care of patient with breast reconstruction

2. ▶ Breast Conservation Therapy : For early stage
▶ Lumpectomy/Quadrantectomy/Segmentectomy + RT
▶ Mastectomy : For advanced stages/ Prophylactic
▶ Total Mastectomy
▶ Skin sparing mastectomy
▶ Nipple sparing mastectomy
▶ MRM

3. ▶ Consequences of mastectomy
▶ Aesthetic
▶ Functional
▶ Emotional
▶ Social
▶ Can lead to
▶ Depression
▶ Loss of libido
▶ Negative body image

4. ▶ Gross anatomy
▶ Fibro fatty tissue located anterior to pectoral muscles
▶ Modified Sweat Gland
▶ Gland anchored to underlying fascia by cooper’s ligaments
▶ Comprises of secretory lobules  lactational ducts  Major ducts
opening into the nipple

5. ▶Extends from 2nd IC to 6th IC space in mid
clavicular line
▶ Extends from anterior axillary fold to lateral
border of sternum at the level of transversally
▶ The tail of Spence extends obliquely up into
the medial wall of the axilla.
▶Nipple located in the 4th IC space just lateral to
midclavicular line

6. ▶ Primary
▶ Internal mammary perforators (2nd-5th)
~60%
▶ Lateral thoracic artery
▶ Anterolateral intercostal perforators
(3rd-8th)
▶ Secondary
▶ Thoracoacromial artery
▶ Vessels of serratous anterior

7. ▶ Dermatomal distribution : Anteromedial
and anterolateral branches of intercostal
nerves (T3-T6)
▶ Supraclavicular nerves supply the upper
and lateral portion
▶ Sensations of nipple carried by lateral
cutaneous branch of T4

8. ▶ Based on Duration post surgery :
▶ Immediate : Just after surgery
▶ Delayed : Following RT
▶ Based on technique :
▶ Implant based
▶ Tissue based
▶ Implant + tissue

9. ▶ Natural appearing breast mound with adequate volume and projection
▶ Skin envelope
▶ Symmetry with contralateral breast
▶ Nipple aerola complex

10. ▶ Patients requirements
▶ Type of mastectomy/BCT
▶ Immediate/Delayed
▶ Condition of operated breast
▶ Status of contralateral breast

11. ▶ Technically easier
▶ No scarring/Irradiation
▶ Skin is more pliable
▶ Inframammary fold easier to delineate
▶ Cost effective
▶ Psychologically beneficial
▶ Disadvantage
▶ Concern for positive margins
▶ Post RT complications

12. ▶ Done after patient has undergone RT
▶ Ensures adequate local control of tumor
▶ Allows for better selection of reconstructive procedure
▶ Disadvantage
▶ Skin is fibrosed and scarred post RT
▶ Inframammary fold is not adequately delineated

13. ▶ Generalopinion
▶ Immediate reconstruction in noninvasive cancer and risk reducing
mastectomies
▶ Delayed reconstruction in case of locally advanced cancer
▶ The choice of the timing of reconstruction (immediate or delayed) should
take into account the indication for postmastectomy radiotherapy

14. ▶ A- midline
▶ B- sternal notch to NAC
▶ C- Nipple to inframammary fold
▶ D- breast width
▶ E – projection of IMF to midline
▶ F- IMF
▶ G- lateral border of torso

15. • ▶
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16. ▶ Technique : 2 stage
▶ 1st stage – expander placed below P major  gradually filled with
saline
▶ 2nd stage – expander removed and permanent prostheses placed +
NAC recon
▶ Complications :
▶ Capsular contracture
▶ Most common
▶ Contraction of fibroblastic capsule
▶ After 6 – 12 months
▶ Requires capsulotomy or implant removal
▶ Baker classification
▶ Implant loss
▶ Infection
▶ Hematoma

17. ▶ Indications :
▶ Poor local condition of chest wall
▶ Post RT muscle fibrosis
▶ Salvage mastectomy after previous conservative treatment
▶ Options:
▶ Pedicled flaps
▶ Latissimus dorsi (LD)
▶ Transverse rectus abdominis muscle ( TRAM)
▶ Free flaps
▶ Free TRAM
▶ Deep Inferior epigastric perforator (DIEAP)
▶ Superior /Inferior gluteal artery perforators

18. ▶ Anatomy :
▶ LD muscle arises from T7- L5 spinous process
▶ Inserts at bicipital groove on the humerus
▶ Nerve supply : Thoracodorsal nerve
▶ Blood Supply : Thoracodorsal artery +
intercostal/lumbar perforators

19. ▶ Pre op marking

20. ▶ Procedure:
▶ Skin island is taken on the back along with LD
muscle
▶ Pedicle moves subcutaneously high in axilla
▶ Moulded in conical shape and transferred to
anterior thoracic wall
▶ Prostheses may be placed in thin patients
▶ Precautions :
▶ Thoracodorsal nerve should be preserved unless
implant is being used
▶ LD should be completely detached from in bony
insertions

21. ▶ Complications
▶ Seroma
▶ Shoulder weakness
▶ Flap necrosis
▶ Winging of scapula

22. ▶ Anatomy
▶ Attachments : Pubic symphysis to xiphoid process and
costal cartilages of ribs 6-10
▶ Covered by rectus sheath anteriorly and posteriorly
▶ Blood Supply : Superior epigastric and inferior
epigastric artery + segmental branches of intercostal
arteries
▶ Nerve Supply : Thoracoabdominal branches of T7-T11
intercostal nerves

23. ▶ PedicledTRAM flap is based on Superior epigastric artery perforators
around the umbilicus
▶ May include one or both rectus muscles
▶ The choice between one or two muscular pedicles depends on the surface
of the skin paddle required
▶ The long donor site scar can be kept very low in the suprapubic area

24. ▶ Technique:
▶ Island of skin and fat along with rectus
muscle taken horizontally under the
umbilicus
▶Transferred through subcutaneous
tunnel created below the costal
margin
▶ Nonabsorbable mesh is used in most
cases of bipedicled flaps to reinforce
the abdominal wall and avoid hernias
and bulging.

25. ▶ Complications
▶ Seroma
▶ Hematoma
▶ Infection
▶ Flap Necrosis
▶ Abdominal wall hernia
▶ Free TRAM
▶ Muscle sparing rtechnique
▶ Better blood supply
▶ reduces abdominal wall complications
▶ Based on Deep inferior epigastric artery

26. ▶ Free flap based
▶ Provides large amount of skin and
subcutaneous tissue
▶ No rectus muscle is harvested, less donor site
morbidity
▶ Based on Deep inferior epigastric artery
perforators

27. ▶ Technique:
▶ Suprafascial dissection to create island of
skin and subcutaneous tissue
▶ Intramuscular dissection to separate the
perforators
▶ Submuscular dissection to separate the DIEA

28. ▶ The anatomical basis for the perfusion of a flap based
on one or several perforators
▶ Angiosome : region perfused by all the perforators of an
ipsilateral DIEA
▶ Hartrampf, Scheflan and Dinner both described
▶zone II as the zone of the contralateral DIEA (across the
midline)
▶ zone III as the zone of the ipsilateral superficial inferior
epigastric artery (SIEA)

29. ▶ Each perforator has its own territory of supply, independent of the zone of supply by the source
vessel
▶ lateral row perforators and medial row perforators have been shown to have fundamental
differences in their zones of perfusion

30. ▶ Anatomy
▶ Origin : Gluteal surface of ilium, lumbar fascia
▶ Insertion Gluteal tuberosity of femur
▶ Blood supply :
▶Superior Gluteal artery : Branch of posterior division
of IIA
▶ Inferior gluteal artery : Anterior division of IIA
▶ Nerve supply : Inferior gluteal nerve

31. ▶ Indications:
▶ Pt with more fat on the buttocks as compared to
abdominal wall
▶ Requiring less skin paddle and more fatty tissue
▶ SGAP
▶ Line is drawn from Posterior superior iliac spine to
greater trochanter
▶ Point of entry is at the junction of upper and middle third
of this line
▶ Skin Flap size : 7-8 cm x 10-12 cm

32. ▶ IGAP
▶ A line is drawn from Posterior inferior iliac spine
to ischial tuberosity
▶ Point of entrance is at the junction of lower and
middle third
▶ Inferior limit of flap is marked 1 cm below and
parallel to gluteal fold
▶ Flap size : 8-10 cm

33. ▶ Prerequisites
▶ Reconstruction should be stable
▶ Symmetry should be achieved
▶ Nipple
▶ Composite nipple graft
▶ Local tattooed skin flap
▶ Skate flap
▶ Star flap

34. Skate flap
Star flap

35. ▶ Aerola
▶ Skin graft
▶ Contralateral aerola
▶ Inner thigh
▶ Labial tissue
▶ Tattoo with mineral pigments

36. ▶ To achieve symmetry after reconstruction
▶ Includes :
▶ Reduction mammoplasty
▶ Mastopexy
▶ Breast augmentation
▶ Prophylactic mastectomy
▶ Can be done in single sitting or delayed
▶ The risk of second primary in contralateral breast is about 4-5%
▶ Risk increases in medullary carcinoma, black race, age >55