Breast Reconstruction

1
Breast Reconstruction

• Jeffrey E. Schreiber, M.D.
• Sinai Hospital of Baltimore
• Resident Teaching Conference
• March 11, 2008

2
Breast Cancer Facts

• 1 in 8 women will develop breast cancer
• In the U.S., 215,990 (1,450 in men) cases of
  breast cancer were diagnosed in 2004
• Incidence of cancer
• 1 skin malignancy
• 2 BREAST CANCER

3
First Things FirstWhen do you perform the
reconstruction?

• Immediate vs Delayed
• Coordination of oncology team and plastic surgeon
• Depends on stage and need for chemo or radiation

4
Immediate Reconstruction Pros and Cons

• Pros
• One hospital admission and one anesthetic
• Single recuperation time
• Cons
• Loss of areas of skin flap can result in implant
  loss
• The final pathology
• Go to sleep with a breast, wake up with a
  different breast

5
Delayed Reconstruction Pros and Cons

• Pros
• Chemo or radiation completed
• Appreciation for new breast
• Cons
• Contracted skin with scars
• Two surgeries/anesthesias
• Without breast for some time

6
Options for Breast Reconstruction

• Alloplastic
• Prosthesis
• Expander/Implant
• Autogenous own body tissue transferred to
  create a new breast mound
• TRAM flap
• Latissimus dorsi flap
• DIEP

7
Expanders/Implants

• Placed at the time of mastectomy or at later
  surgery
• Expanders
• Used to create a pocket for an eventual implant
• Skin resected with breast specimen
• Skin-sparing mastectomy may allow immediate
  implant
• When to avoid
• History of radiation or anticipated need
• Complication rate 68 vs 31
• Failure rate 37 vs 8

8
Alloplastic Breast Reconstruction
9
Expanders/Implants

• Complications
• Leakage
• Rupture
• Infection
• Extrusion
• Implant loss
• Capsular contracture

10
(No Transcript)
11
Latissimus Dorsi Flap

• First described by Schneider et al. in 1977
• Reliable blood supply
• Thoracodorsal artery
• Branches of intercostal and lumbar arteries
• Versatile skin paddle orientation
• Good flap to use in patients who are moderately
  obese, smokers, prior hx of chest wall radiation
• Combine with an implant to obtain projection and
  symmetry
• Complications capsular contracture, seroma,
  nerve traction injuries from positioning

12
(No Transcript)
13
(No Transcript)
14
TRAM flap

• Transverse Rectus Abdominus Myocutaneous
• Transfer skin, fat, and rectus abdominus muscle
  to form a breast mound
• Reconstructs the breast and recontours the
  abdominal wall
• Pedicle TRAM dependant on blood supply via
  superior epigastric artery/vein to rectus
  abdominus muscle
• Free TRAM microvascular anastomosis required
  via deep inferior epigastric artery/vein
• Complications flap loss, bleeding, abdominal
  wall hernia, may restrict strenuous activities

15
(No Transcript)
16
DIEP flap

• Deep Inferior Epigastric Perforator
• Skin and subcutaneous fat from abdomen without
  sacrificing abdominal musculature
• Free flap required microvascular anastomosis
• Not for smokers, diabetic patients, anticipated
  radiation therapy

17
(No Transcript)
18

• Thank you