Breast Reconstruction Flashcards
What are contraindications to breast reconstruction
- uncontrolled disease
- unrealistic expectations
- inflammatory carcinoma (relative)
- metastases (relative)
What are reasos to have or not to have reconstruction?
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
Describe key questions on history and physical for breast reconstruction patient evaluation
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
What are indications for IBR
Stage 1 or 2 breast ca with no planned post-op radiation
What are advantages and disadvantages to IBR
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
What are the advantages and disadvantages of DBR
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
What is Delayed Immediate recon?
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
- Rapid Expansion Protocol (chemotherapy)
- 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)
- MSK:
When do you perform DBR post chemoT? post Rtx?
1yr post Rtx or post Mx
6wks post chemo
What are indications for delayed immediate BR?
Stage 1 or 2 with incrreased risk of requiring PMRT
What are options for BR?
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
What role does FG play in breast reconstruction
- Improve contour deofmrities in patient who have been treated with a Mastectomy and reconstruction
What are indiciations and contratindications to alloplastic reconstruction?
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
*
What are advantages and disadvantages to Alloplastic recon
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
What are 2 types of TE available and the differences
Allergan (MV)
- anatomic shaped implant
- Biocell texturization
- Select height and projection
Mentor (contour profile) MCP
- Anatomic shape dimplant
- Siltex texturization
- Select width, volume, height
What are complications of TE?
EARLY
- PTX
- hematoma, seroma
- infection
- wound dehiscence
- discomfort post expansion
LATE
- CC
- extrusion
- chest wall deformity
- TE failure - leakage/port inaccesible
- Malposition (high riding)
What are the goal sof using textured TE?
- tissue ingrowth
- inhibits migration of expander
- peri-prosthetic pocket forms
Describe 2 stage TE
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
What are becker implants and the advantage//disadvantage
- Becker implants are permanent expander
- Available in Becker 25 (25% silicone outer shell) or becker 50 (50% silicone outer shell)
*
What are the indications for Autogenous recon
- Hx of irradiation
- Refusal for use of alloplastic implants
Wht are contraindications of autogenous recon
- refusal of donor site scar/morbidity
- Medically unfit to undergo long surgery
What are the advantages and disadvantages of autogenous recon
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
Describe the vascular supply to the abdominal wall
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
Describe the vascular supply to the Umbilicus
4 sources
- R and L DIEA perforators
- Subdermal plexus
- Ligamentum terres hepaticus (umbilical vein remnant)
- Medial umbilical ligament (umbilical artery remnant)
What is the source and course of the superior epigastric artery
- Source - IMA
- Size: 2mm diamter, 5cm length
- Course: deep to rectus muscle, along medial mid 1/3 of muscle
What is the source and course of the DIEA and its perforators
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
What is the innervation to the rectus muscle and the sensory innervation and the course of the nerves
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
Describe the anatomy of the abdominal wall musculature and arcuate line
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
WHat are 3 patterns of DIEA branching (Moon&taylor)
- 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
What is the blood supply to the skin flap of the pedicled TRAM flap?
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
Describe the vascular zones of the TRAM flap and the difference between the Hartramf and Ninkovic
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
Describe the dimensions of the pedicled Tram flap and expected skin flap expected to be harvested with a single and double pedicled TRAM
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)
What are the advatnages and disadvantages of a pedicled TRAM for breast recon
ADVANTAGES
- Simultaneous abdominoplasty
- acceptable donor scar
- shorter OR, LOS
- versatile, natural, permanent
DISADVANTAGES
- donor site morbidity (hernia/bulge)
- long recovery/RTW
What are the indiciations for a pedicled TRAM
- habitus
- refusal for alloplastic materials
- unable to tolerate long OR
What are complications of a TRAM flap reconstruction
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
What are indications for a bipedicled TRAM
- reconstruction requiring more volums than provided by a single pedicled TRAM
- midline vertical lower abdoinal scar
What are the advantages and disadvantages of a bipedicled vs unipedicled TRAM
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
What are ways of modifying the conventional TRAM flap for improved perfusion
- 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
Describe elevation of pedicled TRAM
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
What is the vascular supply to the MC flap of the lat dorsi
MN5
dominant - Td - length8-10cm, 2.5mm diameter
Segmental - Intercostal perforators Thoracic T6-12 and lumbar
What is the orgin, insertion, function, innervation to lat dorsi
Origin: thoracolumbar fascia, iliac creast, T6-T12 spinous processes
Insertion: bicipital groove of humerus
Innervation: thoracodorsal nerve (posterior cord)
Function: Internal rotation, adduction
What are the advantages and disadvantages, indications for lat dorsi
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
What is the thoracoepigastric flap
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
How do you classify free TRAM flap
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)
WHat are indicaitions and contraindications for a free tram flap
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
What are advantages of free tram and disadvantages
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
Compare the fat necrosis, flap loss and hernia/bulge rates between SIEA, DIEP, free tram, pedicled Tram
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%
What is the DCIA Reubens flap
MN1 - deep circumflex iliac artery with small cuff of EO, IO, transversus
What are gluteal free flaps for breast reconstruction?
- Superior gluteal myocutaneous flap (SGM)
- Inferior gluteal myocutaneous flap (IGM)
- Superior gluteal artery perforator (SGAP)
- Inferior gluteal artery perforator (IGAP)
What is the origin insertion,function, vascular suply and innervation of the gluteus muscle
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
How do you landmark and elevate the superior gluteal muscle flap (SGM)
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
What are indications, advantage, disadvantage of SGM flp
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
Describe landmark and elevation of IGM flap
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
What is the lateral tranverse thigh flap
MN1 - based on TFL, ascending branch of lateral circumflex femoral artery
LANDMARKS
- 10cm below ASIS, pedicle enters deep surface of TFL
What is the trasnverse upper gracilis flap
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
DIEP vs free tram
2x fat necrosis
2x flap loss and thrombosis
1-2x abdominal bulge
What are indications, contraindications for DIEP
INDICATION
- <70% of tram tissue required
CONTRAINDICATION
- intraop unable to identify suitable perforator
Adv
- no muscle harvest, shorter recovery
Diadv
- tehcnically difficult
What is a SIEA flap, landmarks, elevation
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
How do you decide between SIEA, DIEP, TRAM free flaps
if <50% abdomen required, SIEA
50% required DIEP
>70% required TRAM
What are landamrks, elevation of flap for SGAP
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
What are landmarks, elevation of flap for IGAP
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
What is difference between igap and sgap
- igap longer pedicle
- donor site hidden in crease
- potential for neurosensory flap
What exits greater sciatic foramen below piriformiis
- IGA/V
- sciatic n
- intenal pudendal art
- PCFN
What factors influence managemetn of oppsoite breast
- Oncologic
- Expectations/desires
- Aesthtic
What are options for contralat breast
- reduction
- augmentation
- mastpexy
- augentation mastopexy
- PM
- no alteration
note - only have one chance to recon oppost ebreast w abdo flap
What are revisions to reconstructed breast
- liposuction
- lipofill
- direct excision
- IMF repositioning
- scar revision
Why are lower revision rates associated wa autolgous recon
- superior aesthetic result
- long lasting acceptable result
How do you manage flap necrosis in ealry postop periord?
- 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
What is option for Nipple recon
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
