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Reconstructive Techniques: What Should the Breast Surgeon Know About Reconstruction?Hani Sbitany, MDDivision of Plastic and Reconstructive Surgery

University of California, San FranciscoMarch 7, 2015

Options for Breast Reconstruction

• Implant-Based

– 2-Stage• Implant/Expander

• The standard

– Single Stage• Newer technique

• B-C cup, willing to be smaller

• Thick flaps

• Autologous

– Free Flap• Many tissue options

• Microvascular techniques

– Pedicled• The original autologous

operation

• Abdominally based

• Latissimus dorsi

– + or – implant

– Fat Grafting

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Defining High Risk in Breast Reconstruction

• Postmastectomy Radiation

• Prior Breast Surgery

Plast Reconstr Surg. 134: 396, 2014

Plast Reconstr Surg. 134: 396, 2014 Plast Reconstr Surg. 128: 353, 2011

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Plast Reconstr Surg. 134: 396, 2014

Alloderm Assisted Coverage

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Cohort 1: Implant exchange within 6 months of radiation completion (n=49 patients)Cohort 2: Implant exchange greater than 6 months following radiation completion (n=39 patients)

Right TSSMADM/ 500cc Immediate ExpanderAdjuvant Taxotere/Cytoxan – 4 cyclesPMRT

Right textured, round HP 505 ccgel implant

Left augmentation for symmetry

39 year old femaleRight breast IDC with extensive DCIS1 of 2 sentinel nodes positive Posterior margin less than 1 mm

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Plast Reconstr Surg. 134: 169, 2014

Plast Reconstr Surg. 131: 962, 2013

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Free DIEP Flap

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Free DIEP Flap Bilateral Delayed DIEP Flap, 3 months

Autologous Tissue + PMRT

20

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•Review of TSSM and Immediate Autologous reconstruction from 2005-2013

• 67 patients, 99 autologous reconstructions• 53 pedicle TRAM flaps• 46 microvascular free flaps

•Various incisions for mastectomy•Superior periareolar: 35%• Inframammary: 32%•Radial/Lateral: 33%

Strategies for TSSM and Free Flap Breast Reconstruction - UCSF

Peled AW, Wang F, Foster RD, Hansen SN, Sbitany H. Outcomes Following Total Skin-Sparing Mastectomy and Autologous Breast Reconstruction. Submitted for ASRM Consideration.

•2% partial flap loss, 0% complete flap loss

• Ischemic mastectomy flap morbidity:•NAC Necrosis: 8% partial, 10% complete

•Superior periareolar incision = higher rates of NAC necrosis (p=.03); compared to IMF incisions

Strategies for TSSM and Free Flap Breast Reconstruction - UCSF

Peled AW, Wang F, Foster RD, Hansen SN, Sbitany H. Outcomes Following Total Skin-Sparing Mastectomy and Autologous Breast Reconstruction. Submitted for ASRM Consideration.

• Incision location

•Postoperative monitoring

Technical Planning

•Prospectively maintained database queried for patients between 2011-2013 undergoing TSSM and microvascular reconstruction

•2 Groups•TSSM and immediate autologous flap•TSSM and immediate tissue expander � expansion � 2nd stage DIEP flap

•Assessed for morbidity and aesthetic outcome analysis

Immediate vs. 2-stage delayed

Raghavan S, Peled AW, Hansen SN, Esserman LJ, Sbitany H. Approaches to Microvascular Breast Reconstruction After Total Skin-Sparing Mastectomy: A Comparison of Techniques. California Society of Plastic Surgeons Annual Meeting. Newport Beach, CA. May, 2014.

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Immediate vs. 2-stage delayed

Raghavan S, Peled AW, Hansen SN, Esserman LJ, Sbitany H. Approaches to Microvascular Breast Reconstruction After Total Skin-Sparing Mastectomy: A Comparison of Techniques. California Society of Plastic Surgeons Annual Meeting. Newport Beach, CA. May, 2014.

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Immediate Delayed P-Value

Patients (n) 14 17

Breasts (n) 21 27

Complications

NAC necrosis (partial)

3 (14%) 0 (0%) .08

NAC necrosis (complete)

3 (14%) 0 (0%) .08

NAC necrosis (any)

6 (28%) 0 (0%) .005

Skin flap necrosis 1 (4.7%) 1 (3.7%) 1

Infection 0 (0%) 1 (3.7%) 1

Wound breakdown 0 (0%) 1 (3.7%) 1

Flap loss (complete)

0 (0%) 0 (0%) 1

Flap loss (partial) 1 (4.7%) 0 (0%) 1

Thank You