The breast has become a major part of the practice of most Plastic Surgeons.◦

Reconstructive after Mastectomy◦

Cosmetic

Breast reconstruction after mastectomy may be staged. It can involve several or all of the following procedures:◦

Insertion of tissue expander ◦

Breast mound reconstruction by tissue graft◦

Removal of tissue expander ◦

Insertion of permanent breast implant ◦

Revisions to reconstructed breast ◦

Balancing procedures to native breast ◦

Nipple reconstruction◦

Areolar tattooingSome procedures are performed in separate encounters, others may take place during the same operative session.

Which procedures a patient requires depends to some extent on how much tissue remains after mastectomy.

skin sparing mastectomy…

If there is sufficient tissue, immediate reconstruction may be performed by placing a permanent implant. Or, if additional tissue is needed, a tissue expander may be placed or a graft may be performed.

with tissue expander insertion

Overview of the common options for soft tissue reconsrtuction

Indications for their use versus a free flap.

Rotational FlapsRotational Flaps

TRAM graft

latissimus dorsi graft

Tissue grafts are used when more bulk is needed to reconstruct the breast mound. A TRAM flap transfers tissue from the lower abdominal wall, a latissimus dorsi flap tissue from the back.

Although the transferred tissue alone may be sufficient, an implant can also be placed underneath.

Transverse Rectus Abdominis Myocutaneous (TRAM)◦

Skin, Fat, and Muscle◦

Superior epigastric vessels for pedicle

May be taken as free flap based on inferior epigastric vessels

This is preferred for obese patients and those that smoke◦

May be delayed

Cut inferior epigastric vessels to allow for increased flow through the superior vesselsUsually 2-3 weeks prior to definitive reconstuction

Latissimus Dorsi Flap◦

Skin, Fat, and Muscle◦

Not generally the first choice for reconstruction

Used in obese womenPrevious abdominal operations

◦

Generally does not provide sufficient bulk for complete reconsturction

Paired with implant on occasion

Deep Inferior Epigastric flap (DIEP)Superior Gluteal Artery Perforator flap (SGAP)

Deep Inferior Epigastric Perforator

DIEP◦

Fasciocutaneous Flap◦

Benefit of “tummy tuck”◦

No risk of hernia (as with TRAM)

Superior Gluteal Artery Perforator Flap

SGAP◦

Skin and Fascia only◦

Typically second choice

Lack of sufficient abdominal skin and subcutaneous tissue

◦

Reduced donor site morbidity◦

No functional loss

Recipient Vessels◦

Internal Mammary

Preferred in skin sparring mastectomyHigh perfusion pressures

◦

Thoracodorsal ArteryRisk of injury to intercostobracheal nerve, lymphedema

Tissue Expanders

When additional tissue must first be developed, a tissue expander is placed in the chest wall and filled through a port at regular intervals to stretch out the skin. Some expanders are designed to be left in, but most are removed and replaced with a permanent implant.

Exchange of Tissue Expander for Implant After the tissue expander has been fully expanded, it is removed and replaced by a permanent implant, typically during the the same encounter. Implants are filled with either saline or silicone. Many models are available to try to match the patient’s natural contours.

Because the expander is a foreign body, it’s normal for a capsule to form around it in the breast. Adjustments to the capsule are often necessary to seat the permanent implant properly.

Revision of Reconstructed Breast It is not uncommon for the reconstructed breast to require surgical revision at some point. This can be necessary because of “contour deficits”, such as: irregularity or deformity in the reconstructed tissue; inadequate projection; and asymmetry or disparity with the native breast.

Surgeons are usually adamant that these issues are in the nature of breast reconstruction and do not represent complications of the graft or implant.

contour deficit

asymmetry

Revision for Complications Unlike contour deficits, asymmetry and the like, capsular contracture is a complication of the implant. A thin capsule forms around all implants. Contracture is when the capsule thickens abnormally and forms scar tissue around the implant, becoming hard and painful. Capsular contracture may require capsulotomy or capsulectomy of the reconstructed breast.

Fat necrosis is a complication of TRAM flaps. Fat within the flap becomes ischemic due to inadequate blood supply. It hardens and must usually be excised.

Balancing Procedures to Native Breast As an alternate to revising the reconstructed breast, or sometimes in addition to it, procedures are also performed on the native breast. This includes augmentation, reduction, and mastopexy of a smaller, larger or ptotic native breast for balance with the reconstructed breast.

mastopexy of native breast

reduction of native breast

Nipple and Areolar Reconstruction Nipple reconstruction is usually performed via skin grafts. Common techniques include the skate flap, top-hat flap, and star flap. Nipple reconstruction is usually delayed for several months after breast mound reconstruction, to allow the new breast time to settle.

Areolar reconstruction can also be performed by grafting, though tattooing is much more common.

With a few exceptions, large breasts in vogue since antiquity◦

Brassieres and corsets used to enhance size

19th Century: surgical breast enlargements attempted using ivory, glass, metal, rubber, and paraffin

1895: Czerny performs first reported successful human mammary reconstruction◦

actress who had undergone removal of a fibroadenoma◦

transplanted lipoma from her hip

1903: Charles Miller inserts "braided silk, bits of silk floss, particles of celluloid, vegetable ivory, and several other foreign materials”◦

granulomatous (foreign body) inflammatory reactions disfiguring and painful

1903-1950s: petroleum jelly, beeswax, shellac, and epoxy resins used.Early 1950s: liquid silicon injections used1962: first US woman to receive encapsulated silicon breast implants

1992: FDA bans silicone breast implants except in strictly controlled trials for breast cancer reconstructive surgery due to reports linking the implants with a variety of connective tissue diseases and neurological disorders.Subsequent analyses show no such links

2005: FDA allows silicone breast implants back on market (with registry)A minimum of 15% of modern silicone implants will rupture between the third and tenth year after implantationToday: newer generation silicone implants, saline implants, dermal fillers

2007: Stem cells and fat derived from liposuction used to grow breast tissue in clinical trials in Europe2008: Israeli surgeon develops “breast lift procedure” involving internal titanium bra with silicone cups2008: MyFreeImplants.com ◦

Facilitates communication and funding

Patient Assessment◦

MotivationBMD?Social pressure

◦

YoungerTeen?Young adult?Does the patient understand the procedure?

◦

OlderQuality of the result

Loss of elasticity of tissues over time◦

“Normal”

sizeAccording to whom?

Considerations◦

Scars

Affect the contour of the breast◦

Oncologic

Is this patient at risk for breast cancerHas she been screened?

◦

SensationUnderstand there may be an alteration to this.

◦

Pregnancy/ Lactation◦

Ptosis◦

Symmetry

Planning◦

Size

Chest wallSkin envelopeProjectionAsymmetry

◦

Implant typeSmoothTextured

Designed to limit capsular contracture and rotation of the implant

Planning◦

Markings◦

Incision

Inframammary foldPeriareolarAxillary

IMF

Axillary

Periareolar

IMF◦

Advantages

Preserves parenchymaPrecise pocketScars well

◦

Best candidatesWell-defined IMFNo h/o hypertrophic healingMild ptosisSports (elevate arms)

Periareoloar◦

Advantages

Scars well◦

Disadvantages

Must be AT JUNCTIONNon-expandable difficultBacterial seeding ?

◦

Best candidatesAreola diameter >35 cmThin layer of breast parenchyma

◦

TechniqueSuperficial to superficial layer of superficial fascia to lower border of breast then into sub-pectoral space

Axillary◦

Advantages

Hidden scar◦

Disadvantages

More difficult with rough surfacesNeed endoscope or blindRevision requires different incision

◦

Best candidatesTendency to hypertrophyMarked hypoplasia with poor IMF

◦

TechniqueMark 1.5-2 cm below IMF

Planning ◦

Position

SubglandularGood with moderate ptosisActive body builders

SubmusculofascialDecreased contractureSofterBetter oncologically

Ancillary Procedures◦

Intraoperative expansion

TE or manuallyCan use expander as estimate of volume

◦

Postoperative expansionPermanent expander implantCan alter final volume

◦

AbdominoplastyDifficult through same incision

◦

BiopsiesPreop studies for all >30yo or younger if at higher risk

◦

NO FAT INJECTIONSCan calcify

Capsular contractureImplant ruptureHematomaWound infection

Breast implants decrease sensitivity of screening mammography among asymptomatic women, but do not increase false-positive rate nor affect tumor prognostic characteristics

Cosmetic implants – 12%After prophylactic mastectomy –30%After mastectomy for breast cancer – 34%Latest trend: microsurgical breast reconstruction using implants or autologous tissues

Postoperative Considerations◦

Care Soft elastic bra or ACE wrap

◦

MassageEnlarges pocketSoftens Can help parasthesias

◦

Hematoma: 0.5%-3%Good hemostasisImmediate post op RTORCan cause some asymmetryCan occur 1-2 weeks post-op with increased activity

◦

Sensation: 15%4th intercostal NV bundle most important

Postoperative Considerations◦

Infection: 2.2%

Staph epidermidis most ducts & implantsPeri-op antibioticsIrrigate with iodineAtypical mycobacteria require removal capsulectomy and systemic anti-fungalsBacterial infections can be treated conservatively initially replace +/- capsulectomy

Postoperative Considerations◦

Capsular Contracture

ClassificationGrade I: SoftGrade II: Minimal : palpable not visibleGrade III: Moderate: palpable and discernibleGrade IV: Severe: hard, symptomatic, +/-distortion

Capsular Contracture◦

Prevention

TypeSilicone: Bleed contributesTextured: Lower incidence, not axillary

PositionSubmusculofascial better - ducts not cut (inflammation)

Blunt dissectionLess hematoma, less electrocautery, less necrosis

InfectionMajor cause

PocketNeed adequate size, larger for smooth

Capsular Contracture◦

Treat remote site infections (URI, UTI)◦

Closed capsulotomy: External pressure tears capsule

Not effective, potential danger◦

Open capsulotomy

Asymmetric implant position, best for I or II◦

Open capsulectomy

Thick or calcified capsule, also smooth subglandular

◦

Conversion to submusculofascial◦

Capsulorrhaphy

Suture capsule to reposition pocket into breast confines

Capsular Contracture◦

Long-Term Results

Varying degrees of firmnessNot all contractures require correctionReplacement: Most last 7 –15 years

11,326 procedures performed on 18-year olds in 2003

Phenomenon suggests poor parenting, through the capitulation of financially well-endowed parents to the whims of their children, who likely have self-esteem problems and are not yet emotionally (nor perhaps even physically) mature

4,108 procedures on women 18 and under in 2008

US and EU: breast augmentation surgery allowed on those under age 18 only for medical reasons◦

Yet 50% of procedures done for purely cosmetic reasons