General Surgery & Plastic Surgery Residency
 University of Pittsburgh
 Breast & Microvascular Fellowship
 University of Pennsylvania
 Assistant Professor of Surgery
 Magee-Womens Hospital
 VA Medical Center
 UPMC Presbyterian
 Childrens Hospital of Pittsburgh


 Recovery
 Psychological / aesthetic benefits
 Feeling whole
 Quality of life
 Informed choices

Will I need a mastectomy?

Will I need a chemotherapy or radiation?

Will all of my hair fall out?

Who will take care of everyone when I’m sick?

What will I look like after surgery?

Will my insurance cover all of this?


 Why have breast reconstruction?
 How are breasts reconstructed?
 What to expect
 Who is not a candidate for reconstruction?
 Who pays for all of this surgery?


 Cancer treatment first
 Reconstruction – the end of treatment
 Getting back to normal
 Symbol of femininity
 What will I look like after mastectomy?


 Partial


 Partial


 Partial


 Partial


 Partial
 Skin-sparing


 Partial
 Skin-sparing


 Partial
 Skin-sparing
 Simple


 Partial
 Skin-sparing
 Simple


 Partial
 Skin-sparing
 Simple
 Bilateral


 Partial
 Skin-sparing
 Simple
 Bilateral


 Partial
 Skin-sparing
 Simple
 Bilateral
 Modified radical


 Initial choice – you choose!
 No reconstruction
Prosthesis
 Delayed reconstruction
 Immediate reconstruction


 Personal choice
 Overall health
 Adjuvant therapy
Radiation


 Advantages
Less surgery
Less anesthesia
Improved appearance
Psychological benefit

Two basic types

Implant

Autologous / tissue


 Most commonly performed


 Most commonly performed
 Tissue expander


 Most commonly performed
 Tissue expander
 Expansion process


 Most commonly performed
 Tissue expander
 Expansion process
 Implant
Saline


 Most commonly performed
 Tissue expander
 Expansion process
 Implant
Saline
Silicone


 Advantages
Relatively minor surgeries
More rapid recovery
No donor site
Widely available


 Disadvantages
Less natural
Symmetry
Scar – capsular contracture
Need for future surgery


 Complications
What if it doesn’t work?
Capsular contracture
Implant rupture
Need for future surgery


 Adjuvant radiation
Increased capsular contracture


 Adjuvant radiation
Increased capsular contracture
 Long-term
Decreased cosmesis
Need for future surgery


 Indications
Smaller breasts
Willing to accept a balancing procedure
Bilateral reconstructions
Not candidates for tissue reconstruction


 Using excess tissue from the body


 Flap – unit of tissue
Skin / fat
Muscle
 TRAM flap
Transverse Rectus Abdominus Myocutaneous


 Advantages
Replaces “like with like”


 Advantages
Replaces “like with like”
Borrowing excess
Long-term outcome
Gold standard


 Disadvantages
Longer surgery / recovery


 Disadvantages
Longer surgery / recovery
More complicated
Donor site
Flap loss


 pedicled TRAM flap (pTRAM)


 pedicled TRAM flap (pTRAM)
Sacrifices entire muscle
Excision of fascia +/- mesh
 Hernia / bulge
Limited blood supply


 free TRAM flap (fTRAM)


 free TRAM flap (fTRAM)
Better blood supply
Microsurgery
More technically difficult


 muscle-sparing free TRAM flap (msfTRAM)


 DIEP flap
Deep Inferior Epigastric Perforator flap
No muscle taken
Direct closure of fascia
Reduced donor site defect


 SIEA flap
Superficial Inferior Epigastric Artery flap
No muscle taken
No facial incision
No hernia / bulge
Least donor site


 msf TRAM flap

50%


 DIEP flap

35%


 SIEA flap

15%


 LD flap
ELD (extended) flap


 Latissimus flap reconstruction


 With or without an implant


 Moderate surgery / recovery


 LD flap
ELD (extended) flap
 GAP flap
Gluteal Artery Perforator


 LD flap
ELD (extended) flap
 GAP flap
Gluteal Artery Perforator
 Rubens flap


 Complications
Donor site
 Wound healing
 Hernia / bulge


 Complications
Flap
 Wound healing
 Re-operation
 Partial / Complete loss


 Indications
Broader patient selection
 Smokers
 Obese
 Diabetics
 Radiation
 Other medical problems
 Older age


 Implant-based reconstructions
Surgery – 2 to 4 hrs
Recovery – overnight
Drains – 1 week
Expansion – beginning at 2 weeks


 Implant-based reconstructions
Expansion – lasting 4 to 8 weeks
Cool down period
Exchange for final implant


 Tissue-based reconstruction (free flap)
Surgery – 6 to 10 hrs
Recovery – 4 days
Drains – 1 week
Touch-up – 3 to 4 months


 Personal choice
 Poor overall health
 Morbidly obese
 Advanced stage


 1998 – Women’s Health and Cancer Rights Act
Mandates insurance coverage for all stages of reconstruction after mastectomy
Surgery and reconstruction of the other breast for symmetry
Treatment of complications


 Making informed choices
 Asking questions
 Choosing your surgeon
 Choosing the right procedure for the right patient at the right time