OPTIMISING BREAST AESTHETICSin reconstruction

Stuart JamesThe London Breast Clinic6th October 2011

General Guidance

1st Realistic goal Balance and symmetry in clothing

General Guidance

1st Realistic goal

2nd Two or more operationsspaced over 12 months

General Guidance

1st Realistic goal

2nd Two or more operations

3rd Risk of failure by any methodapproximately 1-2%

General Guidance

1st Realistic goal

2nd Two or more operations

3rd Risk of failure by any method

4th Reconstructive Timing;Immediate or delayed

1 Selection of reconstruction

Implant only reconstruction

Combination implant/flap

Flap reconstruction ‘autologous’

Implant only reconstruction

Implant only Reconstruction

- ‘Augmented’ look- Inadequate autologous

volumes- 2 stages

Implant only

One or Two stagesI) Saline ExpanderII) Silicone Implant

Combination Implant and flap reconstruction

+ Improved result - Donor site scar and implant

Flap ReconstructionsTRAM/DIEP

+ best cosmeticallysoft and warm ages wellno late revisions

- Complexlonger recoverydonor site scar

DIEP reconstruction;The first 12 months

2 months 6 months 12 months

2 Timing and Teamwork

• Immediate reconstruction optimises results

• Skilled mastectomy giving consideration to reconstructive requirements

Breast Reconstruction; Timing Immediate Delayed

3 Technical Advances

• Surgical Technique

• Imaging

Perforator flap reconstruction• 1980’s TRAM flap

– Transverse Rectus Abdominis Myocutaneous flap

• 2000’s DIEP flap– Deep Inferior Epigastric Artery

perforator flap

DIEP or TRAM?

MS 0 - TRAM

MS 1

MS 2

Nahabedian et al PRS 2002

CT Angiography

CT Angiography

DIEP flap

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

DIEP or TRAM?

4 Secondary adjustments

Liposuction AugmentationFat transfer Scar revisionDirect excision

Summary1 General guidance

2 Selection of reconstruction

3 Timing and Teamwork

4 Technical advances

5 Secondary adjustment

Thank you, Questions?