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Breast  Reconstruction: Decision Making  Surgical Planning Michael J. Miller, M.D. Professor of Surgery Director, Division...
Lifetime Probability of Developing Cancer Source:DevCan: Probability of Developing or Dying of Cancer Soft ware, Version 5...
Why Breast Reconstruction?
Mastectomy/ No Reconstruction <ul><li>Advantages   </li></ul><ul><ul><li>no further surgery needed </li></ul></ul><ul><ul>...
<ul><li>Breast Deformities </li></ul><ul><li>Consequences: </li></ul><ul><ul><li>Aesthetic </li></ul></ul><ul><ul><li>Func...
Reconstruction Options Immediate Delayed Timing Technique Tissue Tissue + Implant Implants alone
Delayed Reconstruction <ul><li>Advantages </li></ul><ul><ul><li>shorter hospital stay/ shorter recovery </li></ul></ul><ul...
 
Immediate Reconstruction <ul><li>Advantages </li></ul><ul><ul><li>lowers psychosocial morbidity </li></ul></ul><ul><ul><li...
Reconstruction Options Immediate Delayed Timing Technique Tissue Tissue + Implant Implants alone
Breast Reconstruction Methods UTMDACC 1990 - 2000
Implant Reconstruction <ul><li>Two-Stage </li></ul><ul><ul><li>Stage One: Tissue expansion </li></ul></ul><ul><ul><li>Stag...
Implant Reconstruction <ul><li>Tissue Expanders/Implants </li></ul><ul><ul><li>Advantages </li></ul></ul><ul><ul><ul><li>N...
Two-Stage Implant Reconstruction Pre-op Full Expansion Final Result
Acellular Dermal Matrix (AlloDerm ® ) Zienowicz RJ. Karacaoglu E.  Plastic & Reconstructive Surgery . 120(2):373-81, 2007
Zienowicz RJ. Karacaoglu E.  Plastic & Reconstructive Surgery . 120(2):373-81, 2007
Preminger BA. et. al.  Annals of Plastic Surgery.  60(5):510-3, 2008.
“ Well, this is a fine mess …”
<ul><li>Q. 1  “How in the world did we get here?” </li></ul>“ Well, this is a fine mess …”
<ul><li>Q. 1  “How in the world did we get here?” </li></ul><ul><li>Q. 2  “How do we avoid ever being back here again?” </...
Breast Implantation <ul><li>Autologous Tissue </li></ul><ul><li>Contralateral breast (Verneuil, 1887) </li></ul><ul><li>Li...
<ul><li>paraffin,  </li></ul><ul><li>ivory,  </li></ul><ul><li>glass balls,  </li></ul><ul><li>ground rubber,  </li></ul><...
Breast Implantation <ul><li>Paraffin, Vaseline, “Organogen,” “Bioplaxm” </li></ul><ul><li>Silicone oil  +  some combinatio...
Silicone Implant Alternatives <ul><li>Pain </li></ul><ul><li>Skin discoloration, edema, ulceration, and necrosis </li></ul...
Pre-Silicone Implant Era <ul><li>Women wanted breast enhancement </li></ul><ul><li>Many alternatives </li></ul><ul><li>Man...
Silicone Breast Implants <ul><li>1950’s- shunts and joint replacements </li></ul><ul><li>1964- Cronin and Gerow  </li></ul...
Silicone Breast Implants <ul><li>Early 1990’s, > 2 million women implanted!! </li></ul>
Prior to 1970’s:  little regulation or oversight…
FDA Device Regulation <ul><li>1976- Medical Devices Amendments </li></ul><ul><ul><li>General and Plastic Surgery Advisory ...
Clinical Value + = ?
Clinical Value <ul><li>Determined by:  </li></ul><ul><li>Affect on patient’s:  </li></ul><ul><ul><li>Functional Status  </...
Clinical Value <ul><li>Affect on patient’s:  </li></ul><ul><ul><li>Functional Status  </li></ul></ul><ul><ul><li>Risk Stat...
Clinical Value <ul><li>Affect on patient’s:  </li></ul><ul><ul><li>Functional Status  </li></ul></ul><ul><ul><li>Risk Stat...
Clinical Value
Medical Device Safety Risk Benefit
Silicon Gel Breast Implants <ul><li>After all is said and done… </li></ul><ul><li>Conclusions: </li></ul><ul><ul><li>Local...
<ul><li>“ How in the world did we get here?” </li></ul><ul><li>“ How do we avoid  being back here again?” </li></ul>
Reconstruction Options Immediate Delayed Timing Technique Tissue Tissue + Implant Implants alone
Skin Sparing Mastectomy
Skin Sparing Mastectomy The  ablative surgeon  begins the reconstruction!
Skin-Sparing Mastectomy Incisions only for:  - Nipple and Areola   - Access to the axilla - Biopsy scars   - Skin areas “a...
Skin Sparing Mastectomy
Pre-op Post-op Skin Sparing Mastectomy
Skin Sparing Mastectomy Mastectomy skin flap necrosis
<ul><li>Oncologic Safety </li></ul><ul><li>51 breast cancer patients, Stages 0-II; 1991-1994 </li></ul><ul><li>Median foll...
Oncologic Safety of SSM vs. CM Local Recurrence Rate (T2 tumors) Kroll 104/SSM 271/CM Carlson 327/SSM 188/CM Simmons 77/SS...
Skin Sparing Mastectomy <ul><li>Skin-sparing mastectomy with immediate breast reconstruction is oncologically safe and off...
<ul><li>Technically more demanding </li></ul><ul><li>Oncological safety  </li></ul><ul><li>Superior aesthetic results </li...
Latissimus Dorsi + Implant
 
Latissimus Dorsi Flap + Implant Pre-op Post-op Donor site scar
LD flap- Endoscopic Harvest Post-op. ( 3/1/2005) Pre-op. ( 1/13/2004)
LD flap- Endoscopic Harvest Pre-op Post-op
Reconstruction Options Immediate Delayed Timing Technique Tissue Tissue + Implant Implants alone
Autologous Tissue Reconstruction
Pedicled TRAM
Pedicled TRAM <ul><li>Prone to venous insufficiency leading to fat necrosis  </li></ul>Download illustrations from Moon an...
Microvascular Tissue Transfer
Microsurgical Breast Reconstruction <ul><li>Donor site options </li></ul><ul><ul><li>Free TRAM </li></ul></ul><ul><ul><li>...
Perforator Flaps <ul><li>DIEP flap </li></ul><ul><li>Advantages </li></ul><ul><ul><li>Spares Muscle  </li></ul></ul><ul><u...
5/13/2008
5/29/2008
CT Angiogram Analysis
7/23/2008 7/23/2008
7/8/2008 7/23/2008 7/23/2008
CT Angiogram Analysis: Vessel Selection
9/2/2008 9/2/2008 Autologous Reconstruction: I-Gap Candidate
CT Angiogram Analysis: I-Gap Planning
9/18/2008
Autologous Tissue Reconstruction <ul><li>Advantages </li></ul><ul><ul><li>Natural breast shape and behavior </li></ul></ul...
Autologous Tissue Reconstruction <ul><li>Disadvantages </li></ul><ul><ul><li>Longer surgical procedure </li></ul></ul><ul>...
Ideal Abdominal Tissue Candidate <ul><li>Healthy </li></ul><ul><li>No previous abdominal surgery </li></ul><ul><li>Multipa...
Adjunct Procedures <ul><li>Breast mound reshaping </li></ul><ul><li>Contralateral modifications for symmetry </li></ul><ul...
<ul><li>“ Breast reconstruction-  </li></ul><ul><li>a process…  </li></ul><ul><li>not an operation.” </li></ul>
5/29/2007 10/2/2007 1/29/2008
Nipple Reconstruction 3 cm 4 cm
Nipple Reconstruction 3 cm 4 cm
Nipple Reconstruction
Nipple-Areola Micropigmentation
Final Results <ul><li>Breast mound creation </li></ul><ul><li>Revisions for shape </li></ul><ul><li>Nipple Reconstruction ...
Thank you! University Hospital James Cancer Hospital The Ohio State University Plastic Surgery …  to restore and make whole
 
Skin-Sparing Mastectomy Frozen section control of margins
<ul><li>Oncologic Safety </li></ul><ul><li>51 breast cancer patients, Stages 0-II; 1991-1994 </li></ul><ul><li>Median foll...
Local/Regional Recurrence*after  Skin-Sparing Mastectomy  Immediate Flap Reconstruction  (Stage ll) * Median follow-up 5.4...
Oncologic Safety of SSM vs. CM Local Recurrence Rate (T2 tumors) Kroll 104/SSM 271/CM Carlson 327/SSM 188/CM Simmons 77/SS...
Local Recurrences after Skin-Sparing Mastectomy and Immediate Reconstruction Group Number Pts. Local Recurrences (%) All 1...
Regional recurrence after skin-spring mastectomy is a function of the biology of the tumor and stage of disease
Detection and Management of Local Recurrence Following SSM MDACC Experience <ul><li>437 SSMs in 372 patients with invasive...
Local Recurrence Following SSM MDACC Experience <ul><li>Median time to recurrence: 25 months (3-98) </li></ul><ul><li>Medi...
Imaging of Local Recurrence <ul><li>Mammography visualized:  3/5 </li></ul><ul><li>Ultrasound visualized:  11/12 </li></ul...
 
Distant Relapse and Overall Survival <ul><li>Median follow-up 26 mos. (range 6-105) </li></ul><ul><li>N = 23 </li></ul><ul...
Local Control and Outcome by Treatment Treatment # Pts. Local Control  Alive, NED Local only 3 100% 100% (Surgery or Surge...
Local Control and Outcome by Treatment Local Only Systemic Only Local & Systemic Local Control Alive, NED 100% 80% 60% 40%...
Skin Sparing Mastectomy <ul><li>Skin-sparing mastectomy with immediate breast reconstruction is oncologically safe and off...
<ul><li>Treatment approach depends on extent of local recurrence and presence of synchronous metastases, but resection of ...
MDACC Recommendations <ul><li>Minimize risk of positive margins following skin-sparing mastectomy: - Intraoperative inking...
MDACC Recommendations <ul><li>Management of local recurrence: - Evaluate for distant metastatic disease - Breast ultrasoun...
Reservations Regarding  Skin-Sparing Mastectomy <ul><li>Technically more demanding:  Yes </li></ul><ul><li>Increased surgi...
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2008 breast reconstruction (aust)

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2008 breast reconstruction (aust)

  1. 1. Breast Reconstruction: Decision Making Surgical Planning Michael J. Miller, M.D. Professor of Surgery Director, Division of Plastic Surgery The Ohio State University
  2. 2. Lifetime Probability of Developing Cancer Source:DevCan: Probability of Developing or Dying of Cancer Soft ware, Version 5.1 Statistical Research and Applications Branch, NCI, 2003. http://srab.cancer.gov/devcan 1 in 59 Ovary 1 in 57 NH-Lymphoma 1 in38 Uterine corpus 1 in 18 Colon and rectum 1 in 17 Lung and bronchus 1 in 7 Breast 1 in 3 All Sites Risk Site
  3. 3. Why Breast Reconstruction?
  4. 4. Mastectomy/ No Reconstruction <ul><li>Advantages </li></ul><ul><ul><li>no further surgery needed </li></ul></ul><ul><ul><li>shorter surgery time/hospital stay </li></ul></ul><ul><ul><li>symmetry restored with prosthesis </li></ul></ul><ul><ul><li>may consider reconstruction in future </li></ul></ul><ul><li>Disadvantages </li></ul><ul><ul><li>scar on chest wall </li></ul></ul><ul><ul><li>asymmetry in clothing </li></ul></ul><ul><ul><li>external prosthetic can: </li></ul></ul><ul><ul><ul><li>dislodge </li></ul></ul></ul><ul><ul><ul><li>be uncomfortable </li></ul></ul></ul><ul><ul><ul><li>be impractical for athletic activities </li></ul></ul></ul>
  5. 5. <ul><li>Breast Deformities </li></ul><ul><li>Consequences: </li></ul><ul><ul><li>Aesthetic </li></ul></ul><ul><ul><li>Functional </li></ul></ul><ul><ul><li>Emotional </li></ul></ul><ul><ul><li>Social </li></ul></ul>Decreased Quality of Life
  6. 6. Reconstruction Options Immediate Delayed Timing Technique Tissue Tissue + Implant Implants alone
  7. 7. Delayed Reconstruction <ul><li>Advantages </li></ul><ul><ul><li>shorter hospital stay/ shorter recovery </li></ul></ul><ul><ul><li>adjuvant therapy causes no complications to reconstruction </li></ul></ul><ul><ul><li>allows patient time to consider reconstructive options </li></ul></ul><ul><li>Disadvantages </li></ul><ul><ul><li>soft tissue scar on chest wall </li></ul></ul><ul><ul><li>requires additional surgery and recovery time </li></ul></ul><ul><ul><li>difficult to reconstruct after scarring occurs </li></ul></ul>
  8. 9. Immediate Reconstruction <ul><li>Advantages </li></ul><ul><ul><li>lowers psychosocial morbidity </li></ul></ul><ul><ul><li>lowers surgical morbidity </li></ul></ul><ul><ul><li>superior cosmetic results </li></ul></ul><ul><ul><li>lowers cost of surgery </li></ul></ul><ul><ul><li>No difference in development or detection of local recurrences </li></ul></ul><ul><ul><li>No delays in adjuvant therapies </li></ul></ul><ul><li>Disadvantages </li></ul><ul><ul><li>mastectomy skin flap necrosis possible </li></ul></ul><ul><ul><li>longer hospitalization/recovery </li></ul></ul><ul><ul><li>additional scars </li></ul></ul><ul><ul><li>coordination required between surgeons </li></ul></ul>
  9. 10. Reconstruction Options Immediate Delayed Timing Technique Tissue Tissue + Implant Implants alone
  10. 11. Breast Reconstruction Methods UTMDACC 1990 - 2000
  11. 12. Implant Reconstruction <ul><li>Two-Stage </li></ul><ul><ul><li>Stage One: Tissue expansion </li></ul></ul><ul><ul><li>Stage Two: Permanent implant placement </li></ul></ul><ul><li>One Stage </li></ul><ul><ul><li>Permanent implant placement </li></ul></ul><ul><li>Use of dermal matrix implants </li></ul>
  12. 13. Implant Reconstruction <ul><li>Tissue Expanders/Implants </li></ul><ul><ul><li>Advantages </li></ul></ul><ul><ul><ul><li>No additional scarring </li></ul></ul></ul><ul><ul><ul><li>Shorter procedure/recovery </li></ul></ul></ul><ul><ul><ul><li>Satisfactory shape in clothing </li></ul></ul></ul><ul><ul><li>Disadvantages </li></ul></ul><ul><ul><ul><li>Foreign body causing risk of infection </li></ul></ul></ul><ul><ul><ul><li>Risk of rupture necessitating removal </li></ul></ul></ul><ul><ul><ul><li>Risk of capsule formation and firmness </li></ul></ul></ul><ul><ul><ul><li>Asymmetry </li></ul></ul></ul><ul><ul><ul><li>Implant not permanent </li></ul></ul></ul>
  13. 14. Two-Stage Implant Reconstruction Pre-op Full Expansion Final Result
  14. 15. Acellular Dermal Matrix (AlloDerm ® ) Zienowicz RJ. Karacaoglu E. Plastic & Reconstructive Surgery . 120(2):373-81, 2007
  15. 16. Zienowicz RJ. Karacaoglu E. Plastic & Reconstructive Surgery . 120(2):373-81, 2007
  16. 17. Preminger BA. et. al. Annals of Plastic Surgery. 60(5):510-3, 2008.
  17. 18. “ Well, this is a fine mess …”
  18. 19. <ul><li>Q. 1 “How in the world did we get here?” </li></ul>“ Well, this is a fine mess …”
  19. 20. <ul><li>Q. 1 “How in the world did we get here?” </li></ul><ul><li>Q. 2 “How do we avoid ever being back here again?” </li></ul>“ Well, this is a fine mess …”
  20. 21. Breast Implantation <ul><li>Autologous Tissue </li></ul><ul><li>Contralateral breast (Verneuil, 1887) </li></ul><ul><li>Lipoma (Czerny, 1895) </li></ul><ul><li>Grafts and flaps of muscle, fascia, fat, and dermis </li></ul>
  21. 22. <ul><li>paraffin, </li></ul><ul><li>ivory, </li></ul><ul><li>glass balls, </li></ul><ul><li>ground rubber, </li></ul><ul><li>ox cartilage, </li></ul><ul><li>Terylene wool, </li></ul><ul><li>gutta percha, </li></ul><ul><li>Dicora, </li></ul><ul><li>polyethylene chips, </li></ul><ul><li>Ivalon sponge (poly(vinyl alcohol-formadehyde)), </li></ul><ul><li>Ivalon in polyethylene sac, </li></ul><ul><li>polyether foam sponge (Etheron), </li></ul><ul><li>polyethylene (Polystan) tape or strips wound into a ball, </li></ul><ul><li>polyurethane foam sponge, </li></ul><ul><li>teflon-silicone prosthesis. </li></ul>Breast Implant Devices
  22. 23. Breast Implantation <ul><li>Paraffin, Vaseline, “Organogen,” “Bioplaxm” </li></ul><ul><li>Silicone oil + some combination of: </li></ul><ul><ul><li>ricinoleic acid, animal fatty acid, vegetable fatty acids, mineral oil, vegetable (castor) oil, olive oil, croton oil, peanut oil, concentrated vitamin D, snake venom, talc, beeswax, shellac, glazier’s puddy, epoxy resin, industrial silicone fluids </li></ul></ul><ul><li>Example: Sakurai (> 72,000 cases) </li></ul><ul><li>Medical-grade silicone </li></ul>Direct Injections
  23. 24. Silicone Implant Alternatives <ul><li>Pain </li></ul><ul><li>Skin discoloration, edema, ulceration, and necrosis </li></ul><ul><li>Calcifications </li></ul><ul><li>Granulomas </li></ul><ul><li>Fluid migration </li></ul><ul><li>Infection </li></ul><ul><li>Cysts </li></ul><ul><li>Axillary adenopathy </li></ul><ul><li>Disfigurement </li></ul><ul><li>Loss of the breast </li></ul><ul><li>Liver dysfunction </li></ul><ul><li>Pneumonitis/ARDS </li></ul><ul><li>Pulomonary embolism </li></ul><ul><li>Coma </li></ul><ul><li>Death </li></ul>Complications
  24. 25. Pre-Silicone Implant Era <ul><li>Women wanted breast enhancement </li></ul><ul><li>Many alternatives </li></ul><ul><li>Many complications </li></ul><ul><li>Ideal material not identified </li></ul>Non-rigorous trials… What was known:
  25. 26. Silicone Breast Implants <ul><li>1950’s- shunts and joint replacements </li></ul><ul><li>1964- Cronin and Gerow </li></ul><ul><ul><li>Introduced silicone gel-filled breast implant </li></ul></ul><ul><ul><li>Pre-clinical studies in dogs </li></ul></ul><ul><li>1962-1968 Dow Corning- only manufacturer </li></ul><ul><li>1968-early 1990’s- Multiple manufacturers </li></ul><ul><ul><li>Dow Corning, Heyer-Schulte-Mentor, Cox-Uphoff International, Aesthetech Corp., Surgitek, Inamed-McGhan, Mammatech, foreign manufacturers, … </li></ul></ul>
  26. 27. Silicone Breast Implants <ul><li>Early 1990’s, > 2 million women implanted!! </li></ul>
  27. 28. Prior to 1970’s: little regulation or oversight…
  28. 29. FDA Device Regulation <ul><li>1976- Medical Devices Amendments </li></ul><ul><ul><li>General and Plastic Surgery Advisory Panel </li></ul></ul><ul><ul><li>Implants required general controls and performance standards only. </li></ul></ul><ul><li>1982- FDA proposes reclassification as Class III device requiring stringent controls </li></ul><ul><li>1988- Changed to Class III status requiring pre-market approval (PMA) applications. </li></ul><ul><li>1992- Withdrawn from the market </li></ul>
  29. 30. Clinical Value + = ?
  30. 31. Clinical Value <ul><li>Determined by: </li></ul><ul><li>Affect on patient’s: </li></ul><ul><ul><li>Functional Status </li></ul></ul><ul><ul><li>Risk Status </li></ul></ul><ul><ul><li>Well being </li></ul></ul><ul><li>Cost </li></ul><ul><li>Patient satisfaction and perceived benefit </li></ul><ul><li>Clinical outcome </li></ul>Nelson EC. et al. Joint Commission Journal on Quality Improvement. 22(4):243-58, 1996
  31. 32. Clinical Value <ul><li>Affect on patient’s: </li></ul><ul><ul><li>Functional Status </li></ul></ul><ul><ul><li>Risk Status </li></ul></ul><ul><ul><li>Well being </li></ul></ul><ul><li>Cost </li></ul><ul><li>Satisfaction/perceived benefit </li></ul><ul><li>Clinical outcome </li></ul>Pre-1991 acceptable + Value Score
  32. 33. Clinical Value <ul><li>Affect on patient’s: </li></ul><ul><ul><li>Functional Status </li></ul></ul><ul><ul><li>Risk Status </li></ul></ul><ul><ul><li>Well being </li></ul></ul><ul><li>Cost </li></ul><ul><li>Satisfaction/perceived benefit </li></ul><ul><li>Clinical outcome </li></ul>Pre-1991 acceptable Post-1991 + Value Score acceptable ? ? ? ? ? ?
  33. 34. Clinical Value
  34. 35. Medical Device Safety Risk Benefit
  35. 36. Silicon Gel Breast Implants <ul><li>After all is said and done… </li></ul><ul><li>Conclusions: </li></ul><ul><ul><li>Local complications are well described </li></ul></ul><ul><ul><li>Systemic complications are not supported </li></ul></ul><ul><ul><li>Patients must be informed </li></ul></ul>2006- Silicone Gel implants return to the U.S. market
  36. 37. <ul><li>“ How in the world did we get here?” </li></ul><ul><li>“ How do we avoid being back here again?” </li></ul>
  37. 38. Reconstruction Options Immediate Delayed Timing Technique Tissue Tissue + Implant Implants alone
  38. 39. Skin Sparing Mastectomy
  39. 40. Skin Sparing Mastectomy The ablative surgeon begins the reconstruction!
  40. 41. Skin-Sparing Mastectomy Incisions only for: - Nipple and Areola - Access to the axilla - Biopsy scars - Skin areas “at risk”
  41. 42. Skin Sparing Mastectomy
  42. 43. Pre-op Post-op Skin Sparing Mastectomy
  43. 44. Skin Sparing Mastectomy Mastectomy skin flap necrosis
  44. 45. <ul><li>Oncologic Safety </li></ul><ul><li>51 breast cancer patients, Stages 0-II; 1991-1994 </li></ul><ul><li>Median follow-up 45 months </li></ul><ul><li>Local recurrence rate 2% </li></ul><ul><li>Biopsies of incisions in 32 consecutive patients revealed no evidence of retained breast tissue </li></ul><ul><li>Slavin, et al, Plast Reconstr Surg 1994; 93:1191-1204 </li></ul>Skin-Sparing Mastectomy
  45. 46. Oncologic Safety of SSM vs. CM Local Recurrence Rate (T2 tumors) Kroll 104/SSM 271/CM Carlson 327/SSM 188/CM Simmons 77/SSM 154/CM SSM CM 15% 12% 9% 6% 3% 0%
  46. 47. Skin Sparing Mastectomy <ul><li>Skin-sparing mastectomy with immediate breast reconstruction is oncologically safe and offers superior cosmetic results compared to conventional mastectomy </li></ul><ul><li>Local recurrence rates are similar for skin-sparing and conventional mastectomies </li></ul><ul><li>Most local recurrence are detected by physical exam within 3 years following skin-sparing mastectomy </li></ul>
  47. 48. <ul><li>Technically more demanding </li></ul><ul><li>Oncological safety </li></ul><ul><li>Superior aesthetic results </li></ul>Skin Sparing Mastectomy
  48. 49. Latissimus Dorsi + Implant
  49. 51. Latissimus Dorsi Flap + Implant Pre-op Post-op Donor site scar
  50. 52. LD flap- Endoscopic Harvest Post-op. ( 3/1/2005) Pre-op. ( 1/13/2004)
  51. 53. LD flap- Endoscopic Harvest Pre-op Post-op
  52. 54. Reconstruction Options Immediate Delayed Timing Technique Tissue Tissue + Implant Implants alone
  53. 55. Autologous Tissue Reconstruction
  54. 56. Pedicled TRAM
  55. 57. Pedicled TRAM <ul><li>Prone to venous insufficiency leading to fat necrosis </li></ul>Download illustrations from Moon and Taylor
  56. 58. Microvascular Tissue Transfer
  57. 59. Microsurgical Breast Reconstruction <ul><li>Donor site options </li></ul><ul><ul><li>Free TRAM </li></ul></ul><ul><ul><li>Muscle-sparing free TRAM </li></ul></ul><ul><ul><li>DIEP </li></ul></ul><ul><ul><li>SIEA </li></ul></ul><ul><ul><li>S-GAP </li></ul></ul><ul><ul><li>I-GAP </li></ul></ul><ul><ul><li>Other </li></ul></ul>
  58. 60. Perforator Flaps <ul><li>DIEP flap </li></ul><ul><li>Advantages </li></ul><ul><ul><li>Spares Muscle </li></ul></ul><ul><ul><li>Minimizes Pain </li></ul></ul><ul><ul><li>Less functional morbidity </li></ul></ul><ul><li>Disadvantages </li></ul><ul><ul><li>Technical challenge </li></ul></ul><ul><ul><li>Increased operative time </li></ul></ul><ul><ul><li>Variations in anatomy </li></ul></ul><ul><ul><li>Increased fat necrosis </li></ul></ul>
  59. 61. 5/13/2008
  60. 62. 5/29/2008
  61. 63. CT Angiogram Analysis
  62. 64. 7/23/2008 7/23/2008
  63. 65. 7/8/2008 7/23/2008 7/23/2008
  64. 66. CT Angiogram Analysis: Vessel Selection
  65. 67. 9/2/2008 9/2/2008 Autologous Reconstruction: I-Gap Candidate
  66. 68. CT Angiogram Analysis: I-Gap Planning
  67. 69. 9/18/2008
  68. 70. Autologous Tissue Reconstruction <ul><li>Advantages </li></ul><ul><ul><li>Natural breast shape and behavior </li></ul></ul><ul><ul><li>Natural consistency </li></ul></ul><ul><ul><li>“ Tummy-tuck,” “buttocks lift” </li></ul></ul><ul><ul><li>No foreign body </li></ul></ul><ul><ul><li>Lower costs long-term </li></ul></ul><ul><ul><li>Less emotional trauma </li></ul></ul>
  69. 71. Autologous Tissue Reconstruction <ul><li>Disadvantages </li></ul><ul><ul><li>Longer surgical procedure </li></ul></ul><ul><ul><li>Donor site scarring/deformity </li></ul></ul><ul><ul><li>Possible Complications </li></ul></ul><ul><ul><li>Longer hospitalization </li></ul></ul><ul><ul><li>Longer recovery </li></ul></ul><ul><ul><li>Greater initial cost </li></ul></ul>
  70. 72. Ideal Abdominal Tissue Candidate <ul><li>Healthy </li></ul><ul><li>No previous abdominal surgery </li></ul><ul><li>Multiparous </li></ul><ul><li>Non-smoker </li></ul><ul><li>No plans of radiotherapy </li></ul><ul><li>Compliant patient </li></ul>
  71. 73. Adjunct Procedures <ul><li>Breast mound reshaping </li></ul><ul><li>Contralateral modifications for symmetry </li></ul><ul><li>Nipple reconstruction </li></ul><ul><li>Nipple/areolar micropigmentation </li></ul>
  72. 74. <ul><li>“ Breast reconstruction- </li></ul><ul><li>a process… </li></ul><ul><li>not an operation.” </li></ul>
  73. 75. 5/29/2007 10/2/2007 1/29/2008
  74. 76. Nipple Reconstruction 3 cm 4 cm
  75. 77. Nipple Reconstruction 3 cm 4 cm
  76. 78. Nipple Reconstruction
  77. 79. Nipple-Areola Micropigmentation
  78. 80. Final Results <ul><li>Breast mound creation </li></ul><ul><li>Revisions for shape </li></ul><ul><li>Nipple Reconstruction </li></ul><ul><li>Micropigmentation </li></ul>
  79. 81. Thank you! University Hospital James Cancer Hospital The Ohio State University Plastic Surgery … to restore and make whole
  80. 83. Skin-Sparing Mastectomy Frozen section control of margins
  81. 84. <ul><li>Oncologic Safety </li></ul><ul><li>51 breast cancer patients, Stages 0-II; 1991-1994 </li></ul><ul><li>Median follow-up 45 months </li></ul><ul><li>Local recurrence rate 2% </li></ul><ul><li>Biopsies of incisions in 32 consecutive patients revealed no evidence of retained breast tissue </li></ul><ul><li>Slavin, et al, Plast Reconstr Surg 1994; 93:1191-1204 </li></ul>Skin-Sparing Mastectomy
  82. 85. Local/Regional Recurrence*after Skin-Sparing Mastectomy Immediate Flap Reconstruction (Stage ll) * Median follow-up 5.4 years ** None with stage 0 or stage I breast cancer
  83. 86. Oncologic Safety of SSM vs. CM Local Recurrence Rate (T2 tumors) Kroll 104/SSM 271/CM Carlson 327/SSM 188/CM Simmons 77/SSM 154/CM SSM CM 15% 12% 9% 6% 3% 0%
  84. 87. Local Recurrences after Skin-Sparing Mastectomy and Immediate Reconstruction Group Number Pts. Local Recurrences (%) All 104 6.7 T1 61 3.3 T2 43 11.6 Black’s grade I* 31 12.9 Black’s grade II 48 6.3 Black’s grade III 6 0.0 *The lower the grade, the more anaplastic the tumor Ann Surg Oncol 4:193-197,1997
  85. 88. Regional recurrence after skin-spring mastectomy is a function of the biology of the tumor and stage of disease
  86. 89. Detection and Management of Local Recurrence Following SSM MDACC Experience <ul><li>437 SSMs in 372 patients with invasive T1/T2 breast cancers, 1986-1993 </li></ul><ul><li>Median follow-up 50 months </li></ul><ul><li>23/372 local recurrences detected </li></ul><ul><li>Local recurrence rate = 6.2% Newman, Ann Surg Onc,1998 </li></ul>
  87. 90. Local Recurrence Following SSM MDACC Experience <ul><li>Median time to recurrence: 25 months (3-98) </li></ul><ul><li>Median size of recurrence: 1.5 cm </li></ul><ul><li>Presentation - Palpable skin flap mass: 22/23 (96%) - Non-palpable, CXR finding: 1/23 (4%) </li></ul><ul><li>Histology - Consistent w/primary tumor: 22/23 (96%) - Different histology; ? New primary: 1/23 (4%) </li></ul>
  88. 91. Imaging of Local Recurrence <ul><li>Mammography visualized: 3/5 </li></ul><ul><li>Ultrasound visualized: 11/12 </li></ul><ul><li>CT scan imaged: 3/3 </li></ul><ul><li>MRI imaged: 1/1 </li></ul>
  89. 93. Distant Relapse and Overall Survival <ul><li>Median follow-up 26 mos. (range 6-105) </li></ul><ul><li>N = 23 </li></ul><ul><li>Metastases: 39% - Synchronous 22% - Metachronous 17% </li></ul><ul><li>Survival: - Alive without disease 61% - Alive with disease 9% - Dead with disease 30% </li></ul>
  90. 94. Local Control and Outcome by Treatment Treatment # Pts. Local Control Alive, NED Local only 3 100% 100% (Surgery or Surgery + RT) Systemic only 5 60% 40% Local and 15 86% 71% Systemic
  91. 95. Local Control and Outcome by Treatment Local Only Systemic Only Local & Systemic Local Control Alive, NED 100% 80% 60% 40% 20% 0%
  92. 96. Skin Sparing Mastectomy <ul><li>Skin-sparing mastectomy with immediate breast reconstruction is oncologically safe and offers superior cosmetic results compared to conventional mastectomy </li></ul><ul><li>Local recurrence rates are similar for skin-sparing and conventional mastectomies </li></ul><ul><li>Most local recurrence are detected by physical exam within 3 years following skin-sparing mastectomy </li></ul>
  93. 97. <ul><li>Treatment approach depends on extent of local recurrence and presence of synchronous metastases, but resection of the reconstructed breast is rarely necessary </li></ul><ul><li>Multimodality therapy usually results in excellent local control of disease and prolonged disease-free survival </li></ul>Skin Sparing Mastectomy
  94. 98. MDACC Recommendations <ul><li>Minimize risk of positive margins following skin-sparing mastectomy: - Intraoperative inking of margins - Mammography of serial sections if microcalcifications are present - Resection of additional skin as necessary </li></ul><ul><li>Consider XRT if postoperative margins are microscopically positive </li></ul>
  95. 99. MDACC Recommendations <ul><li>Management of local recurrence: - Evaluate for distant metastatic disease - Breast ultrasound and mammography to evaluate extent of recurrence - Multimodality therapy, including surgery for resectable disease </li></ul>
  96. 100. Reservations Regarding Skin-Sparing Mastectomy <ul><li>Technically more demanding: Yes </li></ul><ul><li>Increased surgical morbidity: No </li></ul><ul><li>Oncologic safety: Yes </li></ul>

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