1. AESTHETIC & RECONSTRUCTIVE BREAST SURGERY DR. LAXMI KANTA MISHRA M.S.,M.Ch (Plastic Surgery) Consultant, Plastic surgery Apollo Hospital, Bhubaneswar

2. BREAST EMBRYOLOGY From the linear ectodermal ridge or mammary ridge, which extends from the axilla to the groin. Milk line appears at 6 th week of fetal development and may develop varying degrees of breast & nipple development at any point of the mammary ridge. 16 th week, 20 ingrowths radially into the breast. 28 th week, the acini develops into the terminal tips of the lactiferous system.

3. ANATOMY A. Position and Attachment 1. Lateral aspect of pectoral region 2. Located between ribs 3 and 6/7 3. Extend form sternum to axilla 4. Surrounded by superficial fascia 5. Rest on deep fascia 6. Fixed to skin & underlying fascia by fibrous C.T. bands a. Cooper’s (Suspensory) ligaments b. Ligaments may retract when breast tumors are present 7. Left breast is usually slightly larger 8. Base is circular, either flattened or concave 9. Separated from pectoralis major muscle by fascia, retro mammary space

4. ANATOMY B. Structure 1. Outer surface convex, skin covered 2. Nipple: a. At fourth intercostal space b. Small conical/cylindrical prominence below center c. Surrounded by areola: pigmented ring of skin d. Thin skinned region lacking hair, sweat glands e. Contains areolar glands 3. Areola: contains dark pigment that intensifies with pregnancy a. Circular and radial smooth muscle fibers b. Cause nipple erection

5. CONT.. 4. Each breast consists of ~ 20 lobes of secretory tissue a. Each lobe has one lactiferous duct b. Lobes (and ducts) arranged radially c. Embedded in connective tissue & adipose of superficial fascia d. Lobes composed of lobules e. Lobules comprise alveoli 5. Excretory (lactiferous) ducts converge toward areola a. Form ampullae (collection sites of lactiferous sinuses) b. Ducts become contracted at base of nipple

6. CONT.. 8. Fatty Tissue: surrounds surface, fills spaces between lobes a. Determines form & size of breast b. No fatty deposit under nipple & areola

7. Breast: Fatty Tissue

8. Retromammary Space

9. Arterial Supply to the Breast

10. –Arteries: derived from thoracic branches of three pairs of arteries a. Axillary arteries 1) continuous with subclavian a. 2) gives rise to external mammary ( = lateral thoracic) artery

11. (b) Internal mammary (thoracic) arteries 1) first descending branch of subclavian artery 2) supply intercostal spaces & breast 3) used for coronary bypass surgery (c) Intercostal arteries: 1) numerous branches from internal & external mammary arteries 2) supply intercostal spaces & breast

12. AUGMENTATION MAMMOPLASTY

13. INDICATION To enhance the body contour of a woman who, for personal reasons, feels her breast size is too small. To restore breast volume lost due to weight loss or following pregnancy To achieve better symmetry when breasts are moderately disproportionate in size and shape To improve the shape of breasts that are sagging or have lost firmness, often used with a breast lift procedure To provide the foundation of a breast contour when a breast has been removed or disfigured by surgery to treat breast cancer To improve breast appearance or create the appearance of a breast that is missing or disfigured due to trauma, heredity, or congenital abnormalities

14. Enhance the appearance and self confidence. Even breast feeding can be done normally later.

15. TYPES OF IMPLANT SALINE SILICON SMOOTH TEXTURED

16. BLOOD TESTS MAMMOGRAPHY ULTRASONOGRAPHY

17. PRE SURGICAL EVALUATION EXPECTATION / DESIRE OE THE PATIENT. CHEST SIZE. AMOUNT OF EXISTING BREAST TISSUE. SKIN ENVELOPE OF THE BREAST. ANY DROOPING OF THE BREAST.

18. INCISION INFRA MAMMARY APPROACH. CIRCUM AREOLAR. TRANS AXILLARY. TRANS UMIBLICAL.

19. PROCEDURE SUB GLANDULAR SUB MUSCULAR DUAL PLANE

20. PLACEMENT OF EXPANDER SCHEMATIC DIAGRAM OF BREAST IMPLANT BOTH ABOVE AND BELOW THE PECTORAL MUSCLE

21. PRE- OP POST-OP

22. PREOPERATIVE POSTOPERATIVE

23. BEFORE AFTER

24. BREAST REDUCTION Surgical reduction of the breast volume to achieve a smaller. Aestheticlly shaped breast mound Relief of the potential symptoms of mammary hypertrophy. Reduce the individual risk of breast cancer.

25. OPERATIVE TECHNIQUES IN BREAST REDUCTION Early horizontal and combined scar techniques Wise pattern Short scar techniques Liposuction assisted reduction

26. SCHEMATIC DIAGRAM INFERIOR PEDICLE TECHINQUE

27. Small to moderate reductions –( 150 – 500gm per side) Major reductions –( 500- 1500 gm per side) Massive reductions –(more than 1500 gm per side)

28. REDUCTION MAMMOPLASTY FRONT VIEW

30. REDUCTION MAMMOPLASTY LATERAL VIEW

32. REDUCTION MAMMOPLASTY

37. REDUCTION MAMMOPLASTY AFTER LIPOSUCTION PROCEDURE

38. COMPLICATIONS Hematomas and seromas Infection Skin necrosis Fat necrosis Nipple loss Nipple numbness Hypertrophic scar Asymmetry Boxy breast deformity Intramammary scarring Inability to breast- feed

39. ASYMMETRY

43. Silicon Breast Implant Vol-222cc,size-11x3.5,

44. Inferior Mammary Incision

50. GOAL To follow the principles of oncological management Psychological & esthetical expectation Symmetry

51. PREOPERATIVE PLANNING Timing Thorough discussion with onco surgeon (a) mastectomy incision (b) preservation of skin and pectoral fascia Discussion with the patient Assessment of opposite breast Symmetry

52. TIMING Immediate - Experienced Team Needed Delayed - most frequently accepted (3to 9 months of post mastectomy)

53. INDICATIONS FOR THE DELAYED BREAST RECONSTRUCTION Patient’s preference Onco surgeon’s preference Postoperative radiation therapy Medical unfit Not psychological ready Doubt about viability of mastectomy skin flaps

54. METHODS Reconstruction with available tissue Tissue expansion Latissimus Dorsi Flap TRAM Flap Gluteus Maximus Flap

55. INDICATIONS Skin Deficiency after mastectomy (Dimensions in Both Horizontal and Vertical) <4 cm 4 to 8 cm 8 to 18 cm > 18 cm Tissue expander +/- Breast Implant Available tissue and placement of silicon breast implant beneath the musculofascial layer LD flap with or without implant TRAM Flap & Microvascular transfer of Gluteus maximus muscle

56. SILICON BREAST IMPLANT ADVANTAGE Provides donor tissue of similar texture, color, and sensation Minimal scar formation Avoidance of problematic donor sites Decreased operating and recovery time Technically easy procedure to perform

57. SILICON BREAST IMPLANT DISADVANTAGE Capsular contracture Lack of natural ptosis Poorly defined inframammary fold Implant deflation Implant extrusion Poor in irradiated area Cost of implants

59. TISSUE EXPANDER/IMPLANT RECONSTRUCTION INDICATION Small to medium sized breast Pt not obese & chest wall not irradiated Medical C/I for large operations Pt objects to scar associated with flaps

60. TISSUE EXPANDER/IMPLANT RECONSTRUCTION CONTRAINDICATIONS Atrophic and tight skin with poor muscle Skin flaps of questionable viability Obese patients Chest wall irradiation

62. L D Flap for reconstruction INDICATIONS Quadrantectomy defects Modified radical mastectomy defects TRAM Flap failures Autogenous conversion of implant reconstruction Radiation ulceration

63. L D Flap for Reconstruction C/I MRM with axillary clearance

68. TRAM Flap INDICATION MRM with large defect Defect with tight, thin chest wall skin, failed previous reconstruction, irradiation to chest wall & large ptotic opposite breast Halstead Radical mastectomy

69. TRAM Flap C/I Chronic pulmonary disease Severe cardiovascular disease Uncontrolled hypertension Morbid obesity IDDM

73. TRAM FLAP

80. Free flap breast reconstruction Free TRAM flap Free DIEP flap (Deep Inferior Epigastric Perforator flap) or the free SIEA (Superficial Inferior Epigastric Artery flap) Free perforator flapsFree DIEP flap (Deep Inferior Epigastric Perforator flap) or the free SIEA (Superficial Inferior Epigastric Artery flap) Flaps taken from the abdomen Flaps taken from the buttock

81. SkinBulkContourDonor Appeara nce Reliabilit y Technic al Ease Free Tram+++++++++++++++++++ Predicled Tram+++++++++++++++ Latissimu s+++++++++++++ Gluteus++++++++++++++++++ DCIA++++++++++++++++ TFL++++++++++++ + = Poor ++ = Average +++ = Good ++++ = Excellent

82. Nipple Reconstruction Keeping the nipple Nipple reconstruction Techniques used Nipple tattooing Nipple prosthesis