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3/7/2015
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Reconstructive Techniques: What Should the Breast Surgeon Know About Reconstruction?Hani Sbitany, MDDivision of Plastic and Reconstructive Surgery
University of California, San FranciscoMarch 7, 2015
Options for Breast Reconstruction
• Implant-Based
– 2-Stage• Implant/Expander
• The standard
– Single Stage• Newer technique
• B-C cup, willing to be smaller
• Thick flaps
• Autologous
– Free Flap• Many tissue options
• Microvascular techniques
– Pedicled• The original autologous
operation
• Abdominally based
• Latissimus dorsi
– + or – implant
– Fat Grafting
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Defining High Risk in Breast Reconstruction
• Postmastectomy Radiation
• Prior Breast Surgery
Plast Reconstr Surg. 134: 396, 2014
Plast Reconstr Surg. 134: 396, 2014 Plast Reconstr Surg. 128: 353, 2011
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Plast Reconstr Surg. 134: 396, 2014
Alloderm Assisted Coverage
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Cohort 1: Implant exchange within 6 months of radiation completion (n=49 patients)Cohort 2: Implant exchange greater than 6 months following radiation completion (n=39 patients)
Right TSSMADM/ 500cc Immediate ExpanderAdjuvant Taxotere/Cytoxan – 4 cyclesPMRT
Right textured, round HP 505 ccgel implant
Left augmentation for symmetry
39 year old femaleRight breast IDC with extensive DCIS1 of 2 sentinel nodes positive Posterior margin less than 1 mm
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Plast Reconstr Surg. 134: 169, 2014
Plast Reconstr Surg. 131: 962, 2013
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Free DIEP Flap
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Free DIEP Flap Bilateral Delayed DIEP Flap, 3 months
Autologous Tissue + PMRT
20
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•Review of TSSM and Immediate Autologous reconstruction from 2005-2013
• 67 patients, 99 autologous reconstructions• 53 pedicle TRAM flaps• 46 microvascular free flaps
•Various incisions for mastectomy•Superior periareolar: 35%• Inframammary: 32%•Radial/Lateral: 33%
Strategies for TSSM and Free Flap Breast Reconstruction - UCSF
Peled AW, Wang F, Foster RD, Hansen SN, Sbitany H. Outcomes Following Total Skin-Sparing Mastectomy and Autologous Breast Reconstruction. Submitted for ASRM Consideration.
•2% partial flap loss, 0% complete flap loss
• Ischemic mastectomy flap morbidity:•NAC Necrosis: 8% partial, 10% complete
•Superior periareolar incision = higher rates of NAC necrosis (p=.03); compared to IMF incisions
Strategies for TSSM and Free Flap Breast Reconstruction - UCSF
Peled AW, Wang F, Foster RD, Hansen SN, Sbitany H. Outcomes Following Total Skin-Sparing Mastectomy and Autologous Breast Reconstruction. Submitted for ASRM Consideration.
• Incision location
•Postoperative monitoring
Technical Planning
•Prospectively maintained database queried for patients between 2011-2013 undergoing TSSM and microvascular reconstruction
•2 Groups•TSSM and immediate autologous flap•TSSM and immediate tissue expander � expansion � 2nd stage DIEP flap
•Assessed for morbidity and aesthetic outcome analysis
Immediate vs. 2-stage delayed
Raghavan S, Peled AW, Hansen SN, Esserman LJ, Sbitany H. Approaches to Microvascular Breast Reconstruction After Total Skin-Sparing Mastectomy: A Comparison of Techniques. California Society of Plastic Surgeons Annual Meeting. Newport Beach, CA. May, 2014.
.
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Immediate vs. 2-stage delayed
Raghavan S, Peled AW, Hansen SN, Esserman LJ, Sbitany H. Approaches to Microvascular Breast Reconstruction After Total Skin-Sparing Mastectomy: A Comparison of Techniques. California Society of Plastic Surgeons Annual Meeting. Newport Beach, CA. May, 2014.
.
Immediate Delayed P-Value
Patients (n) 14 17
Breasts (n) 21 27
Complications
NAC necrosis (partial)
3 (14%) 0 (0%) .08
NAC necrosis (complete)
3 (14%) 0 (0%) .08
NAC necrosis (any)
6 (28%) 0 (0%) .005
Skin flap necrosis 1 (4.7%) 1 (3.7%) 1
Infection 0 (0%) 1 (3.7%) 1
Wound breakdown 0 (0%) 1 (3.7%) 1
Flap loss (complete)
0 (0%) 0 (0%) 1
Flap loss (partial) 1 (4.7%) 0 (0%) 1
Thank You
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