Reconstruction: Introduction

RECONSTRUCTIVE BREAST SURGERY

Georges Orloff, MD Department of Plastic Surgery Providence Saint Joseph Medical Center Burbank, CA 91505

TABLE OF CONTENTS - PLASTIC SECTION Introduction Immediate Breast Reconstruction Immediate Reconstruction with Expander Implant Immediate Reconstruction with TRAM Flap Delayed Reconstruction Management of Complications Post-Reconstruction Revisions Other types of Reconstructions Conclusion

One in eight women will develop breast cancer.

Advances in medical, surgical and radiation therapy have increased the amount of breast-sparing procedures available to avoid removal of the entire breast. Nonetheless, approximately one third of breast cancer patients will require a mastectomy due to the size of the tumor and inability to obtain tumor free margins. Today, reconstructive surgery makes it possible to improve the significant defects that result from mastectomies.

• Who is a Candidate?

All women undergoing a mastectomy are candidates for immediate or delayed reconstruction. There are many options available for breast reconstruction and individual circumstances will help decide the best choice.

• The Initial Evaluation

The initial evaluation is primarily used to educate the patient about reconstructive techniques. The benefits as well as potential complications of each procedure are discussed in detail. Reconstructive recommendations are given based upon the patient's desires and overall health. Recommendations will be made for immediate reconstruction, delayed reconstruction (a second operation once recovery from the mastectomy is complete), or in some cases no reconstruction at all is recommended.

The patient’s past medical history is thoroughly reviewed. Patients with serious co-existing illnesses have increased potential for complications. Conditions such as cardiac disease, diabetes mellitus, smoking and obesity are commonly associated with increased risk of complications.

Surgical histories are obtained to evaluate how previous surgeries may effect reconstructive options. A prior abdominoplasty or upper abdominal scar may eliminate the possibility of a pedicled transverse rectus abdominus myocutaneous (TRAM) flap. Lower abdominal scars may signify injury to perforators or pedicles supplying the tissue utilized for breast reconstruction. However c-section (lower mid-line or transverse) incisions usually do not eliminate the use of the TRAM flap.

If radiation therapy is being considered, patients are strongly advised against expander/implant reconstruction due to the higher incidence of symptomatic capsular contraction (hardening of the breast mound) and difficulties with expansion of irradiated tissue.

One of the most difficult challenges of breast reconstruction is to achieve symmetry between the native breast and the reconstructed breast. Before selecting a reconstructive approach, breast symmetry is discussed in relation to the remaining breast. There is a possibility the reconstructed breast may not be able to match the remaining breast. If the remaining breast is larger or ptotic, reduction mammoplasty or mastopexy may be considered. If the remaining breast is small, consideration may be given to augmentation to achieve symmetry with the reconstructed breast.