Breast Reconstruction Surgery Flashcards
A 41-year-old female patient is undergoing a mastectomy and immediate autologous breast reconstruction surgery for a localised malignancy. She is a smoker and has a body mass index of 35, but is otherwise fit and well with no known allergies.
What are the benefits of using the patient’s own tissues for reconstruction compared to implants?
- Fewer long-term complications.
- Fewer procedures overall despite a longer initial operation.
- Enhanced aesthetics and higher patient satisfaction.
What are the different types of autologous flaps?
- Pedicled: The flap remains attached to the patient during the procedure via a pedicle and is manipulated into the correct position to be used for reconstruction e.g. latissimus dorsi flap.
- Free: The flap is removed from one part of the body and reattached at a different site.
What is the benefit of a DIEP flap over a TRAM flap?
- A deep inferior epigastric perforator (DIEP) flap allows sparing of the rectus abdominis muscles, which means:
- A decrease in the incidence of postoperative hernias.
- Preservation of the patient’s abdominal strength.
- DIEP flaps are therefore preferred over TRAM faps.
What are the risk factors for flap failure in this patient?
- Smoking: Cessation should be encouraged preoperatively due to the physiological effects of nicotine and carbon monoxide leading to decreased, poorly oxygenated blood flow to the flap.
- Raised BMI: Weight loss should be advised preoperatively to decrease the risk of postoperative complications and fap failure.
What are the anaesthetic goals for this procedure?
The anaesthetic goals are based on maintaining excellent blood flow to the flap during the perioperative period, which can be targeted according to the Hagen- Poiseuille equation.
- Maintenance of normothermia through adequate patient warming and core temperature monitoring.
- Ensure normovolaemia.
- Preservation of high cardiac output with low-normal systemic vascular resistance.
- Administer adequate analgesia to decrease the stress response to surgery.
- Ensure a plasma haematocrit of 30%–35% for optimal blood flow to fap.
What monitoring would you like for this patient during the perioperative period?
During induction and maintenance:
* Full minimum AAGBI monitoring.
- Core temperature monitoring.
- Invasive blood pressure monitoring.
- Urinary catheter to monitor urine output.
- Cardiac output monitoring.
- Depth of anaesthesia monitoring.
Postoperatively:
* AAGBI monitoring in PACU until awake and stable.
- Flap monitoring: colour, capillary refill, skin turgor, temperature, bleeding on pinprick and Doppler signal.
What is your plan for postoperative analgesia in this patient?
- Simple analgesia: regular paracetamol and ibuprofen.
- Opioid-based analgesia: oral morphine or morphine/fentanyl PCA if
required. - Regional anaesthesia: transversus abdominis plane block/catheter.
The surgeon asks for methylene blue dye to be injected. A few minutes later you notice a rash on the patient’s chest. Her heart rate is 118 and her blood pressure is now 74/34.
How do you proceed?
- Alert the theatre team immediately.
- Call for urgent senior help.
- Carry out a rapid assessment of the patient and management
according to the anaphylaxis algorithm: - Apply 100% oxygen.
- Stop injection of the dye if ongoing.
- Elevate the patient’s legs.
- Administer a bolus of adrenaline: 50 μg intravenously with a 250 mL crystalloid fluid bolus. This can be repeated as appropriate, but an infusion should be considered after three boluses.
- Administer chlorphenamine (10 mg) and hydrocortisone (200 mg) intravenously when the patient is stable.
- Continuous reassessment and escalation to advanced life support algorithm if the patient deteriorates further. CPR should be commenced if a cardiac arrest occurs or if the systolic blood pressure decreases to less than 50 mmHg.
