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Breast reconstruction



Breast reconstruction manish jian

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Breast reconstruction manish jian

  1. 1. Breast ReconstructionManish Jain1Breast Reconstruction
  2. 2. History• Koshima and soeda (1989) - first clinical application of the inferior epigastric arteryperforator 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 musculocutaneousflap 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 breastreconstruction in 1976 2Breast Reconstruction
  3. 3. Statistical standards for the dimensions of the breastNipple projection - ≥1 cmNippe diameter – 1.1-1.3 cmAreola diameter - 4.2–4.5 cm3Breast Reconstruction
  4. 4. Introduction• Size, symmetry, proportionality and the location of the breast and its landmarks onthe chest wall all play a role in the attractiveness of the breast.• Knowledge of breast anatomy, in particular, the vascular pedicle and location of thenerves, facilitates safe and effective surgical management.4Breast Reconstruction
  5. 5. Vascularity•Primary arterial supplyInternal mammary perforators – 60%Lateral thoracic arteryAnterolateral intercostal perforators•Secondary arterial supplyThoracoacromial artery and its perforatorsVessels of the serratus anterior5Breast Reconstruction
  6. 6. InnervationSensory innervation - three major nerve distributions• Anterior lateral intercostals (T3–T6) - lateral portion of the breast including thenipple areolar complex.• Anterior medial intercostals (T3-T6) - medial breast and nipple areolar complex• Cervical plexus - superior medial aspect6Breast Reconstruction
  7. 7. Treatment/surgical techniqueBreast conserving surgery - for early-stage breast cancerCombination of partial mastectomy (lumpectomy, quandrantectomy, orsegmentectomy) followed by adjuvant radiation therapyMastectomy – several type• Total mastectomy - removes all breast tissue including the nipple-areola complex• Skin-sparing mastectomy - preserves as much of the patients breast skin as possibleand the breast parenchyma, nipple-areola contents are removed• Nipple sparing mastectomy• Prophylactic mastectomy• Modified radical mastectomy - removes the breast tissue, the nipple-areolacomplex, and the Level I–II axillary lymph nodes en bloc7Breast Reconstruction
  8. 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 clothing8Breast Reconstruction
  9. 9. Breast reconstructionTiming TechniqueImmediateAt the time ofresectionVolume displacement Volume replacementDelayed immediate1–2 weeks followingresection(confirmation ofmargins status)DelayedFollowing radiationtherapy9Breast Reconstruction
  10. 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 ofrecurrent cancer10Breast Reconstruction
  11. 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 surgery11Breast Reconstruction
  12. 12. Goals of Reconstruction• Natural appearing breast mound with adequate volume for projection & size• Skin envelope• Symmetry with contralateral breast• Nipple Areola Complexbreast reconstructive surgery aims to create, for all women, a bilateral cosmetic mediumsized breast (400–500 cc), highly projected, with little to moderate ptosis, rather than aptotic gland exactly matching the contralateral.12Breast Reconstruction
  13. 13. Technique Selection• Patients requirements• Type of mastectomy• Immediate or Delayed reconstruction• Status of the opposite breast13Breast Reconstruction
  14. 14. Methods of Reconstruction3 methods of breast reconstruction• Implant based reconstruction• Autologous tissue reconstructionPedicled flap reconstructionFree flap reconstruction• Implant plus autologous tissue reconstruction14Breast Reconstruction
  15. 15. Imaging in reconstructive breast surgeryImaging techniques provide anatomical images that allow us not only to locate the dominantperforator but also extra information about the vessels and donor area.• Hand-held doppler ultrasound - does not distinguish between perforating vessels andmain 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 patientswho are candidates for autologous breast reconstruction.15Breast Reconstruction
  16. 16. Partial Breast Reconstruction• Indicated in patients with tumors in whom a standard lumpectomy would lead tobreast 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 technique16Breast Reconstruction
  17. 17. 17Breast Reconstruction
  18. 18. Volume displacement techniques• Rely on advancement, rotation or transposition of a large area of breast to fill asmall 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 space18Breast Reconstruction
  19. 19. Batwing mastopexy demonstrating removal of a tumor above the nipple, elevation of the nipple areolarcomplex and breast reshaping.A donut type mastopexy is shown, which repositions the nipple and preserves breast shape by removing a tumorjust lateral to the nipple areolar complex followed by reshaping using the mastopexy technique.19Breast Reconstruction
  20. 20. Volume replacement techniques• Women with small to moderate breasts who have insufficient residual breast tissuefor 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 flap20Breast Reconstruction
  21. 21. 21Breast Reconstruction
  22. 22. Volume displacement techniques Volume replacement techniques“Parenchymal remodeling, volumeshrinkage”“Adjacent or distant tissue transfer, volumepreserving”Primary closure Implant augmentation – rareBatwing mastopexy Local flap, Fasciocutaneous flapBreast flap advancement technique Perforator flapsNipple areolar centralization Latissimus dorsi MC flapReduction mastopexy techniques Distant flaps22Breast Reconstruction
  23. 23. Expander-implants breast reconstructions• Employed in all women undergoing immediate or delayed breast reconstructions thatdid 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 reconstruction23Breast Reconstruction
  24. 24. • Disadvantage - Complications inherent to implant use, including implant deflation ormalfunction, capsular contracture, and fear of adverse interactions betweenthe patients immune system and the device Contour irregularities Will not behave like normal vascularized tissue Reconstructed breast will not develop natural ptosis with advancing age24Breast Reconstruction
  25. 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 symmetrywith the reconstructed breast moundCessation of smoking atleast 6 week prior to surgery• Contraindicate - previously radio-treated patientsSerra-Renom et al , recently demonstrated that in mastectomized patients who receivedradiotherapy, fat grafting in addition to traditional tissue expander and implantbreast reconstruction will lead to better reconstructive outcomes with the creation ofnew subcutaneous tissue, accompanied by improved skin quality of thereconstructed breast without capsular contracture.25Breast Reconstruction
  26. 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, projectionImplant volume in no longer considered a determinant size26Breast Reconstruction
  27. 27. Technique• First stage – Expander insertion• Pocket Marked just below oppositeinframammary crease but not more than1 cm Plane - submusculofascial layer Pocket includes  Pectoralis majormuscle serratus anterior OR externaloblique-rectus abdominis aponeurosis27Breast Reconstruction
  28. 28. • Sternal attachments of the pectoralis major are detached from the second intercostalspace 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 toprevent migration• Overexpansion (20% larger than planned volume) and maintain for 3-4 month28Breast Reconstruction
  29. 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.29Breast Reconstruction
  30. 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 resultsBaker classification of capsular contractureGrade DescriptionI SoftII Less soft, but implant not visibleIIIModerate firmness, implant can bepalpated or distortion can be seenIVVery firm, hard, tender, painful, andcold30Breast Reconstruction
  31. 31. • Hematoma• Erythema and cellulitis• Persistent serous drainage• Partial or complete skin necrosis• Expander failure and malfunction• Infection31Breast Reconstruction
  32. 32. Reconstruction with FlapsPedicled 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 flap32Breast Reconstruction
  33. 33. Latissimus dorsi flapIndication -• Patients with poorly-vascularized or radiated defects, contour deformitiesfollowing breast conservation therapy particular lateral defect, or forcovering an implant.• Extended latissimus dorsi flap is a reliable method for totally autologousbreast reconstruction, particularly in women who otherwise are at high riskfor a TRAM flap or an implant procedure.• After a skin-sparing mastectomy when a breast prosthesis is part of the plan33Breast Reconstruction
  34. 34. • Absolute contraindication - previous posterolateral thoracotomy• Relative contraindication - atrophic latissimus dorsi muscle after division ofthe thoracodorsal nerve34Breast Reconstruction
  35. 35. Variation of latissimus dorsi flap -• Split latissimus dorsi flap• Extended latissimus dorsi flap – fleur-de-lis skin island with inverted Tshaped scar• Muscle sparing latissimus dorsi flap35Breast Reconstruction
  36. 36. Anatomy10 cm36Breast Reconstruction
  37. 37. Common placement of the skin island in planning of latissimus dorsi flapreconstruction with a prosthesis.37Breast Reconstruction
  38. 38. When total autogenous latissimus breast reconstruction is planned, the skinisland is designed to include all available excess back skin and fat.flap is folded into a cone shape to increase thevolume and projection of the reconstructedbreast.38Breast Reconstruction
  39. 39. The latissimus dorsi skin paddle39Breast Reconstruction
  40. 40. Patient position40Breast Reconstruction
  41. 41. Plane of dissection – just beneath the fascia superficialis.The deep fat is left attached to the muscle41Breast Reconstruction
  42. 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 themastectomy defect through a subcutaneous tunnel high in the axilla.42Breast Reconstruction
  43. 43. In immediate reconstruction flap directly inset into the defect or placed beneath thepreserved skinFor delayed reconstruction inset between the inframammary incision & existing skinenvelope doneThe expander is placed between the latissimus and pectoralis major muscles43Breast Reconstruction
  44. 44. Complication• Seroma – most common complication• Flap necrosis• Dorsal skin flap necrosis• Shoulder weakness• Winging of scapula• Dorsal hernia44Breast Reconstruction
  45. 45. Transverse Rectus Abdominis FlapIndications• Reconstruction without an implant & Bonus Abdominoplasty• When tissues after total mastectomy or modified radical mastectomy are of Poorquality & quantity• With imminent exposure of implant through attenuated skin• When axillary fill is needed• Tissue deficit in infraclavicular region45Breast Reconstruction
  46. 46. ContraindicationsAbsolute• Previous irradiation to base of flap / mediastinum• Surgical division of the pedicle• Prior abdominoplasty• Multiple scarring of abdomimal wallRelative contraindications• Patients > 65 years• Very obese patients• Pt. With unfavorable microcirculation Diabetes Cigarette smoking46Breast Reconstruction
  47. 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 requiredDisadvantages• Variable predictability47Breast Reconstruction
  48. 48. TRAM flapVascular anatomy of the deep epigastric system.48Breast Reconstruction
  49. 49. Circulatory zones of the TRAM flap49Breast Reconstruction
  50. 50. Bilateral pedicled TRAM is preferred over the bilateral free TRAM. On theother hand, the unilateral free TRAM is preferred over the unilateral pedicleTRAM mostly for perfusion pressure reasons.50Breast Reconstruction
  51. 51. Abdominal markings51Breast Reconstruction
  52. 52. Tunnel location52Breast Reconstruction
  53. 53. (A) Marking extent of recti.(B) Proposed fascial strip centered over SEA signal.(C) Final markings of fascial and muscle strip.53Breast Reconstruction
  54. 54. Lateral muscle dissection. (A) Identifying lateral extent of rectus muscle as alandmark. (B) Careful intramuscular dissection around DIEA.(C) Identifying DIEA hilumentering inferolateral edge of muscle. (D) Clipping the DIEA.54Breast Reconstruction
  55. 55. Demonstrating width and length of fascial and musclestrip and extent of dissection up over costal marginMedial dissection maintaining controlof flap at all times with opposite hand.55Breast Reconstruction
  56. 56. Gently turning the pedicle aroundthe costal margin avoids two kinkswhich result if the pedicle is flipped.Simultaneous fascial closure distributes tensionacross the abdomen and aides in primarilyclosing the fascial defects.56Breast Reconstruction
  57. 57. Free TRAM & variationsAdvantages over pedicled TRAM• Better Blood supply• Lesser donor site morbidity• Based on deep inferior epigastric arteryVariations are• Deep inferior epigastric perforator free flap• Superficial inferior epigastric artery free flap57Breast Reconstruction
  58. 58. The variations of a free TRAMThe MS-0 flap in which the rectusmuscle is completely transected.The MS-I spares the lateral band preferably (asopposed to the medial band) of muscle withthe goal of preserving the innervation of themuscle58Breast Reconstruction
  59. 59. MS-II flap, only a small central portionof the rectus muscle around theperforators is transected.The MS-III, otherwise known as a DIEPpreserves the entire rectus muscle59Breast Reconstruction
  60. 60. The two most common sites for recipient vessel harvest and subsequent vascularanastomoses are the internal mammary vessels and the thoracodorsal vessels.60Breast Reconstruction
  61. 61. Complication• Flap necrosis• Delayed wound healing• Hematoma• Seromas• Loss of native breast skin• Fat necrosis• Dog ears of the abdomen,• Peri-flap depressions61Breast Reconstruction
  62. 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 lessdonor 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 theDIEAP flap62Breast Reconstruction
  63. 63. 63Breast Reconstruction
  64. 64. The different types of perforators that can be found at the lower abdominal wall. (1) The branches of the superficial inferior epigastric arteryare direct perforators that vascularize the subcutaneous fat and skin after perforating the deep and superficial fascia. All other perforators areindirect perforators; (2) perforators that have a predominant vascularization of the subcutaneous fat tissue and skin with few muscularbranches; (3) perforators that branch off of side branches that have a predominant goal of nourishing the muscle; (4) perforators that passthrough the rectus abdominis muscle without branching; (5) perforators that pass through the septum or around the rectus abdominis musclewith the sole goal of vascularizing the subcutaneous tissues.64Breast Reconstruction
  65. 65. • Between two and eight large (>0.5 mm) perforators on each side of themidline.• Location - paramedian rectangular area 2 cm cranial and 6 cm caudal tothe umbilicus and between 1 and 6 cm lateral to the umbilicus.• Lateral perforators – dominant, easier to dissect, run moreperpendicularly through the muscle• Medial perforators - provide better perfusion, longer intramuscularcourse65Breast Reconstruction
  66. 66. Surgical technique• Suprafascial dissection• Intramuscular dissection• Submuscular dissection66Breast Reconstruction
  67. 67. 67Breast Reconstruction
  68. 68. Superior/inferior gluteal artery perforator free flap(SGAP/IGAP)• Patients with excess tissue in the buttock versus the abdomen are the idealcandidates• Patients who require mostly fat and little skin may be candidates forSGAP/IGAPS flaps• Absolute contraindications - previous liposuction at the donor site or activesmoking within 1 month prior to surgery.68Breast Reconstruction
  69. 69. Advantages• Hidden donor site• Good bulkDisadvantages• Technically demanding• Time consuming• Requires repositioning of pt• Flap contouring difficult due to globular fat69Breast Reconstruction
  70. 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 tothe posterior superior angle of the greater trochanter.The point of entrance - corresponds to the junction of the upper and middlethirds of this line.• The pedicle length - 5–8 cm• The flap height and length - 7–10 x 18–24 cm.70Breast Reconstruction
  71. 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 spineto the outer part of the ischial tuberositypoint of entrance – corrospond to the junction of its lower with its middlethird• Pedicle length - 7–10 cm.• The inferior limit of the flap is marked 1 cm inferior and parallel to thegluteal fold.• Skin paddle dimension - 7 18 cm.71Breast Reconstruction
  72. 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 cumbersome72Breast Reconstruction
  73. 73. Prerequisites -• Breast reconstruction should be stable• Breast symmetry should have been achievedGoal• Position - ideally located on the point of most projection on the breast mound• Symmetry• Colour• Size• Projection• SensitivityIdeal timing for reconstruction is approximately 3–5 months after the lastrevisional reconstructive surgeryReconstruction of Nipple & Areola73Breast Reconstruction
  74. 74. Surgical techniqueComposite nipple graft -• Excellent option for patients with contralateral nipple >1 cm projectionDisadvantage –(1) fear of contralateral surgery(2) donor site morbidity(3) decreased contralateral nipple sensation.De-epithelialization of theproposed nipple site.Traction is placed to elongate thenipple and scalpel is used totransect 40–50% of the distalnipplePlacement of the composite nipplegraft and secured with interruptedchromic suture 74Breast Reconstruction
  75. 75. Skate flap• Has reliably produced long-term projection• Used in conjunction with a skin graft for immediate areola reconstruction75Breast Reconstruction
  76. 76. Star flap• Advantage of eliminating skin graft donor site morbidity by allowing forprimary closure• Lack of projection when compared with the skate flap76Breast Reconstruction
  77. 77. C-V Flap• Elements of both the star and skate flaps• Ease of elevation and ability to close the donor site primarily without theuse of a skin graftThe basic design of the C–V flap. The outer V-segments can have variable degrees of angulationfrom sharp to blunted edges. (B) Sutures are first placed to approximate the donor site. The outerwings are then approximated at the midline and sutured together. (C) The central C-segment isthen rotated down to form the rounded dome of the nipple.77Breast Reconstruction
  78. 78. • Arrow flap - Z-plasty configuration may decrease contraction and nippledistortion• Bell Flap- incorporates a purse-string areola closure that provides slightareolar projection.• Top hat flap -78Breast Reconstruction
  79. 79. Flap designs adjacent to scars• S flap• Double opposing tab flap• Spiral flap79Breast Reconstruction
  80. 80. Other methodFlap with autologous graft augmentation -• Cartilage graft• Fat graftFlap with alloplastic augmentation -• Polyurethane coated silicone gel• Injectable calcium hydroxylapatite• Hyaluronic acid• Artificial bone substance• PolytetrafluroethyleneFlap with allograft augmentation -• Alloderm – human derived acellular dermis80Breast Reconstruction
  81. 81. Areola reconstructionMethod –• Skin grafting• Tattooing• Combination of both81Breast Reconstruction
  82. 82. Skin grafting-• Has the advantages of providing a textured, wrinkled surface and distinctpigment differences• Common areola donor sites - Contralateral areola Inner thigh Excess/discarded skin Scar revision skin Labial tissue (rarely used).82Breast Reconstruction
  83. 83. (A) The chosen color is placed uniformly on the proposed tattoo site. (B) The tattoo pigment is electricallydeposited with the use of a tattoo gun. (C) After the tattooing is finished, a nice uniform deposition of pigmentshould 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 oxide83Breast Reconstruction
  84. 84. • Thank you84Breast Reconstruction
  85. 85. 85Breast Reconstruction
  86. 86. 86Breast Reconstruction
  87. 87. 87Breast Reconstruction
  88. 88. Timing of reconstruction after mastectomy• Immediate reconstruction – Standardtreatment nowadays• Delayed reconstruction88Breast Reconstruction
  89. 89. • Distant Flap• latissimus dorsi musculocutaneous flap - lateral, central, inferior and evenmedial defects• thoraco-dorsal artery perforator (TDAP) flap - lateral, superolateral andcentral regions of the breast• lateral intercostal artery perforator (LICAP) flap - lateral and inferiorbreast defects• anterior intercostal artery perforator (AICAP) flap - inferior or medialquadrants of the breast• superior epigastric artery perforator (SEAP) flap• superficial inferior epigastric artery free flap – for large medial defect89Breast Reconstruction
  90. 90. Technique• Pocket for implant– The inferior part of the implant maybe left extra-muscular to give betterdefinition to the inframammarycrease by separating the strenalorigin of the pec. Major fromsecond Intercostal space to inferioredge of pocket– Implant placed in pocket withpatient in sitting position90Breast Reconstruction
  91. 91. Technique• The lateral margin of pec.major muscle sutured tochest wall or to serratusanterior to preventmigration• Nipple-areola surgery oroperations on the breastmound are performed 3months later91Breast Reconstruction
  92. 92. • Only in very slender women or in cases where multiple scarring of theabdominal wall endangers the normal blood circulation of the free flap orthe abdominoplasty flap,• Contraindications concerning general health can also influence thedecision. Morbid and severe obesity, uncontrolled diabetes, debilitatingcardiovascular diseases and uncontrollable coagulopathies• Patients refusing additional scars at the donor site, refusing complexsurgery or accepting the possible microsurgical complications,92Breast Reconstruction
  93. 93. Management of Opposite Breast• Oncologic management as per requirement• Patient’s wish– Does not want operation on opposite breast (flapreconstruction for symmetry)• Otherwise, if opposite breast– Small & flat – Augmentation Mammoplasty– Hypoplastic & ptotic – Submusculofascial Implant &Mastopexy (nipple areola elevated)– Hypertrophic & heavy – Reduction Mammoplasty93Breast Reconstruction
  94. 94. Reconstruction of the nipple-areola complex• Creation of the nipple-areola complex allows the reconstructed breastmound to truly resemble the natural breast.• The NAC is ideally located on the point of most projection on the breastmound• ideal timing for reconstruction is approximately 3–5 months after the lastrevisional reconstructive surgery• Many of the currently used flaps are derivatives of the basic design of theskate flap and star flap.94Breast Reconstruction
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