2008 breast reconstruction (aust)

Breast Breast Reconstruction:Reconstruction:Decision Making Decision Making Surgical PlanningSurgical Planning

Michael J. Miller, M.D.Michael J. Miller, M.D.Professor of SurgeryProfessor of Surgery

Director, Division of Plastic SurgeryDirector, Division of Plastic Surgery

The Ohio State UniversityThe Ohio State University

Lifetime Probability of Developing CancerLifetime 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

SiteSite RiskRiskAll SitesAll Sites 1 in 31 in 3

BreastBreast 1 in 71 in 7

Lung and bronchusLung and bronchus 1 in 171 in 17

Colon and rectumColon and rectum 1 in 181 in 18

Uterine corpusUterine corpus 1 in381 in38

NH-LymphomaNH-Lymphoma 1 in 571 in 57

OvaryOvary 1 in 591 in 59

Why Breast Reconstruction?Why Breast Reconstruction?

Mastectomy/ No ReconstructionMastectomy/ No Reconstruction• AdvantagesAdvantages

– no further surgery neededno further surgery needed

– shorter surgery time/hospital stayshorter surgery time/hospital stay

– symmetry restored with prosthesissymmetry restored with prosthesis

– may consider reconstruction in futuremay consider reconstruction in future

• DisadvantagesDisadvantages– scar on chest wallscar on chest wall

– asymmetry in clothingasymmetry in clothing

– external prosthetic can:external prosthetic can:• dislodgedislodge• be uncomfortablebe uncomfortable• be impractical for athletic activitiesbe impractical for athletic activities

Breast DeformitiesBreast Deformities

Consequences:Consequences:• AestheticAesthetic• FunctionalFunctional• EmotionalEmotional• SocialSocial

Decreased Quality of Life

Reconstruction OptionsReconstruction Options

Immediate

Delayed

Timing

Technique

Tissue

Tissue + Implant

Implants alone

Delayed ReconstructionDelayed Reconstruction

• AdvantagesAdvantages– shorter hospital stay/ shorter recoveryshorter hospital stay/ shorter recovery– adjuvant therapy causes no complications to adjuvant therapy causes no complications to

reconstructionreconstruction– allows patient time to consider reconstructive allows patient time to consider reconstructive

optionsoptions

• DisadvantagesDisadvantages– soft tissue scar on chest wallsoft tissue scar on chest wall– requires additional surgery and recovery timerequires additional surgery and recovery time– difficult to reconstruct after scarring occursdifficult to reconstruct after scarring occurs

Immediate ReconstructionImmediate Reconstruction• AdvantagesAdvantages

– lowers psychosocial morbiditylowers psychosocial morbidity– lowers surgical morbiditylowers surgical morbidity– superior cosmetic resultssuperior cosmetic results– lowers cost of surgerylowers cost of surgery– No difference in development or detection of No difference in development or detection of

local recurrenceslocal recurrences– No delays in adjuvant therapiesNo delays in adjuvant therapies

• DisadvantagesDisadvantages– mastectomy skin flap necrosis possiblemastectomy skin flap necrosis possible– longer hospitalization/recoverylonger hospitalization/recovery– additional scars additional scars – coordination required between surgeonscoordination required between surgeons


Immediate

Delayed

Timing

Technique

Tissue

Tissue + Implant

Implants alone

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% C

as

es

90 91 92 93 94 95 96 97 98 99 00

Year

Implant

LD

Autologous

Breast Reconstruction MethodsUTMDACC 1990 - 2000

Implant ReconstructionImplant Reconstruction

• Two-StageTwo-Stage– Stage One: Tissue expansionStage One: Tissue expansion– Stage Two: Permanent implant placementStage Two: Permanent implant placement

• One StageOne Stage– Permanent implant placementPermanent implant placement

• Use of dermal matrix implantsUse of dermal matrix implants

Implant ReconstructionImplant Reconstruction

• Tissue Expanders/ImplantsTissue Expanders/Implants– AdvantagesAdvantages

• No additional scarringNo additional scarring• Shorter procedure/recoveryShorter procedure/recovery• Satisfactory shape in clothingSatisfactory shape in clothing

– DisadvantagesDisadvantages• Foreign body causing risk of infectionForeign body causing risk of infection• Risk of rupture necessitating removalRisk of rupture necessitating removal• Risk of capsule formation and firmnessRisk of capsule formation and firmness• AsymmetryAsymmetry• Implant not permanentImplant not permanent

Two-Stage Implant ReconstructionTwo-Stage Implant Reconstruction

Pre-op

Full Expansion

Final Result

Acellular Dermal Matrix (AlloDermAcellular 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 Well, this is a fine mess …”fine mess …”

Q. 1 “How in the Q. 1 “How in the world did we get world did we get here?”here?”


Q. 1 “How in the Q. 1 “How in the world did we get world did we get here?”here?”

Q. 2 “How do we Q. 2 “How do we avoid ever being avoid ever being back here again?”back here again?”


Breast ImplantationBreast Implantation

Autologous TissueAutologous Tissue• Contralateral breast (Verneuil, Contralateral breast (Verneuil,

1887)1887)

• Lipoma (Czerny, 1895) Lipoma (Czerny, 1895)

• Grafts and flaps of muscle, fascia, Grafts and flaps of muscle, fascia, fat, and dermis fat, and dermis

• paraffin, paraffin, • ivory, ivory, • glass balls, glass balls, • ground rubber, ground rubber, • ox cartilage, ox cartilage, • Terylene wool, Terylene wool, • gutta percha, gutta percha, • Dicora, Dicora, • polyethylene chips, polyethylene chips,

• Ivalon sponge (poly(vinyl Ivalon sponge (poly(vinyl alcohol-formadehyde)),alcohol-formadehyde)),

• Ivalon in polyethylene sac,Ivalon in polyethylene sac,• polyether foam sponge polyether foam sponge

(Etheron), (Etheron), • polyethylene (Polystan) polyethylene (Polystan)

tape or strips wound into a tape or strips wound into a ball, ball,

• polyurethane foam polyurethane foam sponge, sponge,

• teflon-silicone prosthesis. teflon-silicone prosthesis.

Breast Implant DevicesBreast Implant Devices

Breast ImplantationBreast Implantation

• Paraffin, Vaseline, “Organogen,” “Bioplaxm”Paraffin, Vaseline, “Organogen,” “Bioplaxm”• Silicone oil Silicone oil ++ some combination of: some combination of:

– ricinoleic acid, animal fatty acid, vegetable fatty ricinoleic acid, animal fatty acid, vegetable fatty acids, mineral oil, vegetable (castor) oil, olive oil, acids, mineral oil, vegetable (castor) oil, olive oil, croton oil, peanut oil, concentrated vitamin D, croton oil, peanut oil, concentrated vitamin D, snake venom, talc, beeswax, shellac, glazier’s snake venom, talc, beeswax, shellac, glazier’s puddy, epoxy resin, industrial silicone fluidspuddy, epoxy resin, industrial silicone fluids

• Example: Sakurai (> 72,000 cases) Example: Sakurai (> 72,000 cases) • Medical-grade siliconeMedical-grade silicone

Direct Injections

Silicone Implant AlternativesSilicone Implant Alternatives

• PainPain• Skin discoloration, Skin discoloration,

edema, ulceration, edema, ulceration, and necrosisand necrosis

• CalcificationsCalcifications• GranulomasGranulomas• Fluid migrationFluid migration• InfectionInfection• CystsCysts

• Axillary adenopathyAxillary adenopathy• DisfigurementDisfigurement• Loss of the breastLoss of the breast• Liver dysfunctionLiver dysfunction• Pneumonitis/ARDSPneumonitis/ARDS• Pulomonary embolismPulomonary embolism• ComaComa• DeathDeath

Complications

Pre-Silicone Implant EraPre-Silicone Implant Era

• Women wanted breast Women wanted breast enhancementenhancement

• Many alternativesMany alternatives• Many complicationsMany complications• Ideal material not Ideal material not

identifiedidentified

Non-rigorous trials…

What was known:

Silicone Breast ImplantsSilicone Breast Implants

• 1950’s- shunts and joint replacements1950’s- shunts and joint replacements• 1964- Cronin and Gerow 1964- Cronin and Gerow

– Introduced silicone gel-filled breast implantIntroduced silicone gel-filled breast implant– Pre-clinical studies in dogs Pre-clinical studies in dogs

• 1962-1968 Dow Corning- only manufacturer1962-1968 Dow Corning- only manufacturer• 1968-early 1990’s- Multiple manufacturers1968-early 1990’s- Multiple manufacturers

– Dow Corning, Heyer-Schulte-Mentor, Cox-Uphoff Dow Corning, Heyer-Schulte-Mentor, Cox-Uphoff International, Aesthetech Corp., Surgitek, Inamed-International, Aesthetech Corp., Surgitek, Inamed-McGhan, Mammatech, foreign manufacturers, …McGhan, Mammatech, foreign manufacturers, …

Silicone Breast ImplantsSilicone Breast Implants

Early 1990’s, > 2 million women implanted!!Early 1990’s, > 2 million women implanted!!

Prior to 1970’s: Prior to 1970’s: little regulation or little regulation or oversight…oversight…

FDA Device RegulationFDA Device Regulation

• 1976- Medical Devices Amendments1976- Medical Devices Amendments– General and Plastic Surgery Advisory PanelGeneral and Plastic Surgery Advisory Panel– Implants required general controls and performance Implants required general controls and performance

standards only. standards only.

• 1982- FDA proposes reclassification as Class 1982- FDA proposes reclassification as Class III device requiring stringent controlsIII device requiring stringent controls

• 1988- Changed to Class III status requiring 1988- Changed to Class III status requiring pre-market approval (PMA) applications. pre-market approval (PMA) applications.

• 1992- Withdrawn from the market 1992- Withdrawn from the market

Clinical ValueClinical Value

+ = ?


Determined by: Determined by: • Affect on patient’s: Affect on patient’s:

– Functional Status Functional Status – Risk StatusRisk Status– Well beingWell being

• CostCost

• Patient satisfaction and perceived Patient satisfaction and perceived benefitbenefit

• Clinical outcomeClinical outcome

Nelson EC. et al. Joint Commission Journal on Quality Improvement. 22(4):243-58, 1996


Affect on patient’s: Affect on patient’s: Functional Status Functional Status

Risk StatusRisk Status

Well beingWell being

CostCost

Satisfaction/perceived benefitSatisfaction/perceived benefit

Clinical outcomeClinical outcome

Pre-1991

acceptable

+Value Score


Affect on patient’s: Affect on patient’s: Functional Status Functional Status

Risk StatusRisk Status

Well beingWell being

CostCost

Satisfaction/perceived benefitSatisfaction/perceived benefit

Clinical outcomeClinical outcome

Pre-1991

acceptable

Post-1991

+Value Score

??

??

?

acceptable

?

Medical Device SafetyMedical Device Safety

RiskRisk BenefitBenefit

Silicon Gel Breast ImplantsSilicon Gel Breast Implants

After all is said and done…After all is said and done…

• Conclusions:Conclusions:– Local complications are well describedLocal complications are well described– Systemic complications are not supportedSystemic complications are not supported– Patients must be informed Patients must be informed

2006- Silicone Gel implants return to the U.S. market

““How in the world How in the world did we get here?”did we get here?”

““How do we avoid How do we avoid being back here being back here again?”again?”


Immediate

Delayed

Timing

Technique

Tissue

Tissue + Implant

Implants alone

Skin Sparing Skin Sparing MastectomyMastectomy

Skin Sparing MastectomySkin Sparing Mastectomy

The The ablative surgeonablative surgeon begins the begins the reconstruction! reconstruction!

Skin-Sparing MastectomySkin-Sparing Mastectomy

Incisions only for: Incisions only for: - Nipple and Areola- Nipple and Areola - Access to the axilla - Access to the axilla - Biopsy scars- Biopsy scars - Skin areas “at risk” - Skin areas “at risk”

Pre-op Post-op



Mastectomy skin flap necrosis

Oncologic SafetyOncologic Safety• 51 breast cancer patients, Stages 0-II; 1991-51 breast cancer patients, Stages 0-II; 1991-

19941994• Median follow-up 45 monthsMedian follow-up 45 months• Local recurrence rate 2%Local recurrence rate 2%• Biopsies of incisions in 32 consecutive patients Biopsies of incisions in 32 consecutive patients

revealed no evidence of retained breast tissuerevealed no evidence of retained breast tissue

Slavin, et al, Plast Reconstr Surg 1994; 93:1191-1204Slavin, et al, Plast Reconstr Surg 1994; 93:1191-1204


Oncologic Safety of SSM vs. CMOncologic Safety of SSM vs. CMLocal Recurrence Rate (T2 tumors)Local Recurrence Rate (T2 tumors)

KrollKroll104/SSM104/SSM271/CM271/CM

CarlsonCarlson327/SSM327/SSM188/CM188/CM

SimmonsSimmons77/SSM77/SSM154/CM154/CM

SSMSSM

CMCM

15%15%

12%12%

9%9%

6%6%

3%3%

0%0%


• Skin-sparing mastectomy with immediate breast Skin-sparing mastectomy with immediate breast reconstruction is oncologically safe and offers reconstruction is oncologically safe and offers superior cosmetic results compared to superior cosmetic results compared to conventional mastectomyconventional mastectomy

• Local recurrence rates are similar for skin-Local recurrence rates are similar for skin-sparing and conventional mastectomiessparing and conventional mastectomies

• Most local recurrence are detected by physical Most local recurrence are detected by physical exam within 3 years following skin-sparing exam within 3 years following skin-sparing mastectomymastectomy

• Technically more demandingTechnically more demanding

• Oncological safety Oncological safety

• Superior aesthetic resultsSuperior aesthetic results


Latissimus Dorsi + ImplantLatissimus Dorsi + Implant

Latissimus Dorsi Flap + ImplantLatissimus Dorsi Flap + Implant

Pre-op Post-op

Donor site scar

Post-op. (3/1/2005)

Pre-op. (1/13/2004)

LD flap- Endoscopic HarvestLD flap- Endoscopic Harvest

Pre-op Post-op

LD flap- Endoscopic HarvestLD flap- Endoscopic Harvest


Immediate

Delayed

Timing

Technique

Tissue

Tissue + Implant

Implants alone

Autologous Tissue ReconstructionAutologous Tissue Reconstruction

Pedicled TRAMPedicled TRAM

Pedicled TRAMPedicled TRAM

• Prone to venous Prone to venous insufficiency leading insufficiency leading to fat necrosis to fat necrosis

Download illustrations from Moon and Taylor

Microvascular Microvascular Tissue TransferTissue Transfer

Microsurgical Breast Microsurgical Breast ReconstructionReconstruction

• Donor site optionsDonor site options– Free TRAMFree TRAM– Muscle-sparing free TRAMMuscle-sparing free TRAM– DIEPDIEP– SIEASIEA– S-GAPS-GAP– I-GAPI-GAP– OtherOther

Perforator FlapsPerforator Flaps

DIEP flapDIEP flap• AdvantagesAdvantages

– Spares Muscle Spares Muscle – Minimizes Pain Minimizes Pain – Less functional morbidity Less functional morbidity

• DisadvantagesDisadvantages– Technical challengeTechnical challenge– Increased operative timeIncreased operative time– Variations in anatomyVariations in anatomy– Increased fat necrosis Increased fat necrosis

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


• AdvantagesAdvantages– Natural breast shape and behaviorNatural breast shape and behavior– Natural consistencyNatural consistency– ““Tummy-tuck,” “buttocks lift”Tummy-tuck,” “buttocks lift”– No foreign bodyNo foreign body– Lower costs long-termLower costs long-term– Less emotional traumaLess emotional trauma


• DisadvantagesDisadvantages– Longer surgical procedureLonger surgical procedure– Donor site scarring/deformityDonor site scarring/deformity– Possible ComplicationsPossible Complications– Longer hospitalizationLonger hospitalization– Longer recoveryLonger recovery– Greater initial costGreater initial cost

Ideal Abdominal Tissue CandidateIdeal Abdominal Tissue Candidate

• HealthyHealthy

• No previous abdominal surgeryNo previous abdominal surgery

• MultiparousMultiparous

• Non-smokerNon-smoker

• No plans of radiotherapyNo plans of radiotherapy

• Compliant patientCompliant patient

Adjunct ProceduresAdjunct Procedures

• Breast mound reshapingBreast mound reshaping• Contralateral modifications for Contralateral modifications for

symmetrysymmetry• Nipple reconstructionNipple reconstruction• Nipple/areolar micropigmentationNipple/areolar micropigmentation

““Breast reconstruction- Breast reconstruction-

a process… a process…

not an operation.”not an operation.”

5/29/2007

10/2/2007 1/29/2008

Nipple ReconstructionNipple Reconstruction

3 cm

4 cm

Nipple ReconstructionNipple Reconstruction

Nipple-Areola MicropigmentationNipple-Areola Micropigmentation

Final ResultsFinal Results

• Breast mound creation• Revisions for shape• Nipple Reconstruction• Micropigmentation

Thank Thank you!you!

The Ohio State University

Plastic Surgery… to restore and make whole

University Hospital

James Cancer Hospital

Skin-Sparing MastectomySkin-Sparing MastectomyFrozen section control of margins

Oncologic SafetyOncologic Safety• 51 breast cancer patients, Stages 0-II; 1991-51 breast cancer patients, Stages 0-II; 1991-

19941994• Median follow-up 45 monthsMedian follow-up 45 months• Local recurrence rate 2%Local recurrence rate 2%• Biopsies of incisions in 32 consecutive patients Biopsies of incisions in 32 consecutive patients

revealed no evidence of retained breast tissuerevealed no evidence of retained breast tissue

Slavin, et al, Plast Reconstr Surg 1994; 93:1191-1204Slavin, et al, Plast Reconstr Surg 1994; 93:1191-1204


Local/Regional Recurrence*after Local/Regional Recurrence*after Skin-Sparing Mastectomy Skin-Sparing Mastectomy

Immediate Flap ReconstructionImmediate Flap Reconstruction

(Stage ll) (Stage ll)

** Median follow-up 5.4 yearsMedian follow-up 5.4 years

** ** None with stage 0 or stage I breast None with stage 0 or stage I breast cancercancer

Oncologic Safety of SSM vs. CMOncologic Safety of SSM vs. CMLocal Recurrence Rate (T2 tumors)Local Recurrence Rate (T2 tumors)

KrollKroll104/SSM104/SSM271/CM271/CM

CarlsonCarlson327/SSM327/SSM188/CM188/CM

SimmonsSimmons77/SSM77/SSM154/CM154/CM

SSMSSM

CMCM

15%15%

12%12%

9%9%

6%6%

3%3%

0%0%

Local Recurrences after Skin-Sparing Local Recurrences after Skin-Sparing Mastectomy and Immediate Mastectomy and Immediate

ReconstructionReconstructionGroupGroup Number Pts.Number Pts. Local Local Recurrences (%)Recurrences (%)

AllAll 104104 6.76.7

T1T1 6161 3.33.3

T2T2 4343 11.611.6

Black’s grade I*Black’s grade I* 3131 12.912.9

Black’s grade IIBlack’s grade II 4848 6.36.3

Black’s grade IIIBlack’s grade III 66 0.00.0*The lower the grade, the more anaplastic the tumor*The lower the grade, the more anaplastic the tumor

Ann Surg Oncol 4:193-197,1997Ann Surg Oncol 4:193-197,1997

Regional recurrence after Regional recurrence after skin-spring mastectomy is skin-spring mastectomy is a function of the biology of a function of the biology of

the tumor and stage of the tumor and stage of diseasedisease

Detection and Management of Local Detection and Management of Local Recurrence Following SSMRecurrence Following SSM

MDACC ExperienceMDACC Experience

• 437 SSMs in 372 patients with invasive 437 SSMs in 372 patients with invasive T1/T2 breast cancers, 1986-1993T1/T2 breast cancers, 1986-1993

• Median follow-up 50 monthsMedian follow-up 50 months• 23/372 local recurrences detected23/372 local recurrences detected• Local recurrence rate = 6.2%Local recurrence rate = 6.2%

Newman, Ann Surg Onc,1998Newman, Ann Surg Onc,1998

Local Recurrence Following SSMLocal Recurrence Following SSMMDACC ExperienceMDACC Experience

• Median time to recurrence: 25 months (3-98)Median time to recurrence: 25 months (3-98)• Median size of recurrence: 1.5 cmMedian size of recurrence: 1.5 cm• PresentationPresentation

-- Palpable skin flap mass: 22/23 (96%)Palpable skin flap mass: 22/23 (96%)-- Non-palpable, CXR finding: 1/23 (4%)Non-palpable, CXR finding: 1/23 (4%)

• HistologyHistology-- Consistent w/primary tumor: 22/23 (96%)Consistent w/primary tumor: 22/23 (96%)-- Different histology; ? New primary: 1/23 Different histology; ? New primary: 1/23 (4%)(4%)

Imaging of Local Imaging of Local RecurrenceRecurrence

• Mammography visualized: 3/5Mammography visualized: 3/5

• Ultrasound visualized: 11/12Ultrasound visualized: 11/12

• CT scan imaged: 3/3CT scan imaged: 3/3

• MRI imaged: 1/1MRI imaged: 1/1

Distant Relapse and Overall SurvivalDistant Relapse and Overall Survival

• Median follow-up 26 mos. (range 6-105)Median follow-up 26 mos. (range 6-105)

• N = 23N = 23

• Metastases: Metastases: 39%39% - - SynchronousSynchronous 22%22%- Metachronous- Metachronous 17%17%

• Survival:Survival:- Alive without disease- Alive without disease 61%61%- Alive with disease- Alive with disease 9%9%- Dead with disease- Dead with disease 30%30%

Local Control and Outcome by Local Control and Outcome by TreatmentTreatment

TreatmentTreatment # Pts.# Pts. Local ControlLocal Control Alive, Alive, NEDNED

Local onlyLocal only 33 100%100% 100%100%(Surgery or(Surgery orSurgery + RT)Surgery + RT)

Systemic onlySystemic only 55 60%60% 40%40%

Local and Local and 1515 86%86% 71%71%SystemicSystemic

Local Control and Outcome by Local Control and Outcome by TreatmentTreatment

Local Local OnlyOnly

SystemiSystemic Onlyc Only

Local & Local & SystemiSystemi

cc

Local ControlLocal Control

Alive, NEDAlive, NED

100100%%

80%80%

60%60%

40%40%

20%20%

0%0%


• Skin-sparing mastectomy with immediate breast Skin-sparing mastectomy with immediate breast reconstruction is oncologically safe and offers reconstruction is oncologically safe and offers superior cosmetic results compared to superior cosmetic results compared to conventional mastectomyconventional mastectomy

• Local recurrence rates are similar for skin-Local recurrence rates are similar for skin-sparing and conventional mastectomiessparing and conventional mastectomies

• Most local recurrence are detected by physical Most local recurrence are detected by physical exam within 3 years following skin-sparing exam within 3 years following skin-sparing mastectomymastectomy

• Treatment approach depends on extent of Treatment approach depends on extent of local recurrence and presence of local recurrence and presence of synchronous metastases, but resection of the synchronous metastases, but resection of the reconstructed breast is reconstructed breast is rarelyrarely necessary necessary

• Multimodality therapy usually results in Multimodality therapy usually results in excellent local control of disease and excellent local control of disease and prolonged disease-free survivalprolonged disease-free survival


MDACC RecommendationsMDACC Recommendations

• Minimize risk of positive margins following Minimize risk of positive margins following skin-sparing mastectomy:skin-sparing mastectomy:-- Intraoperative inking of marginsIntraoperative inking of margins-- Mammography of serial sections if Mammography of serial sections if microcalcifications are presentmicrocalcifications are present-- Resection of additional skin as Resection of additional skin as necessarynecessary

• Consider XRT if postoperative margins are Consider XRT if postoperative margins are microscopically positivemicroscopically positive

MDACC RecommendationsMDACC Recommendations

• Management of local recurrence:Management of local recurrence:-- Evaluate for distant metastatic diseaseEvaluate for distant metastatic disease-- Breast ultrasound and mammography Breast ultrasound and mammography to to evaluate extent of recurrenceevaluate extent of recurrence-- Multimodality therapy, including Multimodality therapy, including surgery surgery for resectable diseasefor resectable disease

Reservations Regarding Reservations Regarding Skin-Sparing MastectomySkin-Sparing MastectomyReservations Regarding Reservations Regarding Skin-Sparing MastectomySkin-Sparing Mastectomy

• Technically more demanding: Technically more demanding: YesYes• Increased surgical morbidity:Increased surgical morbidity: No No• Oncologic safety:Oncologic safety: YesYes

• Technically more demanding: Technically more demanding: YesYes• Increased surgical morbidity:Increased surgical morbidity: No No• Oncologic safety:Oncologic safety: YesYes

2008 breast reconstruction (aust)

Health & Medicine

silicone breast implants

implant implants

breast implant devices

breast enhancement

additional surgery

plastic reconstructive

breast implantation

cost of surgery