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new aproach in breast reconstrution

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6 views

new aproach in breast reconstrution

Uploaded by

Sofia Espinoza
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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New Approaches to Breast Reconstruction

Matthew J. Carty, MD
Staff Surgeon, Division of Plastic Surgery
Brigham and Women’s Hospital
Associate Professor of Surgery
Harvard Medical School
Evolution of Outcomes

1984 2021
Goals of Breast Reconstruction

• Safe, reliable procedure


• Normal anatomic appearance in bra (at
minimum) and nude (ideal) with minimal
associated scarring
• Appropriately proportioned breast
mound relative to body habitus
• Aesthetic ptosis
• Adequate symmetry
• Anatomically positioned nipple areolar
complex with modest projection
• Cleavage without synmastia
Breast Reconstruction Requirement

PARTIAL VS TOTAL
Latissimus Dorsi Myocutaneous Flap

Preoperative Flap Transposition Final Result with Nipple


Markings Reconstruction
Thoracodorsal Artery Perforator (TDAP) Flap
Other Local Perforator Flaps for
Partial Breast Reconstruction
Breast Reconstruction Requirement

PARTIAL VS TOTAL
U.S. 2019 Distribution of Breast
Sales
Reconstruction Procedures by Type

1699, 1%
2046, 2%
88005, 82%
10338, 10%

4188, 4%
962, 1%

Implant-Based pTRAM Flap fTRAM Flap


DIEP Flap Latissimus Dorsi Flap Other Flap
Phases of Breast Reconstruction

Diminishing complexity

PHASE I 3 months PHASE II 3 months PHASE III

• Establishment of • Nipple creation • Nipple areolar


definitive breast • Contour/scar complex tattooing
mound correction
• Symmetry-providing
procedure(s)

Full reconstruction requires approximately 6-12 months


Nipple-Sparing (NSM) Techniques

• Complete preservation of native external


breast architecture
• Reduction/elimination of Phase II/III
• Less conspicuous scar configuration,
particularly in case of implant-based
reconstruction
Optimal Patient Selection for NSM

ONCOLOGIC & RECONSTRUCTIVE

• Early stage/prophylactic • Limited ptosis


• Tumor >2cm from nipple • Desires similar size
• Tumor mass <3-4.5cm • Good skin quality with
• Localized disease minimal scarring
• Centrally positioned
NAC
• Non-smoker
Approaches to Reconstruction

IMPLANT VS FLAP

• Synthetic device that • Autologous tissue that


recapitulates lost restores lost breast
breast volume volume
• Requires upkeep • Involves obligatory
over time scarring at remote site(s)
Perforator Flap-Based
Breast Reconstruction

• Involves free (microsurgical)


transfer of tissue from one part
of the body to another
• Requires meticulous
dissection of blood vessels
supplying skin and fat from
underlying muscle
• Muscle remains in place and
intact to perform necessary
functions; minimizes donor-site
morbidity
• Flap(s) generally connected to
internal mammary vessels
located in central chest
• Usually involves partial rib
resection
Primary Donor Sites for Microsurgical
Breast Reconstruction: BWH
n=1656 Flaps

ABDOMEN BUTTOCKS THIGH


DIEP SGAP PAP
SIEA IGAP TUG
fTRAM DUG

BWH FREQUENCIES

96.4% 0.7% 2.9%


DIEP Flaps as a Percentage of
All Abdominal Flap Reconstructions
73%
71%
69%

60% 62% 62% 62%

50% 52%

43%

32%

2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

Source: American Society of Plastic Surgeons


Stacked/Composite Flap Recontruction
Average DIEP Operative Time by
Anatomic Distribution

DISTRIBUTION MEAN OPERATIVE TIME

Unilateral Delayed 423 min


Unilateral Immediate 428 min
Bilateral Delayed 620 min
Bilateral Immediate 600 min
BWH Microsurgical Breast
Reconstruction Complications

Mastectomy Skin Necrosis 7.1%


Fat Necrosis 4.8%
Return to OR 4.6%
Hematoma 4.4%
Donor Site Bulge/Hernia 2.0%
Seroma 1.9%
Operative Site Infection 1.4%
Flap Failure 1.1%

21% Overall Complication Rate


Microsurgical Breast Reconstruction
Operative Efficiency by Surgeon Case Number
1200

1100

1000
Operative Time (in Minutes)

900

800

700

600

500

400

300

200
0 50 100 150 200 250

Surgeon Case Number


DIEP Flap Breast Reconstruction
Complication Rates
40%

35%
Complication Rate

30%

25%

20%

15%

10%

5%

0%

Surgeon Case Number


Neurotization of Breast Reconstruction

• Technique whereby T4 (nipple) intercostal


nerves are coapted to sensory nerves in
transferred tissue or native NAC
• Preliminary study results suggest potential
for substantial recovery of erogenous nipple
sensibility
• Reinnervation has been correlated with
improved patient satisfaction and quality of
life
• Over 230 DIEP flaps neurotized to date at
BWH; assessment of results underway
• Grant proposal for prospective RCT at BWH
currently under review
Thank You!

Matthew J. Carty, M.D.


[email protected]
(617) 983-4555

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