1. Breast Reconstruction
Manish Jain
1Breast Reconstruction

2. History
• Koshima and soeda (1989) - first clinical application of the inferior epigastric artery
perforator flap
• Fujino (1975) - superior gluteal myocutaneous free flap for breast reconstruction.
• Inferior gluteal myocutaneous flap was performed in 1978 by lequang
• Millard proposed the nipple-sharing concept
• Silicone implants were employed for the first time at the beginning of the 1960s
• Iginio tansini (1906) - latissimus dorsi muscle flap, as an axial musculocutaneous
flap to cover mastectomy defects
• Hartrampf and colleagues (1979) - transverse rectus abdominis musculocutaneous
(TRAM) flap
• Fujino and colleagues described the first use of free tissue transfer for breast
reconstruction in 1976 2Breast Reconstruction

3. Statistical standards for the dimensions of the breast
Nipple projection - ≥1 cm
Nippe diameter – 1.1-1.3 cm
Areola diameter - 4.2–4.5 cm
3Breast Reconstruction

4. Introduction
• Size, symmetry, proportionality and the location of the breast and its landmarks on
the chest wall all play a role in the attractiveness of the breast.
• Knowledge of breast anatomy, in particular, the vascular pedicle and location of the
nerves, facilitates safe and effective surgical management.
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5. Vascularity
•Primary arterial supply
Internal mammary perforators – 60%
Lateral thoracic artery
Anterolateral intercostal perforators
•Secondary arterial supply
Thoracoacromial artery and its perforators
Vessels of the serratus anterior
5Breast Reconstruction

6. Innervation
Sensory innervation - three major nerve distributions
• Anterior lateral intercostals (T3–T6) - lateral portion of the breast including the
nipple areolar complex.
• Anterior medial intercostals (T3-T6) - medial breast and nipple areolar complex
• Cervical plexus - superior medial aspect
6Breast Reconstruction

7. Treatment/surgical technique
Breast conserving surgery - for early-stage breast cancer
Combination of partial mastectomy (lumpectomy, quandrantectomy, or
segmentectomy) followed by adjuvant radiation therapy
Mastectomy – several type
• Total mastectomy - removes all breast tissue including the nipple-areola complex
• Skin-sparing mastectomy - preserves as much of the patient's breast skin as possible
and the breast parenchyma, nipple-areola contents are removed
• Nipple sparing mastectomy
• Prophylactic mastectomy
• Modified radical mastectomy - removes the breast tissue, the nipple-areola
complex, and the Level I–II axillary lymph nodes en bloc
7Breast Reconstruction

8. Effects of Mastectomy
• Depression /other mood disturbances
• Loss of libido
• Negative body image
• Loss of femininity
• Fears of recurrence
• Self-consciousness in terms of clothing
8Breast Reconstruction

9. Breast reconstruction
Timing Technique
Immediate
At the time of
resection
Volume displacement Volume replacementDelayed immediate
1–2 weeks following
resection
(confirmation of
margins status)
Delayed
Following radiation
therapy
9Breast Reconstruction

10. Immediate Reconstruction
• Psychologically more beneficial
• Operating on a nonirradiated or surgically scarred defect
• Technically easier
– Skin envelope more pliable
– Native inframammary fold easier to delineate
• Cost effective
• Disadvantage – concern for positive margins but does not delay the detection of
recurrent cancer
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11. Delayed Reconstruction
• Usually 3-9 months after mastectomy
• Better knowledge of cancer control
• Better selection of reconstructive procedure
• Avoids detrimental effects of radio or chemotherapy on the reconstruction
• Patient better appreciates reconstructive surgery
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12. Goals of Reconstruction
• Natural appearing breast mound with adequate volume for projection & size
• Skin envelope
• Symmetry with contralateral breast
• Nipple Areola Complex
breast reconstructive surgery aims to create, for all women, a bilateral cosmetic medium
sized breast (400–500 cc), highly projected, with little to moderate ptosis, rather than a
ptotic gland exactly matching the contralateral.
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13. Technique Selection
• Patients requirements
• Type of mastectomy
• Immediate or Delayed reconstruction
• Status of the opposite breast
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14. Methods of Reconstruction
3 methods of breast reconstruction
• Implant based reconstruction
• Autologous tissue reconstruction
Pedicled flap reconstruction
Free flap reconstruction
• Implant plus autologous tissue reconstruction
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15. Imaging in reconstructive breast surgery
Imaging techniques provide anatomical images that allow us not only to locate the dominant
perforator but also extra information about the vessels and donor area.
• Hand-held doppler ultrasound - does not distinguish between perforating vessels and
main axial vessels
• Color doppler imaging - provides dynamic information on vessel flow
• Multidetector-row computed tomography (MDCT)
• Magnetic resonance imaging (MRI)
MDCT today is considered the technique of choice in the preoperative evaluation of patients
who are candidates for autologous breast reconstruction.
15Breast Reconstruction

16. Partial Breast Reconstruction
• Indicated in patients with tumors in whom a standard lumpectomy would lead to
breast deformity or gross asymmetry (High tumor to breast ratio > 20%)
• Determined by breast size, tumor size, and tumor location.
• Two types
 Volume replacement technique
 Volume displacement technique
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17. 17Breast Reconstruction

18. Volume displacement techniques
• Rely on advancement, rotation or transposition of a large area of breast to fill a
small or moderate-sized defect.
• Include mastopexy or reduction techniques
• Wise pattern markings - allowing tumor resection in any breast quadrant
• The reconstructive goals include:
(1) preservation of nipple viability
(2) reshaping of breast mound
(3) closure of dead space
18Breast Reconstruction

19. Batwing mastopexy demonstrating removal of a tumor above the nipple, elevation of the nipple areolar
complex and breast reshaping.
A donut type mastopexy is shown, which repositions the nipple and preserves breast shape by removing a tumor
just lateral to the nipple areolar complex followed by reshaping using the mastopexy technique.
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20. Volume replacement techniques
• Women with small to moderate breasts who have insufficient residual breast tissue
for rearrangement
• Using non breast local or distant flaps
• Provides breast symmetry without remodeling the contralateral breast.
• Local flap – Small lateral defect (<10% of breast size)
(1) Rhomboid flaps
(2) Subaxillary flap
(3) Superior-based lateral thoracodorsal flap
(4) Inferior-based lateral thoracodorsal flap
(5) Extended lateral thoracodorsal flap
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21. 21Breast Reconstruction

22. Volume displacement techniques Volume replacement techniques
“Parenchymal remodeling, volume
shrinkage”
“Adjacent or distant tissue transfer, volume
preserving”
Primary closure Implant augmentation – rare
Batwing mastopexy Local flap, Fasciocutaneous flap
Breast flap advancement technique Perforator flaps
Nipple areolar centralization Latissimus dorsi MC flap
Reduction mastopexy techniques Distant flaps
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23. Expander-implants breast reconstructions
• Employed in all women undergoing immediate or delayed breast reconstructions that
did not receive previous radiation
• Indicated mainly for small and medium-sized glands with a moderate degree of ptosis.
• Two-stage procedure
• Advantages
 Minimal morbidity
 Reduced operative time
 No donor site morbidity
 Good colour match
 Early return to work (7 – 10 days)
 Maintains the breast space if the flap is later incorporated into a secondary
 reconstruction
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24. • Disadvantage -
 Complications inherent to implant use, including implant deflation or
malfunction, capsular contracture, and fear of adverse interactions between
the patient's immune system and the device
 Contour irregularities
 Will not behave like normal vascularized tissue
 Reconstructed breast will not develop natural ptosis with advancing age
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25. • Criteria
The patient must have an adequate skin envelope to support the expander-implant
 Patient must agree to delayed surgery of the opposite breast to establish symmetry
with the reconstructed breast mound
Cessation of smoking atleast 6 week prior to surgery
• Contraindicate - previously radio-treated patients
Serra-Renom et al , recently demonstrated that in mastectomized patients who received
radiotherapy, fat grafting in addition to traditional tissue expander and implant
breast reconstruction will lead to better reconstructive outcomes with the creation of
new subcutaneous tissue, accompanied by improved skin quality of the
reconstructed breast without capsular contracture.
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26. Evolution of prosthetic implants
• Shape
Round
Anatomical teardrop – implant of choice
• Shell – made of silicon shell
Monolayer or triple layer
Smooth or texture
• Filler material
Saline solution
Silicon gel - prevents capsular contracture and preserves the original shape
• Dimensions – Width, height, projection
Implant volume in no longer considered a determinant size
26Breast Reconstruction

27. Technique
• First stage – Expander insertion
• Pocket
 Marked just below opposite
inframammary crease but not more than
1 cm
 Plane - submusculofascial layer
 Pocket includes  Pectoralis major
muscle serratus anterior OR external
oblique-rectus abdominis aponeurosis
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28. • Sternal attachments of the pectoralis major are detached from the second intercostal
space to the inferior edge of the pocket
• The pocket should be completely sub-muscular except at the inframammary fold
• Small amount of saline (up to 20–30% of final volume) facilitates the insertion
• Implant placed in pocket with patient in sitting position
• The lateral margin of pec. Major muscle sutured to chest wall or to serratus anterior to
prevent migration
• Overexpansion (20% larger than planned volume) and maintain for 3-4 month
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29. Second stage
• Performed 6 months after the end of tissue expansion
• Expander is removed and replaced by a permanent anatomical implant.
• Total capsulectomy has to be performed
• Contralateral breast can also be operated for symmetry.
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30. Complication
• Capsule contracture – most common complication
 Most common reason for reoperation, implant removal
 Open capsulotomy or capsulectomy is the treatment of choice
 Leukotrienes such as zafirlukast yield positive results
Baker classification of capsular contracture
Grade Description
I Soft
II Less soft, but implant not visible
III
Moderate firmness, implant can be
palpated or distortion can be seen
IV
Very firm, hard, tender, painful, and
cold
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31. • Hematoma
• Erythema and cellulitis
• Persistent serous drainage
• Partial or complete skin necrosis
• Expander failure and malfunction
• Infection
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32. Reconstruction with Flaps
Pedicled flaps
• Latissimus Dorsi flap (Tansini)
• Rectus Abdominis flap (Hartrampf)
Free flaps
• Free TRAM/ DIEP/ SIEA flaps
• Superior/Inferior Gluteal artery perforator flaps
• Deep Groin or Ruben’s flap
• Other flaps - Medial & Lateral Thigh flap, gracilis flap
32Breast Reconstruction

33. Latissimus dorsi flap
Indication -
• Patients with poorly-vascularized or radiated defects, contour deformities
following breast conservation therapy particular lateral defect, or for
covering an implant.
• Extended latissimus dorsi flap is a reliable method for totally autologous
breast reconstruction, particularly in women who otherwise are at high risk
for a TRAM flap or an implant procedure.
• After a skin-sparing mastectomy when a breast prosthesis is part of the plan
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34. • Absolute contraindication - previous posterolateral thoracotomy
• Relative contraindication - atrophic latissimus dorsi muscle after division of
the thoracodorsal nerve
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35. Variation of latissimus dorsi flap -
• Split latissimus dorsi flap
• Extended latissimus dorsi flap – fleur-de-lis skin island with inverted T
shaped scar
• Muscle sparing latissimus dorsi flap
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36. Anatomy
10 cm
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37. Common placement of the skin island in planning of latissimus dorsi flap
reconstruction with a prosthesis.
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38. When total autogenous latissimus breast reconstruction is planned, the skin
island is designed to include all available excess back skin and fat.
flap is folded into a cone shape to increase the
volume and projection of the reconstructed
breast.
38Breast Reconstruction

39. The latissimus dorsi skin paddle
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40. Patient position
40Breast Reconstruction

41. Plane of dissection – just beneath the fascia superficialis
.
The deep fat is left attached to the muscle
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42. (A) Elevation of the latissimus dorsi musculocutaneous flap and the underlying anatomy
(B) After division of the muscle insertion, the latissimus flap is transposed anteriorly to the
mastectomy defect through a subcutaneous tunnel high in the axilla.
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43. In immediate reconstruction flap directly inset into the defect or placed beneath the
preserved skin
For delayed reconstruction inset between the inframammary incision & existing skin
envelope done
The expander is placed between the latissimus and pectoralis major muscles
43Breast Reconstruction

44. Complication
• Seroma – most common complication
• Flap necrosis
• Dorsal skin flap necrosis
• Shoulder weakness
• Winging of scapula
• Dorsal hernia
44Breast Reconstruction

45. Transverse Rectus Abdominis Flap
Indications
• Reconstruction without an implant & Bonus Abdominoplasty
• When tissues after total mastectomy or modified radical mastectomy are of Poor
quality & quantity
• With imminent exposure of implant through attenuated skin
• When axillary fill is needed
• Tissue deficit in infraclavicular region
45Breast Reconstruction

46. Contraindications
Absolute
• Previous irradiation to base of flap / mediastinum
• Surgical division of the pedicle
• Prior abdominoplasty
• Multiple scarring of abdomimal wall
Relative contraindications
• Patients > 65 years
• Very obese patients
• Pt. With unfavorable microcirculation
 Diabetes
 Cigarette smoking
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47. Advantages
• Donor scar transverse in lower abdomen (better concealed)
• Versatile flap
• Large amount of fat and skin can be moved to breast area
• Implants not required
Disadvantages
• Variable predictability
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48. TRAM flap
Vascular anatomy of the deep epigastric system.
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49. Circulatory zones of the TRAM flap
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50. Bilateral pedicled TRAM is preferred over the bilateral free TRAM. On the
other hand, the unilateral free TRAM is preferred over the unilateral pedicle
TRAM mostly for perfusion pressure reasons.
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51. Abdominal markings
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52. Tunnel location
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53. (A) Marking extent of recti.(B) Proposed fascial strip centered over SEA signal.
(C) Final markings of fascial and muscle strip.
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54. Lateral muscle dissection. (A) Identifying lateral extent of rectus muscle as a
landmark. (B) Careful intramuscular dissection around DIEA.(C) Identifying DIEA hilum
entering inferolateral edge of muscle. (D) Clipping the DIEA.
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55. Demonstrating width and length of fascial and muscle
strip and extent of dissection up over costal margin
Medial dissection maintaining control
of flap at all times with opposite hand.
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56. Gently turning the pedicle around
the costal margin avoids two kinks
which result if the pedicle is flipped.
Simultaneous fascial closure distributes tension
across the abdomen and aides in primarily
closing the fascial defects.
56Breast Reconstruction

57. Free TRAM & variations
Advantages over pedicled TRAM
• Better Blood supply
• Lesser donor site morbidity
• Based on deep inferior epigastric artery
Variations are
• Deep inferior epigastric perforator free flap
• Superficial inferior epigastric artery free flap
57Breast Reconstruction

58. The variations of a free TRAM
The MS-0 flap in which the rectus
muscle is completely transected.
The MS-I spares the lateral band preferably (as
opposed to the medial band) of muscle with
the goal of preserving the innervation of the
muscle
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59. MS-II flap, only a small central portion
of the rectus muscle around the
perforators is transected.
The MS-III, otherwise known as a DIEP
preserves the entire rectus muscle
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60. The two most common sites for recipient vessel harvest and subsequent vascular
anastomoses are the internal mammary vessels and the thoracodorsal vessels.
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61. Complication
• Flap necrosis
• Delayed wound healing
• Hematoma
• Seromas
• Loss of native breast skin
• Fat necrosis
• Dog ears of the abdomen,
• Peri-flap depressions
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62. deep inferior epigastric artery perforator (DIEAP) flap
• Provides a large volume of soft, malleable tissue
• Preservation of full rectus abdominis muscle function translating into less
donor site morbidity
• Based on perforater of DIEA
• Perforator flap of choice for autologous breast reconstruction.
• Average pedicle length is 10.3 cm and the average vessel diameter is 3.6 mm
• The superficial inferior epigastric vein - draining the skin paddle of the
DIEAP flap
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63. 63Breast Reconstruction

64. The different types of perforators that can be found at the lower abdominal wall. (1) The branches of the superficial inferior epigastric artery
are direct perforators that vascularize the subcutaneous fat and skin after perforating the deep and superficial fascia. All other perforators are
indirect perforators; (2) perforators that have a predominant vascularization of the subcutaneous fat tissue and skin with few muscular
branches; (3) perforators that branch off of side branches that have a predominant goal of nourishing the muscle; (4) perforators that pass
through the rectus abdominis muscle without branching; (5) perforators that pass through the septum or around the rectus abdominis muscle
with the sole goal of vascularizing the subcutaneous tissues.
64Breast Reconstruction

65. • Between two and eight large (>0.5 mm) perforators on each side of the
midline.
• Location - paramedian rectangular area 2 cm cranial and 6 cm caudal to
the umbilicus and between 1 and 6 cm lateral to the umbilicus.
• Lateral perforators – dominant, easier to dissect, run more
perpendicularly through the muscle
• Medial perforators - provide better perfusion, longer intramuscular
course
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66. Surgical technique
• Suprafascial dissection
• Intramuscular dissection
• Submuscular dissection
66Breast Reconstruction

67. 67Breast Reconstruction

68. Superior/inferior gluteal artery perforator free flap
(SGAP/IGAP)
• Patients with excess tissue in the buttock versus the abdomen are the ideal
candidates
• Patients who require mostly fat and little skin may be candidates for
SGAP/IGAPS flaps
• Absolute contraindications - previous liposuction at the donor site or active
smoking within 1 month prior to surgery.
68Breast Reconstruction

69. Advantages
• Hidden donor site
• Good bulk
Disadvantages
• Technically demanding
• Time consuming
• Requires repositioning of pt
• Flap contouring difficult due to globular fat
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70. Superior gluteal artery perforator flap
• Continuation of the posterior division of the internal iliac artery
• Anatomic location - line is drawn from the posterior superior iliac spine to
the posterior superior angle of the greater trochanter.
The point of entrance - corresponds to the junction of the upper and middle
thirds of this line.
• The pedicle length - 5–8 cm
• The flap height and length - 7–10 x 18–24 cm.
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71. Inferior gluteal artery perforator flap
• Terminal branch of the anterior division of the internal iliac artery
• Anatomic location - A line is drawn from the posterior superior iliac spine
to the outer part of the ischial tuberosity
point of entrance – corrospond to the junction of its lower with its middle
third
• Pedicle length - 7–10 cm.
• The inferior limit of the flap is marked 1 cm inferior and parallel to the
gluteal fold.
• Skin paddle dimension - 7 18 cm.
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72. Deep circumflex iliac artery (Ruben’s) Flap
• Based on the perforators from the DCIA
• Utilises excess skin at the flanks (saddlebags)
• Technique is difficult, time consuming
• Donor site closure cumbersome
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73. Prerequisites -
• Breast reconstruction should be stable
• Breast symmetry should have been achieved
Goal
• Position - ideally located on the point of most projection on the breast mound
• Symmetry
• Colour
• Size
• Projection
• Sensitivity
Ideal timing for reconstruction is approximately 3–5 months after the last
revisional reconstructive surgery
Reconstruction of Nipple & Areola
73Breast Reconstruction

74. Surgical technique
Composite nipple graft -
• Excellent option for patients with contralateral nipple >1 cm projection
Disadvantage –
(1) fear of contralateral surgery
(2) donor site morbidity
(3) decreased contralateral nipple sensation.
De-epithelialization of the
proposed nipple site.
Traction is placed to elongate the
nipple and scalpel is used to
transect 40–50% of the distal
nipple
Placement of the composite nipple
graft and secured with interrupted
chromic suture 74Breast Reconstruction

75. Skate flap
• Has reliably produced long-term projection
• Used in conjunction with a skin graft for immediate areola reconstruction
75Breast Reconstruction

76. Star flap
• Advantage of eliminating skin graft donor site morbidity by allowing for
primary closure
• Lack of projection when compared with the skate flap
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77. C-V Flap
• Elements of both the star and skate flaps
• Ease of elevation and ability to close the donor site primarily without the
use of a skin graft
The basic design of the C–V flap. The outer V-segments can have variable degrees of angulation
from sharp to blunted edges. (B) Sutures are first placed to approximate the donor site. The outer
wings are then approximated at the midline and sutured together. (C) The central C-segment is
then rotated down to form the rounded dome of the nipple.
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78. • Arrow flap - Z-plasty configuration may decrease contraction and nipple
distortion
• Bell Flap- incorporates a purse-string areola closure that provides slight
areolar projection.
• Top hat flap -
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79. Flap designs adjacent to scars
• S flap
• Double opposing tab flap
• Spiral flap
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80. Other method
Flap with autologous graft augmentation -
• Cartilage graft
• Fat graft
Flap with alloplastic augmentation -
• Polyurethane coated silicone gel
• Injectable calcium hydroxylapatite
• Hyaluronic acid
• Artificial bone substance
• Polytetrafluroethylene
Flap with allograft augmentation -
• Alloderm – human derived acellular dermis
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81. Areola reconstruction
Method –
• Skin grafting
• Tattooing
• Combination of both
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82. Skin grafting-
• Has the advantages of providing a textured, wrinkled surface and distinct
pigment differences
• Common areola donor sites -
 Contralateral areola
 Inner thigh
 Excess/discarded skin
 Scar revision skin
 Labial tissue (rarely used).
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83. (A) The chosen color is placed uniformly on the proposed tattoo site. (B) The tattoo pigment is electrically
deposited with the use of a tattoo gun. (C) After the tattooing is finished, a nice uniform deposition of pigment
should be observed.
Tattooing- - provide excellent areolar color match with limited morbidity
• Deposited into the upper and mid-papillary dermis
• Typically mixtures of iron and titanium oxide
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84. • Thank you
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85. 85Breast Reconstruction

86. 86Breast Reconstruction

87. 87Breast Reconstruction

88. Timing of reconstruction after mastectomy
• Immediate reconstruction – Standard
treatment nowadays
• Delayed reconstruction
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89. • Distant Flap
• latissimus dorsi musculocutaneous flap - lateral, central, inferior and even
medial defects
• thoraco-dorsal artery perforator (TDAP) flap - lateral, superolateral and
central regions of the breast
• lateral intercostal artery perforator (LICAP) flap - lateral and inferior
breast defects
• anterior intercostal artery perforator (AICAP) flap - inferior or medial
quadrants of the breast
• superior epigastric artery perforator (SEAP) flap
• superficial inferior epigastric artery free flap – for large medial defect
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90. Technique
• Pocket for implant
– The inferior part of the implant may
be left extra-muscular to give better
definition to the inframammary
crease by separating the strenal
origin of the pec. Major from
second Intercostal space to inferior
edge of pocket
– Implant placed in pocket with
patient in sitting position
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91. Technique
• The lateral margin of pec.
major muscle sutured to
chest wall or to serratus
anterior to prevent
migration
• Nipple-areola surgery or
operations on the breast
mound are performed 3
months later
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92. • Only in very slender women or in cases where multiple scarring of the
abdominal wall endangers the normal blood circulation of the free flap or
the abdominoplasty flap,
• Contraindications concerning general health can also influence the
decision. Morbid and severe obesity, uncontrolled diabetes, debilitating
cardiovascular diseases and uncontrollable coagulopathies
• Patients refusing additional scars at the donor site, refusing complex
surgery or accepting the possible microsurgical complications,
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93. Management of Opposite Breast
• Oncologic management as per requirement
• Patient’s wish
– Does not want operation on opposite breast (flap
reconstruction for symmetry)
• Otherwise, if opposite breast
– Small & flat – Augmentation Mammoplasty
– Hypoplastic & ptotic – Submusculofascial Implant &
Mastopexy (nipple areola elevated)
– Hypertrophic & heavy – Reduction Mammoplasty
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94. Reconstruction of the nipple-areola complex
• Creation of the nipple-areola complex allows the reconstructed breast
mound to truly resemble the natural breast.
• The NAC is ideally located on the point of most projection on the breast
mound
• ideal timing for reconstruction is approximately 3–5 months after the last
revisional reconstructive surgery
• Many of the currently used flaps are derivatives of the basic design of the
skate flap and star flap.
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