` The has become a major part of the practice of most Plastic Surgeons. ◦ Reconstructive after ◦ Cosmetic

` after mastectomy may be staged. It can involve several or all of the following procedures: ◦ Insertion of tissue expander ◦ Breast mound reconstruction by tissue graft ◦ Removal of tissue expander ◦ Insertion of permanent breast ◦ Revisions to reconstructed breast ◦ Balancing procedures to native breast ◦ reconstruction ◦ Areolar tattooing

` Some procedures are performed in separate encounters, others may take place during the same operative session. Which procedures a patient requires depends to some extent on how much tissue remains after mastectomy.

If there is sufficient tissue, immediate reconstruction may be performed by placing a permanent implant. Or, if additional tissue is needed, a tissue expander may be placed or a graft may be performed.

skin sparing mastectomy… with tissue expander insertion ¾Overview of the common options for soft tissue reconsrtuction ¾Indications for their use versus a free flap. RotationalRotational FlapsFlaps Tissue grafts are used when more bulk is needed to reconstruct the breast mound. A TRAM flap transfers tissue from the lower abdominal wall, a TRAM latissimus dorsi flap latissimus graft dorsi graft tissue from the back.

Although the transferred tissue alone may be sufficient, an implant can also be placed underneath. ` Transverse Rectus Abdominis Myocutaneous (TRAM) ◦ Skin, Fat, and Muscle ◦ Superior epigastric vessels for pedicle x May be taken as free flap based on inferior epigastric vessels x This is preferred for obese patients and those that smoke ◦ May be delayed x Cut inferior epigastric vessels to allow for increased flow through the superior vessels x Usually 2-3 weeks prior to definitive reconstuction ` Latissimus Dorsi Flap ◦ Skin, Fat, and Muscle ◦ Not generally the first choice for reconstruction x Used in obese women x Previous abdominal operations ◦ Generally does not provide sufficient bulk for complete reconsturction x Paired with implant on occasion ` Deep Inferior Epigastric flap (DIEP) ` Superior Gluteal Artery Perforator flap (SGAP) Deep Inferior Epigastric Perforator ` DIEP ◦ Fasciocutaneous Flap ◦ Benefit of “tummy tuck” ◦ No risk of hernia (as with TRAM)

Superior Gluteal Artery Perforator Flap ` SGAP ◦ Skin and only ◦ Typically second choice x Lack of sufficient abdominal skin and subcutaneous tissue ◦ Reduced donor site morbidity ◦ No functional loss

` Recipient Vessels ◦ Internal Mammary x Preferred in skin sparring mastectomy x High perfusion pressures ◦ Thoracodorsal Artery x Risk of injury to intercostobracheal nerve, Tissue Expanders

When additional tissue must first be developed, a tissue expander is placed in the chest wall and filled through a port at regular intervals to stretch out the skin. Some expanders are designed to be left in, but most are removed and replaced with a permanent implant. Exchange of Tissue Expander for Implant

After the tissue expander has been fully expanded, it is removed and replaced by a permanent implant, typically during the the same encounter. Implants are filled with either or silicone. Many models are available to try to match the patient’s natural contours.

Because the expander is a foreign body, it’s normal for a capsule to form around it in the breast. Adjustments to the capsule are often necessary to seat the permanent implant properly. Revision of Reconstructed Breast

It is not uncommon for the reconstructed breast to require surgical revision at some point. This can be necessary because of “contour deficits”, such as: irregularity or deformity in the contour deficit reconstructed tissue; inadequate projection; and asymmetry or disparity with the native breast. Surgeons are usually adamant that these issues are in the nature of breast reconstruction and do not represent complications of the graft or implant. asymmetry Revision for Complications

Unlike contour deficits, asymmetry and the like, capsular is a of the implant. A thin capsule forms around all implants. Contracture is when the capsule thickens abnormally and forms tissue around the implant, becoming hard and painful. Capsular contracture may require capsulotomy or capsulectomy of the reconstructed breast. Fat necrosis is a complication of TRAM flaps. Fat within the flap becomes ischemic due to inadequate blood supply. It hardens and must usually be excised. Balancing Procedures to Native Breast

As an alternate to revising the reconstructed breast, or sometimes in addition to it, procedures are also performed on the native breast. This includes augmentation, reduction, and of a smaller, larger or ptotic native breast for balance with the reconstructed breast.

mastopexy reduction of native of native breast breast Nipple and Areolar Reconstruction

Nipple reconstruction is usually performed via skin grafts. Common techniques include the skate flap, top-hat flap, and star flap. Nipple reconstruction is usually delayed for several months after breast mound reconstruction, to allow the new breast time to settle. Areolar reconstruction can also be performed by grafting, though tattooing is much more common. ` With a few exceptions, large in vogue since antiquity ◦ Brassieres and corsets used to enhance size ` 19th Century: surgical breast enlargements attempted using ivory, glass, metal, rubber, and paraffin ` 1895: Czerny performs first reported successful human mammary reconstruction ◦ actress who had undergone removal of a fibroadenoma ◦ transplanted from her hip ` 1903: Charles Miller inserts "braided silk, bits of silk floss, particles of celluloid, vegetable ivory, and several other foreign materials” ◦ granulomatous (foreign body) inflammatory reactions disfiguring and painful ` 1903-1950s: petroleum jelly, beeswax, shellac, and epoxy resins used. ` Early 1950s: liquid injections used ` 1962: first US woman to receive encapsulated silicon breast implants ` 1992: FDA bans silicone breast implants except in strictly controlled trials for breast reconstructive due to reports linking the implants with a variety of connective tissue diseases and neurological disorders. ` Subsequent analyses show no such links ` 2005: FDA allows silicone breast implants back on market (with registry) ` A minimum of 15% of modern silicone implants will rupture between the third and tenth year after implantation ` Today: newer generation silicone implants, saline implants, dermal fillers ` 2007: Stem cells and fat derived from used to grow breast tissue in clinical trials in Europe ` 2008: Israeli surgeon develops “breast lift procedure” involving internal titanium bra with silicone cups ` 2008: MyFreeImplants.com ◦ Facilitates communication and funding

` Patient Assessment ◦ Motivation x BMD? x Social pressure ◦ Younger x Teen? x Young adult? x Does the patient understand the procedure? ◦ Older x Quality of the result x Loss of elasticity of tissues over time ◦ “Normal” size x According to whom? ` Considerations ◦ x Affect the contour of the breast ◦ Oncologic x Is this patient at risk for x Has she been screened? ◦ Sensation x Understand there may be an alteration to this. ◦ Pregnancy/ Lactation ◦ ◦ Symmetry

` Planning ◦ Size x Chest wall x Skin envelope x Projection x Asymmetry ◦ Implant type x Smooth x Textured x Designed to limit capsular contracture and rotation of the implant ` Planning ◦ Markings ◦ Incision x x Periareolar x Axillary Axillary

IMF Periareolar ` IMF ◦ Advantages x Preserves parenchyma x Precise pocket x Scars well ◦ Best candidates x Well-defined IMF x No h/o hypertrophic healing x Mild ptosis x Sports (elevate arms) ` Periareoloar ◦ Advantages x Scars well ◦ Disadvantages x Must be AT JUNCTION x Non-expandable difficult x Bacterial seeding ? ◦ Best candidates x diameter >35 cm x Thin layer of breast parenchyma ◦ Technique x Superficial to superficial layer of superficial fascia to lower border of breast then into sub-pectoral space ` Axillary ◦ Advantages x Hidden scar ◦ Disadvantages x More difficult with rough surfaces x Need endoscope or blind x Revision requires different incision ◦ Best candidates x Tendency to hypertrophy x Marked hypoplasia with poor IMF ◦ Technique x Mark 1.5-2 cm below IMF ` Planning ◦ Position x Subglandular x Good with moderate ptosis x Active body builders x Submusculofascial x Decreased contracture x Softer x Better oncologically

` Ancillary Procedures ◦ Intraoperative expansion x TE or manually x Can use expander as estimate of volume ◦ Postoperative expansion x Permanent expander implant x Can alter final volume ◦ x Difficult through same incision ◦ Biopsies x Preop studies for all >30yo or younger if at higher risk ◦ NO FAT INJECTIONS x Can calcify ` Capsular contracture ` Implant rupture ` Hematoma ` Wound infection

` Breast implants decrease sensitivity of screening among asymptomatic women, but do not increase false-positive rate nor affect tumor prognostic characteristics ` Cosmetic implants – 12% ` After prophylactic mastectomy – 30% ` After mastectomy for breast cancer – 34% ` Latest trend: microsurgical breast reconstruction using implants or autologous tissues ` Postoperative Considerations ◦ Care x Soft elastic bra or ACE wrap

◦ Massage x Enlarges pocket

x Softens x Can help parasthesias ◦ Hematoma: 0.5%-3% x Good hemostasis

x Immediate post op RTOR x Can cause some asymmetry x Can occur 1-2 weeks post-op with increased activity ◦ Sensation: 15% x 4th intercostal NV bundle most important

` Postoperative Considerations ◦ Infection: 2.2% x Staph epidermidis most ducts & implants x Peri-op antibiotics x Irrigate with iodine x Atypical mycobacteria require removal capsulectomy and systemic anti-fungals x Bacterial infections can be treated conservatively initially Æ replace +/- capsulectomy ` Postoperative Considerations ◦ Capsular Contracture x Classification x Grade I: Soft x Grade II: Minimal : palpable not visible x Grade III: Moderate: palpable and discernible x Grade IV: Severe: hard, symptomatic, +/-distortion ` Capsular Contracture ◦ Prevention x Type x Silicone: Bleed contributes x Textured: Lower incidence, not axillary x Position x Submusculofascial better - ducts not cut () x Blunt dissection x Less hematoma, less electrocautery, less necrosis x Infection x Major cause x Pocket x Need adequate size, larger for smooth ` Capsular Contracture ◦ Treat remote site infections (URI, UTI) ◦ Closed capsulotomy: External pressure tears capsule x Not effective, potential danger ◦ Open capsulotomy x Asymmetric implant position, best for I or II ◦ Open capsulectomy x Thick or calcified capsule, also smooth subglandular ◦ Conversion to submusculofascial ◦ Capsulorrhaphy x Suture capsule to reposition pocket into breast confines ` Capsular Contracture ◦ Long-Term Results x Varying degrees of firmness x Not all require correction x Replacement: Most last 7 –15 years ` 11,326 procedures performed on 18-year olds in 2003

` Phenomenon suggests poor parenting, through the capitulation of financially well- endowed parents to the whims of their children, who likely have self-esteem problems and are not yet emotionally (nor perhaps even physically) mature ` 4,108 procedures on women 18 and under in 2008

` US and EU: surgery allowed on those under age 18 only for medical reasons ◦ Yet 50% of procedures done for purely cosmetic reasons