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Breast reconstruction Dr . Ezzatollah Rezaei Plastic and reconstructive surgeon History Breast Reconstruction 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 Current 15% 1984-90 3.4% 1994-5 8.3% Breast Reconstruction Advantages Don’t need to wear an external prosthesis Better self esteem Fewer sexual problems Disadvantages 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 Immediate reconstruction Delayed reconstruction Breast Reconstruction Decisions BUT : 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 1. Skin Sparing Mastectomy 2. Breast Reconstruction Non-autologous Fixed volume breast implants Expanders Combination Latissimus dorsi flap with breast implants Autologous (pedicled or free) Transverse rectus abdominis myocutaneous flap (TRAM) Deep inferior epigastric perforator flap (DIEP) Superior gluteal artery perforator flap (SGAP) [gluteus maximus flap] Extended latissimus dorsi flap Tensor fascia lata (TFL) [vertical thigh flap] Modified deep circumflex iliac artery flap (DCIA) 3. Contralateral reduction or lift 4. Nipple reconstruction Implant based reconstruction Two stage One stage Breast implants/expanders Indications: Unsuitable for larger procedure Patient preference Prior surgery limiting flap Thin with small to medium breasts Contraindications: Prior or upcoming irradiation Obesity (increased risk of infection and extrusion) Thin flaps of marginal viability Suture line tension Breast implants/expanders Advantages: No donor site morbidity Decreased operating time Decreased recovery time No additional scar Disadvantages: Implant rupture/leak/extrusion Infection Flap necrosis Capsular contracture Long reconstruction period (expanders) Reoperations for implant-related problems 2 Stage TechniqueStage 1: Placement of tissue expander beneath the pectoralis major muscle Stage 2: Exchange of tissue expander Breast Reconstruction Breast implants/expanders Two stage breast reconstruction Breast implants/expanders 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 Haematoma, infection, flap necrosis, expander malfunction, implant rupture/ leak, capsular contracture Leakage rate for saline <5% over the first 5 years Pedicled autologous reconstruction Indications: Poor recipient tissue (eg thin skin flaps) Insufficient tissue for reconstruction (eg after radical mastectomy) Previous complicated implant reconstruction Patient preference Contraindications 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 Anatomy: Indications: Relies on superior epigastric artery (less dominant than inferior), with retrograde filling of inferior epigastric (divided) Large recipient site defect Patient preference Contraindications 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 Advantages: Adequate tissue Reliable perfusion Consistently good long-term results Better donor site scar ‘Free’ abdominoplasty Disadvantages New scar Longer recovery than lat dorsi Less reliable than free TRAM Unpredictable reliable flap volume (only zone 1 may be viable) Pedicled TRAM flap Complications: 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 Anatomy: Indications: Based on thoracodorsal artery Patient preference Failure of prior autologous reconstruction Prior chest wall irradiation Contraindications: Thoracodorsal artery injury Pedicled Latissimus Dorsi Flap Advantages Reliable Faster recovery of TRAM Less morbidity of TRAM Disadvantages New scar May still need implant Pedicled Latissimus Dorsi Flap Complications: Donor site seroma Heamatoma Infection Flap necrosis (rare) Total flap loss < 2% Minimal donor site morbidity Free TRAM flap Anatomy: Indications Indications: 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: 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 Advantages: 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: Longer operative times Need for microvascular techniques & monitoring Higher risk of total flap loss Other free options 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 Remaining nipple graft vs free or local flap Areolar & nipple tattoo Nipple Reconstruction