This document discusses post-mastectomy breast reconstruction options. It begins with an overview of surgical options for breast cancer treatment, including breast-conserving therapy and mastectomy. It then discusses the reasons for and goals of breast reconstruction. The document outlines the anatomy of the breast and techniques for immediate and delayed breast reconstruction using implants, pedicled flaps like latissimus dorsi flaps and TRAM flaps, and free flaps like DIEP flaps. It also discusses nipple-areolar complex reconstruction and procedures to achieve symmetry in the contralateral breast.

1. Post mastectomy
Breast reconstruction
PRESENTED BY: DR. ANKIT LALCHANDANI
MODERATED BY : DR . DEEPAK KRISHNA

2. Surgical options in CA breast
 Breast Conservation Therapy : For early stage
 Lumpectomy/Quadrantectomy/Segmentectomy + RT
 Mastectomy : For advanced stages/ Prophylactic
 Total Mastectomy
 Skin sparing mastectomy
 Nipple sparing mastectomy
 MRM

3. Why Breast reconstruction
 Consequences of mastectomy
 Aesthetic
 Functional
 Emotional
 Social
 Can lead to
 Depression
 Loss of libido
 Negative body image

4. Breast Anatomy
 Gross anatomy
 Fibro fatty tissue located anterior to pectoral muscles
 Modified Sweat Gland
 Gland anchored to underlying fascia by cooper’s ligaments
 Comprises of secretory lobules  lactational ducts  Major ducts
opening into the nipple

5.  Extends from 2nd IC to 6th IC space in mid
clavicular line
 Extends from anterior axillary fold to lateral
border of sternum at the level of transversally
 The tail of Spence extends obliquely up into
the medial wall of the axilla.
 Nipple located in the 4th IC space just lateral to
midclavicular line

6. Vascular Supply
 Primary
 Internal mammary perforators (2nd-5th)
~60%
 Lateral thoracic artery
 Anterolateral intercostal perforators
(3rd-8th)
 Secondary
 Thoracoacromial artery
 Vessels of serratous anterior

7. Sensory innervation
 Dermatomal distribution : Anteromedial
and anterolateral branches of intercostal
nerves (T3-T6)
 Supraclavicular nerves supply the upper
and lateral portion
 Sensations of nipple carried by lateral
cutaneous branch of T4

8. Breast Reconstruction
 Based on Duration post surgery :
 Immediate : Just after surgery
 Delayed : Following RT
 Based on technique :
 Implant based
 Tissue based
 Implant + tissue

9. Goals of Reconstruction
 Natural appearing breast mound with adequate volume and projection
 Skin envelope
 Symmetry with contralateral breast
 Nipple aerola complex

10. Technique selection
 Patients requirements
 Type of mastectomy/BCT
 Immediate/Delayed
 Condition of operated breast
 Status of contralateral breast

11. Immediate Reconstruction
 Technically easier
 No scarring/Irradiation
 Skin is more pliable
 Inframammary fold easier to delineate
 Cost effective
 Psychologically beneficial
 Disadvantage
 Concern for positive margins
 Post RT complications

12. Delayed Reconstruction
 Done after patient has undergone RT
 Ensures adequate local control of tumor
 Allows for better selection of reconstructive procedure
 Disadvantage
 Skin is fibrosed and scarred post RT
 Inframammary fold is not adequately delineated

13.  General opinion
 Immediate reconstruction in noninvasive cancer and risk reducing
mastectomies
 Delayed reconstruction in case of locally advanced cancer
 The choice of the timing of reconstruction (immediate or delayed) should
take into account the indication for postmastectomy radiotherapy

14. Pre op marking
 A- midline
 B- sternal notch to NAC
 C- Nipple to inframammary fold
 D- breast width
 E – projection of IMF to midline
 F- IMF
 G- lateral border of torso

15. Total Breast Reconstruction with
prosthesis
 Criteria :
 Healthy, adequate skin and muscle
 No h/o irradiation
 May require delayed surgery of opposite breast for
symmetry
 Types of prostheses:
 Inflatable : silicone envelope, filled with saline
 Can be temporary/permanent
 Silicone gel filled : Definitive volume, various shapes
available

16.  Technique : 2 stage
 1st stage – expander placed below P major  gradually filled with
saline
 2nd stage – expander removed and permanent prostheses placed +
NAC recon
 Complications :
 Capsular contracture
 Most common
 Contraction of fibroblastic capsule
 After 6 – 12 months
 Requires capsulotomy or implant removal
 Baker classification
 Implant loss
 Infection
 Hematoma

17. Total breast reconstruction with tissue
 Indications :
 Poor local condition of chest wall
 Post RT muscle fibrosis
 Salvage mastectomy after previous conservative treatment
 Options:
 Pedicled flaps
 Latissimus dorsi (LD)
 Transverse rectus abdominis muscle ( TRAM)
 Free flaps
 Free TRAM
 Deep Inferior epigastric perforator (DIEAP)
 Superior /Inferior gluteal artery perforators

18. LD flap
 Anatomy :
 LD muscle arises from T7- L5 spinous process
 Inserts at bicipital groove on the humerus
 Nerve supply : Thoracodorsal nerve
 Blood Supply : Thoracodorsal artery +
intercostal/lumbar perforators

19.  Pre op marking

20.  Procedure:
 Skin island is taken on the back along with LD
muscle
 Pedicle moves subcutaneously high in axilla
 Moulded in conical shape and transferred to
anterior thoracic wall
 Prostheses may be placed in thin patients
 Precautions :
 Thoracodorsal nerve should be preserved unless
implant is being used
 LD should be completely detached from in bony
insertions

21.  Complications
 Seroma
 Shoulder weakness
 Flap necrosis
 Winging of scapula

22. Pedicled TRAM flap
 Anatomy
 Attachments : Pubic symphysis to xiphoid process and
costal cartilages of ribs 6-10
 Covered by rectus sheath anteriorly and posteriorly
 Blood Supply : Superior epigastric and inferior
epigastric artery + segmental branches of intercostal
arteries
 Nerve Supply : Thoracoabdominal branches of T7-T11
intercostal nerves

23.  Pedicled TRAM flap is based on Superior epigastric artery perforators
around the umbilicus
 May include one or both rectus muscles
 The choice between one or two muscular pedicles depends on the surface
of the skin paddle required
 The long donor site scar can be kept very low in the suprapubic area

24.  Technique:
 Island of skin and fat along with rectus
muscle taken horizontally under the
umbilicus
 Transferred through subcutaneous
tunnel created below the costal
margin
 Nonabsorbable mesh is used in most
cases of bipedicled flaps to reinforce
the abdominal wall and avoid hernias
and bulging.

25.  Complications
 Seroma
 Hematoma
 Infection
 Flap Necrosis
 Abdominal wall hernia
 Free TRAM
 Muscle sparing rtechnique
 Better blood supply
 reduces abdominal wall complications
 Based on Deep inferior epigastric artery

26. DIEAP flap
 Free flap based
 Provides large amount of skin and
subcutaneous tissue
 No rectus muscle is harvested, less donor site
morbidity
 Based on Deep inferior epigastric artery
perforators

27.  Technique:
 Suprafascial dissection to create island of
skin and subcutaneous tissue
 Intramuscular dissection to separate the
perforators
 Submuscular dissection to separate the DIEA

28. Zones of perfusion
 The anatomical basis for the perfusion of a flap based
on one or several perforators
 Angiosome : region perfused by all the perforators of an
ipsilateral DIEA
 Hartrampf, Scheflan and Dinner both described
 zone II as the zone of the contralateral DIEA (across the
midline)
 zone III as the zone of the ipsilateral superficial inferior
epigastric artery (SIEA)

29.  Each perforator has its own territory of supply, independent of the zone of supply by the source
vessel
 lateral row perforators and medial row perforators have been shown to have fundamental
differences in their zones of perfusion

30. SGAP/IGAP flap
 Anatomy
 Origin : Gluteal surface of ilium, lumbar fascia
 Insertion Gluteal tuberosity of femur
 Blood supply :
 Superior Gluteal artery : Branch of posterior division
of IIA
 Inferior gluteal artery : Anterior division of IIA
 Nerve supply : Inferior gluteal nerve

31.  Indications :
 Pt with more fat on the buttocks as compared to
abdominal wall
 Requiring less skin paddle and more fatty tissue
 SGAP
 Line is drawn from Posterior superior iliac spine to
greater trochanter
 Point of entry is at the junction of upper and middle third
of this line
 Skin Flap size : 7-8 cm x 10-12 cm

32.  IGAP
 A line is drawn from Posterior inferior iliac spine
to ischial tuberosity
 Point of entrance is at the junction of lower and
middle third
 Inferior limit of flap is marked 1 cm below and
parallel to gluteal fold
 Flap size : 8-10 cm

33. Reconstruction of NAC
 Prerequisites
 Reconstruction should be stable
 Symmetry should be achieved
 Nipple
 Composite nipple graft
 Local tattooed skin flap
 Skate flap
 Star flap

34. Skate flap
Star flap

35.  Aerola
 Skin graft
 Contralateral aerola
 Inner thigh
 Labial tissue
 Tattoo with mineral pigments

36. Contralateral breast
 To achieve symmetry after reconstruction
 Includes :
 Reduction mammoplasty
 Mastopexy
 Breast augmentation
 Prophylactic mastectomy
 Can be done in single sitting or delayed
 The risk of second primary in contralateral breast is about 4-5%
 Risk increases in medullary carcinoma, black race, age >55

37. THANK YOU