“INDICATIONS FOR BREAST RECONSTRUCTION ”

Dr. Anil Haripriya

IntroductionIntroduction Female breasts hold a place of paramount importance by virtue of their clinical, anatomic, psychosexual and social importance in todays society. Loss of breast, post mastectomy, thence has a dreadful and long lasting implications on the female in the form of loss of self esteem, loss of feminity and sexual and psycho social problems that ensue.

Breast reconstruction has now become an indispensable part of modern day breast surgery as it comes in rescue to the patients who have lost their breast due to various reasons carcinoma being the commonest of all. The concept of breast reconstruction is to treat breast carcinoma in standard fashion by surgically excising the tumor with tumor margins yet maintaining the shape and symmetry These surgeries are gaining popularity each day as they are oncologically safe, cost effective and aesthetically satisfying.

Contrary to the popular belief where breast reconstruction was looked upon as a province of plastic surgeon the evolving ideology believes in equal importance of the topic to both ablative and recontructive surgeons. This is so as it is the ablative surgeon performing mastectomy with whom the patient first enquires about the breast reconstruction options and post mastectomy status like

- How will the mastectomy affect my breast?

- Can I lead a normal life?

- Is there any procedure that can replace my breast?

- What are the breast reconstruction modalities?

- How will be my breast look after reconstruction

It is therefore mandatory for all of us to have a basic understanding of the techniques, timing, patient selection and outcomes of different reconstructive modalities. We in this seminar will discuss How, In Whom and when to reconstruct the lost breast.

HISTORICAL BACKGROUNDHISTORICAL BACKGROUND Historically first attempt of true breast reconstruction

was in 1895 by vincent czerny Tansini described the first ever use of lattissimus

dorsi muscle flap in 1906.Since then upto 1960s many advances were made

but multiple procedures and prolonged treatment course precluded their widespread application.

In 1963 breast augmentation with breast implants was introduced Cronin and Gerow who used these implants to reconstruct mastectomy defects. In the last two or three decades these surgeries have grown magnanimously to attain the present day status with the advent of pedicled, bipedicled, free and now perforator based flaps , each one adding on to the advantages of the predessesor.

INDICATIONS FOR BREAST INDICATIONS FOR BREAST RECONSTRUCTIONRECONSTRUCTION

* After mastectomy : Even with the advent of breast conservative therapy and neoadjuvant chemotherapy as high as 40% of the patients require mastectomy due to adverse tumor : breast ratio acceptable site, multifocal pathology, or by choice of the patient.

* After breast conservation therapy : Recent studies conducted by Loma Linda University California concluded that almost all patients after BCT noticed breast asymmetry and about 35% of them had significant asymmetry more so when >20% of breast volume is resected.

* Congenital anomalies.

* Developmental abnormalities.

* Traumatic disfigurement

PATIENTS SELECTIONPATIENTS SELECTION Studies conducted by Brand Beng and

associate in 2000 inferred that ALL PATIENTS, IRRESPECTIVE OF AGE AND DISEASES STATUS, SHOULD BE OFFERED BREAST RECONSTRUCTION AS THIS SEEMS TO HAVE SIGNIFICANT EFFECT ON THE QUALITY OF LIFE.

In general young patients and early stage disease are best candidates for reconstruction and patients with advanced disease carry high risk.

Patients with autoimmune diseases, diabetes mellitus, substance abuse, chronic systemic diseases or unwillingness should not be offered breast reconstruction.

Risk factor severity score devised by Carl Hartramf each risk factor is given a numerical score. Any one with score >5 or with 3 or more risk factors is a poor candidate for any reconstructive surgery. A score with 2 or more risk factors carry marginal prognosis .

Of the numerous risk factors detrimental in breast reconstruction advanced age, obesity, smoking, concomitant systemic disease and psychological/emotional status are most important.

Operative Risk Factors for Breast Operative Risk Factors for Breast Reconstruction With the TRAM FlapReconstruction With the TRAM Flap ObesityModerate: <25% above ideal body weight Severe: >25% over ideal body weight

 15

Small-Vessel DiseaseLight-to-moderate smoking (1+pack/day for 2-10 yr)Chronic heavy smoking (10-20 packs/yr)Chronic heavy smoking (20-30 packs/yr)Autoimmune disease (e.g., scleroderma, Raynaud’s)Diabetes mellitus: non insulin dependent Diabetes mellitus : insulin dependent

 12585

10

Psychosocial ProblemUnstable emotional state (life crisis) Personality disorderSubstance abuse

 235

Abdominal ScarsIf” planned out” of flap designDisruption of vascular perforators: transaction of superior epigastric vessels (e.g., Chevron incision, abdominoplasty)

 0.510

Patient’s Attitude Patient unwilling or unable to invest time require for healing or objects to abdominal scar

 10

Surgeon’s Inexperience

<10 TRAM flap

 1

Major System Disease Process

Chronic lung disease

Severe cardiovascular disease

 

10

10

Operative Risk Factors for Breast Reconstruction Operative Risk Factors for Breast Reconstruction With the TRAM FlapWith the TRAM Flap Contd…Contd…

TIMING OF RECONSTRUCTIONS TIMING OF RECONSTRUCTIONS • Immediate Breast Reconstruction (IBR) : primary

reconstruction • Delayed Breast Reconstruction (DBR) : secondary

reconstruction. Immediate Breast ReconstructionImmediate Breast Reconstruction• Advantages the immediate reconstruction

1.Decreased emotional impact of mastectomy and significant decrease in level of depression.2. Increased cost effectiveness :3. Better aesthetic outcomes4. Decreased frequency of secondary symmetrization.5. Better breast symmetry.6. More sensate reconstruction.7. No statistically significant difference in complications, risk of recurrence of cancer and no difficulty in recurrence surveillance of breast carcinoma.

Delayed reconstruction Delayed reconstruction

• 1. Done in patients who are candidates for post

operative radiotherapy.

• 2. Suitable for patients with unrealistic cosmetic

expectation.

• 3. Risk of chest wall mastectomy flap necrosis (0%)

as against 16% after immediate breast

reconstruction (De Bono et al, 2002)

Delayed immediate breast reconstruction Delayed immediate breast reconstruction

SURGICAL OPTIONS FOR RECONCTRUCTIONSURGICAL OPTIONS FOR RECONCTRUCTION

A. Autogenousi. Abdominal-based flaps

TRAMUpper abdominal horizontal flapVertical abdominal flapTubed abdominal flap

ii. Latissimus dorsi musculocutaneous flapiii. Gluteal flapiv. Rubens flapv. Thoracoepigastric flapvi. Lateral thigh flapvii. Breast-splitting procedure (now obsolete)

B. Alloplastic

i. Silicone gel implant

ii. Silicone implant with saline fill

Silicon injection

C. Combination procedures

Latissimus dorsi flap with implant

TRAM flap with implant

Site:

* Subcutaneous

* Submuscular

Breast reconstruction with implantBreast reconstruction with implant

Indications: 1. Bilateral reconstruction2. Small breast with minimal ptosis3. Lack of adequate soft tissue on back or abdomen4. Previous abdominal or chest scars causing transections of flap muscle and blood supply 5. Patient unwilling for additional scar on back or abdomen 6. Patient requesting augmentation in addition to reconstruction7.    Patient not suited for long surgery

Contraindications:a. Allergy to siliconb. Implant fearc. Previous failed implantd. Need for adjuvant radiotherapy

Complications:1. Exposure, extrusion and infection of implant2. Malposition, rupture, pain3. Asymmetry4. Capsular contracture5. Breast never mature with age

1. Lattissimus dorsi flap

Based on :

i. Thoracodorsal artery

ii. Segmental perforators of lumbar artery

Breast Breast reconstruction by reconstruction by

autogenous autogenous modalitiesmodalities

Indications: i.   Small breast ii.  Moderate ptosisiii. Abdominal donor site not availableiv. Salvage of previous breast reconstruction

Contraindications:i.  Very large breast, ii. previous lateral thoracotomy, ii. Previous radiotherapy to axilla

Disadvantage:i.   Does not provide enough muscle bulk ii. Simultaneous harvesting of flap with mastectomy not possible iii. donor site morbidity highiv. Fat necrosis in extended LD flap

Gold Standard because - Abdominal skin and subcutaneous fat have same consistency as breast - Enough tissue can be harvested - Abdomino plasty additional cosmetic benefit Based on superior epigastric artery

Indications:1. Breast all size 2. Breast ptosis

Contraindications Previous abdomioplastyPatient unable to tolerate 4-6 wks recovery periodPatient unfit for long procedures

TRAM FlapTRAM Flap

Complications:

• Visible bulge in

epigastrium

• Partial flap necrosis

• Inciscinal

hernia         

                 

Free TRAM flap:

Based on deep inferior epigastric artery which is anastomosed to thoracodorsal or internal mammary artery.

Free FlapFree Flap

DIEP flap:Deep inferior epigastric artery perforator flap. 3-4 perforating vessels from deep inferior epigastric artery which run through rectus abdominis are used Gluteal flap Ruben flaps Free TUG flap Advantages of Free Flaps 1 More distant flaps can be used 2 Vascular pedicle not required; inframammary fold maintained3 Less fat necrosis and partial flap loss4 Can be used in smoker and obese5 Decreased chance of donor site morbidity6 Abdominal hernia uncommon

Other Free FlapsOther Free Flaps

Disadvantages of Free Flap:

i. Loss of whole flap

ii. Need for subsequent corrective surgery

more

iii. Intricate surgery

Factors associated with loss of free flaps:

i. Venous occlusion

ii. Delayed reconstruction

iii. Haematoma

iv. Previous lymph node dissection

v. Previous radiation

BREAST RECONSTRUCTION AFTER BREAST RECONSTRUCTION AFTER BREAST CONSERVATIVE THERAPYBREAST CONSERVATIVE THERAPY

• In 35% of patients significant breast asymmetry has been detected.

• Local flaps minimize the deformity. • Techniques are considered according to the quadrant.• Upper and outer quadrant

i. Mini LD flapii. Sub axillary dermocutaneous flapiii. Parenchymal flaps

• Centrally placed tumors - Local flap rotation- Superior pedicle wise pattern mastopexy for infralveolar tumors - Inferior pedicle wise pattern mastopexy for supralveolar tumors

BREAST RECONSTRUCTION AFTER BREAST BREAST RECONSTRUCTION AFTER BREAST CONSERVATIVE THERAPYCONSERVATIVE THERAPY contd..contd..

• Reconstruction for lower quadrant tumors: modified mastopexy with symmetrization

• Upper medial quadrant : most difficult quadrant to reconstruct

• Modified wise pattern inferior pedicle mastopexy (best option)

• Local parenchymal flapsComplications of Local Flaps:• Flap atrophy• Sepsis• Skin necrosis• Deviation of nipple

NIPPLE AREOLA RECONSTRUCTIONNIPPLE AREOLA RECONSTRUCTION

Final stage in breast reconstruction and should be done only when the reconstructed site has settled i.e., 6-12 months post mastectomy.

Methods of nipple areola complex reconstruction

1. Local flaps : Most commonly used is T flap

NIPPLE AREOLA RECONSTRUCTIONNIPPLE AREOLA RECONSTRUCTION cont… cont…

Free graft

     i.   From contra lateral breast – Nipple sharing

     ii.  Regional mucosal graft

     iii. Labial graft

     iv. Auricular cartilage graft

v. Costal cartilage graft

Medical tattooing

Implants : Tissue engineered nipple

Silicon

Preserved cartilage grafts

Disadvantages: Skin erosion

Breast symmetry is best attained by - Mastopexy - Reduction mammoplasty - Augmentation mammoplasty SURVEILLANCE OF RECURRENCE OF

CARCINOMA IN RECONSTRUCTED BREAST - Most reliable methods

FNAC : Performed when patient has firm subcutaneous mass or

Core or open biopsy : Cobblestoning of skin - Others : MRI, CT scan, scinti mammography - Routine mammography is not recommended

MANAGEMENT OF CONTRA LATERAL BREASTMANAGEMENT OF CONTRA LATERAL BREAST

FRONTIER OF RESEARCHFRONTIER OF RESEARCH

Tissue engineering with patient own cultured adipocytes harvested by liposuction.

CONCLUSIONCONCLUSION1.  Indispensable part of breast surgery in view of significantly enhanced quality of life.

2. All patients undergoing mastectomy should be offered breast reconstruction

3. performed by alloplastic materials and autogenous tissue; the later being aesthetically and emotionally superior

4. Reconstructive surgery can be performed along with mastectomy of 6-12 months later. Current trend is infavour of immediate breast reconstruction

5. Symmetry of the breast reconstruction is the most important factor

6. Breast reconstruction surgeries have glorious past, presently they are the most oncoplastic surgeries performed worldwide and with the increasing interest shown by the patients and the surgeons certainly the future is very promising.