This document discusses techniques for breast reconstruction using prosthetic implants. It describes patient selection criteria, timing considerations for reconstruction, surgical techniques including tissue expansion and implant exchange, and goals for creating symmetry. The key steps are patient education, tissue expansion over multiple sessions to achieve adequate size, and careful implant selection and positioning to match the other breast.

1. BREAST
RECONSTRUCTION
DR G SWAMY VIVEK
SENIOR RESIDENT
DEPT OF PLASTIC SURGERY
GMCH, GUWAHATI

2. PROSTHETIC TECHNIQUES

3. PATIENT SELECTION
 The ideal candidate for breast reconstruction with prosthetic implants is a
thin patient with bilateral reconstruction, or a thin patient with a normal,
non ptotic breast who requires unilateral reconstruction.
 The patient is educated that the goal is to achieve as much symmetry as
possible, but that this may only be accomplished when she is in her
brassiere and clothing.
 For patients with obesity, broad chest wall and multiple medical problems,
an implant-based reconstruction may be more efficient than an
autologous tissue reconstruction.

4.  However, implant-based reconstructions may require more than one
operation and may require revisions over time.
 Additionally, if the patient has a chronic respiratory illness, the pressure
from the tissue expander on the chest wall during the expansion process
may exacerbate that underlying condition.
 Finally, prosthetic-based breast reconstruction often requires multiple
steps and multiple visits to the office.

5.  It is also important to explain to patients that prosthetic breast
reconstruction does not hinder detection of local or regional recurrence.

6. TIMING
 Breast reconstruction using prosthetic techniques can be accomplished
either in the immediate or delayed setting.
 ln the setting of a single-stage breast reconstruction using a permanent
implant, immediate reconstruction allows for the placement of an
optimally sized device.
 Delayed breast reconstruction using a prosthetic technique is also possible;
however, tissue expansion is almost always necessary.
 In the setting of high-risk disease and patients who require chemotherapy
and radiation therapy, a delayed reconstruction may be appropriate as it
will not delay the initiation of adjuvant treatment.

7. TECHNIQUE
 With all types of breast reconstruction, the primary goal is to achieve a
breast mound that is as symmetrical as possible with the other breast or to
the contralateral reconstruction in the setting of bilateral mastectomies.
 Ideally, mastectomy incisions are planned to minimize their impact on
subsequent tissue expansion and their visibility in conventional clothing.
 the site of the inframammary fold should be marked and preserved
whenever possible.
 At the conclusion of the mastectomy, if the inframammary fold has been
detached, it should be repaired.

8.  Expanders can be placed in a complete submuscular or subfascial pocket
by elevating the medial border of the serratus anterior muscle and/or
fascia and elevating the pectoralis major from lateral to medial and
bringing both the subserratus and subpectoral pocket into communication
at the level of or slightly below the inframammary fold.
 Final coverage of the expander occurs by suturing the lateral border of the
pectoralis major muscle to the serratus anterior muscle.
 An alternative to using the serratus anterior muscle and/or fascia for total
submuscular coverage of the tissue expander is to use acellular dermal
matrix.

12.  Once a subpectoral pocket is created for the expander, a sheet of acellular
dermal matrix is tailored to the defect.
 It is placed in the inferior and lateral portions of the expander pocket and
sutured to the pectoralis major muscle superiorly and to the chest wall or
inframammary fold inferiorly.

14. EXPANDERS
 Choosing the appropriate expander is based on several factors, including
breast volume, breast dimensions (height, width, and projection), breast
shape, and the patient's body habitus.
 In general, an anatomically designed, textured surface, integrated valve
tissue expander is preferred.
 The expander comes in various heights, widths, and amounts of projection
that either can be compared with the contralateral breast or can be
matched to another expander if a bilateral procedure is performed.

17.  Final considerations in choosing an expander include the amount and
quality of remaining breast skin after the mastectomy and the impact of
planned contralateral symmetry procedures (augmentation, mastopexy,
and reduction} on the shape of the opposite breast.
 The expander typically comes partially filled with air.
 The air is evacuated from the expander and a small amount of saline
solution is infiltrated into the expander to confirm the functioning of the
port.

19. DELAYED TISSUE EXPANDERS
 Typically, the mastectomy scar is excised and the mastectomy flaps are re-
elevated, although not to the extent as was necessary during the original
mastectomy.
 Once adequate pectoralis muscle is exposed, either the lateral border of
the pectoralis muscle is identified and elevated from the chest wall, or the
muscle is split in the direction of the muscle fibers and a subpectoralis
major pocket is created.
 Similar to immediate expander placement, care is taken to avoid elevation
of the pectoralis minor muscle.

20.  It is critical to free any scar tissue that will restrict expansion of the
mastectomy flaps.
 The expander is placed such that the zone of maximum expansion is
located in the lower pole of the reconstructed breast, allowing for
preferential expansion of the lower pole, for a more natural shape of the
reconstructed breast.
 Acellular dermal matrix may also be used for delayed reconstruction.

22. EXPANSION
 Intraoperatively, the tissue expander is filled to a volume that optimally
obliterates dead space, but does not impart excessive pressure on the
mastectomy skin flaps.
 Because blood supply to the newly created mastectomy skin flap may be
tenuous, overfilling the expander intraoperatively can impede circulation.
 closed suction drainage tubes left at the time of expander placement are
removed when output is <30 mL per 24 hours, which typically occurs
within 2 weeks.
 Tissue expansion begins in the office approximately 10 to 14 days after
surgery.
 A magnetic device is used to identify the site of the integrated fill valve
under the patient's skin.

25.  The area is cleansed with an antiseptic solution and a butterfly needle is used
to gain access to the tissue expander.
 Approximately 30 to 120 mL of saline is injected into the expander during each
expansion session.
 Expansion sessions can occur as frequently as once per week or as infrequently
as once per month, there is no set criterion to the expansion schedule.
 The final goal of the expansion is to achieve a volume that is approximately
25% to 30% greater the expander volume.
 This allows for extra skin to be available at the exchange procedure, which can
be used to create maximum breast ptosis and inferior pole projection.
 Overexpansion also allows for the removal of unsightly mastectomy scars, or
scars that have resulted from delayed or poor wound healing.

28.  Patients can be safely expanded during chemotherapy, although it may be
necessary to coordinate the expansion schedule with their chemotherapy
schedule.
 Final replacement of the expander to a permanent implant is deferred until
the patient's blood counts have returned to normal after the conclusion of
chemotherapy.
 Also after simulation for radiotherapy, it is important not to adjust the
expander volume.
 In general, soft tissues are allowed to rest for at least 1 month between the
time of the last expansion and the time of the exchange procedure.

29. EXCHANGE OF TISSUE EXPANDER FOR
PERAMANENT IMPLANT
 The goals of the exchange procedure are to create a breast mound that
has similar shape, volume, and position as the contralateral breast in a
unilateral reconstruction, and to maximize symmetry and position in a
bilateral reconstruction.
 The second stage in breast reconstruction using a prosthetic device
involves exchanging the tissue expander to a permanent implant.
 Typically, patients will wait at least 1 month following the last expansion
before undergoing the exchange procedure.
 If the patient received chemotherapy as part of her management, then at
least 3 to 4 weeks after the last chemotherapy session is allowed to pass so
that bone marrow suppression induced by chemotherapy can resolve
before undergoing an elective surgical procedure.

32.  The patient is positioned in the operating room such that the
reconstruction can be accomplished in the sitting position, allowing for
maximum ptosis of the natural breast.
 The permanent implant can then be placed with maximum symmetry.
 The type and shape of the device is selected preoperatively.

34.  The selection of the proper final implant is aided by measuring the
dimensions of the normal breast.
 Various techniques facilitate this process.
 (1) comparing the weight of breast removed at the time of mastectomy to
the volume of the tissue expander.
 This will help in approximating the mass and volume needed for
reconstruction.
 (2) is to partially empty the expander prior to removing expander.
 The expander is emptied to the point where its volume approximates the
contralateral breast.

35.  The volume of the remaining fluid in the expander, the base dimension of
the pocket from which the expander came, and the height and projection
of contralateral breast determine the appropriate size and shape of the
implant.

38.  Perhaps, the most important step in placement of the permanent implant
for breast reconstruction is accurate positioning of the inframammary fold.
 Depending on the degree of ptosis and whether a contralateral symmetry
procedure will be performed on the opposite breast, the marking will help
determine the final location of the inframammary fold.
 In general, the position of the inframammary fold of the reconstruction
should match the normal side or contralateral side even in the setting of a
bilateral reconstruction.

40.  In the setting of a more ptotic breast, where the breast gland descends
below the level of the inframammary fold, it may be desirable to place the
bottom of the implant at the level of the bottom of the breast on the
natural side.
 In this circumstance, the inframammary fold on the reconstructed side may
be slightly lower than it is on the contralateral side; however, the overall
position of the breast mounds is similar.

41.  MULTIPLE TECHNIQUES FOR RECREATING THE INFRAMAMMARY FOLD:
 Internal placement of capsulorraphy sutures
 External marionette sutures
 Liposuction of the inframammary fold to allow the external skin to stick to
the chest wall.
 Advancement of upper abdominal skin flap, suturing this internally to the
chest wall to define the fold.

42.  Maximizing projection of the reconstructed breast can be further
accomplished by performing internal capsulotomies positioned either
circumferentially, radially or both or by performing a capsulectomy.
 An inferior pole capsulectomy or capsulotomy will allow for maximizing
inferior pole projection and ptosis in the reconstructed breast.
 If patient desires contralateral symmetry procedure ( augmentation
mammoplasty, mastopexy, or reduction mammoplasty), this is typically
accomplished at the time of exchange of tissue expander with permanent
implant.

44. BREAST RECONSTRUCTION WITH
IMMEDIATE PLACEMENT OF AN IMPLANT
 In select cases, immediate breast reconstruction can be accomplished with
placement of an implant.
 The mastectomy skin flaps must be completely healthy, the pocket must
be of adequate size so as to insert an implant of the appropriate size, and
the appropriate implant must be selected.
 Acellular dermal matrix may be beneficial in single-stage reconstruction.
 The disadvantage of immediate reconstruction includes the risk of
asymmetry with the contralateral breast, inadequate size and projection of
the device, and the potential need for a revision to improve the quality of
the overall reconstruction.

47.  In general, use of a two staged reconstruction with a tissue expander
placed at the first stage, followed by a permanent implant at the second
stage, maximizes the surgeon's control.
 Whenever reconstruction in a single stage is performed with an implant,
patients should be made aware that there may be a need for a revisionary
procedure to improve the overall result.

51. BREAST RECONSTRUCTION AFTER
NIPPLE-SPARING MASTETOMY

53. POST OPERATIVE CARE
 After placement of a tissue expander, or after exchange of an expander for a
permanent implant, the patient is placed in a surgical bra, which helps to hold
dressings in place and provides a place for drains to be fastened.
 The use of oral antibiotics after surgery is discretionary.
 The use of a conforming breast binder to hold the implant position may be
advantageous.
 Patients are instructed to avoid the use of an underwire bra for several weeks
after surgery and. depending on the type of implant used, may be instructed
to massage their implants.
 Implant massage is usually reserved for patients with smooth implants rather
than shaped, anatomic implants where massage may lead to implant
malposition.
 Pain medication is prescribed as needed

54. COMPLICATIONS
 Bleeding in the immediate postoperative period resulting in hematoma
warrants reexploration.
 Hematomas under the mastectomy skin flap and around the tissue
expander or permanent implant increase the risk of infection and
predispose to capsular contracture.
 Infections typically present as cellulitis of the skin flaps over the implant.
Occasionally, an abscess is identified.

55.  Another early complication includes mastectomy skin flap necrosis.
 Superficial- or partial-thickness flap necrosis is usually managed
conservatively with local wound care.
 Occasionally, small areas of full-thickness necrosis can also be managed
with local wound care, particularly if the expander is in a complete
submuscular location, thus having an interface of normal healthy tissue
between the device and the area of skin necrosis.

56.  LATE COMPLICATIONS:
 Asymmetry,
 Implant wrinkling
 Implant malposition
 Implant deflation
 Capsular contracture and
 infection

57.  Fat grafting can be used to improve many of the contour deformities that
result from mastectomy and implant reconstruction.
 The fat is injected in multiple different layers and feathered over the area
that needs to be corrected.
 Some authors use acellular dermal matrix to correct rippling as well as
capsular contracture.

58. IMPACT OF RADIATION ON
PROSTHETIC RECONSTRUCTION
 Radiation therapy, whether it is delivered preoperatively or
postoperatively, complicates breast reconstruction.
 With respect to preoperative radiation therapy, placement of a tissue
expander at the time of the mastectomy may lead to failed expansion,
poor expansion with lack of projection, poor wound healing and an
inability to achieving the desired result from this method of reconstruction.

59.  An approach to the previously irradiated patient with the use of a tissue
expander is immediate placement of a latissimus dorsi myocutaneous
transposition flap over the expander.
 The latissimus flap will have not been previously irradiated and thus is
much more likely to expand without resistance.
 Additionally, the autologous tissue provided by the latissimus flap will
increase the volume of skin for the breast reconstruction, thus enabling the
reconstruction to have more projection and ptosis.
 In patients who require postoperative radiation therapy, radiating the
permanent implant leads to a higher incidence of capsular contracture and
need for revision.

60. AUTOLOGOUS TISSUE TRANSFER FOR
BREAST RECONSTRUCTION

61. PEDICLED FLAP RECONSTRUCTION
 LATISSIMUS DORSI FLAP
 RECTUS ABDOMINIS FLAP

62. LATISSIMUS DORSI FLAP

65. RECTUS ABDOMINIS FLAP

67. FREE FLAPS FOR BREAST
RECONSTRUCTION
 ABDOMINAL FREE FLAPS
 GLUTEAL FREE FLAP
 GRACILIS FREE FLAP

68. RECIPIENT AREA DISSECTION FOR
FREE FLAP RECONSTRUCTION

69. ABDOMINAL FREE FLAPS

73. GLUTEAL FREE FLAP

74. GRACILIS FREE FLAP

76. NIPPLE RECONSTRUCTION
 Nipple reconstruction is an essential component in the creation of an
attractive breast.
 Nipple reconstruction techniques may seem minor in the overall scheme of
breast reconstruction; they are a major factor in the final result and
demand meticulous attention to achieve good aesthetic results.
 The goal of nipple-areolar reconstruction is to create nipples that are
appropriately located on the breast mound and are of appropriate size,
shape, color, and texture.

77. MARKING
 The surgeon uses aesthetic judgment to position the nipple.
 One way to approximate the nipple-areola position is to cover the contralateral breast
and carefully study the reconstructed breast mound and place a mark where the nipple
location appears appropriate.
 The contralateral breast is then uncovered and a careful comparison is made.
Adjustments are made as deemed necessary.
 The patient is allowed to have input into the nipple-areola location as well. A round
adhesive bandage is placed on this location.
 The patient can relocate the bandage to what she feels is an appropriate location.
 In bilateral reconstructions, there is more latitude in nipple location yet the marking
methods are similar.
 Initially, each breast is assessed separately.
 Careful inspection of both breasts is then performed and adjustments/compromises
made as necessary.

78. METHODS
 LOCAL FLAPS
 GRAFTS
 DONATED (HOMOGRAFT) CARTILAGE
 NIPPLE-AREOLA TATTOOING

79. LOCAL FLAPS
 Local flaps are the most frequently performed methods of nipple
reconstruction today.
 A central dermal fat pedicle is wrapped by full- or partial-thickness skin
flaps, creating a nipple.
 Examples of the commonly used pedicle flaps are the skate flap, modified
skate flap, star flap, cervical visor (CV) flap, wrap flap, and fishtail flap.

80. SKATE FLAP

81. STAR FLAP

82. CV FLAP

83. CERVICAL VISOR FLAP

85.  One must keep in mind that these are second-generation flaps; that is,
they are created from flaps of tissue that were themselves either
mastectomy flaps or autologous transferred flaps.
 These methods may not be suitable for reconstructions in patients with
thin skin or irradiated tissue.
 Local flaps are best suited for breast mounds composed of autologous
tissue where these soft-tissue requirements are met.
 These local flaps often lose volume and contract substantially over time.
 Consequently, an initial overcorrection is warranted.

87.  In unilateral reconstruction, the local flap is made 50% to 75% larger than
the contralateral nipple size in anticipation of atrophy.
 If the final result is substantially larger than desired, a reduction is readily
performed as an office procedure.

88. GRAFTS
 Grafts are particularly useful in prosthetic reconstructions as there is often a paucity of
soft tissue to create nipples with sufficient projection using the local flap techniques.
 The disadvantage of autografts is that they require a donor site.
 Grafts of tongue, earlobe, toe, and labia have been used, but these donor sites are
undesirable and are of mostly historical significance.
 One of the best methods in unilateral breast reconstruction is a composite nipple graft
from the contralateral nipple.
 If the patient has sufficient projection in the contralateral nipple and is willing to use it
as a donor site, excellent nipple symmetry can be attained.
 This is an easy technique to perform and can readily be accomplished in the office.
 The patient must be informed that the donor nipple may suffer loss of sensibility and
erectile and ductile function.

89. COMBINED MODIFIED CV FLAP WITH
CONTRALATERAL COMPOSITE NIPPLE
GRAFT

90.  The donor site is dressed with antibiotic ointment and a bandage. The
graft dressings are changed 1 week postoperatively, and are dressed every
other day with Xeroform for an additional week.
 Although the graft may appear dark and dusky after 1 week, it is usually
pink and viable within 2 to 3 weeks.
 Over the next 2 to 3 months, the graft may grow approximately 20% to
30% larger, attaining the appearance of the contralateral nipple.

91. SKIN GRAFTS
 Skin grafts can be used to create the nipple-areola complex, often using an
ellipse of medial thigh skin.
 The graft is placed over the de-epithelialized, circular, donor site and
sutured with a tie-over dressing that is removed 1 week postoperatively.
 A separate, central graft is placed to simulate the nipple. Alternately, the
skin graft is placed around a local flap or composite graft.
 These grafts, however, are poor color matches to "normal" areolae.

92. DONATED (HOMOGRAFT) CARTILAGE
 The use of cartilage is an excellent method of nipple reconstruction,
particularly in prosthetic reconstruction where there might be a soft-tissue
deficiency.
 The surgeon has complete control over the dimensions of the nipple. The
procedure is applicable to both unilateral and bilateral nipple
reconstruction, is an easy procedure to perform, does not involve a donor
site, and maintains long-lasting projection.
 A disadvantage of donated cartilage is that the resulting nipple is with an
unnatural reel.
 If the grafts are placed too superficially and do not have a smooth contour.
they can extrude through the skin, necessitating revision and/or removal.

94. ACELLULAR DERMIS MATTRICES
 Processed dermis can be used as an adjunct to local flap reconstruction or
as the primary material for the nipple.
 A cylindrical roll of ACM can be created and placed in front of the dermal
fat pedicle of any local flap.
 This creates a more rigid "strut" which is then wrapped by the lateral skin
flaps. The dimensions of this strut can be precisely controlled to achieve
the desired dimensions of the nipple.
 The surgeon must pay careful attention when designing the dimensions of
the lateral flaps in order to accommodate the added volume of the ACM
strut.

95. ACELLULAR DERMAL MATRIX

96. NIPPLE AREOLA TATTOOING
 Nipple-areola tattooing is an excellent adjuvant treatment.
 Because color choice is unlimited, excellent symmetry is attainable in both
unilateral and bilateral reconstructions.
 With attention to detail, excellent three-dimensional appearance can be
created with the use of basic light and shading principles.
 The Montgomery glands can also be added to achieve a more natural
appearance.
 Tattooing should be performed approximately 6 to 8 weeks after nipple
reconstruction, to allow for wounds to heal.

98.  This is particularly useful in patients with prosthetic reconstructions who
have thin, tenuous skin that would not support a local flap or graft.
 Tattoos often fade and approximately 60% of patients may require a
secondary tattoo session.
 If the nipple reconstruction is not possible in the patient then entire nipple
areola can be created tattooing in 3 dimension.

100. SECONDARY CASES
 In cases where a reconstructed nipple has insufficient dimensions and there is
disparity with the contralateral nipple, secondary procedures can be
performed.
 Small asymmetries can be rectified with the insertion of a small dermal graft,
ACM, or cartilage into the base of a local flap.
 A skin or composite graft can be placed on top or around a portion of the flap
or graft.
 Autologous fat can be injected into the base of a local flap as well.
 For more significant disparities involving local flaps, a second flap can be
raised using the base of the previous flap as the new nipple location.
 A CV or fishtail flap is particularly useful in this situation.
 The use of long-term injectable fillers can be used to supplement smaller
nipple deficits.

101. INJECTABLE FILLERS
 The use of injectable fillers can be used to create a new nipple as well as
augment or improve the contours of an established nipple.
 Dermal substitutes can also be utilized for this as well.
 Fillers are easily injected in the office.
 We raise a wheal in the skin using the base of a 3 cc syringe that is spilt on
the side to accommodate the needle.
 The syringe helps contain the filler within the confines of the nipple
location.
 We inject 0.3 to O.5 cc per session and repeat it every 3 to 6 months to
build sufficient projection.
 Does not have enough evidence.

103. THANK YOU