Breast Reconstruct ion - The Who, What, When, How and Why

DEAN WHITE MBBS FRACS GRAD.DIP.BIO.EPID. GAICD

PLASTIC AND RECONSTRUCTIVE SURGEON

DEANWHITE.COM.AU

• Plastic and Reconstructive Surgeon

• Clinical Director of Plastic Surgery Eastern Health (Box Hill,

Maroondah, Yarra hospitals)

• Director of the Head and Neck Clinical Institute Epworth

Healthcare Group (Plastic Surgery, ENT, OMFS, Dermatology,

Ophthalmology)

• Clinical cases with realistic results in my hands

• Types of reconstruction available and their evolution

• Advantages and disadvantages of each

• What factors are involved in the surgical decisions/planning

• Not dealing with primary treatment of breast cancer (Lumps,

nipple discharge, radiological findings etc)

• Breast reconstruction post/peri cancer in conjunction with

breast/general surgeons and other members of the

multidisciplinary team

• Complex area

• Individually tailored

• Options keep evolving

• Need all the options to offer a complete service

• Still relatively low rate

RECONSTRUCTIVE OPTIONS

• Nil - external prosthesis

• Alloplastic - Implant based

• Autogenous - Own tissues, Pedicled vs Free Flaps

• Combination

• Primary - at the time of resective surgery

• Secondary - later

IMPLANT RECONSTRUCTION

• Historically often 2 stage operation with use of tissue expander

first

• Currently more able to use DTI (Direct to Implant) with FLEX

HD (ADM)

• Shorter operation

• No other surgical sites

• Less expertise required

• Time to think

• Preserves skin envelope

• Can have XRT, chemo

• Leaves all other options available

• Infection

• Extrusion

• Long term maintenance

• Capsular contracture

• Less natural feel

• Unknown risk profiles (ALCL)

AUTOGENOUS (OWN TISSUES) RECONSTRUCTION

• Own tissues

• Durability and ages with patient

• More natural feel

• Secondary donor benefits

• High expertise

• Two plastic surgeons

• Longer surgery

• Donor site

• Pedicle flaps - TRAM, Latissimus Dorsi

• Free flaps (microsurgery) - TRAM, MS-TRAM, DIEP

Other donor sites - TUG, IGAP, Rubens

LATISSIMUS DORSI - PEDICLE FLAP

• Usually with implant

• Pedicle flap

• Less used now

WHICH OPTION?

• Patient - Age, BMI, SMOKER

• Comorbidities eg Heart disease, diabetes

• Medications - anticoagulants, immunosuppressants

• Cancer vs in situ vs prophylactic (BRCA gene)

• Degree of resection/surgery, RADIOTHERAPY, chemotherapy

• NAC preserved vs taken

• Timing - Concurrent or delayed

• Geographic location

• Pregnancy goals

• Contralateral breast

• Desire re post op size (bigger, smaller, higher?)

• PATIENT PREDETERMINED IDEAS

• Grab and Grope Test

• Fully clothed

• Evening dress

• Bathers/Underwear

• Naked

• Younger

• Prophylactic

• City Dweller

• Private

• Still low rates

ADJUNCTIVE PROCEDURES

• Contralateral breast - reduce/increase and increasingly

prophylactic

• Lift

• NAC

• Fat grafting

• Multiple operations to achieve the ideal endpoint

• Touch-ups

• NAC

• Scar Burden

• Realistic expectations (Photos)

COMPLICATIONS

• What do you mean there will be a scar?

• Aren’t you a plastic surgeon??!?

CASE EXAMPLES

• Individually tailored

• Often multiple options - rarely a “best” operation

• Often several stages

• Techniques constantly evolving

• Patient choice requires consultation with those knowledgeable

about all current management approaches

• microsurgeon.org

• Thank you

• www.deanwhite.com.au

• Australasian Society of Plastic Surgeons - ASPS

www.plasticsurgery.org.au

• Royal Australasian College of Surgeons www.surgeons.org