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Advances in Reconstructive Surgery after
MastectomyLeonard Lu, MD
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?
