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Presentation on theme: "OPTIMISING BREAST AESTHETICS in reconstruction"— Presentation transcript:

Good morning In this talk I wish to bring into focus the issue of economising grafts in rhinoplasty I will discuss alternative methods that are useful, as well as review techniques to make maximum use of harvested material Stuart James The London Breast Clinic 6th October 2011

2 General Guidance 1st Realistic goal Balance and symmetry in clothing

3 General Guidance 1st Realistic goal 2nd Two or more operations spaced over 12 months

4 General Guidance 1st Realistic goal 2nd Two or more operations 3rd Risk of failure by any method approximately 1-2%

5 General Guidance 1st Realistic goal 2nd Two or more operations 3rd Risk of failure by any method 4th Reconstructive Timing; Immediate or delayed

6 1 Selection of reconstruction
Implant only reconstruction Combination implant/flap Flap reconstruction ‘autologous’

7 Implant only reconstruction

8 Implant only Reconstruction
‘Augmented’ look Inadequate autologous volumes 2 stages

9 Implant only One or Two stages I) Saline Expander II) Silicone Implant

10 Combination Implant and flap reconstruction
+ Improved result - Donor site scar and implant

11 Flap Reconstructions TRAM/DIEP
+ best cosmetically soft and warm ages well no late revisions Complex longer recovery donor site scar

12 DIEP reconstruction; The first 12 months

13 2 Timing and Teamwork Immediate reconstruction optimises results
Skilled mastectomy giving consideration to reconstructive requirements

14 Breast Reconstruction; Timing
Immediate Delayed

15 3 Technical Advances Surgical Technique Imaging

16 Perforator flap reconstruction
1980’s TRAM flap Transverse Rectus Abdominis Myocutaneous flap 2000’s DIEP flap Deep Inferior Epigastric Artery perforator flap

17 DIEP or TRAM?

18 MS 0 - TRAM MS 1 MS 2 Nahabedian et al PRS 2002

19 CT Angiography

20 CT Angiography Axial 50-mm section thickness maximum intensity projection (MIP) image obtained with abdominal wall CT angiography shows the labeled segments of a perforator originating from the right DIEA.

21 DIEP flap Three-dimensional graphic illustration of the course of a perforator (anterior musculocutaneous branch) from its origin at the DIEA between the posterior layer of the rectus sheath and the rectus muscle, its intramuscular segment within the rectus muscle, its subfascial segment (not always present) between the anterior aspect of the rectus muscle and the anterior layer of the rectus sheath, and its end branching (subcutaneous segment) within the subcutaneous fat of the anterior abdominal wall. (Image courtesy of Francesco Gaillard, MBBS, Royal Melbourne Hospital, Australia.)

22 Our results 100 cases of abdominal based free flaps in breast reconstruction; The impact of pre-operative CT Angiography Ghattaura, N. Jalalli, Y. Rajapakse, J. Henton, A. Searle, P. Harris, C. Savidge, S. Allen, S. James (JPRAS) Single perforator use up fro 17% to 48% Double use of medial row perforators Over 1 hour saved on average

23 DIEP or TRAM?

24 4 Secondary adjustments
Liposuction Augmentation Fat transfer Scar revision Direct excision

25 Summary General guidance Selection of reconstruction
Timing and Teamwork Technical advances Secondary adjustment

26 Thank you, Questions?

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