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Breast Reconstruction

Breast Reconstruction. Joint Hospital Grand Round 20 th September, 2003. Catherine Choi United Christian Hospital. Breast Cancer. Commonest cancer amongst females in Hong Kong Incidence increasing annually at 3.6% Incidence 1918 (397 deaths) Cumulative life-time risk (0-74yrs): 1 in 23.

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Breast Reconstruction

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  1. Breast Reconstruction Joint Hospital Grand Round 20th September, 2003 Catherine Choi United Christian Hospital

  2. Breast Cancer • Commonest cancer amongst females in Hong Kong • Incidence increasing annually at 3.6% • Incidence 1918 (397 deaths) • Cumulative life-time risk (0-74yrs): 1 in 23 Hong Kong Cancer Registry 2000

  3. Hong Kong Cancer Registry 2000

  4. Treatment of Breast Cancer • Multimodality & Multidisciplinary Management • Surgery • Chemotherapy • Radiation therapy • Hormonal therapy • Surgery important in achieving cure

  5. Evolution of surgery in the treatment of Breast Cancer • Breast Conservation Treatment (BCT) in early breast cancer Fisher et la. Eight year results of a randomized clinical trial comparing total mastectomy and lumpectomy with or without irradiation in the treatment of breast cancer. N Eng J. Med. 1989;320:822-8 National Institute for Health Consensus Conference. Treatment of early stage breast cancer. JAMA 1991; 265:391-5 • Mastectomy still required in majority

  6. Mastectomy • Mutilating and destructive • Loss of femininity • Disturbance in marital/sexual relationship • Limited selection in clothing & activities

  7. Breast Reconstruction NOT A COSMETIC SURGERY Integral part of treatment Reduce psychosocial morbidity & improve quality of life Linda LR. Plast Reconstr Surg 1997

  8. Immediate vs Delayed Reconstruction Immediate Reconstruction…… • Oncologically safe Kroll SS. Ann Surg Oncol 1997 • Easier operation • Better aesthetic outcome • Avoid disfigurement • Avoid second operation • Psychological, social, financial and time-saving advantages

  9. Surgical Options forBreast Reconstruction • Implant or tissue expander • Autologous tissue reconstruction • Latissimus Dorsi (LD) myocutaneous flap • Transverse Rectus Abdominus Myocutaneous (TRAM) flap – free or pedicle • Deep Inferior Epigastric Perforator (DIEP) flap • Superior Gluteal Artery Perforator (SGAP) flap • Inferior Gluteal Artery Perforator (IGAP) flap

  10. Saline or silicon gel Simpler surgical procedure Lower cost Symmetry difficult to achieve Aesthetic result deteriorates over time Capsular contracture, implant failure, infection, etc Clough KB. Plast Reconstr Surg 2002 Problems associated with post-op radiotherapy Breast implants & tissue expanders Short-term advantage offset by Long-term disadvantage

  11. Michigan Breast Reconstruction Outcome Study • 49 implants/expander • 163 TRAM flap • TRAM flap recipient more satisfied • Aesthetic satisfaction • General satisfaction Alderman AK. Plast Reconstr Surg 2000

  12. Latissimus Dorsi (LD) flap • First described by Tansini in 1898 • Standard method in the 1970s • Technically easy, reliable • Used alone for small breast reconstruction or with implant for large breast • Change of position during surgery • Complication of seroma common, others relating to implants

  13. Endoscopic techniques • Harvesting latissimus dorsi myocutaneous flap • Same scar for axillary dissection or a separate incision about one inch in the middle or lower back

  14. TRAM flap • First described by Hartrampf in 1982 • Commonest option • Substantial amount of tissue and skin for reconstruction • Symmetry & Tissue consistency • Change of appearance and size similar to the natural breast • Added benefit of abdominoplasty Clough KB. Plast & Reconstr Surg 2001

  15. TRAM – pedicled flap • Superior epigastric artery • Skin and subcutaneous tissue by subdermal plexus

  16. TRAM - complications • Donor site • Abdominal weakness / hernia • Abdominal wall bulging • Recipient site • Fat necrosis • Partial flap necrosis • Total flap necrosis

  17. TRAM flap - risk factors • Smoking • Microcirculatory problems • Magnified in obese patients • Obesity • increased risk of flap loss with pedicle flap Moran SL. Plast Reconstr Surg 2001

  18. TRAM – risk factors • Unfavorable abdominal scar from previous surgery • TRAM flap pedicles divided • Perforators interrupted • Subdermal plexus damaged Rt subcostal scar Vertical midline scar Pfannenstiel scar

  19. TRAM – free flap • Popularized since 1990s • Deep inferior epigastric artery • Robust blood supply

  20. Advantages Less fat necrosis / partial flap loss Less sacrifice of donor site muscle, so less weakening & less pain Avoid epigastric bulge Better aesthetic outcome Disadvantages Microvascular anastomosis Risk of TOTAL flap loss Long & tedious operation Post-op monitoring requires effort and expense TRAM – free flap

  21. DIEP (deep inferior epigastric perforator) flap • Variation of free TRAM flap • Only one or more perforating branches dissected from rectus • Rectus muscles left intact • Less donor site morbidity • More time consuming and tedious • Indicated for bilateral reconstruction & small breast

  22. Preferred choice of TRAM….. Pedicle flap VS Free flap

  23. Literature search • Keyword: TRAM • Medline / EMBASE / Cochrane library • 5 out of 698 articles comparing outcome of free vs pedicled TRAM • Results • No RCT comparing free vs pedicled TRAM • Prospective non-randomized comparison

  24. Comparisons on… • Patient’s general & aesthetic satisfaction Larson DL. Plast & Reconstr Surg 1999 Edsander N. Plast & Reconstr Surg 2001 • Recipient site morbidity Kroll SS. Plast & Reconstr Surg 1998 • Donor site morbidity Edsander N. Plast & Reconstr Surg 1998 • Cost Serletti JM. Plast & Reconstr Surg 1997

  25. Free Patient & aesthetic satisfaction Recipient site morbidity (fat necrosis)† Donor site morbidity (abd strength) Pedicled Shorter operation time, hospital stay, less blood transfusion† Study Results † Statistical significant result

  26. Skin-sparing total mastectomy with immediate breast reconstruction • Oncologically safe Kroll SS. Surg Gynecol Obstet 1991 • Traditional type involves skin overlying tumor, biopsy scar and nipple-areola complex (skin at risk of recurrence) • Patch like defect at NAC, transverse scar

  27. Skin-sparing total mastectomy with immediate breast reconstruction • Periareolar approach • All breast skin preserved • Optimal aesthetic result Gabka CJ. Plast & Reconstr Surg 1998

  28. Conclusion • Breast reconstruction reduces psychosocial morbidity & increases quality of life after mastectomy • Immediate reconstruction should be offered to patient requiring mastectomy • Autologous tissue reconstruction superior to implants

  29. Conclusion • Periareolar approach skin-sparing mastectomy with immediate breast reconstruction gives the best possible aesthetic outcome without compromise oncological safety Gabka CJ. Plast & Reconstr Surg 1998

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