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Breast > Breast Reconstruction > Flashcards

Breast Reconstruction Flashcards

1
Q

What are contraindications to breast reconstruction

A
  • uncontrolled disease
  • unrealistic expectations
  • inflammatory carcinoma (relative)
  • metastases (relative)
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2
Q

What are reasos to have or not to have reconstruction?

A

Reasons to have recon:

  • restore femininity, sexuality
  • get rid of prosthesis, no clothing limits
  • help forget about cancer

Reasons not ot have recon:

  • fear of complications, no additional surgery
  • unnatural
    • just want to get rid of cancer
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3
Q

Describe key questions on history and physical for breast reconstruction patient evaluation

A

HISTORY

  • Breast Hx
    • Tumor histology, grade, stage
    • Treatment Hx
      • biopsy, lumpx, Mx
      • SLNB/ALND (#nodes)
      • Rtx (timing, dose, last tx, skin changes
      • Chemo
      • CompX
      • Plan for future Surg/Rtx/Chemo
    • Genetics/FamHx
    • Contralateral breast disease
    • Last mammogram
    • Heigh weight bra size
  • Expectations
  • Fitness for surgery
    • PMHx - CV, resp, DM, HTN, DVT, wound healing
    • Smoking
    • Meds allergies
    • PSHx - abdo scar, ALND
    • future pregnancies

PHYSICAL EXAM

  • Breast Exam
    • Mx defect/scar
    • Pec major presence/fx
    • Axilla LNs
    • Skin
      • thickness, elasticity, radiation changes
    • Contralateral breast
      • dimensions
      • volume
      • shape
      • IMF, NAC position
      • Full breast exam andn LN check
  • General Exam
    • CVS, resp
    • body habitus
  • Potential donor sites
    • Abdomen - scars, diastasis, hernia, striae
    • lat dorsi
    • other - medial thigh, gluteal region
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4
Q

What are indications for IBR

A

Stage 1 or 2 breast ca with no planned post-op radiation

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5
Q

What are advantages and disadvantages to IBR

A

ADVANTAGES

  • Technical:
    • no contracture, supple tissue
  • Procedural
    • fewer operations, intra-op communication b/w two teams
  • Aesthetic
    • Better estimate of volume for reconstruction (Mx weight)
    • Natural breast landmarks
  • Psychological
    • less impact of Mx defect
    • achieves goals of recon earlier

DISADVANTAGES

  • Technical
    • Skin viability uncertain
  • Procedural
    • coordination of 2 surgeons for 1 OR
  • Oncologic
    • tumor margins uncertain, pathology may be uncertain
    • May delay adjuvant treatment if complication from recon
  • Aesthetic
    • Patient may be disappointed immediately after
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6
Q

What are the advantages and disadvantages of DBR

A

ADVANTAGES

  • known pathology and tumor margins determined
  • completion of adjuvant therapy
  • Time to consider all recon options

DISADVANTAGES

  • Contrast to all immediate recon advantages
    • Loss of natural landmarks (IMF, envelope)
    • 2 ORs
    • Living iwth Mx defect
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7
Q

What is Delayed Immediate recon?

A

Reconstruction is done in 2stages

1- MX, then SP TE 133 MV insertion and filled to scaffold breast skin to preserve shape and envelope

2- 2wks post op when pathology is available

  • If no adjuvant RTx is required, proceed with exchange to final reconstruction
  • if adjuvant Radiation is required, deflate TE and follow MSK or MDAnd protocol
    • MSK:
      • Rapid Expansion Protocol (chemotherapy)
        • MX+TE-> post 2wks begin inflation -> inflate during ChemoT -> exchange 4wks post completion of ChemoT–>RadT 4wks post exchange
      • Just Rtx - > deflate TE -> PMRT -> reinflate TE ->then delayed recon with LD/implant or DIEP/TRAM/GAP
    • MD anderson: chemoT given neoadjuvant
      • MX+TE ->partial deflation - >PMRT ->reinflation TE ->3months post PMRT do skin-preserving DBR (implant, LD+implant, TRAM/DIEP/GAP)
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8
Q

When do you perform DBR post chemoT? post Rtx?

A

1yr post Rtx or post Mx

6wks post chemo

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9
Q

What are indications for delayed immediate BR?

A

Stage 1 or 2 with incrreased risk of requiring PMRT

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10
Q

What are options for BR?

A

NON-OPERATIVE

  • Camouflage
  • External prosthesis

OPERATIVE

  • Alloplastic
    • 1 stage - implant
    • 2 stage - TE to implant or double lumen
  • Autologous
    • Pedicled - TRAM (uni,bipedicle, microanas), LD (+/- TE/implant), thoracoepigastric???. omental
    • Free
      • Abdomen - DIEP, TRAM, SIEA, DCIA,
      • Thigh - TUG, lateral thigh
      • Gluteal - GAP
      • Back - LD
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11
Q

What role does FG play in breast reconstruction

A
  • Improve contour deofmrities in patient who have been treated with a Mastectomy and reconstruction
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12
Q

What are indiciations and contratindications to alloplastic reconstruction?

A

INDICATION

  • pt has insufficient donor tissue (thin)
  • pt unable/unwilling to tolerate scars at dornor site
  • pt unable/unwilling to tolerate rehabilitation required
  • Patient Mx skin flaps require expansion

CONTRAINDICATION

  • (relative) anticipated or previous RTx
  • pt refuses alloplastic materials
  • pt unwilling to come for multiple visits for TE fill
  • pt has poor tissu quality
  • MX skin flaps poor quality intra-op
    *
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13
Q

What are advantages and disadvantages to Alloplastic recon

A

ADVANTAGE

  • Rapid recovery, rapid RTW
  • shorter OR, technically easier
  • Versatility in size
  • no donor site morbidity

DISADVANTAGE

  • Complications of implants
  • Unable to recreate symmetry with ptotic breast
  • Increased risk of compx with Rtx
  • _>_2stages
  • unnatural appearance
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14
Q

What are 2 types of TE available and the differences

A

Allergan (MV)

  • anatomic shaped implant
  • Biocell texturization
  • Select height and projection

Mentor (contour profile) MCP

  • Anatomic shape dimplant
  • Siltex texturization
  • Select width, volume, height
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15
Q

What are complications of TE?

A

EARLY

  • PTX
  • hematoma, seroma
  • infection
  • wound dehiscence
  • discomfort post expansion

LATE

  • CC
  • extrusion
  • chest wall deformity
  • TE failure - leakage/port inaccesible
  • Malposition (high riding)
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16
Q

What are the goal sof using textured TE?

A
  • tissue ingrowth
  • inhibits migration of expander
  • peri-prosthetic pocket forms
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17
Q

Describe 2 stage TE

A

1- Insertion of TE

  • DBR: Incise through Mx, Sub pectoral pocket avoiding superior pole dissection
  • IBR: total SubMuscular pocket with elevation of pec in continuity with rectus abdominis fascia and serratus to create total SM pocket
  • Inflate as toelrated to scaffold muscle envelope/skin envelope
  • Start inflation 2wks post, q1wk with 50-60cc as tolerated by pt/skin, consolidation 2-3months

2- Permanent implant

  • incise through old scar
  • remove TE and inspect pocket
  • capsulotomy (generally superior and medial)
  • sutures/capsuloplasty along iMF
  • cohesive silicone implant insertion
  • Perform/consider modifications for symmetry to contralat breast (BR, BA, mastopexy
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18
Q

What are becker implants and the advantage//disadvantage

A
  • Becker implants are permanent expander
  • Available in Becker 25 (25% silicone outer shell) or becker 50 (50% silicone outer shell)
    *
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19
Q

What are the indications for Autogenous recon

A
  • Hx of irradiation
  • Refusal for use of alloplastic implants
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20
Q

Wht are contraindications of autogenous recon

A
  • refusal of donor site scar/morbidity
  • Medically unfit to undergo long surgery
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21
Q

What are the advantages and disadvantages of autogenous recon

A

ADVANTANGE

  • Natural
  • Versatile (shaping/volume)
  • Permanent
  • No compx of expander/implant
  • Single stage
  • Tolerant of RTX

DISADVANTAGE

  • donor site scar/morbidity
  • longer OR/rehab/recovery/RTW
  • systemic complications (DVT,PE)
  • technically more demanding
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22
Q

Describe the vascular supply to the abdominal wall

A

Divided into Zones by imaginary lines - horizontal line at level of ASIS, 2 vertical lines along lateral edge of rectus muscle

Zone 1 - between 2 vertical lines and above Horizontal line

= Superior and INferior deep epigatric arteries

Zone 2 - Below Horizontal line

= SIEA, SCIA and external pudendal (CFA)

Zone 3 - Lateral to the vertical lines and above the horizontal line

= intercostals, subcostal and lumbar arteries

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23
Q

Describe the vascular supply to the Umbilicus

A

4 sources

  • R and L DIEA perforators
  • Subdermal plexus
  • Ligamentum terres hepaticus (umbilical vein remnant)
  • Medial umbilical ligament (umbilical artery remnant)
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24
Q

What is the source and course of the superior epigastric artery

A
  • Source - IMA
  • Size: 2mm diamter, 5cm length
  • Course: deep to rectus muscle, along medial mid 1/3 of muscle
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25
Q

What is the source and course of the DIEA and its perforators

A

Source: External Iliac artery

Size: 2.5mm diamter, 5cm length

Course

  • deep to rectus, enters at lateral mid 1/3 of muscle
  • enters muscle at arcuate line, approx 4cm above public tubercle
  • two rows of perforators
    • medial row - within 1cm of linea alba
    • lateral row - withni 2cm of linea semilunaris
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26
Q

What is the innervation to the rectus muscle and the sensory innervation and the course of the nerves

A

Innervation: segmental innervation from T8-T12 intercostals, course lateral to medial between internal oblique and trasnversus abdominis

Mixed nerves enter laterally

  • sensory nerves run with perforators
  • motor nerves run over the DIEA
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27
Q

Describe the anatomy of the abdominal wall musculature and arcuate line

A

Abdominal wall composed of EO, IO, tranversus abdominus and rectus abdominis

Anterior rectus sheath above arcuate is composed of

  • EO, IO -> posterior sheath is composed of IO and TA aponeurosis

Anterior rectus sheath below arcute line is composed of

  • EO, IO, transversus abdominus - > so the posterior sheath is ONLY composed of transversalis fascia - no aponeurosis

Origin of Rectus abdominis - superior crest and pubic symphysis

Insertion - costal cartilage 5,6,7

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28
Q

WHat are 3 patterns of DIEA branching (Moon&taylor)

A
  • Type 1 - single intramuscular vessel from DIEA to SEA
  • Type 2 -(majority 60%) DIEA branches into medial and lateral rows and the arcuate line and communicate with SEA
  • Type 3 - (minotrty 30%) DIEA branches into 3 at the arcuate line
29
Q

What is the blood supply to the skin flap of the pedicled TRAM flap?

A

Superior epigastric artery

BUT

  • dominant abdominal vascular supply is DIEA - so para and infraumbilicl perforators supply abdominal skin via choke vessels in retrograde flow to SEA
  • axial perforators supply lateral extnsion of TRAM across the midline - so can raise nearly whoke TRAM on one pedicle
30
Q

Describe the vascular zones of the TRAM flap and the difference between the Hartramf and Ninkovic

A

HARTRAMF - described for pedicled TRAM

Zone 1 - ipsilat to pedicle, periumbilical

  • Zone 2 - contralat to pedicle, periumbilical*
  • Zone 3 - Ipsilat to pedicle, lateral flap portion*

Zone 4 - contralat to pedicle, lateral flap portion

NINKOVIC - described for free TRAM

Zone 1 - ipsilat to pedicle, periumbilical

  • Zone 2 - Ipsilat to pedicle, lateral flap portion*
  • Zone 3 - contralat to pedicle, periumbilical*

Zone 4 - contralat to pedicle, lateral flap portion

31
Q

Describe the dimensions of the pedicled Tram flap and expected skin flap expected to be harvested with a single and double pedicled TRAM

A

Hartrampf dimensions on average

Vertical width: 13cm (will be equal to base of breast to be created

Width - from ASIS to ASIS, approx 36cm

On a pedicled TRAM, can harvest zone 1, all or some of zone 3 (contralat periumbilicail) and some of zone 2 (ipsilat, lateral zone)

32
Q

What are the advatnages and disadvantages of a pedicled TRAM for breast recon

A

ADVANTAGES

  • Simultaneous abdominoplasty
  • acceptable donor scar
  • shorter OR, LOS
  • versatile, natural, permanent

DISADVANTAGES

  • donor site morbidity (hernia/bulge)
  • long recovery/RTW
33
Q

What are the indiciations for a pedicled TRAM

A
  • habitus
  • refusal for alloplastic materials
  • unable to tolerate long OR
34
Q

What are complications of a TRAM flap reconstruction

A

EARLY

Recipient Site

  • Partial flap loss, Total flap loss
  • Mastectomy flap necrosis
  • hematoma, seroma

Donor Site

  • necrosis of abdominal flap
  • umbilical necrosis

Medical/systemic - DVT/PE, renal injury

LATE

Recipient Site

  • Fat necrosis

Donor Site

  • Abdominal weakness, bulge, hernia
  • Ubilical malposition
  • Mesh infection/extrusion
  • contour irregularities
  • abdominal dysesthesia
35
Q

What are indications for a bipedicled TRAM

A
  • reconstruction requiring more volums than provided by a single pedicled TRAM
  • midline vertical lower abdoinal scar
36
Q

What are the advantages and disadvantages of a bipedicled vs unipedicled TRAM

A

Advantages

  • more volume and skin for recosntruction of breast
  • improved blood supply in those at risk of poor perfusion (hartrampf zone 2 is contralat periumbilical)

Disadvantages

  • abdominal weakening, increase risk hernia/bulge
  • difficulty shaping breast
  • difficulty closing abdominal wall defect
37
Q

What are ways of modifying the conventional TRAM flap for improved perfusion

A
  • Supercharging : additional microvascular anastomosis between DIEA/V and TD A/V to provide a second source of arterial perfusion and venous drainage
  • Turbocharging: transmidline retrograde microvascular loop of DIEA/V to provide increased arterial inflow to zone 4 and venous outflow
  • Vascular delay procedure: ligate SIEA/SIEV bilaterally 2-3weeks prior to flap elevation - increases arterial pressure, decrease venous congestion and fat necrossis
    • Indicated if large volume TRAM in high risk patient unsafe to undergo DIEP
38
Q

Describe elevation of pedicled TRAM

A

LANDMARKS

  • Inguinal crease, ASIS, umbilicus

MARKINGS

  • ASIS to ASIS with superior line above umbilicus and inferior line in suprapubic crease. Test laxity for closure
  • design flap ipsilat for 90’ rotation, measure base width and height, include zone 1, some of zone 2 and some of zone 3

STEPS OF OPERATION

1- Recreation of defect - excise Mx scar, create pocket, tunnel, score superior edge of mastectomy flap to allow for expansion and create dart in skin at anterior axillary line

2- Elevation of flap to pedicle

  • superior incision, raise to subcostal amrgin, create tunnel
  • umbilical separation
  • inferior incision, raise lateral to medial ipsilat side - stop once reached rectus muscle
  • on contralat side, raise lat to medial until reached linea alba and leave 1cm cuff on ipsi side for closure with mesh

3- Pedicle dissection

  • incise fascia ontop of muscle and just lateral to perforators to minimze amount of fascia removed
  • from medial to lateral, raise muscle off fascia and identify pedicle.
  • careful at inscriptions (perforators may be present) @ xphoid, @ umb and midway between
  • pedicle location midpoint between ASIS and pubic symphysis along lateral margin of muscle

4- Inset of flap

  • turn 90degrees
  • inset IMF and medially first

5- Donor site closure

  • Abdo wall repair with prolene mesh both external and internal oblique layers
  • closure of scarpas fascia and umbo inset
39
Q

What is the vascular supply to the MC flap of the lat dorsi

A

MN5

dominant - Td - length8-10cm, 2.5mm diameter

Segmental - Intercostal perforators Thoracic T6-12 and lumbar

40
Q

What is the orgin, insertion, function, innervation to lat dorsi

A

Origin: thoracolumbar fascia, iliac creast, T6-T12 spinous processes

Insertion: bicipital groove of humerus

Innervation: thoracodorsal nerve (posterior cord)

Function: Internal rotation, adduction

41
Q

What are the advantages and disadvantages, indications for lat dorsi

A

Indications

  • Hx of Rtx
  • no abdominal tissue for reconstruction
  • salavge procedure for imminent exposure of implant
  • poland syndrome

Adv

  • reliable
  • short recovery, LOS
  • restore anterior axillary line

Disadv

  • difficult positioning for bilateral recon
  • minimal tissue bulk
  • generally combine dwith alloplastic material
  • shoulder weakness, scapula winging
  • seroma, thoracolumbar hernia
42
Q

What is the thoracoepigastric flap

A

FC flap based on superior epigastric artery and subcostal arteries

  • boundaries: midline (medial), midaxillary line (lateral), midway b/w xiphoid and umbo (inferior, xiphoid (superior)
  • elevate lateral to medial, suprafascial to linea semilunaris
43
Q

How do you classify free TRAM flap

A

Can be raised as a Muscle sparing flap

MS 0 - no muscle spared

MS 1 - lateral band of muscle spared

MS 2 - lateral and medial band of muscle spared

MS 3 - preservation of entire muscle (perforator flap)

44
Q

WHat are indicaitions and contraindications for a free tram flap

A

INDICATION

  • divide SEA
  • abdominal scar precluding pedicled tram
  • ratio of donor site to breast volume is low

CONTRAINDICATION

  • abdominal scar/surgery precluding use of DIEA (paramedian scar, inguinal hernia repair
  • abdominoplasty
  • lack of donor tissue
  • medically unfit
45
Q

What are advantages of free tram and disadvantages

A

AdV

  • more robust blood supply, reduced fat necrosi
  • less muscle harvest, reduced morbidity
  • no subcut tunnel

DisAdv

  • long OR, rehab, RTW
  • systemic risks VTE
  • flap loss
46
Q

Compare the fat necrosis, flap loss and hernia/bulge rates between SIEA, DIEP, free tram, pedicled Tram

A

Total flap loss

  • highest SIEA, rest equal

Partial flap loss and fat necrosis

  • pedicled tram >>>free tram/diep

Abdominal hernia/bulge

pedicled tram 15%> free tram/diep 10%

SIEA 0%

47
Q

What is the DCIA Reubens flap

A

MN1 - deep circumflex iliac artery with small cuff of EO, IO, transversus

48
Q

What are gluteal free flaps for breast reconstruction?

A
  1. Superior gluteal myocutaneous flap (SGM)
  2. Inferior gluteal myocutaneous flap (IGM)
  3. Superior gluteal artery perforator (SGAP)
  4. Inferior gluteal artery perforator (IGAP)
49
Q

What is the origin insertion,function, vascular suply and innervation of the gluteus muscle

A

Origin: gluteal line ilium, aponeurosis erector spinae, Sacrotuberous ligament, sacrum/coccyx

Insertion: iliotibial tract, gluteal tuberosity of femur

Function - extend and rotate externally

Innervation

superior clunial n L1-3

medial clunial nerve S1-3

posterior femonal n

Vascular supply MN3 - 2 dominant

  • terminal branches of internal iliac
  • superior and inferior gluteal arteries, exit above and below piriformis from the greater scaitic foramen
  • inferior is dominant to supplying gluteus maximus
50
Q

How do you landmark and elevate the superior gluteal muscle flap (SGM)

A

LANDAMRKS

  • PSIS to greater trochanter line - at junction of upper 1/3 and lower 2/3 is pedicle location

ellipse oritented oblique, width 13cm

ELEVATION

  • start at superior incision and find lateral border of . maximus.
  • dissect b/w maximus and medius and identify pedicle 5cm from scarum, between piriformis and medius
  • divdie deep br of SGA and raise only superior 1/3 of muscle
51
Q

What are indications, advantage, disadvantage of SGM flp

A

Indication

  • too thin for abdominal flap
  • preference of pt surgeon

Adv

  • well hidden scar, buttock lift
  • always available, good shape

Disadv

  • short pedicle
  • intra-op position difficult for 2nd team
  • hip extension weakness
52
Q

Describe landmark and elevation of IGM flap

A

LANDMARK

  • flap central axis is perpendicular to gluteal crease and
  • 1/2 way b/w PSIS and ischial tubersotiy is pedicle exit from pelvis
  • flap designed between trochanter and ishium vertically along post thigh

ELEVATION

  • elevate inferior to superior, through fascia lata and disinsert muscle below GT
  • watch for scaitic nerve, post femoral n

Disadvantgae - as above for SGM and post cut nerve sacrificed

53
Q

What is the lateral tranverse thigh flap

A

MN1 - based on TFL, ascending branch of lateral circumflex femoral artery

LANDMARKS

  • 10cm below ASIS, pedicle enters deep surface of TFL
54
Q

What is the trasnverse upper gracilis flap

A

MN2 - medial circumflex femoral artery, superficial femoral br

LANDMARK

  • adductor longus tendon. Gracilis is posterior and medial
  • pedicle runs posterior to adductor longus

Innervation

obturator nerve

55
Q

DIEP vs free tram

A

2x fat necrosis

2x flap loss and thrombosis

1-2x abdominal bulge

56
Q

What are indications, contraindications for DIEP

A

INDICATION

  • <70% of tram tissue required

CONTRAINDICATION

  • intraop unable to identify suitable perforator

Adv

  • no muscle harvest, shorter recovery

Diadv

  • tehcnically difficult
57
Q

What is a SIEA flap, landmarks, elevation

A

SIEA - superficial inferior epigastric artery flap

Superficial system present in 70%, suitable in 30%

SIEA arises from SCIA or CFA

LANDMARK

  • ASIS, inguinal ligament, pubis
  • pedicle arises deep to scarpas, 1-3cm below inguinal ligament and travels superior lateral, crossing inguinal lig at midpoint b/w ASIS and pubis

PEDICLE 4-6cm

58
Q

How do you decide between SIEA, DIEP, TRAM free flaps

A

if <50% abdomen required, SIEA

50% required DIEP

>70% required TRAM

59
Q

What are landamrks, elevation of flap for SGAP

A

LANDMARKS

  • draw line b/w PSIS and cocyx; at midpoint of line, (P) connect to greater trochanter = marks upper edge of piriformis
  • line from PSIS to GT outlines maximus muslce axis and at jx of upper 1/3 and lower 2/3rd is the pedicle
  • Pedicle exits 6cm inferior to PSIS and 5cm lateral to midline
  • Pedicle: superior gluteal artery exits from greater scaitic foramen, superior to piriformis, inferior to gluteus medius
  • perforators are found superior to piriformis and lateral to pedicle exit

Flap design

  • ellipse 45’ slant with apex

ELEVATION

  • lateral superior, deep to fascia
  • identify perforator and trace down through muscle
60
Q

What are landmarks, elevation of flap for IGAP

A

LANDMARKS

  • PSIS to coccyx line, midpoint of line (P) to GT = upper edge of piriform muscle
  • PSIS to ischium - alongt his line, at inferior edge of piriformis muscle, pedicle exits
  • Flap designed 4cm above gluteal crease, width 10cm lateral to ischium

ELEVATION

  • infero
61
Q

What is difference between igap and sgap

A
  • igap longer pedicle
  • donor site hidden in crease
  • potential for neurosensory flap
62
Q

What exits greater sciatic foramen below piriformiis

A
  • IGA/V
  • sciatic n
  • intenal pudendal art
  • PCFN
63
Q

What factors influence managemetn of oppsoite breast

A
  • Oncologic
  • Expectations/desires
  • Aesthtic
64
Q

What are options for contralat breast

A
  • reduction
  • augmentation
  • mastpexy
  • augentation mastopexy
  • PM
  • no alteration

note - only have one chance to recon oppost ebreast w abdo flap

65
Q

What are revisions to reconstructed breast

A
  • liposuction
  • lipofill
  • direct excision
  • IMF repositioning
  • scar revision
66
Q

Why are lower revision rates associated wa autolgous recon

A
  • superior aesthetic result
  • long lasting acceptable result
67
Q

How do you manage flap necrosis in ealry postop periord?

A
  • Define PROBLEM
    • A/V thrombosis - take down, revemo clot, trim, redo, use anticoag/thrombolytic (IV heparin, IV tpa) If unsalvegable recipient, move to different site
    • if unsalveagable, TE insertion
68
Q

What is option for Nipple recon

A

NOn-surgical

  • tattoo
  • prosthesis

Surgical

  • composite graft (contralat nipple, ear, toe pulp, labia majora
  • local flap- skate, cv flap

Areaola rcon w STSG abdo groin

69
Q
A

Breast (6 decks)

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