1. Breast Reconstruction Reconstruction Workshop, YSC National Summit March 6, 2015 Breast Reconstruction Reconstruction Workshop, YSC National Summit March 6, 2015 R. Michael Koch, M.D., F.A.C.S. Assistant Professor of Surgery Mount Sinai School of Medicine New York

2. Less is More The surgical treatment of breast cancer continues to evolve. The trend is towards less deforming methods. Goal is to eradicate the tumor without destroying normal tissues. – –Skin-sparing mastectomy – –Breast conservation – –Minimally invasive tumor ablation – –Sentinel Lymph node biopsy

3. Breast Reconstruction Newman LA, Kuerer HM, Hunt KK, et al. Ann Surg Oncol. 1998;5:620-626. American Society of Plastic Surgeons, 2004. Available at http://www.plasticsurgery.org/.

4. Active Participation A parallel development in reconstructive surgery has also occurred. Participation in multidisciplinary Breast Centers Evolution in operative techniques: – –Direct to Implant reconstruction – –Pedicled Flaps i.e. TRAM Flap – –Flap “supercharging” – –Flap “delay” – –Free flaps – –Perforator flaps – –Intraoperative SPY Vascular Studies

5. Improving Outcomes There is a greater emphasis on studying patient outcomes. A finer appreciation of the long-term consequences of the surgical approaches. Success is now gauged by how quickly patients obtain quality-of-life objectives. Patient expectations are increasing.

6. A Team Approach—The NY Group for Plastic Surgery Model A union between the breast and reconstructive surgeon has developed. Shared goals and philosophy Ability to effectively coordinate techniques

7. A Team Approach—The NY Group for Plastic Surgery Model These developments have significantly influenced women’s interest. Many choose to undergo additional reconstructive procedures.

8. Surgical Perspective—the Driving Force for Change Traditionally, plastic- surgical thinking has been thought of as a balance between two interdependent forces: – –Reconstructive vs. Aesthetic Surgery

9. Why Do Surgical Techniques Evolve? Desire to improve results and outcome. Progress has focused on three key issues: – –Minimizing surgical risk – –Improving flap survival – –Minimizing donor-site problems

10. Surgical repertoire Constantly evolving: – –Staged Expander-to-implant – –Single-stage Alloderm and implant – –Pedicled flaps TRAM, LTD – –Free flaps TRAM Rubens ALT Gracilis Gluteal – –Perforator Flaps DIEP SIEA SGAP IGAP

11. Surgical Perspective—the Driving Force for Change The application of surgical principles to physical findings is the true art of plastic surgery. Goal is Surgical Harmony. Result should resonate. Reflect the perfect blending of surgical ingredients.

12. Prosthetic Options-Tissue Expanders  Traditional Two (Three) Stage Approach:  1. Placement of Tissue Expander  2. Office-based injections to adjust volume  3. Exchange for Implant 12

13. Tissue Expander Reconstruction-Initial Step  Tissue Expanders are temporary devices  They create a breast shape by changing the surface area  Expansion requires healthy skin for optimal results 13

14. Tissue Expanders-Second Step  Step Two is the ‘Exchange Procedure”  Performed once the desired breast shape and volume are obtained  Outpatient procedure  Typically gel implants 14

15. Delayed Reconstruction 15

16. Nipple Reconstruction  Nipple reconstruction may be performed as a third step  Local tissue flap is used  Skin tattoo also an option 16

17. TISSUE EXPANSION

19. 6 MONTHS POST-OP TISSUE EXPANDER

20.  Credited with 1 st 1- stage AlloDerm® RTM RTM reconstruction in 2001.  Patients: 49 women, 76 breasts  Incisions: IMF, SSM (periareolar), transverse Ann Plast Surg. 57: 1–5, 2006

21. Direct-to-Implant with Alloderm  Direct to Implant Approach –Adequate and healthy skin surface area –Internal support with dermal matrix –Protection of overlying skin 21

22. HUMAN TISSUE MATRIX  Human cadaver dermis (from tissue bank) processed to remove all cells  Collagen matrix left intact allowing vascular ingrowth  No disease transmission possibility or antigeneic potential

23. Vascular Ingrowth HISTOLOGY AT 6 WEEKS

24. Introducing Alloderm 24

25. PRE-OP RIGHT BREAST CANCER

26. 7 YEARS POST-OP

27. Prosthetic Approaches  Advantages: –Quicker procedure –Shorter recovery –Choose the size –symmetric result for –bilateral procedures –Only one operative site  Disadvantages: –Requires multiple procedures –May require revisions –Visibility and palpability –Life-long risk of infection – Life-long risk of capsular contracture – Rupture –Should not be used in the setting of XRT 27

29. Results  Minor skin flap necrosis (6/30 breasts)  All were excised and closed secondarily  AlloDerm® RTM retained in all cases  No rippling, synmastia, or capsular contractures was observed.  Mean follow-up 18 months (range 15 – 24 months)

30. PROPHYLACTIC MASTECTOMY  GENETICALLY (POSITIVE BRCA 1 OR 2) OR STRONG FAMILY HISTORY WITH NO TESTING OR NEGATIVE  SUBCUTANEOUS MASTECTOMY (FROZEN SECTION IN RETRO AREOLAR TISSUE) INDICAT ED IN NON- CANCER PATIENT S and SELECTE D OTHERS

31. 1 WEEK POST -OP

33. PRE-REDUCTION PROPH MASTECTOMY

34. 6 MONTHS POST-OP

35. A Team Approach—The NY Group for Plastic Surgery Model A union between the breast and reconstructive surgeon has developed. Shared goals and philosophy Ability to effectively coordinate techniques

36. Thank You