Louisville Medicine Volume 66, Issue 8 | Page 27

PLASTIC SURGERY Other breast reconstruction advances soon followed. Implants were found to be more reliable when placed in the subpectoral position to help camouflage the upper pole wrinkles of the im- plant and support the lower implant pole to resist sagging. Tissue expanders could be temporarily used to grow the muscle pocket and skin, to ultimately place appropriate sized implants at a later stage in a short same-day operation. This staging process aided the vascularity and survival of the thin mastectomy skin through reducing pressure on the overlying skin. Over the last decade, several breast reconstruction techniques have been advanced or revisited including the DIEP flap, fat graft- ing, direct to implant, and prepectoral implant placement, and on- coplastic flaps. However, implants are still the most popular meth- od for breast cancer reconstruction, specifically with smooth tex- tured implants to minimize the possible risk for anaplastic large cell lymphoma (ALCL), which has been associated with long term indwelling textured implants. The DIEP flap, which involves a modification of the TRAM flap, was described to minimize donor abdominal weakness and hernia risk. It is similar to the TRAM in lower abdominal skin ter- ritory but allows for sparing more muscle by carving limited blood supply out of the muscle to supply the flap. Having less blood sup- ply, the DIEP has more risk for flap fat necrosis. The DIEP flap, like the TRAM flap, is most suitable for bilateral reconstructions to preserve abdominal muscle strength and reduce hernia or bulge risk. The DIEP flap involves microsurgical connection of blood vessels from the abdomen to the internal mammary vessels be- neath the ribs. As such, this more complex operation requires lon- ger operative time and hospital stay. Fat grafting involves the harvest by liposuction of fat from unwanted areas. This fat is then prepared by a variety of studied mechanisms for injection into specific areas needing more vol- ume. Fat graft injection of the breast was initially popularized for cosmetic breast enlargement by Roger Khouri. Breast fat grafting remained controversial because of the oncogenic potential of pre- cursor stem cells in the lipoaspirate and the creation of masses in the breast obscuring mammogram accuracy. After studies de- lineated differences between benign fat graft and malignant sus- cipious mammographic findings fat grafting became utilized in breast cancer reconstruction. However, fat grafting has only been embraced by the American Society of Plastic Surgeons (ASPS) for mastectomy defects and not lumpectomy defects because of the unknown oncogenic potential of fat into remaining breast cancer areas. Fat grafting is mainly used now for contour corrections and as an adjunct to other primary reconstructions. Acellular dermal matrix (ADM) and other skin substitutes have recently been developed and become popular to allow for placement and maintenance of the implant in the subpectoral po- sition. Using the skin substitute can camouflage the implant edges and assist with pocket control. From this development the direct to implant technique of reconstruction was re-initiated. Direct to implant immediate breast reconstruction can be considered for bi- lateral breast reconstruction when small implants are desired un- der thick mastectomy flaps in non-smoking patients. Loss of skin with skin sparing mastectomy (SSM) reduces the ability for ideal match in unilateral reconstruction with this direct to implant, as the tissue expanding stage is skipped with this approach. Also derived from the development of skin substitutes, implant placement in the prepectoral position has been reintroduced, in an effort to avoid animation of the implant with pectoral muscle strain and to preserve the muscle. With the prepectoral technique, the implant is temporarily maintained from sagging and camou- flaged by the skin substitute. The prepectoral implant reconstruc- tion can be considered for patients with thick mastectomy skin and small implants that won’t weigh and sag much over time. Reduction mammoplasty techniques, initially introduced for breast reconstruction of lumpectomies for benign conditions, have finally been accepted as oncologically safe for cancer defects and are now called Oncoplastic flaps. Oncoplastic reconstruction is used specifically for lumpectomy reconstruction when patients have an abundance of breast tissue and/or need reduction on the other side. These oncoplastic flaps are complex designs based on plastic surgery principles used in various breast reduction pedicles to restore the breast shape and preserve nipple vascularity in relo- cating the nipple to a more desirable position. These patients need to heal fast, as they will require postoperative radiotherapy, and therefore cannot be smokers. Recent media reports have once again created hysteria impli- cating implants to cause tumors, ALCL. What these reports failed to highlight is that ALCL is very rare and also a less aggressive variety of cancer, that has been associated with textured breast implants over an extended period. The predicted risk of ALCL development in a patient with textured surface breast implants is 1:30,000. The majority of implants placed the last several decades have been smooth surface implants. Patients that experience dra- matic enlargement of one breast or new fluid collection around the breast are evaluated for this rare condition by mammogram, ultrasound and then fluid aspirate for cytology. Through the Brown Cancer Center and other tertiary specific referrals, our University of Louisville team of plastic surgeons has contributed to and embraced this evolution of various breast can- cer reconstruction developments. We provide a thorough evalua- tion and individualized approach to each and every one of our pa- tients with the ability to perform cutting-edge care and procedures based on current research to remain at the forefront of our field. Dr. Wilhelmi practices as Chief of Plastic Surgery at the University of Louisville, where he also serves as Leonard J. Weiner, MD, Professor and Plastic Surgery Residency Program Director. In addition, he prac- tices as a Breast Plastic Reconstructive Surgeon at the Brown Cancer Center. JANUARY 2019 25