CHAPTER 14: BREAST RECONSTRUCTION Flashcards
Describe the anatomy of the breast
Boundaries
- 2nd - 6th rib
- sternal edge
- mid axillary line
- deep superomedial = pec fascia, inferolateral = serratus fascia
- axillary tail of Spence
- 10-100 acini -> lobule -> lobe -> lactiferous duct -> nipple
- lobes separated by fibrous septae, upper breast = suspensory ligaments of Astley Cooper
- Montgomery’s tubercles = sebaceous glands under areolar
NAC
- 4TH ics
- sebaceous glands
- montgomery glands
- tubercles of Morgagni (elevations of gland openings)
- radial smooth muscle fibres (erection)
What is the blood supply to the breast?
Similar to blood supply to pec major
- IMA perforators
- lat thoracic
- pectoral branches of thoracoacromial axis
- anterolateral and medial intercostal perforators
What is the lymphatic drainage of the breast?
lateral -> axilla and infraclavicular
medial -> intercostal spaces to int thoracic parasternal nodes (3-20%)
cxns b/t med & lat
What is the nerve supply to the breast?
2nd - 6th intercostals
Nipple - 4th intercostal med & lat branches
Overlying skin - cutaneous branches T4-6, lat cutaneous
Lactation - hormonal
Describe the stages of breast development
Embryology - breast develops in 4th week as downgrowth from a thickened mammary ridge of ectoderm (milk line) from axilla to inguinal region
Tanner’s stages of pubertal breast dvlpmt
1 - prepubertal
5 - adult
Describe the surface anatomy of the breast
Penn - described the ideal breast measurements
Sternal -> nipple & nipple -> = 21cm
Nipple -> IMF = 6.8cm
NAC = 3.8 - 4.5cm
How is bra cup size measured?
Measure circumference of chest at IMF & maximal projection MP - IMF = INCHES 0 = AA 1" = A 2" = B
Breast cancer epidemiology
30,000 new cases / yr in UK, 50% req mastectomy
~ 7500 breast recons / yr
50% under 65, 50% of these req mastectomy
2nd most common cancer after skin in women
1 in 8 lifetime risk (12%)
1 in 9 women who live to 85
Breast = 25% of general surgery referrals
90% breast clinic referrals are d/c
What is the aetiology of breast cancer?
multifactorial, exo and endogenous factors
- gender (99% women)
- age
- Fhx (no. and proximity), their menstrual status, age of diagnosis, bilat cancer
- linked w early menarche, late menopause, late 1st pregnancy
- premalignant histology
- unilat ca -> inc risk of contralateral ca
How is breast cancer classified histologically?
DUCTAL - derive from ductal element (majority)
NON-DUCTAL - derive from epithelium of breast lobules
Non-invasive and invasive (WHO)
malignant transformation process
NORMAL -> HYPERPLASIA ->ATYPICAL HYPERPLASIA -> DCIS -> INVASIVE CA -> takes 10-20yrs
80% adenocarcinoma (males?)
risk of mets increases with no. of +ve nodes, to lung, liver, bone
What types of ductal ca’s are there?
What types of non-ductal ca’s are there?
DCIS (intraductal ca - still in bm of ducts)
- subtypes - comedo, non-comedo
- 10% bilat, 20% multicentric, 30%->invasive
- mammogram - microcalcification
Invasive ductal
- 75% of all breast ca
- adenoca of ductal elements
- grey gritty spiculated hard
LCIS
- no mammogram changes, marker of invasive disease, not precursor (1% -> invasive)
- usu incidental finding
- 40% bilateral, 60% multifocal
Invasive lobular
- 5-10% invasive ca
- extensively infiltrative /o distinct mass
- no microcalcification
- sim prognosis to inv ductal
What are the special types of breast ca?
Medullary ca
- 6% of invasive ca
- soft fleshy well circumscribed
- good prognosis even w mets
Tubular ca
- 2%, = well diff adenoca
- well diff, good prog
Mucinous / Colloid
- < 5%
- soft gel mass
- well diff, excellent prog
Phyllodes
- mixed CT and epithelial tumour
90% 5yr survival, depends on grade and size of tumour
What are the breast cancer genes?
4-5% of all breast ca’s are inherited
AD with high penetrance
>25% of cases under 30y.o. = genetic
> 4 cases under 60 in family = likely genetic
BRCA1 lifetime risk of breast ca = 85%
50% BRCA1 carriers with ca treated by lumpectomy and DXT will develop recurrence / 2nd ca
BRCA 65% risk of ovarian ca by 70
Histo - usu grade 3, ER-ve, medullary type, early onset, bilat
TP53 assoc w sarcoma
BRCA 2 less
Ashkenazi Jews - 2% have BRCA 1/2 mutn
Carriers offered
(a) SSM and recon (risk reducing mastectomy)
- only 90% effective in reducing risk of ca
(b) annual screening
(c) prophylactic tamoxifen - usu not helpful as most are ER-ve
How is a breast lump assessed?
Risk assessment - age, FHx, endogenous oestrogen
Triple assessment - clinical exam, radiology, pathology
MDT discussion
UK Breast screening
- women b/t 50-70, gradually 47-73 (2016)
- identifies 6/1000 screened
- MRI better for premenopausal women, BRCA pts
USS (for solid vs cystic) - High res USS can identify some cancers and for DXT chemo response
- MRI for implant imaging
- linguine sign (implant pulled away from capsule, leaving multiple parallel lines = stepladder sign)
- snowstorm appearance
- Eklund mammogram views for breast implants
What is the role of mammograms?
- part of NHSBSP
- women every 2-3yrs
- US every yr above 40
- signs - microcalcifcation, density changes, asymmetry , architectural distortion
- Swedish trials - decreased 44% mortality w reg mammogram
- BC f/u - annual mammogram
Staging of breast cancer
TNM Staging & 5yr survival (%) I : <2cm T1 (85%) II : mobile axillary nodes N1 (65%) IIIa : fixed axillary nodes N2 (40%) IIIb : chest wall / skin involvement T4 or int mammary nodes N3 (25%) IV : distant mets M1 (10%)
Stage I Early good prog II good prog III locally advanced, poor inflammatory BC (III)
TNM staging, Nottingham Prognostic Index
What are the goals of treatment?
- optiimise local control
- accurate staging
- longterm survival
- preserve / restore body form
When is breast conservation surgery considered?
Name a trial supporting this.
stage 1-2 disease
contraindicated - multiple lesions, diffuse microcalcification
relative contra - small breast + large ca, radiation induced, ongoing pregnancy
NSABP B06 trial
no diff in survival b/t total mastectomy vs lumpectomy vs lumpectomy and DXT
Current Rx - lumpectomy with -ve margins, DXT, ANS / clearance
BCS - quadrantectomy. How do you reconstruct?
usu for T2 tumours
circumareolar orientated mobilisation of breast mound and direct closure of overlying skin
thoraco-epigastic flaps for skin following lower quadrant resection
axillary tail transposition flap for upper outer quadrant
wise pattern reduction
symmetrisizing contralateral breast
What is the follow-up for breast ca?
Postop 3mths (check arm mobility)
6mthly 2yrs
annual 4yrs +/- d/c 6yrs
Classify the different types of mastectomy
- subcutaneous (NAC preserved)
- skin sparing (NAC excised)
- preserves native breast skin & IMF
- indications: prophylaxis, DCIS,stage 1-2 invasive ca, phyllodes, immediate recon - simple (total)
- stage 3-4
- remove entire breast, NAC and skin overlying tumour - modified radical
- simple mast + ax level 1&2 clearance - risk reducing
What are the indications of risk reducing mastectomy?
Hi risk women (>25% lifetime risk) BRCA 1,2 gene mutation carriers - contralateral RRM (depends on histo) - 2 relatives, 1 <60 - 90% risk reduction - upper outer quadrant - highest risk of recurrence
What is management of the axilla in breast ca?
ax LN clearance / sampling
DXT if +ve nodes
prognosis= 90% 5yr with -ve nodes, 60% 1 +ve LN
sentinel LNB
25% clinically normal LN have micromets
Level of dissection - I,II,III (pec minor)
What is the treatment for DCIS?
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
What systemic therapies are there for breast ca?
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
What is the role of neo-adjuvant therapy?
neo-adjuvant chemo may downstage tumour size, and allow BCS, but no survival advantage
DXT usu postop
How does radiotherapy work?
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
What are the side effects of DXT?
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
What and how do breast cancer drugs work?
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
How do you classify breast reconstruction?
immediate vs delayed oncoplastic expander implant flap and expander implant flap only
What are the principles of breast reconstruction?
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
What are the principles of breast conservation surgery & oncoplastics?
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
What are the principles of expander implant recon?
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
What is a Becker expander implant?
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
Expander and flap recon - pros and cons
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
How do you classify flap only breast recon?
Pedicled vs free
Pedicled TRAM
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
Free TRAM
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
Who described the zones of a TRAM flap?
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
DIEP flap
most perforators around umbo
lat perforators dominant - 55%
med 18%
single medial row 27%
Who described IMA & V for free flap breast recon?
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
What paper looked at abdo scars and TRAM flaps?
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
Who described DIEP flap
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%
What paper advocates preop angio for DIEP flap?
Masia JPRAS
What is the risk of hernia in DIEP and TRAM?
Free TRAM 16%hernia, 14%bulge PRS 2008 Ganem
DIEP <1%, 9%
S-GAP flap
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
I-GAP flap
- adv: scar in crease, larger than SGAP
- perforators on both sides of sciatic n
pedicle 8cm - dissect from greater trochanter then medially
Rubens flap
Hartrampf 1991 (based on Iliac crest flap (Taylors) deep circumflex iliac vessels long consistent pedicle need to carefully repair muscles of donor site
Lateral transverse thigh flap
TFL muscle on lat circumflex femoral
donor contour defect
Superficial inferior epigastric flap
Arnez
vessels are v small
quick to raise but longer micro
artery present in 10%?
TMG / TUG flap recon
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
Fat injection
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)
Anatomy of the nipple
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
What are the goals of nipple recon
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
Describe the different ways of nipple recon
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!
Name some local flap nipple recons
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)
Other autologous / allogenic nipple recon
cartilage (rib), n=bone, silicone (tends to extrude)
Nipple recon
Draw
CV flap
Skate
Stick on
Tattoo only
Autologous
What are the common indications for skin sparing mastectomy?
- 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
What is the treatment algorithm for breast recon?
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
What are the pros and cons of immediate and delayed breast recon
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
What was the NICE guidelines for ‘Improving breast cancer care’
- 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.
What is the National Mastectomy and Breast Reconstruction Audit?
- 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.
National Breast Mastectomy and Reconstruction Audit
2008
2009
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
NBMRA
2010
2011
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
