breast reconstruction surgery, a summery

2. Still the
same?

3. BREAST RECONSTRUCTION SURGERY
Wasula athnaweera
2014.12.12

4. HISTORY
 William Halsted
 first radical mastectomy in 1889
• ‘‘The slightest inattention to detail and or attempts to hasten
convalescence by such plastic operations as are feasible
only when a restricted amount of skin is removed, may
sacrifice his patient to disease.”

5.  1895 Vincent Czerny
 transplantation of a large lipoma from the patient’s flank
 1906 the Tanzini
 a pedicled flap of skin and underlying latissimus dorsi
muscle
 1905 Ombredanne
 pectoral muscle as amound.
 luxury operation
 1942 Sir Harold Gilles
 tubed abdominal flap method

6.  1962 silicone breast implants
 cosmetic augmentation
 1970 s LD flap - most popular
 1977 Hohler and Bohmert
 2 stage reconstructions
 thoracoepigastric flap + prosthesis
 1982 Hartrampf
 the first TRAM flap
 1982 Radovan
 tissue expansion

7. INDICATIONS
 After mastectomy
 After BCS
 Congenital anomalies
 Development anomalies
 Traumatic disfigurement

8. CONCERNS BEFORE SX
 Patient factors
 Body habitus
 Past history – Sx, RT, Co morbidity
 Smoking
 Patients wishes and education
 Disease factors
 Volume loss
 Margin status
 Stage of the disease
 Adjuvant therapy
 Surveillance
 Other factors
 Cost
 Availability
 Resources
 Expertise

9. COMPONENTS OF RECONSTRUCTION
 Foot print
 Mound
 Skin
 Volume
 NAC
 Symmetry

10. CLASSIFICATION
 Timing
 Immediate vs delayed
 Composition
 Autologous
 Prosthesis
 Combined
 Primary surgery
 Mastectomy
 MRM
 Simple
 SSM
 NSM
 WLE
 Volume
 Volume displacement
 Volume replacement
 Quadrent affected
 Indication
 Theraputic
 Prophylactic

11.  Unilateral & bilateral
 Contralateral breast surgery
 Reduction
 Augmentation
 NAC reconstruction

12. TIMING OF RECONSTRUCTION
 40% of women in USA undergo mastectomy for Ca
 Total number ~ 18000 a year
 33% undergo breast reconstruction after
mastectomy
 22% immediately
 Cause
 Lack of awareness
 Failure of referral

13. Immediate
 Adv
 Wake up with a breast
 Lesser # of GA
 Better results
 Colour
 Sensate
 Aesthetics
 Shape
Specially with SSM,NSM`
 Disadv
 High expectations
 Failure is a double blow
 Dual surgical
competencies

14. Delayed
 Adv
 Patients are more
satisfied
 Psychological
adjustment for lost
breast
 Better decision making
for primary condition
 Margin status
 Disadv
 Less skin remains
 Tissue expansion
 Less sensate
 2 procedures
 More GA
 More resources

15. COMPOSITION
 Aotologous
 Pedicled myocutaneous flaps
 LD
 LD varients
 Split LD
 Fleur de lis
 Muscle sparing
 TRAM
 Standard
 Super charge TRAM- additional micro surgery to enhance blood
supply from thorax
 Pre ligation of IEA- improve Superior EA blood supply

16. Fleur de lis

17. TRAM
 Indications
 Poor tissue quality after
MRM
 Possible implant
exposure
 Axillary fill
 Infraclavicular tissue
deficit
 Contra indications
 Absolute
 Irradiated flap base
 Sx at the pedicle
 Prior abdominoplasty
 Abdominal scars
 Relative
 >65 yrs
 V obese
 Unfavorable
microcirculation
 Diabetes
 Smoking

18.  Free flaps
 Free TRAM
 Modifications of TRAM- muscle sparing
 MS 0 ,1, 2,3(DIEP)
 SIEA
 Stacked DIEP
 GAP
 SGAP
 IGAP
 MTG
 Ruben`s flap
 deep circumflex iliac artery flap

21.  Adv
 More natural
 Physiologic changes may go
together
 Eg LOW
 Donor benefit
 Abdominoplasty
 Option after RT
 Feel reconstruction is ‘own
breast’
 Disadv
 Risk of failure
 Complications
 Donor site morbidity
 special skills
 Resource demand
 Longer surgery
 Body Habitus
 Non smokers
 Longer recovery

22.  Prosthetic
 Implants
 Silicon gel implant- standard
• Controversy of earlier silicon implant leaking and malignancy
is scientifically excluded in 2000
 Tissue expanders
 Permenant
 Convertion to implant

23. IMPLANTS
 Shape
 Round
 Tear drop
 Shell
 Mono layer/ tripple layer
 Smoooth /textured
 Filler
 Saline
 Silicon gel
 Dimentions
 Coated / uncoated
 polyurathene

24. COMPLICATIONS OF IMPLANTS
 Capsular contracture
 Baker classification
I. Soft
II. Less soft, implant not visible
III. Firm, implant palpable,distortion seen
IV. Very firm, hard tender,cold
 Capsulotomy, capsulectomy
 ? To use leukotriene inhibitors

25.  Haematoma
 Cellulitis
 Seroma
 Skin necrosis- complete/partial
 Implant failure
 Infection

26. Criteria
 Adequate skin envilop
 No hx of radiation
 No smoking 6 weeks pre op

27.  Placement of prosthesis
 (Sub glandular)
 Sub muscular
 Acellular dermal matrix incooperated
 Serratus flap incooperated
 Myocutaneous flap itself incooprated

28.  Adv
 Single stage
 Less time consuming
 No donor scar or
morbidity
 Good for small breasts
 Better volume matching
 Disadv
 Foreign body reaction
 Infection
 Capsular contraction
 sp if RT given
 May need expander
stages
 Difficult following RT

29. PRIMARY SURGERY
BCS-WLE
 Reconstruction technique and volume loss
 <20%- no need of complicated procedures
 20-40% -volume displacement techniques
 >40% volume replacement techniques
 Mini LD
 Thoraco epigastric
 Intercostal perforator flaps

30. Adv
 Adequate margins with good cosmetic results
 Acceptable cosmesis in large volume resections
 Long lasting good results
 Reduce late unacceptable cosmetic effects of
radiation

31. Disadv
 Difficulties of RT planning
- need for clip placement
 If further resection needed
- ending in a mastectomy
 Complication related to oncoplastics
- Skin necrosis
- Fat necrosis
- cosmetically less acceptable results
- Delayed wound healing leading to treatment
delays
 Need of additional training in oncoplasty

32. PRINCIPLES BEHIND ONCOPLASTICS :
(A) vascular supply is maintained :
 move skin with NAC on underlying breast
 move breast against muscle
 breast segments to be moved to a different location
 NAC in appropriate direction
 based on breast blocks ( superior / inferior based pedicles)

33. PRINCIPLES BEHIND ONCOPLASTICS :
(B) Selection criteria :
 Excision volume - as % from breast volume
 Tumour location - quadrant wise / clock position
 Glandular density ( BIRDS)

34. PRINCIPLES BEHIND ONCOPLASTICS
(C) Selection of Levels of oncoplastic procedures
 Level I ops (Dual plane under mining)
- Lesser volume loss
- Patients tolerating Duel-plane undermining
(BIRADS III / IV )
 Level II ops (single plane undermining – dermoglandular flaps)
- For larger volume resections
- For breasts not tolerating duel-plane undermining
(BIRADS I/ II)
- For patients requesting reductions at the same time

35. PARALLELOGRAM FOR UOQ TUMOURS

36. ROUND BLOCK TECHNIQUE FOR 12 TUMOURS

37. BATWING MASTOPEXY FOR UQ TUMOURS

38. TENNIS RACKET METHOD FOR UOQ TUMOURS

39. ROTATION FLAP FOR UIQ TUMOURS

40. GRISOTTI PROCEDURE FOR CENTRAL TUMOURS

41. J mammoplasty for LOQ
tumours

42. V – mammoplasty for LIQ tumours

43. VERTICAL REDUCTION FOR 6 OCLOCK TUMOURS

44. WISE PATTERN REDUCTION MAMMOPLASTY FOR 6 & 12
TUMOURS

45. SUMMARY OF QUADRANT PER QUADRENT PROCEDURES( EG : L BREAST)
Clock position Procedire
5-7 o’clock Lower pole Superior pedicle mammoplasty (wise
type)/ Verticle reduction
7-8 o’clock Lower inner quadrent ,, / ,, - repair rotated to 7-8 o’clock/
V scar
4-5 o’clock Lower outer quadrent ,, / ,, - repair rotated to 4-5 o’clock /
J scar
12 o’clock Upper pole Inferior pedicle mammoplast (wise
pattern) / Round block
9-11 o’clock Upper inner quadrent Batwin / Rotation flap
1-2 o’clock Upper outer quadrent Tennis Racquet mammoplasty /
Parallelogram / Radial scar
Central subareolar Grisotti / Superior pedicle Grisotti type /
inverted T or vertical scar with NAC
resection

47. STANDERDS

48.  Surgery to opposite breast
 Reduction
 Augmentation
 Revision procedures
 Implant revision
 Fine tuning
 Fat injections

49.  NAC reconstruction
 Surgery- local skin flap rearrangement
 Free graft from opposite NAC
 50% loss of nipple height
 Tattooing
 Skin grafts from dark-skinned sites
 Inner thigh
 Cartilage, fat augmentation
 Alloplastis techniques
 Polyurethene coated silicone ggel
 Hyaluronic acid
 PTFE
 ADM

51.  Problems of breast reconstruction
 Image survillance
 Mammo- not possible
 Need MRI
 Insensate
 Breast
 Nipple
 May need further procedures with time
 Same side
 Opposite side
 Physiological changes absent

56. THANK YOU