steven e. copit, m.d
TRANSCRIPT
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Breast Reconstruction
Steven E. Copit, M.D.
Chief- Division of
Plastic Surgery
Thomas Jefferson University Hospital
Philadelphia, PA
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Breast Reconstruction analysis of “ The Defect ”
Skin
Breast Volume
Nipple Areola Complex
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Breast Reconstruction analysis of “ The Defect ”
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Breast Reconstruction
the mastectomy defect
Skin defect
Most difficult to replace
Breast volume
Replaced by fat, muscle, implant
Easier to replace
Nipple-Areola Complex
Easiest
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Breast Reconstruction skin – estimate of defect
Size of tumor / proximity to skin
Previous biopsy
Previous XRT
Smoking
Size of skin flaps
Breast surgeon
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Breast Reconstruction skin
“ Probably the single most important
influence on the improved quality of
breast reconstruction has been the
evolution of the mastectomy
technique.”
F.E.B. , M.D.
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Breast Reconstruction skin sparing mastectomy
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Breast Reconstruction breast volume
Match the reconstructed breast to the
contra-lateral side
Modify the contra-lateral breast to
approximate the result of the
reconstruction
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Breast Reconstruction nipple–areola complex
Appearance
Sensation
Lactation
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Breast Reconstruction
“It’s all about symmetry”
Breast size
Breast Shape - Ptosis
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Breast Reconstruction procedure selection
Implant Reconstruction
Tissue expander / Permanent implant
Latissimus Dorsi Myocutaneous flap and
tissue expander / permanent implant
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Breast Reconstruction procedure selection
Autogenous reconstruction
Abdominal Wall
Pedicle TRAM flap
Free TRAM flap
DIEP Flap
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Breast Reconstruction procedure selection
Gluteal Reconstruction
GAP flap
SGAP flap
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Breast Reconstruction
tissue expander / implant
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Breast Reconstruction tissue expander / implant
Saline filled silastic expander
Exchange for saline or silicone
filled silastic implant
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Breast Reconstruction
tissue expander / implant
Tissue expansion provides skin
Implant exchange provides volume
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Breast Reconstruction
tissue expander / implant
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Breast Reconstruction tissue expander / implant
Pros
No donor site morbidity
Short surgery
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Breast Reconstruction tissue expander / implants
Cons
Poor symmetry
Frequent visits to office for expansion
“Implant under skin”
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Breast Reconstruction implant options
Saline vs. Silicone
Silicone is softer
Silicone has diminished fold flaws
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Breast Reconstruction
Institute of Medicine
No evidence that silicone implants are
responsible for any disease
No evidence of a novel autoimmune disease
No increase in breast cancer
No danger in breast feeding
Implants do not last forever
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Breast Reconstruction implant issues
All complications are local
Rupture
Capsular contracture
Infection
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Breast Reconstruction implant issues
Silicone was used under FDA trials for reconstruction only
FDA has reviewed the results of the trials and has cleared silicone for unrestricted use
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Breast Reconstruction silicone is back
Silicone implants are the most extensively studied medical device in the history of the FDA
Even plaintiff attorneys have to surrender to science
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Breast Reconstruction tissue expander / implant
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Breast Reconstruction tissue expander / implant
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Breast Reconstruction tissue expander / implant
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Breast Reconstruction tissue expander / implant
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Breast Reconstruction latissimus dorsi myocutanious
flap / implant
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Breast Reconstruction latissimus dorsi myocutanious
flap / implant
Rotation flap of muscle and skin from back to replace skin
Permanent implant to replace breast volume
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Breast Reconstruction Lat. dorsi and tissue expander
Pros
Looks better than a tissue expander alone
Replacing skin preserves the natural
shape of the breast (ptosis)
Replacing skin allows more fill in the
expander at the time of the initial
operation
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Breast Reconstruction
Lat. dorsi and tissue expander
Cons
Donor scar (minimal if transverse oriented)
Donor muscle function loss
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Breast Reconstruction
Lat. dorsi and tissue expander
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Breast Reconstruction
Lat. dorsi and tissue expander
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Breast Reconstruction nipple- areola complex
Creation of nipple from breast skin
Tattoo areola and nipple in office
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Breast Reconstruction nipple- areola complex
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Breast Reconstruction timing
Immediate reconstruction
Delayed reconstruction
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Breast Reconstruction
Contraindications
Planned post-op radiation
Smoking
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Breast Reconstruction advantages
Beneficial psychological effects 1,2,3
Pliable skin flaps and IMF preserved
1. Stevens, et al: PRS 73:619, 1984
2. Schain WS: Clinics Plast Surg 11: 237, 1984
3. Wellisch DK: PRS 76:713, 1985
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Breast Reconstruction operative plan
Unilateral Reconstruction
Match normal breast
TRAM
Lat.Dorsi
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Breast Reconstruction operative plan
Bilateral reconstruction
TRAM
Lat. Dorsi and tissue expansion
Tissue expansion
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Breast Reconstruction
My Absolutes
No one perfect choice
No “easy way” to make a breast
The more you do the better it looks
Some people require a higher standard reconstruction- be honest
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Breast Reconstruction
My Absolutes
Allow yourself to think long term
You should “hear“ about all the options
but listen to your surgeon
Mastectomy is easy, reconstruction is
hard
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Thank you