1. Breast Reconstruction Jeffrey R. Scott, Ph.D.

2. Definition Breast Two milk-secreting, glandular organs on the chest of a woman; the human mammary gland.

3. Breast – Primary Function Breast Feeding a Newborn

4. Anatomy / Function – Breast Facts The Average Breast: Consists of 15-20 sections, called lobes, arranged in a petal shape Each lobe consists of many smaller lobules, which end in tiny bulbs that can produce milk. Lobes, lobules, and bulbs are linked by thin tubes (ducts) Ducts lead to the centralized nipple (in center of the areola) Adipose tissue fills the space between lobules and ducts

5. Anatomy – Breast (front view)

6. Anatomy – Breast (side view)

7. Definition Breast Reconstruction The rebuilding of a breast, which involves using autologous tissue or prosthetic materials to reconstruct a natural-looking breast. Often this includes the reformation of a natural-looking areola and nipple. The overall procedure involves the use of implants and/or relocated flaps of the patient's own tissue.

8. Definition Breast Augmentation Breast implant and/or fat-grafting mammoplasty procedures for correcting defects and/or enhancing the size, form, and feel of a woman’s breasts.

9. Definition Breast Cancer Cancer that forms in tissues of the breast, usually the ducts (tubes that carry milk to the nipple) and lobules (glands that make milk).

10. What is the scope of the problem? Scope Breast Cancer is the second leading cause of women, exceeded only by Lung Cancer. 1 in 8 women will be afflicted within their lifetime (12.5%). 1.3 Million New Cases are Diagnosed Annually Worldwide. Greater than 200,000 New Cases Diagnosed Annually in US. Responsible for 40,000 Deaths Annually in US Alone.

11. Types of Breast Cancer (severity)? 1. Non-invasive (in situ) - in which abnormal cancer cells remain within their place of origin, and have not spread to breast tissue around the duct or lobule. (i.e. DCIS – Ductal Carcinoma in situ (precancerous lesion), LCIS – lobular carcinoma in situ.

12. Types of Breast Cancer (severity)? 2. Invasive (metastatic) - in which abnormal cancer cells spread outside the membrane that lines a duct or lobule, invading the surrounding tissues. - cancer cells can then travel to other parts of the body, such as lymph nodes. - Typically graded as stage I, II, III or IV based on severity of invasive spread form origin.

13. Types of Breast Cancer (location)? 1. Ductal Carcinoma (most common) - in which abnormal cancer cells originate in the lining of the milk ducts. 2. Lobular Carcinoma - in which abnormal cancer cells originate in the lobules connected to the milk ducts. 3. Sarcoma (rare) (i.e. angiosarcoma) - in which abnormal cancer cells originate within the connective tissue (blood vessels, muscle, adipose)

14. Breast Cancer Staging: Size, Location, Spread Tumor Size

15. Breast Cancer Staging: Size, Location, Spread Stage I - The tumor is no more than 2 cm in diameter. - The cancer has not spread to the lymph nodes. - The cancer has not spread outside the breast.

16. Breast Cancer Staging: Size, Location, Spread Stage II (if one of the following is true) - The tumor is 2-5 cm in diameter and the cancer may or may not have spread to the axillary lymph nodes. - The tumor is 5 cm in diameter, but the cancer has not spread to the axillary lymph nodes. (A) - The tumor is <2 cm in diameter, but the cancer has spread to no more than 3 axillary lymph nodes. (B) - No tumor is found in breast, but cancer cells are detected in no more than 3 axillary lymph nodes.

17. Breast Cancer Staging: Size, Location, Spread Stage III (if one of the following is true) - The tumor is >5 cm in diameter, with cancer cells that have spread to axillary lymph nodes, which are not attached to each other. (A) - The tumor is <5 cm in diameter, but the cancer has spread to nearby lymph nodes, which are growing into each other or the surrounding tissues. (stroma) - The tumor is <5 cm in diameter, but the cancer has spread to lymph nodes above the collarbone. (B)

18. Breast Cancer Staging: Size, Location, Spread Stage IV - is the most advanced form of Breast Cancer. - cancer cells have spread to other areas of the body, i.e. bones, brain, liver and/or lungs. - called Metastasis

19. What early symptoms are associated with Breast Cancer? Symptoms A breast lump or thickening that feels different than surrounding tissue. Bloody discharge from the nipple. Changes to the breast surface (i.e. dimpling, pitting) Inversion of the nipple. Peeling, Scaling, Flaking of the nipple of breast skin.

20. How does Breast Cancer develop? Cancer begins as a cluster of normal cells (hyperplasia). Over time, the cells can develop abnormalities (atypical hyperplasia) that make them different from normal cells, but not yet cancerous. The abnormal cells may continue to change in appearance and multiply, evolving into noninvasive (in situ) cancer or, eventually, invasive cancer. Invasive cancer can spread to other areas of the body through the bloodstream or the lymphatic system.

21. How is Breast Cancer diagnosed? Diagnostic Tests for an Atypical Hyperplasia Physical Examination (Breast Exam) Blood Tests (to identify risk factor genes, i.e. BRCA 1/2) Mammogram Biopsy (pathological assessment) – in situ vs. invasive Lumpectomy (pathological assessment)

22. How is Breast Cancer diagnosed?

23. Needle Biopsy Lumpectomy

24. How is Breast Cancer diagnosed? Needle Biopsy Lumpectomy

25. Treatment Options? Radiation Therapy Chemotherapy

26. Mastectomy

27. Mastectomy - Video

28. 1998 Mandate? Federal Breast Reconstruction Law Mandates that a health insurer which provides medical and surgical benefits with respect to a full or partial mastectomy, shall also be required to provide coverage for reconstructive and associated restorative procedures.

29. Overview of Breast Reconstructive Procedures - Video

30. Latissimus Dorsi Flap Breast Reconstruction

31. Latissimus Dorsi Flap Breast Reconstruction

32. TRAM / DIEP – Fixed or Free Flap Breast Reconstruction

33. TRAM – Free Flap Breast Reconstruction

34. TRAM – Fixed Flap Breast Reconstruction

35. Breast Reconstruction – with Acellular Dermal Matrix / Silicone Expander

36. Breast Expander or Implant - Biomaterials Tissue Expanders: High-Molecular Weight Silicone Elastomer Shell (to be filled with Saline solution), self sealing silicone port and Titanium (or Stainless Steel) needle guard. Permanent Implants: High-Molecular Weight Silicone Elastomer Shell (filled with Saline or Silicone)

37.  1st generation implants-Thick, smooth-surfaced shells  2nd generation implants- Thinner shells, for a more natural feel  Higher rupture rates  Other innovations- Textured surface to prevent excessive fibrous tissue growth and to help fixation of implant within the breast Breast Implant - Biomaterials

38. Breast Implant – Biomaterials (fillers) Silicone Gel FilledSaline Filled

39. Breast Reconstruction – with Acellular Dermal Matrix / Silicone Expander Expander Pectoralis ADM Pectoralis Expander

40. Breast Reconstruction – with Acellular Dermal Matrix / Silicone Expander Pectoralis Muscle Allograft

41. Breast Reconstruction – with Acellular Dermal Matrix / Silicone Expander - Video

42. Silicone Expander Filling - Video

43. Breast Reconstruction – Silicone Expander Removal / Final Silicone Implant Insertion - Video

44. Novel Animal Models of Breast Reconstruction – Rat Model 12345

45. Novel Animal Models of Breast Reconstruction – Pig Model

46. Breast Reconstruction – Fat Grafting - Video

47. Breast Reconstruction Jeffrey R. Scott, Ph.D.