Reconstructive breast surgery

RECONSTRUCTIVE BREAST SURGERY

BY DR. HAYTHAM MAHMOUD FAYEDLECTURER OF SURGICAL ONCOLOGYALEXANDRIA FACULTY OF MEDICINE

Introduction

Breast reconstruction is an option after:

Unilateral mastectomy Bilateral mastectomy Breast conservation therapy with unsatisfactory cosmetic result.

Breast reconstruction provides psychological, social, emotional, and functional improvements.

Optimal management requires a Multidisciplinary approach and collaborative effort between: Oncological surgeon Reconstructive surgeons Radiologists Pathologists Radiation therapist Medical oncologists

INITIAL RECONSTRUCTIVE EVALUATION

History and physical examination

Disease status Oncologic history, Future treatment plans, Past surgical history Comorbid health problems, Contralateral breast

Women who choose reconstruction face a complex decision-making process with regard to:

Timing of reconstruction Type of reconstruction

Timing of reconstruction

The appropriate timing for reconstruction is essential both to optimize outcomes and minimize the potential for postoperative complications.

Immediate reconstruction can be offered to most patients.

Delayed reconstruction is more appropriate in patients who will need postmastectomy radiation.


Immediate reconstruction:

Initially, delayed procedures were favored but several studies revealed that women undergoing immediate reconstruction experienced significant

psychosocial benefits.


Immediate reconstruction:The advantages of immediate reconstruction include:

One operative setting. As a result, the overall cost of the reconstructive process is decreased.

Provides substantial psychosocial benefits over delayed reconstruction Preserves normal breast landmarks (such as the inframammary fold)


Immediate reconstruction:The disadvantages of immediate reconstruction include:

Prolonged operative time. Necrosis of the mastectomy skin flaps can adversely affect the aesthetic

result of the reconstruction. The need of postoperative RT can adversely affect the reconstruction.


Delayed reconstruction:The advantages of delayed reconstruction include:

Assurance of clear margins prior to definitive reconstruction Minimize the effect of poorly perfused mastectomy skin flaps on the quality of

the reconstruction Allows completion of all adjuvant treatment.


Delayed reconstruction:The disadvantages of delayed reconstruction include:

Need for subsequent surgery Limited reconstructive options following radiation therapy Lesser aesthetic quality compared to immediate reconstruction

RECONSTRUCTIVE OPTIONS

There are two general types of reconstructive options:

Prosthetic devices (eg, saline implants, silicone implants, tissue expanders) Autologous tissue reconstructions.


PROSTHETIC DEVICES:

Modern breast reconstruction began in 1964 with the introduction of the prosthetic device, the silicone breast implant.

Since that time, implants have evolved, and the silicone polymer shell remains essentially unchanged.

The implant shell can be filled with silicone, saline, or a combination of the two.


PROSTHETIC DEVICES:

The advantages of implant reconstruction are: Surgical simplicity, The use of cosmetically similar adjacent tissue for coverage of the implant, The lack of donor site morbidity, Reduced operative time, and more rapid postoperative recovery.

The main disadvantages are that tissue expansion requires frequent clinic visits for expansion (usually every one to two weeks for one to two months) and a second surgery to place the reconstructive implant.


PROSTHETIC DEVICES:

One stage implant reconstruction Two stage implant reconstruction


AUTOGENOUS TISSUE RECONSTRUCTION:

The development of musculocutaneous flaps and microsurgical tissue transplantation paved the way for modern autogenous tissue breast reconstruction.

These flaps may be pedicled, free flap or perforator flap.



Pedicled TRAM flap



Free TRAM flap



Latissimus dorsi flap



Perforator flaps

In an effort to conserve muscle, "perforator" flaps harvest only the skin and fat overlying the muscle along with the perforating vessels and dominant artery and vein supplying the flap. The free flap is then transferred to the recipient site.



Perforator flaps

DIEP perforator flap


AUTOGENOUS TISSUE ECONSTRUCTION:

Perforator flaps

SIEA perforator flap



Perforator flaps

TUG flaps

Depending on the ascending branch of the medial circumflex femoral artery.



Perforator flaps

LTAP flapTDAP flapICAP flapSAAP flap



Perforator flaps

The free fasciocutaneous infragluteal (FCI) flap


Autologous fat grafting:

AFG in breast reconstruction is a promising technique. Safety is not compromised as cancer recurrence and complications are not observed.

Whether AFG interferes with radiological follow-up remains to be elucidated.

Randomized trials with sound methodology are needed to confirm these conclusions.

Future of Breast Reconstruction

“Supramicrosurgery” is an exciting topic of interest in which delicate microsurgical dissections and suturing can be safely performed with the aid of optical devices and instruments.

Advances in diagnostic radiology, therapeutic modalities, and molecular genetics research are other potential future contributors to breast reconstruction.

Tissue regeneration is in active research and could hold promise of better breast reconstruction techniques.

Future of Breast Reconstruction

While breast cancer remains the second leading cause of cancer death in women and continues

to increase 3–5 % annually, one can be sure that plastic surgeons will continue to tirelessly innovate new paradigms in management and

techniques in breast reconstruction.

THANK YOU

Reconstructive breast surgery

Health & Medicine

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