Breast Preservation Foundation: Oncoplastic Talk, Dallas, 12/5/09


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Breast Preservation Foundation: Oncoplastic Talk, Dallas, 12/5/09

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  • Breast Preservation Foundation: Oncoplastic Talk, Dallas, 12/5/09

    1. 1. ONCOPLASTIC SURGERY… First Principles and Current Practice Joel A. Aronowitz, MD Clinical Chief, Division of Plastic Surgery Cedars Sinai Medical Center
    2. 2. Outline <ul><li>Brief history of mastectomy </li></ul><ul><li>The physics of breast shape </li></ul><ul><li>Volume and shape examples </li></ul><ul><li>A rationale for skin incisions and excision </li></ul><ul><li>Use of the Keyhole Principle </li></ul><ul><li>Examples… </li></ul>
    3. 3. A Brief History Mastectomy <ul><li>Breast Cancer and Mastectomy recorded throughout history </li></ul><ul><li>A palliative procedure until anesthesia and Halsted attempt to surgically cure </li></ul><ul><li>Extirpation of skin designed to deal with advanced tumors with skin involvement </li></ul><ul><li>Little possibility of cure until early detection in modern era </li></ul>
    4. 4. A Brief History; Mid 20 th cent. <ul><li>Better early detection and resistance to disfiguring surgery allows less aggressive surgery </li></ul><ul><li>Halsted vs Crile; “Breast Wars” </li></ul><ul><li>Radical Mastectomy is Modified </li></ul><ul><li>Reconstruction still not possible </li></ul><ul><li>Keyhole principle (Wise, 1956) introduced to plastic surgery for elective breast reduction, ignored in oncologic surgery </li></ul>
    5. 5. A Brief History; Plastic surgery of breast CA, late 20 th cent. <ul><li>Development of muscle and free flaps allow transfer of living tissue to breast </li></ul><ul><li>Development of tissue expansion (Radovan and Smith, 1985) expands options in reconstruction </li></ul><ul><li>Widespread acceptance of Keyhole principle guides skin tailoring in all elective breast surgery, ie mastopexy and reduction </li></ul>
    6. 6. Rationale for Transverse, Oblique Skin Incision is Rooted in History <ul><li>Described in earliest medical writings, as least morbid method of mastectomy in pre-anesthesia era. </li></ul><ul><li>Popularized by Crile et al for modified radical as an alternative to Halstead vertical incision, radical mastectomy </li></ul><ul><li>Developed prior to era of breast reconstruction, begun with introduction of silicone gel prosthesis (Cronin & Gerow,1963). </li></ul>
    7. 7. Rationale for Skin Extirpation; Prevention of Local Progression
    8. 8. Early Detection of Breast Cancer
    9. 9. The Physics of Breast Shape <ul><li>Breast growth originates with pubertal eruption of ectodermal breast bud through mesodermal opening at nipple/areola </li></ul><ul><li>Internal parenchymal growth drives skin expansion in predictable fashion </li></ul><ul><li>Mesodermal constriction and scars may restrict skin expansion </li></ul><ul><li>Law of LaPlace helps to model breast growth and reconstruction </li></ul>
    10. 10. External Anatomy of Breast <ul><li>Sternal notch-nipple triangle begins isoseles and becomes elongated </li></ul><ul><li>SN-Nipple 22 cm </li></ul><ul><li>Inter nipple 22 cm </li></ul><ul><li>Nipple- IM crease 7cm </li></ul><ul><li>Areolar dia. ~4.0 cm </li></ul>
    11. 11. Breast shape or chest shape; Pectus Deformity
    12. 12. Tubular Breast Deformity; a lesson in breast shape <ul><li>Shape the result of mesodermal constriction of breast as it emerges in puberty </li></ul><ul><li>Relative paucity of medial and inferior skin </li></ul><ul><li>Pseudoherniation of nipple areola </li></ul>
    13. 13. The Tubular Breast; a lesson in understanding breast shape <ul><li>Breast breast bud responds to estrogen. Skin envelope passively stretches in response to growth. </li></ul><ul><li>Fibrous layer (mesenchyme) resists growth, except at the areola, an area of low resistance. </li></ul><ul><li>Attenuation of periareolar skin results in higher compliance; more stretching…result; tubular shaped breast with a large areola. </li></ul>Grolleau, Jean-Louis M.D.; et al,. Toulouse, Fr PRS:Volume 104(7)December 1999pp 2040-2048
    14. 14. Cause of the Tubular Breast <ul><li>Inner quadrant tightness causes a deficiency of skin toward the midline and sometimes a “Cross-eyed” look to the nipples. </li></ul><ul><li>A mild case may just show a pouty or “herniated” areola. </li></ul><ul><li>A very tight mesenchymal layer may inhibit breast growth so much that size is affected. </li></ul>
    15. 15. Law of LaPlace predicts pattern of breast shape Breast diameter is > in lower pole therefore the skin below the nipple is under greater tension and stretches the most. Nipple decent with the breast.
    16. 16. Law of LaPlace and breast shape <ul><li>Larger diameter = </li></ul><ul><li>more skin tension = </li></ul><ul><li>greater skin stretch = </li></ul><ul><li>more skin = </li></ul><ul><li>More breast ptosis! </li></ul>
    17. 17. Severe Tubular Deformity Note medial tightness, large areola typical of tubular breast. 17 yo treated with 500 cc silicone gel prosthesis and keyhole pattern mastopexy
    18. 18. Ptosis and tubular breast; requires keyhole mastopexy <ul><li>Keyhole mastopexy with dermal flap and 225 cc silicone gel implant, retromammary </li></ul>
    19. 19. Benign Breast Shape and Volume Issues <ul><li>Volume Problems </li></ul><ul><ul><li>Congenital hypoplasia and hypertrophy </li></ul></ul><ul><ul><li>Postpartum, bariatric, senile atrophy </li></ul></ul><ul><ul><li>Post oncologic volume loss </li></ul></ul><ul><li>Shape Problems </li></ul><ul><ul><li>Congenital shape problems </li></ul></ul><ul><ul><li>Postpartum and age related ptosis </li></ul></ul>
    20. 20. Clinical Examples <ul><li>Shape </li></ul><ul><ul><li>Poor breast shape </li></ul></ul><ul><ul><ul><li>Tubular varient </li></ul></ul></ul><ul><ul><ul><li>Ptosis after weight loss, pregnancy etc. </li></ul></ul></ul><ul><ul><ul><li>Post surgical or radiation distortion </li></ul></ul></ul><ul><li>Volume </li></ul><ul><ul><li>Deficient volume </li></ul></ul><ul><ul><ul><li>Congenital </li></ul></ul></ul><ul><ul><ul><li>Post surgical </li></ul></ul></ul><ul><ul><ul><li>Post partum or age related </li></ul></ul></ul><ul><ul><li>Excess volume </li></ul></ul>
    21. 21. Hypoplasia of Breast Skin and Volume; Adjustment w/ implant <ul><li>Rx; 300 cc smooth silicone, retromammary prosthesis </li></ul>
    22. 22. Restoration of Skin Envelope to Volume Proportion <ul><li>Excess skin/volume, 400 cc saline prosthesis </li></ul>
    23. 23. Ptosis due to relative paucity of breast volume Volume restored with prosthesis, skin envelope unchanged Restoration of Skin:Volume Proportion with Prosthesis
    24. 24. Relationship of Breast Skin to Volume Post-partum atrophy, lack of breast volume relative to skin envelope Reduction of skin envelope and adition of volume; ie, augmentation mastopexy
    25. 25. Excess Skin Envelope and Volume; Breast Reduction Excess breast volume and skin envelope. Rx; breast reduction, ie, a reduction of skin and volume
    26. 26. Aesthetic Problems Due to Standard Mastectomy and Breast Biopsy Incisions <ul><li>Scars medial and superior to nipple are visible to patient and show in clothes </li></ul><ul><li>Excision of skin transversely removes most projecting portion breast and causes flattening </li></ul><ul><li>Transverse scars limit stretching of skin envelop </li></ul><ul><li>Replacement of extirpated breast skin with flap creates quilt-like effect </li></ul>
    27. 27. Poor placement of skin incisions <ul><li>Lack of validation of patient’s concern about effect of oncologic surgery on breast size, shape and appearance. </li></ul><ul><li>A lack of sensitivity to the long term effect of post surgical breast deformity on a woman’s quality of life. </li></ul>
    28. 28. The Breast and Lines of Langer <ul><li>Langer’s Lines concept is archaic and flawed </li></ul><ul><li>Concept superseded by Relaxed skin tension lines </li></ul><ul><li>Use of Langer’s Lines leads to problematic biopsy scars and unnecessarily disfiguring mastectomy scars </li></ul>
    29. 29. The Flattening Effect of Excising Transverse Ellipse of Breast Skin <ul><li>Initial biopsy left upper outer quadrant leads to excision of otherwise uninvolved skin at mastectomy. Note flat breast shape. </li></ul>
    30. 30. The Patchwork Effect of Flap Skin after Transverse Mastectomy Surgical textbook drawing of mastectomy skin excisions Lat dorsi skin paddle
    31. 31. Effect of Transverse Skin Excision on Breast Shape
    32. 32. How Transverse Incision Results in Typical Superior Pole Fullness
    33. 33. Typical Skin Envelope after Transverse Mastectomy
    34. 35. Principles Oncoplastic Surgery <ul><li>Incisions placement based on elective breast surgery principles </li></ul><ul><li>Preservation of skin envelope if uninvolved by tumor </li></ul><ul><li>Aesthetic modification of same and opposite breast if desired </li></ul>
    35. 36. WISE Pattern; ideal method of tailoring breast skin <ul><li>The Wise pattern was introduced in 1956 </li></ul><ul><li>Gold Standard for tailoring the skin of the female breast </li></ul><ul><li>Method of transposing the nipple varies (superior, inferior pedicles) </li></ul><ul><li>Skin tailoring may use all or only a portion of full incision, ie, periareolar (donut), vertical (lollipop), full keyhole (inverted T) </li></ul>
    36. 37. Volume replacement: TRAM flap Skin: Intact, Wise Pattern Mastectomy Opposite Breast: Wise pattern Reduction
    37. 38. <ul><li>Preoperative markings for keyhole reduction </li></ul>
    38. 39. Keyhole Operative Technique <ul><li>De-epithelialize central pedicle, dermis left intact </li></ul>
    39. 40. Elevation of lateral flap <ul><li>Short lateral inframammary crease incision used to undermine lateral breast flap </li></ul>
    40. 41. Tailor tacking <ul><li>Confirm markings </li></ul><ul><li>Nipple too high? </li></ul><ul><li>IM crease correct? </li></ul><ul><li>Vertical limb 5-6 cm? </li></ul><ul><li>NAC dia. 38-42 mm </li></ul><ul><li>Pedicle base > 14 cm </li></ul>
    41. 42. Dissection of lateral flap
    42. 43. Central pedicle isolated <ul><li>Central pedicle with NAC, before division of superior pedicle </li></ul><ul><li>Medial and lateral flaps </li></ul>
    43. 44. Lateral flap resection <ul><li>Lateral flap is marked before resection </li></ul>
    44. 45. Latteral flap resection
    45. 46. Tailor tacking closure <ul><li>Pedicle w/ nipple transposed </li></ul><ul><li>Medial and Lateral flaps rotated toward T </li></ul><ul><li>Ready for final skin trimming </li></ul>
    46. 47. Immediate Post Op <ul><li>Nipple-IM= 5-6 cm </li></ul><ul><li>Nipple-SN> 22 cm </li></ul>
    47. 48. The WISE Pattern; how it works
    48. 49. DCIS rx’d with Keyhole Pattern Lumpectomy and Axillary Dissection <ul><li>Free nipple graft technique used </li></ul>
    49. 50. Use of Keyhole Principle to Correct Contour Deformity and Superior Scar <ul><li>Note contour defect after lumpectomy and superior breast scar made per archaic Langer’s Lines concept </li></ul>
    50. 51. Volume: 450cc silicone gel implant Skin replacement: periareolar mastectomy, tissue expansion Opposite breast: bilateral
    51. 52. Operative Technique of Skin Sparing Mastectomy
    52. 53. Operative Technique of Wise Pattern Mastectomy and Reconstruction
    53. 54. Volume replacement Left: silicone implant Skin: intact, Wise pattern mastopexy Opposite breast: Wise pattern mastopexy
    54. 55. Volume: Silicone gel prosthesis Skin: intact, Wise pattern mastectomy Opposite Breast: bilateral
    55. 56. Volume replacement: TRAM flap Skin: original, Lat. Incision Mastectomy Opposite Breast: Keyhole mastopexy
    56. 57. Skin: intact, Wise Pattern Mastectomy Volume: Silicone gel Prosthesis Opposite Breast: bilateral
    57. 58. Mastectomy after breast reduction <ul><li>Immediate reconstruction with expander, FTSG to nipple areola defect </li></ul>
    58. 59. First Principles of Breast Reconstruction <ul><li>1. The Opposite Breast </li></ul><ul><li>2. Assess the Defect </li></ul><ul><li>skin </li></ul><ul><li>volume nipple/areolar complex </li></ul><ul><li>3. Timing of Reconstruction </li></ul><ul><li>immediate vs delayed </li></ul><ul><li>need for postoperative XRT </li></ul><ul><li>4. Accepted Skin Tailoring Principles Apply </li></ul>
    59. 60. The Mastectomy Defect <ul><li>Skin Deficiency </li></ul><ul><ul><li>The major issue in breast reconstruction, determines options available, quality of result </li></ul></ul><ul><li>Volume Deficiency </li></ul><ul><ul><li>Approximately 200 gm/cup size </li></ul></ul><ul><li>Absence of Nipple/Areolar Complex </li></ul><ul><ul><li>Reconstructed in final step </li></ul></ul>
    60. 61. Components of the Mastectomy Defect <ul><li>Skin Deficit </li></ul><ul><ul><li>Location of restricting scars is critical due to LaPlace effect </li></ul></ul><ul><ul><li>XRT effect on skin (periarteriolar fibrosis, low cellular O2) </li></ul></ul><ul><li>Volume deficit </li></ul><ul><ul><li>Approx. 200 cc per cup size </li></ul></ul><ul><li>Nipple Areola Absence </li></ul><ul><li>Loss of Anatomic Landmarks </li></ul><ul><ul><li>inframammary crease </li></ul></ul><ul><ul><li>lateral fold </li></ul></ul><ul><ul><li>sternal attachments </li></ul></ul>
    61. 62. Replacement of Breast Volume <ul><li>Autogenous </li></ul><ul><li>TRAM Flap (variations based on blood supply) Pedicle, free flap, DIEP </li></ul><ul><li>Gluteal Flap (free flap) </li></ul><ul><li>Lat dorsi (inadequate volume, requires implant) </li></ul><ul><li>Alloplastic </li></ul><ul><li>(all implants have smooth or textured silicone shell, fill material is only variable) </li></ul><ul><li>Saline </li></ul><ul><li>Silicone gel </li></ul><ul><li>Cohesive (viscous gel) </li></ul><ul><li>Expanders (Becker etc. postoperatively adjustable implants) </li></ul>
    62. 63. Types of Breast Implants MemoryGel ™ Implants Saline Implants
    63. 64. Textured Implant surfaces Smooth
    64. 65. Contour Profile ® Tissue Expanders
    65. 66. Preservation, Replacement, Tailoring of Breast Skin <ul><li>Local Sources </li></ul><ul><ul><li>Retention of original skin envelope best if feasible </li></ul></ul><ul><ul><li>Tissue Expansion </li></ul></ul><ul><ul><li>Lateral Breast Fold can be used as Skin Flap </li></ul></ul><ul><li>Distant Sources </li></ul><ul><li>Myocutaneous Flaps </li></ul><ul><ul><li>Lat dorsi </li></ul></ul><ul><ul><li>TRAM </li></ul></ul><ul><ul><li>Gluteal </li></ul></ul><ul><ul><li>Lat thigh </li></ul></ul>Restoration of normal anatomic landmarks, (inframammary crease, lateral fold) is essential before restoration of volume or skin
    66. 67. SSM with implant and bilateral latissimus reconstruction before after
    67. 68. Intraop SSM and TRAM
    68. 69. SSM and bilateral TRAM before after
    69. 70. Skin-sparing Mastectomy : A Survey Based Approach to Defining Standard of Care J Shen MD 1 , J Ellenhorn MD 1 , Dajun Qian PhD 1 , David Kulber MD 2 , J Aronowitz MD 2 1 City of Hope Medical Center, Duarte, CA 2 Cedars-Sinai Medical Center, Los Angeles, CA Southern California Chapter of the American College of Surgeons 19 th Annual Scientific Meeting January 18, 2008
    70. 71. Practice Patterns N = 370 Standard transverse elliptical N = 75 (20) Skin-sparing MOST of the time N = 224 (61) Mastectomy with immediate reconstruction N = 331 (89) No immediate reconstruction N = 39 (11) Skin-sparing SOME of the time N = 32 (9)
    71. 72. Safety No. (%) Greater flap necrosis Yes No 91 (25) 279 (75) Excision of biopsy incision is mandatory Yes No 31 (8) 339 (92) Higher rate of local recurrence Yes No 38 (10) 332 (90)
    72. 73. Cosmesis <ul><li>70% of surgeons responded that the cosmetic results of immediate breast reconstruction after skin-sparing mastectomy are substantially better than the results following standard mastectomy </li></ul>
    73. 74. Perceptions by Clinical Setting * P-value ≤ 0.05 vs. Academic, Mixed, and HMO ** P-value ≤ 0.05 vs. HMO *** P-value ≤ 0.05 vs. Academic and HMO Private N = 260 Academic N = 30 Mixed N = 26 HMO N = 54 Skin-sparing mastectomy 158* (61%) 25 (83%) 23 (88%) 50 (93%) Feasibility 174** (67%) 24 (80%) 16 (62%) 48 (89%) Higher recurrence 29 (11%) 3 (10%) 3 (12%) 3 (6%) Improved cosmesis 166*** (64%) 29 (97%) 20 (77%) 42 (78%)
    74. 75. Feasibility <ul><li>71% of respondents believed an oncologically sound mastectomy can be performed through a limited circumareolar incision </li></ul>
    75. 76. Oncologic Safety Chagpar AB. Am Surg 2004;70:425-32. Author Follow-up (mo) SSTM (# pts) SSTM LRR Non-SSTM (# pts) Non-SSTM LRR P -value Newman (1998) 50 437 6.2% 437 7.4% NS Kroll (1999) 72 114 7.0% 40 7.5% NS Rivadeneira (2000) 49 71 5.6% 127 3.9% NS Carlson (2003) 65 565 5.5% - - - Spiegel (2003) 118 221 4.5% - - -
    76. 77. Principles of Incision Placement on the Female Breast <ul><li>Breast Skin is best considered Separately from Breast Tissue , (parenchyma) </li></ul><ul><li>Incisions should anticipate need for future oncologic surgery, eg scar excision w/ mastec. </li></ul><ul><li>Incisions should appreciate effect on blood supply to the breast skin flaps </li></ul><ul><li>Incisions should conform to accepted Plastic Surgery principles of elective scar placement in the absence of other compelling indications </li></ul>
    77. 78. Transverse vs Keyhole <ul><li>Keyhole incisions can increase risk of flap necrosis ,(18% vs25% Lipshy and 14% vs 12% ‘96Grant,’97) </li></ul><ul><li>Keyhole incisions are technically more difficult and time consuming </li></ul><ul><li>Keyhole incisions may require additional axillary incision for node dissection </li></ul><ul><li>No evidence of increased recurrence or excess residual breast tissue (Carlson,’96, Gilliland,’83) </li></ul>
    78. 79. Keyhole vs Transverse; The Myths <ul><li>Keyhole incisions are associated with higher local or distant recurrance </li></ul><ul><li>Keyhole incisions are not superior cosmetically </li></ul>
    79. 80. Removal of Breast Skin in Mastectomy <ul><li>Extirpation of Breast Tissue is Goal of Mastectomy, (not removal of skin) </li></ul><ul><li>Removal of Skin Must Be Justified By; </li></ul><ul><ul><li>Tumor in proximity or invading skin </li></ul></ul><ul><ul><li>Removal of recent biopsy scar </li></ul></ul><ul><ul><li>Tailoring of redundant breast skin </li></ul></ul><ul><ul><li>Skin devascularized by mastectomy </li></ul></ul>
    80. 81. Transverse Incisions in Mastectomy Fail the Test of… <ul><li>First Principles of Surgical Oncology and Plastic Surgery </li></ul><ul><li>Historical Review of Breast Surgery </li></ul><ul><li>Physics of Breast Growth and Development </li></ul><ul><li>Outcomes Based Decision Making </li></ul>
    81. 82. No Rationale Based On Surgical First Principles… <ul><li>Surgical Oncology - preservation of uninvolved skin is a well-accepted idea </li></ul><ul><li>Surgical Technique - breast is a mobile, plastic skin appendage readily accessible via Wise Pattern Keyhole incisions vertical to the nipple and in inframammary crease, axilla is accessible via second incision </li></ul><ul><li>Breast reconstruction -Wise Pattern widely accepted as preferred skin tailoring concept for reduction, lift and reconstruction </li></ul>
    82. 83. Wise Pattern Mastectomy with Implant Reconstruction
    83. 84. IN CONCLUSION Based on 1 st Principles, Physics, History and Outcomes The Wise Pattern For Mastectomy is State of the Art
    84. 85. Skin sparing mastectomy and TRAM reconstruction <ul><li>Courtesy J. Anderson, City of Hope Nat’l Medical Center </li></ul>
    85. 86. Conclusions… <ul><li>Breast Skin best considered separate component from parenchyma, </li></ul><ul><li>Shape is predictable, based on skin envelope </li></ul><ul><li>Skin excision is justified by tumor proximity, biopsy violation and vascular insufficiency </li></ul><ul><li>Breast biopsy should anticipate need for mastectomy or lumpectomy </li></ul><ul><li>Keyhole pattern is accepted standard for skin tailoring, shape modification. </li></ul><ul><li>Keyhole mastectomy incision is Safe & Preferred </li></ul>