Download Breast Reconstruction

Breast Reconstruction
Joint Hospital Grand Round
20th September, 2003
Catherine Choi
United Christian Hospital
Breast Cancer
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Commonest cancer amongst females
in Hong Kong
Incidence increasing annually at 3.6%
Incidence 1918 (397 deaths)
Cumulative life-time risk (0-74yrs): 1
in 23
Hong Kong Cancer Registry 2000
Female Breast Cancer
New Cases & Deaths Registered
100
1,800
90
1,600
80
1,400
70
1,200
60
1,000
50
800
40
600
30
400
20
200
10
0
-1991
-1992
New cases
-1993
Deaths
-1994
-1995
Year
-1996
-1997
Crude Incidence Rate
-1998
-1999
-2000
Rate per 100,000
No.
2,000
0
Crude Mortality Rate
Hong Kong Cancer Registry 2000
Treatment of Breast Cancer
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Multimodality & Multidisciplinary
Management
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Surgery
Chemotherapy
Radiation therapy
Hormonal therapy
Surgery important in achieving cure
Evolution of surgery in the treatment of
Breast Cancer
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Breast Conservation Treatment (BCT)
in early breast cancer
Fisher et la. Eight year results of a randomized clinical trial comparing total
mastectomy and lumpectomy with or without irradiation in the treatment of
breast cancer. N Eng J. Med. 1989;320:822-8
National Institute for Health Consensus Conference. Treatment of early stage
breast cancer. JAMA 1991; 265:391-5
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Mastectomy still required in majority
Mastectomy
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Mutilating and
destructive
Loss of femininity
Disturbance in
marital/sexual
relationship
Limited selection
in clothing &
activities
Breast Reconstruction
NOT A COSMETIC SURGERY
Integral part of treatment
Reduce psychosocial morbidity &
improve quality of life
Linda LR. Plast Reconstr Surg 1997
Immediate vs Delayed Reconstruction
Immediate Reconstruction……
 Oncologically safe
Kroll SS. Ann Surg Oncol 1997
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Easier operation
Better aesthetic outcome
Avoid disfigurement
Avoid second operation
Psychological, social, financial and
time-saving advantages
Surgical Options for
Breast Reconstruction
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Implant or tissue expander
Autologous tissue reconstruction
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Latissimus Dorsi (LD) myocutaneous
flap
Transverse Rectus Abdominus
Myocutaneous (TRAM) flap – free or
pedicle
Deep Inferior Epigastric Perforator
(DIEP) flap
Superior Gluteal Artery Perforator
(SGAP) flap
Inferior Gluteal Artery Perforator
(IGAP) flap
Breast implants & tissue expanders
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Saline or silicon gel
Simpler surgical
procedure
Lower cost
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Symmetry difficult to
achieve
Aesthetic result
deteriorates over time
Capsular contracture,
implant failure,
infection, etc
Clough KB. Plast Reconstr Surg 2002
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Problems associated
with post-op
radiotherapy
Michigan Breast Reconstruction
Outcome Study
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49 implants/expander
163 TRAM flap
TRAM flap recipient more satisfied
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Aesthetic satisfaction
General satisfaction
Alderman AK. Plast Reconstr Surg 2000
Latissimus Dorsi (LD) flap
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First described by
Tansini in 1898
Standard method in the
1970s
Technically easy, reliable
Used alone for small
breast reconstruction or
with implant for large
breast
Change of position
during surgery
Complication of seroma
common, others relating
to implants
Endoscopic techniques
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Harvesting
latissimus dorsi
myocutaneous flap
Same scar for
axillary dissection
or a separate
incision about one
inch in the middle
or lower back
TRAM flap
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First described by
Hartrampf in 1982
Commonest option
Substantial amount of
tissue and skin for
reconstruction
Symmetry & Tissue
consistency
Change of appearance
and size similar to the
natural breast
Added benefit of
abdominoplasty
Clough KB. Plast & Reconstr Surg 2001
TRAM – pedicled flap
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Superior epigastric artery
Skin and subcutaneous tissue by subdermal
plexus
TRAM - complications
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Donor site
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Abdominal weakness / hernia
Abdominal wall bulging
Recipient site
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Fat necrosis
Partial flap necrosis
Total flap necrosis
TRAM flap - risk factors
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Smoking
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Microcirculatory problems
Magnified in obese patients
Obesity
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increased risk of flap loss with pedicle
flap
Moran SL. Plast Reconstr Surg 2001
TRAM – risk factors
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Unfavorable abdominal scar from
previous surgery
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TRAM flap pedicles divided
Perforators interrupted
Subdermal plexus damaged
Rt subcostal scar
Vertical midline scar
Pfannenstiel scar
TRAM – free flap
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Popularized since 1990s
Deep inferior epigastric artery
Robust blood supply
TRAM – free flap
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Advantages
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Less fat necrosis /
partial flap loss
Less sacrifice of
donor site muscle,
so less weakening
& less pain
Avoid epigastric
bulge
Better aesthetic
outcome
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Disadvantages
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Microvascular
anastomosis
Risk of TOTAL flap
loss
Long & tedious
operation
Post-op monitoring
requires effort and
expense
DIEP (deep inferior epigastric
perforator) flap
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Variation of free TRAM flap
Only one or more perforating
branches dissected from rectus
Rectus muscles left intact
Less donor site morbidity
More time consuming and tedious
Indicated for bilateral reconstruction
& small breast
Preferred choice of TRAM…..
Pedicle flap
VS
Free flap
Literature search
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Keyword: TRAM
Medline / EMBASE / Cochrane library
5 out of 698 articles comparing
outcome of free vs pedicled TRAM
Results
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No RCT comparing free vs pedicled TRAM
Prospective non-randomized comparison
Comparisons on…
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Patient’s general & aesthetic
satisfaction
Larson DL. Plast & Reconstr Surg 1999
Edsander N. Plast & Reconstr Surg 2001
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Recipient site morbidity
Kroll SS. Plast & Reconstr Surg 1998
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Donor site morbidity
Edsander N. Plast & Reconstr Surg 1998
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Cost
Serletti JM. Plast & Reconstr Surg 1997
Study Results
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Free
Patient & aesthetic
satisfaction
Recipient site morbidity
(fat necrosis)†
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Pedicled
Shorter operation
time, hospital stay,
less blood
transfusion†
Donor site morbidity
(abd strength)
† Statistical significant result
Skin-sparing total mastectomy with
immediate breast reconstruction
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Oncologically safe
Kroll SS. Surg Gynecol Obstet 1991
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Traditional type involves skin
overlying tumor, biopsy scar and
nipple-areola complex (skin at risk
of recurrence)
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Patch like defect at NAC, transverse
scar
Skin-sparing total mastectomy with
immediate breast reconstruction
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Periareolar approach
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All breast skin preserved
Optimal aesthetic result
Gabka CJ. Plast & Reconstr Surg 1998
Conclusion
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Breast reconstruction reduces
psychosocial morbidity & increases
quality of life after mastectomy
Immediate reconstruction should be
offered to patient requiring
mastectomy
Autologous tissue reconstruction
superior to implants
Conclusion
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Periareolar approach skin-sparing
mastectomy with immediate breast
reconstruction gives the best
possible aesthetic outcome without
compromise oncological safety
Gabka CJ. Plast & Reconstr Surg 1998