2008  breast reconstruction (aust)
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2008 breast reconstruction (aust)

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breast reconstruction general

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  • They are able to achieve wonderful results in reconstruction like these patients who have had breast reconstruction following mastectomy, where patient quality of life is markedly increased from an emotional, physical, and cosmesis standpoint. Despite results like these , clinical limitations in reconstruction following tumor removal are often realized.
  • Guta Percha- a natural resin rubber from a malaysian tree called the Isonandra Gutta tree Terylene, a polyester fiber, the first wholly synthetic fibre invented in the United Kingdom.

2008  breast reconstruction (aust) 2008 breast reconstruction (aust) Presentation Transcript

  • Breast Reconstruction: Decision Making Surgical Planning Michael J. Miller, M.D. Professor of Surgery Director, Division of Plastic Surgery The Ohio State University
  • Lifetime Probability of Developing Cancer Source:DevCan: Probability of Developing or Dying of Cancer Soft ware, Version 5.1 Statistical Research and Applications Branch, NCI, 2003. http://srab.cancer.gov/devcan 1 in 59 Ovary 1 in 57 NH-Lymphoma 1 in38 Uterine corpus 1 in 18 Colon and rectum 1 in 17 Lung and bronchus 1 in 7 Breast 1 in 3 All Sites Risk Site
  • Why Breast Reconstruction?
  • Mastectomy/ No Reconstruction
    • Advantages
      • no further surgery needed
      • shorter surgery time/hospital stay
      • symmetry restored with prosthesis
      • may consider reconstruction in future
    • Disadvantages
      • scar on chest wall
      • asymmetry in clothing
      • external prosthetic can:
        • dislodge
        • be uncomfortable
        • be impractical for athletic activities
    • Breast Deformities
    • Consequences:
      • Aesthetic
      • Functional
      • Emotional
      • Social
    Decreased Quality of Life
  • Reconstruction Options Immediate Delayed Timing Technique Tissue Tissue + Implant Implants alone
  • Delayed Reconstruction
    • Advantages
      • shorter hospital stay/ shorter recovery
      • adjuvant therapy causes no complications to reconstruction
      • allows patient time to consider reconstructive options
    • Disadvantages
      • soft tissue scar on chest wall
      • requires additional surgery and recovery time
      • difficult to reconstruct after scarring occurs
  •  
  • Immediate Reconstruction
    • Advantages
      • lowers psychosocial morbidity
      • lowers surgical morbidity
      • superior cosmetic results
      • lowers cost of surgery
      • No difference in development or detection of local recurrences
      • No delays in adjuvant therapies
    • Disadvantages
      • mastectomy skin flap necrosis possible
      • longer hospitalization/recovery
      • additional scars
      • coordination required between surgeons
  • Reconstruction Options Immediate Delayed Timing Technique Tissue Tissue + Implant Implants alone
  • Breast Reconstruction Methods UTMDACC 1990 - 2000
  • Implant Reconstruction
    • Two-Stage
      • Stage One: Tissue expansion
      • Stage Two: Permanent implant placement
    • One Stage
      • Permanent implant placement
    • Use of dermal matrix implants
  • Implant Reconstruction
    • Tissue Expanders/Implants
      • Advantages
        • No additional scarring
        • Shorter procedure/recovery
        • Satisfactory shape in clothing
      • Disadvantages
        • Foreign body causing risk of infection
        • Risk of rupture necessitating removal
        • Risk of capsule formation and firmness
        • Asymmetry
        • Implant not permanent
  • Two-Stage Implant Reconstruction Pre-op Full Expansion Final Result
  • Acellular Dermal Matrix (AlloDerm ® ) Zienowicz RJ. Karacaoglu E. Plastic & Reconstructive Surgery . 120(2):373-81, 2007
  • Zienowicz RJ. Karacaoglu E. Plastic & Reconstructive Surgery . 120(2):373-81, 2007
  • Preminger BA. et. al. Annals of Plastic Surgery. 60(5):510-3, 2008.
  • “ Well, this is a fine mess …”
    • Q. 1 “How in the world did we get here?”
    “ Well, this is a fine mess …”
    • Q. 1 “How in the world did we get here?”
    • Q. 2 “How do we avoid ever being back here again?”
    “ Well, this is a fine mess …”
  • Breast Implantation
    • Autologous Tissue
    • Contralateral breast (Verneuil, 1887)
    • Lipoma (Czerny, 1895)
    • Grafts and flaps of muscle, fascia, fat, and dermis
    • paraffin,
    • ivory,
    • glass balls,
    • ground rubber,
    • ox cartilage,
    • Terylene wool,
    • gutta percha,
    • Dicora,
    • polyethylene chips,
    • Ivalon sponge (poly(vinyl alcohol-formadehyde)),
    • Ivalon in polyethylene sac,
    • polyether foam sponge (Etheron),
    • polyethylene (Polystan) tape or strips wound into a ball,
    • polyurethane foam sponge,
    • teflon-silicone prosthesis.
    Breast Implant Devices
  • Breast Implantation
    • Paraffin, Vaseline, “Organogen,” “Bioplaxm”
    • Silicone oil + some combination of:
      • ricinoleic acid, animal fatty acid, vegetable fatty acids, mineral oil, vegetable (castor) oil, olive oil, croton oil, peanut oil, concentrated vitamin D, snake venom, talc, beeswax, shellac, glazier’s puddy, epoxy resin, industrial silicone fluids
    • Example: Sakurai (> 72,000 cases)
    • Medical-grade silicone
    Direct Injections
  • Silicone Implant Alternatives
    • Pain
    • Skin discoloration, edema, ulceration, and necrosis
    • Calcifications
    • Granulomas
    • Fluid migration
    • Infection
    • Cysts
    • Axillary adenopathy
    • Disfigurement
    • Loss of the breast
    • Liver dysfunction
    • Pneumonitis/ARDS
    • Pulomonary embolism
    • Coma
    • Death
    Complications
  • Pre-Silicone Implant Era
    • Women wanted breast enhancement
    • Many alternatives
    • Many complications
    • Ideal material not identified
    Non-rigorous trials… What was known:
  • Silicone Breast Implants
    • 1950’s- shunts and joint replacements
    • 1964- Cronin and Gerow
      • Introduced silicone gel-filled breast implant
      • Pre-clinical studies in dogs
    • 1962-1968 Dow Corning- only manufacturer
    • 1968-early 1990’s- Multiple manufacturers
      • Dow Corning, Heyer-Schulte-Mentor, Cox-Uphoff International, Aesthetech Corp., Surgitek, Inamed-McGhan, Mammatech, foreign manufacturers, …
  • Silicone Breast Implants
    • Early 1990’s, > 2 million women implanted!!
  • Prior to 1970’s: little regulation or oversight…
  • FDA Device Regulation
    • 1976- Medical Devices Amendments
      • General and Plastic Surgery Advisory Panel
      • Implants required general controls and performance standards only.
    • 1982- FDA proposes reclassification as Class III device requiring stringent controls
    • 1988- Changed to Class III status requiring pre-market approval (PMA) applications.
    • 1992- Withdrawn from the market
  • Clinical Value + = ?
  • Clinical Value
    • Determined by:
    • Affect on patient’s:
      • Functional Status
      • Risk Status
      • Well being
    • Cost
    • Patient satisfaction and perceived benefit
    • Clinical outcome
    Nelson EC. et al. Joint Commission Journal on Quality Improvement. 22(4):243-58, 1996
  • Clinical Value
    • Affect on patient’s:
      • Functional Status
      • Risk Status
      • Well being
    • Cost
    • Satisfaction/perceived benefit
    • Clinical outcome
    Pre-1991 acceptable + Value Score
  • Clinical Value
    • Affect on patient’s:
      • Functional Status
      • Risk Status
      • Well being
    • Cost
    • Satisfaction/perceived benefit
    • Clinical outcome
    Pre-1991 acceptable Post-1991 + Value Score acceptable ? ? ? ? ? ?
  • Clinical Value
  • Medical Device Safety Risk Benefit
  • Silicon Gel Breast Implants
    • After all is said and done…
    • Conclusions:
      • Local complications are well described
      • Systemic complications are not supported
      • Patients must be informed
    2006- Silicone Gel implants return to the U.S. market
    • “ How in the world did we get here?”
    • “ How do we avoid being back here again?”
  • Reconstruction Options Immediate Delayed Timing Technique Tissue Tissue + Implant Implants alone
  • Skin Sparing Mastectomy
  • Skin Sparing Mastectomy The ablative surgeon begins the reconstruction!
  • Skin-Sparing Mastectomy Incisions only for: - Nipple and Areola - Access to the axilla - Biopsy scars - Skin areas “at risk”
  • Skin Sparing Mastectomy
  • Pre-op Post-op Skin Sparing Mastectomy
  • Skin Sparing Mastectomy Mastectomy skin flap necrosis
    • Oncologic Safety
    • 51 breast cancer patients, Stages 0-II; 1991-1994
    • Median follow-up 45 months
    • Local recurrence rate 2%
    • Biopsies of incisions in 32 consecutive patients revealed no evidence of retained breast tissue
    • Slavin, et al, Plast Reconstr Surg 1994; 93:1191-1204
    Skin-Sparing Mastectomy
  • Oncologic Safety of SSM vs. CM Local Recurrence Rate (T2 tumors) Kroll 104/SSM 271/CM Carlson 327/SSM 188/CM Simmons 77/SSM 154/CM SSM CM 15% 12% 9% 6% 3% 0%
  • Skin Sparing Mastectomy
    • Skin-sparing mastectomy with immediate breast reconstruction is oncologically safe and offers superior cosmetic results compared to conventional mastectomy
    • Local recurrence rates are similar for skin-sparing and conventional mastectomies
    • Most local recurrence are detected by physical exam within 3 years following skin-sparing mastectomy
    • Technically more demanding
    • Oncological safety
    • Superior aesthetic results
    Skin Sparing Mastectomy
  • Latissimus Dorsi + Implant
  •  
  • Latissimus Dorsi Flap + Implant Pre-op Post-op Donor site scar
  • LD flap- Endoscopic Harvest Post-op. ( 3/1/2005) Pre-op. ( 1/13/2004)
  • LD flap- Endoscopic Harvest Pre-op Post-op
  • Reconstruction Options Immediate Delayed Timing Technique Tissue Tissue + Implant Implants alone
  • Autologous Tissue Reconstruction
  • Pedicled TRAM
  • Pedicled TRAM
    • Prone to venous insufficiency leading to fat necrosis
    Download illustrations from Moon and Taylor
  • Microvascular Tissue Transfer
  • Microsurgical Breast Reconstruction
    • Donor site options
      • Free TRAM
      • Muscle-sparing free TRAM
      • DIEP
      • SIEA
      • S-GAP
      • I-GAP
      • Other
  • Perforator Flaps
    • DIEP flap
    • Advantages
      • Spares Muscle
      • Minimizes Pain
      • Less functional morbidity
    • Disadvantages
      • Technical challenge
      • Increased operative time
      • Variations in anatomy
      • Increased fat necrosis
  • 5/13/2008
  • 5/29/2008
  • CT Angiogram Analysis
  • 7/23/2008 7/23/2008
  • 7/8/2008 7/23/2008 7/23/2008
  • CT Angiogram Analysis: Vessel Selection
  • 9/2/2008 9/2/2008 Autologous Reconstruction: I-Gap Candidate
  • CT Angiogram Analysis: I-Gap Planning
  • 9/18/2008
  • Autologous Tissue Reconstruction
    • Advantages
      • Natural breast shape and behavior
      • Natural consistency
      • “ Tummy-tuck,” “buttocks lift”
      • No foreign body
      • Lower costs long-term
      • Less emotional trauma
  • Autologous Tissue Reconstruction
    • Disadvantages
      • Longer surgical procedure
      • Donor site scarring/deformity
      • Possible Complications
      • Longer hospitalization
      • Longer recovery
      • Greater initial cost
  • Ideal Abdominal Tissue Candidate
    • Healthy
    • No previous abdominal surgery
    • Multiparous
    • Non-smoker
    • No plans of radiotherapy
    • Compliant patient
  • Adjunct Procedures
    • Breast mound reshaping
    • Contralateral modifications for symmetry
    • Nipple reconstruction
    • Nipple/areolar micropigmentation
    • “ Breast reconstruction-
    • a process…
    • not an operation.”
  • 5/29/2007 10/2/2007 1/29/2008
  • Nipple Reconstruction 3 cm 4 cm
  • Nipple Reconstruction 3 cm 4 cm
  • Nipple Reconstruction
  • Nipple-Areola Micropigmentation
  • Final Results
    • Breast mound creation
    • Revisions for shape
    • Nipple Reconstruction
    • Micropigmentation
  • Thank you! University Hospital James Cancer Hospital The Ohio State University Plastic Surgery … to restore and make whole
  •  
  • Skin-Sparing Mastectomy Frozen section control of margins
    • Oncologic Safety
    • 51 breast cancer patients, Stages 0-II; 1991-1994
    • Median follow-up 45 months
    • Local recurrence rate 2%
    • Biopsies of incisions in 32 consecutive patients revealed no evidence of retained breast tissue
    • Slavin, et al, Plast Reconstr Surg 1994; 93:1191-1204
    Skin-Sparing Mastectomy
  • Local/Regional Recurrence*after Skin-Sparing Mastectomy Immediate Flap Reconstruction (Stage ll) * Median follow-up 5.4 years ** None with stage 0 or stage I breast cancer
  • Oncologic Safety of SSM vs. CM Local Recurrence Rate (T2 tumors) Kroll 104/SSM 271/CM Carlson 327/SSM 188/CM Simmons 77/SSM 154/CM SSM CM 15% 12% 9% 6% 3% 0%
  • Local Recurrences after Skin-Sparing Mastectomy and Immediate Reconstruction Group Number Pts. Local Recurrences (%) All 104 6.7 T1 61 3.3 T2 43 11.6 Black’s grade I* 31 12.9 Black’s grade II 48 6.3 Black’s grade III 6 0.0 *The lower the grade, the more anaplastic the tumor Ann Surg Oncol 4:193-197,1997
  • Regional recurrence after skin-spring mastectomy is a function of the biology of the tumor and stage of disease
  • Detection and Management of Local Recurrence Following SSM MDACC Experience
    • 437 SSMs in 372 patients with invasive T1/T2 breast cancers, 1986-1993
    • Median follow-up 50 months
    • 23/372 local recurrences detected
    • Local recurrence rate = 6.2% Newman, Ann Surg Onc,1998
  • Local Recurrence Following SSM MDACC Experience
    • Median time to recurrence: 25 months (3-98)
    • Median size of recurrence: 1.5 cm
    • Presentation - Palpable skin flap mass: 22/23 (96%) - Non-palpable, CXR finding: 1/23 (4%)
    • Histology - Consistent w/primary tumor: 22/23 (96%) - Different histology; ? New primary: 1/23 (4%)
  • Imaging of Local Recurrence
    • Mammography visualized: 3/5
    • Ultrasound visualized: 11/12
    • CT scan imaged: 3/3
    • MRI imaged: 1/1
  •  
  • Distant Relapse and Overall Survival
    • Median follow-up 26 mos. (range 6-105)
    • N = 23
    • Metastases: 39% - Synchronous 22% - Metachronous 17%
    • Survival: - Alive without disease 61% - Alive with disease 9% - Dead with disease 30%
  • Local Control and Outcome by Treatment Treatment # Pts. Local Control Alive, NED Local only 3 100% 100% (Surgery or Surgery + RT) Systemic only 5 60% 40% Local and 15 86% 71% Systemic
  • Local Control and Outcome by Treatment Local Only Systemic Only Local & Systemic Local Control Alive, NED 100% 80% 60% 40% 20% 0%
  • Skin Sparing Mastectomy
    • Skin-sparing mastectomy with immediate breast reconstruction is oncologically safe and offers superior cosmetic results compared to conventional mastectomy
    • Local recurrence rates are similar for skin-sparing and conventional mastectomies
    • Most local recurrence are detected by physical exam within 3 years following skin-sparing mastectomy
    • Treatment approach depends on extent of local recurrence and presence of synchronous metastases, but resection of the reconstructed breast is rarely necessary
    • Multimodality therapy usually results in excellent local control of disease and prolonged disease-free survival
    Skin Sparing Mastectomy
  • MDACC Recommendations
    • Minimize risk of positive margins following skin-sparing mastectomy: - Intraoperative inking of margins - Mammography of serial sections if microcalcifications are present - Resection of additional skin as necessary
    • Consider XRT if postoperative margins are microscopically positive
  • MDACC Recommendations
    • Management of local recurrence: - Evaluate for distant metastatic disease - Breast ultrasound and mammography to evaluate extent of recurrence - Multimodality therapy, including surgery for resectable disease
  • Reservations Regarding Skin-Sparing Mastectomy
    • Technically more demanding: Yes
    • Increased surgical morbidity: No
    • Oncologic safety: Yes