BREAST RECONSTRUCTION - gatraweb.org reconstruction.pdf · breast reconstruction in connection with...

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BREAST RECONSTRUCTION Olumayowa Abiodun, MD

Plastic and Reconstructive Surgery

Phoebe Putney Memorial Hospital

Albany, GA

This Photo by Unknown Author is licensed under CC BY-NC-

ND

http://themommaven.com/2011/10/what-action-have-you-taken/

https://creativecommons.org/licenses/by-nc-nd/3.0/

OBJECTIVES

1. Review the history of breast reconstruction

2. Discuss the options for breast reconstruction

3. Review indications and contraindications of breast reconstruction

4. Review oncoplastic surgery

5. Discuss adjuncts to breast reconstruction

This Photo by Unknown Author is licensed under CC BY-NC-ND

BACKGROUND

•Breast cancer is the most common cancer affecting women

•Breast conserving therapy most common treatment • Mastectomy still indicated in many

• Prophylactic mastectomies becoming more popular

•Breast reconstruction and the associated improvement in body image positively impact health-related quality of life in women after mastectomy

WOMEN'S HEALTH AND CANCER RIGHTS ACT (WHCRA)

•The Women's Health and Cancer Rights Act of 1998 (WHCRA) is a federal law that provides protections to patients who choose to have breast reconstruction in connection with a mastectomy.

•If receiving benefits in connection with a mastectomy and breast reconstruction is elected, coverage must be provided for:

• All stages of reconstruction of the breast on which the mastectomy has been performed;

• Surgery and reconstruction of the other breast to produce a symmetrical appearance; and

• Prostheses and treatment of physical complications of all stages of the mastectomy, including lymphedema.

HISTORY

•Halstead first performed radical mastectomy in 1889

• Did not believe in reconstruction

• “The slightest inattention to detail and or attempts to hasten convalescence by such plastic operations as are feasible only when a restricted amount of skin is removed, may sacrifice his patient to disease.”

HISTORY

•First breast reconstruction by Czerny in 1894 using a lipoma from the patient’s flank

ND

IMMEDIATE RECONSTRUCTION

•Done at the time of mastectomy

•Immediately gives patient a breast mound

•Better aesthetic outcomes

•Improved patient perceived self image and quality of life

•High risk of complications in patients requiring radiation*

DELAYED RECONSTRUCTION

•Reconstruction done after mastectomy flaps have healed

•Considered safest option for reconstruction related complications

•Strongly consider in high risk patients

•Used to be only option for patients possibly requiring radiation

•Less favorable aesthetic outcomes

•Often requires autologous tissue

ND

SIMPLE MASTECTOMY

•Traditional mastectomy with removal of nipple, areola and significant amount of breast skin

SKIN SPARING MASTECTOMY

•Leaves native skin envelope

•Useful in both implant based and autologous reconstruction

•Typically used in immediate reconstruction

•Allows a more natural breast shape

•Similar recurrence risk as in standard mastectomy (7% vs 7.5%)

NIPPLE SPARING MASTECTOMY

• Most commonly used in small breasted patients needing prophylactic mastectomy

• Indications extended to include cancer patients with tumors away from the nipple

• Staged procedures with initial breast shaping in larger breasted women followed by mastectomy offered

• Best aesthetic result

• Risk of cancer in nipple-areola complex

• Decreased/no nipple sensation

NIPPLE SPARING MASTECTOMY

ND

RADIATION THERAPY

•Affects reconstructive options

•Limits implant based options

•Typically not recommended in delayed reconstruction

•Does not make immediate reconstruction contraindicated

RADIATION THERAPY

ND

OPTIONS

•Autologous tissue • TRAM • DIEP • Latissimus dorsi • GAP, TUG, stacked flaps

•Implant based reconstruction • 2 stage (Tissue expander/Implant) • 1 stage • Prepectoral • Subpectoral

•Combined • Autologous and implants

• DIEP • Latissimus

au·tol·o·gous /ôˈtäləɡəs/ adjective 1.(of cells or tissues) obtained from the same individual

ND

https://www.google.com/search?sxsrf=ACYBGNQE9uyL4BPMX1wFzQXUMSnz-RQ1gw:1572485430883&q=how+to+pronounce+autologous&stick=H4sIAAAAAAAAAOMIfcRowy3w8sc9YSnjSWtOXmPU5eINKMrPK81LzkwsyczPExLjYglJLcoV4pPi4eJKLC3Jz8lPzy8ttmJRYkrN41nEKp2RX65Qkq9QANSVD9SWqoBQBAAgfD66XwAAAA&pron_lang=en&pron_country=us&sa=X&ved=2ahUKEwjCuJbcrMXlAhUin-AKHRW8BnkQ3eEDMAB6BAgAEAg&sxsrf=ACYBGNQE9uyL4BPMX1wFzQXUMSnz-RQ1gw:1572485430883

AUTOLOGOUS RECONSTRUCTION

•Uses patients own tissue to create breasts

•Lower risks of complications in the right patients

•Longer procedures

•Donor site

•Indications • Any patient in good health

• Adequate autologous tissue • Stacked flaps

•Contraindications • Poor health to tolerate prolonged anesthesia

• Inadequate autologous tissue

• Previous surgery involving pedicle for pedicled flaps

•Free flaps

•Uses microsurgical techniques to transfer tissue from a distant location

•Requires specialized skill

•Highest reliability of all reconstructive options

•Lower risk of abdominal wall complications

•Best longevity

•Free flaps

•Deep Inferior Epigastric Perforator (DIEP) flap

•Free Transverse Rectus Abdominis Myocutaneous (TRAM) flap

•Other free flaps (PAP, TUG, ALT, TDAP, LTAP)

DIEP FLAP

•Delayed reconstruction with DIEP flap

PROFUNDA ARTERY PERFORATOR (PAP) FLAP

SUPERIOR GLUTEAL ARTERY PERFORATOR (SGAP) FLAP

•Pedicled flaps

•Tissue is transferred from a regional location with its native blood supply attached

•Alternative when microsurgery not available

•Risk of fat necrosis

•Good results in appropriately selected patients

•Pedicled flaps

•Pedicled Transverse Rectus Abdominis Myocutaneous (TRAM) flap

•Pedicled Latissimus dorsi myocutaneous flap

PEDICLED TRAM FLAP

•Typically without implant

PEDICLED TRAM FLAP, BILATERAL

ABDOMINAL BASED FLAPS

•Abdominal based flaps

LATISSIMUS DORSI FLAP

•Typically with implant

ND

IMPLANT BASED RECONSTRUCTION

•Two staged •First stage: placement of tissue expander

•Second stage: exchange for implants • Safest method of implant based reconstruction

• Only option for delayed reconstruction with implants

IMPLANT BASED RECONSTRUCTION •One stage (Direct to Implant) • Immediate placement of permanent prosthesis at time of reconstruction • Potentially decreases number of times under anesthesia

• Higher risk of complications due to tension on mastectomy flaps

• Non an option for delayed reconstruction

•Immediate TE/implant based reconstruction with symmetry procedure

•Delayed Implant based reconstruction

•Prepectoral • Implant is placed in front of the muscle

•Less pain, more natural location of the new breast

•Better aesthetic outcome in patients getting radiation

•Higher risk of capsular contracture without ADM*

•Higher risk of rippling

•Dependent on flap thickness

•Use in selected patients

•Prepectoral

•Subpectoral •Traditional placement of prosthesis under the pectoralis major muscle

•More soft tissue covering implant

•Less risk of capsular contracture*

•Less rippling

•Animation deformity

•Subpectoral

ND

COMBINED RECONSTRUCTION

•Combination of autologous and implant based reconstruction

•Latissimus dorsi myocutaneous flap with implant

•DIEP flap with implant

CONTRAINDICATIONS FOR RECONSTRUCTION

•Significant comorbidities

•Poorly controlled diabetes

•Morbid obesity* • Autologous reconstruction

• Inability to tolerate prolonged anesthesia

•Limited life expectancy

COMPLICATIONS OF RECONSTRUCTION

• Infection

•Bleeding

•Wound healing complications

•BIA-ALCL • Breast Implant Associated Anaplastic Large Cell Lymphoma

•Potential delay in oncologic treatment

BREAST CONSERVING THERAPY

•Lumpectomy followed by radiation therapy

•Good option for large breasted patients with unilateral disease

•Contraindicated • in small breasts relative to tumor size

• Multicentric disease

•Oncoplastic surgery • Combining oncologic surgery with aesthetic outcomes

• Using breast reduction patterns for lumpectomy

FAT GRAFTING

•Used as an adjunct to various methods

•Can be used as only reconstructive option

•No data to suggest increased cancer risk

FAT GRAFTING

NIPPLE RECONSTRUCTION

•Final step in reconstructive pathway

•Several methods for reconstruction

•Typically requires tattooing

•3-D tattooing

NIPPLE RECONSTRUCTION

SUMMARY

•Several options exist for breast reconstruction

•Mainly autologous vs implant based

•Best option varies by patient

•Reconstructive options even for BCT patients

•Nipple reconstruction

THANK YOU

•Questions?

BREAST RECONSTRUCTION - gatraweb.org reconstruction.pdf · breast reconstruction in connection with...

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