Steligo.recon2017 - Facing our Risk · 5/31/17 7 Implant Recons"uc#on & &&...
Transcript of Steligo.recon2017 - Facing our Risk · 5/31/17 7 Implant Recons"uc#on & &&...
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Breast Reconstruction ���Choices and Issues
Kathy SteligoAuthor,
The Breast Reconstruc1on Guidebook
Co-‐author, Confron1ng Hereditary Breast and Ovarian Cancer
Confron1ng Chronic Pain
MastectomyRemoves breast 1ssue
Options After Mastectomy
“Going Flat” (no reconstruc1on)
² Incision is made across the breast
² Breast 1ssue, most of breast skin, nipple and areola
are removed
² The closed incision leaves a wide horizontal or
diagonal scar
² Wearing breast prosthesis is op1onal
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Options After MastectomyImmediate reconstruc1on with mastectomy
² back-‐to-‐back procedures (1 visit to OR)
² breast surgeon removes breast 1ssue, preserves most breast skin (skin-‐sparing mastectomy)
² plas1c surgeon replaces volume with implants, your own 1ssue, or combina1on of both Delayed reconstruc1on aOer mastectomy
² addi1onal surgery/recovery weeks, months or years later
Mastectomy and ReconstructionMastectomy Reconstruc1on Creates incisions Can camouflage/hide scars Eliminates breast 1ssue Restores breast volume Removes breast skin Replaces breast skin Removes nipple/areola* Recreates nipple/areola Severs nerves (sensory loss) May encourage some nerve
regenera1on (1ssue flap) Removes milk ducts Doesn’t restore ability to breasWeed
*unless nipple/areola are preserved
Reconstruction Process
Mastectomy
1. Rebuild breast mound 2. Revision surgery to build nipple,
refine reconstruc1on, revise scar 3. TaZoo nipple/areola*
No reconstruc1on
Immediate reconstruc1on
Delayed reconstruc1on
*unless nipple/areola are preserved
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Nipple-sparing Mastectomy
Evolu1on of mastectomy: from radical mastectomy to NSM ² Similar recurrence/survival as standard mastectomy
² Candidates: preven1ve mastectomy or small, early-‐stage tumors
not close to skin/nipple
² Tissue removed at base of nipple (nipple removed if pathology
shows cancer cells)
² Requires greater surgical skill to remove breast 1ssue through
smaller incision, preserve blood supply to nipple
² Nipples may flaZen, lose sensa1on/response, or die
Mastectomy IncisionsImmediate Reconstruc1on
Skin-‐sparing mastectomy incisions
Nipple-‐sparing mastectomy Incisions
Mastectomy IncisionsImmediate Implant Reconstruc1on
Photo: Dr. C. Andrew Salzberg
Nipple-‐sparing mastectomy Skin-‐sparing mastectomy, nipple reconstruc1on, taZoos
Photo: Dr. Frank DellaCroce
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Mastectomy IncisionsDelayed Reconstruc1on
Mastectomy scar remains across the chest
Photos: The Center for RestoraCve Breast Surgery
Breast Implants
² Silicone gel, saline or hybrid (mix of both)
² Textured or smooth
² Round Teardrop
Different materials, shapes, sizes, profiles
Breast Implants
² 80% of all breast reconstruc1ons
² 94% involve silicone implants
Source: American Society of PlasCc Surgeons
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Breast Implants
Components Silicone shell filled with saltwater solu1on
Silicone shell filled with silicone gel
Texture/feel Firm, like a water balloon
Closer to natural breast 1ssue
Incision Smaller (implant is deflated when inserted)
Larger (implant is full when inserted)
Implant informaCon/staCsCcs at www.fda.gov
Saline Silicone
Breast Implants
Tradi1onal Tissue expansion
Newer Direct-‐to-‐Implant (no expansion)
Newest Self-‐controlled expansion
Implant Reconstruction: Expansion
² Tissue expander behind
pectoral muscle creates space for implant
² Saline added every 7-‐10 days
² Muscle and skin stretches over several weeks, crea1ng pocket for implant of desired size
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Implant Reconstruction: Expansion
Expander is gradually filled with saline
Implant Reconstruction: Expansion
² May be larger, higher or different shape than final breast
² SeZles in place for 6-‐8 weeks or longer
² Exchanged for implant
² Op1onal nipple reconstruc1on with or without taZoo
Implant Reconstruction: Expansion
² AeroForm® inflates with carbon dioxide instead of saline
² Pa1ent uses remote control to expand at home
² Self-‐paced: Average comple1on 21 days
AeroForm expanders: www.airxpanders.com
Pa1ent-‐controlled Expansion
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Implant Reconstruction
AOer skin-‐sparing mastectomy, 1ssue expansion and reconstruc1on with breast implants
Before mastectomy
Photos: Mentor®
Direct-to-Implant
² No expansion. No exchange surgery
² Requires nipple-‐sparing mastectomy ² “One-‐step” = “two-‐step” if revisions are needed
or complica1ons require addi1onal surgery
One step. One surgery. One recovery.
Direct-to-Implant
² Sterile soO 1ssue replacement
² Skin from human cadaver, bovine or swine (also silk) ² Stripped of cells but retains collagen, other proteins
² Supports growth of new cells and blood vessels
Acellular dermal matrix
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Direct-to-Implant
² Implant placed immediately under
the pectoral muscle
² Acellular dermal matrix sewn to muscle edges and inframammary breast fold
² “Internal bra” forms instant pocket; supports implant in posi1on, covers lower por1on of implant
Image: LifeCell
Direct-to-Implant
AOer nipple-‐sparing mastectomy, reconstruc1on with silicone gel implants
Before mastectomy
Photos: Dr. C. Andrew Salzberg
Implant Reconstruction
Size maZers
“My implants are too big!”
“My implants are too small!”
² Smaller, larger or same as your natural breast size
² Discuss size with your plas1c surgeon before your reconstruc1on
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Tissue Flap Reconstruction
² Flaps from abdomen, back, buZock,
hip or thigh are relocated to the chest
² Creates addi1onal incision at donor site
² Different procedures, surgical skill, length of surgery, hospital stay, recovery
Breasts of your own living 1ssue
Tissue Flap Reconstruction
All flaps are not equal
² Flaps include fat and skin moved from the donor
site to the chest
² Tradi1onal methods also remove muscle
² Advanced methods use fat and skin; preserve muscle
Tissue Flap Reconstruction
Flaps don’t need muscle the new breast (flap) needs the blood supply that
runs through the muscle
Flaps access the blood supply in different ways, requiring different surgical skills:
² AZached (pedicled) flaps use en1re muscle
² Free flaps use “small” amount of muscle
² Perforator flaps use no muscle. Blood supply is detached from muscle; reconnected in chest -‐ Fewer qualified surgeons -‐
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Tissue Flap Reconstruction
Flaps don’t need muscle they do need the blood supply that runs through the muscle
Tissue Flap Reconstruction
Abdominal Flaps: AZached TRAM ² Low hip-‐to-‐hip incision
² Fat, skin and muscle tunneled
under skin to chest; remains tethered to original blood supply
² Reduced abdominal strength (sit-‐ups, gemng out of bed without rolling over)
² Bonus: tummy tuck
fat
muscle
Tissue Flap Reconstruction
Abdominal Flaps: Free TRAM ² Same hip-‐to-‐hip incision, same scar, same tummy tuck
² Fat, skin and some muscle
surrounding blood supply moved from abdomen to chest
² Microsurgeon reconnects blood vessels in chest
² Cumng across muscle reduces abdominal strength/support
Image: University PlasCc Surgery
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Perforator Flap Reconstruction
Abdominal Flaps: DIEP
² Same incision, same scar, same tummy tuck
² Most common flap for breast reconstruc1on*
² Blood vessels are teased away from muscle
² En1re muscle remains fully func1onal
² Less intense recovery; reduced chance of hernia, other complica1ons
*American Society of PlasCc Surgeons
Perforator Flaps: DIEP
Before and aOer: Bilateral nipple-‐sparing mastectomy with immediate DIEP reconstruc1on, later nipple reconstruc1on and taZoos
Photos: Dr. Minas Chrysopoulo
Tissue Flap Reconstruction
Comparing TRAM and DIEP
They look alike from the outside; very different on the inside
AZached TRAM DIEP Free Tram
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Tissue Flap Reconstruction
Back flap: La1ssimus dorsi (Lat)
² AZached flap: muscle
tunneled under skin from back to chest
² Adequate for A-‐ or B-‐cup
² Implant usually added
Tissue Flap Reconstruction
Images: MacMillan Cancer Support
Back flap: La1ssimus dorsi (Lat)
Tissue Flap Reconstruction
BuZock Flaps: Superior Gluteal Artery Perforator (S-‐GAP)
Inferior Gluteal Artery Perforator (I-‐GAP)
² Perforator flaps (use no muscle)
² Op1on for women without enough abdominal fat
² Firmer than abdominal 1ssue
² Longer surgery; less intense recovery
² Few surgeons perform GAP; even fewer offer bilateral simultaneous GAP
SGAP
IGAP
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Perforator Flaps: GAP
Photos: Center for RestoraCve Breast Surgery
Before and aOer: Prophylac1c bilateral mastectomy with immediate GAP reconstruc1on
Perforator Flaps: GAP
Photos: Center for RestoraCve Breast Surgery
Before and aOer: SGAP reconstruc1on donor site
Tissue Flap Reconstruction
Thigh Flaps: TUG
² Free flap: transverse upper gracilis (inner thigh) muscle
² No func1onal loss; other muscles take up the slack
² Crescent-‐shaped flap provides excellent breast shape and projec1on; creates immediate nipple reconstruc1on in some women
² Scar hidden in groin
² Bonus: inner thigh liO Image: Dr. Anureet Bajaj
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Other Perforator Flaps
ICAP From the underarm adjacent to breast LAP From the “love handles” PAP From the upper thigh beneath buZock TDAP/TAP From the back
Tradi1onal implants
Expansion Revision surgery; exchange, build nipple#
TaZoo#
Direct-‐to-‐Implant*
Replace breast 1ssue with implants
Tissue flaps Harvest 1ssue for breast mound
Revision surgery; Build nipple#
TaZoo#
* with nipple-‐sparing mastectomy #not required with nipple-‐sparing mastectomy
Comparing Implants and Flaps
Step 1 Step 2 Step 3
Comparing Implants and Flaps
Eventual replacement Lifelong
Less natural shape and feel Natural soOness of living 1ssue
Incision @ mastectomy site Incisions @ mastectomy and donor sites
More difficult to match opposite healthy breast
Easier to match opposite healthy breast
Shorter surgery; longer 1meline* Longer surgery; shorter 1meline
Easier, quicker recovery More invasive surgery, longer recovery
* TradiConal expansion. Direct-‐to-‐implant = shortest overall Cmeline
Implants Flaps
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Fat Grafting
1. Moves liposuc1oned fat from abdomen, thighs, hips, or anywhere else you have it to spare
2. Cleansed of blood and cellular debris 3. Injected in 1ny amounts into the new breast 4. May require mul1ple sessions
5. Affected by future weight loss/gain
50-‐70% of fat typically remains in the breast (the rest is resorbed by the body)
Fat Grafting
² adds volume ² smooths contour irregulari1es ² improves cleavage ² fills in sunken area above the breast ² hides implant edges, camouflages rippling and wrinkling ² soOens/improves texture of previously radiated 1ssue ² refines scars
Can make a good reconstruc1on beZer
Fat Grafting
Images: Dr. Minas Chrysopoulo
AOer bilateral DIEP flap reconstruc1on Subsequent fat graOing improves overall symmetry, volume, and shape
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Fat Grafting
Seems to be the best thing since…
Nipple Reconstruction
² Op1onal last step
² Usually created from mini-‐flap of breast skin
² Many different types of nipple flaps
Nipple Reconstruction
² Ini1ally 50% larger than desired; new nipple shrinks in 1me
² Nipple/areola taZooed to match natural nipples or lip color; eventually fades
² Op1onal “stuffing” with acellular dermal matrix, other synthe1c filler: Headlights on!
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Nipple Reconstruction: Before
Immediate reconstruc1on Delayed reconstruc1on
Nipple Reconstruction: After
Photos: Center for RestoraCve Breast Surgery
Nipple Reconstruction: Alternatives
² 3-‐D taZoo simula1on of nipple
² No nipples
² Temporary adhesive nipples
Photo: Red Rose TaQoo
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Creative Tattooing
Photos: Black and Blue TaQoo, Ink Couture
Reconstruction After Radiation
² Inhibits blood flow and skin elas1city; can delay healing
² Implants aOer radia1on = greater likelihood of complica1ons -‐ Radiated breast skin can be difficult to expand
-‐ Pre-‐padding mastectomy site with fat graOs may help ² Tissue flap = fewer complica1ons, beZer aesthe1cs
(brings healthy 1ssue to radiated area)
Reconstruction After Radiation
Delayed-‐immediate reconstruc1on
Pathologyindicates needfor radiation?
Completeradiation
Exchangeexpander for
implant ortissue flap
Exchangeexpander for
tissue flap
Deflateexpander
no
yes
Placefully inflated
tissue expander
Skin-sparingmastectomy
Reinflateexpander
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Mastectomy: You Have More Options
Tradi1onal Methods Newer Methods*
Removes breast 1ssue, skin Preserves most breast skin and muscle Preserves muscle
Removes nipple and areola Nipple-‐ and/or areola-‐ sparing
* immediate reconstrucCon
Tradi1onal Methods Advanced Methods
Tissue expansion Direct-‐to-‐implant Self-‐expansion
Flaps that sacrifice muscle Muscle-‐sparing flaps
Few surgical op1ons Numerous surgical op1ons
Minimal/no insurance coverage WHCRA
Reconstruction: You Have More Options
The Best Reconstruction…
Procedures and results have drama1cally improved in the past decade
Good reconstruc1on looks natural, with or without clothing
No reconstruc1on is one-‐size-‐fits-‐all: all procedures have advantages and disadvantages
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Reconstruction: Your Right
² Health insurers who cover mastectomy must also pay for prostheses, all stages of reconstruc1on, and related complica1ons
² Does not guarantee coverage for any surgeon, any hospital, or any procedure. (May require use of in-‐network physicians/hospitals)
² Usual and customary coverage consistent with exis1ng plan benefits: same deduc1bles and co-‐payment
The Women’s Health and Cancer Rights Act of 1998
Choosing A Plastic Surgeon
The single-‐most important aspect of reconstruc1ve surgery
² All surgeons don’t perform all procedures
² Choose a board-‐cer1fied surgeon with lots of experience with the procedure you want…and who does it rou1nely
² Get a second opinion (three is beZer)
² Talk to pa1ents who have had same procedure
Making Your Decision
² Show & Tell (tonight)
² ReconstrucCon Q&A panels (today and tomorrow)
² “Ask the Experts” roundtable (tomorrow)
² Talk to women who have made the journey
² FORCE message boards
² The Breast ReconstrucCon Guidebook
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Making Your Decision
² If possible, take the 1me you need: It’s a BIG decision
² Consider the benefits/limita1ons of different procedures
² It’s a process, with a beginning and end
² Reconstruc1on is a personal choice
What Else Can You Do?
² Learn as much as you can
² Know what to expect
² Stop smoking
² Lose weight if you need to
² Eat well
² Get fit…train for surgery/recovery
² Cul1vate a posi1ve mental amtude
.
Questions?