3/7/2015 Reconstructive Techniques: What Should the Breast - - PowerPoint PPT Presentation

3/7/2015 1 Reconstructive Techniques: What Should the Breast Surgeon Know About Reconstruction?

Hani Sbitany, MD

Division of Plastic and Reconstructive Surgery University of California, San Francisco

March 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
• peration
• 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 TSSM ADM/ 500cc Immediate Expander Adjuvant Taxotere/Cytoxan – 4 cycles PMRT

Right textured, round HP 505 cc gel implant Left augmentation for symmetry 39 year old female Right breast IDC with extensive DCIS 1 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

3/7/2015 5 Free DIEP Flap Bilateral Delayed DIEP Flap, 3 months Autologous Tissue + PMRT

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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

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