Breast Reconstruction with Autologous Tissue Art and Artistry

372 Pages·1999·8.37 MB·English

by  Stephen S. Kroll

Breast Reconstruction with
Autologous Tissue
Springer
New York
Berlin
Heidelberg
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London
Milan
Paris
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Tokyo
Breast Reconstruction with
Autologous Tissue
Stephen S. Kroll, M.D.
M.D. Anderson Cancer Center
Department of Plastic Surgery
The University of Texas
Houston, Texas
USA
With 621 Illustrations
0 Springer
Stephen S. Kroll, M.D.
M.D. Anderson Cancer Center
Department of Plastic Surgery
The University of Texas
1515 Holcombe Boulevard
Houston, TX 77030
USA
Cover photo: Marble Amazon, 430 BC/© The Granger Collection, Ltd.
Library of Congress Cataloging-in-Publication Data
Kroll, Stephen S.
Breast reconstruction with autologous tissue /
Stephen S. Kroll.
p. cm.
Includes bibliographical references and index.
ISBN 0-387-98670-7 (hardcover alk. paper)
1. Mammaplasty. 2. Flaps (Surgery) I. Title.
[DNLM: 1. Mammaplasty—methods. 2. Tissue Transplantation—
methods. 3. Surgical Flaps. WP 910 K93a 2000]
RD539.8.K76 2000
618.1(cid:1)90592—dc21 98-51594
Printed on acid-free paper.
© 2000 Springer-Verlag New York, Inc.
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Preface
Plastic surgery is a unique specialty that is composed of two parts: engineering and
art. The engineering part is concerned with transferring tissues, keeping those tis-
sues alive while they are healing, and minimizing donor site morbidity. This part
of plastic surgery is interesting and challenging but is, in many ways, not so dif-
ferent from other surgical specialties. What is unique about plastic surgery is its artis-
tic aspect: turning a flap that used to be a forehead into something that truly looks like
a nose, or turning a transverse rectus abdominis myocutaneous (TRAM) flap into a
breast. It is this artistry that makes successful plastic surgeons stand out from their peers.
It is this artistic aspect of breast reconstruction that this book addresses.
Many books already exist about flaps, breast surgery, and breast reconstruction.
This book is not meant to replace them. What is unique about this book is its focus
on artistry. Before now, very little has been written on the artistic aspects of breast re-
construction. What this book provides—possibly for the first time—is some basic prin-
ciples for transferring, shaping, and revising a TRAM (or other autologous tissue flap)
so that it really looks like a breast that matches its opposite counterpart. As such, this
book is intended to help improve the aesthetic quality of the reader’s results, whatever
the current level of those results might be.
Although this book includes chapters on the fundamentals of breast reconstruction
and is therefore suitable for the beginning surgeon, the intended target audience is the more
experienced surgeon who seeks superior aesthetic outcomes. The chapters on the free TRAM
flap, breast shaping, breast revision, surgery of the opposite breast, and nipple reconstruc-
tion will be of special interest to such individuals. Although certain opinions presented here
may change in years to come (or be disagreed with by some even today), I believe that
everyone who performs breast reconstruction will find something useful here.
Who then should read this book? This book is for surgeons who believe in
the importance of breast reconstruction and care about aesthetic outcomes. It is for sur-
geons who believe that they can improve and learn more about their art. It is for
surgeons who want to do as much as they can to help their patients. If you are such a
surgeon, this book was written for you.
Stephen S. Kroll, M.D.
M.D. Anderson Cancer Center
The University of Texas
Contents
Preface v
1 Goals of Breast Reconstruction 1
2 Why Autologous Tissue? 7
3 Why Use Free Flaps? 17
4 Immediate Breast Reconstruction 29
5 Delayed Breast Reconstruction 41
6 Bilateral Breast Reconstruction 53
7 Choice of Technique 69
8 Conventional (Pedicled) TRAM Flap 83
9 Free TRAM Flap 101
10 Deep Inferior Epigastric Perforator Flap 133
11 TRAM Flap Postoperative Care and Complications 143
12 The Extended Latissimus Dorsi Myocutaneous Flap 161
13 The Superior Gluteal Free Flap 179
14 The Inferior Gluteal Free Flap 191
15 The Rubens Fat Pad Free Flap 201
16 Shaping the Breast Mound in Immediate Reconstruction 211
17 Shaping the Breast Mound in Delayed Reconstruction 237
18 Shaping the Breast Mounds in Bilateral TRAM
Flap Breast Reconstruction 259
19 Correction of Partial Mastectomy Defects 273
20 Breast Mound Revision Surgery 293
21 The Opposite Breast 313
viii CONTENTS
22 Nipple and Areolar Reconstruction 327
23 Follow-Up of TRAM Flap Breast Reconstruction Patients 347
Index 365
Goals of Breast
1
Reconstruction
Why Do We Reconstruct Breasts?
For most women, mastectomy is a mutilating and deforming operation that has the
capacity to severely damage a woman’s self-image and lead her to question her de-
sirability as a sexual partner.1–3This can be true even when a loving husband (or “sig-
nificant other”) is providing support and when abandonment by a mate is, in real-
ity, unlikely. Breasts are a potent symbol of femininity, and the loss of a breast can have
important psychological consequences. Some women may be inhibited from entering into
relationships in which their deformity might be revealed, or may withdraw from rela-
tionships with men and even other women. This isolation can be harmful not only to the
patient herself but to her family, coworkers, and anyone else who depends on her. For
some women, fear of possible deformity is significant enough to cause them to refuse can-
cer treatment, even though the absence of a breast can be easily concealed by clothing.
In theory, the loss of a breast can be corrected without difficulty using a pros-
thesis. Unfortunately, for many women a prosthesis is inadequate treatment. In the pri-
vacy of her bedroom, a woman who has undergone mastectomy without reconstruction
is confronted by her deformity each time she undresses and is reminded that she is not
only deformed but at risk for a cancer recurrence. She is limited in her selection of
clothing and must be careful about choosing activities (like swimming or dancing) that
might cause the prosthesis to become dislodged. Moreover, if the prosthesis is large, it
may be uncomfortable, particularly in hot climates. For these and other reasons, use of
an external prosthesis to replace a missing breast is not always a satisfactory option.
Breast reconstruction does not solve all the problems caused by mastectomy, but
it solves many of them. A woman who has had a successful reconstruction (Fig 1-1) can
usually wear almost all types of normal clothing (including many bathing suits) and par-
ticipate fully in recreational activities without showing any external sign of her surgery.
She is not handicapped by her cancer treatment in her daily living and is not reminded
of her breast cancer except when visiting her doctors for routine checkups. She can re-
turn to an active and productive life, working and providing support to her family and
friends as well as receiving it from them. This is important not only to breast cancer pa-
2 C H A P T E R 1 GOALS OF BREAST RECONSTRUCTION
A B
FIG. 1-1 (A) A 22-year-old woman following right modified radical mastectomy for breast cancer. (B) After breast reconstruc-
tion with a latissimus dorsi flap and a silicone implant. The patient sunbathes and has resumed an active life. (From Kroll SS:
Clin Plast Surg. 1998;25:135–143. Used with permission.) See color insert, p. I-1.
tients but to society at large because breast cancer patients are often in their prime of
life, and are highly productive individuals upon whom the fabric of our society depends.
Contraindications to
Breast Reconstruction
The overwhelming majority of women who have had (or will need) a mastectomy can
undergo successful breast reconstruction, if they choose to. Who should not be recon-
structed? Women who have unrealistic expectations, and who refuse to accept the re-
quired scars, should be rejected as candidates until their expectations become realistic.
This is rarely a problem in patients requesting delayed breast reconstruction, who al-
ready have scars and are likely to be pleased by any improvement in their appearance
that the surgeon can provide. Unrealistic expectations can occasionally be a problem,
however, for women who are requesting immediate reconstruction. Fortunately, the
overwhelming majority of women who request immediate reconstruction understand
that the reconstructed breast will not be flawless and that, if a flap is used, the surgeon
will be required to create scars in the donor site.
Another group of women who should not have breast reconstruction are those in
very poor health, who are not really candidates for any type of elective surgery. Fortu-
nately for reconstructive surgeons, most such patients are aware of their status and do
not request inappropriate reconstruction, so that rejection of such patients is rarely nec-
essary. If a patient who is not an appropriate candidate for elective surgery does request
breast reconstruction, she need not be rejected out of hand. Such a patient can be man-
aged by gently informing her that her current medical condition does not permit breast
reconstruction, but that her health may well improve, and that when it does the sur-
geon will be happy to revisit the issue.