Breast Reconstruction and Augmentation Mammoplasty

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The breast has become a major part of the
practice of most Plastic Surgeons.
◦ Reconstructive after Mastectomy
◦ Cosmetic
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Breast reconstruction after mastectomy may be
staged. It can involve several or all of the following
procedures:
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Insertion of tissue expander
Breast mound reconstruction by tissue graft
Removal of tissue expander
Insertion of permanent breast implant
Revisions to reconstructed breast
Balancing procedures to native breast
Nipple reconstruction
Areolar tattooing
Some procedures are performed in separate
encounters, others may take place during the same
operative session.
Which procedures a patient requires depends to some
extent on how much tissue remains after mastectomy.
If there is sufficient tissue, immediate reconstruction may
be performed by placing a permanent implant. Or, if
additional tissue is needed, a tissue expander may be
placed or a graft may be performed.
skin sparing mastectomy…
with tissue expander insertion
¾Overview of the common
options for soft tissue
reconsrtuction
¾Indications for their use
versus a free flap.
Rotational Flaps
TRAM
graft
Tissue grafts are used
when more bulk is
needed to reconstruct
the breast mound. A
TRAM flap transfers
tissue from the lower
abdominal wall, a
latissimus dorsi flap
tissue from the back.
Although the transferred
tissue alone may be
sufficient, an implant
can also be placed
underneath.
latissimus
dorsi graft
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Transverse Rectus Abdominis Myocutaneous
(TRAM)
◦ Skin, Fat, and Muscle
◦ Superior epigastric vessels for pedicle
x May be taken as free flap based on inferior epigastric
vessels
x This is preferred for obese patients and those that smoke
◦ May be delayed
x Cut inferior epigastric vessels to allow for increased
flow through the superior vessels
x Usually 2-3 weeks prior to definitive reconstuction
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Latissimus Dorsi Flap
◦ Skin, Fat, and Muscle
◦ Not generally the first choice for reconstruction
x Used in obese women
x Previous abdominal operations
◦ Generally does not provide sufficient bulk for
complete reconsturction
x Paired with implant on occasion
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Deep Inferior Epigastric flap (DIEP)
Superior Gluteal Artery Perforator flap (SGAP)
Deep Inferior Epigastric Perforator
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DIEP
◦ Fasciocutaneous Flap
◦ Benefit of “tummy tuck”
◦ No risk of hernia (as with TRAM)
Superior Gluteal Artery Perforator Flap
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SGAP
◦ Skin and Fascia only
◦ Typically second choice
x Lack of sufficient abdominal skin and subcutaneous
tissue
◦ Reduced donor site morbidity
◦ No functional loss
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Recipient Vessels
◦ Internal Mammary
x Preferred in skin sparring mastectomy
x High perfusion pressures
◦ Thoracodorsal Artery
x Risk of injury to intercostobracheal nerve, lymphedema
Tissue Expanders
When additional tissue must first be
developed, a tissue expander is
placed in the chest wall and filled
through a port at regular intervals to
stretch out the skin.
Some expanders are designed to be
left in, but most are removed and
replaced with a permanent implant.
Exchange of Tissue
Expander for Implant
After the tissue expander has been fully
expanded, it is removed and replaced by
a permanent implant, typically during the
the same encounter. Implants are filled
with either saline or silicone. Many
models are available to try to match the
patient’s natural contours.
Because the expander is a foreign body,
it’s normal for a capsule to form around it
in the breast. Adjustments to the capsule
are often necessary to seat the
permanent implant properly.
Revision of Reconstructed Breast
It is not uncommon for the
reconstructed breast to require
surgical revision at some point.
This can be necessary because of
“contour deficits”, such as:
irregularity or deformity in the
reconstructed tissue; inadequate
projection; and asymmetry or
disparity with the native breast.
Surgeons are usually adamant that
these issues are in the nature of
breast reconstruction and do not
represent complications of the graft
or implant.
contour deficit
asymmetry
Revision for Complications
Unlike contour deficits, asymmetry
and the like, capsular contracture is a
complication of the implant. A thin
capsule forms around all implants.
Contracture is when the capsule
thickens abnormally and forms scar
tissue around the implant, becoming
hard and painful. Capsular contracture
may require capsulotomy or
capsulectomy of the reconstructed
breast.
Fat necrosis is a complication of TRAM flaps. Fat within
the flap becomes ischemic due to inadequate blood
supply. It hardens and must usually be excised.
Balancing Procedures to Native Breast
As an alternate to revising the reconstructed breast, or
sometimes in addition to it, procedures are also performed
on the native breast. This includes augmentation,
reduction, and mastopexy of a smaller, larger or ptotic
native breast for balance with the reconstructed breast.
mastopexy
of native
breast
reduction
of native
breast
Nipple and Areolar Reconstruction
Nipple reconstruction is usually performed via skin grafts.
Common techniques include the skate flap, top-hat flap,
and star flap. Nipple reconstruction is usually delayed for
several months after breast mound reconstruction, to
allow the new breast time to settle.
Areolar reconstruction can also be performed by grafting,
though tattooing is much more common.
With a few exceptions, large
breasts in vogue since antiquity
◦ Brassieres and corsets used to
enhance size
` 19th Century: surgical breast
enlargements attempted using
ivory, glass, metal, rubber, and
paraffin
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1895: Czerny performs first reported
successful human mammary reconstruction
◦ actress who had undergone removal of a
fibroadenoma
◦ transplanted lipoma from her hip
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1903: Charles Miller inserts "braided silk,
bits of silk floss, particles of celluloid,
vegetable ivory, and several other foreign
materials”
◦ granulomatous (foreign body) inflammatory
reactions disfiguring and painful
1903-1950s: petroleum jelly,
beeswax, shellac, and epoxy
resins used.
` Early 1950s: liquid silicon
injections used
` 1962: first US woman to receive
encapsulated silicon breast
implants
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1992: FDA bans silicone breast implants
except in strictly controlled trials for breast
cancer reconstructive surgery due to reports
linking the implants with a variety of
connective tissue diseases and neurological
disorders.
Subsequent analyses show no such links
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2005: FDA allows silicone breast implants
back on market (with registry)
A minimum of 15% of modern silicone
implants will rupture between the third and
tenth year after implantation
Today: newer generation silicone implants,
saline implants, dermal fillers
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2007: Stem cells and fat derived from
liposuction used to grow breast tissue in
clinical trials in Europe
2008: Israeli surgeon develops “breast lift
procedure” involving internal titanium bra
with silicone cups
2008: MyFreeImplants.com
◦ Facilitates communication and funding
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Patient Assessment
◦ Motivation
x BMD?
x Social pressure
◦ Younger
x Teen?
x Young adult?
x Does the patient understand the procedure?
◦ Older
x Quality of the result
x Loss of elasticity of tissues over time
◦ “Normal” size
x According to whom?
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Considerations
◦ Scars
x Affect the contour of the breast
◦ Oncologic
x Is this patient at risk for breast cancer
x Has she been screened?
◦ Sensation
x Understand there may be an alteration to this.
◦ Pregnancy/ Lactation
◦ Ptosis
◦ Symmetry
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Planning
◦ Size
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x
x
x
Chest wall
Skin envelope
Projection
Asymmetry
◦ Implant type
x Smooth
x Textured
x Designed to limit capsular contracture and rotation of the
implant
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Planning
◦ Markings
◦ Incision
x Inframammary fold
x Periareolar
x Axillary
Axillary
IMF
Periareolar
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IMF
◦ Advantages
x Preserves parenchyma
x Precise pocket
x Scars well
◦ Best candidates
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x
x
x
Well-defined IMF
No h/o hypertrophic healing
Mild ptosis
Sports (elevate arms)
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Periareoloar
◦ Advantages
x Scars well
◦ Disadvantages
x Must be AT JUNCTION
x Non-expandable difficult
x Bacterial seeding ?
◦ Best candidates
x Areola diameter >35 cm
x Thin layer of breast parenchyma
◦ Technique
x Superficial to superficial layer of superficial fascia to
lower border of breast then into sub-pectoral space
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Axillary
◦ Advantages
x Hidden scar
◦ Disadvantages
x More difficult with rough surfaces
x Need endoscope or blind
x Revision requires different incision
◦ Best candidates
x Tendency to hypertrophy
x Marked hypoplasia with poor IMF
◦ Technique
x Mark 1.5-2 cm below IMF
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Planning
◦ Position
x Subglandular
x Good with moderate ptosis
x Active body builders
x Submusculofascial
x Decreased contracture
x Softer
x Better oncologically
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Ancillary Procedures
◦ Intraoperative expansion
x TE or manually
x Can use expander as estimate of
volume
◦ Postoperative expansion
x Permanent expander implant
x Can alter final volume
◦ Abdominoplasty
x Difficult through same incision
◦ Biopsies
x Preop studies for all >30yo or younger if at higher risk
◦ NO FAT INJECTIONS
x Can calcify
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Capsular contracture
Implant rupture
Hematoma
Wound infection
Breast implants decrease sensitivity of
screening mammography among
asymptomatic women, but do not increase
false-positive rate nor affect tumor
prognostic characteristics
Cosmetic implants – 12%
` After prophylactic mastectomy –
30%
` After mastectomy for breast
cancer – 34%
` Latest trend: microsurgical breast
reconstruction using implants or
autologous tissues
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Postoperative Considerations
◦ Care
x Soft elastic bra or ACE wrap
◦ Massage
x Enlarges pocket
x Softens
x Can help parasthesias
◦ Hematoma: 0.5%-3%
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x
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x
Good hemostasis
Immediate post op RTOR
Can cause some asymmetry
Can occur 1-2 weeks post-op with increased activity
◦ Sensation: 15%
x 4th intercostal NV bundle most important
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Postoperative Considerations
◦ Infection: 2.2%
Staph epidermidis most ducts & implants
Peri-op antibiotics
Irrigate with iodine
Atypical mycobacteria require removal capsulectomy
and systemic anti-fungals
x Bacterial infections can be treated conservatively
initially Æ replace +/- capsulectomy
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x
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x
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Postoperative Considerations
◦ Capsular Contracture
x Classification
x
x
x
x
Grade
Grade
Grade
Grade
I: Soft
II: Minimal : palpable not visible
III: Moderate: palpable and discernible
IV: Severe: hard, symptomatic, +/-distortion
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Capsular Contracture
◦ Prevention
x Type
x Silicone: Bleed contributes
x Textured: Lower incidence, not
axillary
x Position
x Submusculofascial better - ducts not cut (inflammation)
x Blunt dissection
x Less hematoma, less electrocautery, less necrosis
x Infection
x Major cause
x Pocket
x Need adequate size, larger for smooth
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Capsular Contracture
◦ Treat remote site infections (URI, UTI)
◦ Closed capsulotomy: External pressure
tears capsule
x Not effective, potential danger
◦ Open capsulotomy
x Asymmetric implant position, best for I or II
◦ Open capsulectomy
x Thick or calcified capsule, also smooth
subglandular
◦ Conversion to submusculofascial
◦ Capsulorrhaphy
x Suture capsule to reposition pocket into breast confines
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Capsular Contracture
◦ Long-Term Results
x Varying degrees of firmness
x Not all contractures require correction
x Replacement: Most last 7 –15 years
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11,326 procedures performed on 18-year
olds in 2003
Phenomenon suggests poor parenting,
through the capitulation of financially wellendowed parents to the whims of their
children, who likely have self-esteem
problems and are not yet emotionally (nor
perhaps even physically) mature
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4,108 procedures on women 18
and under in 2008
US and EU: breast augmentation
surgery allowed on those under
age 18 only for medical reasons
◦ Yet 50% of procedures done for
purely cosmetic reasons