Advances in Reconstructive Surgery after …...S Advances in Reconstructive Surgery after Mastectomy...

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Advances in Reconstructive Surgery after

MastectomyLeonard Lu, MD

leonardlu@gmail.com

Plastic and Reconstructive Surgery

Advocate Condell Medical Center

Advocate Lutheran General Hospital

Statistics

S Increase in number of mastectomies (especially bilateral) in

certain populations of women

S National Cancer Data Base

S 12% of women for Stages 0-to-3 in 2012 vs 2% in 1998

S Insurance coverage of breast reconstruction

S Advances in plastic surgery

S “Angelina” effect

Genetic Testing

S BRCA

S Prophylactic mastectomies

S Healthier

S No adjuvant treatments

Why have Breast

Reconstruction?

S To make chest look balanced

S To regain breast shape

S To avoid a breast external prosthesis

S To be happier with their bodies and how they feel about

themselves and relationships

Patient Questions

S Who is a candidate for surgery?

S Will breast reconstruction interfere with cancer treatment or detection?

S Are there some women who should not have a reconstruction?

S How does adjuvant therapy impact on reconstruction?

S How do you get the breasts symmetric?

S Does a breast reconstruction look and feel natural?

Goals

S Mound reconstruction

S Size

S Skin coverage

S Adjunctive procedures

S Fat transfer

S Symmetry (contralateral breast)

S Nipple reconstruction

S Areola reconstruction

Timing of Surgery

S Immediate

S Advantages: decrease the number of surgeries

S Disadvantages: more upfront surgery

S Start/Finish the reconstruction at the time of mastectomy

S Delayed

S Advantages: less surgery upfront

S Disadvantages: additional surgery, “being flat”

Advances in Reconstruction

S Methods to reduce scarring or improve contour

S Skin sparing, Nipple sparing

S Different incision patterns for mastectomies

S Methods to reduce the potential complications from the donor site

by way of muscle-sparing flaps and perforator flaps

S The changing mindset and elevated standards for aesthetic

outcomes, which has led to an increased number of procedures

performed on the contralateral breast for improved symmetry

Nipple Sparing Mastectomies

Techniques

S Implants

S Tissue expanders

S Saline/silicone implants

S Autologous Tissue

S Abdominal (DIEP, TRAM, SIEA)

S Latissimus dorsi flap, TAP flap

S SGAP, DCIA (Ruben’s), TUG

S Fat Transfer

Implants and Matrices

S More implant choices

S Anatomic vs Round

S Silicone (“Gummy Bear”)

S Longeavity

S Safety

Acellular Dermal Matrix

(ADM)

S Acellular Dermal Matrix (ADM)

S Alloderm, Flex HD, Neoform, DermaMatrix

S Prepectoral vs Subpectoral

Implants

S One step direct to implant (silicone)

S Especially with nipple sparing mastectomies

S Advantages: Minimizes number of surgery

S Disadvantages: Predictability of results, revision rate, tension

on skin

Direct to Implant

Reconstruction

Tissue Expander

Reconstruction

S Adjustable post-operatively with eventual implant exchange

S Advantages: corrects skin deficiency, predictability,

enhanced results, off-load skin, choose size

S Disadvantages: multiple office visits and surgeries,

discomfort, no MRI

Tissue Expander

Reconstruction

Prepectoral Implant Placement

S ADM

S Less pain/recovery

S Soft tissue coverage

S Palpability

S Visibility

Prepectoral Implant

Reconstruction

Autologous Tissue

S Corrects skin deficiency

S Normal subcutaneous tissue

S No foreign material/implants

S Longer operative time

S Higher morbidity

Abdominal Flaps

S TRAM

S DIEP

S SIEA

Abdominal Flap Reconstruction

Back Tissue

S Latissimus Dorsi Flap

S Typically with implant

S Thoracodorsal Artery Perforator (TAP) Flap

Back Flap Reconstruction

Microvascular Flaps

S Superior Gluteal Artery (SGAP)

S Deep Circumflex Iliac Artery (DCIA, Ruben’s)

S Transverse Upper Gracilis (TUG)

Fat Transfer

S Soft Tissue Filler

S Upper pole of breast

S Fill in contour abnormalities

S Breast Reconstruction

Fat Transfer Reconstruction

Contralateral Breast

S Breast Reduction

S Breast Lift (Mastopexy)

S Breast Augmentation

Breast Reduction

Breast Lift (Mastopexy)

Breast Augmentation

Nipple Reconstruction

S Local Flaps

S Acellular Dermal Matrix

Areolar Reconstruction

S Tattoo

3D Tattoo

S “Braless”

Questions?