Breast Reconstruction - The Who, What, When, How and Why · Breast Reconstruction - The Who, What,...
Transcript of Breast Reconstruction - The Who, What, When, How and Why · Breast Reconstruction - The Who, What,...
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
• www.deanwhite.com.au
• Australasian Society of Plastic Surgeons - ASPS
www.plasticsurgery.org.au
• Royal Australasian College of Surgeons www.surgeons.org