Chapter 79.

Breast Reconstruction

BREAST CANCER

BREAST RECONSTRUCTION

Timing

method Selection

RECONSTRUCTION WITH AVAILABLE TISSUE

RECONSTRUCTION WITH TISSUE EXPANSION

RECONSTRUCTION WITH LATISSIMUS DORSI FLAP

RECONSTRUCTION WITH TRAM FLAP

RECONSTRUCTION WITH GLUTEUS MAXIMUS FLAP

PROPHYLACTIC MASTECTOMY

MANAGEMENT OF THE OPPOSITE BREAST

RECONSTRUCTION OF NIPPLE AREOLA

BREAST CANCER

1. oncologic management of breast cancer

① local control

ⓐ radical mastectomy

ⓑ radiation theraphy

② systemic theraphy

ⓐ adjuvant chemotheraphy

ⓑ hormonal theraphy

2. sequalae of radiation theraphy to the chest wall

① breast necrosis

② osteoradionecrosis

③ coronary artherosclerosis

④ brachial plexitis

⑤ lymphedema

⑥ secondary tumor induction

3. patient selection factors of local treatment for breast cancer

① size & location of tumor

② size & consistency of breast

③ age of patient

④ status of axillary nodes

□ BR usually initiated after ChT program is completed

BREAST RECONSTRUCTION

1. goal of breast reconstruction

① follow principles of oncologic management

② reconstruct breasts that meet patient's expectations both psychologically & esthetically

2. breast symmetry : major factor for women in achieving satisfactation after reconstruction

Timing

1. immediated reconstruction

① incision : should properly incorporated area of breast biopsy & nipple areola, but any other excess skin should not be sacrificed

② fascia : 특히 over the lower chest, should be reserved if it is not in proximity to the tumor

2. delayed reconstruction

① 대부분의 breat reconstruction : mastectomy 시행후 3 ~ 9개월 후

② 2 stages

ⓐ 1st stage : breast & chest wall reconstruction

ⓑ 2nd stage : nipple areola reconstruction, other correction to achieve optimal form & symmery

□ tissue expansion : 2nd stage전 place permanent implant

Method Selection

1. 방법 선택시 고려할 요소

① patient's expectations

② status of opposite breast

③ breast symmetry

2. appearance & oncologic status of other breast : important determinants of symmetry

3. 방법	① reconstruction with local tissue available after mastectomy

② tissue expansion

③ LD flap : most versatile & reliable resource of tissue

④ TRAM flap

⑤ Gluteus Max MC flap, free flap

4. assessing the type of breast reconstruction

□ vertical or horizontal dimension 상 skin deficiency

① > 1.6 cm: flap

ⓑ < 1.6 cm: tissue expansion

5. defect size

① > 6 cm : flap

② 4-6 cm : tissue expansion

③ < 4 cm : available tissue with silicone implant only

RECONSTRUCTION WITH AVAILABLE TISSUE

1. breast implant의 위치 : chest wall의 musculofascial layers 아래

2. 장점	① simplicity

② predictability

③ 추가적인 incision없이 mastectomy scar를 통해 시행

④ not comouflage any local recurrences of the tumor

⑤ not obviate the need for other technique

3. indication

① mastectomy avallable tissue가 good quantity & quality

② 1 or 2 procedure로 other breast와 match 시킬 수 있을 때

4. contraindications

① deficient or irradiated skin

② radical mastectomy 시행했을 경우

5. 합병증 : improper implant size(mc), fibrous capsule

6. 적당한 implant size 선택방법

① estimated final size of opposite breast

② brassiere안에 여러 size implant넣고 반대 breast와 비슷할 때 size 선택

③ size & weight of the mastectomy specimen

④ slightly larger than the other side

□ infrmammary incision시 반대편 crease 보다 1.5-2 cm아래에 넣는 이유

: 술 후 capsular contracture로 upward shift하는 경향

□ mc site of local recurrence : mastectomy scar

□ dissection m for pocket(fig 79-5) : PM, SA, EOf, RA

□ nipple-areola surgery : 3개월 후

RECONSTRUCTION WITH TISSUE EXPANSION

1. expander position : mastectomy scar를 통해 submusculofascial position

2. 반대편 breast volume보다 200ml overfilled

□ 이유

① provides ptosis

② reduces intensity & firmness of capular contracture

3. advantages of tissue expansion

① flaps are not required

② additional scar 없이 symmetry 유지가능

③ breast implant 단독만으로 재건할 수 없는 경우에 적당

④ not prevent use of other methods of breast reconstruction

: skin이 충분히 stretch되기 때문에 2o procedure가 용이하다

4. disadvantage

① need for silicone breast implant

② capsular contracture --> firmness & distorsion of breast

③ add extraoperation to breast reconstruction

④ frequent visit at weekly intervals for gradual fill of device

⑤ failure of device with early deflation

⑥ exposure of device

5. indication

① modified radical or total mastectomy pt

② opposite breast is full with some element of glandular ptosis

③ satisfactory skin cover,  400mL이상의 breast reconstruction필요한 경우

④ ptosis is desirable in reconstructed breast

6. contraindication

① thin skin cover

② advanced irradiation changes

7. permanent breast implant volume 측정법 : expander내의 fluid를 withdraw

--> opposite breast와 size가 같을 때의 expander 내의 vol

RECONSTRUCTON WITH LATISSIMUS DORSI FLAP

1. 방법	① adding back skin to supplement missing skin

② muscle to replace or supplement any muscle deficiency

ⓐ enhance cover of silicone breast implant

ⓑ contribute to softness & natural appearance of reconstruction

2. indications

① flap is needed

② when pt is interested in axillary fill

③ radical mastectomy pt

④ not good candidates for TRAM flap

⑤ thin, tight or irradiated skin

⑥ breast implant의 exposure 가능성이 높은 사람

⑦ additional fullness in lower outer quadrant, can contribute to ptosis

3. thoracodorsal vessel : 10cm long & based on the axillary vessel

4. 가장 흔한 합병증 : back donor site의 seroma

--> 처치 : drain & shoulder motion 제한

RECONSTUNCTION WITH TRAM FLAP

1. TRAM flap이 LD flap보다 유용한 경우

① silicone breast implant없이 재건가능

② acceptable scar : lower abdomen, transverse

③ reduced abdominal excess

2. indications

① LD를 사용하기 어려운 경우 : denervated, divided, atrophic

② silicone breast implant로 Cx 발생 시

③ preserve appearance of opposite breast

<-- versatility of the flap & large amount of skin and fat

④ radical mastectomy 후 axillary & infraclavicular region의 large soft tissue defect

⑤ breast implant로 재건하기 어려운 large breast patient

3. contraIndication(definite limitation)

① previous irradiation to base of flap or mediastinum

② surgical division of pedicle

③ very obese pt.

④ > 65세

⑤ microcirculation problem pt : DM, long-term cigarette smoking

⑥ pt 가 major op(significant pain, long convalescence등으로) 준비가 안될 때

4. anatomy

① unblilius 주변에 perforator들이 집약

--> TRAM flap의 max. reliability위해서는 포함

② direct perforator들이 ipsilat. RA m위를 supply

ⓐ midline across하는 부분과 m의 lat.부분의 flap은 random

ⓑ contralat side distal lat portion : often unrelialbe

ⓒ subdermal plexus : midline across의 major random blood supply

--> should be thinned below scarpa's farcia

③ strategy for enhancing blood flow to flap

ⓐ flap can be moved to area for BR with both RA m pedicle

ⓑ DIE vessel을 axillary vessel과 anastomosis

□ upper pedicle이 division

□ contralat blood supply enhance위하여

④ design

ⓐ traneverse ellipse of excess tissue in lower abdomen

: abdominoplasty시 discard 할 tissue

ⓑ inframammary crease를 너무 inf. positon에 하지 않는 이유

: tight abdomen closure후 crease line이 inf. displace되므로

5. surgical procedure

① flap의 microcirculation을 maximize

: 술중 vasoconstriction은 피함 : flap이 cold sensitive --> warm fluid 사용

② N2O 사용 안함 : bowel distension --> closure곤란

③ incision시 upward로 beveled : 좀더 많은 periumbilical perforator포함

④ skin과 fat이 모두 필요한 경우 : contralateral pedicle사용

□ 단지 filling목적 : ipsilat TRAM flap

⑤ m divide는 arcuate line level에서 DIEA를 따라 시행

--> RA sheath는 두고 elevation 함

⑥ upper fill혹은 lower projection이 필요한 경우 flap 일부를 deepithelize하여 사용

⑦ Prolene mesh사용

ⓐ additional security

ⓑ reduce possibility of postoperative stretching of abdominal wall

⑧ 2 pedicle이 필요한 경우

ⓐ bilateral breast reconstruction

ⓑ enhancement of TRAM flap

⑨ TRAM flap시 nipple areola reconstruction 안하는 이유

: flow in flap↓ --> not support vascularization of SG

6. complications

① perfusion감소와 관련된 합병증

□ 예방방법

ⓐ careful patient selection

ⓑ 술중 flap의 vasocontriction을 방지

ⓒ 술후 O2 administration

② abdominal wall Cx. : 약해진 복벽을 통한 복강내용물의 protrusion

□ 예방	ⓐ secure abdominal closure

ⓑ prolene mesh를 사용한 reinforcement

RECONSTRUCTION WITH GLUTEUS MAXIMUS FLAP

1. indication : 다른 flap으로 제건이 어려운 경우

2. 장점	① autogenous tissue

② avoid silicone implants

③ sufficient tissue to obtain attractive result

④ donor scar, easily hidden on buttocks beneath brief clothing

3. 단점 : highly refined & technically demanding

4. sup. gluteal a.를 int. mamm a.에 연결(4, 5th costal cartilage 아래)

PROPHYLACTIC MASTECTOMY

1. op designed to reduce risk of developing breast ca. by removing high percentage of breast tissue

2. several major high risk factors

① first degree relative(mother or sister)에 breast ca. history가 있는 경우

: 특히 bilat or premenopause에 발생 시 risks↑

② previous cancer in one breast

③ young patient

3. pathologic indicators of increased risk

① multifocal areas of breast cancer

② lobular cancer in situ

③ changes of epithelial hyperplasia and atypias

④ multiple areas of in situ intraductal ca

4. ptosis가 mild한 경우 nipple areolar not remove

but! severe : skin reduction후 upper position에 free graft

MANAGEMENT OF THE OPPOSITE BREAST

1. opposite breast가 hypoplastic and ptotic 할 때

: submusculofascial silicone implant & mastopexy

2. opposite breast가 hypertrophic & heavy

: 재건되는 breast에 match --> surgical reduction mammoplasty

3. prophylatic mastectomy를 동시에 시행할 경우 고려해야 할 사항

① esthetic correction of nipple-areolar position

② placement of correct-sized silicone implant

③ removal of any extra skin

RECONSTRUCTION OF NIPPLE AREOLA

1. sources

① skin from axilla or regions of mastectomy scar

② opposite areola

③ upper inner thigh

④ skin graft from resected areola(frozen section examination후)

2. 방법(fig 79-31)

① nipple sharing

② quadrapod flap