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The 2014 Mid-MO Regional Cancer Conference

The 2014 Mid-MO Regional Cancer Conference. Audrain Medical Center April 25, 2014. Breast Reconstruction. Lin Puckett. Breast Reconstruction. Why? When? Value?. Why?. A certain % of women with Breast Ca desire reconstruction post surgical treatment

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The 2014 Mid-MO Regional Cancer Conference

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  1. The 2014 Mid-MORegional Cancer Conference Audrain Medical Center April 25, 2014

  2. Breast Reconstruction Lin Puckett

  3. Breast Reconstruction Why? When? Value?

  4. Why? A certain % of women with Breast Ca desire reconstruction post surgical treatment Interestingly, a rather low % (20%) This varies from one institution to another And, often, upon the availability of a Plastic Surgeon

  5. When? A woman can choose to have recon at any subsequent time Or she may choose to have immediate recon begun during the same operative time as her mastectomy At the University of Missouri where Pl Surgeons work closely and comfortably with Oncologic Surgeons well over 50% of mastectomy pts have Immediate Recon And, thereby save a separate operation

  6. Value? Breast Cancer is every woman’s nightmare (1 in 8 lifetime risk), Though this varies from 1/7 to 1/9 currently Fear of loss of life or health Fear of loss of femininity Not unlike the male facing penile or testicular Ca The female breast has, through out history, been a visible symbol of femininity Successful reconstruction can be an aid in the concept of healing, restoration, and finality of the ordeal Those of us who do a lot of breast reconstruction have all heard pts say some variation of, “I didn’t feel whole until reconstruction was complete”

  7. Breast Reconstruction History While there are reports of attempted breast recon dating back to the late 1800’s Such as the use of a lipoma to restore or enhance the breast And attempts at “sharing” tissue from the other breast But none of these efforts were lasting or capable of producing a consistently normal looking breast

  8. Three Concepts That have Paved The Way For Modern Breast Reconstruction • Mid 60’s general availability of a reliable breast implant (silicone gel) by Cronin and Gerow • Late 70’s and early 80’s a reliable method of autologous reconstruction with abdominal tissue by Hartramp • And, simultaneously, an appreciation of the concept of tissue (skin) expansion (Argenta, and others)

  9. Breast Implants The original intent of silicone breast implants was for breast enhancement But it didn’t take long for plastic surgeons to begin using them for breast reconstruction Early efforts were plagued by a high rate of “capsule contracture” But that has steadily improved as we have advanced through four generations of implants

  10. So… the same implants used for augmentation can be, and are, used for reconstruction of a new breast mound

  11. Indeed, in the unilateral reconstruction pt, any of the cosmetic breast operations may frequently be used on the remaining normal breast to gain symmetry Augmentation Mastopexy (lift) Reduction

  12. Augmentation

  13. Age: 32 Height: 5’4” Weight: 104 lbs Implant: Mentor Smooth Round Saline Size: 325cc filled to 350cc Placement: Subpectoral Incision Lines: Infrmammary Children: 1 before surgery , 1 after surgery (3.5 years) Breastfed: unknown Bra Size: Before 32A/B After After Pictures: above right - 6wks, below left - 2 years, below right - 9 years

  14. Preop 6 weeks postop 2 years postop 9 years postop

  15. Age: 22 Height: 5’5” Weight: 105 lbs Implant: Mentor Smooth Round Saline Size: 275cc filled to 300cc Placement: Subpectoral Incision Lines: Circumareolar Children: None Bra Size: Before 32A After After Picture: 9 months postop

  16. Age: 23 Height: 5’5” Weight: 117 lbs Implant: Mentor Smooth Round Saline Profile: Moderate Size: 300cc filled to 320cc Placement: Subpectoral Incision Lines: Circumareolar Children: None Bra Size: Before 34A After Pictures: above right - 6 months, below right - 7 years

  17. preop 6 months postop 7 years postop

  18. Mastopexy

  19. Mastopexy plus Augmentation

  20. Reduction Mammaplasty

  21. W.J. 3/1/07R 565, L 770

  22. A.C. 3/15/07R 597, L 468

  23. L. P. 8/2/07R 1377, L 1454

  24. Achievable Goals in Breast Reconstruction Today Comfort in appearance, with or without clothes Avoidance of an external prosthesis Reasonable breast symmetry

  25. Does Reconstruction Impact Breast Cancer Care? Limit options or timing of adjunctive treatment? Mask recurrence? Interfere with mammography? Do implants predispose to breast cancer occurrence? NO!

  26. Timing and Anatomy may Significantly Influence Reconstructive Choices and Options In general there are two approaches available: expander-implant and autologous tissue transfer

  27. Simple Reconstruction(Expander-Implant) • Chest skin and muscle adequate • Needs volume replacement • Nipple-areolar reconstruction • May wish adjustment of opposite breast for symmetry

  28. Immediate Reconstruction • Eliminates an operation • Significant emotional boost • Avoids even temporary use of an external prosthesis

  29. Short operation Outpatient surgery Brief recovery Potential implant problems capsule contracture visible implant Big operation Hospitalization Longer recovery Some feel better aesthetics Tummy tuck Possible hernia Comparison of Techniques of ReconstructionExpander-Implant -vs- Autologous

  30. Expander – Implant Approach Two significant operations Expansion usually requires 4 to 6 injections Minimum of 4 mo between placement and permanent implant Nipple-areola reconstruction – 1 to 3 minor procedures

  31. Expanders

  32. Expanders Suture tab Lower Pole expansion

  33. Expansion

  34. Autologous Reconstruction Most commonly is some version of getting the abdominal fat and skin to the breast area Extended Latissimus flaps are sometimes adequate (Fleur de lis) But usually require an implant for volume Thus would be a hybrid Gluteal free flaps are rarely done

  35. Autologous Reconstruction The single muscle pedicled TRAM was the most common technique during the early 80’s and through the 90’s But analysis revealed a significant incidence of complications

  36. Pre-op TRAM

  37. Intra-op

  38. Post-op

  39. Donor site: Muscle weakness Abdominal bulges Hernia Breast site (ischemia): Total flap loss Partial flap necrosis Fat necrosis “the shrinking flap” TRAM Flap Complications

  40. TRAM Flap Problems Delay procedures helped but added an operation Double pedicle TRAM’s helped with ischemia problems but abd problems were increased Free TRAM’s addressed the ischemia problem but not the abdominal problems

  41. Today most transfers of the abdominal tissue to the breast are done with microsurgical reconstruction of the blood flow to the tissue My partner Dr Stephen Colbert does most of these cases

  42. Anastamosis Tailoring

  43. Perforator Flaps (DIEP) Best solution to both ischemic and abd wall problems Most of the muscle is retained But this procedure is complex (steep learning curve)

  44. DIEP Flap Has been shown to decrease hernias Less abdominal bulges Probably preserves abd strength

  45. Breast Reconstruction

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