BREAST RECONSTRUCTI

ONDr. Vanessa Voge

Wichita Surgical Specialists

BREAST RECONSTRUCTION Brief overview Types of breast reconstruction available

after mastectomy Types of “reconstruction” that can be

combined with lumpectomy

BREAST RECONSTRUCTION Each year more than 250,000 American

women face breast cancer. Undergoing Mastectomy affects one in

many dimensions--emotionally, physically, psychologically, etc…

In the past, reconstructive options were not available or not widely offered.

BREAST RECONSTRUCTION New kinds of treatment as well as

improved reconstructive surgery mean that women who have breast cancer today have better choices.

Breast reconstruction is a type of surgery for women who have had a breast removed.

The goal is to provide a treatment for breast cancer and still provide shape and symmetry to the breasts.

BREAST RECONSTRUCTION Often patients have many questions

Forefront is the cancer itselfWhat will I look like after mastectomy?What are reconstruction options?What will my breast(s) look like after

reconstruction?How is reconstruction affected by additional

cancer treatments such as chemo or radiation?

BREAST RECONSTRUCTION Treating the breast cancer first Very patient dependent Cancer treatment dependent Individualize treatment plans

BREAST RECONSTRUCTION Reconstruction or not

Some patients are not candidates Severe obesity, systemic disease,

psychological/emotional state

Prosthesis Pros- decreased amount of surgery and surgery

sequela, can vary size, effect of water Cons- Can shift, weight, not a part of body

BREAST RECONSTRUCTION Timing of Reconstruction

Time of Mastectomy- “immediate breast reconstruction”

After one has healed from mastectomy- “delayed reconstruction”

BREAST RECONSTRUCTION At the time of mastectomy

Currently most common way

Pros: Save skin, better aesthetic result, reconstruction started or possibly finished at time of mastectomy

Cons: Post-operative radiation, possible increase in skin healing problems

BREAST RECONSTRUCTION Types of reconstruction- patient

dependentTissue Expander/Implant basedLatissimus flap/implantTRAM flapFree Flap- DIEP, free tram, S-GAP, etc…

Nipple and areolar reconstruction

BREAST RECONSTRUCTION Tissue Expander/Implant

Makes up more than 75% of breast reconstructions in the United States

Requires minimum of two surgeriesAt the time of mastectomy the tissue

expander is placed--“first stage breast reconstruction”

TISSUE EXPANDER

TISSUE EXPANDER

TISSUE EXPANDER WITH BIOLOGICAL MESH SUPPORT There is more use of a biological

support, such as alloderm.

TISSUE EXPANDER/IMPLANT Second surgery involves the exchange

of the tissue expander for an implant- “second stage breast reconstruction”

Approximately 4 months from first surgery, but varies greatly from patient to patient and surgeon to surgeon

BREAST IMPLANTS

TISSUE EXPANDER/IMPLANT

TISSUE EXPANDER/IMPLANT Pros: Shorter surgery time, breasts

remain same size and overall position, If bilateral symmetry possibly improved, less scarring, less operative sites, decreased “overall” complication rates

TISSUE EXPANDER/IMPLANT

Cons: Foreign objects, not lifelong devices, capsular contracture, loss of implants, stay the same with time, asymmetry

SINGLE STAGE BREAST RECONSTRUCTION WITH IMPLANT Placing the breast implant at the time of

mastectomyNot as commonOnly in certain patients with ideal anatomy

and cancersAlmost always with Alloderm or equivalent

SINGLE STAGE RECONSTRUCTION WITH IMPLANT

TRAM FLAP TRAM- Transverse Rectus Abdominus

Myocutaneous Rectus muscles- Abdominal “six pack”Core muscle

TRAM FLAP

TRAM FLAP Pros: Own tissue (replacing like with

like), affected some by gravity, fluctuates with weight, possibly no additional surgery except nipple/areolar creation, matches other non reconstructed breast, remove excess abdominal tissue

TRAM FLAP Cons: Larger/longer surgery, longer

recovery, not true abdominoplasty, risk hernia/abdominal bulge, bulge upper abdomen, weakness to abdomen, Full loss of flap, partial loss of flap, fat necrosis, specific candidates (previous surgeries, weight, smoking, etc…)

LATISSIMUS FLAP Latissimus dorsi muscle is on back Activities for “lat pulls”, cross country

skiing, rock climbing, etc… can be affected.

LATISSIMUS FLAP

LATISSIMUS FLAP

LATISSIMUS FLAP Pros: Own tissue, non-radiated tissue,

“covers” implant

Cons: larger/longer surgery, muscle weakness, fluid collection, often needs implant or tissue expander/implant

FREE FLAPSDisconnecting the blood supply to an area

of tissue and “reconnecting” the tissue’s blood supply at a distant site

Often under a microscopeOnly at certain medical centers

FREE FLAPS DIEP- Deep Inferior Epigastric Perforator

FREE TRAM FLAP

DIEP AND FREE TRAM FLAPS Benefits over TRAM flap

Rectus muscle remains in abdomen Debate on functionality of muscle as nerves may

be injured, different techniques, etc…Decreased risk of hernia or abdominal bulgePotential decreased recovery timeCan use is some people who smoke or are

obeseLess chance partial flap loss and fat

necrosis

FREE FLAPS Downside to free flaps

Higher risk complete flap lossOnly available at certain centersLonger Surgery

GAP FLAP GAP: Gluteal Artery Perforator

S- Gap: Superior I- Gap: Inferior

TUG FLAP TUG Flap: Transverse Upper Gracilis

RADIATION NEEDED OR DELAYED RECONSTRUCTION Adapt reconstruction plan as needed Some reconstruction options not

available

NIPPLE/AREOLAR RECONSTRUCTION Many different ways to create Choice to have performed or not

NIPPLE CREATION

NIPPLE AND AREOLAR CREATION

NIPPLE/AREOLAR CREATION Tattoo only “Stick-ons” Temporary tattoos

MATCHING PROCEDURE The non-operated breast may be

LargerSmallerHang lower

MATCHING PROCEDURES Breast reduction Breast augmentation Breast lift

Oh, my friend, it’s not what they take away from you that counts- it’s what you do with what you have left…..Hubert Humphrey

ONCOPLASTICS Incorporating breast tissue movement

at the time of lumpectomyTo decrease chance of defect or asymmetryOperating on radiated tissue has increased

risk of complications

ONCOPLASTICS Reduction at the same time as

lumpectomy If you ever thought of a breast reduction,

ask if you are a candidate for a reduction with lumpectomy

Some breasts or cancers not amendable

BREAST REDUCTION PATTERN

ONCOPLASTIC Tissue rearrangement

To prevent or decrease the chance of a breast defect

Have to have tissue that can be moved into potential defect site

ONCOPLASTIC Despite best devised surgical

treatments breast defects or distortion can occur after lumpectomy and radiation

Reconstruction options available

BREAST RECONSTRUCTION Available options to reconstruct a breast Oncoplastic options during lumpectomy Future

THANK YOU