RECONSTRUCTIVE BREASTSURGERY AFTER MASTECTOMY

An EssaySubmitted In Partial Fulfilment Of The Master Degree In

General Surgery

By

Marwa Gaber Abd EL-Kader(M.B,B.Ch)

Supervisors

Prof.Dr.Abd El-Ghani Mahmmoud El- ShamyProfessor Of General Surgery

Faculty Of Medicine,Ain Shams University

Dr. Mohammed Hamdi HammodaAssistant Professor Of General Surgery

Faculty Of Medicine,Ain Shams University

Dr.Ahmed Sobhy El-SobkyLecturer Of General Surgery

Faculty Of Medicine,Ain Shams University

Faculty Of MedicineAin Shams University

2009

First and foremost I would like to thank

(ALLAH )for every thing. This would not be achieved

without the willing and support of (ALLAH).

Acknowledgment

I would like to express my deepest gratitude to Prof.Dr. Abd El-Ghani

Mahmmoud El-Shamy, Professor Of General Surgery,Faculty Of Medicine

,Ain Shams University.for his constant help,encouragement, meticulous

constructive advice and keen supervision to me .

I would like to express my deepest gratitude to Dr. Mohammed Hamdi

Hammoda Assistant Professor Of General Surgery, Faculty Of Medicine,Ain

Shams University. For his guidance,help ,effort,support and advices during the

study.

I am greatly honoured to express my deep gratitude to Dr.Ahmed Sobhy

El-Sobky, Lecturer Of General Surgery, Faculty Of Medicine,Ain Shams

University .He gave me much of his time ,experience and endless support that

can not be expressed in words.

Finally, I wish to Acknowledge my family , for their great support not

only in this work but in all my life.They gave me every thing and took

nothing.

Contents

1 Introduction 12 Aim of the work 33 Anatomical consideration 44 Indications of breast reconstruction 215 Techniques of breast reconstruction 336 The reported results 1097 Summary 1178 Conclusion 1199 Arabic summary 12010 References 122

List Of Figures

No. Title Page1 Schematic representation of breast and pectoral fascia. 52 Arterial distribution of blood to the breast, axilla, and chest wall . 63 Schematic drawing of the breast identifying the position of lymph nodes

relative to the breast and illustrating routes of lymphatic drainage.7

4 Anatomy of latissimus dorsi muscle. 85 Anterior view of latissimus dorsi muscle and blood supply (pectoralis major

muscle removed).9

6 Anatomy of rectus abdominis muscle. 117 blood supply of rectus abdominis muscle. 128 Types of modified radical Mastectomy(1-4). 14-159 Types of skin sparing mastectomy(1-4). 17-18-

1910 Incision for simple mastectomy. 20

1-Algorithm for choosing a technique for unilateral breast reconstruction. 27112- Algorithm for choosing a technique for bilateral breast reconstruction. 28

12 Breast reconstruction aims to restore not only volume, but also shape andcontour of the breast .

37

13 Height (see a) and base width (see b) must be accurately assessed and shouldcorrespond to the contralateral breast.

45

14 Serratus muscle is brought up and pectoralis muscle brought down to create apocket for a prosthesis.

46

15 Prosthesis underneath muscle. 4716 Closure of both skin and subcutaneous tissues and Inflation the expander. 4717 Expansion of tissue with inflations over a period of 3 to 6 months. 4818 Breast Reconstruction Involving a Tissue Expander and Implant. 4919 Preoperative view and Postoperative view after replacement of expander, right

nipple reconstruction and contralateral reduction .50

20 Breast reconstruction with latissimus dorsi flap,blood supply and possible skinpaddles.

53

21 The tips of the star or fleur-de-lis can be sutured together to form a somewhatglobular mass of soft tissue.

55

22 Design for an ELD flap using the low horizontal skin pattern. 5523 Latissimus dorsi flap. 56

24 Folding of the latissimus dorsi muscle to provide bulk for the breast mound 5725 Breast Reconstruction Involving a Latissimus Dorsi Flap, Tissue Expander,

and Implant.58

26 A typical Precision TRAM marking showing the full abdominal markingsmade preoperatively.

65

27 Pedicle TRAM flap technique. 69

28 Bipedicle TRAM flap. 6929 FreeTRAM flap technique. 7530 a): 2.5 mm deep inferior epigastric vessels.

b)Anastomosis of the deep inferior epigastric vessels on to the internalmammary axis .

80

31 Preoperative condition of woman after mastectomy. (Below) The SIEA flapafter harvest. (Above,right) Photograph of the patient approximately 3 monthsfollowing the second stage after SIEA reconstruction .

83

32 Flap design with SGAP flap perforator signal points marked out. 86

33 The flap is elevated with the dominant SGAP. 86

34 Right): Planning of the flap approximately7x 20cm.left):A deepithelializedflap (220g) was harvested with subcutaneous tissue and a prepared skin islandvertically and very strong muscle horizontally.

90

35 Algorithm for immediate conservative breast surgery reconstruction based onthe type of breast and extent of defect.

93

36 Design of the MDOT flap. 10137 Markings for the C-V nipple flap. 10238 Stepes of skate flap technique. 10339 Preoperative marks in preparation for purse-string nipple-areola

Reconstruction.105

40 (A)Preoperative view after right mastectomy .(B)Final post operative viewdemonstrating right prosthetic reconstruction and contralateral implantaugmentation demonstrating ideal symmetry.

108

List Of Abbreviations

AD Areolar diameterASIS Anterior superior iliac spineDBR Delayed breast reconstructionDCIA Deep circumflex iliac arteryDCIS Ductal carcinoma in situDIEP Deep inferior epigastric perforatorFDA Food and Drug AdministrationIBR Immediate breast reconstructionIGAP Inferior gluteal artery perforatorIMC→IA Inframammary crease to the inferior areolar distanceLD latissimus dorsiMDOT Modified double-opposing tab flapMS Muscle-sparing techniqueNAC Nipple-areola complexSA→SB Superior areola to the superior breast distanceSGAP Superior gluteal artery perforatorSIEA Superficial Inferior epigastric arterySSM Skin sparing mastectomyTRAM The transverse rectus abdominis muscleTUG Transverse Upper Gracilis

List Of Tables

No. Title PageTable(1) Differences between immediate and delayed expander insertion. 35Table(2) Advantages and disadvantages of the implant devices . 39Table(3) A Comparison Summary of Ipsilateral and Contralateral Symmetry

Procedures After Unilateral Breast Reconstruction115

جراحة إعادة بناء الثدي بعد إستئصالھ

رسالة مقدمةتؤطئة للحصول على درجة الماجستیر

في الجراحة العامة

منمقدمةمروة جابر عبد القادر/الطبیبة

تحت إشراف

عبد الغني محمود الشامي /الأستاذ الدكتورأستاذ الجراحة العامة

جامعة عین شمس-كلیة الطب

حمودةمحمد حمدي/الدكتورأستاذ مساعد الجراحة العامة

جامعة عین شمس-كلیة الطب

أحمد صبحي السبكي/الدكتورمدرس الجراحة العامة

جامعة عین شمس-كلیة الطب

كلیة الطبجامعة عین شمس

1

INTRODUCTION

The breast represents a secondary sexual characteristics and symbol of

feminity and maternity .A radical and modified radical mastectomy is a

mutilate surgical intervention which causes a number of emotional and social

problems .Reconstructive surgery helps to overcome psychosocial problems of

a patient and her return to everyday activities (Kosovac et al.,2001).

Mastectomy involves the removal of breast tissue, varying amounts of

skin and invariably the nipple-areola complex. The removal of these tissues

results in the loss of volume, shape ,and contour of the breast .Breast

reconstruction aims to restore these attributes and uses the opposite breast as

an aesthetic reference point (Snelling et al.,2005).

Breast reconstruction can help to address the disfigurement and sense of

loss that often follow mastectomy .The decision whether to pursue

reconstruction and the choice of reconstructive strategy are individualized and

take into account the patient’s body characteristics, overall health , breast

cancer treatment plan and personal preferences (Diohan et al.,2008).

Timing of breast reconstruction after mastectomy is determined primarily

by patient factors and the need for postmastectomy radiation therapy. If the

risk of postmastectomy radiation is low, then immediate reconstruction

produces the optimal aesthetic result. If the risk of postmastectomy radiation is

high ,then delayed reconstruction is preferable to optimize both radiation

delivery and aesthetic outcome (Ananthakrishnan et al.,2008).

Breast reconstruction generally consists of two stages: restoration of the

breast mound and reconstruction of the nipple–areola complex. Reconstruction

of the breast mound itself can be performed with the use of either implants or

autogenous tissues (Cordeiro ,2008).

2

In cases of flap reconstruction ,skin,fat,and muscle are transferred either

as a pedicled flap ,with its own vascular supply ,or as a free flap which

requires microvascular reattachment of the blood vessels .The most common

pedicled myocutaneous flap is the transverse rectus abdominis myocutaneous

(TRAM) flap (Cordeiro ,2008).

Implant reconstruction maybe single or two stage procedures.

Traditionally ,small breasts with minimal ptosis are suited for single-stage

reconstruction. Large breasts or inadequate skin require expanders followed

by implants (Mohammadi et al.,2006).

The creation of a nipple–areola complex following breast reconstruction

improves the cosmetic outcome ,and many patients may request such a

procedure (Jatoi et al.,2006).

All procedures for breast reconstruction are associated with an increase in

morbidity beyond that associated with mastectomy alone.Each procedure has

advantages and disadvantages that must be weighed by the patient and her

physicians to reach an appropriate decision (Cordeiro ,2008).

3

AIM OF THE WORK The aim of this work is to highlight the current surgical techniques of

reconstruction after mastectomy ,stress on the commonly used techniques of

reconstructive surgery ,timing of surgery and the reported results.

Chapter1 Anatomical Considerations

-4-

ANATOMICAL CONSIDERATIONS

Anatomy Of BreastThe breast is a modified cutaneous gland of “skin appendage”. It is

enclosed between the superficial and deep layers of the superficial fascia of

the anterior abdominal wall .The supefricial layer is a very delicate but

definite structure, which can be seen by the surgeon who looks for it. It is not

as well defined in fatty breasts and along the inframammery fold (Beer et

al.,2002).

The roughly circular base of the female breast extends transversely from

the lateral border of the sternum to the midaxillary line and vertically from the

2nd to the 6th ribs. A small part of the breast may extend toward the axillary

fossa, forming an axillary tail of Spence. Two thirds of the breast rests on the

pectoral fascia ; the other third rests on the fascia covering the serratus anterior

muscle. Between the breast and the pectoral fascia is a well-defined space

called retromammary space (bursa) (Moore et al, 2007).

The retromammary bursa contains loose areolar tissue, which allows for a

degree of mobility of the breast over the chest wall. Projections of the deep

layer of the supericial fascia cross the retromammary space and fuse with the

pectoral fascia. These form the posterior suspensory ligaments of the breast.

Skiles showed that small islands of the breast parenchyma might accompany

these fibrous processes, which are attached to the pectoral fascia (Carlson ,

2006).

The breast glandular tissue is firmly attached to the dermis of the

overlying skin by the suspensory ligaments (of Cooper).These ligaments,

particularly well developed in the superior part of the gland support the

mammary gland lobules. At the greatest prominence of the breast is the nipple,

surrounded by a circular pigmented area (the areola). The breast contains 15to

20 lobules of glandular tissue, which constitute the parenchyma of the

Chapter1 Anatomical Considerations

-5-

mammary gland .Each lobule is drained by a lactiferous duct, which opens

independently on the nipple (Moore et al, 2007).

.

Figure (1): Schematic representation of breast and pectoral fascia (Mugea ,2009).

The Blood supply of the breast is gained mainly from the axillary artery

via its lateral thoracic and acromiothoracic branches and the internal thoracic

(internal mammary) artery via its perforating branches; these pierce the first to

the fourth intercostal spaces, then traverse pectoralis major to reach the breast

along its medial edge. The first and second perforators are the largest of these

branches and From the intercostal arteries via their lateral perforating branches

(Ellis , 2006).

Chapter1 Anatomical Considerations

-6-

Fig(2): Arterial distribution of blood to the breast, axilla, and chest wall (Romrell et

al.,2006).

The lymphatic drainage of the breast is important because of its role in the

metastasis of cancer cells. Lymph passes from the nipple, areola and lobules

of the gland to the subareolar lymphatic plexus and from it:

Most lymph (> 75%), especially from the lateral quadrants of the breasts,

drains to the axillary lymph nodes (pectoral, humeral, subscapular, central,

and apical), However, some lymph may drain to interpectoral,

deltopectoral, supraclavicular, or inferior deep cervical nodes (Bland

,2007).

Most of the remaining lymph, particularly from the medial breast

quadrants, drains to the parasternal lymph nodes or to the opposite breast.

Lymph from the inferior breast quadrants may pass deeply to abdominal

lymph nodes (inferior phrenic nodes) (Romrell et al.,2006).

Lymph from the axillary nodes drains to infraclavicular and

supraclavicular nodes and from them to the subclavian lymphatic trunk. ymph

from the parasternal nodes enters the bronchomediastinal trunks, which

ultimately drain into the thoracic or right lymphatic duct(Romrell et al.,2006).