BREAST RECONSTRUCTION

Indications

  • Optional
  • Suitable candidates are those who have, or are expected to have, considerable asymmetry of the breasts after tumour ablative surgery.
  • women with locally advanced disease may be suitable for breast reconstruction and should not be excluded.

Contraindications

  1. metastatic disease
  2. anaesthetic risk factors such as significant cardiopulmonary disease.

Immediate vs Delayed

Immediate breast reconstruction

Advantages

  1. for the patient
  2. Patients have less psychological morbidity than those who have delayed reconstruction
  3. eliminate a second surgery and anesthesia
  4. provide a quality of life similar to that enjoyed preoperatively.
  5. More aesthetic result if no radiotherapy planned
  6. for the surgeon
  7. easier operation - do not have to work with irradiated tissue

Disadvantages

  1. inability to determine which patients will require postmastectomy radiation therapy
  2. with subsequently irradiation, can have increased rates of fat necrosis, volume loss, and flap and/or capsular contracture.
  3. can interfere with the delivery of postmastectomy radiation therapy

Delayed breast reconstruction

Advantages

  1. patient has time to consider the operation and make firm decision
  2. less implant complications
  • Ann Plast Surg Apr 2003 - There is little correlation between local recurrence of breast cancer after mastectomy and timing of reconstruction (delayed vs immediate) or no reconstruction vs reconstruction.

Contraindications for immediate reconstruction

  1. inflammatory tumour
  2. needs chemotherapy immediately

Principles

  1. Reconstruction of the breast mound matching the excision of breast tissue in volume and breast shape,
  2. Reconstruction of skin

Reconstructive Options

  1. Oncoplastic techniques
  2. Alloplastic
  3. Autologous
  4. A combination of autologous and alloplastic

Selection of the best procedure is based on considerations of

1)laxity and thickness of the remaining chest skin

2)condition of the pectoralis and serratus muscles

3)size of the opposite breast

4)postoperative radiotherapy

5)availability of flap donor sites.

Oncoplastic techniques

  • Used for partial mastectomy defects in women with macromastia
  • Reconstructive techniques for partial defects
  • local tissue rearrangement (LTR)
  • breast reduction
  • use of a latissimus dorsi myocutaneous flap or thoracoepigastric skin flap
  • Spear PRS Mar 2003
  • immediate reduction after frozen sections from the lumpectomy/partial mastectomy margins were determined to be negative
  • Immediate reconstruction of the breast with reduction techniques creates symmetric, aesthetically pleasing breasts; allows contralateral breast tissue to be evaluated; and spares women from undergoing a second operative procedure.
  • Results assessed by Kronowitz (PRS Jan 2006)
  • Overall delayed reconstruction was associated with a complication rate almost twice that of immediate reconstruction (42 vs 26%)
  • Complications for delayed reconstruction were associated with poor wound healing after radiation therapy.
  • With using flaps, however, the complication rate was higher in the setting of immediate reconstruction.
  • In the setting of immediate reconstruction, the use of local tissues was associated with better aesthetic outcomes; however, in the setting of delayed reconstruction, the use of a flap was associated with better aesthetic outcomes.

Summary

  • immediate repair of partial mastectomy defects using local tissue rearrangement or breast reduction is preferable to delayed repair because of a decreased incidence of complications.
  • Immediate reconstruction with local tissue rearrangement or breast reduction also results in a better aesthetic outcome than immediate repair with a flap because use of local tissues maintains the color and texture of the breast.
  • Important not to use TRAM flap for immediate reconstruction after partial mastectomy as this may be required for reconstruction of completion mastectomy should margins come back positive

Alloplastic reconstruction

  • Options
  1. one stage implant reconstruction
  2. used in skin sparing or small breasted women with minimal or no ptosis
  3. more difficult to match size, use of intraoperative sizers useful
  4. two staged expander-implant reconstruction
  5. one stage permanent expander implant (McGhan 150)
  • depends on the presence of a sufficient amount of uncompromised skin so that complete coverage of the prosthesis can be obtained.
  • Breast implants do not interfere with chemotherapy, and neither block nor enhance the absorbed radiation dose
  • Capsular contracture rate reduced (28-50% to 2-5%) with

1)Saline implants

2)Submuscular position

3)Textured implant

4)No irradiation

  • Clough (PRS June 2001) – prospective evaluation of 334 patients over 9 years
  • early complication rate (< 2 months) was 9.2 percent, with an explantation rate of 1.7%.
  • late complication rate (> 2 months) was 23%,
  • pathological capsular contracture rate of 11% at 2 years and 15% at 5 years
  • an implant removal rate of 7%.
  • revisional surgery rate 30%.

  • Immediate alloplastic reconstruction is not recommended if radiotherapy is planned. Most authors (except Cordiero) report higher risk of capsular contracture (32 vs 0%), extrusion rates and more likely to require salvage flaps (27 vs 2%)

Combined autologous/alloplastic reconstruction

Latissimus Dorsi and Expander-Implant

  • With skin sparing mastectomy, use expander rather than implant to avoid stretch on the muscle/pedicle, especially with large reconstructions.
  • Place tunnel as high in the axilla as possible to prevent displacement of the implant to the back and prevent bulging of the pedicle low in the back.
  • Endoscopic-assisted vs Open harvest of muscle
  • Used where SSM has been performed
  • Advantages

1. scar size

2. much less postoperative pain

3. more immediate upper limb activity

4. earlier recovery from surgery

  • No statistically significant differences in the amount of intraoperative bleeding, the incidence of postoperative hematoma and seroma, and the incidence of donor-site wound infection (PRS Sept 1999)\
  • endoscopic harvesting of latissimus dorsi muscle might have the disadvantage of limitation in flap size.
  • greatest difficulty in endoscopic harvesting of latissimus dorsi muscle flaps is how to develop an optimal optical cavity.
  • Several methods were attempted to achieve and maintain a wide optical cavity, such as a designed tripod retraction device, retraction suture, manual retractor, balloon dissector, or insufflation.
  • The insufflation technique requires closing the port incisions and obtaining an air seal space. The prevention of gas leakage can be particularly cumbersome as the CO2 pressure increases in the optical cavity. The elimination of ports is cost saving.
  • Balloon dissectors decrease workload and fatigue. The skill requirements for balloon dissection are also less than those for sharp dissection
  • Functional loss after muscle harvest (review by Spear PRS Jun 2005)
  • acts on the humerus in medial rotation, adduction, shoulder extension, depressing of the raised arm, and downward rotation of the scapula
  • upper extremity disability in strength and shoulder motion should be anticipated following latissimus dorsi transfer, which in most cases is minimized by the recruitment of synergistic muscle units especially teres major
  • dynamic muscle tests demonstrate a deficit of muscle power and endurance of shoulder extension and adduction following latissimus dorsi muscle transfer.
  • Weakness does not seem to be a symptomatic complaint in most patients
  • Patients do complain of a more rapid onset of fatigue during prolonged activities involving adduction/extension - swimming, ladder climbing, overhead painting
  • Vigorous range-of-motion exercises following surgery should be encouraged to minimize adhesions and joint capsule stiffness.
  • By 2 to 3 weeks, patients should be using full range of motion.
  • The amount of time for the teres major muscle to fully take over the function of the latissimus may take 6 to 12 months
  • Social changes in occupation and daily living activities were noted which were not a problem for most patients.
  • Specific complications

1. seroma are common, occurring in up to 80% of patients– in 1 study, quilting reduced the seroma rates from 56% to 0% (local experience in Perth mirrors this)

2. cosmetic appearance of scar

3. scar contracture may limit shoulder mobility

4. loss of about 15%-30% of volume over time

5. muscle contraction if nerve not divided

6. should weakness

Autologous Options

Extended Latissimus Dorsi

Fat pads to capture include

1)fatty zone situated under the cutaneous crescent of the skin paddle

2)the fatty zone lying on the entire surface of the latissimus dorsi

3)the scapular fatty zone situated above the superomedial border of the latissimus dorsi, which is folded over it as a hinged flap;

4)the anterior fatty zone situated forward of the latissimus dorsi muscle and folded over it as a hinged flap

5)the supra-iliac fatty zone, which accompanies the fat located above the iliac crest (the so-called love handles)

Vascularity

  • zones 1 and 2- musculocutaneous and musculo-fatty perforators, which together ensure a good vascularization of the fatty tissues.
  • zone 3 (the scapular fatty zone)- small perforator vessels running cranially from the supero-medial border of the latissimus dorsi toward the scapular fat zone.
  • zone 4, which passes 3 to 4 cm beyond the anterior border of the latissimus dorsi muscle - small perforator vessels coming from the latissimus dorsi.
  • zone 5, distal musculo-fatty perforators of the latissimus dorsi (most tenuous)

Methods

1. maximizing the skin island with a fleur-de-lis incision (McCraw and Papp)

  • abandoned by the authors due to unfavourable scar

2. Horizontal skin ellipse extending into the lateral chest wall (McCraw/Papp)

3. lumbar extension of the latissimus dorsi flap(Hokin and Silfverskiold)

  • long, narrow cutaneous island was inset in a spiral that left an unwieldy scar in the breast mound.
  • Partial skin necrosis in 10.8% of cases.

4. scapular extension (Guenter Germann PRS Apr 2003)

  • combines fleur-de-lis incision with harvested fat in the territory of the circumflex scapular axis
  • leaves 5mm of fat on the skin flaps

Results (Chang PRS Sep 2002)

  • 75 extended latissimus dorsi flap in 67 patients
  • Flap complications developed in 28.0% and donor-site complications developed in 38.7 percent
  • donor-site seroma 25.3%
  • Patients with size D reconstructed breasts had significantly higher odds of flap complications compared with those with size A or B reconstructed breasts
  • Obesity (BMI >30 kg) associated with a 2.15x increase in the odds of developing donor-site complications compared with patients with BMI<30

Disadvantages

  1. contour irregularities
  2. scar
  3. seroma

TRAM

Contraindications to TRAM

  1. previous abdominoplasty
  2. large abdominal pannus
  3. patients planning for future pregnancy
  4. Grotting and Chen have reported successful normal pregnancies and delivery after TRAM flap surgery
  5. previous inguinal hernia repair (for Free TRAM)
  6. previous subcostal incision (for pedicled TRAM)
  7. vertical scar (for Hartrampf zone II,IV)
  8. animal studies show contralateral skin flap is not reliable in the presence of a vertical scar regardless of pedicle orientation or time constraints.

Vascular supply

  • Moon and Taylor (PRS 1988)
  • Type I - single deep superior pedicle and single deep inferior pedicle(29%)
  • Type II – double branched connection between the two systems (57%)
  • Type III - three or more vessels from each artery (14%)
  • In only 2% of their dissections was the circulation bilaterally symmetrical.

  • Anatomic studies show that the area of choke vessels is superior to the umbilicus,
  • two vertical rows of perforators lying along the rectus abdominis muscle, one in the lateral one third of the muscle and the other in the medial one third
  • Most perforators are in the centred around the periumbilical region
  • Hartrampf traditional perfusion zones challenged (Holm PRS Jan 2006). Perfusion of zone III shown to have consistently faster and with a higher intensity than in zone II.
  • Thus zones should be reclassified with II and III swapped around:
  • Importance of this is that flaps can be carried successfully across 1 watershed area (dynamic territory) but will need delay for 2 areas (potential territory)
  • ligation of the ipsilateral deep and superficial inferior epigastric arteries shown to increase perfusion of the rectus midportion by 4x.

Pedicled TRAM

  • most often mobilized on the contralateral vascular pedicle and inset vertically
  • More transverse placements of the island have been suggested to increase mound projection and to correct wide mastectomy defects extending into the lateral chest.
  • Flap should not be rotated more than 90° on inset to prevent torsion and kinking of the pedicle
  • Ipsilateral pedicle TRAM flap breast reconstruction is usually reserved for cases in which scars preclude use of the contralateral pedicle.

Techniques to improve survival

  1. delay
  2. venous supercharging
  3. DIEV to thoracodorsal vein
  4. Some feel that supercharging the artery leads to lower perfusion of the flap
  5. turbocharging
  6. anastamosing ipsilateral DIE vessels to contralateral DIE vessels
  7. double pedicle (proposed by Hartrampf for patients who are at high risk, have a midline lower abdominal scar, or require extensive soft tissue reconstruction)

Delay

  • Delay procedure ensures greater reliability of the TRAM flap in all patients but especially in those at high risk for flap necrosis (Jensen PRS 1995)
  • smokers
  • obese
  • prior radiation therapy
  • previous abdominal procedures.
  • Delay improves arterial inflow and venous outflow
  • improvement from delay becomes evident clinically after 1 week and TRAM flap perfusion is not further enhanced by extending the time of delay to 2 weeks before breast reconstruction.
  • Many of the vascular problems associated with the TRAM flap probably stem from venous congestion rather than from arterial insufficiency.
  • Venous insufficiency probably occurs when attempts are made to preserve the lateral one-third of the muscle with transection of the lateral venous drainage system, and can be averted if both the medial and lateral rows of perforators are included in the muscle pedicle.

Traditional delay technique (vascular delay)

  • inferior incision and a bilateral deep inferior epigastric vessel ligation (Boyd PRS 1984)
  • no attempt is made to detach zones II and IV from the periumbilical perforators

Extended skin island delay (Jensen PRS 1995)

  • Skin island is incised and the ipsilateral side of the skin flap is raised off the fascia to the midline

Surgical delay and insertion of tissue expander

Selective embolisaiton of DIEA

Technique of extraperitoneal endoscopic delay

  • infra-umbilical median sagittal incision is made in the skin to accommodate a 10mm diameter port.
  • anterior rectus sheath incised along the medial edge of the rectus abdominis muscle contralateral to the breast to be reconstructed.
  • Scope inserted behind the muscle into the extraperitoneal space, and directed towards the symphysis pubis
  • Balloon dissection is carried out until the retropubic space of Retzius is reached, and the deep inguinal ring is identified.
  • deep inferior epigastric vessels arise from the terminal segment of the external iliac vessels just before they pass deep to the inguinal ligament, medial to the deep inguinal ring.

Conventional Free TRAM

  • Advantages over pedicled TRAM
  1. All four zones of abdominal skin can be transferred with greater reliability
  2. skin island can be designed lower in the abdomen.
  3. better shape of the new breast can be achieved without medial fullness from the tunnelled pedicle.

Muscle Sparing TRAM

Nahabedian PRS Aug 2002

Nahabedian PRS Aug 2002

  • significant increase in abdominal bulge with the MS-0 and MS-1 free TRAM flaps but not with the MS-2 free TRAM flap when compared with the DIEP flap.
  • no difference in flap failure, fat necrosis, venous congestion, or the ability to perform sit-ups comparing MS-0, MS-1, and MS-2 to the DIEP flap

Nahabedian PRS Feb 2005

  • no significant differences in fat necrosis, venous congestion, or flap necrosis after DIEP or MS-2 free TRAM flap reconstruction.
  • The percentage of women who are able to perform sit-ups and the percentage of women who did not develop a postoperative abdominal bulge is increased after DIEP flap reconstruction; however, this difference is not statistically significant.

Bajaj, Chang DW PRS Mar 2005

  • no significant difference in flap-related complications or donor-site morbidity between the free muscle-sparing TRAM flap(MS-2) and the free DIEP flap

Lateral strip preservation (MS-1)

  • motor branches of the intercostal nerves travel on the undersurface of the rectus abdominis muscle and penetrate the muscle in its midportion. Leaving a lateral strip is unlikely to result in fuctional muscle
  • Post operative CT studies show that the lateral strip fibrosis

DIEP Flap

  • Advantage - reduces donor site morbidity
  • Less lower abdominal bulging
  • Flexibility in flap orientation
  • Indications - decided on the basis of the physical characteristics of the patient and the anatomic characteristics of the flap.
  • Contraindications
  1. active smokers
  2. in patients who need more than 70% of the usual TRAM flap skin paddle
  3. breast reconstructions not exceeding 1000gm
  4. converting the operation to a free TRAM flap if the perforators found at surgery (especially the vein or veins) are not of sufficient size (1mm)

Technical Pointers

  • mean reduction of skin perfusion in zone IV of 95%, when compared with the perfusion of the surrounding skin, which was not involved in surgery
  • in 33%, zone IV had total lack of perfusion
  • Zone IV should be routinely discarded
  • the presence of an unusually large, superficial inferior epigastric vein serves as a red flag warning of the possible presence of small veins in the DIEP system. If a large superficial inferior epigastric vein is found when making the incision along the inferior border of the flap, it should be preserved for several centimeters in case it is needed later for auxiliary flap drainage

Fat necrosis

  • Kroll (PRS Oct 1998)
  • free TRAM flap - 8.2 % clinically evident fat necrosis, and 2% had necrosis only detectable by mammography.
  • pedicled TRAM- 26.9% had clinically detectable fat necrosis and 13% had necrosis detectable mammographically.
  • Fat necrosis was more common in patients who were obese or had a history of smoking, but neither association was statistically significant.
  • Kroll (PRS Sep 2000)
  • DIEP - fat necrosis 17.4% and partial flap loss 8.7%
  • free TRAM flap- fat necrosis 12.9%, partial flap loss 2.2%

Summary

  • Fat necrosis – Pedicled TRAM(30%)>DIEP(20%)>Free TRAM(10%)

Contour irregularities

  • incidence of abdominal bulge or hernia depends primarily on the method of fascial closure rather than the amount of muscle removed
  • pedicled TRAM tends to cause upper abdominal bulging, free TRAM lower abdominal bulging
  • Techniques to close the anterior rectus sheath include one layer, two layers, or the use of mesh – use of modern techniques reduces bulge rates from 30% to 5%.
  • In bilateral TRAM flaps, muscle sparing procedures give better contour
  • Hernia rate in conventional TRAMs is 2%

Abdominal Strength