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Breast Reconstruction. Joint Hospital Grand Round 20 th September, 2003. Catherine Choi United Christian Hospital. Breast Cancer. Commonest cancer amongst females in Hong Kong Incidence increasing annually at 3.6% Incidence 1918 (397 deaths) Cumulative life-time risk (0-74yrs): 1 in 23.

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breast reconstruction

Breast Reconstruction

Joint Hospital Grand Round

20th September, 2003

Catherine Choi

United Christian Hospital

breast cancer
Breast Cancer
  • Commonest cancer amongst females in Hong Kong
  • Incidence increasing annually at 3.6%
  • Incidence 1918 (397 deaths)
  • Cumulative life-time risk (0-74yrs): 1 in 23

Hong Kong Cancer Registry 2000

treatment of breast cancer
Treatment of Breast Cancer
  • Multimodality & Multidisciplinary Management
    • Surgery
    • Chemotherapy
    • Radiation therapy
    • Hormonal therapy
  • Surgery important in achieving cure
evolution of surgery in the treatment of breast cancer
Evolution of surgery in the treatment of Breast Cancer
  • Breast Conservation Treatment (BCT) in early breast cancer

Fisher et la. Eight year results of a randomized clinical trial comparing total mastectomy and lumpectomy with or without irradiation in the treatment of breast cancer. N Eng J. Med. 1989;320:822-8

National Institute for Health Consensus Conference. Treatment of early stage breast cancer. JAMA 1991; 265:391-5

  • Mastectomy still required in majority
  • Mutilating and destructive
  • Loss of femininity
  • Disturbance in marital/sexual relationship
  • Limited selection in clothing & activities
breast reconstruction7
Breast Reconstruction


Integral part of treatment

Reduce psychosocial morbidity & improve quality of life

Linda LR. Plast Reconstr Surg 1997

immediate vs delayed reconstruction
Immediate vs Delayed Reconstruction

Immediate Reconstruction……

  • Oncologically safe

Kroll SS. Ann Surg Oncol 1997

  • Easier operation
  • Better aesthetic outcome
  • Avoid disfigurement
  • Avoid second operation
  • Psychological, social, financial and time-saving advantages
surgical options for breast reconstruction
Surgical Options forBreast Reconstruction
  • Implant or tissue expander
  • Autologous tissue reconstruction
    • Latissimus Dorsi (LD) myocutaneous flap
    • Transverse Rectus Abdominus Myocutaneous (TRAM) flap – free or pedicle
    • Deep Inferior Epigastric Perforator (DIEP) flap
    • Superior Gluteal Artery Perforator (SGAP) flap
    • Inferior Gluteal Artery Perforator (IGAP) flap
breast implants tissue expanders
Saline or silicon gel

Simpler surgical procedure

Lower cost

Symmetry difficult to achieve

Aesthetic result deteriorates over time

Capsular contracture, implant failure, infection, etc

Clough KB. Plast Reconstr Surg 2002

Problems associated with post-op radiotherapy

Breast implants & tissue expanders

Short-term advantage

offset by

Long-term disadvantage

michigan breast reconstruction outcome study
Michigan Breast Reconstruction Outcome Study
  • 49 implants/expander
  • 163 TRAM flap
  • TRAM flap recipient more satisfied
    • Aesthetic satisfaction
    • General satisfaction

Alderman AK. Plast Reconstr Surg 2000

latissimus dorsi ld flap
Latissimus Dorsi (LD) flap
  • First described by Tansini in 1898
  • Standard method in the 1970s
  • Technically easy, reliable
  • Used alone for small breast reconstruction or with implant for large breast
  • Change of position during surgery
  • Complication of seroma common, others relating to implants
endoscopic techniques
Endoscopic techniques
  • Harvesting latissimus dorsi myocutaneous flap
  • Same scar for axillary dissection or a separate incision about one inch in the middle or lower back
tram flap
TRAM flap
  • First described by Hartrampf in 1982
  • Commonest option
  • Substantial amount of tissue and skin for reconstruction
  • Symmetry & Tissue consistency
  • Change of appearance and size similar to the natural breast
  • Added benefit of abdominoplasty

Clough KB. Plast & Reconstr Surg 2001

tram pedicled flap
TRAM – pedicled flap
  • Superior epigastric artery
  • Skin and subcutaneous tissue by subdermal plexus
tram complications
TRAM - complications
  • Donor site
    • Abdominal weakness / hernia
    • Abdominal wall bulging
  • Recipient site
    • Fat necrosis
    • Partial flap necrosis
    • Total flap necrosis
tram flap risk factors
TRAM flap - risk factors
  • Smoking
    • Microcirculatory problems
    • Magnified in obese patients
  • Obesity
    • increased risk of flap loss with pedicle flap

Moran SL. Plast Reconstr Surg 2001

tram risk factors
TRAM – risk factors
  • Unfavorable abdominal scar from previous surgery
    • TRAM flap pedicles divided
    • Perforators interrupted
    • Subdermal plexus damaged

Rt subcostal scar

Vertical midline scar

Pfannenstiel scar

tram free flap
TRAM – free flap
  • Popularized since 1990s
  • Deep inferior epigastric artery
  • Robust blood supply
tram free flap20

Less fat necrosis / partial flap loss

Less sacrifice of donor site muscle, so less weakening & less pain

Avoid epigastric bulge

Better aesthetic outcome


Microvascular anastomosis

Risk of TOTAL flap loss

Long & tedious operation

Post-op monitoring requires effort and expense

TRAM – free flap
diep deep inferior epigastric perforator flap
DIEP (deep inferior epigastric perforator) flap
  • Variation of free TRAM flap
  • Only one or more perforating branches dissected from rectus
  • Rectus muscles left intact
  • Less donor site morbidity
  • More time consuming and tedious
  • Indicated for bilateral reconstruction & small breast
preferred choice of tram
Preferred choice of TRAM…..

Pedicle flap


Free flap

literature search
Literature search
  • Keyword: TRAM
  • Medline / EMBASE / Cochrane library
  • 5 out of 698 articles comparing outcome of free vs pedicled TRAM
  • Results
    • No RCT comparing free vs pedicled TRAM
    • Prospective non-randomized comparison
comparisons on
Comparisons on…
  • Patient’s general & aesthetic satisfaction

Larson DL. Plast & Reconstr Surg 1999

Edsander N. Plast & Reconstr Surg 2001

  • Recipient site morbidity

Kroll SS. Plast & Reconstr Surg 1998

  • Donor site morbidity

Edsander N. Plast & Reconstr Surg 1998

  • Cost

Serletti JM. Plast & Reconstr Surg 1997

study results

Patient & aesthetic satisfaction

Recipient site morbidity (fat necrosis)†

Donor site morbidity (abd strength)


Shorter operation time, hospital stay, less blood transfusion†

Study Results

† Statistical significant result

skin sparing total mastectomy with immediate breast reconstruction
Skin-sparing total mastectomy with immediate breast reconstruction
  • Oncologically safe

Kroll SS. Surg Gynecol Obstet 1991

  • Traditional type involves skin overlying tumor, biopsy scar and nipple-areola complex (skin at risk of recurrence)
    • Patch like defect at NAC, transverse scar
skin sparing total mastectomy with immediate breast reconstruction27
Skin-sparing total mastectomy with immediate breast reconstruction
  • Periareolar approach
    • All breast skin preserved
    • Optimal aesthetic result

Gabka CJ. Plast & Reconstr Surg 1998

  • Breast reconstruction reduces psychosocial morbidity & increases quality of life after mastectomy
  • Immediate reconstruction should be offered to patient requiring mastectomy
  • Autologous tissue reconstruction superior to implants
  • Periareolar approach skin-sparing mastectomy with immediate breast reconstruction gives the best possible aesthetic outcome without compromise oncological safety

Gabka CJ. Plast & Reconstr Surg 1998