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Breast Reconstruction

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Penny L McManus FRCS

Consultant oncoplastic breast surgeon
Hull UK

Published in: Health & Medicine

Breast Reconstruction

  1. 1. Breast reconstructionBreast reconstruction Penny L McManus FRCSPenny L McManus FRCS Consultant oncoplastic breast surgeonConsultant oncoplastic breast surgeon Hull UKHull UK
  2. 2. Breast ReconstructionBreast Reconstruction  Immediate (with mastectomy)Immediate (with mastectomy)  Better cosmetic outcomesBetter cosmetic outcomes  CheaperCheaper  Early Psychological benefitEarly Psychological benefit  DelayedDelayed  Patient has more time to consider optionsPatient has more time to consider options  Adjuvant therapy completedAdjuvant therapy completed  Higher long term patient satisfaction ratesHigher long term patient satisfaction rates
  3. 3. Skin sparing mastectomy for immediate reconstructionSkin sparing mastectomy for immediate reconstruction
  4. 4. Techniques in BreastTechniques in Breast ReconstructionReconstruction  Expander/ImplantExpander/Implant  Latissimus Dorsi (LD)Latissimus Dorsi (LD)  TRAM / DIEPTRAM / DIEP  Other free flaps – SGAP, IGAP, TUGOther free flaps – SGAP, IGAP, TUG  lipomodelinglipomodeling
  5. 5. Implant ReconstructionImplant Reconstruction  2 stage:2 stage:  Tissue expander then permanent siliconTissue expander then permanent silicon implantimplant  1 stage:1 stage:  Permanent expander-implantPermanent expander-implant  Permanent implant with dermal sling orPermanent implant with dermal sling or Acellular dermal matrixAcellular dermal matrix
  6. 6. 2 stage implant reconstruction2 stage implant reconstruction  Delayed and immediateDelayed and immediate  Submuscular tissueSubmuscular tissue expanderexpander  Serial expansionSerial expansion  Change to permanentChange to permanent silicone implantsilicone implant
  7. 7. Tissue expander placed in submuscular pocketTissue expander placed in submuscular pocket
  8. 8. Delayed 2 stage implant reconstructionDelayed 2 stage implant reconstruction
  9. 9. AAdvantagesdvantages  Short operating timeShort operating time and recoveryand recovery  Low complication rateLow complication rate  No donor siteNo donor site morbiditymorbidity  Normal appearance inNormal appearance in clothingclothing
  10. 10. DDisadvantagesisadvantages  2 operations2 operations  No ptosisNo ptosis  No change with bodyNo change with body weight/ageweight/age  Feels coldFeels cold  Late complicationsLate complications RadiotherapyRadiotherapy
  11. 11. Immediate implant with dermal slingImmediate implant with dermal sling  Wise pattern mastectomyWise pattern mastectomy  Lower pole skin de-Lower pole skin de- epithelialised & sutured toepithelialised & sutured to lower edge pectoralislower edge pectoralis  Ptotic breastsPtotic breasts  Patients requestingPatients requesting reductionreduction  Risk reductionRisk reduction mastectomymastectomy
  12. 12. Immediate implant with dermal slingImmediate implant with dermal sling
  13. 13. Immediate implant with acellular dermalImmediate implant with acellular dermal matrixmatrix  Strattice, Alloderm,Strattice, Alloderm, Permacol, SurgimendPermacol, Surgimend  Sutured to lower edgeSutured to lower edge pectoralis andpectoralis and inframammary foldinframammary fold  Smaller, non-ptoticSmaller, non-ptotic breastbreast  High complications rateHigh complications rate  High costHigh cost
  14. 14. Immediate implant with ADMImmediate implant with ADM
  15. 15. ComplicationsComplications  EarlyEarly  Wound breakdownWound breakdown  InfectionInfection  explantationexplantation  RotationRotation  LateLate  Capsular contracture (20% at 10 years)Capsular contracture (20% at 10 years)  Deterioration of overlying tissuesDeterioration of overlying tissues  Implant ruptureImplant rupture
  16. 16. Patient selectionPatient selection  Patient desires & expectationsPatient desires & expectations  Small, non-ptotic breastSmall, non-ptotic breast  Contralateral reduction or mastopexyContralateral reduction or mastopexy  Avoid in diabetics, smokers, steroids, RTAvoid in diabetics, smokers, steroids, RT
  17. 17. Latissimus Dorsi Flap
  18. 18. Extended Latissimus Dorsi flapExtended Latissimus Dorsi flap
  19. 19. Extended LD flapExtended LD flap
  20. 20. Pros and ConsPros and Cons  Operating time 4-5Operating time 4-5 hourshours  Stay 4 daysStay 4 days  Recovery 4-5 weekRecovery 4-5 week  Safe and reliable flapSafe and reliable flap  Can be irradiated ifCan be irradiated if autologousautologous  Donor site scar andDonor site scar and morbiditymorbidity  TwitchingTwitching  SeromaSeroma  Flap failureFlap failure  Flap atrophyFlap atrophy
  21. 21. LD with implantLD with implant Preop immediate LD + Implant 2 years postop Preop delayed LD + Implant 2 years postop
  22. 22. Autologous LDAutologous LD Preop immediate LD 3 months postop Preop delayed LD 12 months postop
  23. 23. Autologous LD & fat transferAutologous LD & fat transfer Pre-op 5 years post-op Pre-op 2 years post-op
  24. 24. TRAM/DIEPTRAM/DIEP FlapsFlaps  Anterior abdominal wall tissueAnterior abdominal wall tissue  PedicledPedicled  Transverse Rectus Abdominis MyocutaneousTransverse Rectus Abdominis Myocutaneous (TRAM) Flap(TRAM) Flap  Free:Free:  Free TRAMFree TRAM  Deep Inferior Epigastric Perforator (DIEP) FlapDeep Inferior Epigastric Perforator (DIEP) Flap  SIEA flapSIEA flap  Operating time 6-8 hoursOperating time 6-8 hours  Stay 4-5 daysStay 4-5 days  Recovery 7-8 weeksRecovery 7-8 weeks
  25. 25. Pros and ConsPros and Cons  Larger reconstructionLarger reconstruction  Muscle sparingMuscle sparing  Natural feel &Natural feel & consistencyconsistency  ““tummy tuck”tummy tuck”  longer operating timelonger operating time  higher risk of flap losshigher risk of flap loss  donor site morbiditydonor site morbidity  donor site scardonor site scar
  26. 26. Fat graftingFat grafting  Autologous fat transfer / LipomodelingAutologous fat transfer / Lipomodeling  Fat removed by liposuction from areas of excessFat removed by liposuction from areas of excess  Centrifuged in theatre to remove blood and deadCentrifuged in theatre to remove blood and dead cellscells  Injected into breastInjected into breast  Can be used with other types of reconstructionCan be used with other types of reconstruction  Can be used to correct defects after breastCan be used to correct defects after breast conserving surgery or failed reconstructionconserving surgery or failed reconstruction  Low morbidityLow morbidity
  27. 27. Fat transferFat transfer
  28. 28. Fat transfer to revise reconstructionFat transfer to revise reconstruction
  29. 29. Fat transfer for asymmetryFat transfer for asymmetry
  30. 30. Fat transfer for breast conserving surgery defectFat transfer for breast conserving surgery defect
  31. 31. Fat transfer alone for reconstructionFat transfer alone for reconstruction
  32. 32. SummarySummary  Reconstruction benefits patientsReconstruction benefits patients  Wide range of optionsWide range of options  Patient selection is keyPatient selection is key  ““Reconstructive ladder”Reconstructive ladder”
  33. 33. Thank youThank you

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