PRINCIPLE OF BREAST RECONSTRUCTION

NGUYÊN TẮC TRONG PHẪU THUẬT TÁI TẠO VÚ SAU UNG THƯ

NGƯỜI THỰC HIỆN: BS. TRẦN NGUYỄN NHẬT KHÁNH

NGƯỜI HƯỚNG DẪN: TS. BS. LÊ THỪA TRUNG HẬU
HISTORY

 Halsted 1889 Radical Mastectomy

 Advised against reconstruction
 1960s – breast conservation techniques
 1961 – silicone breast implant
 Delayed reconstruction
 1971 - 1st immediate reconstruction
MASTECTOMY DEFECT

 A critical determinant of the aesthetic quality of the reconstruction

 Preservation of IMF
 Thick, but not too thick, mastectomy skin flaps
NIPPLE-SPARING MASTECTOMY

 Appropriate for:
 Prophylactic mastectomy
 BRCA+ patients
 Small tumors >2 cm away from nipple

 IMF incision
 Blood supply preserved to enable nipple survival
POST-MASTECTOMY RECONSTRUCTION

 Indications
 All post-mastectomy defects are candidates for breast reconstruction
 Questions are:
 #1 – When to perform reconstruction?
 Immediate versus delayed

 #2 – How to perform reconstruction?

 Implants versus flaps
 TIMING OF BREAST RECONSTRUCTION

• Reconstructive surgery can be done at the time of the mastectomy (immediate breast reconstruction), or at

any time after the mastectomy (delayed breast reconstruction).

• Early stage (I-II)

• Majority is done wt immediate recon

• Contrain: Few, if any, reasons to delay reconstruction

if patient wishes

• Advanced stage (III-IV)

• Controversial

• Overall poor prognosis

• Effects of radiation are unpredictable

RADIATION AND IMPLANT

 Studied 2,133 breast reconstructions with

implants
 319 breasts received radiation
 72% capsular contracture

 9% implant loss
 FLAPS AND RADIATION

 Studied patients who underwent mastectomy,

radiation, and TRAM flap reconstruction
 32 had flap before radiation (immediate)

 70 had flap after radiation (delayed)

 Patients who underwent flap before radiation

(immediate) had more complications
 28% required second flap to correct deformity after
radiation
 Question #1 – Immediate versus Delayed
 Which patients may NOT be a candidate for immediate reconstruction?
 Patients who are likely to receive radiation therapy
 Why?
 If implants: poor outcomes

 If flaps: damage to flap

 Who is likely to receive post-mastectomy radiation?

 Tumor size: larger than 5 cm

 Lymph nodes: more than 3 axillary lymph nodes involved

 In these patients, best approach is delayed breast reconstruction with flap

 DELAYED RECONSTRUCTION

 Wait at least 6-12 months after radiation

before starting breast reconstruction
 Examine patient and radiation injury starting at 3
months
 Then every 2 months until suitable

 If patient does NOT end up receiving radiation,

wait at least 3 months
 For swelling and inflammation to resolve
 TIMING: OVERALL

Immediate
Advantages • Saves 1 surgery
• Patient wakes up from
surgery with breast
reconstruction
Delayed
• Cancer treatment will not
affect the reconstruction
• Reconstruction will not
affect the cancer
treatment

Disadvantages • Cancer treatment can • 1 additional surgery

affect the reconstruction
• Reconstruction can affect
the cancer treatment

Other differences Cosmetic outcome

IMMEDIATE RECON
IMMEDIATE RECONSTRUCTION
Implant Breast Reconstruction

Exchange for
Expand the implant +
Revision Nipple
expander symmetry
procedure

Mastectomy
+
EXPANDER

Chemotherapy Radiation

Cancer Treatment
 Expand the TREAT
INFECTION
expander INFECTION

Mastectomy
+
EXPANDER

RESTART chemo-
STOP chemotherapy
Chemotherapy therapy

Cancer Treatment is Delayed

 WOUND DEHISCENCE REPAIR DEHISCENCE

Mastectomy + FLAP

Chemo- RESTART
STOP chemotherapy
therapy chemo-therapy

Cancer Treatment is Delayed

 DELAYED RECONSTRUCTION

 Advantage
 No delay in postopchemotherapy/radiotherapy
 Skin damage of mastectomy/radiation can be Some is
replaced at saved, but
 Disadvantages: some is lost
from Removed
 Loss of breast skin envelope and natural landmark
contraction
 Recipient vessel dissection more tedious because of
scarred/irradiated axilla or chest wall
 Flap size requirement usually greater than with
immediate reconstruction
 Psychological morbidity of living with mastectomy
defect
Flat chest wall with loss of Reconstructing breast shape is more challenging,
significant skin scars are longer and more visible

Loss of natural IMF

TAKE-AWAY MESSAGE

 IMMEDIATE reconstruction should be considered in most patients:

 Fewer surgeries

 Psychological benefit

 Complications are infrequent

 Cosmetic outcome is better

 DELAYED reconstruction should be

considered in patients:
 With risk factors for complications (smoking)
 Reconstruction complications can interfere with cancer treatment

 Who are likely to require radiation treatment

 Radiation can damage a previously good breast reconstruction
SELECTION OF RECONSTRUCTIVE OPTION

 Highly variable
 Rarely the same scenario
 Laxity/ Thickness of mastectomy flaps
 History of radiation/need for radiation
 Condition of skin and pectoralis major muscle
 Size and shape of the opposite breast
 Age of the patient/ Comorbid conditions
 Availability of donor sites for autologous flaps
 Degree of effort/ surgery pationt willing to go through
 Bilateral vs Unilateral
TYPE OF RECONSTRUCTION
Tissue
expander
Alloplastic
Implant

LD
Breast
reconstruction Pedicle
TRAM
flap
Omentum
Autologous
DIEP

Free flap SIEP

SGAP
 Breast Cancer

Radiation No radiation

Bilateral Unilateral
Free Flap
Mastectomy Mastectomy

Breast Ptosis
Expander Reconstruction
Ideal for Nonptotic Breasts
Yes No

Free Flap Expanders

 Implants Flaps
Advantages • Shorter surgery Implants• Lasts forever
Flaps
• Shorter recovery
Surgery • More natural
• Every patient is a candidate 1 hour • Higher satisfaction
8 hours
(except radiation) • Effective with radiation
Hospital stay
1 night 3-5 nights
Disadvantages • Require replacement • Longer surgery
• Less natural(no
Recovery • Longer recovery
• Lower
liftingsatisfaction
over 5 lbs.) 6 weeks • Donor site3 months
• Ineffective with radiation • Not every patient is a candidate
 Implants
Advantages • Shorter surgery
• Shorter recovery
• Every patient is a candidate
(except radiation)
Disadvantages • Require replacement
• Less natural
• Lower satisfaction
• Ineffective with radiation
Flaps
• Lasts forever
• More natural
• Higher satisfaction
• Effective with radiation
• Longer surgery
• Longer recovery
• Donor site
• Not every patient is a candidate
LONGTERM OUTCOME OF IMPLANT RECONSTRUCTION

 86% initial satisfaction

 50% satisfaction rate at 5 years
 Implant lifetime failure rate 0.3-1%/year
 Multiple operative procedures over lifetime
 Average 3 revisional procedures post-reconstruction
 Capsular contracture
 14% baseline rate increases to 50-70% with history radiation

*UCLA Division of Plastic and Reconstructive Surgery

 Implants
 Measuring the rate of implant rupture is
difficult
 At 10 years after surgery, approximately 15%
of implants will have ruptured
 Patients should be advised that their implant
will rupture in their lifetime (and thus need
additional surgery)
CANDIDATE?

 Indication
 Small, nonptotic breasts
 Lack of available tissue in abdomen
 Bilateral mastectomy
 Contrain

 Prior radiation
 Locally advanced disease requiring adjuvant XRT

(relative contraindication)
 Very thin mastectomy skin flaps
EVOLUTION

Initially

Subcutaneous plane • Problem? -> capsular contracture

over the muscle

Under the • Hard to achieve a natural appearance with ptosis

muscle

• lack secure coverage of the inferior pole of implant

Dual • less control over IMF
plane • superior migration of pectoralis major m. & TE 

Human ADM
 ADM

 ADM in immediate implant based breast reconstruction

became popular in 2005 after Brueing et al. published a
case series describing its use as a sling to cover the
inferior-lateral pole in immediate permanent implant
reconstruction[1]
 Subsequently several case series were published to
further support this technique and expand its use to two-
stage tissue expander reconstruction [2][3][4]

[1] Breuing KH, Warren SM. Immediate bilateral breast reconstruction with implants and inferolateral AlloDerm slings. Ann Plast Surg. Sep 2005;55(3):232-239.
[2] Spear SL, Parikh PM, Reisin E, Menon NG. Acellular dermis-assisted breast reconstruction. Aesthetic Plast Surg. May 2008;32(3):418-425.
[3] Nahabedian MY. AlloDerm performance in the setting of prosthetic breast surgery, infection, and irradiation. Plast Reconstr Surg. Dec 2009;124(6):1743-1753.
[4] Bindingnavele V, Gaon M, Ota KS, Kulber DA, Lee DJ. Use of acellular cadaveric dermis and tissue expansion in postmastectomy breast reconstruction. J Plast
Reconstr Aesthet Surg.2007;60(11):1214-1218.
ADM

 Pros:
 inferior-lateral pole coverage of the implant where the pectoralis muscle is absent
 greater initial tissue expansion.
 improved aesthetic outcomes.
 Cons: increased postoperative infectious complications, seroma, and explantation
Scarless LD flap
AUTOLOGOUS
BREAST
RECONSTRUCTION
TYPE OF RECONSTRUCTION

LD

Alloplastic Pedicle flap

Breast reconstruction TRAM

Autologous
DIEAP
Free flap
(abdominally
based)
SIEAP
 PEDICLE FLAPS

 Latissimus dorsi
 Transverse Rectus Abdominis Muscle (TRAM)
 LD FLAP

 Play a significant role in primary and secondary

reconstruction
 LD flap is reliable, techinically simpler, and
associated with fewer short-term complication
 An important salvage option following failed
prosthetic or abdominal-based reconstruction

INDICATION
– With implant-based reconstruction
– Are not candidates for abdominal-based
reconstruction
– Failed prosthetic breast reconstruction
– Partial mastectomy
 Both lateral and transverse branches of the
thoracodorsal artery give off numerous perforating
vessels to the overlying skin  safety harvesting
skin paddle within the confines of the muscle
borders
 LD FLAP

 Review of the American College of Surgeons National Surgical Improvement Program (NSQIP), LD flaps:
 Accounted for nearly 1/3 of all breast reconstruction (32.7%)
 30 day complication rates were lower the pedicled TRAM and free flap
including rates of flap failure, surgical site infection, and overall complication
 Cons:
 Back scars
 Back contour deformity
 Loss of 15% of shoulder function
 Problem with athletes - golfers and tennis players
TRAM FLAP

 Used to be the favourite in US (before free-flap)

 Allows complete autologous reconstruction in many patients
 Avoids disadvantages of implants
 Good long-term result
 Allow contouring of the abdominal areas
ipsilateral flap is preferred
 INDICATIONS

 Indications:
 Anybody with enough lower abdominal tissue
 Significant breast ptosis
 Prior radiation
 Contraindications:
 Not enough tissue
 Previous abdominoplasty
OMENTUM FLAP

 Omentum surface: 300– 1500 cm2

 Dimension:
 20 - 46 cm in width
 14 – 36 cm in length

 Weight: 300 – 2000 grm

-> unpredictable, prefer for medium to small

breast reconstruction
 Pedicle: right gastroepiploic
 Larger diameter: 2.8 mm
FREE FLAP

 Free TRAM flap

 Perforator flap

WHY PRESERVE ABDOMINAL MUSCLES?

- Functional recovery
- Less chance of hernias, bulges, and weakness of abdominal wall
- Less pain
FREE TRAM FLAP

 A muscle-sparing flap
 Has a reliable and predictable blood supply based off the
inferior epigastric artery and vein
 Zones are different
 Advantages:
 Less fat necrosis and flap loss
 Good vessel size match to either IM artery of thoracodorsal vessels
 No pedicle bulge from tunnelling
 Ease of breast mound shaping and contouring
FREE TRAM FLAP
FREE TRAM
 DIEA/SIEA

 DIEA is proved that:

 More important
 Larger
 The vast majority of cutaneous perforators are located in the peri-umbilical
region, inferior to the watershed anastomotic zone  DIEA territory
 GUIDELINES ON CHOOSING THE RIGHT PERFORATOR

 Preop: color duplex scan, a multidetector spiral CT  a

road map to aid dissection and decision-making
 Dissect all, find the dominant perforator. Usually only
one perforator of adequate diameter (0.1 mm) is
sufficient to vascularize the entire lower abdominal skin.
 IMPORTANT: size of accompanying vein

* Dr. Fu Chen Wei - Flaps and Reconstructive Surgery

Textbook
 FREE FLAP BREAST RECONSTRUCTION

IM Thoracodorsal
 Recipient vessel option
Pros • Easier access for microsurgery • Often exposed with the
• Good size match for vessels mastectomy/axillary node dissection
• More medial placement of the flap compared • Consistent anatomy
with using thoracodorsal vessels; less lateral
fullness
• Avoids axillary dissection – related morbidity
Cons • Vessels can be thin walled and more fragile, • May be damaged by mastectomy/axillary
especially veins node dissection
• Left IM vein tends to be smaller • Lateral placement of the flap
• Respirator changes the level of focus during • Increased axillary dissection and
microsurgery morbidity
• Future use of IM for coronary artery bypass
• Small but potential risk for pneumothorax
VENOUS COUPLER
WHY DIEP FLAP?
 Advantage
 Less muscle and fascia was removed  minimize compromising the anterior abdominal wall
 Less donor site morbidity
 Less functional deficit

 Disadvantage
 Long operating time
 Decreased perfusion to flap with less perforator
OMENTAL FREE FLAP

 Uncommon reconstructive option

 Omental fat-augmented free-flap (O_FAFF)
FOLLOWING SURGERIES

 RECONSTRUCTION USUALLY REQUIRES MULTIPLE STAGES

STAGE 2:
STAGE 1: STAGE 3:
• Breast mound revision
• Manage contraleteral
Breast mound Areolar Tattoo or skin
breast
Reconstruction graft
• +/- nipple
reconstruction
STAGE 2: ACHIEVING SYMMETRY

 Management of the contralateral breast

 Reduction
 Lift (mastopexy)
 Augmentation
SUMMARY

 When determining method of reconstruction:

 Question #1 – is there any reason why a patient is NOT a candidate for implant or flap?
 Small patient/prior surgery  not good candidate for flap

 Radiated  not good candidate for implant

 Major medical comorbidities and can’t tolerate long surgery  not good candidate for flap

 Question #2 – If patients are candidates for both implants and flaps, which do they prefer?
 I present advantages and disadvantages …

 … then allow patient to decide

 CONCLUSION

 Substantial psychological benefit to reconstruction

 BR does not interfere with the detection of local recurrences (LRs) and have not been associate with an
increase in breast cancer recurrence.
THANK YOU