1. Options for reconstruction after mastectomy: Silicone implants
-Advantages: feels more natural, looks better
-Disadvantages: costs more, holds its shape when it ruptures so ruptures can be silent, ruptures can also cause a significant inflammatory reaction,
2. Options for reconstruction after mastectomy: Saline implants
-Advantages: cheaper, deflatable (good for older/sicker women who wouldn't tolerate a removal surgery if something went wrong)
-Disadvantages: feels more plastic, more prone to visible skin wrinkling
3. Implants & Radiation
-Radiation damages the skin/muscle bed and makes it a worse recipient of both an expander and an implant, leading to worse medical and cosmetic outcomes.
-If you irradiate an implant, it damages both the tissue and the implant and increases risk of extrusion, contracture, and other complications.
-The best case scenario is if someone needs radiation, to avoid artificial implants altogether and got to an autologous tissue reconstruction. If you must use implants, wait for the skin to heal after radiation. Never irradiate an implant.
4. Implant general information:
-If you place it under muscle, the risk of extrusion is lower and the cosmetic appearance is often better.
-An expander may not be needed in everyone-- if the skin and muscle are in good quality, you might be able to put in an implant without an expander. But if someone is really skinny, or the tissue is really tight, you may need an expander.
5. Autologous tissue breast reconstruction: fat grafting +/- BRAVA
-Liposuction various parts of the body, inject into breast into various tissue planes
-BRAVA applies suction to breast, some people believe it opens up vascular spaces so that more of the fat grafts will take
-Some people think you can reconstruct an entire breast with fat grafting; however you will not get the same projection as with a flap or an implant.
5. Local flaps-- Classic latissimus flap
-Supplied by thoracodorsal artery
-usually does not have enough tissue to reconstruct a full breast, will likely still need an implant.
-You dissect out the entire muscle, swing it through the axilla to the front
-No functional loss unless the person is a rock climber or serious swimmer
6. Local flaps- TAP (Thoracodorsal artery flap)
-Like a classic latissimus, but instead of taking the pedicle and entire muscle, you take a much smaller segment by dissecting out only the perforators that go to the skin.
7. Local flaps- TRAM (transverse rectus abdominus myocutaenous)
-Based on the superior epigastric vessels (continuous with internal mammary vessels through "choke point")
-You take the skin and fat b/l, and then take the rectus muscle on the side that you take the pedicle. If you only take one pedicle and its a really big flap, you will almost certainly lose the far lateral contralateral portion of the flap to ischemia. If you take both rectus muscles, you will have much better perfusion of the flap, but this is extremely morbid...
-Because the TRAM is a pedicled flap, it's faster and easier, so good for people who are too sick to tolerate a long time under anesthesia.
-The risk of kinking a vessel (more likely vein, lower pressure) is present; you can prophylactically do another venous-venous anastomosis with one of the vessels to a vein in the axilla.
-If you cut the inferior epigastric vessels a few weeks before surgery, you will increase flow through the superior epigastrics.
8. Free flaps- free TRAM
-Blood comes from deep inferior epigastrics instead of the superior epigastrics
-Advantages over pedicled TRAM: all of the zones of the flap are better perfused, the vessels are usually bigger than superior epigastrics
9. Free flaps- DIEP (deep inferior epigastric perforators)
-Instead of taking the deep inferior epigastrics as a pedicle, you take the perforators. When you find them, trace them back to the origin off the DIEP to dissect them out.
-The smaller the perforators, the more you need, and the more likely you are to have to take out a cuff of muscle with them.
-Because you have to cut the fascia, you get complications (hernia, etc)
10. Free flaps- SIEA (superficial inferior epigastric perforators)
-You take the perforators of the superficial interior epigastric vessels, which enter above the fascia, in this way you avoid having to cut the fascia.
-Disadvantages is that these vessels are usually very small (<1.5mm, sometimes <1mm) and being superficial vessels, they are much more prone to spasm.
-You can do unilateral or bilateral SIEA