In a second stage or a second operation that tissue expander is removed through the same incision and the implant is placed within the chest pocket.

Transcription

1 Hello, I m Summer Hanson. I m an assistant professor in the Department of Plastics & Reconstructive Surgery at The University of Texas MD Anderson Cancer Center and today I m going to talk about the role of plastic surgery and reconstruction in breast cancer survivorship. Upon completion of this lecture participants will be able to describe the benefits of reconstruction in breast cancer patients; compare the most common techniques of reconstruction; and detail the benefits and risks potentially associated with each; and outline the different methods of reconstruction and identify the method considered best for each patient. Oftentimes when there s a breast cancer diagnosis there is a great amount of depression and anxiety associated with this. There s an uncertainty of prognosis. There s a consideration for the life-threatening aspect of the disease and then there s concerns specific to the loss of the breast. Patients often have a fear of rejection or a loss of femininity and self-esteem related to the loss of the breast. That s potentially a constant reminder of their disease process. And then there may be physical considerations such as body imbalance, shoulder and back pain. We like to think that reconstruction offers the ability to re-establish body wholeness and symmetry and improve self-image as part of the therapeutic process for cancer patients. We typically refer to this quote from Gaspar Talgliacozzi in the 16 th century that says that We restore, repair, and make whole those parts which nature has given but fortune has taken away. So why do we perform reconstruction? Well in 1998, Congress actually assisted us in pre --- passing the Woman s Health & Cancer Rights Act. This mandates that group health insurance plans provide medical and surgical benefits to cover the cost associated with reconstructive breast surgery and this includes symmetry procedures for patients that have had mastectomy. Due to an improved cancer detection and survival rate, it s estimated that approximately 75% of patients undergoing mastectomy will go on to have reconstruction. The reasons that we give for choosing reconstruction are often for patients to feel less cumbersome in dealing with the uncomftabl --- [excuse me] --- uncomfortable prosthesis, that they are able to wear most types of clothing again comfortably and not selfconsciously. Patients often cite that they regain their femininity and often feel whole again after their reconstruction. These are statistics from the recent survey of The American Society of Plastic Surgeons on reconstructive breast surgery procedures. And you can see that nearly 100,000 procedures were performed in 2013 and we expect this number to increase with the next round of statistics. Typically these are implant-based reconstructions most commonly.

2 At MD Anderson we find that approximately 50% of our plastic surgery cases performed each year are related to breast cancer surgery and approximately 80% of our patients will undergo an immediate reconstruction. About half of these will pref --- we will performed some sort of implant-based reconstruction. You can see here 76% performed --- underwent immediate reconstruction compared to 24% delayed and the number of reconstructions is increasing each year here at MD Anderson. We are fortunate to have a multidisciplinary team approach to breast cancer. Patients are often seen by not only the breast medical oncologist and surgical oncologist but the radiation oncologist and the plastic and reconstructive surgeon. And we all work together to determine which technique and the timing of reconstruction will be best for the patient. When I speak of timing I refer to either immediate reconstruction in which the reconstruction is performed at the time of the mastectomy or delayed in which case it is performed after adjuvant therapies and recovery. And technique, we refer to approximately three different routes. Tissue-based reconstruction is using the patient s own tissue and we ll discuss the different donor sites to come. Tissue plus implant is using the patient s own tissue but often adding an implant in order to improve on the contour or the shape of the breast. And then implant alone in specific candidates for implant-based reconstruction and this can be a single stage implant or two stage tissue expander to implant and I ll describe that next. We find that there is some difference when the timing is immediate versus delayed specifically psychosocially. Most patients prefer immediate reconstruction. There s a much higher degree of satisfaction with the results after immediate reconstruction compared to delayed. And we can find that there may be distress in recalling the mastectomy surgeon --- [excuse me] --- surgery in the immediate reconstruction group compared to the delayed reconstruction group. Patients undergoing immediate reconstruction are more often satisfied. They have less anxiety or depression and overall betty --- better body image, self-esteem, and attractiveness. Patients undergoing delayed reconstruction had poorer body image scores but we find that approximately one year following surgery and beyond that both immediate and delayed reconstructive patients have an improvement in their quality of life and their satisfaction. So fortunately we see that even delayed reconstruction patients benefit after their recovery. There is a slight difference in the appearance of the reconstructed breast not only in the technique that we use but specific to whether the procedure is performed in immediate or delayed fashion. Here you can see that the breast envelope which is the draping of the skin that remains after the mastectomy when the breast tissue is removed is preserved during immediate reconstruction and the tissue is perform --- is placed within that pocket. And it can result in either a circular scar where autologous tissue is re --- used or it can be a straight line scar where the incision is closed particularly in implant reconstruction.

3 In delayed reconstruction that breast envelope or that skin is removed as well and there is typically a straight line incision across the chest. When I come back and perform reconstruction in a delayed fashion a lot of that skin is removed and so there is less tissue to work with. And typically more of the reconstruction is then using tissue from the patient s own donor sites either from the back or from the abdomen and we ll talk about that briefly. Again, I said there are three categories of reconstruction: implant-based, autologous tissue-based, and this can either be freed where the tissue is detached from the body and then reconnected or pedicled where it s actually rotated on its blood supply. The most common sites are TRAM or transverse rectus abdominis myocutaneous flap which can be muscle sparing, DIEP which refers to a perforator flap or SIEA which refers to the superficial version of that flap and then other flaps or other donor sites. The latissimus dorsi is the most common other site, so to speak, but we do have potential donor sites in the gluteal region and what s considered an ALT or the anterior lateral thigh. And then there s a combination of the two where we use both autologous tissue and an implant reconstruction and this is most commonly that latissimus dorsi with the placement of an implant as well. The type of reconstruction depends on the cancer diagnosis; their status or prognosis; any potential adjuvant therapies or treatments that are needed either before or after the surgery; the overall health status of the patient; their donor site tissue availability; and what tissues I have as a reconstructive surgeon to work with; and then the patient preference or lifestyle considerations. Certainly this has --- the type of reconstruction has an impact on their recovery and there are certain requests or preferences that patients have. Implant-based reconstruction is probably the most commonly performed worldwide but also here at MD Anderson. Candidates must have an adequate skin envelope and that s typically the skin that remains from a skin sparing mastectomy. This allows me to place an implant at the time of the mastectomy and fill in that tissue, so to speak. But patients without ald --- adequate autologous tissue are often good candidates for implant reconstruction. Patient lifestyle and preference in this case refers to the fact that it s an easier recovery since we re not creating any new donor sites or new scars anywhere else and it s not as big of an operation or big as a procedure as the abdominal based flaps. We often reserve this for patients that have no history of current need for radiation therapy. As I discussed in the late effects of breast reconstruction we can see an increased rate of capsular contracture in patients who have radiation therapy and implantbased reconstruction. So this is something to make people aware of if we know that they need radiation therapy. Typically this is commonly performed as a two stage reconstruction. First a tissue expander is placed under the mastectomy skin flap and pectoralis major muscle at the time of the mastectomy and that s the grayed out implant that you see here under the muscle.

4 This has a port directly within the implant that allows us to add fluid, typically saline, in the clinic and this allows us to expand or stretch out the skin and soft tissue, getting a sho -- - size and volume of reconstructed breast that s appropriate for the patient and their skin quality. In a second stage or a second operation that tissue expander is removed through the same incision and the implant is placed within the chest pocket. The advantages to implant-based reconstruction I think are --- are most commonly associated with the appearance of the reconstruction so typically we see a perky appearing breast or more youthful appearing breast and there are no additional scars on the body that the patient has to worry about. In addition to that there is less hospitalization and less recovery time. In a select group of patients this can be performed as a one stage reconstruction in which the implant is placed directly under the tissue at the time of the mastectomy. But as I said this is more commonly a two stage operation. The disadvantages are associated with having an implant, so there is maintenance of the implant. It s considered a foreign body and so there will be some scar that builds up around it. There may potentially be infection, failure, or capsular contracture. There are changes that we see with time, with aging, with changes in the weight of the patient that may result in the need for an additional procedure for symmetry. Unfortunately, like I said, it s most commonly a two stage procedure so this does warrant two surgeries during the patient s recovery time. And it s often hard to match an implant-based reconstruction to a natural breast. So in uti --- unilateral reconstruction we do see a slight decrease in patient satisfaction compared to bilateral implant-based reconstruction. Typically associated with this type of reconstruction is the use of a bioprosthetic sling. So your pectoralis major muscle or your chest muscle covers about two-thirds of the chest and when we elevate that in order to place the tissue expander we sort of lose some of that coverage over the implant. A bioprosthetic sling, which is comprised of an acellular collagen matrix derived from the dermis, allows us to extend that muscle and cover the implant completely. You can see in this picture there is the muscle here and that bioprosthetic sling or that ADM. And they re sutured with the muscle overlapping the bioprosthetic. This is commonly fetal bovine, human or porcine, depending on the type of tissue that s warranted. It s treated so it s biocompatible and it s cell friendly. It actually allows for your own tissue to grow into the area, revascularize, and become integrated into the host tissue. It allows less tension on the skin and it acts as an extension of the pectoralis major muscle so giving us full coverage of that expander. This allows me to add more fill volume at the time of the surgery and can improve the aesthetics of the reconstruction because we are able to recreate the inframammary fold and the lateral aspect of the chest wall that can sometimes be disrupted with the mastectomy. A bioprosthetic sling is typically necessary in immediate reconstruction when we go to --- direct to an implant or just one stage. The downside as with any prosthetic material is the expense. It is also a foreign body just like the implant and so can be prone to infection or fluid collection or seroma.

5 When we talk about implant reconstruction there are two choices of the type of implant used, saline versus silicone. Saline implants have been approved by the FDA since Prior to that silicone implants were used. Prior to 1992 silicone leakage and fear of potential causes of cancer or autoimmune diseases such as lupus were associated with silicone-based implants and, therefore, they were removed from the market in 1992 by the FDA. After 1992 we have large scale studies of patients who had silicone implants placed in order to determine the safety of the silicone implants. And we actually found that there was no connection between in sil --- between using silicone implants and the development of cancer or autoimmune diseases. So in 2006 the FDA actually reversed its ban on silicone breast implants and now both types are available, saline and silicone. Both saline and silicone implants are FDA approved and safe for breast reconstruction and this provides us many shapes and sizes available for our patients. Next I ll talk about the latissimus dorsi myocutaneous flap. So this is a combination of an implant-based reconstruction and using autologous tissue where the donor site is the back muscle, the latissimus dorsi, as well as skin from the overlying tissues. Candidates for this type of procedure are typically patients that do not have enough adequate abdominal tissue for an autologous reconstruction using their abdominal tissue or their buttock. Patient lifestyle and preference can come into play because, again, this is a slightly less complex operation with less recovery time. It s preferred in patients who do not have a history or need for radiation therapy. If they do need radiation the latissimus dorsi can potentially be used after in a delayed fashion in order to bring in healthy vascularized tissue. But typically we see this immediately used if the patients have a lack of skin coverage for their implant placement. This allows the entire latissimus dorsi muscle to cover the tissue expander or the implant. You can see here in this cartoon there is a skin petal of the overlying tissue that can be moved as well as the entire latissimus dorsi muscle here. This is rotated around to the front and tunneled under the arm and then that can be used to cover the implant entirely. The advantages are that it provides a more natural breast shape than an implant alone so this gives us good healthy tissue to cover the implant and sort of mask some of the potential late effects that we can see such as rippling or wrinkling. The scar can be hidden along the bra line so it doesn t seem obvious to the patient and it gives, again, extra coverage of the implant itself. This can potentially be placed as a one stage reconstruction but depending on the size and shape of the reconstructed breast may potentially be two stages in which case the tissue expander is placed under the muscle and in a second stage the expander is exchanged for an implant similar to implant-based reconstruction. Disadvantages compared to an implant-based reconstruction are that it s a longer surgical procedure and there is additional scarring as well as potentially fullness under the arm where the muscle is tunneled through. There are potential complications associated with using your own tissue and specifically that s donor site morbidity so at the donor site of

6 the back and potentially flap loss. Compared to an implant this is a longer hospitalization and longer recovery. However, compared to abdominal tissue reconstruction this is less hospitalization and less recovery. So next I ll talk about the abdominal-based reconstruction options. The most common is the transverse rectus abdominis myocutaneous flap, the TRAM or TRAM flap you ll hear me refer to it as. There are several variations of this flap and all of which refer to essentially using the muscle --- some form of the muscle, the skin, and the adipose tissue of the lower abdomen. Pedicled TRAM is using that tissue, taking the entire portion of the rectus abdominis muscle, keeping it attached on its blood supply, and actually rotating it up to the chest wall similar to the pedicle latissimus dorsi. Free TRAM refers to taking the entire muscle, the skin, and subcutaneous or adipose tissue, detaching it from the body, and then reconnecting it to the blood vessels up in the chest. Free muscle sparing TRAM as it sounds is taking that tissue but splitting the muscle and preserving as much of it as you can but taking a small portion of it with the blood supply, again detaching it and reconnecting it up at the chest. The free DIEP or deep inferior epigastric perforator flap refers to splitting the muscle and taking the perforating blood vessels that come through the muscle. Again, all of that skin and subcutaneous adipose tissue are included. This is detached and then reconnected up at the chest and the free SIEA or superficial inferior epigastric artery refers to that skin and subcutaneous tissue but not entering the abdominal wall at all and just taking all that superficial tissue. Again it is detached and then reconnected up at the chest. As we go through this list from pedicled TRAM down to free SIEA there is a trend towards minimizing the amount of abdominal donor site morbidity and how much tissue you re taking or disrupting. And we see that clinically there is a trend towards preserving this as well. The advantages of using this abdominal tissue is that it provides a breast shape and behavior that s very natural. It s the patient s own tissue so as they age, as they change weight, gain or lose weight, the shape of the breast and the shape of the reconstructed breast will age similarly. And it won t be exactly the same if we re just doing a unilateral reconstruction because the natural breast will sh --- will age and --- and change differently but overall it provides a much more natural appearance on the chest wall than an implantbased reconstruction and there s a natural consistency. It s uniform tissue from the abdomen. From the donor site patients do often view this as essentially a tummy tuck because we re taking away all of that redundant lower abdominal tissue and it offers a reconstruction that does not involve a foreign body or implant. The disadvantages, however, is that it s a longer surgical procedure. It s a much longer recovery time and longer hospitalization stay. There is additional scarring from hip to hip essentially on the lower abdomen and a small scar around the belly button. There are potential complications that we don t see as much with the other types of reconstruction specifically flap loss. As I said the reconstruction is based on a connection --- new connection of blood vessels and that can potentially clot off or cause thrombosis and then donor site morbidity. Any time we disrupt the abdominal wall there is a potential for hernia or bulge. Again, I said longer hospitalization and longer recovery compared to the other types of reconstruction.

7 I will briefly go through the anatomy here to show you the --- those reconstructions using the abdominal tissue. So this is your chest wall and your pectoralis major muscle and the internal mammary vessels are here and the thoracodorsal vessels are here. So the thoracodorsals provide the blood supply to your latissimus dorsi muscle or it can be a potential donor site --- [I m sorry] --- recipient site for the free reconstruction or microsurgical reconstruction. Most commonly we go to the internal mammary vessels. The rectus abdominis muscle runs along --- [excuse me] --- runs along the abdominal wall there and provides your six pack muscles and this is that tissue that we take. So pretty much everything below the belly button from hip to hip. And these are either the superficial inferior epigastric or the deep inferior epigastric vessels which provide the recipient --- the donor blood supply to our recipient reconstruction. So when we pedicle the --- the TRAM flap or the transverse rectus abdominis myocutaneous flap, again, we keep that connection and rotate the tissue up to do the breast reconstruction and provide all the skin and fat tissue here and you can see the muscle is still attached. When we perform a free reconstruction that tissue is disconnected from the abdomen and then reconnected to the internal mammary blood vessels and this is considered the anastomosis and then the flap is inset along the lower portion. But here you can see we maintain as much of that muscle as we can. When you look at the layers of the abdominal wall there s the skin and adipose tissue or subcutaneous tissue and that s common to all types of abdominal flaps that we re talking about. The difference in the terminology then refers to how much of this rectus abdominis muscle we either divide or remove completely. When we talk about a DIEP flap, the deep inferior epigastric perforator, these are the perforators that we re talking about, so small vessels that are coming off of the larger blood supply through the muscle and up to the skin and subcutaneous tissue. The advantage of perforator flaps are that it spares muscle, it typically minimizes pain, and long term provides less functional morbidity because we re preserving as much of the muscle as we can. The disadvantages are that it s very technically challenging and provide an increased operative time. Oftentimes there are variations in patients anatomy which allow the blood vessels to travel through the muscle in sort of a circuitous route and we end up having to take more muscle than --- than we would anticipate. This slide just illustrates again the different variations of that transverse rectus abdominis or --- or TRAM flap or abdominal flap. The SIEA is the superficial one, so we re not going into the muscle at all. You can see there is no muscle associated. The deep inferior epigastric, we re splitting the fascia and the muscle but we re not actually taking it. So here you can see the blood supply with no muscle. And then the muscle sparing TRAM where we take a small portion of that muscle included with the blood supply and that s the portion here and then the remaining muscle is seen on either side of the abdomen there.

8 So ideal candidates for this type of reconstruction in abdominal-based flap regardless of the type of perforator or how much muscle or muscle sparing we use, we do look specifically for healthy candidates so minimal comorbidities. Again, it s a long operation, a long recovery so we don t want to add any additional stress if we know that going in. Patients who have had previous abdominal surgery can sometimes not be a candidate for this because their scars or their exposure for other abdominal surgeries can affect the --- the muscle and the ability to use that tissue. Patients who are non-smokers are a must because we know that the effects of smoking on wound healing can be pretty significant but also on that new blood vessel reconnection. Typically we prefer if there is no plan for radiation therapy. Oftentimes if we know that the patients have to have radiation we reserve the TRAM flap for a delayed reconstruction and bring in all of that healthy skin and tissue. Patients must be compliant. As I said this is a --- a bigger operation and a bigger recovery so they do need to be careful after the surgery --- after the reconstruction and give themselves adequate time to heal. And typically patients with a BMI less than 35 are ideal candidates. Once we have a patient greater than BMI of 35 we know that their wound healing complication rates are much higher and their potential for flap failure is higher. This does require a little additional preoperative planning as well. Typically we like to assess the blood supply and the pattern of those blood vessels that I showed you going through the rectus muscle and this is most commonly with CT angiography. You could potentially use a Doppler or cul --- cultor --- [excuse me] --- color ultrasonography in order to map these out but we find that the protocols that we have here to assess the perforating patterns with CT angiography give us adequate visualization. Some people do nothing and just go based on the fact that they haven t had any additional surgeries and there should be blood vessels there and be fine but that may potentially add operative time. I think having the visualization of the pattern of blood vessels ahead of time with the CTA helps me to plan ahead and reduce my operative time. Definitely in patients that have had previous abdominal surgeries or have had liposuction, it s good to have the CT angiography in order to confirm that the blood supply is there. And like I said I think it speeds up the procedure or the operative time to have that plan ahead. This is just an example of what we re looking for in those images so you can see that deep inferior epigastric artery is running here and these are some perforating vessels so we know that this patient has both medial and lateral perforators and similar here. This is the main vessel, the main trunk in the muscle and then these are the perforators. And in a different view we can see the blood vessels, those perforators, coming through the muscle and all the way up to the skin and subcutaneous tissues so we know that this whole area of tissue will have adequate blood supply. There are other free flaps. I ve spent the majority of the time talking about the TRAM flap because it is the most common and it offers us --- [excuse me] --- allows us the best reconstruction in terms of volume of tissue and --- and redraping of the skin but there are other options in patients who aren t candidates for TRAM. This is considered a second line reconstructive option, however, because again the abdominal tissue is safer, offers

9 more tissue, more reliable in terms of the patterns of blood supply and it s less technically challenging than some of these others. I think the next most common is the gluteal flap and this can be either superior or inferiorly based off of the perforating vessels to the superior or inferior gluteal arteries. And then other options are the transverse gracilis myocutaneous flap or the TUG flap. This refers to the inner thigh. The anterolateral thigh flap which refers to the outer thigh and the TFL is a tensor fascia lateral flap which is also a --- a portion of the outer thigh. A lot of times the patients don t have enough adequate soft tissue there for a full breast reconstruction but these can be useful if needed. And these just illustrate those inferior and superior gluteal flaps. Again, it s a --- commonly a --- a portion of skin and soft tissue based on the blood supply and this is inferiorly based or superiorly based. Breast reconstruction is a multi-stage process and this is a discussion that I have with patients on several occasions prior to their surgery just to make sure that we re all on the same page. The first stage is the creation of the breast mound. And whether this is performed immediate or in a delayed fashion, this is true regardless of the type of reconstruction we use. So if it s a flap it s getting that healthy tissue up to the reconstructed site and letting it heal and establish new blood supply. If it s an implant it s a matter of having it under the muscle and the subcutaneous tissue and then expanding it to the size and shape that we want and that s true also in a combination. On average we wait about three months after the initial reconstruction or the first stage in order to perform a second stage. Now this timing can also change if there is chemotherapy or radiation therapy necessary. The second stage is what I consider refinement or fine tuning and this is revisions to the reconstruction so potentially reshaping, any scar revision that might have to happen. If it s a two stage implant reconstruction it would be taking out the tissue expander and placing the new implant and then any symmetry procedure to the natural breast in a unilateral reconstruction. So typically that would be either a reduction or a mastopexy, a lift or potentially placement of an implant in order to add volume. We wait an additional two to three months after the fine tuning procedures or the balancing procedures and perform the third stage. Sometimes we may need additional refinement or balancing if necessary but oftentimes we can go next to the nipple/areolar reconstruction Oftentimes we have to perform revision or symmetry surgeries during that fine tuning or that balancing stage two. This can be, again, something performed on the opposite breast or the natural breast to match the reconstruction in either an augmentation where an implant is placed, a lift or a reduction. Or sometimes we perform an operation to the breast that s previously had a lumpectomy and radiation and now has a change in the contour or the size. Nipple reconstruction is most commonly performed with a small flap of tissue from the breast skin. As you can see here this is called a C V flap. So the central portion is a C and then either limb on the sides are Vs and this tissue is sort of rotated to itself and sutured down to perform a projecting nipple ---or provide a projecting nipple.

10 We then go on to tattooing and that s to shade the areola to match the patient s native breast areola. These are some examples of a reconstruction with both the nipple procedure where the small flap is made here and then areolar tattooing. This is what s called three dimensional tattooing in which case there was not a nipple flap procedure made but the nipple is shaded with the tattooing to give the appearance of a three dimensional projecting nipple. And this is an example of nipple reconstruction with the flap and then a skin graft actually placed in order to give the pigmentation of the areola. I will touch briefly on partial breast reconstruction so patients who have had a lumpectomy not a full mastectomy followed by radiation. And whether patients have this operation versus a mastectomy I really leave up to them and the breast and medical/surgical oncologist to determine from a cancer standpoint what the best operation is. There are some things that I can recommend from an aesthetic standpoint of what may result in the --- the most natural appearing breast reconstruction but really if patients are considered candidates for breast conservation therapy or lumpectomy there are options that I can provide them from a reconstructive standpoint. Again, there is timing considerations so immediate, at the time of their lumpectomy, or delayed after their radiation. Immediate procedures are typically called oncoplastic so it s a combination of their oncology surgery and a plastic surgery and we use local flaps or local tissue rearrangement in order to reshape or redrape the breast. Oftentimes if we need to we can use pedicled or distant flaps such as that latissimus dorsi in order to provide partial reconstruction. But typically that s reserved for patients who are having a full mastectomy reconstruction. Delayed immediate reconstruction. This is a new term I m introducing but this refers to delaying the reconstruction until after their initial operation but not until --- but doing it before their radiation therapy and so this is typically one to two weeks after the resection. They have their lumpectomy, we see that their margins are clear, and that we are allowed to proceed then with a reconstruction prior to the patients having radiation therapy. This is typically only performed in a delayed immediate fashion in these partial breast reconstructions. Again, if we know that they re having radiation after a full mastectomy we typically delay their reconstruction altogether. And then delayed reconstruction is after completion of radiation therapy. This slide just illustrates some of the techniques that we re able to use. The most common is rearranging the breast parenchyma. So this is where we typically use techniques that are very similar to cosmetic breast procedures or aesthetic breast procedures such as a breast reduction or a mastopexy lift. And instead of cutting away tissue in order to reduce the size of the breast we take advantage of the location of the tumor. And the breast surgeon will remove that tissue and then we use aesthetic type techniques in order to fill in that defect. A lot of times because we re performing this similar to a reduction or a mastopexy a symmetry procedure is indicated on the other side for symmetry, essentially reducing or lifting the opposite breast to match. We find that this is a good option in patients who have larger breasts and smaller tumors and allow us the extra tissue to sort of rearrange or to reduce.

11 Again like I said we can use that latissimus dorsi flap to bring in tissue from the lateral chest if we need to but I typically reserve this for full reconstruction. This has the disadvantage of providing an additional scar on the back or along the side and then can actually provide additional patches of skin or irregularity on the breast if additional tissue is needed from the back. This is more commonly performed after radiation therapy if there is a significant defect. Fat grafting is an option that we have been offering more and more to patients in order to provide better contour and additional tissue support after reconstruction. This is essentially reverse liposuction. We basically perform liposuction on the abdomen or wherever the patient has adequate fat tissue in order to suction some of that tissue away, wash it in the operating room or process it, and then re-inject it into the breast tissue. This we find actually corrects contour irregularities or concavities as well as we find some softening or --- or potentially changes in radiation skin and potentially damaged skin. We do find with the grafting procedure that about 50% of it is reabsorbed so we tend to overfill, expect some of it to --- to reabsorb and then potentially offer a second procedure or in some cases multiple procedures to get the desired effect. This has been used for decades in cosmetic surgical procedures and we re offering it now, as I said, more and more to our reconstructive patients as well. The thought is that fat can be an ideal filler. It s soft, it s readily available in most patients, it is easily collected and harvested through liposuction techniques and there is minimal morbidity or minimal donor site problems. The downside is the variability and graft absorption or graft loss rates. As I said it s approximately 50%. In the literature it s re --- reported anywhere from 20 to 90%, so that s pretty variable when you consider the types of surgery that we re offering this for. The thought is that there are two primary cell types within the fat tissue that we re transferring. One is preadipocytes or progenerator cells and these are tissues --- [excuse me] --- these are cells within the tissue that are transferred and survive in order to proliferate and provide more adipose tissue. That s approximately 10% of the population. The other population is mature adipocytes which are the actual fat cells of the tissue and those are the ones that contain the lipid or the --- the fatty oil tissue. Under ischemic conditions we find that these cells actually die and so these are the ones that are being reabsorbed and it s probably the preadipocytes or the progenerator cells that are surviving and providing the viable tissue. We find that lipofiller or fat grafting in patients undergoing breast conservation therapy is being studied now and it s under a scientific protocol here at MD Anderson and can be helpful in restoring the shape or volume after that partial mastectomy or that partial breast reconstruction. In patients who have had full mastectomy we find that the fat can actually add additional coverage over the implant to improve rippling or contour irregularities. In patients who have had autologous reconstruction using their abdominal tissue or their back we do actually offer fat grafting in certain areas where there may be some contour irregularities or changes in the reconstruction related to fat necrosis. There are some

12 places that offer total breast reconstruction with fat grafting but this requires multiple procedures and multiple liposuction procedures so patients do need to have adequate adipose tissue for this. And more importantly now we re try --- starting to see improvement in the skin quality particularly after radiation of the mastectomy tissues. There is no evidence to suggest that there is an interference with breast cancer detection so one concern is that if we re adding tissue back to the breast with our fat grafting that there might be changes in the quality of the tissue or the architecture of the tissue that interferes with breast cancer detection. And there have been only a few studies to show --- or to study this but they have shown that there is no difference. There is no delay in diagnosis, detection or treatment of cancer recurrence in the incidences where there was recurrence but more importantly there is no change in the ability to detect or no change in the likelihood of cancer recurrence related to the fat grafting. One concern is those progenerator cells or those preadipocytes are potentially multilineage differentiation potential cells that promote healing, that promote neovascularization and there is a concern as to whether or not they could potentially promote cancer recurrence. And in the large studies that we ve done including one here at MD Anderson there is no evidence to support that so there is no difference in local regional recurrent ra --- recurrence rates or metastatic disease rates. And so we know that fat grafting is a safe procedure to offer our patients. We found that --- So that --- that s what this next statement is. In 7.6 years after fat grafting there was no difference in --- in local recurgional --- [excuse me] --- locoregional recurrence rates after follow-up. So in summary reconstruction can be for --- performed immediately at the time of the mastectomy or in a delayed fashion. In general there are three types of reconstruction that we perform and these include implant-based, implant with autologous tissue, and autologous only. The type of reconstruction performed depends on patient characteristics including their BMI or their body mass index, comorbidities, prior surgeries and treatments, and potentially adjuvant therapies like chemo and radiation. Reconstruction involves multiple procedures and it often takes up to a year to complete if there are no other cancer therapies required. In the setting of radiation therapy, it can take several years to complete their reconstruction after they ve recovered from their radiation. That concludes my talk and we welcome any feedback. Thank you.