| Question |
Answer |
| 75 y.o. L Mastec, primary recon? |
Implant alone |
| 35 y.o. L Mastec, primary recon? |
TRAM |
| 35 y.o. L Mastec, wants B, prim. rec? |
Expanders + Implants |
| 35 y.o. L Mast, wants B, prior XRT |
NOT IMPLANT, needs decide TRAM or LAT |
| 35 y.o. L Mast, wants B, prior XRT and abdominoplasty |
NOT IMPLANT, NOT TRAM, needs LAT |
| Types of difficult BR recon scenario? |
Single side, delay, XRT, Elderly, Obese, Ptosis |
| Types of simplest recon? |
Bilateral, immediate, non-XRT, Young, Thin |
| Only VOLUME needed (good skin): best option |
Expander |
| VOLUME needed and SKIN needed |
LAT and EXPANDER |
| SKIN needed and FAT for VOLUME needed |
TRAM |
| Implant alone (no expander) conditions? |
small breasts, nipple spared (ideal) |
| ADV expanders vs implant immed. |
ability to adjust the pocket, control for skin loss |
| Expander implant regimen |
EXP under pec, fill at 1 wk, 4-6 weeks fill, wait 3 mos, place implant |
| ISSUES with EXP/IMP |
least post op recov, most post op f/u, no w/XRT, Ideal for B, Most difficult to modify contra-br |
| Who marks sites for mastectomy? |
YOU DO |
| How high dissect above IMF for expander? |
ONLY to top of expander, not to clavicle or implant will ride up. |
| Release muscle like augment? |
No, need 100% muscle coverage |
| Mastect after augment? |
evaluate implant. if w/d capsule and good muscle cover - leave it. replace later. |
| Unilateral expander implant: ?ptosis |
if opposite has minimal ptosis can use expander and implant alone |
| ADV Lat dorsi + implant? |
replaces mastect tissue, good if skin with XRT, more durable, can add expander fluid at time of inset |
| LAT+imp vs. EXP+imp |
longer OR, longer hosp stay, but fewer f/u visits. |
| Location of inset LAT dorsi, XRT chest wall, no IMF apparent |
1-2 cm above pre-op marked IMF |
| LAT Dorsi - where design the flap |
so can use entire muscle to cover expander |
| LAT Dorsi - where design for delay recon with IMF apparent |
across midportion of lat perp to muscle, inset at mastectomy scar level. |
| LAT Dorsi - where set the paddle for just nipple recon? |
set at lateral border |
| Variations of TRAM? |
SINGLE, both, DELAYED, Free, DIEP, SIEA |
| TRAM markings |
ipsilateral, superior line, base width:flap width, inferior line, incision above IMF |
| TRAM : IMMEDIATE : location of incision |
around areola |
| TRAM: DELAYED : location of incision |
Replace mastectomy skin down to IMF |
| Wishes Bilateral and size is large |
Consider reduction incision patterns for symmetry |
| Importance of DELAY |
Regardless of size, allows more skin and fat to be used. |
| Complication list for BR RCON |
infection, bleeding, scarring, muscle/nerve injury, asymmetry, capsular contracture, deflation, future surgery |
| Capsular contracture higher: silicone or Saline |
Silicone about 50% saline about 27% |
| Silicone implant rupture: MAMMOGRAM S/S |
SENS 40-60% SPEC 50-85% (least sensitive) |
| Silicone implant rupture: ULTRASOUND S/S |
SENS 65% SPEC 85% |
| Silicone implant rupture: MRI S/S |
SENS 96-100% SPEC 80% (most sensitive, same specific) |
| Silicone rupture: algorythm : MMG+ US = NL |
Follow clinically |
| Silicone rupture: algorythm : MMG+US = ABN |
Operate |
| Silicone rupture: algorythm : MMG+US = EQUIV |
MRI - normal - follow/ MRI - abn - operate |
| Capsular contracture : smooth vs Textured |
Textured is lower <15% vs smooth 20-40 |
| Tough case: 72 hx BR aug, left BR CA |
Rem expander, wait 6 months, LAT DORSI with implant delayed recon. |
| CARD 1: Breast Recon: Key aspects |
Expectations, staged procedure, complications, |
| CARD 2: Breast Recon: Body habitus and Implants |
Poor projection and contour with morbid obesity |
| XRT prior to recon: ? implant |
relative contraindication b/c fibrosis occurs making expansion difficult |
| CARD 3: Selecting Prosthesis:general |
Shape, texture, size, filler |
| Card 3: Selecting Prosthesis: Best projection |
contoured and high profile |
| Purpose of textured implants |
prevent malrotation |
| Adv smooth surface of implant |
for round implants allows more mobility |
| ADV silicone |
mimic feel, less wrinkling and rippling, |
| Size implant based on |
patient desire, volume, base diameter, surface characteristics, body habitus |
| Key points of discussion with prosthetic |
not forever, more than one operation, pre-post outcomes photos shown, location scars, pink 1-2 yrs |
| Methods of expander placement |
total muscle coverage, dual plane, pectoralis extender bioprosthetic |
| Two stage: expander implant |
attain volume first, optimal shape, size, and position. |
| One stage: implant ok when what conditions? |
nipple/areolar preservation, skin sparing mastectomy in small non-ptotic breast |
| Factors considered with expander planning? |
type of mastectomy, implant type, skin flap quality, XRT before or after, +/- alloderm. |
| Pre-implant considerations: |
base diameter, skin compliance, volume |
| Handling of expander: key concepts |
Gloves changed, sharp objects no contact, soak implant in abx solution, all air evacuated, 50 cc fill |
| ADV dual plane |
eliminates high riding implant |
| UNIQUE SCENARIO: narrow chest wall, larger base diameter implant |
may need dissection inside serratus to make a pocket - prevents lateral displacement |
| Chemotherapy and expansion |
can be safely done at same time |
| XRT and Expansion |
contraindicated |
| Steps additional if using alloderm? |
4x16, hydration 20 minutes, basement membrane up, 2-0 absorbable suture, two drains |
| One stage implant uses what additional device? |
Remote port. |
| Treatment of implant infection: |
immediate hospitalization, IV antibiotics. |
| Superficial vs. deep infections of implant |
48 hours - superficial will clear. |
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