Breast Reconstruction
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1 Steven E. Copit, M.D. Chief- Division of Plastic Surgery Thomas Jefferson University Hospital Philadelphia, PA
2 analysis of The Defect Skin Breast Volume Nipple Areola Complex
3 analysis of The Defect
4 the mastectomy defect Skin defect Most difficult to replace Breast volume Replaced by fat, muscle, implant Easier to replace Nipple-Areola Complex Easiest
5 skin estimate of defect Size of tumor / proximity to skin Previous biopsy Previous XRT Smoking Size of skin flaps Breast surgeon
6 skin Probably the single most important influence on the improved quality of breast reconstruction has been the evolution of the mastectomy technique. F.E.B., M.D.
7 skin sparing mastectomy
8 breast volume Match the reconstructed breast to the contra-lateral side Modify the contra-lateral breast to approximate the result of the reconstruction
9 nipple areola complex Appearance Sensation Lactation
10 It s all about symmetry Breast size Breast Shape - Ptosis
11 procedure selection Implant Reconstruction Tissue expander / Permanent implant Latissimus Dorsi Myocutaneous flap and tissue expander / permanent implant
12 procedure selection Autogenous reconstruction Abdominal Wall Pedicle TRAM flap Free TRAM flap DIEP Flap
13 procedure selection Gluteal Reconstruction GAP flap SGAP flap
14 tissue expander / implant
15 tissue expander / implant Saline filled silastic expander Exchange for saline or silicone filled silastic implant
16 tissue expander / implant Tissue expansion provides skin Implant exchange provides volume
17 tissue expander / implant
18 tissue expander / implant Pros No donor site morbidity Short surgery
19 tissue expander / implants Cons Poor symmetry Frequent visits to office for expansion Implant under skin
20 implant options Saline vs. Silicone Silicone is softer Silicone has diminished fold flaws
21 Institute of Medicine No evidence that silicone implants are responsible for any disease No evidence of a novel autoimmune disease No increase in breast cancer No danger in breast feeding Implants do not last forever
22 implant issues All complications are local Rupture Capsular contracture Infection
23 implant issues Silicone was used under FDA trials for reconstruction only FDA has reviewed the results of the trials and has cleared silicone for unrestricted use
24 silicone is back Silicone implants are the most extensively studied medical device in the history of the FDA Even plaintiff attorneys have to surrender to science
25 tissue expander / implant
26 tissue expander / implant
27 tissue expander / implant
28 tissue expander / implant
29 latissimus dorsi myocutanious flap / implant
30 latissimus dorsi myocutanious flap / implant Rotation flap of muscle and skin from back to replace skin Permanent implant to replace breast volume
31 Lat. dorsi and tissue expander Pros Looks better than a tissue expander alone Replacing skin preserves the natural shape of the breast (ptosis) Replacing skin allows more fill in the expander at the time of the initial operation
32 Lat. dorsi and tissue expander Cons Donor scar (minimal if transverse oriented) Donor muscle function loss
33 Lat. dorsi and tissue expander
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46 Lat. dorsi and tissue expander
47 nipple- areola complex Creation of nipple from breast skin Tattoo areola and nipple in office
48 nipple- areola complex
49 timing Immediate reconstruction Delayed reconstruction
50 Contraindications Planned post-op radiation Smoking
51 advantages Beneficial psychological effects 1,2,3 Pliable skin flaps and IMF preserved 1. Stevens, et al: PRS 73:619, Schain WS: Clinics Plast Surg 11: 237, Wellisch DK: PRS 76:713, 1985
52 operative plan Unilateral Reconstruction Match normal breast TRAM Lat.Dorsi
53 operative plan Bilateral reconstruction TRAM Lat. Dorsi and tissue expansion Tissue expansion
54 My Absolutes No one perfect choice No easy way to make a breast The more you do the better it looks Some people require a higher standard reconstruction- be honest
55 My Absolutes Allow yourself to think long term You should hear about all the options but listen to your surgeon Mastectomy is easy, reconstruction is hard
56 Thank you
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