CRITICAL QUESTIONS - REFINEMENTS IN IMPLANT BASED

BREAST RECONSTRUCTIONStamatis Sapountzis M.D

Division of Plastic SurgeryChina Medical University Hospital

Department of Plastic and Reconstructive Surgery

Seoul National University Hospital

ssapountzis@yahoo.com

Goals of Breast Reconstruction

Provide permanent breast contour

Make the breasts look balanced

Avoid the need for external prosthesis

Re-establish normalcy and confidence

Breast Reconstruction

Implant Based Autologous Tissue Implant + Autologous Tissue

80 % of Women in 2010 received Implant- Based Breast Reconstruction

Plastic and Reconstructive Surgery • December 2009

The 70% of women Plastic Surgeon prefer Implant Based Reconstruction

for themselves

Immediate Vs Delayed Breast reconstruction – Benefits & Risks

Immediate

•Better aesthetic result•Better psychological effect•Lower cost

•Higher risk of complications independently the method of reconstruction

•Lower complication rate•Less optimal result

•High percentage of anxiety, depression and impairment of their sexual attractiveness

•Higher cost (2 operations, hospital stays)

Delayed

Comparison Immediate- Delayed Reconstruction to the same patient

Preoperative with previous right mastectomy

Result of delayed right breast reconstruction and immediate left breast reconstruction with bilateral deep inferior epigastric perforator (DIEP) flaps shown 21 months postoperatively

80 % of breast reconstructions are immediate

What is the effect of radiation on Implant

based breast reconstruction?

The objective of this meta -analysis is to examine:

whether patients requiring post-mastectomy radiotherapy should have an immediate or delayed reconstruction

whether a prosthesis or autologous reconstruction is associated with the optimum outcome in terms of postoperative morbidity

conclusion Post-mastectomy radiation, irrespective of the method

of reconstruction, increases the incidence of postoperative complications; however, this study demonstrates that an autologous flap offers a more favorable outcome in terms of morbidity than expander/implant reconstruction

Can we always know if RT is going to be followed?

Indication for Post-mastectomy RT Many decisions regarding radiation therapy are made after mastectomy

•T3 or T4 tumors or four or more positive axillary lymph nodes needs RT•Radiation in T1 or T2 tumors and one to three positive axillary nodes is controversial.

•fine-needle aspiration instead of open excisional biopsy techniques, has limited the ability to diagnose the amount of invasive tumor within the breast parenchyma compared to the permanent section

•sentinel lymph node biopsy cannot detect lymph node micrometastases

Delayed-Immediate Breast Reconstruction

2 weeks

2 weeks

4 to 6 months

Benefits of Delayed-Immediate Breast Reconstruction

Avoid problems associated with PMRT after an immediate breast reconstruction.

Better aesthetic outcome than is achieved with standard delayed reconstruction. Specifically, re-expansion of the mastectomy skin after PMRT provides additional usable breast skin to perform delayed breast reconstruction.

Provides an additional option that broadens patients’ treatment choices and allows patients to participate fully in treatment and reconstruction decisions.

Aesthetic outcomes similar to immediate reconstruction Patients who do not require PMRT:

Patients who require PMRT :

151 patients , TE/I Reconstruction followed by PMRT.7-year Follow-Up:• PIRR rate was 29%.•Reasons for PIRR included infection (15),implant extrusion, shift, leak, or rupture (4), patient request (1), or multifactorial (17)

What is the role of Fat Grafting in Implant Based Reconstruction in the

presence of Radiotherapy?

Does it Affect the Follow-up?

Are there Pharmacologic agents to prevent the PR fibrosis?

Tissue expander under the pectoralis major + 150 (+- 25 cc) of fat in the upper quadrants between the skin and the muscle and also inside the muscle

In the 1st operation

In the 2nd operation After 3 months, removal of expander, insertion of the cohesive silicone prosthesis, and injection of 150 (+-30 cc) of fat in the lower quadrants

65 mastectomized patients who had received radiotherapy.

Mean follow-up was 1 year.

No complications were recorded with the fat injections.

Patients’ mean satisfaction rating was 4 on a scale of 1 (low) to 5 (high), and the capsularcontracture was never above 1 on the Baker classification

Plastic and Reconstructive Surgery • August 2011

From 2000 to 2010, the authors reviewed 646 lipofilling procedures from 513 patients

The average follow-up time from the last lipofilling procedure to the last visit was 19.2 months (range, 1 to 107 months)

12 radiologic images appeared after lipofilling:

From 7 histopathologic reports:

7: Benign calcifications2: Benign opacity masses3 :Suspicious lesions

5: Benign lesion2: Local breast relapse

Conclusion

Lipofilling following breast cancer treatment leads to a very low rate of complications

Does not affect the radiologic follow-up

There is no proof of the safety of lipofilling in terms of cancer recurrence or distant metastasis

Lipofilling should be performed in experienced hands, and a cautious oncologic follow-up protocol is advised

Pharmacologic Agents

Leukotriene antagonists (LTRAs) have emerged as effective prophylactic agents in the management of reactive airway diseases

Montelukast and Zfirlukast have “Off-Label” use in Breast Augmentation

They seem to prevent and improve the Capsular Contracture

There are no series of using these agents in breast reconstruction

with RT

Pharmacologic Agents

Impact Factor: 1.389

In our Hypotheses we suggest that the Zafirlukast is able to prevent the post-radiation capsular contracture by blocking the TGF which plays key role in radiation induced fibrosis

S.Sapountzis, JH Kim, DF Veiga, LM Ferreira

Human Acellular Dermal Matrix: Why? Effective?

Infection?

Limitation of Other Implant Techniques

Total Muscle Cover Difficult Painful Bloody Limited space Poor shape Poor IMF definition Superior malposition

Partial Muscle Cover Implant migration More infections? More contractures? More exposures? More explantation

Benefits of AlloDerm

• Technically easier than total muscle cover

• Less morbidity than total muscle

• Better shape than total muscle

• Better control of folds and shape than total muscle only

• Less capsular contraction

Plastic and Reconstructive Surgery • December 2010

Twenty patients underwent tissue expander reconstruction using the “dual-plane” acellular cadaveric dermis technique (AlloDerm). During implant exchange, intraoperative biopsy specimens were obtained of (1) biointegrated acellular cadaveric dermis and (2) native subpectoral capsule (internal control).

Is it Safe?

Review Study of 9 Articles

A total of 203 patients underwent 337 immediate TE/I Breast reconstructions :

•With acellular dermal matrix: 208 (61.7 %)•Without 129 (38.3 %)

(Plast.Reconstr. Surg. 128: 403e, 2011.)

The key points of our technique are:

• advantages of Alloderm

•eliminate the “Step- off” deformity

•Recreate the normal tail of the breast toward the axilla

33 Patients/ 36 Breast

Reconstructions

1st Stage:Tissue Expander

+ Alloderm

2nd Stage:Permanent

Silicone Implant + Fat

grafting :134cc (21cc to 228)

3 months later

Results 7 patients required surgical intervention to the

contralateral breast for symmetry achievement.

Mean follow-up was 1 years (ranged from 6 to 17 months) Two patients with infection in the early postoperative

period required expander removal (5.4%). No complications were noticed after fat injection. During the follow-up period the capsular contracture

was never above 1 on the Baker classification

female 40 years old, prior to total mastectomy b) 3 months after immediate reconstruction with 275cc tall height profile tissue expander and 12x4 cm AlloDerm c) 1 years after the second stage of reconstruction with 265cc smooth round implant, moderate plus and 91cc of fat grafting

female 48 years old, 3 months after immediate breast reconstruction with 450cc tall height expander and 16X4cm AlloDerm b) 1 year after the second stage of reconstruction with 350cc smooth round high profile implant and 141cc of fat grafting c) profile view: note the fullness of the upper pole and the absence of “step-off” deformity between the reconstructed breast and the chest wall

Plastic Surgery

Plastic Surgery