Download Breast Reconstruction

Breast reconstruction
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Dr . Ezzatollah Rezaei
Plastic and reconstructive surgeon
History Breast Reconstruction
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1890’s Tansini - Lat dorsi flap for wound healing
Early 1900’s Disuse due to Halsted
1960’s Cronin and Greenberg - Silicone breast prosthesis
1970’s Rediscovery of the lat dorsi flap Discovery of tissue
expanders
1980’s Vertical rectus abdominis flap Pedicled TRAM flap
Gluteal, lateral thigh, DCIA myocutaneous, perforator flaps
1990’s DIEP – deep inferior epigastric perforator free flap
Breast Reconstruction Incidence
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Current 15%
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1984-90
3.4%
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1994-5
8.3%
Breast Reconstruction
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Advantages
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Don’t need to wear an external prosthesis
Better self esteem
Fewer sexual problems
Disadvantages
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More surgery
Delays for planning/organization
Longer recovery
Unsatisfying outcome (expectations too high)
Specific surgical side effects
Other scars if tissue is taken from elsewhere, with associated risks
Breast Reconstruction
Objective is to restore symmetry by recreating:
Volume
Shape
Position
Compared to the opposite breast
Breast reconstruction
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Immediate reconstruction
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Delayed reconstruction
Breast Reconstruction
Decisions
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BUT :
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Best cosmetic results are achieved with immediate autologous reconstruction
Requires preoperative planning
Skin sparing mastectomy offers the best outcomes
No increased risk of recurrence
May be compromised by unexpected pathological findings:
Positive margins
Nodal involvement
Need for re-excision
Need for post-operative chemo/radiotherapy
NOTE: Autologous reconstructions can usually withstand postoperative radiation
but significant atrophy occurs in up to 1/3. Implants on the other hand can
harden and/or extrude
Breast Reconstruction
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1. Skin Sparing Mastectomy
2. Breast Reconstruction
Non-autologous
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Fixed volume breast implants
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Expanders
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Combination
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Latissimus dorsi flap with breast implants
Autologous (pedicled or free)
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Transverse rectus abdominis myocutaneous flap (TRAM)
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Deep inferior epigastric perforator flap (DIEP)
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Superior gluteal artery perforator flap (SGAP) [gluteus maximus flap]
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Extended latissimus dorsi flap
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Tensor fascia lata (TFL) [vertical thigh flap]
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Modified deep circumflex iliac artery flap (DCIA)
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3. Contralateral reduction or lift
4. Nipple reconstruction
Implant based reconstruction
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Two stage
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One stage
Breast implants/expanders
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Indications:
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Unsuitable for larger procedure
Patient preference
Prior surgery limiting flap
Thin with small to medium breasts
Contraindications:
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Prior or upcoming irradiation
Obesity (increased risk of infection and extrusion)
Thin flaps of marginal viability
Suture line tension
Breast implants/expanders
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Advantages:
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No donor site morbidity
Decreased operating time
Decreased recovery time
No additional scar
Disadvantages:
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Implant rupture/leak/extrusion
Infection
Flap necrosis
Capsular contracture
Long reconstruction period (expanders)
Reoperations for implant-related problems
2 Stage TechniqueStage
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1: Placement of tissue expander beneath the
pectoralis major muscle
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Stage 2: Exchange of tissue expander
Breast Reconstruction
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Breast implants/expanders
Two stage breast reconstruction
Breast implants/expanders
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Placed sub pectoral
Inflation begins 2 weeks after surgery
50-100ml every 1-2 weeks
Need to achieve 20-30% overinflation
Maintained for 8 weeks for capsule maturation
Exchanged for permanent implant with
additional procedures if necessary
Complications
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Haematoma, infection, flap necrosis,
expander malfunction, implant rupture/
leak, capsular contracture
Leakage rate for saline <5% over the first 5 years
Pedicled autologous reconstruction
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Indications:
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Poor recipient tissue (eg thin skin flaps)
Insufficient tissue for reconstruction (eg after radical mastectomy)
Previous complicated implant reconstruction
Patient preference
Contraindications
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Injury to donor pedicle
Uncontrolled hypertension or diabetes
Obesity
Heavy smoking (increased platelet adherence and decreased flap
perfusion)
Severe cardio-pulmonary disease
Autoimmune disease (eg scleroderma, Raynaud’s)
Pedicled TRAM flap
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Anatomy:
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Indications:
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Relies on superior epigastric artery (less dominant than inferior), with
retrograde filling of inferior epigastric (divided)
Large recipient site defect
Patient preference
Contraindications
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Prior abdominal surgeries with injury to superior epigastric or perforators
Pendulous or inadequate panniculus
Prior chest wall irradiation
Not as reliable as the lat dorsi flap and previous contraindications will have
more of an effect on TRAM than lat dorsi flaps
Pedicled TRAM flap
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Advantages:
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Adequate tissue
Reliable perfusion
Consistently good long-term results
Better donor site scar
‘Free’ abdominoplasty
Disadvantages
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New scar
Longer recovery than lat dorsi
Less reliable than free TRAM
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Unpredictable reliable flap volume (only zone 1 may be viable)
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Pedicled TRAM flap
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Complications:
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Skin/fat/flap necrosis (fat necrosis 5-30%, can form
nodules that mimic malignancy)
Abdominal weakness or hernia
Seroma
Infection
Haematoma
Total flap failure < 1%
Pedicled Latissimus Dorsi Flap
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Anatomy:
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Indications:
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Based on thoracodorsal artery
Patient preference
Failure of prior autologous reconstruction
Prior chest wall irradiation
Contraindications:
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Thoracodorsal artery injury
Pedicled Latissimus Dorsi Flap
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Advantages
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Reliable
Faster recovery of TRAM
Less morbidity of TRAM
Disadvantages
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New scar
May still need implant
Pedicled Latissimus Dorsi Flap
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Complications:
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Donor site seroma
Heamatoma
Infection
Flap necrosis (rare)
Total flap loss < 2%
Minimal donor site morbidity
Free TRAM flap
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Anatomy:
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Indications
Indications:
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Flap based on inferior epigastric artery & venae comitantes
Most common recipient vessels are thoracodorsal vessels, alternatives are
circumflexscapular, internal mammary, thoracoacromial, circumflex humeral
& axillary
Need for large volume of tissue
Previous injury to superior epigastric artery
Contraindications:
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Division of deep inferior epigastric artery from previous surgery (eg hernia
or paramedian incisions)
smoking or obese. Perfusion from inferior epigastric is better. Similar as for
pedicled, however free preferred if at higher risk of flap failure eg.
Free TRAM flap
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Advantages:
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Enhanced blood supply makes larger flaps possible with
less necrosis
No pedicle constraints on bulk
Less donor site morbidity
Faster recovery (less muscle taken)
Disadvantages:
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Longer operative times
Need for microvascular techniques & monitoring
Higher risk of total flap loss
Other free options
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DIEP – Deep inferior epigastric perforator flap (skin
& fat only) 1.5 hours longer than free TRAM
Decreased rate of hernia or weakness
Gluteus maximus flap – based on superior &
inferior gluteal
arteries
TFL (Tensor Fascia Lata) flap – based on transverse
branch of lateral circumflex femoral artery
DCIA (Deep
Nipple Reconstruction
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Remaining nipple graft vs free or local flap
Areolar & nipple tattoo
Nipple Reconstruction