breast reconstruction
TRANSCRIPT
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Still the
same?
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BREAST RECONSTRUCTION SURGERYWasula athnaweera
2014.12.12
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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.”
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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
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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
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INDICATIONS
After mastectomy
After BCS
Congenital anomalies
Development anomalies
Traumatic disfigurement
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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
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COMPONENTS OF RECONSTRUCTION
Foot print
Mound
Skin
Volume
NAC
Symmetry
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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
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Unilateral & bilateral
Contralateral breast surgery
Reduction
Augmentation
NAC reconstruction
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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
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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
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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
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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
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Fleur de lis
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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
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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
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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
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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
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IMPLANTS
Shape
Round
Tear drop
Shell
Mono layer/ tripple layer
Smoooth /textured
Filler
Saline
Silicon gel
Dimentions
Coated / uncoated
polyurathene
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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
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Haematoma
Cellulitis
Seroma
Skin necrosis- complete/partial
Implant failure
Infection
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Criteria
Adequate skin envilop
No hx of radiation
No smoking 6 weeks pre op
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Placement of prosthesis
(Sub glandular)
Sub muscular
Acellular dermal matrix incooperated
Serratus flap incooperated
Myocutaneous flap itself incooprated
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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
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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
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Adv
Adequate margins with good cosmetic results
Acceptable cosmesis in large volume resections
Long lasting good results
Reduce late unacceptable cosmetic effects of
radiation
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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
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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)
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PRINCIPLES BEHIND ONCOPLASTICS :
(B) Selection criteria :
Excision volume - as % from breast volume
Tumour location - quadrant wise / clock position
Glandular density ( BIRDS)
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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
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PARALLELOGRAM FOR UOQ TUMOURS
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ROUND BLOCK TECHNIQUE FOR 12 TUMOURS
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BATWING MASTOPEXY FOR UQ TUMOURS
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TENNIS RACKET METHOD FOR UOQ TUMOURS
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ROTATION FLAP FOR UIQ TUMOURS
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GRISOTTI PROCEDURE FOR CENTRAL TUMOURS
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J mammoplasty for LOQ
tumours
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V – mammoplasty for LIQ tumours
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VERTICAL REDUCTION FOR 6 OCLOCK TUMOURS
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WISE PATTERN REDUCTION MAMMOPLASTY FOR 6 & 12
TUMOURS
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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
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STANDERDS
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Surgery to opposite breast
Reduction
Augmentation
Revision procedures
Implant revision
Fine tuning
Fat injections
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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
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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
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THANK YOU