Still the

same?

BREAST RECONSTRUCTION SURGERYWasula athnaweera

2014.12.12

HISTORY

William Halsted first radical mastectomy in 1889

• ‘‘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.”

1895 Vincent Czerny

transplantation of a large lipoma from the patient’s flank

1906 the Tanzini

a pedicled flap of skin and underlying latissimus dorsi

muscle

1905 Ombredanne

pectoral muscle as amound.

luxury operation

1942 Sir Harold Gilles

tubed abdominal flap method

1962 silicone breast implants

cosmetic augmentation

1970 s LD flap - most popular

1977 Hohler and Bohmert

2 stage reconstructions

thoracoepigastric flap + prosthesis

1982 Hartrampf

the first TRAM flap

1982 Radovan

tissue expansion

INDICATIONS

After mastectomy

After BCS

Congenital anomalies

Development anomalies

Traumatic disfigurement

CONCERNS BEFORE SX

Patient factors Body habitus Past history – Sx, RT, Co morbidity Smoking Patients wishes and education

Disease factors Volume loss

Margin status

Stage of the disease

Adjuvant therapy

Surveillance

Other factors Cost

Availability

Resources

Expertise

COMPONENTS OF RECONSTRUCTION

Foot print

Mound

Skin

Volume

NAC

Symmetry

CLASSIFICATION

Timing Immediate vs delayed

Composition Autologous

Prosthesis

Combined

Primary surgery Mastectomy

MRM

Simple

SSM

NSM

WLE Volume

Volume displacement

Volume replacement

Quadrent affected

Indication Theraputic

Prophylactic

Unilateral & bilateral

Contralateral breast surgery

Reduction

Augmentation

NAC reconstruction

TIMING OF RECONSTRUCTION

40% of women in USA undergo mastectomy for Ca

Total number ~ 18000 a year

33% undergo breast reconstruction after

mastectomy

22% immediately

Cause

Lack of awareness

Failure of referral

Immediate

Adv

Wake up with a breast

Lesser # of GA

Better results

Colour

Sensate

Aesthetics

Shape

Specially with SSM,NSM`

Disadv

High expectations

Failure is a double blow

Dual surgical

competencies

Delayed

Adv

Patients are more

satisfied

Psychological

adjustment for lost

breast

Better decision making

for primary condition

Margin status

Disadv

Less skin remains

Tissue expansion

Less sensate

2 procedures

More GA

More resources

COMPOSITION

Aotologous

Pedicled myocutaneous flaps

LD

LD varients

Split LD

Fleur de lis

Muscle sparing

TRAM

Standard

Super charge TRAM- additional micro surgery to enhance blood

supply from thorax

Pre ligation of IEA- improve Superior EA blood supply

Fleur de lis

TRAM

Indications

Poor tissue quality after

MRM

Possible implant

exposure

Axillary fill

Infraclavicular tissue

deficit

Contra indications

Absolute

Irradiated flap base

Sx at the pedicle

Prior abdominoplasty

Abdominal scars

Relative

>65 yrs

V obese

Unfavorable

microcirculation

Diabetes

Smoking

Free flaps

Free TRAM

Modifications of TRAM- muscle sparing

MS 0 ,1, 2,3(DIEP)

SIEA

Stacked DIEP

GAP

SGAP

IGAP

MTG

Ruben`s flap

deep circumflex iliac artery flap

Adv

More natural

Physiologic changes may go

together

Eg LOW

Donor benefit

Abdominoplasty

Option after RT

Feel reconstruction is ‘own

breast’

Disadv

Risk of failure

Complications

Donor site morbidity

special skills

Resource demand

Longer surgery

Body Habitus

Non smokers

Longer recovery

Prosthetic

Implants

Silicon gel implant- standard

• Controversy of earlier silicon implant leaking and malignancy

is scientifically excluded in 2000

Tissue expanders

Permenant

Convertion to implant

IMPLANTS

Shape

Round

Tear drop

Shell

Mono layer/ tripple layer

Smoooth /textured

Filler

Saline

Silicon gel

Dimentions

Coated / uncoated

polyurathene

COMPLICATIONS OF IMPLANTS

Capsular contracture

Baker classification

I. Soft

II. Less soft, implant not visible

III. Firm, implant palpable,distortion seen

IV. Very firm, hard tender,cold

Capsulotomy, capsulectomy

? To use leukotriene inhibitors

Haematoma

Cellulitis

Seroma

Skin necrosis- complete/partial

Implant failure

Infection

Criteria

Adequate skin envilop

No hx of radiation

No smoking 6 weeks pre op

Placement of prosthesis

(Sub glandular)

Sub muscular

Acellular dermal matrix incooperated

Serratus flap incooperated

Myocutaneous flap itself incooprated

Adv

Single stage

Less time consuming

No donor scar or

morbidity

Good for small breasts

Better volume matching

Disadv

Foreign body reaction

Infection

Capsular contraction

sp if RT given

May need expander

stages

Difficult following RT

PRIMARY SURGERY

BCS-WLE

Reconstruction technique and volume loss <20%- no need of complicated procedures

20-40% -volume displacement techniques

>40% volume replacement techniques

Mini LD

Thoraco epigastric

Intercostal perforator flaps

Adv

Adequate margins with good cosmetic results

Acceptable cosmesis in large volume resections

Long lasting good results

Reduce late unacceptable cosmetic effects of

radiation

Disadv

Difficulties of RT planning

- need for clip placement

If further resection needed

- ending in a mastectomy

Complication related to oncoplastics

- Skin necrosis

- Fat necrosis

- cosmetically less acceptable results

- Delayed wound healing leading to treatment delays

Need of additional training in oncoplasty

PRINCIPLES BEHIND ONCOPLASTICS :

(A) vascular supply is maintained :

move skin with NAC on underlying breast

move breast against muscle

breast segments to be moved to a different location

NAC in appropriate direction based on breast blocks ( superior / inferior based pedicles)

PRINCIPLES BEHIND ONCOPLASTICS :

(B) Selection criteria :

Excision volume - as % from breast volume

Tumour location - quadrant wise / clock position

Glandular density ( BIRDS)

PRINCIPLES BEHIND ONCOPLASTICS

(C) Selection of Levels of oncoplastic procedures

Level I ops (Dual plane under mining)

- Lesser volume loss

- Patients tolerating Duel-plane undermining

(BIRADS III / IV )

Level II ops (single plane undermining – dermoglandular flaps)

- For larger volume resections

- For breasts not tolerating duel-plane undermining

(BIRADS I/ II)

- For patients requesting reductions at the same time

PARALLELOGRAM FOR UOQ TUMOURS

ROUND BLOCK TECHNIQUE FOR 12 TUMOURS

BATWING MASTOPEXY FOR UQ TUMOURS

TENNIS RACKET METHOD FOR UOQ TUMOURS

ROTATION FLAP FOR UIQ TUMOURS

GRISOTTI PROCEDURE FOR CENTRAL TUMOURS

J mammoplasty for LOQ

tumours

V – mammoplasty for LIQ tumours

VERTICAL REDUCTION FOR 6 OCLOCK TUMOURS

WISE PATTERN REDUCTION MAMMOPLASTY FOR 6 & 12

TUMOURS

SUMMARY OF QUADRANT PER QUADRENT PROCEDURES( EG : L BREAST)

Clock position Procedire

5-7 o’clock Lower pole Superior pedicle mammoplasty (wise

type)/ Verticle reduction

7-8 o’clock Lower inner quadrent ,, / ,, - repair rotated to 7-8 o’clock/

V scar

4-5 o’clock Lower outer quadrent ,, / ,, - repair rotated to 4-5 o’clock /

J scar

12 o’clock Upper pole Inferior pedicle mammoplast (wise

pattern) / Round block

9-11 o’clock Upper inner quadrent Batwin / Rotation flap

1-2 o’clock Upper outer quadrent Tennis Racquet mammoplasty /

Parallelogram / Radial scar

Central subareolar Grisotti / Superior pedicle Grisotti type /

inverted T or vertical scar with NAC

resection

STANDERDS

Surgery to opposite breast

Reduction

Augmentation

Revision procedures

Implant revision

Fine tuning

Fat injections

NAC reconstruction

Surgery- local skin flap rearrangement

Free graft from opposite NAC

50% loss of nipple height

Tattooing

Skin grafts from dark-skinned sites

Inner thigh

Cartilage, fat augmentation

Alloplastis techniques

Polyurethene coated silicone ggel

Hyaluronic acid

PTFE

ADM

Problems of breast reconstruction

Image survillance

Mammo- not possible

Need MRI

Insensate

Breast

Nipple

May need further procedures with time

Same side

Opposite side

Physiological changes absent

THANK YOU