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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