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

3/7/2015 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 • Autologous – Free Flap • Many tissue options – 2-Stage • Microvascular techniques • Implant/Expander • The standard – Pedicled – Single Stage • The original autologous operation • Newer technique • Abdominally based • B-C cup, willing to be • Latissimus dorsi smaller – + or – implant • Thick flaps – Fat Grafting 1

3/7/2015 Defining High Risk in Breast Reconstruction Plast Reconstr Surg . 134: 396, 2014 Postmastectomy Radiation • Prior Breast Surgery • Plast Reconstr Surg . 128: 353, 2011 Plast Reconstr Surg . 134: 396, 2014 2

3/7/2015 Alloderm Assisted Coverage Plast Reconstr Surg . 134: 396, 2014 10 39 year old female Right breast IDC with extensive DCIS 1 of 2 sentinel nodes positive Posterior margin less than 1 mm Right TSSM Right textured, round HP 505 cc ADM/ 500cc Immediate Expander gel implant Adjuvant Taxotere/Cytoxan – 4 cycles Cohort 1: Implant exchange within 6 months of radiation completion (n=49 patients) PMRT Left augmentation for symmetry Cohort 2: Implant exchange greater than 6 months following radiation completion (n=39 patients) 3

3/7/2015 Plast Reconstr Surg . 131: 962, 2013 Plast Reconstr Surg . 134: 169, 2014 Free DIEP Flap 15 4

3/7/2015 Bilateral Delayed DIEP Flap, 3 Free DIEP Flap months Autologous Tissue + PMRT 20 5

3/7/2015 Strategies for TSSM and Free Flap Breast Strategies for TSSM and Free Flap Reconstruction - UCSF Breast Reconstruction - UCSF • Review of TSSM and Immediate Autologous • 2% partial flap loss, 0% complete flap loss reconstruction from 2005-2013 • Ischemic mastectomy flap morbidity: • 67 patients, 99 autologous reconstructions • NAC Necrosis: 8% partial, 10% complete • 53 pedicle TRAM flaps • 46 microvascular free flaps • Superior periareolar incision = higher rates of • Various incisions for mastectomy NAC necrosis (p=.03); compared to IMF • Superior periareolar: 35% incisions • Inframammary: 32% • Radial/Lateral: 33% Peled AW, Wang F, Foster RD, Hansen SN, Sbitany H. Outcomes Following Total Skin-Sparing Mastectomy and Autologous Breast Peled AW, Wang F, Foster RD, Hansen SN, Sbitany H. Outcomes Following Total Skin-Sparing Mastectomy and Autologous Breast Reconstruction. Submitted for ASRM Consideration. Reconstruction. Submitted for ASRM Consideration. Technical Planning Immediate vs. 2-stage delayed • Prospectively maintained database queried for patients between 2011-2013 undergoing TSSM and microvascular reconstruction • Incision location • 2 Groups • TSSM and immediate autologous flap • Postoperative monitoring • TSSM and immediate tissue expander � expansion � 2 nd stage DIEP flap • Assessed for morbidity and aesthetic outcome analysis 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. . 6

3/7/2015 Immediate vs. 2-stage delayed Immediate Delayed P-Value Patients (n) 14 17 Breasts (n) 21 27 Complications NAC necrosis 3 (14%) 0 (0%) .08 (partial) Thank You NAC necrosis 3 (14%) 0 (0%) .08 (complete) NAC necrosis 6 (28%) 0 (0%) .005 (any) 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 0 (0%) 0 (0%) 1 (complete) Flap loss (partial) 1 (4.7%) 0 (0%) 1 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. . 7