breast reconstruction - gatraweb.org reconstruction.pdf · breast reconstruction in connection with...
TRANSCRIPT
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BREAST RECONSTRUCTION Olumayowa Abiodun, MD
Plastic and Reconstructive Surgery
Phoebe Putney Memorial Hospital
Albany, GA
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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
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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
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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.
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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.”
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HISTORY
•First breast reconstruction by Czerny in 1894 using a lipoma from the patient’s flank
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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*
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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
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SIMPLE MASTECTOMY
•Traditional mastectomy with removal of nipple, areola and significant amount of breast skin
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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%)
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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
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NIPPLE SPARING MASTECTOMY
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RADIATION THERAPY
•Affects reconstructive options
•Limits implant based options
•Typically not recommended in delayed reconstruction
•Does not make immediate reconstruction contraindicated
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RADIATION THERAPY
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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
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au·tol·o·gous /ôˈtäləɡəs/ adjective 1.(of cells or tissues) obtained from the same individual
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AUTOLOGOUS RECONSTRUCTION
•Uses patients own tissue to create breasts
•Lower risks of complications in the right patients
•Longer procedures
•Donor site
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AUTOLOGOUS RECONSTRUCTION
•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
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AUTOLOGOUS RECONSTRUCTION
•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
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AUTOLOGOUS RECONSTRUCTION
•Free flaps
•Deep Inferior Epigastric Perforator (DIEP) flap
•Free Transverse Rectus Abdominis Myocutaneous (TRAM) flap
•Other free flaps (PAP, TUG, ALT, TDAP, LTAP)
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DIEP FLAP
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•Delayed reconstruction with DIEP flap
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PROFUNDA ARTERY PERFORATOR (PAP) FLAP
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SUPERIOR GLUTEAL ARTERY PERFORATOR (SGAP) FLAP
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AUTOLOGOUS RECONSTRUCTION
•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
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AUTOLOGOUS RECONSTRUCTION
•Pedicled flaps
•Pedicled Transverse Rectus Abdominis Myocutaneous (TRAM) flap
•Pedicled Latissimus dorsi myocutaneous flap
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PEDICLED TRAM FLAP
•Typically without implant
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PEDICLED TRAM FLAP, BILATERAL
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ABDOMINAL BASED FLAPS
•Abdominal based flaps
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LATISSIMUS DORSI FLAP
•Typically with implant
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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
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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
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•Immediate TE/implant based reconstruction with symmetry procedure
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IMPLANT BASED RECONSTRUCTION
•Delayed Implant based reconstruction
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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
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IMPLANT BASED RECONSTRUCTION
•Prepectoral
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IMPLANT BASED RECONSTRUCTION
•Subpectoral •Traditional placement of prosthesis under the pectoralis major muscle
•More soft tissue covering implant
•Less risk of capsular contracture*
•Less rippling
•Animation deformity
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IMPLANT BASED RECONSTRUCTION
•Subpectoral
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IMPLANT BASED RECONSTRUCTION
•Animation deformity
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IMPLANT BASED RECONSTRUCTION
•Animation deformity
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COMBINED RECONSTRUCTION
•Combination of autologous and implant based reconstruction
•Latissimus dorsi myocutaneous flap with implant
•DIEP flap with implant
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CONTRAINDICATIONS FOR RECONSTRUCTION
•Significant comorbidities
•Poorly controlled diabetes
•Morbid obesity* • Autologous reconstruction
• Inability to tolerate prolonged anesthesia
•Limited life expectancy
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COMPLICATIONS OF RECONSTRUCTION
• Infection
•Bleeding
•Wound healing complications
•BIA-ALCL • Breast Implant Associated Anaplastic Large Cell Lymphoma
•Potential delay in oncologic treatment
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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
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BREAST CONSERVING THERAPY
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BREAST CONSERVING THERAPY
•Oncoplastic surgery • Combining oncologic surgery with aesthetic outcomes
• Using breast reduction patterns for lumpectomy
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FAT GRAFTING
•Used as an adjunct to various methods
•Can be used as only reconstructive option
•No data to suggest increased cancer risk
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FAT GRAFTING
![Page 58: BREAST RECONSTRUCTION - gatraweb.org reconstruction.pdf · breast reconstruction in connection with a mastectomy. •If receiving benefits in connection with a mastectomy and breast](https://reader035.vdocument.in/reader035/viewer/2022062402/5fc76d8af8c9c441e225a9a2/html5/thumbnails/58.jpg)
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NIPPLE RECONSTRUCTION
•Final step in reconstructive pathway
•Several methods for reconstruction
•Typically requires tattooing
•3-D tattooing
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NIPPLE RECONSTRUCTION
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NIPPLE RECONSTRUCTION
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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
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THANK YOU
•Questions?