Reconstructive surgery following mastectomy

Transcription

1 Reconstructive surgery following mastectomy Kseniya Roudakova, MD

2 A CASE FROM SUNY DOWNSTATE 60F who presented for right mastectomy with immediate TRAM flap reconstruction for recurrent breast cancer Oncologic Hx: right breast ca (T1bN0M0) in 2001 s/p chemo RT; biopsy proven recurrent breast ca in 2016 PMHx: obesity (BMI 40), DM, HTN, HLD, hypothyroidism PSHx: c-section x2, right breast lumpectomy, hysterectomy SoHx: non-smoker

3 Peri-operative course 12/9/16: Right breast mastectomy and SLNB with immediate TRAM flap reconstruction and nipple-areola graft POD1: breast flap warm and dry with PICO dressing intact with 2 JP s draining ss fluid POD2-3: Tm POD4: PICO dressing changed; epidermolysis present on 2 areas of flap measuring 1x1cm at 6 ad 7 o clock; silver sulfadiazine applied POD5: Tm102.6; right breast skin hyperpigmented CXR: right lower lobe consolidation started on Zosyn POD6: started on Vancomycin POD7: CT chest/a/p: no large drainable collection, right lower lobe consolidation seromacath placed in R nipple, <10 ml ss discharge expressed

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11 Peri-operative course 12/9/16: Right breast mastectomy and SLNB with immediate TRAM flap reconstruction and nipple-areola graft POD1: breast flap warm and dry with PICO dressing intact with 2 JP s draining ss fluid POD2-3: Tm (Bcx negative) POD4: PICO dressing changed; epidermolysis present on 2 areas of flap measuring 1x1cm at 6 ad 7 o clock; silver sulfadiazine applied POD5: Tm102.6; right breast skin hyperpigmented CXR: right lower lobe consolidation started on Zosyn POD6: started on Vancomycin POD7: CT chest/a/p: no large drainable collection, right lower lobe consolidation seromacath placed in R nipple, <10 ml ss discharge expressed

12 Peri-operative course (continued) POD9-12: Tm 101.8, leukocytosis, right TRAM flap skin breakdown, free flap areola dark and cold to touch with fat necrosis around the site POD13: areola free flap removed POD14: patient underwent wound debridement, R TRAM flap reconstruction with split thickness skin graft and wound vac placement

13 Pathology 12/9/16: invasive ductal carcinoma, 1.6 cm, DCIS; negative margins; 0/4 LN 12/22/16: nipple and areola skin with foci of acute necrotizing inflammation and abscess formation, no evidence of carcinoma 12/23/16: gangrenous skin with necrosis and acute inflammation extending into the subdermis, necrotic fibroadipose tissue

14 LAW PICTURE Women s Health and Cancer Rights Act 1998 NYS Post Mastectomy Breast Reconstruction Mandate 2011

15 Patient-reported Quality of Life and Satisfaction with Cosmetic Outcomes After Breast Conservation and Mastectomy with and without Reconstruction: Results of a Survey of Breast Cancer Survivors Ann Surg Jun:261(6): Jagsi R., Li Y., Morrow M., Janz N., Alderman A., Graff J., Hamilton A., Katz S., Hawley S women 963 breast conserving surgery 263 mastectomy without reconstruction 222 mastectomy with reconstruction Satisfaction not significantly different between the group receiving breast conservative surgery and the group receiving mastectomy with reconstruction with either implant or autologous technique Satisfaction was slightly but significantly lower in patients receiving mastectomy alone than those who receive breast conservation alone.

16 Comparison of quality of life based on surgical technique in patients with breast cancer Jpn J Clin Oncol Sun Y., Kim SW., Heo CY., Kim D., Hwang Y., Yom CK., Kang E. 407 women 254 breast conserving surgery mastectomy without reconstruction 31 mastectomy with reconstruction Women in the breast-conserving surgery group showed better outcomes than women in the total mastectomy and reconstruction group after total mastectomy groups with respect to emotion-social function, nausea/vomiting, financial difficulty, body image, arm symptoms and self esteem Patients in the reconstruction after total mastectomy group had significantly better outcomes on the sexual scale and arm symptoms than the total mastectomy group

17 Determinants of patient satisfaction regarding aesthetic outcome and skin sensitivity after breast-conserving surgery World J Surg Oncol Dec7:14(1):303 Dahlback C., Manjer J., Rehn M., Ringberg A. 297 women after BCS and RT 84% were satisfied or very satisfied with the overall aesthetic result 68% were satisfied with symmetry of breasts 67% were satisfied with skin sensitivity Factors associated with less satisfied patients Excision of more than 20% of the affected breast BMI of more than Re-excision and post-operative infection

18 Overview Basic definitions of surgical techniques for treatment of breast cancer Timing of reconstruction Partial breast reconstruction Volume replacement Volume displacement Implant-based reconstruction Total autologous tissue reconstruction Accessory procedures Risk factors and complications Questions

19 Definitions of surgical techniques for breast cancer treatment Breast conserving therapy (BCT) followed by radiation Early stage (I and II) breast cancer Contraindications: Prior radiation therapy to breast or chest wall Persistently positive surgical margins after re-excision Multicentric disease Scleroderma or lupus erythematosus Pregnancy (unless diagnosed in 3 rd trimester) Skin-sparing mastectomy with immediate reconstruction Nipple-areolar sparing mastectomy Not advisable for patients who will undergo RT Total mastectomy Modified radical mastectomy

20 Timing of reconstruction Immediate reconstruction Decreased risk of social and emotional difficulties Better cosmetic outcome Fewer surgeries, lower cost Longer surgery and recovery Potential delay in ajuvant therapy Delayed breast reconstruction (3-6 months after mastectomy) Avoids mastectomy flap unreliability and radiation therapy unpredictability Pt is subjected to additional operative procedure Cosmetic result often worse

21 BCT and Partial Breast Reconstruction Displacement Techniques Parenchymal remodeling Achieved via mastopexy and reduction techniques Wise pattern incision Re-arrangement of area of breast to fill a small to moderately sized defect

22 BCT and Partial Breast Reconstruction Volume Replacement Techniques Best for small breasts with insufficient residual breast tissue Provides breast symmetry without remodeling contralateral breast

23 Implant Placement Advantages Absence of donor site morbidity Short operative times Short recovery Disadvantages More reconstructive stages Lack of natural feel and ptotic appearance Infection, rupture Long term: scarring, capsular contracture, visible deformity Contralateral breast may need to be operated on for symmetry

24 Tissue Expanders

25 Autologous Tissue Reconstruction Pedicled flap reconstruction TRAM flap Latissimus dorsi myocutaneous flap Free flap reconstruction Free TRAM/DIEP/SIEA flaps Superior and inferior gluteal artery perforator flaps Deep groin flap Medial and lateral thigh flap, gracilis flap Implant plus autologous tissue reconstruction

26 TRAM Flap

27 Latissimus dorsi myocutaneous flap Can be performed as part of volume replacement technique after BCT totally autologous breast reconstruction in conjunction with breast implant Contraindications: previous posterolateral thoracotomy, atrophic latissimus dorsi (after division of thoracodorsal nerve) Complications: Seroma most common Shoulder weakness, winging of scapula Dorsal hernia Flap necrosis

28 Superior/Inferior Gluteal Artery Perforator Free Flap

29 Profunda Artery Perforator Flap

30 Transverse Upper Gracilis Flap

31 Accessory Procedure Nipple and Areola Reconstruction ideally approximately 3-5 months after the last revisional reconstructive surgery Composite nipple graft Skin graft (Skate, Star, CV flap, etc) Tattooing Scar revision Fat grafting Breast mound revision

32 Complications in postmastectomy breast reconstruction: two-year results of the Michigan Breast Reconstruction Outcome Study Plast Reconstr Surg. Alderman AK., Wilkins EG., Kim HM, Lowery JC. Factors associated with significantly higher total as well as major complication rates Immediate reconstruction Higher body mass index Implant patients who received RT TRAM flap patients who received chemotherapy

33 Impact of Time Interval between Radiation and Free Autologous Breast Reconstruction J Reconstr Microsurg Oct 31 Mull AB., Qureshi AA., Zubovic E., Rao YJ., Zoberi I., Sharma K., Myckatyn TM. No significant difference in major complications between flaps who had reconstruction within 12 months and greater than 12 months after radiation. Only having a more muscle sparing technique or smaller vein size were independent risk factors for major complications.

34 Effects of Obesity on Postoperative Complications After Breast Reconstruction Using Free Muscle-Sparing Transverse Abdominis Myocutaneous, Deep Inferior Epigastric Perforator, and Superficial Inferior Epigastric Artery Flap: A Systematic Review and Meta-analysis Ann Plast Surg May:76(5): Lee KT., Mun GH. Obesity increases the risk of both flap-related and donor-related complications in breast reconstruction using mstram, DIEP, and SIEA flaps. In comparison to conventional TRAM flaps, however, muscle-conserving abdominal flaps may have an advantage in reducing the morbidity in obese patients

35 Venous Congestion and Leech Therapy Medical leeches for surgically uncorrectable venous congestion after free flap breast reconstruction. Microsurgery Oct; 34(7): Pannucci et al. Venous congestion associated with lower Hgb nadirs and higher number of transfusion Leech therapy was associated with higher total flap loss rates (75% vs 42%) and a longer length of stay (8 vs 6.5 days) Comparison of medical leech therapy with venous catheterization in the treatment of venous congestion of the sural flap. Mocrosurgery Jan:31(1): Mozafari et al. VC superior to leech therapy in Amount of blood removed Wound infection and dehiscence rates Patient and nuses satisfaction

36 Question You are planning to perform a left mastectomy on a 39 year old female. The patient inquires about postmastectomy breast reconstruction and prefers not to have an implant. You discuss the pedicle transverse rectus abdominis (TRAM) flap with her. Which of the following puts her at high risk for complications following TRAM reconstruction? A. History of right lower extremity DVT B. Hyperlipidemia C. Hypertension D. Obesity E. Unilateral breast reconstruction *TrueLearn

37 Answer D. Obesity and heavy cigarette use puts patients at high risk for postoperative complications following TRAM flap reconstruction.

38 Question Which of the following statements about wound seromas after breast surgery is TRUE? A. Seromas occur in 75% of patients having major breast surgery B. Daily aspirations resolve seromas more quickly than aspirations only for symptoms C. Intraoperative local wound application of tetracycline increases seroma formation D. Iodine toxicity has been reported when providone iodine is used as a sclerosing agent E. Drain placement after one aspiration is recommended *SESAP

39 Answer C. Sclerotherapy has been tried with a number of agents. Intraoperative use of tetracycline was associated with a seroma incidence of 53% at two weeks postoperatively compared with 22% in a control group.

40 Works Cited New York Times: August 19, 2010, on Page A23 of the New York edition with the headline: Before Breast Is Removed, A Reconstruction Discussion. Anemona Hartocollis Brunicardi, F. Charles., and Seymour I. Schwartz. Schwartz's Principles of Surgery. New York: McGraw-Hill, Health Pub. Division, Print. Patient-reported Quality of Life and Satisfaction with Cosmetic Outcomes After Breast Conservation and Mastectomy with and without Reconstruction: Results of a Survey of Breast Cancer Survivors Ann Surg Jun:261(6): Jagsi R., Li Y., Morrow M., Janz N., Alderman A., Graff J., Hamilton A., Katz S., Hawley S. Comparison of quality of life based on surgical technique in patients with breast cancer Jpn J Clin Oncol Sun Y., Kim SW., Heo CY., Kim D., Hwang Y., Yom CK., Kang E. Determinants of patient satisfaction regarding aesthetic outcome and skin sensitivity after breast-conserving surgery World J Surg Oncol Dec7:14(1):303 Dahlback C., Manjer J., Rehn M., Ringberg A. Complications in postmastectomy breast reconstruction: two-year results of the Michigan Breast Reconstruction Outcome Study Plast Reconstr Surg. Alderman AK., Wilkins EG., Kim HM, Lowery JC. Impact of Time Interval between Radiation and Free Autologous Breast Reconstruction J Reconstr Microsurg Oct 31 Mull AB., Qureshi AA., Zubovic E., Rao YJ., Zoberi I., Sharma K., Myckatyn TM. Effects of Obesity on Postoperative Complications After Breast Reconstruction Using Free Muscle-Sparing Transverse Abdominis Myocutaneous, Deep Inferior Epigastric Perforator, and Superficial Inferior Epigastric Artery Flap: A Systematic Review and Meta-analysis Ann Plast Surg May:76(5): Lee KT., Mun GH. Medical leeches for surgically uncorrectable venous congestion after free flap breast reconstruction. Microsurgery Oct; 34(7): Pannucci et al. Comparison of medical leech therapy with venous catheterization in the treatment of venous congestion of the sural flap. Mocrosurgery Jan:31(1): Mozafari et al.