Transcript Breast Reconstruction Reconstruction Workshop, YSC National Summit March 6, 2015 R. Michael Koch, M.D., F.A.C.S. Assistant Professor of Surgery Mount Sinai School of Medicine New York.

Breast Reconstruction
Reconstruction Workshop, YSC National Summit
March 6, 2015
R. Michael Koch, M.D., F.A.C.S.
Assistant Professor of Surgery
Mount Sinai School of Medicine
New York
Less is More
The surgical treatment of breast cancer
continues to evolve.
The trend is towards less deforming methods.
Goal is to eradicate the tumor without destroying
normal tissues.
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Skin-sparing mastectomy
Breast conservation
Minimally invasive tumor ablation
Sentinel Lymph node biopsy
Percentage of Reconstructions
Breast Reconstruction
100%
Delayed Reconstruction
Immediate Reconstruction
80%
60%
40%
20%
0%
1975-1989
1990-2000
2003
Year
Newman LA, Kuerer HM, Hunt KK, et al. Ann Surg Oncol. 1998;5:620-626.
American Society of Plastic Surgeons, 2004. Available at http://www.plasticsurgery.org/.
Active Participation
A parallel development in reconstructive surgery
has also occurred.
Participation in multidisciplinary Breast Centers
Evolution in operative techniques:
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Direct to Implant reconstruction
Pedicled Flaps i.e. TRAM Flap
Flap “supercharging”
Flap “delay”
Free flaps
Perforator flaps
Intraoperative SPY Vascular Studies
Improving Outcomes
There is a greater emphasis on studying
patient outcomes.
A finer appreciation of the long-term
consequences of the surgical approaches.
Success is now gauged by how quickly
patients obtain quality-of-life objectives.
Patient expectations are increasing.
A Team Approach—The NY Group for
Plastic Surgery Model
A union between the
breast and
reconstructive
surgeon has
developed.
Shared goals and
philosophy
Ability to effectively
coordinate techniques
A Team Approach—The NY Group for
Plastic Surgery Model
These developments
have significantly
influenced women’s
interest.
Many choose to
undergo additional
reconstructive
procedures.
Surgical Perspective—the Driving Force for
Change
Traditionally, plasticsurgical thinking has
been thought of as a
balance between two
interdependent
forces:
– Reconstructive vs.
Aesthetic Surgery
Why Do Surgical Techniques Evolve?
Desire to improve results and outcome.
Progress has focused on three key issues:
– Minimizing surgical risk
– Improving flap survival
– Minimizing donor-site problems
Surgical repertoire
Constantly evolving:
– Staged Expander-to-implant
– Single-stage Alloderm and implant
– Pedicled flaps
TRAM, LTD
– Free flaps
TRAM
Rubens
ALT
Gracilis
Gluteal
– Perforator Flaps
DIEP
SIEA
SGAP
IGAP
Surgical Perspective—the Driving Force for
Change
The application of
surgical principles to
physical findings is the
true art of plastic surgery.
Goal is Surgical
Harmony.
Result should resonate.
Reflect the perfect
blending of surgical
ingredients.
Prosthetic Options-Tissue
Expanders
 Traditional Two
(Three) Stage
Approach:
 1. Placement of
Tissue Expander
 2. Office-based
injections to adjust
volume
 3. Exchange for
Implant
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Tissue Expander
Reconstruction-Initial Step
 Tissue Expanders are
temporary devices
 They create a breast
shape by changing
the surface area
 Expansion requires
healthy skin for
optimal results
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Tissue Expanders-Second Step
 Step Two is the
‘Exchange
Procedure”
 Performed once the
desired breast shape
and volume are
obtained
 Outpatient procedure
 Typically gel implants
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Delayed Reconstruction
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Nipple Reconstruction
 Nipple reconstruction
may be performed as
a third step
 Local tissue flap is
used
 Skin tattoo also an
option
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TISSUE EXPANSION
TISSUE EXPANSION
6 MONTHS POST-OP TISSUE EXPANDER
Ann Plast Surg. 57: 1–5, 2006
 Credited with 1st 1-
stage AlloDerm® RTM
RTM reconstruction in
2001.
 Patients: 49 women,
76 breasts
 Incisions: IMF, SSM
(periareolar),
transverse
Direct-to-Implant with Alloderm
 Direct to Implant
Approach
– Adequate and healthy
skin surface area
– Internal support with
dermal matrix
– Protection of overlying
skin
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HUMAN TISSUE MATRIX
 Human cadaver dermis (from tissue bank)
processed to remove all cells
 Collagen matrix left intact allowing
vascular ingrowth
 No disease transmission possibility or
antigeneic potential
HISTOLOGY AT 6 WEEKS
Vascular Ingrowth
Introducing Alloderm
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PRE-OP RIGHT BREAST
CANCER
7 YEARS POST-OP
Prosthetic Approaches
 Disadvantages:
 Advantages:
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Quicker procedure
Shorter recovery
Choose the size
symmetric result for
bilateral procedures
Only one operative
site
– Requires multiple
procedures
– May require revisions
– Visibility and
palpability
– Life-long risk of
infection
– Life-long risk of
capsular contracture
– Rupture
– Should not be used in
the setting of XRT
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Results
 Minor skin flap necrosis (6/30 breasts)
 All were excised and closed secondarily
 AlloDerm® RTM retained in all cases
 No rippling, synmastia, or capsular
contractures was observed.
 Mean follow-up 18 months (range 15 – 24
months)
PROPHYLACTIC MASTECTOMY
 SUBCUTANEOUS
 GENETICALLY
(POSITIVE BRCA 1
OR 2)
OR
STRONG FAMILY
HISTORY WITH NO
TESTING OR
NEGATIVE
MASTECTOMY
(FROZEN SECTION
IN RETRO AREOLAR
TISSUE)
INDICAT
ED IN
1 WEEK POST -OP
PRE-REDUCTION PROPH MASTECTOMY
6 MONTHS POST-OP
A Team Approach—The NY Group for
Plastic Surgery Model
A union between the
breast and
reconstructive
surgeon has
developed.
Shared goals and
philosophy
Ability to effectively
coordinate techniques
Thank You