1. Breast Reconstruction
Joint Hospital Grand Round
20th September, 2003
Catherine Choi
United Christian Hospital

2. Breast Cancer Commonest cancer amongst females in Hong Kong
Incidence increasing annually at 3.6%
Incidence 1918 (397 deaths)
Cumulative life-time risk (0-74yrs): 1 in 23
Hong Kong Cancer Registry 2000

3. Hong Kong Cancer Registry 2000

4. Treatment of Breast Cancer
Multimodality & Multidisciplinary Management
Surgery
Chemotherapy
Radiation therapy
Hormonal therapy
Surgery important in achieving cure

5. Evolution of surgery in the treatment of Breast Cancer
Breast Conservation Treatment (BCT) in early breast cancer
Fisher et la. Eight year results of a randomized clinical trial comparing total mastectomy and lumpectomy with or without irradiation in the treatment of breast cancer. N Eng J. Med. 1989;320:822-8
National Institute for Health Consensus Conference. Treatment of early stage breast cancer. JAMA 1991; 265:391-5
Mastectomy still required in majority

6. Problems of BCT
BCT aims to preserve as much of a patient’s natural appearance as possible. Deformity can be considerable with large tumor.
This can be overcome by:
Reshaping (large defect in large breast) + contralateral breast reduction. This is similar to reduction mammaplasty.
LD myocutaneous flap if defect too large for correction
With oncological and plastic surgeries indications for BCT and breast reconstruction can be widened
Clough KB et al. Cosmetic sequelae after conservative treatment of breast cancer: classification and results of surgical correction. Ann. Plast.Surg. 1998; 41:471-81
Clough KB et al. An approach to the repair of partial mastectomy defects. Plastic and Reconstructive Surgery. 1999; 104:
Petit JY et al. Integration of plastic surgery in the course of breast-conserving surgery for cancer to improve cosmetic results and radicality of tumor excision. Recent Results Cancer Res. 1998; 152:202-11

7. Mastectomy Mutilating and destructive Loss of femininity
Disturbance in marital/sexual relationship
Limited selection in clothing & activities

8. Breast Reconstruction
NOT A COSMETIC SURGERY
Integral part of treatment
Reduce psychosocial morbidity & improve quality of life
Linda LR. Plast Reconstr Surg 1997

9. Immediate vs Delayed Reconstruction
Immediate Reconstruction……
Oncologically safe
Kroll SS. Ann Surg Oncol 1997
Easier operation
Better aesthetic outcome
Avoid disfigurement
Avoid second operation
Psychological, social, financial and time-saving advantages

10. Contraindication to Breast Reconstruction
Patient in very poor health
Patient with very poor disease prognosis (inflammatory carcinoma of breast)
Ambivalence or unrealistic expectation

11. Surgical Options for Breast Reconstruction
Implant or tissue expander
Autologous tissue reconstruction
Latissimus Dorsi (LD) myocutaneous flap
Transverse Rectus Abdominus Myocutaneous (TRAM) flap – free or pedicle
Deep Inferior Epigastric Perforator (DIEP) flap
Superior Gluteal Artery Perforator (SGAP) flap
Inferior Gluteal Artery Perforator (IGAP) flap

12. Other Autologous Tissue Reconstruction
Rubens Fat Pad Free flap
Transverse Fascia Lata flap
Transverse Gracilis Flap
Omentum Flap
Groin Flap

13. When to choose autologous tissue instead of implants?
It is difficult to recruit or expand more than 7 or 8cm of additional tissue with tissue expander. When the vertical tissue requirements exceed this amount, autologous tissue is needed.

14. Breast implants & tissue expanders
Saline or silicon gel
Simpler surgical procedure
Lower cost
Symmetry difficult to achieve
Aesthetic result deteriorates over time
Capsular contracture, implant failure, infection, etc
Clough KB. Plast Reconstr Surg 2002
Problems associated with post-op radiotherapy
Short-term advantage
offset by
Long-term disadvantage

15. Michigan Breast Reconstruction Outcome Study
49 implants/expander
163 TRAM flap
TRAM flap recipient more satisfied
Aesthetic satisfaction
General satisfaction
Alderman AK. Plast Reconstr Surg 2000

16. Latissimus Dorsi (LD) flap
First described by Tansini in 1898
Standard method in the 1970s
Technically easy, reliable
Used alone for small breast reconstruction or with implant for large breast
Change of position during surgery
Complication of seroma common, others relating to implants

17. Extended LD flap Transfer addition tissues from back
Breast implant not required
For patient with previously abdominal surgery
Suitable for Asians

18. Endoscopic techniques
Harvesting latissimus dorsi myocutaneous flap
Same scar for axillary dissection or a separate incision about one inch in the middle or lower back

19. TRAM flap First described by Hartrampf in 1982 Commonest option
Substantial amount of tissue and skin for reconstruction
Symmetry & Tissue consistency
Change of appearance and size similar to the natural breast
Added benefit of abdominoplasty
Clough KB. Plast & Reconstr Surg 2001

20. TRAM – pedicled flap Superior epigastric artery
Skin and subcutaneous tissue by subdermal plexus

21. TRAM – pedicled flap Blood supply improves by: Bipedicled flap
(absence of zones II & IV)
Aagner DS. Plast Reconstr Surg. 1991
Supercharging
Harashina T. Br J Plast Surg. 1987
Flap delay procedure
Codner MA. Plast Reconstr Surg. 1995

22. TRAM - complications Donor site Recipient site
Abdominal weakness / hernia
Abdominal wall bulging
Recipient site
Fat necrosis
Partial flap necrosis
Total flap necrosis

23. TRAM flap - risk factors
Smoking
Microcirculatory problems
Magnified in obese patients
Obesity
increased risk of flap loss with pedicle flap
Moran SL. Plast Reconstr Surg 2001

24. TRAM – risk factors Unfavorable abdominal scar from previous surgery
TRAM flap pedicles divided
Perforators interrupted
Subdermal plexus damaged
Rt subcostal scar
Vertical midline scar
Pfannenstiel scar

25. TRAM – free flap Popularized since 1990s
Deep inferior epigastric artery
Robust blood supply

26. TRAM – free flap Advantages Disadvantages
Less fat necrosis / partial flap loss
Less sacrifice of donor site muscle, so less weakening & less pain
Avoid epigastric bulge
Better aesthetic outcome
Disadvantages
Microvascular anastomosis
Risk of TOTAL flap loss
Long & tedious operation
Post-op monitoring requires effort and expense

27. DIEP (deep inferior epigastric perforator) flap
Variation of free TRAM flap
Only one or more perforating branches dissected from rectus
Rectus muscles left intact
Less donor site morbidity
More time consuming and tedious
Indicated for bilateral reconstruction & small breast

28. Preferred choice of TRAM…..
Pedicle flap VS
Free flap

29. Literature search Keyword: TRAM Medline / EMBASE / Cochrane library
5 out of 698 articles comparing outcome of free vs pedicled TRAM
Results
No RCT comparing free vs pedicled TRAM
Prospective non-randomized comparison

30. Comparisons on… Patient’s general & aesthetic satisfaction
Larson DL. Plast & Reconstr Surg 1999
Edsander N. Plast & Reconstr Surg 2001
Recipient site morbidity
Kroll SS. Plast & Reconstr Surg 1998
Donor site morbidity
Edsander N. Plast & Reconstr Surg 1998
Cost
Serletti JM. Plast & Reconstr Surg 1997

31. Study Results Free Pedicled Patient & aesthetic satisfaction
Recipient site morbidity (fat necrosis)†
Donor site morbidity (abd strength)
Pedicled
Shorter operation time, hospital stay, less blood transfusion†
† Statistical significant result

32. Skin-sparing total mastectomy with immediate breast reconstruction
Oncologically safe
Kroll SS. Surg Gynecol Obstet 1991
Traditional type involves skin overlying tumor, biopsy scar and nipple-areola complex (skin at risk of recurrence)
Patch like defect at NAC, transverse scar

33. Skin-sparing total mastectomy with immediate breast reconstruction
Periareolar approach
All breast skin preserved
Optimal aesthetic result
Gabka CJ. Plast & Reconstr Surg 1998

34. Conclusion
Breast reconstruction reduces psychosocial morbidity & increases quality of life after mastectomy
Immediate reconstruction should be offered to patient requiring mastectomy
Autologous tissue reconstruction superior to implants

35. Conclusion TRAM (free/pedicled) Free TRAM flap ……At the expense of
superior aesthetic outcome
Free TRAM flap
fewer recipient & donor site morbidity
……At the expense of
Risk of TOTAL flap loss
Cost
Special expertise
Post-op monitoring effort & expense

36. Conclusion Pedicled flap is justified to be used
Free flap considered in selected patients
obese
smoker
unfavorable abdominal scar

37. Conclusion
Periareolar approach skin-sparing mastectomy with immediate breast reconstruction gives the best possible aesthetic outcome without compromise oncological safety
Gabka CJ. Plast & Reconstr Surg 1998