This document discusses reconstructive breast surgery options after mastectomy or breast conservation therapy. It describes the multidisciplinary approach required and covers timing considerations for reconstruction. The two main types of reconstruction - prosthetic devices and autologous tissue reconstruction - are outlined. Autologous techniques discussed include pedicled and free TRAM flaps, latissimus dorsi flap, and various perforator flaps. Future directions like supramicrosurgery and tissue regeneration are also mentioned.

1. RECONSTRUCTIVE BREAST
SURGERY
BY
DR. HAYTHAM MAHMOUD FAYED
LECTURER OF SURGICAL ONCOLOGY
ALEXANDRIA FACULTY OF MEDICINE

2. Introduction
Breast reconstruction is an option after:
 Unilateral mastectomy
 Bilateral mastectomy
 Breast conservation therapy with unsatisfactory cosmetic result.
Breast reconstruction provides psychological, social, emotional, and functional
improvements.

3. Optimal management requires a Multidisciplinary approach and collaborative effort
between:
 Oncological surgeon
 Reconstructive surgeons
 Radiologists
 Pathologists
 Radiation therapist
 Medical oncologists

4. INITIAL RECONSTRUCTIVE EVALUATION
History and physical examination
 Disease status
 Oncologic history,
 Future treatment plans,
 Past surgical history
 Comorbid health problems,
 Contralateral breast

5. Women who choose reconstruction face a complex decision-
making process with regard to:
 Timing of reconstruction
 Type of reconstruction

6. Timing of reconstruction
The appropriate timing for reconstruction is essential both to optimize outcomes and
minimize the potential for postoperative complications.
Immediate reconstruction can be offered to most patients.
Delayed reconstruction is more appropriate in patients who will need postmastectomy
radiation.

7. Timing of reconstruction
Immediate reconstruction:
Initially, delayed procedures were favored but several studies revealed that women
undergoing immediate reconstruction experienced significant psychosocial benefits.

8. Timing of reconstruction
Immediate reconstruction:
The advantages of immediate reconstruction include:
 One operative setting. As a result, the overall cost of the reconstructive process is
decreased.
 Provides substantial psychosocial benefits over delayed reconstruction
 Preserves normal breast landmarks (such as the inframammary fold)

9. Timing of reconstruction
Immediate reconstruction:
The disadvantages of immediate reconstruction include:
 Prolonged operative time.
 Necrosis of the mastectomy skin flaps can adversely affect the aesthetic result of the
reconstruction.
 The need of postoperative RT can adversely affect the reconstruction.

10. Timing of reconstruction
Delayed reconstruction:
The advantages of delayed reconstruction include:
 Assurance of clear margins prior to definitive reconstruction
 Minimize the effect of poorly perfused mastectomy skin flaps on the quality of the
reconstruction
 Allows completion of all adjuvant treatment.

11. Timing of reconstruction
Delayed reconstruction:
The disadvantages of delayed reconstruction include:
 Need for subsequent surgery
 Limited reconstructive options following radiation therapy
 Lesser aesthetic quality compared to immediate reconstruction

12. RECONSTRUCTIVE OPTIONS
There are two general types of reconstructive options:
 Prosthetic devices (eg, saline implants, silicone implants, tissue expanders)
 Autologous tissue reconstructions.

13. RECONSTRUCTIVE OPTIONS
PROSTHETIC DEVICES:
Modern breast reconstruction began in 1964 with the introduction of the prosthetic device,
the silicone breast implant.
Since that time, implants have evolved, and the silicone polymer shell remains essentially
unchanged.
The implant shell can be filled with silicone, saline, or a combination of the two.

14. RECONSTRUCTIVE OPTIONS
PROSTHETIC DEVICES:
The advantages of implant reconstruction are:
 Surgical simplicity,
 The use of cosmetically similar adjacent tissue for coverage of the implant,
 The lack of donor site morbidity,
 Reduced operative time, and more rapid postoperative recovery.
The main disadvantages are that tissue expansion requires frequent clinic visits for
expansion (usually every one to two weeks for one to two months) and a second surgery
to place the reconstructive implant.

15. RECONSTRUCTIVE OPTIONS
PROSTHETIC DEVICES:
 One stage implant reconstruction
 Two stage implant reconstruction

16. RECONSTRUCTIVE OPTIONS
AUTOGENOUS TISSUE RECONSTRUCTION:
 The development of musculocutaneous flaps and microsurgical tissue transplantation
paved the way for modern autogenous tissue breast reconstruction.
 These flaps may be pedicled, free flap or perforator flap.

17. RECONSTRUCTIVE OPTIONS
AUTOGENOUS TISSUE RECONSTRUCTION:
Pedicled TRAM flap

18. RECONSTRUCTIVE OPTIONS
AUTOGENOUS TISSUE RECONSTRUCTION:
Free TRAM flap

19. RECONSTRUCTIVE OPTIONS
AUTOGENOUS TISSUE RECONSTRUCTION:
Latissimus dorsi flap

20. RECONSTRUCTIVE OPTIONS
AUTOGENOUS TISSUE RECONSTRUCTION:
Perforator flaps
In an effort to conserve muscle, "perforator" flaps harvest only the skin and fat overlying
the muscle along with the perforating vessels and dominant artery and vein supplying
the flap. The free flap is then transferred to the recipient site.

21. RECONSTRUCTIVE OPTIONS
AUTOGENOUS TISSUE RECONSTRUCTION:
Perforator flaps
DIEP perforator flap

22. RECONSTRUCTIVE OPTIONS
AUTOGENOUS TISSUE ECONSTRUCTION:
Perforator flaps
SIEA perforator flap

23. RECONSTRUCTIVE OPTIONS
AUTOGENOUS TISSUE RECONSTRUCTION:
Perforator flaps
TUG flaps
Depending on the ascending branch of the
medial circumflex femoral artery.

24. RECONSTRUCTIVE OPTIONS
AUTOGENOUS TISSUE RECONSTRUCTION:
Perforator flaps
LTAP flap
TDAP flap
ICAP flap
SAAP flap

25. RECONSTRUCTIVE OPTIONS
AUTOGENOUS TISSUE RECONSTRUCTION:
Perforator flaps
The free fasciocutaneous infragluteal (FCI) flap

26. RECONSTRUCTIVE OPTIONS
Autologous fat grafting:
AFG in breast reconstruction is a promising technique. Safety is not compromised as
cancer recurrence and complications are not observed.
Whether AFG interferes with radiological follow-up remains to be elucidated.
Randomized trials with sound methodology are needed to confirm these conclusions.

27. Future of Breast Reconstruction
 “Supramicrosurgery” is an exciting topic of interest in which delicate microsurgical
dissections and suturing can be safely performed with the aid of optical devices and
instruments.
 Advances in diagnostic radiology, therapeutic modalities, and molecular genetics
research are other potential future contributors to breast reconstruction.
 Tissue regeneration is in active research and could hold promise of better breast
reconstruction techniques.

28. Future of Breast Reconstruction
While breast cancer remains the second leading cause
of cancer death in women and continues to increase
3–5 % annually, one can be sure that plastic surgeons
will continue to tirelessly innovate new paradigms in
management and techniques in breast reconstruction.