This is part of our back to basics series. On this episode, we cover the essentials of breast surgery and aesthetics. Great for medical students and learners rotating on plastic surgery.

 

Topics: Breast Reconstruction, Breast Cancer, and Breast Implants

Breast Cancer Treatment

• Patients either undergo a mastectomy where all tissue is removed or lumpectomy aka breast conservation therapy (BCT) – studies show that these have equivalent outcomes
• Types of Mastectomies
  • Nipple sparing mastectomy – nipple areolar complex is saved
  • Skin sparing mastectomy – nipple areolar complex is removed
• Borders of the Breast (common question for learners)
  • Superior – clavicle
  • Inferior – IMF
  • Lateral – anterior border of serratus (or latissimus)
  • Medial – sternum and pec fascia
• SLNB : sentinel lymph node biopsy
  • Trying to identify what is the dominant drainage pattern of the breast and taking a biopsy of the most dominant node to assess for metastasis

Chemotherapy vs. Radiation

• Chemotherapy – addresses systemic disease
• Radiation – addresses local disease
  • Used for larger tumors, multiple positive nodes
  • Will cause the irradiated tissue to be smaller, tighter; raises the level of the IMF
  • Can also impact implant placement; will generally place a tissue expander prior to radiation
  • Leads to hypovascularity, narrows vessels, hypoxia, depletes fibroblasts, decreases epithelial cell activity, and alters cell signaling and leads to disorganized collagen

 

Staged Reconstruction

• Two staged reconstruction often implies the use of a tissue expander first
  • A tissue expander is essentially a spacer
• One stage is often called “direct to implant” reconstruction
• Timing & Terminology
  • Delayed reconstruction : mastectomy  close the skin, and later perform reconstruction
  • Immediate reconstruction: mastectomy  definitive
  • Delayed – Immediate : two staged approach involving a tissue expander and a later definitive reconstruction

Implants

• Why use a tissue expander?
  • Helps keep a pocket open in the setting of potential radiation
  • Has tabs to suture in place and really define your pocket

 

Options for autologous reconstruction or flap reconstruction:

• Often rely on the epigastric vessels – inferior or superior
• Historically before microsurgery surgeons perform pedicled TRAM using the superior epigastric vessels
• Perforator version of this flap – MS-TRAM or DIEP
  • MS-TRAM – (muscle sparing TRAM) take a portion of the rectus muscle
  • DIEP – Deep inferior epigastric perforator flap
    • dissecting through the rectus muscle down to the pelvis to the deep inferior epigastric system
    • Contraindications : prior abdominal surgery where the perforators are impacted
  • Second line
    • PAP: profunda artery
    • SGAP and IGAP: superior gluteal and inferior gluteal
    • Lateral thigh perforator flap
    • Lumbar artery perforator flap

 

Counseling patients in their decision-making process:

• Discussing implants vs. flaps
  • Implants are a prosthetic material while a flap is their own tissue
    • No donor site, no other injury to another part of your body
    • Long term monitoring of the implant
    • Risks of contracture, infection, rupture
  • Tissue transfer or autologous
    • Longer hospital stay
    • Donor site on the abdomen
    • Long term more permanent
    • Appearance will look more natural over time
  • Hybrid option
    • Implant + Latissimus from the back— create a subcutaneous tunnel through the back to the breast
    • Often taught as a bail-out option
  • TDAP
    • Thoracodorsal artery flap, perforator based flap, dissecting through latissimus

 

Fat Grafting

• Liposuction, then cleaning and filtering of the fat, and finally re-injecting in small aliquots
• Corrects defects in augmenting small areas of a reconstruction; Helps resurface and recontour some areas
• Used as an adjunct for implant or autologous based reconstruction

 

Implant Options

• Surface texture: textured or smooth
  • Textured can be associated with less capsular contracture (scar tissue around the implant), also can have less migration and allows for more shaped implants
  • Downside of texture implants include BIA-ALCL, type of lymphoma
  • Smooth implants, less rippling but have more migration and rotation
• Shape : anatomic round or tear-drop shape
  • Tear shaped has less rotation
• Fill or Contents: silicone or saline
  • Silicone has a more natural feel but requires more monitoring
    • Cannot tell from exam whether there is rupture
    • More expensive
    • Requires a 4cm incision
  • Saline
    • Ability to fill them in the operating room using a remote port or one on the back of the implant
    • Don’t require monitoring in the same way
    • If this ruptures the patient will be able to tell as fluid gets resorbed by body
    • Sizers are often saline as they are adjustable
  • Silicone implants – cohesive and responsive
    • The most cohesive implants are used for reconstruction patients as they hold shape better, they are more firm
    • More responsive implants are softer but will ripple more and often those patients need some adequate coverage
  • Implant sizing factors – you can choose 2 to adjust
    • Projection
    • Base width
    • Volume
  • Placement of implant
    • In an augmentation patient can put above muscle – subglandular
    • In a reconstruction patient above the muscle is called pre-pectoral
    • Pre-pectoral/ subglandular
      • Less pain
      • Higher capsular contracture
      • No animation deformity
        • Animation deformity occurs in sub-pectoral where the implant moves upwards with the muscle contraction
      • Downside – not as much coverage over top of the implant so the implant ridge is more visible
        • Pinch test – evaluate thickness of their tissue
      • Sub-pectoral (under the pectoral muscle)
        • Less capsular contracture
        • Smoother upper pole
        • More pain with placement
        • Animation deformity
        • Potential to create separate plane where breast tissue becomes ptotic while implant stays up
      • Dual-Plane
        • Releasing pectoralis muscle inferiorly so that implant is partially under the pectoralis muscle
      • Incision
        • Often using prior incisions in reconstructive patients
        • Augmentation patient : peri-areolar, IMF, in the axilla, or umbilicus
          • Silicone in peri-areolar or IMF since you need 4cm
          • Axilla or umbilicus can be used for saline implants
          • Ducts of nipple areolar complex can  higher infection risk with that incision
        • Complications of Implant Reconstruction
          • Capsular contracture – 5-15% at 10 years and 100% by 23 years
            • Grade I – breast looks normal
            • Grade II – palpable
            • Grade III – palpable and visible
            • Grade IV – palpable, visible, and painful
          • Rupture – silicone harder to identify and linguini sign seen on MRI
            • 1% a year
          • Infection
          • BIA-ALCL
            • Textured implants