The document discusses the evolution and techniques of breast reconstruction, detailing approaches using implants and autologous tissue, notably the latissimus dorsi and TRAM flaps. It emphasizes the role of general surgeons in planning and executing these procedures while highlighting patient considerations and post-operative results. Historical references illustrate the advancements in surgical methods and their impacts on reconstruction outcomes.

1. BREAST RECONSTRUCTION IMPLANT
OR AUTOLOGOUS TISSUE
Presenter
DR NIKHIL AMEERCHETTY,MS

2. ROLE OF THE GENERAL SURGEON IN BREAST
RECONSTRUCTION
•“What will it look like when you are done?”
• “Will I have to live without a breast?”

3. History
• Volkmann, Czerny, and Billroth local recurrence rates 52% to 85%.
• William Halsted 6% recurrence rate.
• Halsted concept “To attempt to close the breast by any plastic method is
hazardous, and in my opinion, to be vigorously discounted.”
• The first attempt by Vincent Czerny in 1895 transplanted a large lipoma .
• Tansini (1896) latissimus dorsi myocutaneous flap
• In 1942, Sir Harold Gillies of England started using a tubed pedicle technique of
breast reconstruction.
• Olivari, McCraw, and Muhlbauer in 1970 reintroduced myocutaneous flap .
• In 1963, the silicone breast implant .

4. CLASSIC HALSTED OPERATION

5. TUBED ABDOMINAL PANNICULUS GRAFT

6. TUBED ABDOMINAL PANNICULUS GRAFT

7. SILICON IMPLANT

8. PROCEDURE SELECTION AND SURGICAL
PLANNING

9. PREREQISITS
• Type of mastectomy (ie.. skin-sparing technique vs. the standard modified
radical mastectomy)
• Body habitus (thin women or fat women).
• Contralateral breast size and shape.
• Donor site evaluation
• Course of overall health

10. THE IDEAL TOTAL MASTECTOMY
• Preserve pectoralis major muscle
• 2cm excess margin
• Incision
• Best is oblique
• Worst is transverse patey incision.

11. FAVORABLE AND UNFAVORABLE INCISION

12. IMPLANTS
• Silicone gel implants represented an historic medical breakthrough.
• Biologically inert
• Fibrous encapsulation
• Better results with under muscle placement
• Low grade infection

13. TISSUE EXPANSION
• Stretch the retained breast skin
• Decreasing the encapsulation seen with the permanent silicone
implant
• Best suited for a well built patient
• Avoid placing under tight. Thin. Or irradiated skin.

14. Technique
• The pectoralis muscle for superomedial aspect of the implant.
• Serratus anterior and some of the fascia of the rectus muscle inferiorly.
• Light compressive dressing& applied to the superior pole of the breast
to prevent migration for 4-6 weeks .
• Major drawback is distortion of shape over time and repeated
corrections , not suited for large defects

15. IMPLANT

16. IMPLANT

17. MYOCUTANEOUS FLAPS
• LATISSIMUS DORSI BREAST RECONSTRUCTION
• Revolutionized the reconstruction of the radical mastectomy defect
1. Replacement of the pectoralis muscle
2. Muscle coverage of the implant
3. Replacement of missing skin

18. Techinique
• Flap marked before the breast surgery in standing position
• Paraspinous origins of the muscle divided while preserving the
thoracodorsal neurovascular bundle.
• The flap is carefully rotated on its humeral insertion toward the
anterior chest wall
• Cornerstone is protecting thoracodorsal artery and vein during axillary
dissection

19. • 2-cm. layer of fat on the surface of the latissimus dorsi
muscle can provide 500 g of fat.
• Immediate reconstruction is possible and with single
stage
• Functional loss is unnoticed .

20. • In irradiated patients it brings a robust blood supply into a deficient
region.
• Irradiated skin is best excised
• If an implant is used. it must be covered in its entirety with muscle.
• latissimus dorsi myocutaneous flap is refractory to radiation-induced
loss due to its rich blood supply.

21. Latissmus flap

22. SKIN MARKING OF LATISSMUS DORSI FLAP

23. LATISSIMUS DORSI FLAP WITH C/L REDUCTION
MAMMOPLASTY

25. AUTOGENOUS MYOCUTANEOUS FLAPS
• Hartrampf in 1982 used the TRAM flap.
• It was the first breast reconstruction using only vascularized
autologous tissue
• In the late 1980s, the autologous extended latissimus flap was
developed
• 1990s, microvasular transfer of the TRAM to ·high-risk" patients
(smoking , diabetics , obesity) .

26. TRAM FLAP
• Gold standard of breast reconstruction.
• Used mainly for difficult reconstructions (extensive skin
removal)
• Management of the donor site is needed
• If B/L flap taken closed with a onlay mesh

27. TECHNIQUE
• 'TRAM flap differs from every other myocutaneous flap in that its
vascular supply is more tenuous requiring delicate handling.
• These flaps are supplied by musculcutaneous perforating branches from
the deep superior epigastric artery and vein.
• One or two pedicled flaps
• Excellent for B/L mastectomy reconstruction

28. TRAM FLAP

29. TRAM FLAP

30. TRAM FLAP WITH POST RADIATION THERAPY

31. FREE TISSUE TRANSFERS
• Decreased complication rate and requires fewer revisions
1. Superior Gluteal Artery Perforator (SGAP) flap.
2. Inferior Gluteal Artery Perforator (IGAP) flap.
3. Deep Inferior Epipstric Artery Perforator (DIRP) flap.
4. Superficial Inferior Epigastric Artery (SIEA) flap.
• Microvascular anastomosis is performed to either the thoracodorsal or
the internal mammary vessels .

32. FREE FLAPS

33. SGAP FLAP AND IGAP FLAP

35. DIEP RECONSTRUCTION

36. SGAP

37. TUG FLAP

38. FREE TISSUE TRANSFER
Advantages
1. Deep inferior epigastric
artery and vein
2. Better blood supply
3. Lower incidence of fat
necrosis
4. Decreases donor site
morbidity.
5. Does not require tunneling
6. No epigastric bulge
Disadvantages
• Longer operative time
• Needs monitoring
• Needs specialised training

39. PARTIAL MASTECTOMY
• AUTOLOGOUS TISSUE TRANSFER TECHNIQUE
• PREFFERED IS LATISSIMUS DORSI FLAP

40. MODIFIED RADICAL MASTECTOMY
• If done with skin sparing – Implants
• If extensive skin loss - autologous tissue transfer technique

41. Radical mastectomy
•Autologous reconstruction

42. DELAYED RECONSTRUCTION
• Reasons that patient expresses for delayed reconstruction
1. Fear of additional prodedure
2. Relif from negative feelings
3. Symmetry
4. Lasting results
5. Emotional recovery

43. Immediate reconstruction
• Differentiation should stop between the treatment and
reconstruction
• Immediate reconstruction does not interfer with surgical
treatment
• Favoured procedure for stage I and IIa and for advanced stages
if patient choices immediate can be opted
• RECURRENCES NEVER OCCUR ON THE FLAPS

44. CHEMOTHERAPY IMPACT
• Chemotherapy can be started while there is still a surface wound that
has not yet epithelialized
• Avoided if frank tissue necrosis, seroma, or infection.
• In anticipated bad wounds flaps are better than implants

45. Mastectomy and radiation effects
• Scarring between skin and pectoralis major muscle
• Shrinkage of both skin and muscle
• Causes persistent perivascular inflammation.

46. OPPOSITE BREAST CONSIDERATIONS
• Reduction mammaplasty involves the removal of breast tissue as well as
excess skin.
• Mastopexy in contrast corrects breast ptosis by elevating the breast
mound (preserves breast volume )
• Augmentation mammoplasty

47. Volume
displacement
Volume
replacement
TRAM
LD FLAP
Prosthetic
implant
•Inferior pedicle techniques
• Superior pedicle techniques
• Vertical scar techniques
•Round block techniques
•L mamoplasty
•S shaped mamoplasty
•Batwing mamoplasty

48. NIPPLE RECONSTRUCTION
• Can be done immediate or delayed(preffered)
• The nipple is formed by local bilobed or trilobed flaps.
• The arms of these flaps are wrapped around themselves to form a
standing cone.
• Nipple and Areola are provided by imbedding pigments
using a tattooing machine.

49. Multidiciplinary approach
PATIENT
SURGICAL
ONCOLOGIST
RECONSTRUCTIVE
SURGEON