Breast Reconstruction

Breast Reconstruction Indications Post-mastectomy -> immediate or delayed. Significant deformity due to: Trauma Burns Radiotherapy Large cell lymphoma Cosmetic enhancement Principles Patient centred approach. Treatment plan Consent Time of reconstruction Immediate reconstruction Performed at the same time as the mastectomy. Advantages: Fewer surgeries Maintaining the breast contour. May be complicated by the need for post-surgical treatments such as radiation. Delayed reconstruction Performed weeks, months or years after. Allows for any additional cancer treatments such as radiation therapy to be completed first and often chosen treatmentrelated complications are expected. Symmetry considerations Choosing type Staging and multi-step procedures. Oncologic safety. Minimizing complications. Psychological and quality of life. Advances in technology and techniques. Post surgical care and follow up. Types/Options Skin sparing mastectomy First performed when doing an immediate reconstruction. Removes all breast tissue via a peri areolar incision. Simplest expansion option performed with: Implants Tissue expanders Gradually flatten and later exchanged for a permanent implant. These are placed deep to the pectoralis muscle. Use of myocutaneous flap Involves muscles, skin and fat. Surgeons take a flab and move it to the chest and shape it into a new breast. Mastectomy Indications Breast cancer -> most common. Radiotherapy and chemotherapy may be used in combination as neoadjuvant or adjuvant therapy. Paget’s disease Rare manifestation of breast cancer. Neoplastic cells in the epithelium in the dermis of the nipple-areolar complex. Inflammatory breast cancer This is very aggressive disease. Persistently positive margins Insufficient response to chemo or radiotherapy. Key Equipment If doing a sharp dissection Scalpel or scissors Alternative to sharp dissections Electrocautery or ultrasonic devices. Retractors Suction Absorbable sutures. Pre-operation preparation Usually an elective surgery Anti-biotics to reduce infection risk. First generation cephalosporins are commonly used. Patient is to be in supine position Surgery Radical Mastectomy (Halsted Technique) : Complete en bloc resection of the breast, including the pectoralis major muscle and regional lymphatics. Sacrifices a significant amount of skin, often requiring a skin graft. Associated with significant deformities and disabilities. Modified Radical Mastectomy (Patey Technique) : Preserves the pectoralis muscle. Outcomes show fewer postoperative complications (pain, lymphedema, mobility limitations). May include level I-III axillary lymphadenectomy for staging. Total Mastectomy : Removes all mammary tissue. No axillary node dissection required. Skin-Sparing Mastectomy : Designed for immediate breast reconstruction. Preserves a healthy skin envelope while achieving adequate margins. Critical to maintain blood supply to the nipple-areolar complex. Nipple-Sparing Mastectomy : Removes mammary tissue and pectoral fascia while preserving the nipple-areolar complex. Done only in patients undergoing immediate breast reconstruction. Dissection Technique : Uniform flaps created just above the superficial layer of the superficial fascia. Continue dissection to the anatomic boundaries of the breast. Elevate and retract flaps at a right angle to the chest wall. Remove the breast from superomedial to inferolateral border. Place a closed suction drain beneath skin flaps and close the incision with absorbable sutures. Consideration (this applies to all of the above) Flap Creation: During mastectomy, uniform flaps are created. These flaps are dissected just above the superficial layer of the superficial fascia of the breast. Controversy Over Flap Thickness: There has been ongoing debate about the ideal flap thickness. The goal is to remove all possible breast tissue while preserving skin viability. Dissection Boundaries: Regardless of the type or location of the skin incision used, mastectomy dissection should extend to the anatomic boundaries of the breast. Flap Elevation and Retraction: Flaps are elevated and retracted at a right angle to the chest wall. Surgeons retract the breast tissue away from the overlying tissue. Extent of Skin Flap Elevation: The skin flap is elevated: Superiorly to the clavicle level Laterally to the anterior border of the latissimus dorsi Medially to the sternal border Inferiorly just below the inframammary crease Breast Removal: After completing the dissection of the overlying flaps, the breast is removed. The removal process typically starts from the superomedial border and proceeds to the inferolateral border. Closure and Drain Placement: A closed suction drain is usually placed beneath the skin flaps in the wound bed. The incision is closed using an absorbable suture in a 2-layer fashion. Contraindications Elderly people Frail people Pregnancy -> 1 st and 2 nd trimesters Metastasis Steroid dependant collage vascular disease Small/large breast tumor. Radiation induced Complications Seroma Hematoma Skip flap breakdown or necrosis Lymphedema Surgical site infection Most commonly S. aureus