This document summarizes various reconstructive breast surgery options following mastectomy. It discusses prosthetic reconstruction as well as autologous reconstruction options including pedicled flaps such as the latissimus dorsi flap and free flaps such as the deep inferior epigastric perforator flap. It also discusses timing of reconstruction, pre-operative considerations, complications, and outcomes of different procedures.

1. RECONSTR-
UCTION OF
BREAST
SHILPI KARMAKAR
M.S., M.Ch., D.N.B., FDFM, FRSPH
Assistant Professor
Department of Burns and Plastic Surgery

2. The goal of reconstructive breast surgery
is no longer to create a breast mound but
to create a breast with natural shape,
volume, contour, and symmetry.

3. Options following mastectomy
– Prosthetic devices
– Pedicled musculocutaneous flaps
- LD, TRAM
⁻ Free flaps
- TRAM (MS-0, 1, 2)
- MS-3 or DIEP
- SIEA
- LD, TDAP
- SGAP, IGAP
- TUG, DUG, TMG
- ICAP, IMAP
Limitations
- Foreign body ,
- Smoking, prior radiation, overweight or
obese pts.
- Sacrifice of total muscle, donor site
weakness, abnormal contour.
- Advantages of free flaps
- Considered in pts with Increased BMI,
smoking, prior radiation, failed prosthetic
reconstruction.
- Preserves donor site muscles.
- Flaps raised on both sides of body

4. Timing of reconstruction
- Immediate (with mastectomy)
- Better cosmetic outcomes
- Cheaper
- Psychological benefit
- Delayed
- Patient has more time to consider options
- Adjuvant therapy completed
- Higher long term patient satisfaction rates

5. Pre-operative considerations for
reconstruction.
– breast volume and contour,
– body habitus,
– Reconstructive requirements,
– donor site considerations,
– medical comorbidities,
– tumor characteristics,
– potential need for adjuvant therapy.
– Imaging findings.
– patient preferences and expectations

6. Prosthetic devices
- 1 stage:
- Permanent expander-implant
- Permanent implant with dermal sling or Acellular dermal matrix
- 2 stage: Tissue expander then permanent silicon implant
- Pocket of placement of prosthesis

7. Delayed reconstruction

8. Complications
- Early
-Wound breakdown
-Infection - explantation
- Late
-Capsular contracture (20% at 10 years)
-Deterioration of overlying tissues
-Implant rupture
- Candidates - Small, non-ptotic breast
- - Contralateral reduction or mastopexy
- Avoid in diabetics, smokers, steroids, RT

9. Latissimus dorsi flap
– Type 5
– Pedicled/free,
– ipsilateral/contralateral/ bilateral
breast,
– musculocutaneous/ muscle only,
– Endoscopic / open harvest
– With/ without prosthetic implant.
– Complete/partial breast

10. Latissimus dorsi flap

11. MS-LD flap
– MS-LD 1 - 2 – 4 cm segment of muscle is incorporated around the perforators
– MS-LD 2- segment upto 5 cm in width is incorporated in the flap; and
– MS-LD 3 - most of the muscle is included in the flap

12. Thoracodorsal artery perforator
flap
– Pedicled/free
– Lateral breast, partial defects
– 5-9 perforators of >0.5 mm caliber
over LD muscle.
– Inconsistent direct cutaneous
branch off the extramuscular
portion of the thoracodorsal artery
in 55% of cases

13. Vascular
anatomy
of
anterior
abdom-
inal wall

14. TRAM flap

16. DIEP flap

17. SIEA flap
– 1.1-1.6 mm
– 7 cm
– Fat necrosis (3.7%),
– partial flap loss (3.7%),
– arterial thrombosis (3.7%), and
– venous congestion (3.7%),
– no bulge or hernia
Spiegel AJ, Khan FN. An intraoperative
algorithm for use of the SIEA flap for breast
reconstruction. Plast Reconstr Surg
2007;120:1450–9.

19. Outcome of DIEP
– Partial flap loss occurred in 2.5% of cases.
– Total flap loss occurred in less than 1% of all cases.
Problems with the vein or venous anastomoses were nearly
8 times more likely than problems with the artery or arterial
anastomoses.
– Fat necrosis - 13% of flaps.
– Seroma formation at the abdominal donor site was
approximately 5%.
– Abdominal hernia occurred in 0.7% of cases
– Gill P, Hunt J, Guerra A, et al. A 10-year retrospective
review of 758 DIEP flaps for breast reconstruction. Plast
Reconstr Surg 2004;113:1153–60
– MS-2 TRAM - total necrosis in 1.8% of cases,
– fat necrosis in 7.1%, venous congestion in 2.7%, and
– abdominal bulge in 4.6% of unilateral reconstruction and
21% of bilateral reconstruction
– Nahabedian MY, Tsangaris T, Momen B. Breast
reconstruction with the DIEP flap or the musclesparing
(MS-2) free TRAM flap: is there a difference? Plast
Reconstr Surg 2005;115:436–44.

20. SGAP flap vascular anatomy

21. IGAP vascular anatomy

22. Gluteal flaps (SGAP/IGAP)
– Type III muscle
– SGA – 2.5 mm
– IGA – 3 mm
– Laterally based perforators- 5-7cm,
– medially based perforators -4–6 cm
– 450gm of tissue
– Indications
– Inadequate abdominal tissue
– History of extensive liposuction, or
abdominoplasty
– Supplement DIEP flap in stacked
flap fashion in women with large
breast.
– Desired by patient

23. Gluteal flaps (SGAP/IGAP)
Advantages
– Skin upto 10 cm
– Tissue bulk adequate without
Implant
– Fat has firm consistency –
projection of breast
– Minimal donor site morbidity.
– IGAP – long pedicle, scar in crease.
limitations
– Patient repositioning during
surgery
– Gluteal asymmetry
– Short pedicle of SGAP
– IGAP- sciatic nerve exposure
during dissection postop
discomfort.
– Risk of wound dehiscence
– Anaesthesia of posterior thigh.

24. Outcome of SGAP flap
– arterial and venous complication (6%),
– donor site contour deformity requiring
secondary correction (4%),
– partial flap necrosis (4%),
– donor site seroma (2%), and
– donor site hematoma (1%)
– Guerra AB, Metzinger SE, Bidros RS.
Breast reconstruction with gluteal artery
perforator (GAP) flaps. A critical analysis
of 142 cases. Ann Plast Surg 2004;52:118–
25

25. Thigh IGAP flap (TGAP)
– Perforators of IGA to posterior thigh
skin and fat.
– Incisions – just below inferior
gluteal fold , 6-7cm below,
transversely 20-26 cm
– No buttock deformity

26. Vascular
anatomy
of gracilis
flap

27. Medial thigh flaps
– Vascular pedicle predictable.
– 1.5-2.5 cm
– Perforators of 0.5–1 mm, from the
proximal aspect of the muscle at the
level of the major pedicle
– 150-550 cc.
– insufficient abdomen skin and fat, who
prefer not to use the abdomen
– 25X10 cm transverse skin and fat
paddle

28. Posterior thigh flap – Profunda
Artery Perforator flap(PAP)
– 250-700 gm.
– Perforators of profunda femoris
artery and vein in the posterior
compartment of leg
– Lymphedema risk is minimal,
– pedicle length is increased,
– gluteal contour is not affected

29. IMAP flap
– Partial breast
reconstruction, esp. medial
quadrants
– Any of the upper four
internal mammary
perforators
– 0.6-1.2 mm
– Costal cartilage can be
removed to access the IMA

30. ICAP flap

31. Fat transfer for correcting minor
contour irregularities

32. Areola reconstruction
– Tattooing
– Skin graft

33. Nipple reconstruction
– nipple graft from opposite breast
– Dermal fat
– Flap
– Fillers

34. REFERENCES

35. Thank
You