breast reconstruction - the who, what, when, how and why · breast reconstruction - the who, what,...
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Breast Reconstruct ion - The Who, What, When, How and Why
DEAN WHITE MBBS FRACS GRAD.DIP.BIO.EPID. GAICD
PLASTIC AND RECONSTRUCTIVE SURGEON
DEANWHITE.COM.AU
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• Plastic and Reconstructive Surgeon
• Clinical Director of Plastic Surgery Eastern Health (Box Hill,
Maroondah, Yarra hospitals)
• Director of the Head and Neck Clinical Institute Epworth
Healthcare Group (Plastic Surgery, ENT, OMFS, Dermatology,
Ophthalmology)
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• Clinical cases with realistic results in my hands
• Types of reconstruction available and their evolution
• Advantages and disadvantages of each
• What factors are involved in the surgical decisions/planning
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• Not dealing with primary treatment of breast cancer (Lumps,
nipple discharge, radiological findings etc)
• Breast reconstruction post/peri cancer in conjunction with
breast/general surgeons and other members of the
multidisciplinary team
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• Complex area
• Individually tailored
• Options keep evolving
• Need all the options to offer a complete service
• Still relatively low rate
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RECONSTRUCTIVE OPTIONS
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• Nil - external prosthesis
• Alloplastic - Implant based
• Autogenous - Own tissues, Pedicled vs Free Flaps
• Combination
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• Primary - at the time of resective surgery
• Secondary - later
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IMPLANT RECONSTRUCTION
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• Historically often 2 stage operation with use of tissue expander
first
• Currently more able to use DTI (Direct to Implant) with FLEX
HD (ADM)
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• Shorter operation
• No other surgical sites
• Less expertise required
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• Time to think
• Preserves skin envelope
• Can have XRT, chemo
• Leaves all other options available
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• Infection
• Extrusion
• Long term maintenance
• Capsular contracture
• Less natural feel
• Unknown risk profiles (ALCL)
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AUTOGENOUS (OWN TISSUES) RECONSTRUCTION
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• Own tissues
• Durability and ages with patient
• More natural feel
• Secondary donor benefits
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• High expertise
• Two plastic surgeons
• Longer surgery
• Donor site
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• Pedicle flaps - TRAM, Latissimus Dorsi
• Free flaps (microsurgery) - TRAM, MS-TRAM, DIEP
Other donor sites - TUG, IGAP, Rubens
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LATISSIMUS DORSI - PEDICLE FLAP
• Usually with implant
• Pedicle flap
• Less used now
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WHICH OPTION?
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• Patient - Age, BMI, SMOKER
• Comorbidities eg Heart disease, diabetes
• Medications - anticoagulants, immunosuppressants
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• Cancer vs in situ vs prophylactic (BRCA gene)
• Degree of resection/surgery, RADIOTHERAPY, chemotherapy
• NAC preserved vs taken
• Timing - Concurrent or delayed
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• Geographic location
• Pregnancy goals
• Contralateral breast
• Desire re post op size (bigger, smaller, higher?)
• PATIENT PREDETERMINED IDEAS
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• Grab and Grope Test
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• Fully clothed
• Evening dress
• Bathers/Underwear
• Naked
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• Younger
• Prophylactic
• City Dweller
• Private
• Still low rates
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ADJUNCTIVE PROCEDURES
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• Contralateral breast - reduce/increase and increasingly
prophylactic
• Lift
• NAC
• Fat grafting
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• Multiple operations to achieve the ideal endpoint
• Touch-ups
• NAC
• Scar Burden
• Realistic expectations (Photos)
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COMPLICATIONS
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• What do you mean there will be a scar?
• Aren’t you a plastic surgeon??!?
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CASE EXAMPLES
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• Individually tailored
• Often multiple options - rarely a “best” operation
• Often several stages
• Techniques constantly evolving
• Patient choice requires consultation with those knowledgeable
about all current management approaches
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• www.deanwhite.com.au
• Australasian Society of Plastic Surgeons - ASPS
www.plasticsurgery.org.au
• Royal Australasian College of Surgeons www.surgeons.org