Indications for breast reconstruction

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Indications for breast reconstruction
Dr.Anil Haripriya

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Indications for breast reconstruction

  1. 1. <ul><li>“ INDICATIONS FOR BREAST RECONSTRUCTION ” </li></ul><ul><li> Dr. Anil Haripriya </li></ul>
  2. 2. Introduction <ul><li>Female breasts hold a place of paramount importance by virtue of their clinical, anatomic, psychosexual and social importance in todays society. Loss of breast, post mastectomy, thence has a dreadful and long lasting implications on the female in the form of loss of self esteem, loss of feminity and sexual and psycho social problems that ensue. </li></ul><ul><li>Breast reconstruction has now become an indispensable part of modern day breast surgery as it comes in rescue to the patients who have lost their breast due to various reasons carcinoma being the commonest of all. The concept of breast reconstruction is to treat breast carcinoma in standard fashion by surgically excising the tumor with tumor margins yet maintaining the shape and symmetry These surgeries are gaining popularity each day as they are oncologically safe, cost effective and aesthetically satisfying. </li></ul>
  3. 3. <ul><li>Contrary to the popular belief where breast reconstruction was looked upon as a province of plastic surgeon the evolving ideology believes in equal importance of the topic to both ablative and recontructive surgeons. This is so as it is the ablative surgeon performing mastectomy with whom the patient first enquires about the breast reconstruction options and post mastectomy status like </li></ul><ul><li>- How will the mastectomy affect my breast? </li></ul><ul><li>-  Can I lead a normal life? </li></ul><ul><li>-  Is there any procedure that can replace my breast? </li></ul><ul><li>-  What are the breast reconstruction modalities? </li></ul><ul><li>-  How will be my breast look after reconstruction </li></ul><ul><li>It is therefore mandatory for all of us to have a basic understanding of the techniques, timing, patient selection and outcomes of different reconstructive modalities. We in this seminar will discuss How, In Whom and when to reconstruct the lost breast. </li></ul>
  4. 4. HISTORICAL BACKGROUND <ul><li>Historically first attempt of true breast reconstruction was in 1895 by vincent czerny </li></ul><ul><li>Tansini described the first ever use of lattissimus dorsi muscle flap in 1906. </li></ul><ul><li>Since then upto 1960s many advances were made but multiple procedures and prolonged treatment course precluded their widespread application. </li></ul><ul><li>In 1963 breast augmentation with breast implants was introduced Cronin and Gerow who used these implants to reconstruct mastectomy defects. </li></ul><ul><li>In the last two or three decades these surgeries have grown magnanimously to attain the present day status with the advent of pedicled, bipedicled, free and now perforator based flaps , each one adding on to the advantages of the predessesor. </li></ul>
  5. 5. INDICATIONS FOR BREAST RECONSTRUCTION <ul><li>* After mastectomy : Even with the advent of breast conservative therapy and neoadjuvant chemotherapy as high as 40% of the patients require mastectomy due to adverse tumor : breast ratio acceptable site, multifocal pathology, or by choice of the patient. </li></ul><ul><li>* After breast conservation therapy : Recent studies conducted by Loma Linda University California concluded that almost all patients after BCT noticed breast asymmetry and about 35% of them had significant asymmetry more so when >20% of breast volume is resected. </li></ul><ul><li>* Congenital anomalies. </li></ul><ul><li>* Developmental abnormalities. </li></ul><ul><li>* Traumatic disfigurement </li></ul>
  6. 6. PATIENTS SELECTION <ul><li>Studies conducted by Brand Beng and associate in 2000 inferred that ALL PATIENTS, IRRESPECTIVE OF AGE AND DISEASES STATUS, SHOULD BE OFFERED BREAST RECONSTRUCTION AS THIS SEEMS TO HAVE SIGNIFICANT EFFECT ON THE QUALITY OF LIFE. </li></ul><ul><li>In general young patients and early stage disease are best candidates for reconstruction and patients with advanced disease carry high risk. </li></ul><ul><li>Patients with autoimmune diseases, diabetes mellitus, substance abuse, chronic systemic diseases or unwillingness should not be offered breast reconstruction. </li></ul>
  7. 7. <ul><li>Risk factor severity score devised by Carl Hartramf each risk factor is given a numerical score. Any one with score >5 or with 3 or more risk factors is a poor candidate for any reconstructive surgery. A score with 2 or more risk factors carry marginal prognosis . </li></ul><ul><li>Of the numerous risk factors detrimental in breast reconstruction advanced age, obesity, smoking, concomitant systemic disease and psychological/emotional status are most important. </li></ul>
  8. 8. Operative Risk Factors for Breast Reconstruction With the TRAM Flap Obesity Moderate: <25% above ideal body weight Severe: >25% over ideal body weight   1 5 Small-Vessel Disease Light-to-moderate smoking (1+pack/day for 2-10 yr) Chronic heavy smoking (10-20 packs/yr) Chronic heavy smoking (20-30 packs/yr) Autoimmune disease (e.g., scleroderma, Raynaud’s) Diabetes mellitus: non insulin dependent Diabetes mellitus : insulin dependent   1 2 5 8 5 10 Psychosocial Problem Unstable emotional state (life crisis) Personality disorder Substance abuse   2 3 5
  9. 9. Operative Risk Factors for Breast Reconstruction With the TRAM Flap Contd… Abdominal Scars If” planned out” of flap design Disruption of vascular perforators: transaction of superior epigastric vessels (e.g., Chevron incision, abdominoplasty)   0.5 10 Patient’s Attitude Patient unwilling or unable to invest time require for healing or objects to abdominal scar   10 Surgeon’s Inexperience <10 TRAM flap   1 Major System Disease Process Chronic lung disease Severe cardiovascular disease   10 10
  10. 10. TIMING OF RECONSTRUCTIONS <ul><ul><li>Immediate Breast Reconstruction (IBR) : primary reconstruction </li></ul></ul><ul><ul><li>Delayed Breast Reconstruction (DBR) : secondary reconstruction. </li></ul></ul><ul><ul><li>Immediate Breast Reconstruction </li></ul></ul><ul><ul><li>Advantages the immediate reconstruction </li></ul></ul><ul><ul><li>1.Decreased emotional impact of mastectomy and significant decrease in level of depression. </li></ul></ul><ul><ul><li>2.   Increased cost effectiveness : </li></ul></ul><ul><ul><li>3. Better aesthetic outcomes </li></ul></ul><ul><ul><li>4. Decreased frequency of secondary symmetrization. </li></ul></ul><ul><ul><li>5.   Better breast symmetry. </li></ul></ul><ul><ul><li>6.   More sensate reconstruction. </li></ul></ul><ul><ul><li>7. No statistically significant difference in complications, risk of recurrence of cancer and no difficulty in recurrence surveillance of breast carcinoma. </li></ul></ul>
  11. 11. Delayed reconstruction <ul><ul><li>1. Done in patients who are candidates for post operative radiotherapy. </li></ul></ul><ul><ul><li>2. Suitable for patients with unrealistic cosmetic expectation. </li></ul></ul><ul><ul><li>3. Risk of chest wall mastectomy flap necrosis (0%) as against 16% after immediate breast reconstruction (De Bono et al, 2002) </li></ul></ul>
  12. 12. Delayed immediate breast reconstruction
  13. 13. SURGICAL OPTIONS FOR RECONCTRUCTION <ul><li>A. Autogenous </li></ul><ul><li>i. Abdominal-based flaps </li></ul><ul><li>TRAM </li></ul><ul><li>Upper abdominal horizontal flap </li></ul><ul><li>Vertical abdominal flap </li></ul><ul><li>Tubed abdominal flap </li></ul><ul><li>ii. Latissimus dorsi musculocutaneous flap </li></ul><ul><li>iii. Gluteal flap </li></ul><ul><li>iv. Rubens flap </li></ul><ul><li>v. Thoracoepigastric flap </li></ul><ul><li>vi. Lateral thigh flap </li></ul><ul><li>vii. Breast-splitting procedure (now obsolete) </li></ul>
  14. 14. <ul><li>B . Alloplastic </li></ul><ul><li>i. Silicone gel implant </li></ul><ul><li>ii. Silicone implant with saline fill </li></ul><ul><li>Silicon injection </li></ul><ul><li>C. Combination procedures </li></ul><ul><li>Latissimus dorsi flap with implant </li></ul><ul><li>TRAM flap with implant </li></ul>
  15. 15. <ul><li>Site: </li></ul><ul><li>* Subcutaneous </li></ul><ul><li>* Submuscular </li></ul>Breast reconstruction with implant
  16. 16. <ul><li>Indications: </li></ul><ul><li>1. Bilateral reconstruction </li></ul><ul><li>2.   Small breast with minimal ptosis </li></ul><ul><li>3.   Lack of adequate soft tissue on back or abdomen </li></ul><ul><li>4.   Previous abdominal or chest scars causing transections of flap muscle and blood supply </li></ul><ul><li>5.   Patient unwilling for additional scar on back or abdomen </li></ul><ul><li>6. Patient requesting augmentation in addition to reconstruction </li></ul><ul><li>7.     Patient not suited for long surgery </li></ul><ul><li>Contraindications: </li></ul><ul><li>a.   Allergy to silicon </li></ul><ul><li>b.   Implant fear </li></ul><ul><li>c.   Previous failed implant </li></ul><ul><li>d. Need for adjuvant radiotherapy </li></ul><ul><li>Complications: </li></ul><ul><li>1.   Exposure, extrusion and infection of implant </li></ul><ul><li>2.   Malposition, rupture, pain </li></ul><ul><li>3.   Asymmetry </li></ul><ul><li>4.   Capsular contracture </li></ul><ul><li>5. Breast never mature with age </li></ul>
  17. 17. <ul><li>1. Lattissimus dorsi flap </li></ul><ul><li>Based on : </li></ul><ul><li>i. Thoracodorsal artery </li></ul><ul><li>ii. Segmental perforators of lumbar artery </li></ul>Breast reconstruction by autogenous modalities
  18. 18. <ul><li>Indications: </li></ul><ul><li>i.     Small breast </li></ul><ul><li>ii.    Moderate ptosis </li></ul><ul><li>iii.   Abdominal donor site not available </li></ul><ul><li>iv. Salvage of previous breast reconstruction </li></ul><ul><li>Contraindications: </li></ul><ul><li>i.    Very large breast, </li></ul><ul><li>ii.   previous lateral thoracotomy, </li></ul><ul><li>ii. Previous radiotherapy to axilla </li></ul><ul><li>Disadvantage: </li></ul><ul><li>i.     Does not provide enough muscle bulk </li></ul><ul><li>ii. Simultaneous harvesting of flap with mastectomy not possible </li></ul><ul><li>iii.   donor site morbidity high </li></ul><ul><li>iv. Fat necrosis in extended LD flap </li></ul>
  19. 19. <ul><li>Gold Standard because </li></ul><ul><li> - Abdominal skin and subcutaneous fat have same consistency as breast </li></ul><ul><li>- Enough tissue can be harvested </li></ul><ul><li>- Abdomino plasty additional cosmetic benefit </li></ul><ul><li>Based on superior epigastric artery </li></ul><ul><li>Indications: </li></ul><ul><li>1. Breast all size 2. Breast ptosis </li></ul><ul><li>Contraindications </li></ul><ul><li>Previous abdomioplasty </li></ul><ul><li>Patient unable to tolerate 4-6 wks recovery period </li></ul><ul><li>Patient unfit for long procedures </li></ul>TRAM Flap
  20. 20. <ul><li>Complications: </li></ul><ul><li>Visible bulge in </li></ul><ul><li>epigastrium </li></ul><ul><li>Partial flap necrosis </li></ul><ul><li>Inciscinal </li></ul><ul><li>hernia          </li></ul><ul><li>                  </li></ul>
  21. 21. <ul><li>Free TRAM flap: </li></ul><ul><li>Based on deep inferior epigastric artery which is anastomosed to thoracodorsal or internal mammary artery. </li></ul>Free Flap
  22. 22. <ul><li>DIEP flap: </li></ul><ul><li>Deep inferior epigastric artery perforator flap. 3-4 perforating vessels from deep inferior epigastric artery which run through rectus abdominis are used </li></ul><ul><li>Gluteal flap </li></ul><ul><li>Ruben flaps </li></ul><ul><li>Free TUG flap </li></ul><ul><li>Advantages of Free Flaps </li></ul><ul><li>1 More distant flaps can be used </li></ul><ul><li>2 Vascular pedicle not required; inframammary fold </li></ul><ul><li>maintained </li></ul><ul><li>3 Less fat necrosis and partial flap loss </li></ul><ul><li>4 Can be used in smoker and obese </li></ul><ul><li>5 Decreased chance of donor site morbidity </li></ul><ul><li>6 Abdominal hernia uncommon </li></ul>Other Free Flaps
  23. 23. <ul><li>Disadvantages of Free Flap: </li></ul><ul><li>i. Loss of whole flap </li></ul><ul><li>ii. Need for subsequent corrective surgery </li></ul><ul><li>more </li></ul><ul><li>iii. Intricate surgery </li></ul><ul><li>Factors associated with loss of free flaps: </li></ul><ul><li>i. Venous occlusion </li></ul><ul><li>ii.   Delayed reconstruction </li></ul><ul><li>iii.   Haematoma </li></ul><ul><li>iv.   Previous lymph node dissection </li></ul><ul><li>v. Previous radiation </li></ul>
  24. 24. BREAST RECONSTRUCTION AFTER BREAST CONSERVATIVE THERAPY <ul><ul><li>In 35% of patients significant breast asymmetry has been detected. </li></ul></ul><ul><ul><li>Local flaps minimize the deformity. </li></ul></ul><ul><ul><li>Techniques are considered according to the quadrant. </li></ul></ul><ul><ul><li>Upper and outer quadrant </li></ul></ul><ul><ul><li>i. Mini LD flap </li></ul></ul><ul><ul><li>ii. Sub axillary dermocutaneous flap </li></ul></ul><ul><ul><li>iii. Parenchymal flaps </li></ul></ul><ul><ul><li>Centrally placed tumors </li></ul></ul><ul><ul><li>- Local flap rotation </li></ul></ul><ul><ul><li>- Superior pedicle wise pattern mastopexy for infralveolar tumors </li></ul></ul><ul><ul><li>- Inferior pedicle wise pattern mastopexy for supralveolar tumors </li></ul></ul>
  25. 25. BREAST RECONSTRUCTION AFTER BREAST CONSERVATIVE THERAPY contd.. <ul><ul><li>Reconstruction for lower quadrant tumors : modified mastopexy with symmetrization </li></ul></ul><ul><ul><li>Upper medial quadrant : most difficult quadrant to reconstruct </li></ul></ul><ul><ul><li>M odified wise pattern inferior pedicle mastopexy (best option) </li></ul></ul><ul><ul><li>Local parenchymal flaps </li></ul></ul><ul><ul><li>Complications of Local Flaps : </li></ul></ul><ul><ul><li>Flap atrophy </li></ul></ul><ul><ul><li>Sepsis </li></ul></ul><ul><ul><li>Skin necrosis </li></ul></ul><ul><ul><li>Deviation of nipple </li></ul></ul>
  26. 26. <ul><li>NIPPLE AREOLA RECONSTRUCTION </li></ul><ul><li>Final stage in breast reconstruction and should be done only when the reconstructed site has settled i.e., 6-12 months post mastectomy. </li></ul><ul><li>Methods of nipple areola complex reconstruction </li></ul><ul><li>1. Local flaps : Most commonly used is T flap </li></ul>
  27. 27. <ul><li>NIPPLE AREOLA RECONSTRUCTION cont… </li></ul><ul><li>Free graft </li></ul><ul><li>      i.   From contra lateral breast – Nipple sharing </li></ul><ul><li>      ii.  Regional mucosal graft </li></ul><ul><li>      iii. Labial graft </li></ul><ul><li>      iv. Auricular cartilage graft </li></ul><ul><li> v. Costal cartilage graft </li></ul><ul><li>Medical tattooing </li></ul><ul><li>Implants : Tissue engineered nipple </li></ul><ul><li>Silicon </li></ul><ul><li>Preserved cartilage grafts </li></ul><ul><li>Disadvantages: Skin erosion </li></ul>
  28. 28. <ul><li>Breast symmetry is best attained by </li></ul><ul><li>- Mastopexy </li></ul><ul><li>- Reduction mammoplasty </li></ul><ul><li>- Augmentation mammoplasty </li></ul><ul><li>SURVEILLANCE OF RECURRENCE OF CARCINOMA IN RECONSTRUCTED BREAST </li></ul><ul><li>- Most reliable methods </li></ul><ul><li>FNAC : Performed when patient has firm subcutaneous mass or </li></ul><ul><li>Core or open biopsy : Cobblestoning of skin </li></ul><ul><li>- Others : MRI, CT scan, scinti mammography </li></ul><ul><li>- Routine mammography is not recommended </li></ul>MANAGEMENT OF CONTRA LATERAL BREAST
  29. 29. <ul><li>FRONTIER OF RESEARCH </li></ul><ul><li>Tissue engineering with patient own cultured adipocytes harvested by liposuction. </li></ul><ul><li>CONCLUSION </li></ul><ul><li>1.  Indispensable part of breast surgery in view of significantly enhanced quality of life. </li></ul><ul><li>2. All patients undergoing mastectomy should be offered breast reconstruction </li></ul><ul><li>3. performed by alloplastic materials and autogenous tissue; the later being aesthetically and emotionally superior </li></ul><ul><li>4. Reconstructive surgery can be performed along with mastectomy of 6-12 months later. Current trend is infavour of immediate breast reconstruction </li></ul><ul><li>5. Symmetry of the breast reconstruction is the most important factor </li></ul><ul><li>6. Breast reconstruction surgeries have glorious past, presently they are the most oncoplastic surgeries performed worldwide and with the increasing interest shown by the patients and the surgeons certainly the future is very promising. </li></ul>

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