Breast Reconstruction Flashcards
best candidates for
immediate and single-stage reconstruction
Healthy
patients with smaller breasts, early stage breast cancer, and
healthy mastectomy skin flaps are the best candidates for
immediate and single-stage reconstruction
Acellular dermal matrix useful adjunct to provide total implant coverage while
defining and maintaining implant position
T
Risk factors
for complications in implant reconstruction
■ Smoking
■ Obesity (BMI >30)
■ Large breasts
■ Diabetes (Hgb AlC >6.5%)
large mastectomy specimen weight was found to be an independent risk factor for implant loss in prosthetic reconstruction
T
activesmokers have an odds ratio of four
for early tissue expander loss compared to nonsmokers
T
those who stopped smoking I month or more
before surgery, is similar to the rate of complications in active smokers.
T
even
well-controlled diabetes (average preoperative blood glucose 137 mg/
dL) increases the I-year rate of wound healing problems following
autologous reconstruction
F following prostheticbut not autologous reconstruction
perioperative glucose management should
be undertaken with the goal of preoperative Hgb AlC <6.5%, and
perioperative glucose levels under 200 mg/dL.
T
I-year rate of infectious and wound complications in
patients undergoingexpander/implant reconstruction was significantly
higher in patients with BMI >30
T
patients with BMI >30 were almost seven times more likely
to experience reconstructive failure following prosthetic reconstruction than their nonobese counterparts
T
device projection
may be severely limited in patients with overly thick mastectomy flaps
T
Obese patients should be counseled that preoperative weight
loss will.
decrease their risk of postoperative complications
improve the appearance of the final result.
macromastia is contraindication
to implant-based reconstruction
F macromastia is not a contraindication
to implant-based reconstruction, but does require attention to tailoring
of the skin envelope
delayed prosthetic reconstruction
have argued that this approach results in a lower rate of complications including mastectomy skin flap necrosis, capsular contracture,
and need for device removal
T
The decision to perform a prosthetic
reconstruction based on»_space;»
based on patient factors, oncologic factors, and technical aspects of the
mastectomy itself
immediate reconstruction will achieve optimal results inpatients with a lower preoperative risk profile (nonsmoker, nonobese) and early stage cancers
T
intraoperative decision to delay reconstruction may be
appropriate
T
A
direct-to-implant approach has the obvious advantage
(1) multiple office visits for device expansion, (2) risk of infection related to expander filling access and manipulation, and (3)
second-stage surgery for expander-to-implant exchange.
quality mastectomy is a major determinant ofthe success of
direct-to-implant reconstruction
T
Adjuncts such as indocyanine green angiography can provide an
objective assessment of skin flap perfusion
T
skin flap necrosis, need for reoperation,
and reconstructive failure in patients undergoing direct-to-implant
reconstruction
T
The overall
absolute rate ofimplant loss was 14.4% for single- and 8.7% for two-stage reconstruction
T
ADM benefit
can help maintain the device in the optimal position on the chest wall, add
definition to the inframammary fold and lateral breast border, and
improve lower pole projection
a higher intraoperative fill volume and shorter time to optimal expansion
ADM is useful in both the primary prevention and secondary treatment of capsular contracture
ADM may ameliorate some ofthe negative sequelae associated with radiation treatment
Percentage of breast contracture with ADM
Decrease from 10% and 30% to 0-4 %
Acute postoperative complications of ADM
infection, seroma, skin flap necrosis, and reconstructive failure in prosthetic reconstructions employing ADM
the benefits of ADM use likely outweigh the
potential drawbacks
T
Implant projection the most important
parameter for intraoperative device selection
F , base width is the most important
parameter for intraoperative device selection
matching the device base
Width to the width of the breast footprint on the chest wall eliminates
dead space and skin redundancy while optimizing the final expansion
pocket
T
Expander capacity is less important, as many expander devices
may be filled well beyond their stated maximum volumes.
T
saline implant have higher rates of implant visibility and
rippling.
T
silicone leak or implant rupture may
be harder to detect and can lead to capsular contracture; in contrast,
saline is physiologically inert and is simply absorbed ifthere is a leak.
T
Salin implant has hight rate of rapture than silicon implant
F rupture and capsular contracture
maybe slightly higher in silicone implants than in saline at 10 years
the following implantation
patients with silicone implants are more likely to develop rare
neurologic or connective tissue diseases
F There is no evidence to support the idea
that patients with silicone implants are more likely to develop rare
neurologic or connective tissue diseases
rates of capsular contracture
do appear to be lower with textured devices, though this difference
appears less significant when implants are placed in the submuscular
position
T
benefit of textured implants
includes a more stable position within the pocket, which theoretically
decreases lower pole stretch over time.
T
breast-implant-associated anaplastic large-cell
lymphoma(BIA-ALCL) increases with smooth implant
There appears to be a small
increase in the risk of breast-implant-associated anaplastic large-cell
lymphoma(BIA-ALCL) with the use of textured devices. This effect may
be greatest with macrotexturedimplants
Anatomic-shaped implants better match the device to the original breast footprint
T
Shaped implants may result in improved upper
pole shape and volume, especially in reconstruction of breasts that are
taller than they are wide
T
Draw back of anatomical implant
- without precise pocket control, implant
rotation may result. - firmer feel compared to a softer, round silicone implant
All currently available anatomic-shaped
implants are also textured to limit unwanted implant movement/
rotation;
T
If viability or skin
quality is a concern, by Indocyanine green angiography placement of an expander is relatively contraindicated and may be deferred to a later time.
T
Additional muscle origin along the most inferior
portions of the sternum may be divided further if increased lower
pole projection is needed or desired
T
Radiation of a prosthetic device can lead to increased rates of early
complications such as infection, seroma, and mastectomy flap necrosis, as well as delayed complications such as capsular contracture,
poor aesthetic outcome, and reconstructive failure
T
Patient with prosthetic reconstruction develop reconstructive failure is generally accepted to be around 20% compared to 3% in those not receiving adjuvant radiotherapy
T
radiation of the permanent implant
was associated with a higher rate of capsular contracture and subsequently worse aesthetic outcomes
T
In the setting of radiation of the tissue expander, increasing the interval of
time between completion of radiation and exchange to permanent
implant appears to improve outcomes, with intervals ranging from 3
to 8 months.
T
However, with modern techniques and modeling, more recent data seem to suggest that radiation
of even a fully inflated expander or permanent implant is safe, does
not result in decreased radiation dose administration, and may result
in a lower rate of complications compared to radiation of a deflated
device
T
he use of ADM in previously irradiated patients is not
protective against reconstructive failure and may increase the rate
of skin flap and infectious complications
T
Although increasing tl1e time interval between previous irradiation and salvage mastectomy beyond 1 year does not appear to
improve the rate of complications, performing the reconstruction in
a delayed rather than immediate fashion may result in a lower rate of
reconstructive failure
T
there is no clear evidence that either neoadjuvant or adjuvant chemotherapy increases complication rates in patients undergoing prosthetic reconstruction,
T
Cmplication of implant base breast reconstruction
Hematoma
Infection
Capsular Contracture
Implant Malposition or Asymmetry
most hematomas require return to
the operating room for evacuation,
T
even small
hematomas can increase the risk of mastectomy skin flap necrosis,
capsular contracture, and poor aesthetic outcome.
T
elevated white blood cell count at admission and methicillin-resistant S. aureus (MRSA) infection as predictors of salvage failure of the implant
T
Rates of capsular contracture following implant-based reconstruction at 3 years are estimated at between
10% and 13%
T
. Hematoma,
radiation, silicone rupture, and biofilm formation are all considered
to increase the incidence of capsular contracture
T
evidence-based approach to treatment of capsular contracture is
lacking
T
drains are left in the
subcutaneous space until output is less than 30 cc over a 24-hour
period. Typical drain duration is I to 2 weeks.
T
there was insufficient evidence to recommend continuing antibiotics on an outpatient basis
T
Disadvantages of implant base reconstraction
■ Implant-related complications (implant infection, capsular
contracture, implant malposition, rippling, rupture)
■ Less natural feel compared to autologous tissue
■ Difficult to achieve symmetry in unilateral reconstruction
active smokers have an odds ratio of four
for early tissue expander loss compared to nonsmokers
t
. The size of the tumor and lymph node status are crucial
pieces of information for the reconstructive surgeon
T
Immediate breast reconstruction optimize aesthetic outcomes and patient satisfaction
T
intraoperative decision to delay reconstruction may be
appropriate
T
undergoing direct-to-implant
reconstruction found a significantly increased risk of skin flap necrosis, need for reoperation,
and reconstructive failure
T
found a significantly increased risk of skin flap necrosis, need for reoperation,
and reconstructive failure in patients
T
late
complications such as capsular contracture and reconstructive failure
appear to be two to three times more likely in previously irradiated
patients
T
the rate of successful completion of prosthetic reconstruction
in previously irradiated breasts was 83%
T
no evidence that hormonal therapies such as tamoxifen or
aromatase inhibitors increase complication rates in prosthetic recon
T
Gram-positive bacteria such as Staphylococcus, Streptococcus, and
Propionibacteria are the most common pathogenic organisms in
implant-associated infection
T
