1. BREAST RECONSTRUCTION Mark S. Granick, MD, FACS Professor of Surgery, tenured Chief of Plastic Surgery

2. Why? “I have a long life to live and I want to live it whole.” “I wanted to once again put on a beautiful nightgown and fill it all out.” “”I was gardening one day when I bent over and my prosthesis fell out. Crying I picked it out of the muddy water. The next day I called a Plastic Surgeon.”

3. Patient Questions Who is a candidate for surgery? Will breast reconstruction interfere with cancer treatment or detection? Are there some women who should not have a reconstruction? Does the type of cancer make a difference? How does adjuvant therapy impact on reconstruction?

4. Patient Questions How do you get the breasts symmetric? If a patients gains or loses weight, how does it affect the reconstruction? Does a breast reconstruction look and feel natural? Are there psychological implications concerning breast reconstruction?

5. Goals Mound reconstruction Size Size Skin coverage Skin coverage Nipple reconstruction Areola reconstruction Symmetry

6. Timing ImmediateDelayed

7. Options Implant, with or without expansion AutogenousCombination

9. Implants 1 stage Skin deficiency uncorrected Facilitated by alloderm sling Good for small breasts with minimal ptosis Late capsular formation

14. Permanent Expander 1Step Corrects skin deficiency Multiple office visits

15. Expander - Implant 2 Stages Corrects skin deficiency Multiple office visits

19. Pre-op

20. Fully Expanded

21. Implant in Place

22. Nipple Areola Reconstruction

23. Autogenous Tissue Corrects skin deficiency Normal subcutaneous tissue No foreign material Longer operative time Higher morbidity

24. Latissimus Dorsi May require an implant Cannot be used if the thoracodorsal pedicle is damaged

25. Latissimus Dorsi

27. Latissimus Flap Planning

31. TRAM Carl Hartrampf,MD Single or double pedicle Muscle sparing (perforator) Cannot use if the rectus muscle is divided superiorly (Kocher incision) Risks fat necrosis fat necrosis donor site slough donor site slough flap failure flap failure hernia hernia

35. Pre-op

36. Single Pedicle TRAM

37. Post-op

38. Pre-op

39. Intra-op

40. Post-op

41. Free Flap TRAMGluteal Lateral Thigh DIEP

42. Pre-op

43. Intra-op

44. Microsurgery

45. Post-op

46. Nipple Reconstruction

47. Areola Reconstruction

48. NAC Reconstruction

49. Post Radical and Radiation

50. TRAM