Breast reconstruction can be done immediately during mastectomy or delayed after adjuvant therapy completion. Immediate reconstruction provides better cosmetic outcomes and early psychological benefits, while delayed allows more time for consideration and ensures therapy is done. Techniques include expanders/implants, latissimus dorsi flaps, TRAM/DIEP flaps, and fat grafting. Each option has pros and cons like operating time, recovery duration, and risks of complications or donor site morbidity that require considering patient factors and desires. A multidisciplinary team can help personalize the optimal reconstructive approach.

1. Breast reconstructionBreast reconstruction
Penny L McManus FRCSPenny L McManus FRCS
Consultant oncoplastic breast surgeonConsultant oncoplastic breast surgeon
Hull UKHull UK

2. Breast ReconstructionBreast Reconstruction
 Immediate (with mastectomy)Immediate (with mastectomy)

Better cosmetic outcomesBetter cosmetic outcomes

CheaperCheaper

Early Psychological benefitEarly Psychological benefit
 DelayedDelayed

Patient has more time to consider optionsPatient has more time to consider options

Adjuvant therapy completedAdjuvant therapy completed

Higher long term patient satisfaction ratesHigher long term patient satisfaction rates

3. Skin sparing mastectomy for immediate reconstructionSkin sparing mastectomy for immediate reconstruction

4. Techniques in BreastTechniques in Breast
ReconstructionReconstruction
 Expander/ImplantExpander/Implant
 Latissimus Dorsi (LD)Latissimus Dorsi (LD)
 TRAM / DIEPTRAM / DIEP
 Other free flaps – SGAP, IGAP, TUGOther free flaps – SGAP, IGAP, TUG
 lipomodelinglipomodeling

5. Implant ReconstructionImplant Reconstruction
 2 stage:2 stage:
 Tissue expander then permanent siliconTissue expander then permanent silicon
implantimplant
 1 stage:1 stage:
 Permanent expander-implantPermanent expander-implant
 Permanent implant with dermal sling orPermanent implant with dermal sling or
Acellular dermal matrixAcellular dermal matrix

6. 2 stage implant reconstruction2 stage implant reconstruction
 Delayed and immediateDelayed and immediate
 Submuscular tissueSubmuscular tissue
expanderexpander
 Serial expansionSerial expansion
 Change to permanentChange to permanent
silicone implantsilicone implant

7. Tissue expander placed in submuscular pocketTissue expander placed in submuscular pocket

8. Delayed 2 stage implant reconstructionDelayed 2 stage implant reconstruction

9. AAdvantagesdvantages
 Short operating timeShort operating time
and recoveryand recovery
 Low complication rateLow complication rate
 No donor siteNo donor site
morbiditymorbidity
 Normal appearance inNormal appearance in
clothingclothing

10. DDisadvantagesisadvantages
 2 operations2 operations
 No ptosisNo ptosis
 No change with bodyNo change with body
weight/ageweight/age
 Feels coldFeels cold
 Late complicationsLate complications
RadiotherapyRadiotherapy

11. Immediate implant with dermal slingImmediate implant with dermal sling
 Wise pattern mastectomyWise pattern mastectomy
 Lower pole skin de-Lower pole skin de-
epithelialised & sutured toepithelialised & sutured to
lower edge pectoralislower edge pectoralis
 Ptotic breastsPtotic breasts
 Patients requestingPatients requesting
reductionreduction
 Risk reductionRisk reduction
mastectomymastectomy

12. Immediate implant with dermal slingImmediate implant with dermal sling

13. Immediate implant with acellular dermalImmediate implant with acellular dermal
matrixmatrix
 Strattice, Alloderm,Strattice, Alloderm,
Permacol, SurgimendPermacol, Surgimend
 Sutured to lower edgeSutured to lower edge
pectoralis andpectoralis and
inframammary foldinframammary fold
 Smaller, non-ptoticSmaller, non-ptotic
breastbreast
 High complications rateHigh complications rate
 High costHigh cost

14. Immediate implant with ADMImmediate implant with ADM

15. ComplicationsComplications
 EarlyEarly

Wound breakdownWound breakdown

InfectionInfection  explantationexplantation

RotationRotation
 LateLate

Capsular contracture (20% at 10 years)Capsular contracture (20% at 10 years)

Deterioration of overlying tissuesDeterioration of overlying tissues

Implant ruptureImplant rupture

16. Patient selectionPatient selection
 Patient desires & expectationsPatient desires & expectations
 Small, non-ptotic breastSmall, non-ptotic breast
 Contralateral reduction or mastopexyContralateral reduction or mastopexy
 Avoid in diabetics, smokers, steroids, RTAvoid in diabetics, smokers, steroids, RT

17. Latissimus Dorsi Flap

18. Extended Latissimus Dorsi flapExtended Latissimus Dorsi flap

19. Extended LD flapExtended LD flap

20. Pros and ConsPros and Cons
 Operating time 4-5Operating time 4-5
hourshours
 Stay 4 daysStay 4 days
 Recovery 4-5 weekRecovery 4-5 week
 Safe and reliable flapSafe and reliable flap
 Can be irradiated ifCan be irradiated if
autologousautologous
 Donor site scar andDonor site scar and
morbiditymorbidity
 TwitchingTwitching
 SeromaSeroma
 Flap failureFlap failure
 Flap atrophyFlap atrophy

21. LD with implantLD with implant
Preop immediate LD + Implant 2 years postop
Preop delayed LD + Implant 2 years postop

22. Autologous LDAutologous LD
Preop immediate LD 3 months postop
Preop delayed LD 12 months postop

23. Autologous LD & fat transferAutologous LD & fat transfer
Pre-op 5 years post-op
Pre-op
2 years post-op

24. TRAM/DIEPTRAM/DIEP FlapsFlaps
 Anterior abdominal wall tissueAnterior abdominal wall tissue
 PedicledPedicled

Transverse Rectus Abdominis MyocutaneousTransverse Rectus Abdominis Myocutaneous
(TRAM) Flap(TRAM) Flap
 Free:Free:

Free TRAMFree TRAM

Deep Inferior Epigastric Perforator (DIEP) FlapDeep Inferior Epigastric Perforator (DIEP) Flap

SIEA flapSIEA flap
 Operating time 6-8 hoursOperating time 6-8 hours
 Stay 4-5 daysStay 4-5 days
 Recovery 7-8 weeksRecovery 7-8 weeks

25. Pros and ConsPros and Cons
 Larger reconstructionLarger reconstruction
 Muscle sparingMuscle sparing
 Natural feel &Natural feel &
consistencyconsistency
 ““tummy tuck”tummy tuck”
 longer operating timelonger operating time
 higher risk of flap losshigher risk of flap loss
 donor site morbiditydonor site morbidity
 donor site scardonor site scar

28. Fat graftingFat grafting
 Autologous fat transfer / LipomodelingAutologous fat transfer / Lipomodeling
 Fat removed by liposuction from areas of excessFat removed by liposuction from areas of excess
 Centrifuged in theatre to remove blood and deadCentrifuged in theatre to remove blood and dead
cellscells
 Injected into breastInjected into breast
 Can be used with other types of reconstructionCan be used with other types of reconstruction
 Can be used to correct defects after breastCan be used to correct defects after breast
conserving surgery or failed reconstructionconserving surgery or failed reconstruction
 Low morbidityLow morbidity

29. Fat transferFat transfer

30. Fat transfer to revise reconstructionFat transfer to revise reconstruction

31. Fat transfer for asymmetryFat transfer for asymmetry

32. Fat transfer for breast conserving surgery defectFat transfer for breast conserving surgery defect

33. Fat transfer alone for reconstructionFat transfer alone for reconstruction

34. SummarySummary
 Reconstruction benefits patientsReconstruction benefits patients
 Wide range of optionsWide range of options
 Patient selection is keyPatient selection is key
 ““Reconstructive ladder”Reconstructive ladder”

35. Thank youThank you