Breast Reconstruction

Steven E. Copit, M.D.

Chief- Division of

Plastic Surgery

Thomas Jefferson University Hospital

Philadelphia, PA

Breast Reconstruction analysis of “ The Defect ”

Skin

Breast Volume

Nipple Areola Complex

Breast Reconstruction analysis of “ The Defect ”

Breast Reconstruction

the mastectomy defect

Skin defect

Most difficult to replace

Breast volume

Replaced by fat, muscle, implant

Easier to replace

Nipple-Areola Complex

Easiest

Breast Reconstruction skin – estimate of defect

Size of tumor / proximity to skin

Previous biopsy

Previous XRT

Smoking

Size of skin flaps

Breast surgeon

Breast Reconstruction skin

“ Probably the single most important

influence on the improved quality of

breast reconstruction has been the

evolution of the mastectomy

technique.”

F.E.B. , M.D.

Breast Reconstruction skin sparing mastectomy

Breast Reconstruction breast volume

Match the reconstructed breast to the

contra-lateral side

Modify the contra-lateral breast to

approximate the result of the

reconstruction

Breast Reconstruction nipple–areola complex

Appearance

Sensation

Lactation

Breast Reconstruction

“It’s all about symmetry”

Breast size

Breast Shape - Ptosis

Breast Reconstruction procedure selection

Implant Reconstruction

Tissue expander / Permanent implant

Latissimus Dorsi Myocutaneous flap and

tissue expander / permanent implant

Breast Reconstruction procedure selection

Autogenous reconstruction

Abdominal Wall

Pedicle TRAM flap

Free TRAM flap

DIEP Flap

Breast Reconstruction procedure selection

Gluteal Reconstruction

GAP flap

SGAP flap

Breast Reconstruction

tissue expander / implant

Breast Reconstruction tissue expander / implant

Saline filled silastic expander

Exchange for saline or silicone

filled silastic implant

Breast Reconstruction

tissue expander / implant

Tissue expansion provides skin

Implant exchange provides volume

Breast Reconstruction

tissue expander / implant

Breast Reconstruction tissue expander / implant

Pros

No donor site morbidity

Short surgery

Breast Reconstruction tissue expander / implants

Cons

Poor symmetry

Frequent visits to office for expansion

“Implant under skin”

Breast Reconstruction implant options

Saline vs. Silicone

Silicone is softer

Silicone has diminished fold flaws

Breast Reconstruction

Institute of Medicine

No evidence that silicone implants are

responsible for any disease

No evidence of a novel autoimmune disease

No increase in breast cancer

No danger in breast feeding

Implants do not last forever

Breast Reconstruction implant issues

All complications are local

Rupture

Capsular contracture

Infection

Breast Reconstruction implant issues

Silicone was used under FDA trials for reconstruction only

FDA has reviewed the results of the trials and has cleared silicone for unrestricted use

Breast Reconstruction silicone is back

Silicone implants are the most extensively studied medical device in the history of the FDA

Even plaintiff attorneys have to surrender to science

Breast Reconstruction tissue expander / implant

Breast Reconstruction tissue expander / implant

Breast Reconstruction tissue expander / implant

Breast Reconstruction tissue expander / implant

Breast Reconstruction latissimus dorsi myocutanious

flap / implant

Breast Reconstruction latissimus dorsi myocutanious

flap / implant

Rotation flap of muscle and skin from back to replace skin

Permanent implant to replace breast volume

Breast Reconstruction Lat. dorsi and tissue expander

Pros

Looks better than a tissue expander alone

Replacing skin preserves the natural

shape of the breast (ptosis)

Replacing skin allows more fill in the

expander at the time of the initial

operation

Breast Reconstruction

Lat. dorsi and tissue expander

Cons

Donor scar (minimal if transverse oriented)

Donor muscle function loss

Breast Reconstruction

Lat. dorsi and tissue expander

Breast Reconstruction

Lat. dorsi and tissue expander

Breast Reconstruction nipple- areola complex

Creation of nipple from breast skin

Tattoo areola and nipple in office

Breast Reconstruction nipple- areola complex

Breast Reconstruction timing

Immediate reconstruction

Delayed reconstruction

Breast Reconstruction

Contraindications

Planned post-op radiation

Smoking

Breast Reconstruction advantages

Beneficial psychological effects 1,2,3

Pliable skin flaps and IMF preserved

1. Stevens, et al: PRS 73:619, 1984

2. Schain WS: Clinics Plast Surg 11: 237, 1984

3. Wellisch DK: PRS 76:713, 1985

Breast Reconstruction operative plan

Unilateral Reconstruction

Match normal breast

TRAM

Lat.Dorsi

Breast Reconstruction operative plan

Bilateral reconstruction

TRAM

Lat. Dorsi and tissue expansion

Tissue expansion

Breast Reconstruction

My Absolutes

No one perfect choice

No “easy way” to make a breast

The more you do the better it looks

Some people require a higher standard reconstruction- be honest

Breast Reconstruction

My Absolutes

Allow yourself to think long term

You should “hear“ about all the options

but listen to your surgeon

Mastectomy is easy, reconstruction is

hard

Thank you