David H. Song, MD, MBA, FACS, discusses breast cancer care and the fundamentals of reconstruction.
DR. DAVID SONG: Hello. My name is David Song. I'm the Cynthia Child professor of surgery, chief of plastic and reconstructive surgery, vice chairman for the Department of Surgery, and the associate dean for continuing medical education. I'll be discussing the state of the art in breast cancer care as it pertains to breast reconstruction. I have no disclosures. We're going to review oncoplastic reconstruction, implant-based reconstruction, and then a few of these flaps that we use routinely at the University of Chicago Medicine. First and foremost, oncoplastic reconstruction. This is a new field of reconstruction, relatively speaking, that allows a plastic surgeon to reconstruct lumpectomy defects. Everything else we may be talking about is covering the topic of mastectomy reconstruction, or full breast reconstruction. This is partial reconstruction. Breast conservation. Here's actually the problem. When a tumor is in the lower half of the breast and the tumor is removed, the patient is given radiation, which is once again equivalent to a mastectomy alone, this can happen, particularly if it's in the lower pole of the breast. When this happens, this is a disturbing outcome, given the fact that the patient has been cured of cancer and yet the outcome is suboptimal. So how do we prevent this? Well, in the face of radiation after the defect has occurred, trying to reconstruct this with a flap falls very short, as you can see in the bottom half of the screen, because of the junction between the radiated breast and then the supple, soft, nonradiated flap that we've placed in juxtaposition to the breast to reconstruct it. You can see that that junction is quite obvious and thus precludes an aesthetically pleasing result. So with the help of our radiology colleagues and accurate imaging, we're able to afford immediate lumpectomy reconstruction after the tumor has been removed. That three-dimensional MRI gives us a road map to where the margins are. And after the tumor is precisely removed and the margins are clear, we're able to reconstruct the defect much like this, using the principles of plastic surgery. Now let me back up for moment and say that most patients with a tumor like this would be closed. Patient would then fill with a saroma. And after the saroma gets absorbed and the patient's given radiation, the slide that I showed two slides ago would be the outcome of this patient. But when we intervene early, before the radiation hits, before the saroma is created, we're able to have a result much like this on the left-hand side of the screen. The patient's right breast, which is on the left-hand side of the screen, is a breast that we've reconstructed before radiation. And here is an outcome six months after the radiation effects have taken place. So as you can see, the contour of the breast is aesthetically restored. The shape, the volume, is acceptable. And most importantly, this is done without additive delay of the cancer treatment. Similarly, in a patient where the tumor is an inferior pole, as you can see in the bottom half of the right-hand side of the screen, the highlighted region is actually the breast cancer. We're able to, with proper imaging, estimate the volume of the defect and allow for a timely reconstruction immediately in the setting of the lumpectomy, as opposed to having to wait. Even in smaller-breasted patients, rearrangement of the tissues can prove ultimately optimal, as you can see in the right-hand side of your screen. The patient's left breast, which is, once again, on the right-hand side of the screen, is the reconstructed breast six months after the last dose of radiation. As you can see, the shape has not only been restored, but occasionally can actually be enhanced, and without additive surgery from other parts of the body or without implants. We've covered oncoplastic reconstruction. I'm going to go through options in implant-based reconstruction. Then cover abdominal flap options. And hopefully we'll be able to cover one more flap. Tissue expander-based reconstruction, or what we call alloplastic reconstruction, is probably the most common method of reconstruction in the United States. It's the least invasive. And the reconstructive goal's here, once again, really to create a mound, provide symmetry in clothing, and with a minimal amount of recovery time. So after the mastectomy is done and expanders placed underneath the muscle, oftentimes we use an acellular dermal matrix, which is human skin that's been extracted of all its identity and contents and immunogenicity. And that supports the lower pole of the breast in an internal hammock type of strategy, as you can see in the pictures below. The head is to the bottom of the screen. The feet are to the top of the screen. And the pectoralis major muscle of the right breast is being elevated in order to accommodate the tissue expander. So the acellular dermal matrix, which is human skin, cadaver skin that's been removed and devoid of all immunogenicity, is in place in the lower pole of the breast and sutured so that it provides an internal support or a hammock type effect for the expander. The expander is in place in this pocket . And the pectoralis major muscle is then sutured to the acellular dermal matrix. And immediate expansion is then possible with the help of a magnet to find the port. And as you can see here in this patient, here she is after bilateral mastectomies with tissue expanders that are placed. And now she's ready for the tissue expanders to be removed and the permanent implants to be placed. We've been one of the first groups, at University of Chicago Medicine, to provide nipple-sparing techniques in the Midwest. We prefer to do this through an inframammary approach, thereby optimizing the aesthetic outcome. And here's a representative patient, where she has had a right mastectomy. So this is on the left side of your screen. Through an inframammary approach and an implant-based reconstruction. The patient preferred to be enhanced. And so as you can see that the left normal breast has been enhanced to provide symmetry and a result that does not have the sequelae of cancer surgery but perhaps has been replaced with something more aesthetic, giving us an optimal outcome. So now I'm going to talk about flaps that are used from the back. And this is what's called the thoracodorsal artery perforator flap. Many of my colleagues use the latissimus flap, and many would be familiar with that. We at the University of Chicago Medicine prefer not to sacrifice muscle. And this is a technique to do so. And taking the skin and fat from the back without sacrificing muscle and the innervated muscle and function that would be sacrificed if the latissimus muscle is taken. So the fat is then harvested through this technique. So as you can see that this is the patient's back. And there's a tremendous amount of skin and fat that can be harvested while sparing the latissimus and the functioning of the latissimus muscle. The flap is then elevated and then interpolated into the breast. And in a situation where the abdominal donor site is not available, this isn't actually a choice option for us to restore the skin and the shape with an implant. In the patient in the upper right-hand corner of the screen, you can see that that's the final outcome prior to nipple reconstruction. And the paddle of skin is actually from the back. And her latissimus muscle is spared. And here is our actual donor site. And the favorable donor site and the scar position is another testament to the advantage of this technique. Here's another lady who previously had a latissimus flap reconstruction on her right side. And she comes with the unfortunate circumstance of having a secondary breast cancer on the left side. And in this situation, we're able to spare her latiss and use a thoracodorsal artery perforator flap, giving us a very similar outcome without the destruction of her latissimus muscle. So I'm going to move on to autologous breast reconstruction using the abdominal-based flaps. And this has become an evolution since the early '80s, where the entire muscle is taken, to in the late '80s, where a free tissue transfer is then utilized by removing only a portion of the muscle, to the early '90s, where the vessels are taken and the skin and fat only, and the muscle is spared. And then, shortly thereafter, the superficial inferior epigastric artery flap, where the blood vessel is in a different plane and not associated with the rectus muscle, thereby providing the same amount of skin and fat from the lower abdomen without ever touching the musculoskeletal system of the lower abdomen. So this is my personal experience through 2010. And that was a while ago. But I've probably done over 1,000 of these now. And you can see that with these anastomoses, I prefer to go into the internal mammary system. And here is an actual close up under the microscope of the artery to the right and the vein to the left. These are 9-0 sutures that allow us to restore blood into these flaps. Here are some representative examples. This is an old patient from a while back, who had right breast DCIS. So this is on the left-hand side of your screen. The deep inferior gastric vessels are then dissected through a muscle-sparing technique. And you're able to actually see that this is not a deep flap, but a muscle-sparing flap where just a small swatch of muscle is taken and the rest of the muscle, which remains innervated, remains, thereby not disrupting the integrity of the abdominal wall. And here's her result right on the table. And here's her result after nipple reconstruction and tattooing, which is approximately six years later. Same patient pre- and post-op. Here's another situation where we're sparing the muscle, doing an immediate reconstruction in a reduction pattern, once again to try to take the sequelae of breast cancer away and replace it with something that's more acceptable, as in a reduction or a mastopexy. Her left breast, which is on the right side of the screen, is the reconstructed breast. Her right breast, which is on the left side of the screen, is a reduced breast. And you can see the abdominal donor site. Here's another view of the reconstructed breast after nipple construction and tattooing. And as you can see, the breast is enhanced, lifted. And the abdominal contour has been smoothed, without the bulge that is seen for a patient that has had multiple children. Now on to the DIEP flap. This is the operation that I perform the most. And you can see that this is a flap where we take no muscle at all. And in the center of the screen, you see the blood vessels going right into the skin and the fat while sparing the muscles to the side. This allows for maximal harvest of the skin and fat for breast reconstruction with minimal donor site morbidity. Here's a patient that's representative. On her right side, which on the left side of the screen, is that she had a mastopexy to match the left side, which is the fully reconstructed breast. And she's only two weeks after the nipple construction here. So you actually see the contours of the sutures. Here's another view of that same patient. And a final view in the lateral of that same patient after nipple construction. Here's a situation where a patient had BRCA gene mutation. And she had a bilateral DIEP flap and nipple tattooing. And so in a patient like this, with some amount of ptosis, we're able to do a reduction pattern and replace the sequelae of breast cancer and mastectomy reconstruction with something that's more acceptable and common as any lift or a mastopexy. And here's that lateral view, with the nipple in the optimal position. Finally, the flap that I prefer the most beyond the DIEP flap is the superficial inferior epigastric artery flap, which as a blood vessel that's above the plane or superficial to the muscular aponeurotic system, and thereby, when a patient has this anatomy, and about 30% of the time for our experience, we're able to harvest the flap much quicker and with very minimal pain because this is not touching the fascia of the abdominal wall. So here you can see that the superficial inferior epigastric artery is to the bottom of the screen. And the vein is to the top of the screen. Here's a close-up view of that anatomy, where the red string is around the artery and the blue is around the vein. And this blood vessel allows for the perfusion and drainage of a hemi-abdominal flap. So here is a situation where a patient had bilateral SIEA flaps and bilateral reconstruction. It also helps that the patient lost about 30 pounds post-op. But you can see that the abdominal donor site is akin to an abdominoplasty. And the breast reconstruction is an acceptable outcome that's long lasting without revision. Final example of that is this lady with bilateral SIEA flaps where we're able to harvest the lower half of the abdomen, divide that in half, and each half goes to reconstruct each breast. And here she is approximately eight months after surgery. She preferred not to have nipples, but just a three-dimensional tattooing. And you can see that the contour of her abdominal region is enhanced. And a stable, soft, natural reconstruction is afforded for the long term. She also lost a significant amount of weight post-op to enhance her final result. So we've covered oncoplastic construction. We've covered alloplastic reconstruction using acellular dermal matrix. We've then covered the thoracodorsal artery perforator flap in lieu of the latissimus flap. Finally, we went to the abdominal-based regions, covering the deep inferior epigastric perforator flap, the superficial inferior epigastric artery perforator flap. And finally, I'll end with the vertical upper gracilis flap. So when patients don't have options from the abdomen, we're able to then harvest from the medial thigh. And here is a situation where a patient similarly had very little fat from the abdomen. We're able to harvest this from the medial thigh and afford a soft tissue reconstruction without implants that's long-lasting and stable. I'll end with the gluteal artery perforator flap. This is a flap that we use not infrequently. But to me, in my hands, I prefer the other flaps prior to going to the gluteal artery side because it requires a shift in position of the patient and is not optimal for me. Here is a situation where a patient had a gluteal artery perforator flap reconstruction. And you can see that her donor site is here. The scar can be quite favorable and hidden in a bikini and affords a complete mastectomy reconstruction. The downsides are there is pain on the backside and the character of the fat from the buttock region is not as supple and soft as that from the lower abdominal region or from the medial thighs. Appreciate your focus and the time that you've allowed for this presentation. Thank you very much.