Breast Reconstruction

Question 1

What features should you look for on examination of a breast reconstruction?

Answer 1

Evidence of flap reconstruction:

• Recess in rectus muscle: Ask patient to lift head off bed when lying supine
• Scars: Extending over back or abdominal wall
• Recess on back- lat dorsi removal

Evidence of implant reconstruction:

• Rounder shape, may be higher
• May have palpable sc port in axilla if Becker implant

Question 2

What are the advantages of using implants for breast reconstruction?

Answer 2

• Simpler technique
• Can be primary (same op as mastectomy) or delayed

Question 3

What are the disadvantages of using implants for breast reconstruction?

Answer 3

• Cosmetic result not as good- lies higher than other breast
• Requires plenty of available skin
• Late complications:
  
  • Capsular contracture
  • Implant leakage
  • Infection requiring removal

Question 4

What are the advantages of using myocutaneous flaps for breast reconstruction?

Answer 4

• Can be used if little remaining skin or muscle
• Good cosmetic result
• Can be primary (with mastectomy op) or delayed

Question 5

What are the disadvantages of using myocutaneous flaps for breast reconstruction?

Answer 5

• Increased blood loss
• Increased operation time and complications
• Cannot use rectus muscle if patient has had abdominal surgery
• Late complications:
  
  • Flap necrosis and infection

Question 6

What are the types of myocutaneous flaps?

Answer 6

1. Latissimus Dorsi myocutaneous flap
2. Transverse Rectus Abdominis Myocutaneous (TRAM) Flap
3. Deep Inferior Epigastric Perforator (DIEP) Flap

Question 7

What is pedicled in a latissimus dorsi myocutaneous flap?

Answer 7

Skin, fat, muscle and blood supply:

• Supplied by: Thoracodorsal artery via the subscapular artery

Question 8

What is done in a latissimus dorsi myocutaneous flap reconstruction?

Answer 8

• Lat dorsi mobilised and tunnelled medially –> neo breast
• Often augmented with an implant

Question 9

What is pedicled in a TRAM (Transverse Rectus Abdominis Myocutaneous) Flap?

Answer 9

Inferior epigastric artery (may be free and attached to internal thoracic artery)

Question 10

When is a Transverse Rectus Abdominis Myocutaneous Flap CI?

Answer 10

• Poor circulation
• Smokers
• Obese
• PVD
• DM

Question 11

What are the benefits of a Transverse Rectus Abdominis Myocutaneous Flap reconstruction?

Answer 11

• No implant necessary
• Combines with a “tummy tuck”

Question 12

What are the disadvantages of a Transverse Rectus Abdominis Myocutaneous Flap reconstruction?

Answer 12

Risk of abdominal hernia

Question 13

What is a Deep Inferior Epigastric Perforator (DIEP) Flap?

Answer 13

Evolution of a TRAM flap- spares rectus –> reduced pain and risk of herniation

Question 14

When might a Deep Inferior Epigastric Perforator Flap not be possible?

Answer 14

If small perforators

Question 15

What type of breast reconstruction has this patient has (this may be an unfair question)

Answer 15

Latissimus Dorsi Myocutaneous Flap- look on back for scars

Question 16

What type of breast reconstruction has this patient had?

Answer 16

Latissimus dorsi myocutaneous flap

Question 17

What type of breast reconstruction has this patient had?

Answer 17

TRAM Flap

NB: Would differentiate from a DIEP on asking the patient to raise their head off the bed?