best of breast reconstruction options · history breast cancer described as far back at 1600bc...
TRANSCRIPT
BEST OF THE BREAST RECONSTRUCTION OPTIONS
Ginger Mars, RN, MSN, CCRN, CPSN, NP-c
Nurse Practitioner Department of Reconstructive Plastic SurgeryNYU Langone Medical CenterNew York, NY
History
Breast Cancer described as far back at 1600BC
Papyrus writings of ancient Egyptians
Halsted performed 1st radical mastectomy 1889
Aggressive surgical technique to control disease
Halsted’s teachings kept reconstruction from emerging as option
Fear that reconstruction would hide local recurrence or modify disease course
History
Breast reconstruction dates back to 1800’s
Attempt to transplant lipoma to mastectomy site
Shift toward breast conservation occurred with time
Contradiction to Halsted
Continues today as standard of care for early breast cancers
Early Reconstruction
1895 1st autologous reconstruction
Lipoma transplanted from flank to create breast
1906 1st musculo-cutaneous flap
(Latissimus flap) (Tanzini) Technique soon forgotten/only
occasionally performed due to Halsted’s principles.
1942 Tubed abdominal flap method
designed (1919) & performed (1942). (Sir Harold Gilles)
1963 Invention of silicone implant Delayed insertion following
mastectomy
1971 1st direct to implant recon
Late 1970’s/1979 Pedicled VRAM Latissimus dorsi flap
reintroduced 1st Free flap to breast
1982 Creation of Tissue
Expander/delayed recon 1st pedicled TRAM flap
The limiting factors in all early reconstruction
Staged surgery over months/years
Infection risk
Radical mastectomies with resultant scarring
Poor results
Technology
Flap Failure
Mastectomy technique
Likely single most influential factor in reconstructive outcomes.
Shift from ‘tissue eradicating’ to ‘tissue sparing’ philosophy.
Change in technique resulted in improved quality of surrounding tissue.
Implant Reconstruction
One reconstructive option
Tissue expanders
Direct to implants
Timing for reconstruction
TE to implant
Radiation
Nipples
Areola Tatoo
Implant Reconstruction
PROS May be single stage
(DTI)
Appearance
More Rapid Recovery
Shorter OR Time
Much less technically demanding
CONS May require multiple
stages (TE to Implant)
Requires re-op (approx10 years)
Need for symmetrizing procedure if unilateral
Scar contracture
Timing for Radiation Tx
Infection/Foreign body
?Auto-immune disease link
Appearance ?”Fake”
Complications Associated with Implants
Deflation or malfunction
Capsular contracture
Contour irregularities
Infection
Issues with radiation
Infection
Immune interactions
Patient complaints:
Doesn’t feel like a natural breast
Cooler than other body parts in cold weather
If unilateral, no ptosis with age.
Breast Flap Reconstruction Rotational/Pedicled Flaps
Latissimus
VRAM – Vertical Rectus Abdominus Myocutaneous
TRAM- Transverse Rectus Abdominus Myocutaneous
Free Flaps TRAM – Transverse Rectus Abdominus
DIEP- Deep Inferior Epigastric Perforator
SIEP – Superficial Inferior Epigastric Artery Perforator
GAP/SGAP – Gluteal Artery Perforator/Superior Gluteal Artery Perforator
PAP – Profunda Artery Perforator
TUG – Transverse Upper Gracilis
LTP – Lateral Thigh Perforator
The Best of the Breast Reconstruction Options
Choosing the “Right” Procedure
Considerations in Decision-Making Medical History/Co-Morbidities
Surgical History
Oncologic Treatment Plan
Body Habitus
Life-Style
Patient preference/expectations
Patient Compliance
Risk Factors for Poor Prognosis SMOKING
Infection
Flap necrosis
Fat necrosis
Donor site necrosis
Obesity Wound-related
complications
Seroma
Malnutrition/poor healing
Under-weight Malnutrition/poor
healing
Wound related complications
Scarring
Co-morbidities Diabetes
Coronary Disease
Hypertension
Autoimmune disease
PEDICLED BREAST FLAPS
Latissimus Dorsi
Lat Flaps
PRO Reliable Circulation
Minimal risk of flap necrosis even in smokers & DM
CON Usually requires implant
for volume
Painful/muscle spasm
Large scar
Axillary fullness
High incidence of seroma formation
ROM difficulties
Latissimus Flaps
Not usually 1st choice in reconstructive arena
Most common complication – back seroma
Other possible complications:
Dorsal flap necrosis
Loss of shoulder mobility
Shoulder weakness
Winging of scapula
.
Latissimus Dorsi Flap
Lat Flap with Implant Insertion
- Back seroma and breakdown- Re-op R back for recurrent seroma- L Thoraco-dorsal neurectomy for
persistent pain.
Back Scars
PEDICLED BREAST FLAPS
VRAM/TRAMVertical RectusTransverse Rectus
TRAM FLAP
Developed 1970’s
VRAM came 1st and then evolved into TRAM
Problem with VRAM – large vertical scar
Musculo-cutaneous flap
# 1 flap done in the U.S.
Tram Flap
PROS
Single stage procedure
Shorter Operative Time
CONS
Removes Muscle
May require mesh
Abdominal Hernia
Chest bulge at cleavage/IM line
BREAST RECONSTRUCTION - PEDICLED TRAM FLAP
PEDICLED TRAM
Pedicled VRAM
FREE FLAPS
Free TRAM
PROS Single stage procedure
‘Natural’ looking breast
Autologous tissue
CONS Long operative time
Technically challenging
Muscle sacrifice
Increased post op pain
Risks associated with all MVFF reconstruction
Risk of hernia formation
Abdominal seroma with obese patient
Risk to umbilicus
Longer recovery time
Free VRAM Flap
HERNIA FOLLOWING FREE-TRAM FLAP
POST-OP CORRECTION OF DEFECT
Deep Inferior Epigastric Artery Perforator
Superficial Inferior Epigastric Artery Perforator
DIEP/SIEA FLAPS
DIEP/SIEP Flap
Skin and fat of abdomen used, no muscle
“Tummy tuck”/ improved abdominal contouring
DIEP/SIEA FLAPS
PROS Single stage No abdominal muscle
used
Preserved abdominal strength
Avoids need for mesh
Less post op pain
Autologous tissue
CONS Long operative
procedure
SIEA choice limited by vessel size
Technically challenging
Longer recovery
Risk of seroma in obese patients
Risk to umbilicus
Breasts may grow with weight gain.
Marking for Flap
Potential Post op Complications of Donor Site
Wound dehiscence
Umbilical necrosis
Gluteal Artery Perforator
Superficial Gluteal Artery Perforator
GAP/SGAP FLAPS
GAP Flap
SGAP
PROS Single stage procedure
Able to perform on patients With lower BMI
With little/no abdominal fat
With prior abdominal surgery
Hidden scars
Less pain
CONS Technically challenging
Long OR time Need to turn patient
during surgery
All risks of MVFF
SGAP FLAP
Stacked SGAP FlapBreast Reconstruction
Stacked GAPs
Post op Stacked SGAPs
Post Op
Hidden Scar
Pre-Op Planning/Markings
SGAP – Post Op
The Croissant GAP
SGAP Augmentation
Pre and Post-op
Profunda Artery Perforator
PAP FLAPS
PAP Flaps
PROS
Single stage procedure
Able to perform on patients With lower BMI
With little/no abdominal fat
With prior abdominal surgery
Hidden scars
CONS
Technically difficult
Long operative time
Painful to sit and walk
Prone to breakdown
Long operative time
All risks for MVFF
Awkward positioning Risk for nerve damage due
to positioning
PAP Flap
Pre-Op Markings
Post –Op Hidden Scars
Transverse Upper Gracilis
TUG FLAPS
TUG Flaps
PROS
Single stage procedure
Shape well suited to breast
Able to perform on patients With lower BMI
With little/no abdominal fat
With prior abdominal surgery
CONS
Long operative time
Technically difficult
All associated risks with MVFF
Awkward positioning Risk of nerve damage
Challenging to void
Credit: Microsurgeon.org
The new kid on the block
LTP Flaps
Lateral Thigh Perforator
LTP Flaps
PROS
Less post op pain
Less prone to breakdown
Corrects “saddle-bags”
Able to perform on patients
With lower BMI/Higher BMI
With little/no abdominal fat
With prior abdominal surgery
CONS
Longer procedure
Technically difficult
All associated MVFF risks
Visible scars
Pre op LTPs
Ample Adipose
824g
Bilateral LTP FLAPS
preop postop
Post-Op
Post-Operative Scars
Getting Fancy
Combined flaps for greater volume Stacked DIEP
Combined DIEP plus:
TUG
PAP
LTP
In Conclusion
There are multiple options available for patients to choose from.
Many times, the options offered are based on surgeon’s experience and comfort with procedure.
Legislature makes it mandatory that patients be informed of their options.
This doesn’t always lead to the ‘right’ procedure being done.
Caveat Emptor
Every job is a SELF - PORTRAIT
of the person who does it.
Autograph your work
with EXCELLENCE!Author Unknown