Breast reconstruction

Breast reconstruction. Breast reconstruction is a surgical procedure that allows a woman to return to the original appearance of her breasts, probably after having suffered cancer, an accident or trauma, which has caused severe damage to one or both breasts.

Summary

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  • 1 History
    • 1 First breast reconstructions
  • 2 Types of postmastectomy breast reconstruction
  • 3 Breast reconstruction techniques
  • 4 Breast reconstruction by latissimus dorsi myocutaneous flap
  • 5 TRAM flap breast reconstruction
  • 6 Human resources
  • 7 Material resources
  • 8 Participation of each professional and service involved
  • 9 Preoperative
  • 10 Surgical techniques
    • 1 Reconstruction with TRAM flap
    • 2 Reconstruction with latissimus dorsi flap
  • 11 Postoperative
  • 12 Evaluation and control
    • 1 Human resources
    • 2 Material resources
    • 3 Organizational
  • 13 Information to patients and relatives
  • 14 References
  • 15 Sources

History

Breast reconstruction is a fundamental part of the treatment of the mastectomized woman. Although early attempts to reconstruct a breast back to the end of the nineteenth century , it was not until the seventies of the twentieth centurythat the various techniques currently used are progressively developed. Until that decade, breast reconstruction did not achieve popularity, mainly due to the teachings of Halsted, who considered that plastic surgery violated local cancer control. After verifying that breast reconstruction did not negatively influence neoplastic disease, but was essential for the physical and psychological rehabilitation of the patient, its development has been favored by several advances: the trend towards less aggressive mastectomy techniques, which facilitate the skin coverage; the introduction and progress of silicone breast prostheses; the submuscular implantation of the prostheses, which prevents local complications; the technique of breast tissue expansion;

First breast reconstructions

The first attempts at breast reconstruction were made in the late 19th century. According to Wickman [1] , the French surgeon Verneuil used in 1887 part of a healthy breast, transferred over an upper pedicle to reconstruct the other breast. Vincenz Czerny , a German professor of surgery at Heidelberg, published in 1895 a case of subcutaneous mastectomy for fibroadenoma and chronic mastitis, in which he used for reconstruction a large lipoma, larger than a fist, obtained from the right lumbar region. According to Czerny, the reconstructed breast maintained a good shape one year after the intervention, without lipoma growth. [two]

Types of postmastectomy breast reconstruction

Breast reconstruction can be immediate or delayed, depending on whether it is performed at the same surgical time as the mastectomy or at a later surgical time. Several specialists suggest that performing an immediate reconstruction is completely favorable, in most cases, since the absence of the breast continually recalls the disease, in addition to interfering in personal relationships, psychologically affecting the patient undergoing mastectomy.

Breast reconstruction techniques

Different techniques of postmastectomy breast reconstruction have been described; all of them valid, both for immediate and deferred reconstruction:

  • Breast reconstruction with expander prostheses.
  • Breast reconstruction with lateral thoracodorsal or thoracoepigastric fasciocutaneous flap plus silicone prosthesis, expander or not.
  • Breast reconstruction with an island myocutaneous flap of the latissimus dorsi muscle, with or without a silicone prosthesis.
  • Breast reconstruction with a transverse island flap of the rectus abdominis muscle (TRAM), without a silicone prosthesis.
  • Breast reconstruction with myocutaneous microsurgical transplants (TRAM), or perforating vessel-based skin transplants (DIEP or SGAP), without silicone prostheses.

Breast reconstruction by latissimus dorsi myocutaneous flap

  • Absence of radical postmastectomy breast, uni or bilateral.
  • Oncological discharge.
  • The reproduction period has not ended.
  • Abdominal fat pad less than 3 cm thick.
  • Presence of postsurgical abdominal scars .
  • Presence of weaknesses or hernias of the abdominal wall.
  • Absence of chronic decompensated diseases such as diabetes, hypertension, heart disease, psychiatric disorders.

Breast reconstruction with TRAM flap

  • Absence of radical postmastectomy breast, uni or bilateral.
  • Oncological discharge.
  • Having completed the genetic period .
  • Adipose panniculus greater than 3 cm thick.
  • Absence of abdominal scars.
  • Absence of hernias or weaknesses of the abdominal wall.
  • Age less than 60 years.
  • No smoking habit.
  • Dorsal thoracic artery injury during mastectomy.
  • Absence of decompensated chronic diseases such as diabetes, hypertension, heart disease, epilepsy , psychiatric disorders.

Human Resources

  • Team of reconstructive surgeons.
  • Mastologist .
  • Oncologist .

Material resources

  • 150-175 mL silicone gel breast endoprosthesis for latissimus dorsi flap reconstructions .
  • Prolene mesh to repair abdominal wall defects in TRAM flap reconstructions.
  • Plastic surgery instruments set.
  • 2/0, 3/0 and 4/0 monofilament nylon sutures.
  • Elastic bandage and abdominal girdle.
  • Continuous negative pressure suction drain (Hemovac).

Participation of each professional and service involved

The multidisciplinary group for breast cancer must discharge the patients oncologically and approve them for this reconstruction. Mastologist surgeons participate in immediate reconstructions together with reconstructive surgeons and mediate using the TRAM flap technique.

Preoperative

  1. Indicate by external consultation the necessary and indispensable preoperative checkup.
  2. The following indications are made the day before surgery:
  • Fasting from 6 PM.
  • Shave the pubis or armpits according to the selected technique.
  • Cefazolin 1 g EV at 6 AM and intraoperatively.
  • Diazepam (5 mg) 1 tablet 9 PM.
  • Anesthesia consultation.
  • Operation planning (flap design).
  • Evacuating enemas 9 PM (in cases of flap reconstruction

TRAM).

Surgical techniques

TRAM flap reconstruction

  • er time (Delay)
  • Incision use infraumbilical skin to the fascia and ligature of the inferior epigastric artery to its entry into the sheath of the rectus muscle against lateral to the breast to be reconstructed; skin island in place.
  • or time (7 days)
  • Horizontal supra pubic incision that coincides with the lower edge of the skin spindle and extends to the superior anterior iliac spines.
  • Disinsertion of the navel.
  • Decorated at the level of muscle fascia to the xiphoid appendix.
  • Traction of the flap and cutting of excess skin and excess fat.
  • Incision of the anterior sheet of the sheath of the anterior rectus muscle and section thereof distal to the use of skin.
  • Disinsertion of the muscle with respect to the posterior leaf of the sheath up to the level of the costal arch.
  • Marking of the submammary groove in the skin with continuous basting suture.
  • Exeresis of the scar from the mastectomy and subcutaneous decoration up to the mark of the submammary groove to make a pocket for the skin island.
  • Tilling of the subcutaneous tunnel above the sternum to interpolate the muscle flap with its skin island and position it at the site of the new breast.
  • Repair of the defect of the abdominal wall.
  • Transposition of the navel .
  • Suture of skin of the abdomen leaving drains.
  • Suture of the skin spindle to the edges of the pectoral wound leaving drainage below the flap.

3rd stage (reconstruction of the areola-nipple complex and reductive versus lateral mastoplasty at 3 months)

  • Reconstruction of the nipple using the stripe technique (design of 3 small clover leaf flaps, the middle one is raised and the bloody face is covered by approaching the sides).
  • Areola reconstruction using areola versus lateral graft without macrothelia, or using full skin graft on the inner thigh .
  • Reducing mastoplasty of the breast against the side to compensate for anisomastia.

Latissimus dorsi flap reconstruction

  • er time
  • Incision of the skin and fat spindle to the fascia.
  • Disinsertion of the muscle from its insertions in the lumbar fascia and in the spinous processes of the dorsal vertebrae , maintaining its insertion in the humerus through which the thoracodorsal artery pedicle enters.
  • Exeresis of the pectoral scar and skin decoration and TCS to make a pocket for the prosthesis and the skin spindle.
  • Making a tunnel through the armpit and transpolating the muscle with the skin island through it to the pectoral region .
  • Close the donor area of ​​the skin spindle on the back leaving drainage.
  • Placing the silicone prosthesis on the rib cage and covering it with the muscle and the skin spindle.
  • Fixation of the dorsal muscle around the prosthesis to the rib cage.
  • Suture of the skin island to the edges of the pectoral wound leaving drainage.
  1. ortime (3 months)
  • Reconstruction of the areola-nipple complex and contralateral reductive mastoplasty as previously described.

Postoperative

The following indications are made:

  • Parenteral feeding with dextrose 5%.
  • Dipyrone 600 mg 1 amp IM every 8 h
  • Gravinol 10 mg 1 amp IM if vomiting
  • Cefazolin 1 g EV at 6 PM
  • Watch for bleeding from drains.
  • Flap monitoring every 2 hours (staining and capillary refill).
  • 24 hours after surgery, a dry cure is done with alcohol by the doctor and the drainage collection is measured.
  • The drain is removed when the collection is less than 10 mL in 24 h.
  • Discharge is given on the 4th day of surgery if there are no complications.
  • The stitches will be removed after 15 days.
  • The use of an abdominal belt for 6 months is indicated to prevent widened scars and hernias of the abdominal wall in patients operated on with the TRAM flap.
  • Follow-up by external consultation will be weekly until the month of surgery and then every 3 months until the year of surgery. Patients must simultaneously continue their follow-up by oncology consultation.

Evaluation and control

Structure Indicators Plan% Good Regular Bad

Human Resources

  1. % composition and qualification of personnel according to PA including trained auxiliary personnel 95 95 – <80
  2. Instrumental insurance and medical equipment according to PA 95 95 – <80
  3. Dispose of the medicines exposed in the PA 95 95 – <80
  4. Dispose of the expendable material including the Tissue Bank 95 95 – <80

Material resources

  1. Have the resources to carry out research 95 95 – <80
  2. Availability of organizational design to apply PA 95 95 – <80
  3. PA data collection form 100 100 – <100

Organizational

  1. Electronic database 100 100 – <100
  2. % patients with MT criteria that could be included in the BP were not <10 <10 10-20> 20.
  3. % MT operated patients lost to follow-up / MT operated patients <5 <5 5-10> 10.
  4. % patients operated on for MT with wide dorsal flap without complications> 85> 85 94-90 <90.
  5. % patients operated on MT with straight abdominal flap without complications> 85> 85 1-3> 5.
  6. % patients operated on MT with wide dorsal flap satisfied with the operation> 85> 85 94-90 <90.
  7. % patients operated on MT with abdominal rectum flap satisfied with the operation> 85> 85 1-3> 5.

Information to patients and relatives

General information about the diagnosis and treatment of your injury, as well as the side effects and sequelae of the treatments used, as well as in rehabilitation. Patients will undergo various therapeutic procedures which will be explained initially or when there is a change in therapy. Make a written informed consent at the beginning of the treatment, be it surgical or chemotherapy (as the case requires). A brochure or fold-out will be made with information for patients and family members on prevention and detection of complications.

 

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