    13. 13. Can we always know if RT isgoing to be followed?
    14. 14. Indication for Post-mastectomy RT Many decisions regarding radiation therapy are made after mastectomy•T3 or T4 tumors or four or more •sentinel lymph node biopsy cannotpositive axillary lymph nodes needs RT detect lymph node micrometastases •fine-needle aspiration instead of open•Radiation in T1 or T2 tumors and one to excisional biopsy techniques, hasthree positive axillary nodes is limited the ability to diagnose thecontroversial. amount of invasive tumor within the breast parenchyma compared to the permanent section
    15. 15. Delayed-Immediate Breast Reconstruction 2 weeks 2 weeks 4 to 6 months
    16. 16. Benefits of Delayed-Immediate Breast Reconstruction Aesthetic outcomes similar to immediatePatients who do not require PMRT: reconstruction Avoid problems associated with PMRT after an Patients who require PMRT : immediate breast reconstruction. Better aesthetic outcome than is achieved with standard delayed reconstruction. Specifically, re- expansion of the mastectomy skin after PMRT provides additional usable breast skin to perform delayed breast reconstruction. Provides an additional option that broadens patients’ treatment choices and allows patients to participate fully in treatment and reconstruction decisions.
    17. 17. 151 patients , TE/I Reconstructionfollowed by PMRT.7-year Follow-Up:• PIRR rate was 29%.•Reasons for PIRR included infection(15),implant extrusion, shift, leak, orrupture (4), patient request (1), ormultifactorial (17)
    18. 18. What is the role of Fat Grafting in Implant Based Reconstruction in the presence of Radiotherapy? Does it Affect the Follow-up?Are there Pharmacologic agents to prevent the PR fibrosis?
    19. 19. 65 mastectomized patients who had received radiotherapy.In the 1st operation Tissue expander under the pectoralis major + 150 (+- 25 cc) of fat in the upper quadrants between the skin and the muscle and also inside the muscle After 3 months, removal of expander, insertion of theIn the 2nd operation cohesive silicone prosthesis, and injection of 150 (+-30 cc) of fat in the lower quadrants
    20. 20. Mean follow-up was 1 year. No complications were recorded with the fatinjections.Patients’ mean satisfaction rating was 4 ona scale of 1 (low) to 5 (high), and the capsularcontracture was never above 1 on the Bakerclassification
    21. 21. Plastic and Reconstructive Surgery • August 2011From 2000 to 2010, the authors reviewed 646 lipofilling procedures from513 patientsThe average follow-up time from the last lipofilling procedure to the last visitwas 19.2 months (range, 1 to 107 months) 7: Benign calcifications 12 radiologic images appeared 2: Benign opacity masses after lipofilling: 3 :Suspicious lesions 5: Benign lesion From 7 histopathologic reports: 2: Local breast relapse
    22. 22. Conclusion Lipofilling following breast cancer treatment leads to a very low rate of complications Does not affect the radiologic follow-up There is no proof of the safety of lipofilling in terms of cancer recurrence or distant metastasis Lipofilling should be performed in experienced hands, and a cautious oncologic follow-up protocol is advised
    23. 23. Pharmacologic Agents Leukotriene antagonists (LTRAs) have emerged as effective prophylactic agents in the management of reactive airway diseases Montelukast and Zfirlukast have “Off-Label” use in Breast Augmentation They seem to prevent and improve the Capsular Contracture There are no series of using these agents in breast reconstruction with RT
    24. 24. Pharmacologic AgentsS.Sapountzis, JH Kim, DF Veiga, LM Ferreira Impact Factor: 1.389 In our Hypotheses we suggest that the Zafirlukast is able to prevent the post-radiation capsular contracture by blocking the TGF which plays key role in radiation induced fibrosis
    25. 25. Human Acellular DermalMatrix: Why? Effective? Infection?
    26. 26. Limitation of Other Implant Techniques Total Muscle Cover  Partial Muscle Cover  Difficult  Implant migration  Painful  More infections?  Bloody  More contractures?  Limited space  More exposures?  Poor shape  More explantation  Poor IMF definition  Superior malposition
    27. 27. Benefits of AlloDerm •Technically easier than total muscle cover •Less morbidity than total muscle •Better shape than total muscle •Better control of folds and shape than total muscle only •Less capsular contraction
    28. 28. Plastic and Reconstructive Surgery • December 2010 Twenty patients underwent tissue expander reconstruction using the “dual-plane” acellular cadaveric dermis technique (AlloDerm). During implant exchange, intraoperative biopsy specimens were obtained of (1) biointegrated acellular cadaveric dermis and (2) native subpectoral capsule (internal control).
    29. 29. Review Study of 9 Articles
    30. 30. (Plast.Reconstr. Surg. 128: 403e, 2011.)A total of 203 patients underwent 337immediate TE/I Breast reconstructions :•With acellular dermal matrix: 208 (61.7 %)•Without 129 (38.3 %)
    31. 31. The key points of our technique are:• advantages of Alloderm•eliminate the “Step- off” deformity•Recreate the normal tail of the breasttoward the axilla
    32. 32. 1st Stage: Tissue Expander + Alloderm 33 Patients/ 36 3 months later BreastReconstructions 2nd Stage: Permanent Silicone Implant + Fat grafting :134cc (21cc to 228)
    33. 33. Results 7 patients required surgical intervention to the contralateral breast for symmetry achievement.Mean follow-up was 1 years (ranged from 6 to 17 months) Two patients with infection in the early postoperative period required expander removal (5.4%). No complications were noticed after fat injection. During the follow-up period the capsular contracture was never above 1 on the Baker classification
    34. 34. Plastic Surgeryfemale 40 years old, prior to total mastectomy b) 3 months after immediate reconstruction with 275cc tallheight profile tissue expander and 12x4 cm AlloDerm c) 1 years after the second stage of reconstructionwith 265cc smooth round implant, moderate plus and 91cc of fat grafting Plastic Surgery female 48 years old, 3 months after immediate breast reconstruction with 450cc tall height expander and 16X4cm AlloDerm b) 1 year after the second stage of reconstruction with 350cc smooth round high profile implant and 141cc of fat grafting c) profile view: note the fullness of the upper pole and the absence of “step-off” deformity between the reconstructed breast and the chest wall