Steligo.recon2017 - Facing our Risk · 5/31/17 7 Implant Recons"uc#on & && AOer&skinLsparing&mastectomy,&1ssue& expansion&and&reconstruc1on&with&breast implants& Before&mastectomy&

5/31/17

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Breast Reconstruction ��Choices and Issues

Kathy SteligoAuthor,

The Breast Reconstruc1on Guidebook

Co-‐author, Confron1ng Hereditary Breast and Ovarian Cancer

Confron1ng Chronic Pain

MastectomyRemoves breast 1ssue

Options After Mastectomy

“Going Flat” (no reconstruc1on)

²  Incision is made across the breast

²  Breast 1ssue, most of breast skin, nipple and areola

are removed

²  The closed incision leaves a wide horizontal or

diagonal scar

²  Wearing breast prosthesis is op1onal

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Options After MastectomyImmediate reconstruc1on with mastectomy

²  back-‐to-‐back procedures (1 visit to OR)

²  breast surgeon removes breast 1ssue, preserves most breast skin (skin-‐sparing mastectomy)

²  plas1c surgeon replaces volume with implants, your own 1ssue, or combina1on of both Delayed reconstruc1on aOer mastectomy

²  addi1onal surgery/recovery weeks, months or years later

Mastectomy and ReconstructionMastectomy Reconstruc1on Creates incisions Can camouflage/hide scars Eliminates breast 1ssue Restores breast volume Removes breast skin Replaces breast skin Removes nipple/areola* Recreates nipple/areola Severs nerves (sensory loss) May encourage some nerve

regenera1on (1ssue flap) Removes milk ducts Doesn’t restore ability to breasWeed

*unless nipple/areola are preserved

Reconstruction Process

Mastectomy

1.  Rebuild breast mound 2.  Revision surgery to build nipple,

refine reconstruc1on, revise scar 3.  TaZoo nipple/areola*

No reconstruc1on

Immediate reconstruc1on

Delayed reconstruc1on

*unless nipple/areola are preserved

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Nipple-sparing Mastectomy

Evolu1on of mastectomy: from radical mastectomy to NSM ²  Similar recurrence/survival as standard mastectomy

²  Candidates: preven1ve mastectomy or small, early-‐stage tumors

not close to skin/nipple

²  Tissue removed at base of nipple (nipple removed if pathology

shows cancer cells)

²  Requires greater surgical skill to remove breast 1ssue through

smaller incision, preserve blood supply to nipple

²  Nipples may flaZen, lose sensa1on/response, or die

Mastectomy IncisionsImmediate Reconstruc1on

Skin-‐sparing mastectomy incisions

Nipple-‐sparing mastectomy Incisions

Mastectomy IncisionsImmediate Implant Reconstruc1on

Photo: Dr. C. Andrew Salzberg

Nipple-‐sparing mastectomy Skin-‐sparing mastectomy, nipple reconstruc1on, taZoos

Photo: Dr. Frank DellaCroce

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Mastectomy IncisionsDelayed Reconstruc1on

Mastectomy scar remains across the chest

Photos: The Center for RestoraCve Breast Surgery

Breast Implants

²  Silicone gel, saline or hybrid (mix of both)

²  Textured or smooth

²  Round Teardrop

Different materials, shapes, sizes, profiles

Breast Implants

²  80% of all breast reconstruc1ons

²  94% involve silicone implants

Source: American Society of PlasCc Surgeons

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Breast Implants

Components Silicone shell filled with saltwater solu1on

Silicone shell filled with silicone gel

Texture/feel Firm, like a water balloon

Closer to natural breast 1ssue

Incision Smaller (implant is deflated when inserted)

Larger (implant is full when inserted)

Implant informaCon/staCsCcs at www.fda.gov

Saline Silicone

Breast Implants

Tradi1onal Tissue expansion

Newer Direct-‐to-‐Implant (no expansion)

Newest Self-‐controlled expansion

Implant Reconstruction: Expansion

²  Tissue expander behind

pectoral muscle creates space for implant

²  Saline added every 7-‐10 days

²  Muscle and skin stretches over several weeks, crea1ng pocket for implant of desired size

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Expander is gradually filled with saline


²  May be larger, higher or different shape than final breast

²  SeZles in place for 6-‐8 weeks or longer

²  Exchanged for implant

²  Op1onal nipple reconstruc1on with or without taZoo


²  AeroForm® inflates with carbon dioxide instead of saline

²  Pa1ent uses remote control to expand at home

²  Self-‐paced: Average comple1on 21 days

AeroForm expanders: www.airxpanders.com

Pa1ent-‐controlled Expansion

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Implant Reconstruction

AOer skin-‐sparing mastectomy, 1ssue expansion and reconstruc1on with breast implants

Before mastectomy

Photos: Mentor®

Direct-to-Implant

²  No expansion. No exchange surgery

²  Requires nipple-‐sparing mastectomy ²  “One-‐step” = “two-‐step” if revisions are needed

or complica1ons require addi1onal surgery

One step. One surgery. One recovery.

Direct-to-Implant

²  Sterile soO 1ssue replacement

²  Skin from human cadaver, bovine or swine (also silk) ²  Stripped of cells but retains collagen, other proteins

²  Supports growth of new cells and blood vessels

Acellular dermal matrix

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Direct-to-Implant

²  Implant placed immediately under

the pectoral muscle

²  Acellular dermal matrix sewn to muscle edges and inframammary breast fold

²  “Internal bra” forms instant pocket; supports implant in posi1on, covers lower por1on of implant

Image: LifeCell

Direct-to-Implant

AOer nipple-‐sparing mastectomy, reconstruc1on with silicone gel implants

Before mastectomy

Photos: Dr. C. Andrew Salzberg

Implant Reconstruction

Size maZers

“My implants are too big!”

“My implants are too small!”

²  Smaller, larger or same as your natural breast size

²  Discuss size with your plas1c surgeon before your reconstruc1on

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Tissue Flap Reconstruction

²  Flaps from abdomen, back, buZock,

hip or thigh are relocated to the chest

²  Creates addi1onal incision at donor site

²  Different procedures, surgical skill, length of surgery, hospital stay, recovery

Breasts of your own living 1ssue


All flaps are not equal

²  Flaps include fat and skin moved from the donor

site to the chest

²  Tradi1onal methods also remove muscle

²  Advanced methods use fat and skin; preserve muscle


Flaps don’t need muscle the new breast (flap) needs the blood supply that

runs through the muscle

Flaps access the blood supply in different ways, requiring different surgical skills:

²  AZached (pedicled) flaps use en1re muscle

²  Free flaps use “small” amount of muscle

²  Perforator flaps use no muscle. Blood supply is detached from muscle; reconnected in chest -‐ Fewer qualified surgeons -‐

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Flaps don’t need muscle they do need the blood supply that runs through the muscle


Abdominal Flaps: AZached TRAM ²  Low hip-‐to-‐hip incision

²  Fat, skin and muscle tunneled

under skin to chest; remains tethered to original blood supply

²  Reduced abdominal strength (sit-‐ups, gemng out of bed without rolling over)

²  Bonus: tummy tuck

fat

muscle


Abdominal Flaps: Free TRAM ²  Same hip-‐to-‐hip incision, same scar, same tummy tuck

²  Fat, skin and some muscle

surrounding blood supply moved from abdomen to chest

²  Microsurgeon reconnects blood vessels in chest

²  Cumng across muscle reduces abdominal strength/support

Image: University PlasCc Surgery

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Perforator Flap Reconstruction

Abdominal Flaps: DIEP

²  Same incision, same scar, same tummy tuck

²  Most common flap for breast reconstruc1on*

²  Blood vessels are teased away from muscle

²  En1re muscle remains fully func1onal

²  Less intense recovery; reduced chance of hernia, other complica1ons

*American Society of PlasCc Surgeons

Perforator Flaps: DIEP

Before and aOer: Bilateral nipple-‐sparing mastectomy with immediate DIEP reconstruc1on, later nipple reconstruc1on and taZoos

Photos: Dr. Minas Chrysopoulo


Comparing TRAM and DIEP

They look alike from the outside; very different on the inside

AZached TRAM DIEP Free Tram

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Back flap: La1ssimus dorsi (Lat)

²  AZached flap: muscle

tunneled under skin from back to chest

²  Adequate for A-‐ or B-‐cup

²  Implant usually added


Images: MacMillan Cancer Support

Back flap: La1ssimus dorsi (Lat)


BuZock Flaps: Superior Gluteal Artery Perforator (S-‐GAP)

Inferior Gluteal Artery Perforator (I-‐GAP)

²  Perforator flaps (use no muscle)

²  Op1on for women without enough abdominal fat

²  Firmer than abdominal 1ssue

²  Longer surgery; less intense recovery

²  Few surgeons perform GAP; even fewer offer bilateral simultaneous GAP

SGAP

IGAP

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Perforator Flaps: GAP

Photos: Center for RestoraCve Breast Surgery

Before and aOer: Prophylac1c bilateral mastectomy with immediate GAP reconstruc1on

Perforator Flaps: GAP


Before and aOer: SGAP reconstruc1on donor site


Thigh Flaps: TUG

²  Free flap: transverse upper gracilis (inner thigh) muscle

²  No func1onal loss; other muscles take up the slack

²  Crescent-‐shaped flap provides excellent breast shape and projec1on; creates immediate nipple reconstruc1on in some women

²  Scar hidden in groin

²  Bonus: inner thigh liO Image: Dr. Anureet Bajaj

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Other Perforator Flaps

ICAP From the underarm adjacent to breast LAP From the “love handles” PAP From the upper thigh beneath buZock TDAP/TAP From the back

Tradi1onal implants

Expansion Revision surgery; exchange, build nipple#

TaZoo#

Direct-‐to-‐Implant*

Replace breast 1ssue with implants

Tissue flaps Harvest 1ssue for breast mound

Revision surgery; Build nipple#

TaZoo#

* with nipple-‐sparing mastectomy #not required with nipple-‐sparing mastectomy

Comparing Implants and Flaps

Step 1 Step 2 Step 3

Comparing Implants and Flaps

Eventual replacement Lifelong

Less natural shape and feel Natural soOness of living 1ssue

Incision @ mastectomy site Incisions @ mastectomy and donor sites

More difficult to match opposite healthy breast

Easier to match opposite healthy breast

Shorter surgery; longer 1meline* Longer surgery; shorter 1meline

Easier, quicker recovery More invasive surgery, longer recovery

* TradiConal expansion. Direct-‐to-‐implant = shortest overall Cmeline

Implants Flaps

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Fat Grafting

1.  Moves liposuc1oned fat from abdomen, thighs, hips, or anywhere else you have it to spare

2.  Cleansed of blood and cellular debris 3.  Injected in 1ny amounts into the new breast 4.  May require mul1ple sessions

5.  Affected by future weight loss/gain

50-‐70% of fat typically remains in the breast (the rest is resorbed by the body)

Fat Grafting

²  adds volume ²  smooths contour irregulari1es ²  improves cleavage ²  fills in sunken area above the breast ²  hides implant edges, camouflages rippling and wrinkling ²  soOens/improves texture of previously radiated 1ssue ²  refines scars

Can make a good reconstruc1on beZer

Fat Grafting

Images: Dr. Minas Chrysopoulo

AOer bilateral DIEP flap reconstruc1on Subsequent fat graOing improves overall symmetry, volume, and shape

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Fat Grafting

Seems to be the best thing since…

Nipple Reconstruction

²  Op1onal last step

²  Usually created from mini-‐flap of breast skin

²  Many different types of nipple flaps

Nipple Reconstruction

²  Ini1ally 50% larger than desired; new nipple shrinks in 1me

²  Nipple/areola taZooed to match natural nipples or lip color; eventually fades

²  Op1onal “stuffing” with acellular dermal matrix, other synthe1c filler: Headlights on!

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Nipple Reconstruction: Before

Immediate reconstruc1on Delayed reconstruc1on

Nipple Reconstruction: After


Nipple Reconstruction: Alternatives

²  3-‐D taZoo simula1on of nipple

²  No nipples

²  Temporary adhesive nipples

Photo: Red Rose TaQoo

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Creative Tattooing

Photos: Black and Blue TaQoo, Ink Couture

Reconstruction After Radiation

²  Inhibits blood flow and skin elas1city; can delay healing

²  Implants aOer radia1on = greater likelihood of complica1ons -‐ Radiated breast skin can be difficult to expand

-‐ Pre-‐padding mastectomy site with fat graOs may help ²  Tissue flap = fewer complica1ons, beZer aesthe1cs

(brings healthy 1ssue to radiated area)

Reconstruction After Radiation

Delayed-‐immediate reconstruc1on

Pathologyindicates needfor radiation?

Completeradiation

Exchangeexpander for

implant ortissue flap

Exchangeexpander for

tissue flap

Deflateexpander

no

yes

Placefully inflated

tissue expander

Skin-sparingmastectomy

Reinflateexpander

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Mastectomy: You Have More Options

Tradi1onal Methods Newer Methods*

Removes breast 1ssue, skin Preserves most breast skin and muscle Preserves muscle

Removes nipple and areola Nipple-‐ and/or areola-‐ sparing

* immediate reconstrucCon

Tradi1onal Methods Advanced Methods

Tissue expansion Direct-‐to-‐implant Self-‐expansion

Flaps that sacrifice muscle Muscle-‐sparing flaps

Few surgical op1ons Numerous surgical op1ons

Minimal/no insurance coverage WHCRA

Reconstruction: You Have More Options

The Best Reconstruction…

Procedures and results have drama1cally improved in the past decade

Good reconstruc1on looks natural, with or without clothing

No reconstruc1on is one-‐size-‐fits-‐all: all procedures have advantages and disadvantages

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Reconstruction: Your Right

²  Health insurers who cover mastectomy must also pay for prostheses, all stages of reconstruc1on, and related complica1ons

²  Does not guarantee coverage for any surgeon, any hospital, or any procedure. (May require use of in-‐network physicians/hospitals)

²  Usual and customary coverage consistent with exis1ng plan benefits: same deduc1bles and co-‐payment

The Women’s Health and Cancer Rights Act of 1998

Choosing A Plastic Surgeon

The single-‐most important aspect of reconstruc1ve surgery

²  All surgeons don’t perform all procedures

²  Choose a board-‐cer1fied surgeon with lots of experience with the procedure you want…and who does it rou1nely

²  Get a second opinion (three is beZer)

²  Talk to pa1ents who have had same procedure

Making Your Decision

²  Show & Tell (tonight)

²  ReconstrucCon Q&A panels (today and tomorrow)

²  “Ask the Experts” roundtable (tomorrow)

²  Talk to women who have made the journey

²  FORCE message boards

²  The Breast ReconstrucCon Guidebook

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Making Your Decision

²  If possible, take the 1me you need: It’s a BIG decision

²  Consider the benefits/limita1ons of different procedures

²  It’s a process, with a beginning and end

²  Reconstruc1on is a personal choice

What Else Can You Do?

²  Learn as much as you can

²  Know what to expect

²  Stop smoking

²  Lose weight if you need to

²  Eat well

²  Get fit…train for surgery/recovery

²  Cul1vate a posi1ve mental amtude

.

Questions?

Documents

Steligo.recon2017 - Facing our Risk · 5/31/17 7 Implant Recons"uc#on & && AOer&skinLsparing&mastectomy,&1ssue& expansion&and&reconstruc1on&with&breast implants& Before&mastectomy&