Breast Reconstruction

Breast reconstructionBreast reconstruction

Penny L McManus FRCSPenny L McManus FRCS

Consultant oncoplastic breast surgeonConsultant oncoplastic breast surgeonHull UKHull UK

Breast ReconstructionBreast Reconstruction Immediate (with mastectomy)Immediate (with mastectomy)

Better cosmetic outcomesBetter cosmetic outcomes CheaperCheaper Early Psychological benefitEarly Psychological benefit

DelayedDelayed Patient has more time to consider optionsPatient has more time to consider options Adjuvant therapy completedAdjuvant therapy completed Higher long term patient satisfaction ratesHigher long term patient satisfaction rates

Skin sparing mastectomy for immediate reconstructionSkin sparing mastectomy for immediate reconstruction

Techniques in Breast Techniques in Breast ReconstructionReconstruction

Expander/ImplantExpander/Implant

Latissimus Dorsi (LD)Latissimus Dorsi (LD)

TRAM / DIEP TRAM / DIEP

Other free flaps – SGAP, IGAP, TUGOther free flaps – SGAP, IGAP, TUG

lipomodelinglipomodeling

Implant ReconstructionImplant Reconstruction

2 stage: 2 stage: Tissue expander then permanent silicon Tissue expander then permanent silicon

implantimplant

1 stage: 1 stage: Permanent expander-implantPermanent expander-implant Permanent implant with dermal sling or Permanent implant with dermal sling or

Acellular dermal matrixAcellular dermal matrix

2 stage implant reconstruction2 stage implant reconstruction

Delayed and immediateDelayed and immediate

Submuscular tissue Submuscular tissue expanderexpander

Serial expansionSerial expansion

Change to permanent Change to permanent silicone implantsilicone implant

Tissue expander placed in submuscular pocketTissue expander placed in submuscular pocket

Delayed 2 stage implant reconstructionDelayed 2 stage implant reconstruction

AAdvantagesdvantages

Short operating time Short operating time and recoveryand recovery

Low complication rateLow complication rate No donor site No donor site

morbiditymorbidity Normal appearance in Normal appearance in

clothingclothing

DDisadvantagesisadvantages

2 operations2 operations No ptosisNo ptosis No change with body No change with body

weight/ageweight/age Feels coldFeels cold Late complicationsLate complications

RadiotherapyRadiotherapy

Immediate implant with dermal slingImmediate implant with dermal sling

Wise pattern mastectomyWise pattern mastectomy Lower pole skin de-Lower pole skin de-

epithelialised & sutured to epithelialised & sutured to lower edge pectoralislower edge pectoralis

Ptotic breastsPtotic breasts Patients requesting Patients requesting

reductionreduction

Risk reduction Risk reduction mastectomymastectomy

Immediate implant with dermal slingImmediate implant with dermal sling

Immediate implant with acellular dermal Immediate implant with acellular dermal matrixmatrix

Strattice, Alloderm, Strattice, Alloderm, Permacol, SurgimendPermacol, Surgimend

Sutured to lower edge Sutured to lower edge pectoralis and pectoralis and inframammary foldinframammary fold

Smaller, non-ptotic Smaller, non-ptotic breastbreast

High complications rateHigh complications rate High costHigh cost

Immediate implant with ADMImmediate implant with ADM

ComplicationsComplications

EarlyEarly Wound breakdownWound breakdown Infection Infection explantation explantation RotationRotation

LateLate Capsular contracture (20% at 10 years)Capsular contracture (20% at 10 years) Deterioration of overlying tissuesDeterioration of overlying tissues Implant ruptureImplant rupture

Patient selectionPatient selection

Patient desires & expectationsPatient desires & expectations

Small, non-ptotic breastSmall, non-ptotic breast Contralateral reduction or mastopexyContralateral reduction or mastopexy

Avoid in diabetics, smokers, steroids, RTAvoid in diabetics, smokers, steroids, RT

Latissimus Dorsi Flap

Extended Latissimus Dorsi flapExtended Latissimus Dorsi flap

Extended LD flapExtended LD flap

Pros and ConsPros and Cons Operating time 4-5 Operating time 4-5

hourshours Stay 4 daysStay 4 days Recovery 4-5 weekRecovery 4-5 week

Safe and reliable flapSafe and reliable flap Can be irradiated if Can be irradiated if

autologousautologous

Donor site scar and Donor site scar and morbiditymorbidity

TwitchingTwitching

SeromaSeroma Flap failureFlap failure Flap atrophyFlap atrophy

LD with implantLD with implantPreop immediate LD + Implant 2 years postop

Preop delayed LD + Implant 2 years postop

Autologous LDAutologous LDPreop immediate LD 3 months postop

Preop delayed LD 12 months postop

Autologous LD & fat transferAutologous LD & fat transfer

Pre-op 5 years post-op

Pre-op 2 years post-op

TRAM/DIEPTRAM/DIEP Flaps Flaps Anterior abdominal wall tissueAnterior abdominal wall tissue

PedicledPedicled Transverse Rectus Abdominis Myocutaneous Transverse Rectus Abdominis Myocutaneous (TRAM) Flap(TRAM) Flap

Free: Free: Free TRAM Free TRAM Deep Inferior Epigastric Perforator (DIEP) FlapDeep Inferior Epigastric Perforator (DIEP) Flap SIEA flapSIEA flap

Operating time 6-8 hoursOperating time 6-8 hours Stay 4-5 daysStay 4-5 days Recovery 7-8 weeksRecovery 7-8 weeks

Pros and ConsPros and Cons Larger reconstructionLarger reconstruction Muscle sparingMuscle sparing Natural feel & Natural feel &

consistencyconsistency ““tummy tuck”tummy tuck”

longer operating timelonger operating time higher risk of flap losshigher risk of flap loss

donor site morbiditydonor site morbidity donor site scardonor site scar

Fat graftingFat grafting Autologous fat transfer / LipomodelingAutologous fat transfer / Lipomodeling

Fat removed by liposuction from areas of excessFat removed by liposuction from areas of excess Centrifuged in theatre to remove blood and dead Centrifuged in theatre to remove blood and dead

cellscells Injected into breast Injected into breast

Can be used with other types of reconstructionCan be used with other types of reconstruction Can be used to correct defects after breast Can be used to correct defects after breast

conserving surgery or failed reconstructionconserving surgery or failed reconstruction Low morbidityLow morbidity

Fat transferFat transfer

Fat transfer to revise reconstructionFat transfer to revise reconstruction

Fat transfer for asymmetryFat transfer for asymmetry

Fat transfer for breast conserving surgery defectFat transfer for breast conserving surgery defect

Fat transfer alone for reconstructionFat transfer alone for reconstruction

SummarySummary

Reconstruction benefits patientsReconstruction benefits patients Wide range of optionsWide range of options Patient selection is keyPatient selection is key

““Reconstructive ladder”Reconstructive ladder”

Thank youThank you