CHAPTER 14: BREAST RECONSTRUCTION Flashcards

Question

What is the treatment for DCIS?

Answer 1

``` local recurrence - after surgical excision only ~ 30% (50% will become invasive) NHSBP B17 (Fisher 1993) - lump only 16% local recurrence - lump + DXT 7% extensive DCIS => SSM ```

Answer 2

increase disease free survival in premeno CMF C, methotrexate, 5FU FAC - 5FU, A, C AC - doxorubicin, cyclophosphamide Receptors ER/PR TAMOXIFEN / LETROZOLE (postmeno) HER2 (Human epidermal growth factor 2) HERCEPTIN triple -ve

Answer 3

neo-adjuvant chemo may downstage tumour size, and allow BCS, but no survival advantage DXT usu postop

Answer 4

High energy X rays damage tumour cells, whilst normal cells recover b/t cycles eradicate remaining ca cells and reduce local recurrence uses - following lumpectomy - following mastectomy - following ALND (NOT clearance - inc lymph oedema) - neoadjuvant

Answer 5

Common - skin rxns: red, hyperpigment, tender, itch, blister - aches, shooting pain - tired Uncommon - lung tissue inflammation (dry cough, SOB) - dec appetite, nausea - axillary hardening, fibrosis, lymphoedema Rare - fibrosis, decrease breast size, telangectasia, fracture, parasthesia

Answer 6

``` Oestrogen receptor antagonists aromatase inhibitors (Arimidex, Femara) - blocks androgen to estrogen conversion - should NOT be used premeno (doesnt inhibit ovarian estrogen synthesis gonadorelin analogues (Zoladex - goserelin) cytotoxic chemo trastuzumab (Herceptin) Progestogens Retinoids ```

Answer 7

``` immediate vs delayed oncoplastic expander implant flap and expander implant flap only ```

Answer 8

choice based on - patient - cancer and adjuvant Rx (DXT) - contralateral breast size - availability of autologous tissue Questions to ask - does pt want good match only in bra or in & out of bra? - match contralateral breast to recon or recon to c/l breast? - does c/l breast need symmetrisation? if pt doesn't want c/l breast op, abdo flap can create any shape / ptosis

Answer 9

better sited scars primary recon of defects - e.g. SSM and immediate recon, or BBR & mastopexy techniques to resect tumour (BCS) BCS lower pole - superior pedicle Wise medial - dermoglandular flap of lat breast tissue with Wise incision central upper - upside down keyhole Therapeutic mammaplasty (McCulley, Nottingham) - use mammoplasty techniques post WLE to avoid contour defects - can use more than 1 pedicle

Answer 10

suitable for reconstructing small non-irradiated breasts chest wall DXT increases capsular contracture, skin less pliable and doesn't expand, increased risk of wound dehiscence tissue expander - round if small, anatomical for more projection if larger - subpectoral +/- ADM lower pole - base at or lower than contralateral IMF - avoid making pocket too high - overexpand, to create ptosis

Answer 11

it consists of an outer layer of low-bleed silicone gel (25=25% gel, 50=50%), with inner cavity for saline expansion. smooth or textured - expansion through remote port, which may be removed or expander may be replaced for permanent impact

Answer 12

indication - if implant only or autologous not suitable Pros - easy, reliable, well vascularised tissue (post DXT) low complications Cons - still requires implant, donor scar poor Can do extended LD for more volume

Answer 13

Pedicled vs free

Answer 14

Described by Holstrom 1979, then Hartrampf 1982 (transverse abdo island flap pedicle = superior epigastrics can be supercharged (IMA, thoracodorsal) turbocharge - link R & L DIEP art and vein fat necrosis 7-16% endoscopic delay - ligate DIEA

Answer 15

``` IMA thoracodorsal (end to end circumflex scapular or thoracodorsal above serratus branch to preserve LD (retrograde flow from intercostal supply to serratus) ``` contraindicated - midline scar, liposuction, prev abdominoplasty

Answer 16

``` Hartrampf I ipsilateral medial II contralateral medial III ipsilateral lateral IV contralateral lateral ``` ``` Holme (2006) - true zones I ipsilateral medial II ipsilateral lateral III contralateral medial IV contralateral lateral ```

Answer 17

most perforators around umbo lat perforators dominant - 55% med 18% single medial row 27%

Answer 18

Ninkovic 1995 Arnez BJPS 1995 shorter pedicle needed remove 3rd / 4th costal cartilage >80% TRAMS ipsilateral advantages cf thoracodorsal - spares LD, better positioning, zone IV lateral not medial, avoids lymphoedema risk disadvantages - iatrogenic pneumothorax, resp mvmts during anastomosis

Answer 19

Takeishi PRS 1997 Pfannenstiel - investigate (may or may not be divided) lower paramedian - vessels divided lower midline - design flap higher (means transverse abdo scar postop) subcostal - free flap ok based on inf epigastric appendix

Answer 20

Bob Allen 1994 abdo skin and sc tissues based on 1-2 perforators from DIEA intermuscular dissection, DIEA passed through muscle split preserve horizontal nerve flaps can be made sensate must discard zone IV Blondeel 1999 100 free DIEPs no need to go down to ext iliac if IMA/V raise pedicle side 1st, leave other as lifeboat ipsilat ->IMV, contralat -> thoracodorsal vac anatomy - lat br of DIEP connected to perfs = 50% - med & lat branches equal = 15% - 1 common vessel - 30% ``` open up fascia widely 99% success 7% fat necrosis <1% donor bulging turbocharge with SIEV in 8% ```

Answer 21

Masia JPRAS

Answer 22

Free TRAM 16%hernia, 14%bulge PRS 2008 Ganem | DIEP <1%, 9%

Answer 23

Bob Allen 1995 dissect perforator through gluteus maximus to sup gluteal artery skin 29x3cm 5-8cm pedicle can make sensate with dorsal br of lumbar segmental to 4th intercostal adv - if DIEP not possible single perforator, hidden scar, no loss of function, sciatic nerve covered by muscle disadv - fat firmer, scar unsightly, short perforator

Answer 24

- adv: scar in crease, larger than SGAP - perforators on both sides of sciatic n pedicle 8cm - dissect from greater trochanter then medially

Answer 25

``` Hartrampf 1991 (based on Iliac crest flap (Taylors) deep circumflex iliac vessels long consistent pedicle need to carefully repair muscles of donor site ```

Answer 26

TFL muscle on lat circumflex femoral | donor contour defect

Answer 27

Arnez vessels are v small quick to raise but longer micro artery present in 10%?

Answer 28

Transverse myocutaneous gracilis flap perforators in upper 1/3 up to 30cm long (add longus to inf gluteal fold, 10cm wide can be used for augmentation post bariatric, combined with thigh lift can turbo/supercharge using long saphenous

Answer 29

for adjustments massive vol / definitive recon controvery calcification may complicate imaging Cytori system - lipoaspirate mixed with stem cells (fat grafting on to expanders prior to definitive implant - fat graft programming. Calabresi and Urena)

Answer 30

nipple contains ductal cells therefore must be removed areolar is skin appendage & doesn't require resection unless within margins central on breast mound 35-45mm diameter at or just above IMF level

Answer 31

position, symmetry, colour, size, projection, ?sensitivity if marked asymmetry - place on pt of max projection ask pt to wear prosthesis / position ECG dot on day of surgery

Answer 32

``` Nipple graft (Adams 1944) nipple sharing (Millard 1972) - lower 1/2 or tip sutured into minimally de-epithelialised bed other composite grafts - ear lobe - toe pulp - papillomas! ```

Answer 33

dermal fat flap (Hartrampf and Culbertson 1984) skate flap (Little, Adv Plas Surg 1987) star flap Anton, Eskenazi and Hartrampf 1991) fish tail McCraw 1992 CV flap (Bostwick 1998) Bell flap (Eng 1996)

Answer 34

cartilage (rib), n=bone, silicone (tends to extrude)

Answer 35

Draw CV flap Skate Stick on Tattoo only Autologous

Answer 36

- prophylactic mastectomy - stage 1-2 invasive breast ca (although BCS and DXT is also adequate Rx) - DCIS - multicentric tumours - Phyllodes tumour - where immediate recon is planned

Answer 37

SMALL Expander implant LD with implant Extended LD MEDIUM Expander implant LD with implant free flap ``` LARGE free flap (bipedicled DIEP / TRAM) ``` Contralateral breast reduction

Answer 38

``` Immediate Pros - 1 main op - more aesthetic - less psychological trauma - cheaper ``` Delayed - loss of native skin envelope and IMF - requires dissection of previously operated / irradiated tissues

Answer 39

* all breast cancer patients should be managed by multi-disciplinary teams * breast reconstruction should be available at the initial surgical operation * breast cancer referrals should only be made to units which deal with at least 100 new cases per year * there should be regular network-level audits of service provision and the outcomes attained, including an assessment of patients’ and carers’ experiences.

Answer 40

- described provision of and access to breast reconstruction in England and Wales - evaluated current clinical practice in mastectomy and breast reconstruction - measured outcomes following mastectomy with or without reconstruction - assessed the quality of information provided to women undergoing mastectomy and their satisfaction with the reconstructive choices made.

Answer 41

Looked at primarily 18216 women 150 NHS hospitals, 114 independent 1 in 5pts immediate, 1 in 10 had delayed recon 2008 Although overall satisfaction rates of pts are high, there is inequity in availability of IBR, likely due to waiting list targets and providing op for BC pts within 31 days of diagnosis 2009 Pts for IBR increased from 11% 2005-2006 to 21% in 2008-2009 There was a wide variation b/t breast cancer networks, suggesting IBR is more widely available in some BCNs than others

Answer 42

2010 local complication - 10% mastectomy only (1 in 5 antibiotics) - 15-18% recon gp (1 in 4 had abx) Implant loss at 3 months following BR 9% of IBR patients 7% of DBR patients Unplanned return to theatre following BR 5% of IBR and 6% of DBR patients Free flap BR who had an unplanned return to theatre 13% of IBR and 11% of DBR patients Unplanned re-admission within 3 months 9% of mastectomy patients, 16% of IBR patients and 14% of DBR patients ``` 2011 Mastectomy only 83% satisfied with appearance clothed 42% unclothed 75% confident in social setting 10% pain in breast area 12% arm pain 41% satisfied with sex life ``` ``` Immediate, delayed breast recon 90 93 59 76 85 92 7 4 8 9 52 60 ```