Thesis For Master Degree in Plastic Surgery

Different Modalities of Breast Reconstruction after Mastectomy

Doctor Mohamed Ahmed El Rouby Consultant of Plastic & Reconstructive Surgery Ain Shams University Cairo Egypt +2 0101556023 +2 0126531265 http://www.elroubyegypt.com http://tajmeel.ohost.de elroubyegypt@elroubyegypt.com elroubyegypt@gmail.com elroubyegypt@hotmail.com dr_mohamed_a@yahoo.com . -

CONTENTS

Subject Page Contents ---------------------------------------------------A List of Abbreviation -------------------------------------B List of Tables ---------------------------------------------C List of Figures and Photos ------------------------------D Introduction and aim of the work -------------------1 Review of literature Anatomy of normal female breast -----------------3 Pathology of breast cancer ---------------------------- 20 Breast examination ----------------------------------29 Types of mastectomy ---------------------------------- 34 Goals & timing of breast reconstruction ----------- 38 Different modalities of breast reconstruction -----43 Prosthetic breast reconstruction: ----------------44 Breast implants ----------------------------------44 Tissue expanders ---------------------------------- 49 Autologous breast reconstruction: ----------------63 Latissimus Dorsi muscle flap -------------------65 Rectus Abdominis muscle flap ----------------79 Microsurgical free flaps ------------------------- 100 Shaping of Autologous reconstructed breast ------ 111 Nipple-Areola complex reconstruction ------------ 118 Patients and Methods ------------------------------------- 125 Results ----------------------------------------------------- 137 Discussion ------------------------------------------------- 147 Summary and Conclusion ------------------------------- 153 References ------------------------------------------------- 157 Arabic Summary -----------------------------------------

LIST OF ABBREVIATIONS
Abbreviation

Meaning

LCIS IDC UICC AJC BSE MCP IMF LDMF TRAM VRAM DIEP SGAP ASIS SSN Ni Ac AFIP WHO NAC

Lobular carcinoma in situ Invasive duct carcinoma International Union Against Cancer American Joint Commission Breast self examination mid-clavicular point Inframammary fold Latissimus dorsi muscle flap Transversus rectus abdominis muscle flap Vertical rectus abdominis muscle flap Deep inferior epigastric perforator vessels Superior gluteal artery perforator Anterior superior iliac spine Suprasternal notch Nipple Acromium Armed Forces Institute of Pathology World Health Organization Nipple-areola complex

INTRODUCTION
The breast is considered a significant component of feminine health. A womans reaction to any actual or suspected disease of the breast may include fear of disfigurement, fear of loss of sexual attractiveness and fear of death. Men have similar fear regarding personal experience with breast disease of that of a loved one, (Pujato, 1987). Therefore, while many women undergoing mastectomies eventually adjust to their deformity, some never do so, and suffer morbidity related to self-esteem, interpersonal relationships, discomforts and embarrassments related to the use of external prosthesis. The lives of these women can be transformed by reconstruction of the breast. Hence, the possibility of breast reconstruction needs to be considered for all women requiring mastectomies for whatever reason, (Bostwick, 1990). Breast reconstruction either can be immediate at the time of mastectomy, delayed after six months or late up to five years after mastectomy, (Kroll, 1997).

There are many modalities for breast reconstruction:

1. External prostheses e.g. breast cup. 2. Internal prostheses e.g. tissue expanders with or without subsequent breast
implants. 3. Autologous tissue such as transversus rectus abdominis muscle (TRAM) flaps, latissimus dorsi flaps (LDMF), superior and inferior gluteal flaps, either pedicled or free flaps, (Franchelli et al, 1998). Reconstruction usually entails a series of long hospitalization during which pedicled flaps and subcutaneous tissue are transferred from the abdomen, flanks or both to reconstruct the breast mound. The nipple-areola complex can be reconstructed later using a free graft from the contralateral nipple-areola complex, labia, inner aspect of thighs or toes, (Kincaid, 1984). It is the duty of plastic surgeons not only to restore the breast mound anatomically but to reassure the patients that breast reconstruction is an integral part of treating their disease, (Kroll et al., 1998). Reconstruction of the breast after mastectomy is predominantly a demand of women in the western world and the well-developed countries. Nevertheless, in the developing countries, the women hardly demand breast reconstruction after mastectomy unless offered or motivated. The causes of these facts are not clearly understood, (Vyas, 1998). In this thesis, we will try to investigate these causes and to spread the idea of breast reconstruction after mastectomy between Egyptian females.

AIM OF THE WORK

The aims of this thesis are: 1. To review the different modalities of breast reconstruction after mastectomy with thorough analysis of cases being operated upon during this year 1999-2000. 2. To identify the causes of refusal of Egyptian women to reconstruct their breasts after mastectomy and to evaluate their compliance for breast reconstruction.

ANATOMY OF THE NORMAL FEMALE BREAST

The female breast is one of the signs of femininity that consists of a group of highly specialized cutaneous glands. Shape: The transverse shape of the young adult female breast can be represented best as a cone with a spherical surface contour, an arched base and an eccentrically situated top deviated fifteen degrees laterally. Using the nipple as a reference point, each breast is divided into four quadrants, superolateral, superomedial, inferolateral and inferomedial. In addition, there is a retroareolar area and axillary tail, (Peck, 1951). Extension: The breast tissue extends from the second to the sixth ribs and from the para-sternum to the mid-axillary lines. However, the glandular tissue extends upwards to the clavicle, downwards below the costal arch, medially to the midline and in about 95% of women, laterally to the axillary fossa as the axillary tail of Spence. The axillary tail of Spence passes through a foramen in the axillary fascia known as the foramen of Langer, (Monsen, 1992). The breast parenchyma lies between the deep layer of the superficial fascia and the fascial investment of the pectoralis major muscle (about two thirds of breast tissues). The other one third is related to the serratus anterior muscle and the aponeurosis of the external oblique muscle, (Skandalakis et al.,
1995).

The retromammary space is a bloodless plane containing some loose areolar tissue, small blood vessels and lymphatics. Thickenings called posterior suspensory ligaments, extend from the deep surface of breast to the deep pectoral fascia. So, in mastectomy, the correct plane is under the pectoral fascia and includes the retromammary space, (Iglehart, 1991). Another bloodless plane lies just deep to the dermis, in thin individuals. This plane is 2-3 mm deep to the skin. Fibrous tissue strands extend from the deep fascia to the skin. These are called the ligaments of Asteley Cooper, which are responsible for the protuberant appearance of the young female breast. With age, they become atrophic and allow the breast to drop. Also, in cases of carcinoma of the breast dimpling of the skin occur when it involves these ligaments, (McVay, 1984). Size and weight: There is a tremendous variation in the size and the weight of the female breast. At maturity, the glandular portion has a

distinctive protuberant conical form. The base of the cone is roughly circular, measuring 10-12cm in diameter and 5-7cm in thickness, (Peck, 1951) The nulliparous females have typical hemispherical configuration, whereas the multiparous females, who experienced hormonal stimulation associated with pregnancy and lactation, have pendulous and larger breasts. Postmenopausal, the breast usually decreases in volume , (Cody et al, 1984). The typical non-lactating breast weights between 150-225gm, whereas the lactating one exceeds 500gm, (Cody et al, 1984). The areola is a circular area of skin around the nipple, variable in size, pink white in nulliparous and dark brown in multiparous women. The areola contains numerous sebaceous glands, Montgomery glands, which secrete an oily material for lubrication of areola, (Moore, 1992). The nipple is a conical or cylindrical prominence that is located in the center of the areola. In nulliparous females, the nipples are usually situated at the level of the fourth intercostal spaces. However, the position of the nipples varies even in the same woman. The tip of the nipple is formed of a circulatory arranged smooth muscle fibers that compress the lactiferous ducts and erect the nipple when they contract, (Moore, 1992). Consistency: The breast is composed of acini, which together make lobules and lobes of the gland. The lobes are arranged in a radiating fashion, converging towards the nipple where each lobe is drained by a duct. There are 15 main ducts, where each one is dilated into an ampulla beneath the areola forming lactiferous sinuses, where they open separately on the summit of the nipple, (Last, 1996).

Blood Supply of the Breast:

Arterial blood supply (Figure 3): Blood supply of the breast comes from many sources and within the breast arterial interconnection leads to collateralization of flow, (Russell,
1983). (1)

Lateral Thoracic Artery: The lateral thoracic artery is a branch from the second part of the axillary artery. It is the main source of blood supply for the lateral part of the mammary gland. In the absence of this artery, the thoracodorsal artery, which is the continuation of the subscapular artery from the third part of the axillary artery, becomes the main source of blood supply, (Monsen, 1992).

(2)

Internal Mammary Arteries: The internal mammary arteries are branches from the first part of the subclavian artery. They course downwards along the lateral border of the sternum, sending branches through the intercostal spaces, to supply the medial part of the breast, (McMinn, 1990).

(3) Intercostal Perforators: The intercostal perforators are the lateral branches of the second, third and fourth posterior intercostal arteries, which supply the inferior and lateral parts of the breast, (McMinn, 1990). Venous drainage (Figure 4): The venous drainage of the breast is important not only because the veins are the route of hematogenous metastases but also because the lymphatic vessels generally follow the same course. It can be classified into the superficial subcutaneous veins and the deep veins, (Haagensen, 1986). A. The Superficial Subcutaneous Veins: Around the nipple the superficial subcutaneous veins form the anastomatic circle, the circulus venosus. The superficial veins radiate from this circle to the periphery of the breast then unite into vessels, which join the internal mammary, axillary and posterior intercostal veins. The majority of these veins drain into the internal mammary vein, (Haagensen, 1986). B. The Deep Veins: The deep veins drain along routes roughly corresponding to the arterial blood supply, (Rush, 1989). 1- The perforating branches of the internal mammary veins: These are the largest veins draining the breast. They end finally into the innominate veins, then to the pulmonary capillary network. 2- Multiple tributaries to the axillary vein. 3- The intercostal veins: They are one of the most important routes of venous drainage from the breast. They travel posteriorly to the vertebral veins and hence to the azygos veins and superior vena cava. They are the third pathway from the breast to the lungs, (McVay, 1984). C. The Vertebral System of Veins:

This is a separate system paralleling the caval system. They drain not only the vertebrae but also the bones of the pelvis, upper ends of the femur, the shoulder girdle, upper end of the humerus and the skull, (McVay, 1984). The anastomosis of the deep veins of the breast with vertebral veins through the intercostal veins is the explanation for the metastasis of breast cancer to the vertebral bodies or even the sacrum or pelvis without presence of metastatic deposits in the lungs, (Rush, 1989).

Innervation of the Breast (Figure 5):

The breast, has a segmental sensory innervation that follows the distribution of the intercostal nerves, which are subdivided into an anterior and posterior nerve rami. The anterior ramus courses laterally in the intercostal space to about the level of the anterior axillary line, where, after piercing the serratus anterior, it gives rise to a lateral cutaneous branch. The main ramus then continues anteriorly where it terminates in the midline as the anterior cutaneous branch, (Rush, 1989). The smooth muscles present in blood vessels and the nipple-areola complex receive their innervation via the sympathetic nervous system, (Serafin, 1976).

Lymphatic Drainage of the Breast (Figure 6):

The lymphatic drainage of the breast is extremely important because breast cancer spreads along such channels, (McVay, 1984). In the subareolar area, there is a particularly numerous meshwork of lymphatics that widens peripherally to form a dense circumareolar plexus (Retroareolar plexus of Sappy). From this, enormous external and internal trunks are the main routes of lymphatic drainage from the breast to axilla: 1. The External Trunk: Passes from the subareolar plexus to the outer border of the pectoralis major and receives collaterals from the upper half of the breast. 2. The Internal Trunk: From the medial edge of subareolar plexus to the outer border of the pectoralis major and receives tributaries from the lower half of the breast. Both these trunks pass around the outer edge of the pectoralis major muscle, then penetrate the costo-coracoid fascia and terminate in the axillary lymph nodes, (McVay, 1984).

There are two accessory routes of lymphatic drainage from the breast to the nodes at the apex of the axilla, these are: a. The Transpectoral route: Begins as a retromammary plexus of lymphatics. Then, they perforate the pectoralis major and following the course of the pectoral branch of the thoracoacromial artery, empties into the subclavicular group of axillary lymph nodes. b. The Retropectoral route: It is a lymphatic pathway found in about one third of subjects and drains the upper internal portion of the breast. It runs laterally to rotate around the outer edge of pectoralis major and then runs upward on its under surface or under the pectoralis minor to the apex of the axilla where it empties into the subclavicular group of axillary lymph nodes. This group is a more direct pathway to the subclavicular nodes than the main lymphatic route, (Rush, 1989). Lymphatic Drainage to the Internal Mammary Nodes: The central and medial lymphatics of the breast pass medially along the course of the blood vessels perforating down through the pectoralis major muscle and empty into the internal mammary chain of nodes situated in the interspaces between the costal cartilages within 3 cm of the sternal edge, (McVay, 1984). Lymphatic Drainage to the Contralateral Axillary lymph nodes: The crossing of skin lymphatics from one breast area to the opposite side provides one explanation for metastasis reaching the opposite axilla in breast cancer. A second route for such contralateral spread is along the deep pectoral fascia lymphatics from one side to the other, (McVay, 1984). Lymphatic Drainage of the Muscles of the Chest Wall: These follow the general course of their blood supply. The lymphatics of the medial portion of pectoralis major and pectoralis minor muscles empty into the internal mammary lymph nodes, while the lateral portions drain to the axillary lymph nodes, (Rush, 1989).

Lymph nodes:
I) The Axillary Lymph Nodes (Figure 7): They are of large size and vary from twenty to thirty in number. There are five principle groups that lie beneath the coracoid fascia along with the

axillary blood vessels, nerves, connective tissue and fat and which are held together by strong fascial network making dissection in one mass easy, (McVay, 1984). 1. The external Mammary group (Anterior group): lies along the medial wall of the axilla, outside the fascia covering the digitations of serratus anterior muscle from the sixth rib to the axillary vein following the course of the lateral thoracic vein. 2. The Subscapular group (Posterior group): lies along the subscapular and thoracodorsal blood vessels and extend from the lateral thoracic wall to the axillary vein. 3. Axillary Vein group (Lateral group): is the most numerous, and lies along the lateral portion of the axillary vein. 4. The Central group: is the second most numerous, as well as being the largest of the axillary nodes. They are also the most frequently felt axillary lymph nodes. They lie embedded in the fat in the center of the axilla. 5. The Subclavicular group (Apical group): lies at the apex of the axilla where the subclavian vein disappears beneath the subclavius muscle. The collecting trunks from all other axillary groups of nodes end into this group, (Rush, 1989). Drainage of the axillary lymph nodes: Large efferent lymph vessels from the subclavicular group pass upward beneath the clavicle for 3cm to terminate in one of three pathways: a) Directly into the venous system at the junction of the subclavian and jugular veins. b) With the jugular and bronchomediastinal lymphatic trunks to form a common duct ends in the jugular-subclavian venous confluence. c) Into the Sentine nodes of supraclavicular (inferior deep cervical) group close to the jugular-subclavian venous confluence, (McVay, 1984). For surgical purposes, the axillary lymph nodes are divided into three levels according to their relationship with the pectoralis minor muscle.
1. Nodes lying lateral to pectoralis minor are termed level I. 2. Nodes lying deep to pectoralis minor are termed level II.
3. Nodes lying medial to pectoralis minor are termed level III , (Haagensen, 1986).

Level I and II lymph nodes are removed in an extended total mastectomy (mastectomy with axillary dissection). Removal of the level III lymph nodes requires excision or division of the pectoralis minor muscle, as in radical mastectomy or Pateys radical mastectomy where the pectoralis minor muscle is preserved, (Haagensen, 1986). Involvement of the supraclavicular lymph nodes, unlike involvement of lymph nodes of the axillary chain is considered as a distant metastasis because it occurs in a retrograde fashion, from the lymph nodes at the jugular-subclavian venous confluence, (McMinn, 1994). II) The Internal Mammary lymph Nodes: They are situated in the interspaces between the costal cartilages within 3cm of the sternal edge. They are small nodes about 5mm in diameter and their average number is 6 per subject with the greatest concentration in the upper three interspaces. Sometimes, there are retromanubrial nodes at the level of the first interspace connecting the right and left internal mammary chains, (Haagensen, 1986). Efferent lymphatics of these nodes empty into the thoracic duct on the left side and the right lymphatic duct on the right side or they may empty directly into the jugular-subclavian venous confluence, (McVay, 1984). III) The Posterior Intercostal Lymph Nodes: They are one to three nodes in each interspace lying upon the inner aspect of thoracic wall, close to the head of the ribs. These nodes also receive tributaries from the parietal pleura, the vertebrae and the spinal muscles and provide a retrograde route where-by carcinomatous emboli from the breast may reach the pleura or the vertebrae. The normal efferent channel from these posterior intercostal lymph nodes is to the thoracic duct, (McVay, 1984).

ANTHROPOMORPHIC BREAST MEASUREMENT

The breast is an organ with varied volume, width, height, projection, tissue density, composition, shape and position on the chest wall, (Penn,
1955).

The aesthetically perfect breast was defined as a non-ptotic breast in which no common aesthetic procedure would be considered appropriate to enhance the breasts form, (Melvyn, 1997). Although the results of the measurements indicate the range and variance in the aesthetically perfect breast, there still was a statistically significant correlation of some of the parameters of the breast and torso shape to breast volume. This correlation can be used preoperatively to predict the desired breast shape and volume in breast reconstruction, (Melvyn, 1997). The parameters that should be recorded are shape, volume, relative position to the trunk and the other breast, ptosis and projection, (Melvyn,
1997).

Measurements to the nipple were made to the center of the nipple. Measurements to the umbilicus and pubis were to the superior border of each. The clavicular point is defined as a point on the upper border of the clavicle 5 cm lateral to the clavicular-manubrial joint, (Smith, 1986). Definitions of parameters measured to determine the aesthetically perfect breast include: 1. Suprasternal notch (SSN)- inframammary fold (IMF): the vertical midline measurement from SSN to the point level with the most inferior point of the inframammary fold. 2. SSN- Xiphoid, (16.73~17.4 cm). 3. SSN-Umbilicus, (33.51~34.9 cm). 4. SSN-Pubis, (47.6~48.9 cm).

Acromion 6

SSN

11 7 5

432
1
9
12

8 13

Nipple

17
IMF

14 BP

18

17

Fig 8:Anthropomorphic breast measurements, (Melvyn, 1997).

5. SSN-center of the nipple (Ni), (18.6~19.3 cm). 6. SSN-Point of maximal lateral prominence of Acromion (Ac), (18.3~19.1 cm). 7. Nipple-Clavicle: the vertical measurement from a point 5 cm lateral to the clavicular-manubrial joint, (18.6~23 cm).

8. Nipple to nipple: the horizontal measurement of the center of both nipples, (19.35~20.76 cm). 9. Areola-IMF: the vertical measurement of the inferior areolar edge to the lowest point of IMF, (5.1~6.1 cm). 10. Areola-Low: the vertical measurement of the inferior areolar edge to the most dependant point of the breast, (5.1~6.1 cm). 11. Nipple-Acromion, (21~23 cm). 12. Nipple width, (3.49~4 cm). 13. Nipple height, (3.69~4.2 cm). 14. Breast projection (BP): it is measured at 90 degrees to the chest wall just beneath the breast, (12~16). 15. Infra right: the circumlinear measurement of the inferior 180 degrees about the nipple on the right IMF, (16.86~18.6 cm). 16. Chest circumference: this is measured at the level of the most inferior point of IMF, (71.94~75 cm). 17. Chest width: this is measured at the level of the most inferior point of IMF, (25.1~27.4 cm). 18. Chest depth: this is measured at the level of the most inferior point of IMF, (17.1~19.2 cm). 19. Volume: the volume of the breast, (260~340 cm3), (Melvyn, 1997). By definition, the areola-low, item 10, equal the distance from areola to IMF, item 9. So, if there is a discrepancy between the two, it would indicate ptosis, (Melvyn, 1997). There is a formula to calculate the volume of the breast: Volume = (SSN-Ni)1.103x(Ni-Ni)0.811 On average, the sizes desired are between 1~2 standard deviations above the predicted volume, (Melvyn, 1997). The ideal nipple plane is 1defined as a line level to the midpoint on the shaft of the humerus, (Maliniac, 1950).

Another important consideration in female breast surgery is that the higher the breast, the smaller is the volume necessary to obtain an appropriate volume, (Melvyn, 1997).

PATHOLOGY OF THE BREAST CANCER

I-CARCINOMA OF THE BREAST
Pathological examination is considered to be the backbone in the diagnosis as well as the treatment decision of the breast cancer. Histopathology is not only essential in the diagnosis of breast carcinoma and its differentiation from benign conditions, but also, it is very important now to select the proper treatment so as to get the best results. The histopathological features of the disease will determine its aggressiveness and accordingly the mode of treatment and prognosis, (Kumar et al, 1992). Currently about one in ten women develop breast cancer during their lifetime, and breast carcinoma causes about 20% of cancer deaths among women, (Robbins et al, 1995). Incidence / Epidemiology of Breast Cancer: It rarely develops before the age of 25 years with a peak incidence during perimenopausal years. A greater risk in women who have an early menarche and late menopause. More common in nulliparous than in multiparous women. Obesity is associated with increased risk attributed to synthesis of estrogens in fat depots.

Exogenous estrogens for menopausal symptoms are associated with moderately increased risk of breast carcinoma. More common in patients with a family history of breast carcinoma ,
(Robbins et al, 1995).

Distribution and Incidences: Fifty percent of breast carcinomas arise in the upper outer quadrant, 10% in each of the remaining quadrants and 20% in the central and sub-areolar region. Lesions are multifocal in about one third of patients and not infrequently bilateral, especially lobular carcinoma of the breast, (Robbins et al, 1995).
Table 1: Risk Factors of breast cancer

(Schwartz, 1989)
Risk factors Age Old High risk group Young Asia, Africa High Low Ever married Rural Black Low risk group

Race America, Europe Socioeconomic state Marital state

Never married Urban White White No Late Early Thin Yes Yes

Place of residence Race > 45 years <45 years Black Nulliparity Yes

Age of menopause Age of menarche Weight Obese

Early Late

+ve Past history +ve Family history

No No

Classification of Breast Carcinomas: Several pathologic classifications of mammary carcinomas are in use. The most commonly used are those presented by the Armed Forces Institute of pathology (AFIP) and the World Health Organization (WHO), (Harris et al, 1993). A perfect classification system would ideally correlate both clinical manifestation and histological features with the prognosis, (Iglehari, 1991). The WHO system, which has the definite advantage of worldwide distribution and which, with minor modifications,

represents a decent compromise among different opinions is widely used, (Silverberg, 1983).
Table 2: World Health Organization histological classification of proliferative and tumoral lesions of the breast (Iglehari, 1991).
1st. Benign mammary dysplasia : A. Cysts: One) Simple cyst Two) Papillary cyst B. Adenosis C. Typical, regular epithelial proliferation of the lactiferous ducts or the lobules. D. Duct ectasia E. Fibrosis F. Gynecomastia G. Other non-cancerous proliferative lesions. 2nd. Benign or apparently benign tumours : A. Breast adenoma B. Nipple adenoma C. Lactiferous duct papilloma D. Fibroadenoma: One) Pericanalicular fibroadenoma Two) Intracanalicular fibroadenoma 1. Simple type 2. Cellular type (cystosarcoma phyllodes) E. Benign soft tissue tumors 3rd. Carcinomas: A. Intracanalicular and non infiltrating interlobular carcinoma B. Infiltrating carcinoma C. Specific histological types of carcinoma: One) Medullary carcinoma Two) Papillary carcinoma Three) Adenoid cystic (cribirform) carcinoma Four) Mucoid carcinoma Five) Lobular carcinoma Six) Squamous carcinoma Seven)Pagets disease Eight) Carcinoma arising from cystosarcoma phyllodes 4th. Sarcomas: A. Sarcoma arising in cystosarcoma phylloides B. Other sarcomas 5th. Carcino-sarcoma 6th. Unclassified tumors

Types of Breast carcinoma:I. In situ carcinoma : A. Intraduct Carcinoma:

Characterized by pleomorphic carcinoma cells that fill the ducts and ductules with carcinoma cells but remain confined within the basement membrane. Various patterns are present such as solid, cribriform, papillary, micropapillary and comedo-carcinoma variants. Poorly differentiated, pleomorphic in situ tumors often show central necrosis, with recurrence rate up to 40% after lumpectomy. Well-differentiated variants exhibit very little necrosis with recurrence rate 0% to 10% of cases, (Robbins et al, 1995). B. Lobular Carcinoma in Situ (LCIS): Characterized by a proliferation of small, uniform cells, which fill and distend at least 50% of the acinar units of a single lobule. Invasive carcinoma develops in about 30% of cases of LCIS if untreated with mastectomy, (Robbins et al, 1995).

II. Invasive Breast Cancer : A. Invasive Duct Carcinoma (IDC):

(schirrous carcinoma) (94%): It is the most prevalent form of invasive carcinoma, which is characterized by infiltration of the stroma by malignant epithelial cells that are usually arranged in nests, (Robbins et al, 1995).

B. Invasive Lobular Carcinoma (5%):

It tends to be multifocal and bilateral compared with other breast carcinomas. It has about the same prognosis as invasive duct carcinoma but tends to be bilateral or multicentric (20%), (Robbins et
al, 1995).

C. Medullary Carcinoma (1-5%):

The paradox of medullary carcinoma is that, inspite of the highly anaplastic cytological appearance of its cells and despite the presence of axillary lymph node metastasis at the time of diagnosis in many cases, it is associated with a very good prognosis, (Ridolfi et
al, 1977).

D. Mucinous Carcinoma:
It characterized by a very good prognosis in their pure form.

E. Pagets Disease of the Nipple

Pagets disease of the nipple is not so much a separate type of mammary carcinoma as it is a highly specialized manifestation of ductal carcinoma. Grossly, the skin of the nipple and areola is frequently ulcerated and fissured. Histologically, the duct carcinoma cells appear as large pale somewhat vacuolated cells located within the overlying

keratinizing squamous epithelium. Pagets disease has been associated with a high incidence of nodal metastasis at the time of diagnosis, (David, 1996).

F. Tubular Carcinoma:
A very well differentiated variant of invasive ductal carcinoma.

G.Papillary Carcinoma:
Papillary carcinomas are defined by the presence of fibrovascular cores that support the overlying abnormal epithelium. However, these tumors still behave in a relatively benign fashion, about 90% of patients are alive 5 years after their modified radical mastectomies, (Fisher, 1980).

H.Adenoid Cystic Carcinoma:

This rare variant has an excellent prognosis and often does not have lymph node metastasis, (Silverman, 1991).

I. Apocrine Carcinoma:
Apocrine carcinoma is an unusual variant of breast carcinoma possibly of sweat duct, (Kline, 1988) or ductal origin, (Frable et al, 1980). The biologic behavior is similar to that of the common invasive ductal carcinoma , (Silverman, 1991).

J. Inflammatory Carcinoma
It is characteristized clinically by erythema, peau dorange and skin ridging with or without the presence of a palpable mass, (Brustein S, 1987).

Staging of breast carcinoma

The most widely used staging system is one adopted by the International Union Against Cancer (UICC) and the American Joint Commission on cancer staging and end results reporting (AJC) and is based on TNM system. UICC-AJC clinical staging system is used for preoperative assessment of the patient. For better staging pathological criteria may be used hence UICC-AJC pathological staging system was designed (PTNM), (Kirbty et al,
1991).

TNM breast cancer classification system: Primary tumor: TX Primary tumor cannot be assessed.

T0 No evidence of primary tumor. It is carcinoma in situ: intraductal carcinoma, lobular carcinoma in situ, or Pagets disease of the nipple with no tumor. T1 Tumor is 2 cm or less in greatest dimension. T1a < 0.5 cm in greatest dimension. T1b 0.5 ~ 1 cm in greatest dimension. T1c 1 ~ 2 cm in greatest dimension. T2 2 ~ 5 cm in greatest dimension. T3 > 5 cm in greatest dimension. T4 Tumor of any size with direct extension to chest wall or skin. T4a Extension to chest wall T4b Edema (including peaudorange) or ulceration of the skin of the breast or satellite skin nodules confined to the same breast. T4c Both (T4a and T4b)

Regional lymph node NX Regional lymph nodes cannot be assessed or previously removed. N0 No regional lymph node metastasis. N1 Metastasis to moveable ipsilateral axillary lymph nodes. N2 Metastasis to ipsilateral axillary lymph nodes fixed to one another or to other structures. N3 Metastasis to ipsilateral internal mammary lymph nodes. Distant metastasis M
X

Presence of distant metastasis can not be assessed No distant metastasis

M
0

M
1

Distant metastasis (includes metastasis to ipsilateral supraclavicular lymph nodes)

Stage grouping: Table3: Staging of Breast Cancer, (Anderson, 1989).

Stage 0 T0 N0 M0 Stage I T1 N0 M0 Stage IIA T0 N1 M0 T1 N1 M0 T2 N0 M0 Stage IIB T2 N1 M0 T3 N0 M0 Stage IIIA T0 N2 M0 T1 N2 M0 T2 N2 M0 T3 N1, N2 M0 Stage IIIB T4 Any N M0 Any T N3 M0 Stage IV Any T Any N M1

Pathological classification (PN) Regional lymph nodes can not be assessed (e.g., previously removed or not removed for pathological study). PNX Regional lymph nodes can not be assessed (e.g., previously removed for pathological study or not). PN0 No regional lymph node metastasis PN1 Metastasis to moveable ipsilateral axillary lymph nodes PN1a Only micrometastasis (none larger than 0.2 cm) PN1b Metastasis to lymph nodes, any larger than 0.2 cm PN1bi Metastasis in 1 to 3 lymph nodes, 0.2 ~ 2 cm in greatest dimension. PN1bii Metastasis to 4 or more lymph nodes, 0.2 ~ 2 cm in greatest dimension. PN1biii Extension of tumor beyond the capsule of a lymph node metastasis, < 2 cm in greatest dimension. PN1biv Metastasis to a lymph nodes > 2 cm in greatest dimension PN2 Metastasis to ipsilateral axillary lymph that are fixed to one another or to other structures PN3 Metastasis to ipsilateral internal mammary lymph nodes

II- SARCOMA OF THE BREAST

They are a heterogeneous group of lesions which include fibromatosis, fibrosarcoma, malignant fibrous histiocytoma, liposarcoma, leiomyosarcoma, osteogenic sarcoma, and chondrosarcoma, (Gutman H, 1994).

III- LYMPHOMA OF THE BREAST

Primary lymphomas of the breast are rare. Presentation is that of a large lesion (mean size 4 cm) in the postmenopausal patient. Mammary lymphomas are identical to other malignant lymphomas, with tumor cells that are densely infiltrative throughout the breast parenchyma. There is a predominance of diffuse histiocytic lymphomas, (Brustein S, 1987).

BREAST EXAMINATION
BREAST SELF-EXAMINATION (BSE): The routine BSE is based on the following beliefs: 1. Cancer detected by BSE is likely to be of smaller size than that found accidentally. 2. Survival rates after treatment are better for patients with small tumours and no lymph nodes metastasis than those with large tumours and lymph nodes metastasis. 3. Small tumours enlarge progressively if left without treatment. 4. Large lesions are more frequently associated with axillary node metastases than small lesions. 5. Prognosis is directly related to the presence and extent of lymph node metastases, (O'Higgins, 1991). 1. 2. 3. BSE has three primary components: Manual examination in the shower Visual examination in the mirror Manual examination when laying flat. All women should complete all these maneuvers 5 to 7 days after the last day of their menstrual period. The instructions for a breast self examination are as follows: In the shower Raise one arm, with fingers flat, touch every part of each breast, gently feeling for a lump or thickening. In front of a mirror With arms at your sides, then raised above your head, look carefully for changes in the size, shape, and contour of each breast. Look for puckering, dimpling, or changes in skin texture. Gently squeeze both nipples and look for discharge. Lying down With fingers flat press gently in small circles, starting at the outermost top edge of your breast and spirally in toward the nipple. Examine every part of the breast. Repeat with left breast. With your arm resting on a firm surface, use the same circular motion to examine the underarm area, (O'Higgins, 1991).

Fig 9: Breast Self Examination, (O'Higgins, 1991).

CLINICAL EXAMINATION: Inspection: Inspection of the breast is an important part of the physical examination, as many lesions can be detected by inspection. The breasts should be looked at directly from infront and from the side of the examiner. The patient should be examined with her arms by her side and while she is asked to raise her arms fully above the head. During this movement, minor degrees of asymmetry, dimpling or tethering of the skin can be detected and movement of the breast on the pectoral muscles and chest wall can be identified. Abnormalities of the nipple such as retraction, discharge, ulceration or encrustation are noted. The skin over the breast is examined for signs of thickening, edema, erythema, ulceration or prominent veins, (Rush, 1988). Palpation: Palpation should be carried out with the patient in the upright and the supine positions, using the volar aspect and tips of the fingers. If a lump is detected in the breast, the relation of the mass to the breast substance is determined by holding the breast with one hand and trying to move the mass by the other hand. The mobility of the lesion on the pectoralis major muscle from side to side and from above downwards is then assessed. The mobility of the lump

should be checked when the muscle is both contracted and relaxed, (Rush,
1988).

Physical examination of the regional lymph nodes is a routine during the time of examination of the breast. The medial, anterior, posterior and lateral walls of the axilla are first examined followed by the examination of the apical area and supraclavicualr lymph nodes, (Rush, 1988).

Inspectio n

Fig 10: Breast Clinical Examination, (Schwartz, 1991)

Palpation

CLINICAL EXAMINATION OF THE MASTECTOMIZED PATIENTS: In the first consultation, the following must be determined: Whether the patient is a good candidate for autologous reconstruction. Whether she is willing to undergo the additional surgery required. Special considerations in the patients history include existing medical problems such as diabetes mellitus, lupus, cardiac disease, pulmonary problems, and peripheral vascular disease. A previous mastectomy or radiation therapy to the chest or axilla may affect local skin quality and tightness. Other considerations include past or current smoking, and the patients occupation and lifestyle. The patients height, weight, and bra size are recorded, (Bernard, 1998). Physical examination consists of careful assessment of the affected and the normal breast. The anthropomorphic breast measurements are recorded, (Bernard, 1998). We should be minded by four important items that will help us to decide the options for breast reconstruction, and those suitable for a particular patient. These four items are:

1. The location of previous incisions and scars should be made with attention to the most recent biopsy site to incorporate the biopsy incision with the nipple-areola complex in the mastectomy incision 2. The skin quality and vascularity. 3. The amount of subcutaneous fat. 4. The pectoralis muscle: if it is present or not and if it is atrophied or not, (Heinz, 1997). Donor site considerations include the adequacy of sufficient vascularized tissue in the various donor sites and patient preference, (Bernard, 1998). The contralateral breast should be examined also, as other procedures can be considered if the opposite breast is large or ptotic, and may be performed at the initial operation or with secondary nipple reconstruction, (Bernard,
1998).

During general examination we should consider: The general built of the patient. The chest shape. The state of the abdominal wall and the presence of other abdominal scars, (Heinz, 1997).

TYPES OF MASTECTOMY
I) Halsted (Radical) Mastectomy: As classically described by Halsted (1894-1907), radical mastectomy involves enbloc removal of all breast tissue and an abundant overlying portion of skin, the entire pectoralis major and minor muscles, and all of the fibrous and fatty tissue beneath the axillary vein including the axillary lymph nodes. II) Modified Radical Mastectomy: It was described by Patey and Dyson in 1948 and subsequently by Richard Handley. This operation involves resection of the breast, pectoralis major fascia, pectoralis minor muscle and the axillary lymph nodes where the pectoralis major muscle is preserved. Further modification by Auchincloss preserved the pectoralis minor muscle as well. III) Extended (Radical) Mastectomy: In this type of mastectomy, the skin incision incorporates the nipple and may be either oblique or transverse, depending upon whether the pectoralis major is removed or not. The radical mastectomy portion of the procedure removes all breast tissue in conjunction with an axillary dissection, (Veronsei, 1981). Super Radical Mastectomy: The super-radical mastectomy goes beyond the Halsted radical mastectomy to include removal of all breast tissue and both pectoral muscles and dissection of the axillary, internal mammary and supraclavicular lymph nodes, (Veronsei, 1981). Total (Simple) Mastectomy: In this approach, the entire breast with a safety margin of skin at least 4cm around the tumor is removed with the underlying pectoral fascia and the nipple-areola complex. Both pectoralis major and minor muscles are preserved. Less extensive skin margins are acceptable when the procedure is done for early cancer (lesions less than 1cm diameter) or for insitu or premalignant lesions. The axillary tail of Spence is included in the en-bloc specimen. In general, no axillary dissection is employed, (Rosato, 1986). Breast Conservation Surgeries:

IV)

V)

VI)

Breast conservation surgeries involve removal of the primary tumor and a variable safety margin of surrounding normal breast tissue.
There are various terms to describe these approaches. They include lumpectomy, tumorectomy, segmental mastectomy, local excision, partial mastectomy and quadrantectomy, (Harris, 1993).

In 1990, the National institute of Health published the consensus development conference statement of The patients with early stage breast cancer. It states that "breast conservation treatment is an appropriate method of primary therapy for the majority of women with stage I and II breast cancer and is preferable because it provides survival equivalent to total mastectomy and also preserves much of the breast tissues", (Osborne et al., 1990). The primary goals of this therapy are: 1. Tumor control 2. An acceptable appearance of the breast. If both goals are not obtained, then the treatment has failed ,
(Osborne et al., 1990).

Selection criteria for breast conservative treatment:

The tumor size is less than 5cm. A motivated patient. A solitary lesion that can be completely excised. Focal not diffuse microcalcifications.

Contraindications for breast conservative treatment:

Absolute contraindications: The presence of multiple primaries. The tumor size is more than 5cm. Pregnancy. Collagen vascular disease. Diffuse microcalcifications. Relative contra indications: Extensive ductal carcinoma in-situ. Very young patients, (Wells, 1993). VII) Subcutaneous Mastectomy: Subcutaneous mastectomy removes only the major portion of the breast tissue, preserving the nipple, both the pectoral muscles and the axillary lymph nodes. The skin is

subcutaneously dissected off the underlying breast tissue, leaving a skin flap 4~8mm in thickness, (Shone and Press, 1983). VIII) Prophylactic Mastectomy: Some women have a high risk of developing breast cancer. Prophylactic mastectomy is an operation designed to reduce this risk by removing a high percentage of the breast tissue. This option has become more attractive for the woman at high risk since the development of satisfactory methods of immediate breast reconstruction, (Jarrett, 1978; Woods, 1980). Surgeons differ in their opinions in the most suitable operation for each patient, varying from extensive preventive surgeries, as simple or total mastectomy, to subcutaneous mastectomy for aesthetic results, (Heinz, 1997).

Indications: 1. Histological diagnosis: The premalignant lesions and preinvasive carcinoma are the most urgent 2. Age: The younger the woman, the better to perform a subcutaneous mastectomy. 3. Personality and Mental state: play important roles. 4. Family History: of breast cancer, especially if the mother and/or one of the patients sisters had a past history of breast cancer, (Heinz, 1997). Technically, after excision of most of the breast tissue, simple methods of breast reconstruction should be used if possible. However, selection of the breast reconstruction procedure must be chosen individually depending on various conditions: 1) Implantation of silicone implants. 2) Latissimus dorsi musculocutaneous flap. 3) The TRAM flap can be used to avoid the disadvantages of alloplastic materials. 4) The muscular fascial turnover flaps from the external oblique muscle and parts of rectus fascia or rectus abdominis muscle improve the muscular coverage of the implant at the medial inferior area, (Heinz, 1997).

THE GOALS OF BREAST RECONSTRUCTION

Regardless the timing of the breast reconstruction and the nature of mastectomy procedure, the goals of reconstruction still the same, which are: To restore the breast mound and contour. To achieve symmetry between the reconstructed breast and the remaining natural breast. Reconstruction of the anterior axillary folds in case of pectoralis muscle loss. Reconstruction of the nipple-areola complex. Psychological benefits of breast reconstruction, (Heinz, 1997). Reconstruction was clearly associated with reducing the psychological trauma generally attributed to amputation of the breast. Also, reconstruction improves the women's sense of femininity, elevates her self-esteem and encourages sexual expressiveness. It has been approved that immediate breast reconstruction has additional benefits: 1. The patients can expect the restored physical state from the beginning of treatment. 2. She does not have to grieve the loss of the breast. 3. She dose not experience psychological disturbance or loss of the general daily activities of life, (McDonald, 1988).

1) 2) 3) 4) 5)

THE TIMING OF BREAST RECONSTRUCTION

There are two important considerations in breast reconstruction after mastectomy, the timing and the choice of technique.

The timing of breast reconstruction has usually been delayed until primary treatment and adjuvant therapies have been carried out, (Bostwick, 1990). However, oncologically, there is no reason preventing immediate breast reconstruction unless the patient refuses the operation or has a poor prognosis, (Kroll, 1997). Whether to undergo immediate or delayed breast reconstruction, this will not by any means affect the decision regarding the type of mastectomy to be performed, (Dinner,
1984).

Patients vary in their reactions and response to the necessity for mastectomy. Some refuses to undergo the primary treatment without the knowledge that the breast can be reconstructed immediately. Other patients, however, prefer the removal of the cancerous breast before they can contemplate the physical and psychological implication of breast reconstruction. Close cooperation between the patient, the general surgeon, and the reconstructive surgeon is mandatory, for patient to make a well-informed intelligent decision, (Dinner, 1984).

A. IMMEDIATE BREAST RECONSTRUCTION:

Indications: The ideal patient for immediate reconstruction is a young female with a small non-ptotic opposite breast. Her tumor is small (less than 1 cm in diameter); her biopsy indicates a minimal or intraductal breast carcinoma, with other social, emotional or personal problems that can be aggravated by this surgery, (Patrizi et al, 1993). Advantages: Some women find it difficult simultaneously to face the specter of breast cancer and to loose the primary symbol of their femininity. This leads some women to delay or refuse the mastectomy. With immediate reconstruction, there is no fear of mutilation or loss of breast thus avoiding the postoperative psychological trauma, (Bostwick, 1990). Disadvantages:

I. The patient must understand that immediate breast reconstruction is the initial procedure after mastectomy and other operations are required. II. The operation takes a long time; so, it needs two operative teams (general surgeons and plastic surgeons). III. There is a higher rate of postoperative complications, (Heinz, 1997). Technique: The simplest approach is usually selected for reconstruction at the time of mastectomy: If there is a small non-ptosed breast on the opposite side one can place a small implant at the time of mastectomy. In case of a moderate-sized non-ptosed breast on the opposite side or a relative shortage of tissue to cover an appropriate-sized prosthesis, another technique may be more suitable. When a relative lack of tissue is noted, an esthetic match to the opposite side can be achieved by placing a tissue expander at the same time of mastectomy and after the surgical wound has healed, gradually expanding the prosthesis, so that there will be adequate tissue coverage. Alternatively, a latissimus dorsi flap or rectus abdominis flap may be immediately performed for reconstruction, (Mc
Donald, 1988).

B. DELAYED BREAST RECONSTRUCTION:

Time: Delayed reconstruction can be performed at any time from few days to years after mastectomy. It is usually considered three to six months after mastectomy, as by this time, the soft tissues will have recovered from the operative trauma. Also, adjuvant chemotherapy treatment is usually ended, (Heinz, 1997). Advantages: 1. Permits histopathological study of specimens to determine the exact nature of the tumour and the margins of resection and to ascertain the status of the axillary lymph nodes. 2. In cases of breast reconstruction with prosthesis, delayed breast reconstruction is better than immediate breast

3. 4. 5.

6.

reconstruction to avoid hazards of radiation as hypoperfusion and fibrosis. Allows the wound to heal and mature so as to evaluate the skin deficit after mastectomy Less postoperative complications than the immediate breast reconstruction (less incidence of haematoma or seroma). The patient experiences living with the deformity for sometimes, thus accepting any possible outcomes of breast reconstruction. Provides both patient and plastic surgeon the time to decide the best method of reconstruction, (Mc Donald, 1988).

Disadvantages: 1. Pre-mastectomy anxiety and fear from loss of this symbol of femininity which may lead some women to delay or to refuse mastectomy. 2. Post-mastectomy psychological trauma, (Bostwick, 1990).

Technique: It is usually done in two stages: The first to reconstruct the mastectomized breast and the chest wall. The second one is to correct the opposite breast if in need to do that and to perform the nipple-areola reconstruction. There may be another stage if tissue expansion technique is used by placing the permanent implant prior to reconstruction of the nipple-areola complex, (Radovan, 1982).

(I) PROSTHETIC BREAST RECONSTRUCTION

A) RECONSTRUCTION WITH AVAILABLE TISSUE AND BREAST IMPLANT (SILICONE-GEL BREAST IMPLANTS)
This is the simplest and quickest reconstruction technique if skin and muscle have been well preserved, (Bardsley, 1991). History of Breast Implants:
In 1963, Dow Corning introduced the first generation implants which were composed of a thick gel and a thick elastomeric wall, (Peters, 1994). In 1970, Don McGhan joined Heyer-Schulte and subsequently developed the first soft Cohesive silicone-gel with a high degree of softness, (Peters, 1994). Throughout the 1970s, saline inflatable implants were also marketed by many implant manufacturers with high rate of spontaneous deflation, (Gruber, 1978). As the failure properties of the soft second generation implants became more apparent, further studies demonstrated measurable levels of silicone in the capsules surrounding implants, (Peters, 1994). In 1974, the third generation implant was introduced, which had a stronger shell (High Performance [HP] elastomer), and an inner surface which was coated with a barrier layer to reduce the diffusion of silicone. In 1979, it had a biphenyl barrier layer of proprietary composition, between an inner and outer layer of HP elastomer. The new Dow Corning (Silastic II) implant had a fluorosilicone layer to restrict silicone bleed. The corresponding Surgitek implant (Strong Cohesive LowBleed [SCL]) also had a biphenyl barrier layer, (Peters, 1994). In the early 1980s, The newest evolution was the change from smooth-surfaced to textured-surface envelopes, which seem to have minimized the incidence of unwanted firmness from capsular contracture, (Garry, 1998).

Types and Contents of Breast Implants: There were several types of devices but the basic to all implants is a silicone rubber shell, which can be single or double, smooth or textured or covered with polyurethane foam. The contents are either factory filled with silicone gel of various consistencies or filled at surgery with normal saline (inflatable). There have, and continue to be, other fill materials used or proposed, but these were either short lived or are still considered experimental. The double-lumen devices contain the silicone in one chamber and the saline in the other. The original envelopes were made of thick, smooth-walled silicone rubber (elastomer) containing the silicone gel material, (Garry, 1998).

Silicone products are especially well tolerated by the body, and in general the patients body has a mild fibroblastic reaction resulting in a thin encapsulation. There is almost no adherence of living tissue to the silicone rubber envelop and there have been no substantial reports of cancer caused by implantation of silicone in humans in over 30 years of experience using silicone prosthesis. Also WHO permits a silicone-serum level up to 1mg/cm2 of barrel surface, (Garry, 1998). Various hydrogels and a pure form of triglycerides are the two main fill formulations. The major advantage of the triglycerides material is a Znumber that is similar to fat, therefore compromising mammography little or none. All currently considered substances are designed to be harmlessly absorbed and excreted if the shell breaks, (Garry, 1998). Autoclaving and physical characters of the implants: Gel -Fill Implants Autoclave by one of the following gravity displacement
1-Standard cycle: 30 minutes at 250F (121 3C) and 15psi (1kg/cm2). 2-Alternative cycle: 15 minutes at 273F (134 4C) and 30psi (2kg/cm2).

Saline-Gel Implants. Sterilize with fill tube in situ in the valve. Use a syringe to instill 5-10 cc sterile normal saline through tube into the outer lumen. Disconnect syringe, leaving fill tube in place. Remove as much air as possible from the outer lumen through the fill tube.
1-Standard cycle: 55 minutes at 250F (121 3C) and 15psi (1kg/cm2). 2-Alternative cycle: 40 minutes at 273F (134 4C) and 30psi (2kg/cm2), (Mentor H/S, 1992).

Indications: 1. For delayed breast reconstruction, this method of breast reconstruction is used if there is: An adequate quality and vascularity of the local skin. An adequate amount of subcutaneous tissues. A muscle to cover the breast implant. 2. For immediate breast reconstruction, it is ideal in the patient with a round, pubescent-like breast with no glandular or nipple ptosis, (Bostwick, 1983). Advantages:

1. It can be carried out through the existing scars, so that no new scars are created. 2. It is a relatively short and uncomplicated operative procedure compared with other reconstructive procedures of the breast. 3. It does not mask local recurrence of diseases, because the prosthesis is placed in the plane under the muscle on the anterior chest wall, below the plane of mastectomy, (Bostwick, 1990). 4. There are many variables to achieve the best result and patient satisfaction: 1. Timing of reconstruction. 2. Size of the reconstructed breast. 3. Placement of the implant subcutaneously or submuscularly (partial or complete muscle coverage) 4. The methods of application of the implants, include placement of a permanent implant, placement of a permanent expander or serial expansion with permanent implant exchange, (Francel et al., 1993). Contraindications and Disadvantages: 1. The technique is generally not suitable if: a) There is inadequate skin, subcutaneous tissue and muscle as after Halsted Radical Mastectomy. b) There is a skin graft. c) The pectoralis major muscle is denervated. d) The patient has glandular or nipple ptosis. 2. Failure to match the symmetry with the opposite breast. 3. Saline implants have always tendency to wrinkle more than gelfilled implants, especially, in thin-skin women and in the lower lateral quadrant where the muscle coverage may be deficient. 4. By using the thick-wall textured implants, the prostheses become palpable, visible or both, (Bostwick, 1994). Techniques: In choosing the suitable implant, the width (base diameter), height, projection, shape and estimated weight or volume of the breast are the key factors. So round implants match women with small flat breasts, (Scott, 1998). After mastectomy, the skin flaps and under lying muscle should be inspected for signs of excessive damage or impending necrosis and then, start the reconstructive procedure by suturing the lateral edge of the pectorals major muscle to the serratus anterior muscle with 3/0 chromic catgut. This will secure the lateral portion of the muscular layer, which will cover the implant, (Scott, 1998).

Fig 11: Selection of proper implant by measuring the three dimensions, (Scott, 1998)

In cases of delayed reconstruction after mastectomy, the reconstruction is begun by reopening of a small segment in the old mastectomy scar. Then, an incision is made using the cutting cautery parallel to the line of direction of lateral fibers of pectoralis major muscle in the mid-zone of the muscle (others prefer incision through lateral part of pectoralis major muscle using the blunt or the sharp dissection). An extensive pocket is created under pectoral muscles, serratus anterior and the upper portion of rectus abdominis, (Jackson, 1989). After haemostasis, the breast implant should be fit easily into the pocket. Then a suction drain is placed in the sub-muscular pocket and the skin is closed without tension or tightness. A dressing of gauze and strapping is used to hold the implant in the allowed position in the pocket and inframammary fold, (Jackson, 1989).

B) RECONSTRUCTION USING TISSUE EXPANDERS

The concept of tissue expansion in plastic surgery was introduced by Neuman in 1957. In 1979, it was adapted for use in breast reconstruction. The methods apparent simplicity and versatility made it popular, since it seemed to obviate the need for distant flaps in many cases, (Gibney, 1989).

Principles of tissue expansion: A tissue expander is simply an empty silicone bag that is placed through the mastectomy incision beneath the musculofascial layer. It has either a contained valve or a small tubing and a filling valve, placed beneath the skin of the lateral chest wall, (Gibney, 1987). After the wound has healed, the tissue expander is gradually inflated by injections of 50 to 200 ml of saline. Many surgeons slightly over-inflate the expander in relation to the opposite breast to decrease the likelihood of scar capsule contracture. Once the local tissues are expanded to the surgeons satisfaction, the tissue expander is removed under local or general anesthesia and the permanent breast implant is placed in the subpectoral muscle pocket, (Bostwick, 1990). The breast reconstruction can not be considered successful unless acceptable symmetry with the opposite breast is achieved. The expanders provide larger reconstructed breasts, therefore minimizing the number of reductions of the natural opposite breast, (Radovan, 1982). Types of Breast expanders: There are two distinctly different types of breast expansion devices:
1. Radovan type: which is expanded with saline, (Cohen et al, 1987). 2. Becker style implant: double-lumen permanent expander implant, (Becker,
1986).

Recent advances in expander design include improvements in shape, the development of textured surfaces, and alterations in valve design. Taken together, these changes have enhanced the aesthetic results of tissue expander breast reconstruction and decreased the number of complications, (Fisher et a1, 1994). Becker Expander/Mammary Prostheses The Becker expander/mammary prostheses are a family of devices that have low-bleed, gel-filled outer lumens and an adjustable saline-filled inner lumens. The resulting device has combined some of the advantages of tissue expanders with the feel of a gel-filled mammary implant. The outer and inner shells are made with successive crossed-linked layers of silicone elastomer. The standard Becker prosthesis is produced with either an outer

shell or a Siltex shell to provide disruptive surface for collagen interface ,

(Mentor H/S, 1992).

Both the standard smooth Becker expander and the Siltex Becker expander are designed with a silicone gel volume of 25% of normal implant size. Both are designed to tolerate temporary over expansion. However, The Siltex Becker-50 prosthesis has a gel volume that is 50% of the normal implant size. It is not indicated for temporary over expansion and therefore is best classified as an adjustable implant rather than an expansion device ,
(Mentor H/S, 1992).

Each prosthesis is supplied with a connector system, (Mentor H/S TrueLock connector) and a choice of two injection domes: 1. The microinjection dome, which may be used in thin patients. 2. The standard injection dome is larger in diameter, (Mentor H/S, 1992). The standard Heyer-Schulte type inflatable breast implant has been modified to enable a reservoir to be attached and detached at a side-filling valve. The breast implant, therefore, functions initially as a tissue expander and then remains in position as a permanent implant once the reservoir is removed, (Becker, 1984). Shape: 25% gel The original Radovan tissue expander has a circular base diameter and a contour that is spherically symmetric. It creates a breast with a wide base and an unaesthetic fullness in the upper pole of the breast. With the development of shaped expanders, it becomes possible to decrease the amount of upper pole fullness and lower the most projecting point of the expander to create a more ptotic appearance of the breast, (Hammond et al, 1993). Textured Surface: The advantages of the textured expander over the smooth walled expander: 1. Creating an irregular surface texture has dramatically decreased the incidence of capsular contracture, (Fisher et al, 1994). 2. Textured expanders remain immobile at the site of original positioning to tissue ingrowth into the interstices of the texture, whether by tissue ingrowth or simple friction, (Fisher et al, 1994). 3. Easy and less painful expansion. 4. The collagen in the surrounding capsule is non-linear. 5. The dimensionally correct expander with an appropriate base diameter allows the inframammary fold to be created passively in many patients by the expansion process alone.

6. Incidences of infection with the textured expanders are less than that of the smooth walled expanders. 7. Theoretically, no need to remove the textured expander in second operation, (Maxwell et al, 1992). Incorporated valve: Previous valve designs incorporated a remote port connected to the body of the expander by silicone tubing. New generations developed by fixing the valve into the body of the expander, to eliminate the complication of remote valves like flipping and infection, (Fisher et al,
1994).

Indications: Tissue expanders are valuable when the local tissues remaining after total mastectomy are inadequate for breast implant, (Cohen, 1987). There are two indications for use of expander/prostheses: 1. If the opposite breast is non-ptotic or if the patient agrees to do mastopexy to the opposite breast, a Becker device can be used that has size adjustment without removal. 2. If the opposite breast is ptotic or if the patient refuses to do mastopexy to the opposite breast, then a simple expander such as the Radovan is used and positioned low down on the chest wall, (Cohen,
1987).

Advantages: 1. Less surgical procedure with minimal hospital stay. 2. A shorter postoperative recovery time. 3. An improved aesthetic result achieved by means of volumetric adjustments, (Maxwell et al, 1992).

non-operative

Tissue expanders have many advantages over the use of flaps for breast reconstruction as: a) The skin color and texture are identical. b) There is maximum control over the size adjustment of the prosthesis. c) Avoidance of the debilitating problems caused by the removal of muscle and tissue at the site of donor flaps. d) In some sense, the woman sometimes feels that she is regrowing her missing breast, (Bostwick, 1990). e) With expanders, the opposite breast can be matched without the need for additional scars, (Gibney, 1987).

However, tissue expansion does not eliminate the use of other methods of breast reconstruction and if there is a less adequate or unsatisfactory result with this method, the TRAM flap and latissimus dorsi muscle flap should be used, (Gibney, 1987).

Disadvantages: 1. Placement of an expander frequently necessitates a second operation for exchange with a permanent prosthesis, however, use of permanent expander/implant device may reduce the need for this second procedure. 2. Although textured surfaces have decreased the rate of capsular contracture, this still remains troublesome, resulting in firm and sometimes-painful breast. 3. Prosthetic devices are subjected to failure with leakage of gel or saline. 4. Saline devices may exhibit wrinkling, particularly when the soft tissue cover is thin, (Fisher, 1994). 5. For inflation of the device, multiple visits to the doctors clinic are required. This can be avoided by teaching the patients to inflate the device by herself, (Gibney, 1987). Technique: I. First stage: Using local or general anesthesia, the position of the temporary subcutaneous tissue expander is outlined on the chest. A 5 cm subaxillary incision either through the lateral tail of the old mastectomy scar or through a new oblique incision. It is important to place the inframammary border of the pocket on the same line as the opposite breast, (Radovan, 1982). The pocket is developed mainly by a blunt scissors or finger dissection and preferably about 3 cm wider in circumference than the base of the expander. A small subcutaneous pocket is developed posterior to the incision for placement of the reservoir dome, (Radovan, 1982). The expander is initially filled with 50 to 100 cc of normal saline and any remaining air in the expelled. The lower edge of the expander should reach the inframammary line, (Radovan, 1982).

Fig 14: The pocket is developed mainly by blunt scissors or finger dissection, (Scott, 1998).

3 inches at least

Fig 15:The position of the reservoir dome, (Scott, 1998).

The reservoir dome is placed posterior to the incision, which is then closed in two layers. It is important to approximate the subcutaneous tissues between the expander and the reservoir to prevent sliding of the reservoir toward the expander, (Radovan, 1982). Subsequent normal saline injections are preformed according to the expansion protocol, (Scott, 1998). The expansion protocol: The expansion process usually begins within 2 weeks after insertion of the expander depending on the local wound condition. If there are any concerns regarding the wound healing or the skin flap viability, expansion should be delayed, (Scott, 1998). The skin overlying the injection site is carefully prepared with betadiene before insertion of a 21-gauge needle. Saline is then added (about 50cc) to the expander to reach the end-point of moderate softtissue tension, (Scott, 1998). Expansion continues every 2 weeks until: The desired maximum point of projection is obtained. Passive creation of a new inframammary fold (IMF) occurs.

 Final volume within the expander should closely match the size of the opposite breast, limiting over-expansion to approximately 10% to 15%, (Scott, 1998). Once full expansion is obtained, the expander should remain in place for 4 to 6 months. This allows time for tissue adherence with the surface of the expander to develop, producing a mature, pliable capsule. This period of maximum expansion also prevents any recoil of the soft-tissue envelope once the expander is removed, (Scott, 1998). II. Second stage: Through the same subaxillary approach, the expander and the reservoir can be removed. The old scar is excised, and electrocautery can be used for dissection around the expander or reservoir dome, as the device is heat resistant. If necessary, readjustment of the pocket should be performed by partial capsulotomy at the desired corners. The amount of normal saline in the expander should be calculated, and a smaller implant should be placed in the pocket, to allow mobility and flexibility of the reconstructed breast. The incision should then be closed in two or three layers, (Radovan, 1982). Operative technique for application of Becker prosthesis: The size of the prosthesis is determined, then the filling valve is attached to the valve of the implant and the deflated implant is then placed in position. Saline is now added through the filling tube until some pressure is exerted on the overlying skin. The prosthesis is placed beneath the muscle rather than subcutaneously. The muscle and skin are, therefore expanded in this procedure. The reservoir is fixed to a subcutaneous pocket. The skin incision is approximated in the usual fashion. Once the viability of the skin flaps is ensured, the implant is further filled by saline (A volume of 50 cc is injected twice weekly until the
desired volume is achieved).

At this stage, the reservoir is removed through a small opening in the original incision, detaching the filling tube at the self-sealing valve, (Becker,
1984).

Complications of prosthetic breast reconstruction: A. Intra-operative complications : 1- Muscular tears: If the pectoralis major muscle is traumatized at the time of mastectomy or during pocket dissection, the implant may herniate through the defect that may lead to skin erosion and implant exposure, (Jackson, 1989).

Management: If the defect is small, repair may be sufficient by direct closure. If the defect is medium or large, a TRAM flap with its overlying sheath based superiorly is turned up to cover the deficient muscles. If there is extensive muscle tears, a tissue expander is placed and not inflated until it is considered safe 10-24 days later, (Jackson, 1989). 2- Deficient skin flaps to close the wound: As long as the implant has a complete musculofascial coverage, there is no concern regarding inferior migration of the implant resulting from this maneuver. Management: If there is excess tension on skin flaps following approximation the abdominal skin and subcutaneous tissues are undermined off the abdominal wall for a distance sufficient to allow advancement of the inferior flap and closure., (Jackson, 1989). 3- Skin flaps circulatory compromise: The patient is given intravenous fluorescen and the skin flaps are examined under the Wood's lamp. Management: If there is still cause for concern, the implant is completely deflated to its gel component and nitropaste is applied. Intravenous corticosteroids are given to help protect against the effect of ischaemia on the skin flaps, (Jackson, 1989). 4- Haematoma: Management: If acute intraoperative haematoma occurs, the sutures must be removed and the haematoma is promptly evacuated and the bleeder could be managed before replacement of the implant, then proceed toward closure, (Jackson, 1989). 5- Pleural tear: This is more likely to occur if a curved scissors is used with the points towards the chest wall. Management: If a small tear occurs sutures are initially placed and left untied. A small drain is inserted into the pleural space and placed on suction and removed while the suture is air tied. The adequacy of the repair can be tested also by

filling the field with sterile saline and observing for bubbles during several inspiratory cycles, (Shaw, 1992). B. Early postoperative complications:

1- Hematoma: This is unusual but may occur within the first 24 to 48 hours. Management: There should be immediate exploration with control of bleeding, copious irrigation with dilute betadine and reinsertion of the implant, (Jackson, 1989). 2- Infection: The most common site of infection is the wound. Management: Drainage is indicated. Since the implant is under the muscle, it is rarely involved. If there is infection in relation to the implant the latter is removed and the pocket is irrigated and drained. In this situation, it is probably wise not to implant another prosthesis for six months. Early replacement may result in another infection, (Jackson, 1989). 3- Wound breakdown: This is usually due to ischaemia of the wound edges due to either prolonged forcible retraction at surgery or closure under tension. Management: Debridment then either secondary sutures or frequent dressing to inforce healing by secondary intension. Once the expander is exposed, it should be removed, (Jackson, 1989). 4- Implant displacement: This occurs most frequently in a cranial direction but may caudal or lateral. Management: The pocket is reopened surgically and enlarged by incising the capsule with a cutting cautery in the direction of the desired implant positioning. In large displacements a portion of the pocket may have to be obliterated with non-absorbable sutures to prevent redisplacement, (Jackson, 1989). 5- Postoperative pain: A significant number of patients have complained of shoulder, arm and chest wall pain after immediate reconstruction and this may persist for many months. It is important in the preoperative interview to stress that the

postoperative symptoms of pain, paraesthesia may be painful because of dissection to form the pocket, but this is short lived, in a few patients long term pain may occur, because of capsular contraction, (Jackson, 1989). 6- Rupture of implant: The ruptured implant is an uncommon complication. The symptoms and signs are frequently vague, the diagnosis is usually difficult. Patient with ruptured breast implant do not necessarily have a history of trauma. A number of changes in the breast texture, symmetry and size imply breast implant rupture. Mammography is a good screening test and is very, accurate when silicone has migrated away from the implant. Management: A number of procedures have been used to remove silicone from soft tissue These procedures include: Suction assisted removal. Wide local excision of soft tissue and excisional biopsy of silicon granuloma, (Anderson et al, 1989). 7- Mondors disease: Thrombophlebitis of some part of the superficial mammary venous plexus may result in a tender cord-like lesion. Extending out of the breast into the thoraco-epigastric vein. Management: Supportive measures with warm, moist compresses and salicylates. Spontaneous resolution usually occurs, (Woods, 1994). C. Delayed postoperative complications: 1- Capsular contracture: The formation of a postoperative fibrous tissue capsule around a mammary prosthesis occurs in all patients in varying degrees. However, there is no clinical significance unless the capsule contracts, causing pain, excess breast tissue firmness, a misshapen breast, increased palpability of the implant, wrinkling of the implant, or displacement of the prosthesis. Capsular contracture in implants with the Siltex surface has been a far less common occurrence than seen with smooth-walled implants of any variety either gel-filled or saline-filled. When tissue expansion is the goal, the development of capsular contracture during inflation is less frequent with the Siltex Becker expander implant than with the smooth-walled Radovan expander. The latter is frequently accompanied by scar contracture during expansion, and the contracted capsule must be addressed during the second

stage of the expansion procedure then the Radovan expander is removed and is replaced by a permanent implant, (Woods, 1994). 2- Recurrence of cancer: This is uncommon. Fortunately, it will usually occur in the skin and can be resected without disturbing the implant. If the underlying muscles are involved, it is usually necessary to remove the implant. The presence of an implant does not negate the use of chemotherapy or Radiotherapy, (Jackson,
1989).

3- Rupture of implant or deflation of the expander: Deflation of the expander may also occur spontaneously or if punctured with a needle at the inflation time or ruptured by direct trauma. Management: Once it is ruptured it should be removed and replaced by either another expander or by an implant, (Anderson et al, 1989). Postoperative care of prosthetic breast reconstruction: 1. The patient is advised to do massage of the breasts after 12 hours postoperatively and to wear a sling for 12-24 hours to give gentle pressure against the prosthesis and help control oozing of serum into the cavity. 2. The dressing and brassiere are retained unchanged for 2 weeks. 3. The patient should not raise the upper arm above the horizontal plane during this period, but gentle use of the arm is recommended. 4. At the end of this time, the dressing is removed although the patient is advised to retain a brassiere day and night for the next 6 weeks. The type and shape of the brassiere chosen by the patient will determine the shape of ensuring mound to a great extend, (Watts, 1982).

A- RECONSTRUCTION WITH LATISSIMUS DORSI MUSCLE FLAP (LDMF)

The latissimus dorsi muscle flap is an excellent choice for myocutaneous flaps for breast reconstruction after mastectomy. Also, it is the flap of choice to replace the missing pectoralis major muscle from the upper breast area and axilla. It is a muscle flap type V with a major vessel and segmental arteries on the other side, (Bostwick, 1990). Anatomy: The latissimus dorsi muscle is a flat, fan-shaped back and shoulder muscle, which forms the posterior wall of axilla. Deep to the latissimus dorsi lie the erector spinae, serratus posterior, inferior and the serratus anterior muscle.
Trapez ius muscle

latissimus Dorsi Muscle

Fig 17: Surface of Latissimus Dorsi muscle, (Ward, 1986)

Origin: The muscle arises from the spine of the lower six thoracic vertebrae, the posterior iliac crest, small muscular slips from the lower four ribs, interdigitating with the slips of origin of the external oblique muscle of the abdomen. Insertion: Into the intertubercular groove of humerus, (Mathes and Nahai,
1981).

Blood Supply: The blood supply to the latissimus dorsi muscle is constant and exhibits no significant anatomic variations that prevent muscle transposition, (Scott, 1998).

Brachial A.

Axillary A.

Lateral Thoracic Artery Subscapular A. Circumflex Scap. A.

Serratus Collateral A. Latissimus Dorsi M.

Serratus Ant. M.

Fig 18: Blood Supply of LDM, (Scott, 1998).

The primary blood supply to the latissimus dorsi is from the thoracodorsal artery, a branch of the subscapular artery that arises from the axillary artery. The thoracodorsal vessels enter the muscle on the deep surface approximately 10 cm from the origin where the muscle forms the posterior axillary fold. The thoracodorsal artery is accompanied by the thoracodorsal nerve and two veins into the muscle. The serratus branch extends from the thoracodorsal and enters the latissimus dorsi muscle to the outer surface of the serratus anterior muscle. Normally blood flows from the thoracodorsal artery into the serratus branch. However, in cases where the thoracodorsal pedicle has been divided, reversal of flow through the serratus branch provides adequate blood flow to the flap, allowing it to be safely transposed, (Bostwick, 1983). There are numerous musculocutaneous perforators, that allow skin islands to be safely designed anywhere within the margins of the muscle, although the most reliable location is over the lateral aspect of the muscle corresponding to the course of the lateral branch of the thoracodorsal artery, (Bostwick, 1983). Nerve Supply: The motor nerve supply is the thoracodorsal nerve which arises from C6, 7, 8 roots of the posterior cord of the brachial plexus. It runs with the thoracodorsal vessels on the deep surface of the muscle, (Romanes, 1976).

The sensory nerves of the skin of the back are segmental, they are divided when the latissimus dorsi muscle is elevated. Reinnervation of the flap is possible by suture of the fourth intercostal nerve to the sensory nerve supply to the latissimus dorsi skin island, (Bostwick, 1987).

Actions of the Latissimus Dorsi muscle: It is an adductor and medial rotator of the humerus. It also assists in securing the tip of the scapula against the posterior chest wall. Transposition of this muscle anteriorly has been shown to be well tolerated by patients and results in only a minimal functional deficit, although dynamic weakness in shoulder extension and adduction may occur, (Fraulin
et al., 1995)

Shape of the muscle: The shape of the muscle flap to be used depends primarily on the shape of the patient's latissimus dorsi muscle and secondarily on the specific pectoralis muscle and subcutaneous defect under the chest skin after mastectomy. For testing of the latissimus muscle function and innervation, there are three simple tests, which are helpful: a) Resistance test. b) Scapular test. c) Cough test. One) The resistance test: the surgeon supports the abducted arm, palpates the latissimus dorsi laterally, and asks the patient to push down. When the muscle is denervated, the scapula tip pulls upwards and appears "winged". Two) The Scapular test: To check for winging of the scapula the patient should place her hands on her hips and push inwards, the surgeon looks and feels for the latissimus dorsi function. There is usually an apparent asymmetry after latissimus dorsi denervation Three) The cough test: by having the patient inhale and then cough, the surgeon can confirm contraction of the latissimus muscle, (Kendall, 1983). The mastectomy scar dictates the shape of the flap so: The low transverse scar confined to the inframammary line is ideal and the flat pie-wedge skin island will probably be chosen to give the best projection at the nipple.

 The lateral oblique scar that runs from the axilla into the inframammary line will need a skin island shape, like a half-moon with one tip cut-off to produce the ideal breast projection. A mid-oblique scar if not placed too medially will need a similar halfmoon with a blunt end. In the high transverse mastectomy scar, a simple elliptical skin island may be the first choice if the scar itself is not acceptable. If projection is desired, a diamond-shaped skin will be beneficial, (Millard, 1982). Technique of elevation of the flap: Elevation and anterior transposition of the Latissimus Dorsi muscle flap is easy once surrounding landmarks have been identified, (Dennis, 1998). Accurate preoperative markings are vital to properly position the skin island and should always be made with the patient upright. The superior margin: is identified by locating the tip of the scapula and drawing a curved line across this landmark up into the axilla over the top of the posterior axillary fold. The lateral margin: is identified by drawing a straight line along the anterior margin of the posterior border of the axilla down to the iliac crest. Between these lines, the posterior border of the iliac crest and the midline of the back, lies the latissimus dorsi muscle, (Dennis, 1998). First of all, the entire dorsal region is perfused with adrenalinated serum (1 mg of adrenaline in 200 ml of physiologic serum). The infiltration is achieved in the subcutaneous fat in the plane of the fascia superficialis. This perfusion has two objectives: a. It is hemostatic. b. It helps with the lifting of cutaneous flaps, (Emmanuel et al., 1998) There are three methods to harvest the LDM flap:
1. 2. 3. Open method. Balloon assisted endoscopic method. Vascularized Latissimus Dorsi musculocutaneous Free Flap.

1) OPEN METHOD
After incising through the skin, dissection proceeds superiorly to identify the superior border of the muscle. Medially the covering fibers of the trapezius muscle are identified and elevated away from the underlying latissimus muscle. After identifying the superior border of the latissimus, dissection is carried superolaterally towards the axilla, separating away the fibers of the teres major muscle that fuse with those of the latissimus, (Dennis, 1998). The superior, portion of the muscle is then elevated away from the chest wall, working inferiorly. Once the proper plane has been identified, the medial fascial attachments to the paraspinous fascia can be released. Care must be taken to avoid incising through the paraspinous fascia as this makes the proper plane of dissection difficult. The dense fascial attachment of the lower border of the serratus to the latissimus can be easily identified and divided, to avoid elevation of the serratus anterior with the latissimus, (Dennis, 1998). Dissection then proceeds across the inferior origin of the muscle to the inferolateral border, where muscle fibers fuse with those of the external oblique and intercostals and must be sharply divided. The lateral border of the muscle is then identified, and dissection is then carried toward the axilla. The serratus branch is easily identified and left intact because it is not necessary to divide this vessel to allow adequate anterior transposition of the muscle. The latissimus muscle is fully detached from its attachments to the teres major and the overlying fat, but it is not necessary to fully identify the thoracodorsal pedicle at this point. The muscle is then tucked into the axilla and the back wound closed over a closed suction drain, (Dennis, 1998). Further dissection then proceeds through the mastectomy wound. The thoracodorsal pedicle is easily identified and protected. It is not necessary to release the insertion of the muscle to achieve adequate anterior transposition of the muscle, and this is done only in cases where the tendon is to be reinserted anteriorly to recreate the anterior axillary fold, (Dennis, 1998).

2) BALLOON ASSISTED ENDOSCOPIC METHOD

The donor site scar of LDMF, is usually 15 to 25 cm in length. Although the incision can be hidden in either the area of the bra strap or laterally, the

scar tends to be long and frequently widens and hypertrophies with time, (Moore, 1992). If the muscle is required alone for the reconstruction, endoscopic harvest techniques have become valuable. As with abdominal and thoracic surgical procedures, endoscopic techniques are likely to result in better aesthetic results, shorter recovery time, and less pain than open procedures, (Friedlander, 1994). A standard endoscopic setup (similar to laparoscopic cholecystectomy) is used for the dissection. This setup includes a light source, endoscopic video camera, and video monitor. A high flow insufflator, using CO2 gas, may be used during the procedure. Endoscopic instruments include 10-mm ports, 5mm ports, blunt and sharp forceps, clip appliers, and scissors. The endoscope is a l0-mm; 30-degree angled laparoscope, (Nolan et al, 1996). The balloons were custom made to approximate the size of the latissimus dorsi muscle. The balloons measure 30.5 x 33 cm and are tillable to 2500 cc using air or saline, (Nolan et al, 1996).
The incisions are three: One of them is 5 to 6 cm axillary incision placed parallel to the lateral edge of the latissimus dorsi muscle. Another two incisions 1 cm or less in length. One is at the midlateral edge of the muscle. The other incision is at the superior-medial border of the muscle.

The pedicle is clearly defined and dissected distally onto the muscle and then proximally beyond the serratus branch, The vessel is retracted and protected with vessel loops. The undersurface of the muscle is always dissected first, (Nolan et al, 1996). When the dissection has gone as far distally as possible with the lighted retractor, a balloon dissection device is inserted under the muscle. The balloon is inflated until the required dissection is complete using either saline or CO2, (Nolan et al, 1996). There usually are attachments distally and medially that need to be dissected sharply. Ports are inserted at the sites of the other smaller incisions. The electric cautary or hemoclips could be used to control the bleeding vessels. It is critical, at this point, that all of the edges of the muscle be clearly and completely dissected. In addition, the distal surface of the muscle should be transected while freeing the undersurface of the muscle.

The pedicle dissection is then completed proximally, and the muscle flap is ready for the appropriate transfer. One of the small incisions is used as the site for a hemovac drain. The average harvest time is 2.5-3 hours, (Nolan et al, 1996).

3) VASCULARIZED LATISSIMUS DORSI MUSCULOCUTANEOUS FREE FLAP

The contralateral latissimus dorsi can be transplanted as a free flap, when the ipsilateral latissimus dorsi is not available. During dissection, the entire muscle is taken with a smaller elliptical cutaneous paddle. An extensive amount of donor tissue is thus available to replace the extirpated pectoralis major muscle. Thus the infraclavicular depression is corrected and an anterior axillary fold is created. Because wound closure is performed in two separate layers, muscle and skin, augmentation with a prosthesis can be done safely during the initial procedure. A neural coaptation between the proximal recipient nerve to the latissimus dorsi muscle and the corresponding donor nerve is done if dissection is not too difficult or lengthy. Subjectively, there appears to be less muscle atrophy. Therefore, capsular contracture and fibrosis are inhibited. The lengthy vascular pedicle facilitates flap positioning and performance of the vascular anastmosis. An attempt must be done to perform an end to end vascular anastmosis to a branch of the axillary and to one of the axillary vena comitants. If the dissection is difficult because of excessive fibrosis, an end to side arterial and/or venous anastmosis is performed. The neuro-vascular pedicle is often of sufficient length to reach the more distant recipient vessels. If not, an interpositional vein graft may be used during this technique, (Serafin et al., 1982).

1. 2. 3. 4. 5. 6. 1. 2. 3.

Risk Factors: Smoking. Insulin dependant diabetes mellitus. Morbid obesity. Irradiation to the base of the flap or to the mediastinum. Previous transection of the thoraco-dorsal vessels or posterio-lateral thoracotomy. Old age more than 65 years old, (Emmanuel et al, 1998). Indications: Patients who have had a radical mastectomy if: The pectoralis muscle has been excised. The skin is of inadequate quality or quantity. Patients who have had a modified radical mastectomy if: The pectoralis muscle has been denervated secondary to the cancer surgery. Women who have received radiation. Women with thin skin over the mastectomy site. It is most useful for thin patients who are not good candidates for transverse rectus abdominis myocutaneous flap e.g. hypertension, diabetes, obesity, and smoking habits, (De Mey et al., 1991).

Contraindications: 1. The use of this flap is limited when the thoracodorsal pedicle has been cut during the cancer surgery. 2. In-patients who have had a posterolateral thoracotomy, because the incision cuts across the latissimus muscle, interrupting the blood supply to the lower part of the muscle, (Mc Donald, 1988).

Advantages: The advantages of the latissimus dorsi flap are: 1. It is a large flat muscle and when transferred to the front of the chest can simulate the shape of the pectoralis muscle. 2. It can be used to replace the deficiency in the axillary fold by moving the insertion from the back of the humerus to the front. 3. It may also carry skin with it to release tightness.

4. It is a hearty flap, which can usually be transferred without tissue loss, ( Mc

Donald, 1988).

5. Advantages of LDMF over TRAM flap: Minimal blood loss. A very low complication rate. A recovery period similar to mastectomy. 6. It is a one-stage procedure that is not possible with a tissue expander. Therefore, in patients who desire a single-staged breast reconstruction at the time of mastectomy and are not good candidates for a TRAM flap either by choice or by medical condition, the latissimus flap remains a very good option, (Corral, 1996). Disadvantages: 1. It requires an implant, which induces the same rate of capsular contracture. 2. It results in additional scars on the back, it may weaken the shoulder girdle in a patient who already has some deficit secondary to mastectomy. Patients may notice this type of weakness when they attempt to push themselves up out of a chair. 3. It can result in a patch work appearance on the reconstructed breast. This is because of the sun exposure and, therefore, the color of the skin of the back is different from that on the front of chest, (De Mey, 1991). Complications: 1. Injury to brachial plexus, (Maxwell et al, 1979). 2. Flap loss: The most common situation, in which flap loss occurs, is following division of the thoracodorsal vessels as well as the serratus branches. Management: Total flap loss: can be treated by excision of the flap and skin grafting of the defect, which may be able to be reconstructed at a later date by other means such as an abdominal flap. Partial flap loss: managed by excision of the necrotic tissue and direct closure, (Ward, 1986). 3. Seroma or hematoma of the donor site: is the most frequent problem associated with a donor site area. The use of a drain for 4 to 5 days, help in minimizing this complication, (Bostwick, 1983). Postoperative care:

a. The flap is kept under closed supervision by means of an aperture left in the bandaging for 48 hours. b. Some early mobilization is recommended (lateral supine position of duration of 5 to 10 minutes, every 2 hours, on the contralateral side) to avoid risk of marginal necrosis in the dorsal skin flaps. c. The day after the operation, the patient gets out of bed and must pass the greater part of the day in an armchair. d. It is necessary to warn the patients not to take notice of contractions in the breast during certain shoulder movements. These contractions decrease progressively over time. e. Three out of four drains are removed on the sixth postoperative day, and the patient leaves the hospital with a dorsal drain that is left at least until the fifteenth day, or sometimes for three weeks if it produces more than 30 ml per day. f. A compressive dorsal belt is prescribed and is carried 24 hours a day, especially for whom there is a continuing risk of dorsal seroma. We also prescribe a hypolipidic regime. g. Rehabilitation of the scapular region started after the first month. The best is to practice swimming, as this helps in the recovery of normal scapular and dorsal function, (Emmanuel et al., 1998).

B- RECONSTRUCTION WITH RECTUS ABDOMINIS

MUSCLE FLAP
The transverse rectus abdominis myocutaneous (TRAM) flap has proven itself over the years as the autogenous tissue of choice for breast reconstruction. It is a muscle flap type III that has two predominant arterial blood supply, (Hartrampf, 1991). Several strategies have emerged to meet these goals. The surgeon usually uses a single-pedicle or whole muscle technique while avoiding the use of a bipedicle technique when possible. Most importantly, we treat the abdomen as if it were the primary reason for the procedure, and to that end, synthetic mesh is used in all cases. In unusual circumstances, bipedicled and free TRAM flap techniques are used, (Zienowicz, 1995). Anatomy: The rectus abdominis muscle is long and strap like, extending along the entire anterior abdominal wall. It is attached:

 Superiorly: to the lower and anterior border of the 5th, 6th and 7th ribs and the xiphoid process as an insertion. Inferiorly: it originates from the body of the pubis and symphysis. Medial border: is separated from its fellow by the linea alba. Below the umbilicus, the linea alba is narrow and the two recti are partially in contact, but above the umbilicus it is almost 0.5 inch wide, (Dinner et al,
1982).

The rectus abdominis is enclosed in an aponeurotic sheath except on the posterior aspect of its lower quarter below the arcuate line, where the sheath is absent, and superiorly the muscle lies directly on the anterior surface of the costal cartilage. Blood Supply: The epigastric vascular system is the primary supply to the muscle and overlying musculocutaneous area of the anterior abdominal wall. 1st) The superior epigastric artery: It nourishes the superiorly based TRAM flap. It originates at the bifurcation of the internal mammary artery opposite the 6th costal cartilage. It enters the abdominal wall beneath the lower costal arch through the xiphocostal portion of the diaphragm 2 to 3 cm from the midline. The superior epigastric pedicle is at first behind the rectus abdominis muscle then enters the midportion of the upper rectus abdominis muscle and courses inferiorly, (Bostwick, 1983).

Superior epigastric A&V.

Fig 22: Blood Supply of TRAM, (Scott, 1998)

Arcuate line Inferior epigastric A&V.

2nd) The inferior epigastric artery :

(a) (b) (c) (d)

It is a branch of the external iliac artery and approaches the deep lower portion of the rectus abdominis muscle from below and laterally. It courses upward behind the muscle until the region of arcuate line. It enters the deep central portion of the rectus abdominis muscle and branches within the rectus abdominis muscle, (Bostwick, 1983). The deep inferior epigastric artery with its twin on the other side (the arteriovenous system) provides the major supply to all the layers of the anterior abdominal wall. With its paired venae comitantes it ascends within the rectus sheath on the deep surface of the rectus muscle and divides usually into two primary branches. This division generally occurs below the umbilicus and the primary branches ascend within the muscle to connect with the superior epigastric system above the umbilicus. During its course the artery supplies peritoneal, muscular and cutaneous branches which radiate in all directions from the main stem and its primary divisions like the spokes of a wheel. The dominant branches fan from the para-umbilical region in all layers of the abdominal wall to form a series of laminated vascular planes. As these dominant branches radiate from the para-umbilical region they link directly by reduced caliber arteries with: Cranially, the superior epigastric system, Laterally, the intercostal and lumbar vessels, Caudally, the superficial and deep vessels from the groin, Medially, with branches of the opposite deep inferior epigastric system. These connections, which occur in all the layers of the anterior abdominal wall, provide the anatomical basis for a versatile variety of tissue combinations which can be harvested for local or distant flap transfer, ( Taylor
et al., 1984).

The superior and inferior epigastric vessels converge within the substance of the muscle and form a collateral vascular network, (Bostwick, 1983). Nerve Supply: The nerve supply is the segmental motor branches from the 6th through 12th intercostal nerves which innervate the muscle from its deep surface. Actions of the rectus abdominis muscle: The muscle flexes the vertebral column and tightens the abdominal wall; it is a relatively expandable muscle, (Mathes and Nahai, 1979). Shape of the muscle: The rectus muscle is separated into four equal units by transverse tendinous inscriptions. Each unit is individually nourished and innervated

from the thoracolumber vessels and nerves. These tendinous inscriptions are densely adherent to the tough anterior rectus sheath, (Mc Gibbon, 1984). Techniques and methods of elevation of the TRAM flap: I. Pedicled Flaps: 1. Vertical rectus abdominis myocutaneous flap. 2. Lower transverse rectus abdominis myocutaneous flap. 3. Upper transverse rectus abdominis myocutaneous flap. 4. Double pedicle TRAM flap II. Microvascular flaps: 1. Endoscopic harvesting of TRAM flap. 2. Free lower TRAM flap. 3. Deep inferior epigastric artery perforator flap (DIEP). III. Combination of pedicled and microvascular flaps: 1. Extended TRAM flap, 2. Supercharged TRAM flap. 3. Turbocharged TRAM flaps. Common goals for any breast reconstructive procedure are: 1) Safe and well-perfused volume of tissue transferred. 2) Minimizing the donor site morbidity, (Zienawicz,
1995).

Vascular delay is a method used to improve the perfusion to rectus muscle flaps This is accomplished by ligating collateral circulation to the flap 13 weeks before the reconstructive procedure, (Bostwick, 1992).

1) VERTICAL RECTUS ABDOMINIS MYOCUTANEOUS FLAP (VRAM)

This may be the procedure of choice if the latissimus dorsi flap or the lower TRAM flap can not be used. Women with excess tissue in the midabdominal region are suitable for this procedure. However, those with flat abdomens or athletes who count on abdominal musculature integrity are not suitable candidates, neither are those women who object to an abdominal scar especially if it extends above the umbilicus, (Drever, 1984). Operative Technique: The skin ellipse up to 15 x 20 cm is designed over the muscle, dissection is not extended below the linea arcuate. The flap is incised through skin and

subcutaneous tissue and through the underlying anterior rectus sheath. A 1 cm strip of the anterior rectus sheath is preserved near the midline for closure, Finger dissection beneath the lateral margin separates the entire muscle from the posterior sheath. The segmental nerves enter beneath this lateral edge and must be divided. The distal end of the muscle is transected at the linea arcuate, at which level the posterior rectus sheath disappears. The inferior epigastric artery and vein are ligated and cut, and the flap is raised from distal to proximal at the costal margin. Care must be taken in isolating the superior epigastric artery and vein because they emerge through the fascia of the seventh intercostal space. The attachment of the muscle to ribs can be separated, allowing full rotation of this island myocutaneous flap. The flap is rotated as needed into the defect. The edge of the rectus muscle is sutured to the lateral border of the remaining pectoralis major muscle. The other margin of the rectus muscle is sutured to the predetermined level of the IMF. The anterior rectus sheath is repaired by advancement of the external oblique muscle and sutured to the remnants of medial rectus fascia. The skin portion of the flap is then sutured in place, (Dinner et al., 1982).

2) LOWER TRANSVERSE RECTUS ABDOMINIS FLAP (LOWER TRAM)

The TRAM myocutaneous flap is an ellipse of skin and fat from the lower abdomen attached to the rectus muscle. The blood supply of the flap is derived from the musculocutaneous perforators coursing through the rectus abdominis fascia in the periumbilical area. Breast reconstruction with the lower abdominal skin and fat provides an abundant source of tissue for the patient who desires a reconstruction without a silicone breast implant and who also wants an abdominoplasty, (Bostwick, 1990). 1. 2. 3. Advantages of single-pedicled TRAM flap: The other rectus muscle is left intact and the patient retains greater abdominal length. The operative procedure is less complicated. The anterior abdominal wall defect easily re-approximated in a direct manner without the need for prolene mesh, (Beasley, 1994). The breast reconstruction by the TRAM flap is an attractive method as :

4. The use of generally unwanted abdominal wall tissue. The scar is placed in a relatively hidden position on the body.

 Contour changes often result in improvement, and the tissues can be readily
shaped into a variety of new breast configurations, (Elliott, 1994).

Pre-Operative Planning For Use of TRAM Flap: With the patient erect, the exact limits of the mastectomy defect are marked and the expected level of the inframammary crease is drawn. The actual chest incision should be 2 or 3 cm above this level to compensate for the downward pull of the abdominoplasty, (Hartrampf, 1984). Pre-operative assessment of TRAM flap perforators: Preoperative knowledge of the number, location, and flow characteristics of TRAM flap perforators of 1 mm external diameter is possible with ColorLow Duplex Scanning. The preoperative detection of the perforators has a significant impact on flap design and intraoperative elevation techniques in order to capture the dominant vessels within the flap. This information allows the surgeon to individualize the planning and technical performance of TRAM flap surgery on the basis of each patients specific vascular anatomy. In addition, preoperative knowledge of the number and flow velocity characteristics of the perforators allows the selection of single pedicled, double pedicled or free TRAM flap based on each patients individual perfusion characteristics. If robust perforators are detected, the single pedicled TRAM flap procedure may be approached with confidence. Conversely, if the perfusion appears marginal, a double pedicled or free TRAM flap should be selected, (Rand, 1994).

Fig 23: Distribution of perforators along TRAM, (Heinz, 1997)

Operative Technique: A transverse infraumbilical skin island measuring up to 30x12cm, is designed so as not to extend beyond either anterosuperior iliac spines. The random contralateral extension is elevated above the external oblique and anterior rectus fascia to the midline. The ipsilateral skin island is elevated above the external oblique fascia to the lateral margin of the carrier rectus muscle. The anterior rectus fascia beneath the skin island is incorporated with the flap. The cut fascial edge is secured to the overlying dermis with temporary stay sutures. The abdominal skin proximal to the rectus flap is elevated above the abdominal wall fascia to the inferior costal margins. On the mastectomy side, dissection continues above the costal margin to the chest incision. The anterior rectus sheath of the carrier muscle is then opened along its lateral border. The inferior epigastric pedicle is identified just below the arcuate line and isolated. The rectus muscle with its attached skin island is dissected from its sheath. Several arterial and venous branches will be encountered piercing the posterior rectus sheath, which may be ligated safely. Caudal to the arcuate line, the muscle is dissected from fascia transversalis. Following division of the inferior epigastric pedicle, the flap unit is delivered into the recipient defect, (Bunkis et al., 1983). With bilateral lower rectus breast reconstruction, the transverse lower abdominal skin island is divided in the midline, and the dissection is modified to allow each half of the skin island to be brought to the chest defect with the underlying rectus muscle, (Bunkis et al., 1983).

3) TRANSVERSE UPPER RECTUS ABDOMINIS FLAP (UPPER TRAM)

Operative Technique: With the patient in a supine position and both arms abducted, the upper abdominal ellipse is marked as a "reverse" abdominoplasty, extending from the epigastrium to just below the umbilicus. The horizontal ellipse extended to the anterior axillary line bilaterally and is elevated as an island pedicle flap based on the ipsilateral rectus abdominis muscle. The rectus sheath is entered just below the inferior border of the ellipse, and the muscle and anterior rectus sheath are transected at this level. A wide portion of the rectus sheath is elevated with the musculocutaneous flap. The origin of the rectus muscle is carefully detached from the lower ribs, so as not to injure the underlying deep epigastric vessels. A segment of the lower two-costosternal cartilages is removed and the internal thoracic pedicle is dissected free. The rectus abdominis myocutaneous flap is now attached only by the internal thoracic pedicle. In preparation for the flap inset, the chest-wall skin flaps are raised to the clavicle, to the sternum, and to the suggested inframammary fold. The island myocutaneous flap is transposed into the defect and sutured to the clavicle and margins of the pocket. Excess skin is deepithelialized and the abdominal fat is shaped to simulate a breast. The chest skin flaps are sutured to the edges of the skin island. The "reverse" abdominoplasty is completed by mobilizing the lower abdominal apron relocating the umbilicus, (Hartrampf et al., 1982).

4) DOUBLE-PEDICLE (TRAM) FLAP

Indication:
1) Large soft-tissue requirements. 2) Previous abdominal operation compromising the blood supply to portions of the anterior abdominal wall. 3) Selected patients with suspected microvascular pathology e.g. smoker, older patients and patients with past history of radiation along the course of the internal mammary artery, (Ishii et al., 1985).

 Advantages of double-pedicled TRAM flap:

It improves the arterial blood supply and venous drainage for a larger volume of the abdominal tissues, which improves the flap safety, ( Beasley,
1994).

Disadvantages of double-pedicled TRAM flap:

1. A more complicated pedicle dissection. 2. A more difficult abdominal wall closure that usually requires a prolene mesh. 3. Increased abdominal wall morbidity, (Beasley, 1994).

Operative Technique
The skin island is marked preoperatively with the patient standing. The skin is designed as low as possible so that the final transverse scar is just above the pubis. The upper transverse limb of the skin island is just above the umbilicus. The recti are transected just below the level of the arcuate line, and mobilization of each rectus abdominis muscle pedicle is achieved with preservation of the lateral third of the muscle. The island is supplied by periumbilical perforators through an elliptical segment of anterior rectus fascia that is elevated with the underlying muscle to help preservation of the vascular network. The skin island is divided in the midline to allow for independent, safe manipulation of two islands of tissue in reconstruction. These islands can be stocked to achieve greater projection of the breast mound. Abdominal wall closure is achieved by the use of a prolene mesh and fascial plication, (Ishii,
1985).

5) THE EXTENDED (TRAM) FLAP

A (TRAM) flap based on one of the rectus abdominis muscles, can be extended towards the contralateral side by including the superficial epigastric vessels and the superficial circumflex iliac vessels, and anastomosing either artery and vein of those to the recipient vessels. Thus, the blood supply to this extended flap is derived from the superior epigastric vessels of the same side and artery and vein of either the superficial circumflex iliac vessels or superficial epigastric vessels of the other side. By utilizing this technique, the random portion of the TRAM flap can be extended and transferred with vigorous deepithelization of the flap safely performed, (Takyangi, 1989).

6) SUPERCHARGED TRAM FLAP

The most important problem of the superiorly based TRAM flap for breast reconstruction is distal necrosis or fat lysis due to poor circulation. In order to utilize the entire TRAM flap tissue in extensive tissue defects the contralateral rectus muscle is used as a pedicled carrier and the ipsilateral superficial or deep inferior epigastric vessels are anastomosed with appropriate recipient vessels in the axilla, (Harashina et al., 1987). The supercharged TRAM flap has been presented as a method where the single superiorly based pedicle can be augmented by additional flow by means of the microvascular anastomosis of the vessels to recipient vessels in the axilla, (Beegle, 1991). The deep inferior epigastric artery, in fact, has been demonstrated to be the dominant artery to the lower abdominal region, (Boyd et al., 1984). The free TRAM flap exploits this principle and has evolved as a popular and reliable choice in breast reconstruction, (Grotting et al., 1989 and Shaw, 1984). The preferred recipient vessels for the supercharged flap as well as the free TRAM flap, include: OneThe axillary vessel branches (e.g. the subscapular vessels and its divisions). TwoThe internal mammary system which has also been utilized successfully. Vein grafts or turndown of the external jugular vein may be required to establish venous drainage. The success of both the supercharged flap and the free TRAM flap is totally dependent on the quality and availability of the recipient vessels. A short pedicle may cause difficulty in shaping and positioning the breast, requiring the use of interpositional vein grafts, (Beegle,
1991).

Radiation and previous extensive obliterative surgery may cause further problems in finding reliable recipient vessels, (Bostwick, 1990). Indications for the supercharged TRAM flap: OneIn patients in whom a large volume of lower abdominal skin is required but there is a lower abdominal midline scar. TwoIt also provides an alternative to the double-pedicle TRAM flap or as a method of salvage for a single-pedicle TRAM flap in trouble, (Beegle, 1991).

7) TURBOCHARGING TRAM FLAP

A technique was presented with a modification of the single-pedicle supercharge TRAM flap in which the random segment of the flap is augmented.

The augmenting blood flow is provided in a retrograde fashion through the distal aspect of the main pedicle into the opposite deep inferior epigastric artery/vein system. A contralateral single-pedicle TRAM flap is designed with special care taken to preserve the deep inferior epigastric artery and vein through out its entire length. Close to the external iliac vessels, the venae comitantes often form a single large vein. On the ipsilateral side, a small patch of anterior rectus fascia, and rectus muscle is taken, again preserving the deep inferior epigastric artery and vein as long as possible. The ipsilateral and contralateral vascular pedicles are then oriented for microvascular anastmosis. There are still clinical situations that challenge the surgeon even with the available choices: Previous abdominal surgery (midline scars) in patients requiring a
large volume of tissue or damaged Absent recipient vessels in the axillae or chest area.

Following the anastomosis, the flow crosses the deep inferior epigastric artery anastomosis and moves from a retrograde flow system into a physiologic vascular tree with normal direction flow, low pressure and low resistance. The venous outflow from the random segment is also physiologic until it crosses back into the main rectus pedicle, where it becomes retrograde. The venous anatomy of the deep inferior epigastric veins has been well documented, (Taylor, 1988). The increased volume of venous outflow from the random portion heading into the retrograde system may help to overcome the valvular obstruction and possibly quicken the realignment of physiologic axial flow within the choke vessel system. The opening of arteriovenous shunts within the muscle under different flow conditions also may result in adaptive compensation in myocutaneous flaps, (Hjortdal et al., 1991).

2. 3. 4. 5. 6. 7.

Advantages of Turbocharged TRAM flap:

1. Augmented flow to the random portion of the flap with an intrinsic anastomosis
independent of the quality or quantity of recipient vessels in the axillae. The recipient vessels are not in the axilla. A large volume of tissue raised on a single-pedicle regardless of a midline scar. Ease of breast mound, shaping and minimal epigastric mound. Abdominal-wall donor morbidity similar to that of a single pedicle. Recipient vessels intrinsic within the flap away from radiation damage and scarring. Augmented venous outflow from the random portion of the flap.

Disadvantages of Turbocharged TRAM flap: 1. Sufficient retrograde flow must be demonstrated and may be presented only in a selected group of patients. 2. Violation of the opposite rectus muscle pedicle may occur.

8) ENDOSCOPIC HARVESTING OF TRAM FLAP

Endoscopic techniques have the benefits of limiting scars and incisions morbidity. They are safe, reliable, easily learned, and time and cost effective when compared with traditional methods, (Peters, 1991). Endoscopically, the rectus muscle can be harvested by two different ways: The extraperitoneal dissection: from within the rectus sheath - with balloon "optical space" dissecting devices. The transperitoneal technique: approaches the muscle from the posterior rectus sheath, (Miller, 1993). As the initial step, the abdomen is insufflated with carbon dioxide through the Hassan cannula. The video camera was then introduced so that the remaining ports were placed under direct vision in a way to avoid any injury to the underlying viscera. Now, the rectus abdominis muscle can be easily seen through the posterior rectus sheath, as well as the inferior epigastric vascular pedicle on the undersurface of the muscle, traversing through the preperitoneal fat towards the external iliac vessels Muscle perforators that pierce the anterior sheath usually can be cauterized or hemoclipped. When the dissection of the muscle within the sheath goes below the entry point of the inferior epigastric vessel, the muscle is transected and there are two options for muscle delivery: From the low access port. That could be dilated by 30-mm Ethicon Endosurgery port/ tissue extraction system. A short 4-cm Pfanninstiel-type incision was made and the muscle directly removed. As the final step in the procedure, using the two high ports, a fascialstapling device is then used to reestablish the posterior sheath continuity across the midline By developing these muscle harvest techniques, it is possible for a single surgeon to harvest the muscle with an assistant for camera control, ( Miller,
1993).

AB-

12-

9) FREE LOWER TRAM FLAP.

Free TRAM flap transfer for breast reconstruction following mastectomy overcomes the shortcomings of the pedicled TRAM flap.

10) DEEP INFERIOR EPIGASTRIC ARTERY PERFORATOR FLAP (DIEP)

This flap is a variation of the free TRAM flap in which the deep inferior epigastric vessels are dissected away from the rectus abdominis muscle so that no muscle is harvested with the flap to reduce donor site morbidity, (Kroll et al., 1998).

Indications of rectus abdominis muscle flaps: 1. Patients with a moderate excess of tissue on the abdominal wall and no desire for breast reconstruction with prosthesis. 2. Patients who had failure of other methods of reconstruction. 3. It is indicated when the latissimus dorsi muscle is denervated, divided or atrophic. 4. It is also useful for the patient who has had a complication with the silicon breast implant. 5. For patients with a radical mastectomy with a large tissue deficit in the axillary and infraclavicular region. 6. For patients with a large breast as reconstruction with the silicone implant is often disappointing in such patients, (Scheflan, 1983). Risk Factors and Contraindications of TRAM flap: The risk factors for elective TRAM flap for breast reconstruction are well established and should be strictly reinforced. These were stated by Hartrampf, 1988 as: 7. Smoking. 8. Insulin dependant diabetes mellitus. 9. Uncontrolled hypertension. 10. Morbid obesity. 11. Irradiation to the base of the flap or to the mediastinum. 12. Previous transection of the superior epigastric artery. 13. Previous disruption of the periumbilical perforators. 14. Old age more than 65 years old. 15. Sever cardiovascular diseases. 16. Chronic obstructive lung diseases.

1. 2. 3. 4.

5. 6.

Advantages: The transferred tissue closely matches the color and texture of the opposite breast. It is associated with abdominoplasty. It can be performed without the use of a prosthetic device. The transferred tissue brought from the abdomen can simulate breast ptosis and has movement and flow approximating the natural breast, (Drever, 1984). One stage breast reconstruction is performed with the patient in the supine position throughout the operation. The amount of transferred tissues and their arc of rotation are such that the infraclavicular hollow and pectoral fold can be easily reconstructed, (Hartrampf et al., 1982). Disadvantages:

1. Time, magnitude and length of the procedure 2. Loss of blood, with a possible need for transfusion. 3. Transfer of the rectus abdominis muscle, thereby creating a potential for hernia formation below the arcuate line. 4. Meticulous repair of this area and the use of a mesh will preclude complications, (Dinner, 1984). Complications: 1. Problems of the donor site: Abdominal seroma is a frequent complication, it is decreased some what by suction drains and abdominal support. When a seroma occurs, aspiration is sometimes helpful, but it may be necessary to open the incision and insert a drain, (Bostwick, 1983). 2. Injury of the lateral cutaneous nerve of the thigh: In the course of dissection of the flap, it may lead to injury of the lateral cutaneous nerve of the thigh, leading to dysanesthesia over the anterolateral aspect of the thigh. Management: This can be effectively treated by excision of any neuroma, and allowing the proximal end of the nerve to retract into a deeper and insulated retroperitoneal position, (Kalisman, 1984). 3. Problems of the flap viability:

Inadequate venous drainage with excessive hyperemia and very rapid blanching and refill is a frequent problem of the transverse rectus abdominis flap and attention should be directed to proper positioning of the flap in relation to its pedicle, (Bostwick, 1983). 4. Fat necrosis: Localized fat necrosis of the deepithelialized portion of the reconstructed breast occurred in about 4.2% of patients. Management: by local incision and drainage of the specific area, (Bostwick, 1983). 5. Fat Fibrosis: Fat fibrosis is one of the most serious complications usually occuring in the post-operative period. It is manifested as a local indurated area in the deepithelialized portion of the reconstructed breast. Mammography and needle biopsy must be done to exclude the possibility of recurrence. It is suggested that all indurated area should be removed to avoid liquefaction and secondary infection, (Bostwick, 1983). Postoperative care: During her typical 3-day hospital stay: 1. The patient will remain on antibiotics, steroids, and calcium channel blocker. 2. The ambient temperature of the hospital room will be increased to prevent cold reflex. 3. The patient takes clear liquids the night of surgery and full diet the next day. 4. The Foley catheter is removed the first postoperative day, and she beams ambulation. 5. Pneumatic stockings are worn except when she is walking. 6. Hematocrite is monitored daily. At discharge: 1. The axillary and large abdominal drains are removed, whereas the small abdominal drain is retained. 2. She will continue antibiotics, analgesics, and iron supplement after discharge. 3. The importance of frequent ambulation in elastic stockings is stressed during the recovery period at home. 4. Exercise and activity is gradually resumed. 5. Abdominal exercises are forbidden for 6 weeks.

IV

II III

Fig 27: Zones of TRAM flap, (Scott, 1998).

Fig 38: Tetrapod-flap, (Elliot, 1990)

S-GAP flap

Gluteus Med. M.

Superior gluteal A. Gluteus Max. M. (splited)

Fig 29: Superior Gluteal Myocutaneous flap (Scott, 1998).

C- BREAST RECONSTRUCTION BY MICROVASCULAR FREE FLAPS

Although various techniques produce satisfactory results, microvascular techniques are of great value in the autologous breast reconstruction, ( Serafin
et al., 1982).

1)

2) 3) 4)

Indications: Marked deficiency of well-vascularized skin of the chest. Also, they are used to replace radiated tissue, with its deficient cutaneous and osseous blood supply. Failure of other methods of breast reconstruction. Restoration of form and contour with a minimal secondary donor deformity. Patient preference, (Shaw, 1987).

Advantages: 1. Surgeon can move a large block of tissue to its definitive location without delay or staging. 2. The free flap allows the flap to undergo irradiation or additional surgery either for the purpose of revision to improve contour or for local recurrence. 3. Free flap procedures allow the surgeon to select the right kind of donor tissue for specialized reconstruction. 4. It provides more selection in matching skin texture, skin color and tissue volume. 5. Choice of donor tissue from a distance rather than a nearby source minimizes donor site disfigurement. 6. The free flap is not depending on a fixed pedicle, one has more freedom in designing the breast repair, (Shaw, 1987). Recipient Vasculature: In any free flap transfer, the surgeon must have recipient vessel of suitable: Size. Location. Length. Expandability. Undamaged and away from the injury of previous surgery, (Shaw,
1987).

The recipient arteries are: The internal mammary artery.

The recipient veins are: Internal mammary vein.

Thoraco-acromial artery. Thoraco-dorsal artery. Posterior humeral circumflex. Vein graft to axillary artery.

vein.

Cephalic vein of the arm. Branch of the axillary Vein graft to axillary vein

The internal mammary artery provides excellent caliber (1.5 to 3mm). The meticulous dissection after resection of the third or fifth costal cartilage allows the flap to be situated in a comfortable position matching the other side. If the internal mammary vein is small (less than 1.5mm), a conscious choice is made to use vein grafts to the axillary or to mobilize the cephalic vein from the middle of the upper arm through small incision, (Shaw, 1987). Donor Sites: Selection of donor site depends on: The patients decisions to carry out the risks associated with free flaps in comparison to other methods. A careful assessment of the anatomical deformities and the suitable methods of correction are then determined. Examination of the opposite breast to determine the size, shape and the location of the nipple and areola. Another important factor is the surgeons experience. Based on these factors the patient and the surgeon can establish a realistic reconstructive plan, (Shaw, 1987). A firm and conical breast can be reconstructed by gluteal or tensor flaps, whereas a soft, highly ptotic breast is more ideally reconstructed by TRAM flap. In planning the chest incision, one must take into account the best access to the recipient vessels, the manner of minimizing unsightly scars, and the best way in setting and contouring the breast, (Shaw, 1987). The presence of the extensive and deleterious effects of both surgery and irradiation, indicate that the axillary dissection to isolate the recipient vasculature would be hazardous. So, a branch of the internal carotid artery and an adjacent fascial vein are selected and an end to end arterial and venous anastomosis is performed. There are specific types of donor tissue that have been successfully employed in breast reconstruction: 1) The free lower transverse rectus abdominis flap (TRAM). 2) Deep inferior epigastric artery perforator flap (DIEP). 3) Vascularized superior gluteal musculocutaneous flap.

4) 5) 6) 7) 8) 9) 10)
11)
12)

Vascularized inferior gluteal musculocutaneous flap. Vascularized latissimus dorsi musculocutaneous flap (LDMF). Tensor fascia latae. Contralateral breast. Rubens flap (Vascularized groin flap). The lateral transverse thigh flap. The medial transverse thigh flap. Superficial inferior epigastric artery flap. Omentum (Elliott LF, 1994, Heinz, 1997).

1) FREE LOWER TRAM FLAP

It ensures the perfusion of the entire flap via its dominant vascular pedicle and allows flexibility in the design of the breast mound, (Arnez et al., 1988). Dissection of the flap is very straightforward. The inferior epigastric pedicle is both long (as much as 10cm in length) and large in caliber (2.5~ 3mm). The length and caliber of these vessels allows the surgeon considerable latitude in choosing recipient vessels. There is no need for vein grafts or repositioning of the patient, (Friedman et al., 1985). With two teams working, the chest team excises the mastectomy scar and explores the axilla preparing the recipient vessels (the thoracodorsal axis is
preferred but if it is not available, the circumflex scapular or the circumflex humeral vessels offer reliable alternatives).

Meanwhile, the abdominal team prepares a TRAM flap, which is raised in the same way as the standard pedicled flap, with preservation of the periumbilical perforators. At the lower margin of the muscle, the inferior epigastric vessels are dissected to yield a vascular pedicle 8-10cm. The muscle is divided just above the umbilical level and the TRAM flap is delivered to the chest team for revascularisation. Either ipsilateral or contralateral rectus abdominis may be used, (Arnez et al., 1988). The abdominal wall is closed in the standard manner. The microvascular anastomoses are then performed preferably using end to end anastomosis. The final orientation of the flap is made to achieve the desired contour, (Arnez et al., 1988).

2) DEEP INFERIOR EPIGASTRIC ARTERY PERFORATOR FLAP (DIEP)

This flap is a variation of the free TRAM flap in which the deep inferior epigastric vessels are dissected away from the rectus abdominis muscle so that no muscle is harvested with the flap to reduce donor site morbidity. Usually, dissection of two or three perforators is done and all others are sacrificed. This flap often has a less robust blood supply than the conventional free TRAM flap. Consequently, the perforator flap has a higher incidence of fat necrosis than the standard free TRAM flap. The surgeon also is less able to fold and aggressively shape the perforator flap compared with the free TRAM flap. The perforator flap is most useful in:
1. Patients who need only a small amount of tissue for breast reconstruction. 2. Patients who cannot tolerate a reduction in abdominal wall strength.

In most other patients, the surgeons prefer a free TRAM flap that harvests only a small portion of the muscle so that the reduced morbidity of the perforator flap is approached although, admittedly, not equaled, (Kroll et al.,
1998).

3) VASCULARIZED SUPERIOR GLUTEAL MUSCULOCUTANEOUS

FLAP

The upper gluteus provides the best free tissue transfer source for breast reconstruction since it supplies sufficient bulk with excellent skin texture and color, so augmentation, particularly in moderately obese patients, may not be necessary. The gluteus maximus free flap has large dependable vessels the superior gluteal artery, and it leaves minimal donor deformity. Advantageously, most people and the patient herself rarely see or think about the superior gluteal area, (Shaw, 1987).

In the operating room, the patient is placed into the lateral decubitus position and the ipsilateral flap is used for reconstruction. Two operating teams simultaneously work on the donor and recipient sites when both sides are ready and haemostasis is completed in the donor site, the flap is divided and brought into the chest. The donor site is then quickly closed so that the patient can be brought into a more or less supine position for the microvascular anastomosis on the chest, (Shaw, 1987).

4) VASCULARIZED INFERIOR GLUTEAL MUSCULOCUTANEOUS

FLAP

The inferior gluteal musculocutaneous flap usually provides a sufficient amount of autogenous tissue for breast reconstruction when adequate tissue is not present in the lower abdomen or back. Dissection of the inferior gluteal musculocutaneous free flap begins with a transverse incision just beneath the inferior gluteal crease. The subcutaneous tissue is dissected in such a way as to bevel inferiorly. The posterior cutaneous nerve of the thigh is identified as it exits beneath the inferior gluteal maximus muscle just lateral to the ischeal tuberosity, (Palett et al.,
1989).

The posterior cutaneous nerve of the thigh and its accompanying inferior gluteal artery are then dissected superiorly beneath the lower portion of the gluteal maximus muscle. Once these structures are identified, the superior portion of the flap can be designed and incised with the upper portion of the flap over the lower part of the gluteal maximus muscle. At and above the ischeal tuberosity, the posterior cutaneous nerve of the thigh and inferior gluteal artery are in close proximity, but superficial to the sciatic nerve, which runs just to the lateral side. At its most proximal level, the inferior gluteal artery has several anastomotic branches with the perineurium of the sciatic nerve, and these are carefully ligated during the dissection, ( Palett et
al., 1989).

One must dissect a (5x8cm) segment of inferior gluteal maximus muscle adjacent and lateral to the inferior gluteal artery pedicle to ensure adequate blood flow to the overlying soft tissue through the muscular perforators. Proximal dissection permits an increased length of the pedicle for microvascular transfer. During this proximal dissection, two or three branches of the inferior gluteal nerve are encountered and preserved in order to maintain nerve supply to the remaining gluteus maximus muscle.

The flap must be carefully dissected away from the sciatic nerve. The inferior gluteal vessels are anastomosed to the internal mammary or to the thoracodorsal artery in the axilla, (Palett et al., 1989).

5) VASCULARIZED LATISSIMUS DORSI MUSCULOCUTANEOUS

FLAP

The contralateral latissimus dorsi can be transplanted as a free flap, when the ipsilateral latissimus dorsi is not available. During dissection, the entire muscle is taken with a smaller elliptical cutaneous paddle. Because wound closure is performed in two separate layers, muscle and skin, augmentation with a prosthesis can be done safely during the initial procedure. A neural coaptation between the proximal recipient nerve to the latissimus dorsi muscle and the corresponding donor nerve is done if dissection is not too difficult or lengthy. Subjectively, there appears to be less muscle atrophy. Therefore, capsular contracture and fibrosis are inhibited. The lengthy vascular pedicle facilitates flap positioning and performance of the vascular anastomosis. An attempt must be done to perform an end to end vascular anastomosis, but, if the dissection is difficult, an end to side anastomosis is performed, (Serafin et al., 1982).

6) TENSOR FASCIA LATAE

The tensor fascia latae musculocutaneous flap also may be employed in reconstruction. The greatest usefulness of this composite tissue, however, is the tough fascia latae, which can stabilize large thoracic defects and minimize paradoxical respiration. Its lengthy vascular pedicle facilitates placement and anastomosis. Although the donor defect can be closed primarily, the resulting deformity is significant. Aesthetic considerations are second to the functional reconstruction with this donor tissue, (Serafin et al., 1982).

7) CONTRALATERAL BREAST
In this method, the lateral half of the contralateral breast based on the lateral thoracic artery and vein is used for free flap reconstruction, ( La Quang,
1979).

Now it is restricted because of the increased risk for later cancer, however the most disadvantageous point is the need to resect the original breast as well as the reconstructed breast, (Shaw, 1987).

8) RUBENS FLAP (VASCULARIZED GROIN FLAP)

The first Rubens flap transfer for breast reconstruction was performed in 1990.

This flap is supplied by the deep circumflex iliac system which perfuse both the iliac crest as well as fat and skin overlying the crest, (Taylor, 1979). The deep circumflex iliac vessels are located 1 cm to 2 cm deep to the anterior superior iliac spine (ASIS) and travel along the inguinal ligament and conjoint tendon in the plane just deep to the internal iliac musculature and superficial to the transversus abdominis musculature, (Taylor, 1979). Although, the superficial circumflex iliac artery also has been reported as a main supply to the groin flap, however, this vessel is not reliable to transfer the fat overlying the iliac crest, (Hester, 1984).
Skin island

Fat harvest Fig 30: Cross section of the Rubens flap (Elliott, 1998).
Iliac creast
Deep circumflex iliac vessels

Operative Details: Large segments of composite tissue usually can be obtained (11x27 cm) and the donor site can be closed primarily. There is a certain limitation to the vertical height of the skin island because tight closure leads to a widened unattractive scar. The skin island generally starts at the ASIS, with the incision extending medially toward the pubic tubercle. The fat harvest dimensions also should be outlined based upon the width and height dimensions of the breasts, (Elliott, 1998). On the operation table, the patient is positioned essentially in the supine manner, although the hip is lifted up with the support of a beanbag. In the bilateral simultaneous operation, each hip can be propped and draped to an adequate lateral extent. During the operation, first one side, and then the other, is elevated and supported by the beanbag for sequential dissection, (Elliott, 1998). The skin island is harvested down in a cephalic direction to the external oblique fascia, caudal to the gluteus maximum, and posteriorly to the posterior iliac crest. The incision extends medially toward the pubic

tubercle. An incision is made through the external oblique, internal oblique, and transversus abdominis musculature about 1cm to 2cm cephalic to the inguinal ligament. Once the transversus is split, the preperitoneal fat is retracted cephalad, and the deep circumflex iliac vessels can be found along the inguinal shelf, or near the origin of the deep inferior epigastric vessels. The pedicle length is generally 6cm to 7cm , (Elliott, 1998). A sterile Doppler can be helpful in locating the deep circumflex iliac vessels, (Elliott, 1998). The shaping of the breast is relatively uncomplicated because the breast essentially has been shaped during flap harvest. It is tacked superiorly and medially in the pocket to prevent its inferolateral migration, (Elliott, 1998).

9) THE LATERAL TRANSVERSE THIGH FLAP

The lateral transverse thigh flap is a modification of the tensor fascia lata musculocutaneous flap based on the terminal branch of the lateral circumflex femoral artery. The residual scar will be obvious and a significant contour deformity in the thigh results, (Elliott, 1989).

10) THE MEDIAL TRANSVERSE THIGH FLAP

If there is significant medial thigh fatty excess, a medial transverse thigh flap can be designed based on musculocutaneous perforators of the medial circumflex femoral artery via gracilis muscle. Although pedicle length is relatively short (4~5cm), the donor site is hidden and results in thigh lift, but usually there is not enough tissue in this area to satisfy the volume requirement, (Heinz, 1997).

11) SUPERFICIAL INFERIOR EPIGASTRIC ARTERY FLAP

The lower abdominal panniculous may also be transferred on the superficial inferior epigastric artery. However, there is an anatomical variation of the vessels with absence in 20% of population, (Hartrampf, 1991).

12) OMENTUM
It is rare nowadays to be done but it still indicated in cases with extensive chest wall deformity and cases of radiation neuritis of the brachial plexus. It can be also harvested endoscopically, so avoid risks of laparotomy and donor site morbidities, (Hartrampf, 1991). Disadvantages of reconstruction with microvascular free flap: 1. Increased complexity requiring specialized equipment and experience. 2. Long operation time due to the added time for microvascular anastomosis of the artery and vein. 3. Fear of failure of the anastomosis resulting in total loss, (Shaw, 1987). Complications:

The main complication with free tissue transfer is the failure of the vascular anastomosis, resulting in loss of the tissue. In experienced hands, however, this should not exceed 5% to 10%, (Mc Donald, 1988).

RECONSTRUCTION OF NIPPLE-AREOLA COMPLEX (NAC) For the nipple-areola complex (NAC) reconstruction, it is advisable to wait at least three months until the breast mound has settled so that, the nipple-areola complex can be symmetrically positioned, (Ward, 1986). It can be performed under local anesthesia since sensation from the breast mound is either entirely absent or diminished, (Bostwick, 1990). Multiple techniques are available for reconstruction of the nipple and areola. The patients native nipple-areola complex (NAC) serves as a template. When the two breasts are nearly symmetric, the site of localization is measured from fixed points, the sternal notch, midline, midclavicular line and inframammary crease, (Cronin, 1979). In cases with breast asymmetry but symmetrical volume, so it is best to use the disposable electro-cardiographic electrodes to be adjusted to the size of the normal areola with the aid of scissors, (Kon, 1985).
Areola reconstruction:

If the normal contralateral areola is sufficiently large, it usually provides the best
result when shared with the reconstructed breast. It is rotated in a circular fashion on the deepithelized bed of the reconstructed breast. The inner margin is sutured with 5/0 absorbable interrupted sutures, while the periphery is also closed with 5/0 silk sutures. After the nipple graft is placed, the ends of the sutures are tied over a bolus dressing which remain place for 7-10 days, (Schwartz, 1976).

A split thickness dermal graft may be taken from the normal breast by a drum
dermatome. The dermatome cement is carefully applied only to the areola and not to surrounding skin or nipple, (Millard, 1972).

Full thickness grafts from the upper inner thigh or the non-hair bearing inguinal
crease are suitable for areolar reconstruction. The texture and color of these grafts are usually similar to the patients areola and the skin graft will darken with time, (Broadent et al., 1977).

Tattooing is a method to reconstruct the areola that may be a single procedure (four to
six months after nipple/areolar reconstruction) or it can be accomplished simply under local anesthesia. Care is taken to use sufficient dark brown and red pigment in the tattooed area (The Permark tattooing system). The mid-portion of the tattooed area should be darker than the periphery to simulate a nipple, (Georgiade, 1976).

Dermabrasions: This technique is used in black females. It is safe, simple, and rapid
and there is no need for a donor site. It depends on the hyperpigmentation of skin after split thickness removal in dark people, (Cohen, 1981). 1) Nipple Reconstruction: Composite graft from:

a) Opposite nipple: The opposite nipple is the first choice as a donor area. This approach provides for a better symmetry and enables the surgeon to perform a biopsy from the opposite nipple. This is done by excision of the distal 1/3 or 1/2 of the normal nipple. This portion is transferred to the deepithelized recipient site in the center of the reconstructed areola, where it is sutured with 5/0 absorbable interrupted sutures. The donor defect is allowed to epithelize, (Bostwick, 1983). b) Ear lobule: The ear lobe is an excellent donor for the nipple projection and texture which are reasonable when compared to the opposite protuberant nipple without the disadvantage of violating the normal breast, (Rose, 1985). In this method, a clover leaf-shaped auricular graft is harvested from the inferior pole of the ear lobule. This composite graft is inserted into the deepithelized part of areola, where it retains the pinkish appearance of the vascularized donor site. The donor site is closed directly or with Z-plasty, (Rose, 1985). c) Labial graft: The composite free labial graft is a time-honored method. A wedge is excised and the resulting defect is closed primarily with absorbable sutures. Any area around the labia minora may be used, as it is usually brown. This is the method of choice in bilateral NAC reconstruction, (Morgan, 1984). d) Toe pulp: It is done by using the pulp of the second to the fourth toe depending on the desired size. The donor site is left for contraction and reepithelization, (Klastsky, 1981). 2) Reconstruction with local flap: a) T-flap: The T-shaped flap is based on the dermal plexus. The flap is elevated at the dermal fat level, the remainder of the skin within the areolar marking is intradermally deepithelized. In shaping the nipple, the T-flap is folded on itself and the horizontal limb of the T-flap is warped around and sutured to the vertical limb along the lateral markings. The width of the transverse limb of the flap is about three times the desired diameter of the nipple. The nipple diameter is determined by the length of the vertical limb of the flap, (Chang, 1984). b) Tetrapod flap: This technique gives a well formed projecting nipple. The site of the areola is marked with a No. 15 blade. Four opposing flaps are done based on a central disk forming a modified cross form. Once the four limbs are freed to the central disk, they are collectively lifted and the dermis around the nipple margin is incised. With 6/0 absorbable sutures, the pods are joined at their eight corners. A graft is applied to the donor site. A part of plastic syringe barrel is used to protect the nipple from pressure exerted by the tie-over dressing, (Little et al, 1983).

c) Dermal flap:

This technique result in a nipple of natural color and size with lasting projection. The apex of this flap corresponds to the upper limit of the new areola. The length and width is determined by the size of the other nipple. The amount of fat taken with the flap is determined by the volume of the opposite nipple. Care must be taken during release of fat for free projection to protect the delicate blood supply entering from the subdermal plexus at the base of the flap. The donor is closed primarily. No compressing dressing is used for three weeks, (Hartrampf, 1984). Combined nipple and areola reconstruction: 1) The conjoined spiral technique: In this technique, one can use the entire NAC as a full thickness skin graft. The commashaped graft is removed and the spiral is closed on itself on the recipient bed. Each complex has an area of 50% of the donor complex, thus no tissue is wasted, (Cronin, 1979).

2) Star flap: This technique is a one-stage procedure using a local flap that is tattooed immediately before its elevation in the same procedure. It has the advantages of being a reliable, safe and low cost method of nipple areola reconstruction. High patients acceptance can be achieved by sharing them in process of color selection and nipple location, (Eskenazi, 1993). Several points should be emphasized about the modified Star flap technique: The nipple can be based inferiorly, superiorly or laterally as local scarring dictates, but more natural projection appearance to the patient is obtained by basing the flap superiorly. The flap is primarily based on subdermal plexus but can be based reliably on a previous incision line if the scar is six or more weeks old. The "wings" of the flap will determine the nipple height, the height of the flap should be 150% the ultimate desired height allowing for 50% decrease in projection over time. The nipple flap is tattooed with darker pigments before flap elevation and excess pigment is removed with alcohol before incision. The flap is incised through dermis, preserving a base equal to the diameter of the nipple. The donor incisions are closed around the base of the nipple with 3/0 nylon to maintain projection. The "cap flap is brought down and sutured loosely, and if the surgeon is satisfied with the projection and contour of the nipple, the remaining donor incisions are closed with interrupted 5-0 plain gut sutures. Finally, a thick coat of polysporin and a layer of xeroform are applied, followed by a 4x4 gauze with a hole cut centrally for the nipple, (Eskenazi, 1993). 3) Skate technique:

Two wings are elevated on each side of a central base. The wings are elevated at the level of the deep dermis. The dermis at the base of each wing is incised into the subcutaneous tissue and the two wings are drawn out at 90 to the surface. The wings are wrapped around their base, and the donor wound is grafted to reconstruct an areola, (Elliott, 1990).

X Y

Fig 40: Star flap, (Elliot, 1990) Fig 37: T-flap, (Chang, 1984)

PATIENTS AND METHODS

The patients in this thesis were divided into two groups: A. First group: it includes a group of 50 patients, who were subjected to a questionnaire to evaluate the idea of breast reconstruction between Egyptian females. B. Second group: it includes all the patients who came for breast reconstruction after mastectomy during this year (1999-2000). A-First group: A Questionnaire was applied for 50 patients with breast cancer in General Surgery and Radiotherapy Departments (in El-Demrdash Hospital) during September-1999 to September-2000 to evaluate their compliance for breast reconstruction. These fifty patients were classified into two subgroups: Subgroup A: it includes ten cases presented before mastectomy. Subgroup B: it includes forty cases presented after mastectomy. (25 cases still under treatment and the other 15 cases finished their adjuvant chemoradiotherapy including two cases already had reconstructed by TRAM flaps). Each one analyzed for the following items: Age. Pregnancies and abortion. Body weight. Previous pathology. Sexual life. Past history of Chemotherapy, Radiotherapy or hormonal therapy. Effect of the operation on their life (socially, physically and psychologically). Their opinion in breast reconstruction. The causes of objection for breast reconstruction. Their choice for method of breast reconstruction.

Questionnaire for Patients for Their Opinion about Methods of Breast Reconstruction

: : : : : : : : : : - : : : - : : - : : : : : :

: :

: :

: : : : :

: : : : : : : : : :

It reconstruction -3 surgery department in El-Demrdash (immediate or delayed) in the plastic .0002-Hospital during the period of September-1999 to September :This group was further subdivided into three subgroups Subgroup A: patients who came for immediate breast reconstruction .)(one case 4( Subgroup B: patients who came for delayed breast reconstruction .)cases

1 - ( ) -2 underwent breast ( includes ) seven patients who

:B-Second group

: :

 Subgroup C: patients who came for secondary procedures after breast reconstruction (2 cases). METHODS The choice of the breast reconstruction procedure chosen individually according to following parameters: a) The age of the patients. b) The desires of the patients. c) Histopathology results of cancer breast. d) The conditions of the local tissues and the donor sites. e) Bilaterality. f) The experiences of the plastic surgeons. g) The facilities. Preoperative evaluation: Clinical examination was done for all cases with thorough analysis of medical problems if present as one of the patients was complaining of diabetes mellitus, hypertension and obesity. Preoperative Duplex was done for the patients those were candidates for TRAM flaps to access the superior and inferior epigastric vessels. Preoperative photography. Preoperative instructions were given to all patients to:
1) Do not smoke and to be away from any smoker. 2) Donate Blood: two units of blood before surgery. 3) Preoperative Labs: include: blood picture, electrocardiogram, chest X-ray, random blood sugar level, renal function tests and liver function tests were done for all patients. 4) Preoperative visits a one day before surgery: a) To go over the planning procedure. b) To answer any question the patient may have. c) To be evaluated by the anesthetist. d) To apply some markings. 5) Patients were advised to prepare bra and binders to use them postoperatively.

Operative techniques: Preoperative marking was done for all the patients. All the patients were operated upon under general anesthesia. Intraoperative photography. Subgroup A (one case): This case had unilateral infiltrative duct carcinoma grade II and was operated upon by modified radical mastectomy with immediate breast reconstruction by contralateral pedicled TRAM flap. Subgroup B (four cases):

 Two cases with unilateral mastectomy of 4 and 5 years ago came for delayed breast reconstruction by contralateral pedicled TRAM flaps. A case with bilateral mastectomy of 4 years ago underwent delayed breast reconstruction by bilateral ipsilateral pedicled TRAM flaps. A case with bilateral mastectomy of 6 years ago underwent delayed breast reconstruction by bilateral prepectoral breast silicone-filled implants. They were smooth in texture, rounded in shape and 250cc in size. Subgroup C (two cases): two cases were previously reconstructed by pedicled TRAM flap of 1 and 2 years ago One came for reconstruction of the nipple and the areola of the reconstructed breast by local flap with graft from the other areola, mastopexy of the other breast by inferior pedicled technique and creation of umbilicus. The other one came for refashioning and debulking of the reconstructed breast and repair of the anterior abdominal wall bulge by repair of the rectus sheath and application of a prolene mesh. TRAM flaps were harvested by the usual technique and zone IV was discarded in all cases. In all, cases, TRAM flaps were inserted oblique to transverse, with zone I medially situated and deepithelized zone II laterally situated. All of them, had two or three blood units intraoperatively and early postoperatively. In two cases were breast reconstruction had been done by TRAM flaps closure of abdominal defects were done by On-lay prolene mesh to strengthen the repair, and by direct closure in the other two cases. For all these cases, the portovacs were inserted for abdominal and chest wounds ranging 3-6 days. Operative time was ranging from three to eight hours by the end of this work. In case where bilateral prostheses where used for breast reconstruction two portovacs were inserted for chest wounds for 3 days. Postoperative instructions: All the patients were advised to:
1) Do not smoke and to be away from any smoker for one month after surgery. 2) Good nutrition is important for healing. 3) There is a certain amount of tightness' in the area where the flap was taken from. This will slowly relax within a few months. 4) Start walking on the second day postoperatively.

5) 6) 7) 8)

Not lift anything heavier than five pounds for 10 days. The patient may shower starting 3 days after surgery. The patient may perform usual household duties three weeks after surgery. Gentle massage is recommended in cases with prosthetic breast reconstruction to avoid capsular contracture.

The case of the immediate breast reconstruction was transferred to radiochemotherapy department to complete here adjuvant chemo/radiotherapy. Follow up was done for a period of 6-12 months for all the patients after the breast reconstruction to detect tumour recurrence, flap changes and donor site complications and to assess the satisfaction and psychological state of the patient after reconstruction. Also, the patients continued follow up with their oncologists and general surgeons. Postoperative photography was done for all patients after 3days, 2 weeks, 3 months and 6 months postoperatively. Second stage breast reconstruction was discussed with all patients for the following Procedures:
Reconstruction of the nipple and the areola. Revision of the flap. Revision of the donor site. Surgery on opposite breast for symmetry, if indicated:

1. 2. 3. 4.

RESULTS
A- First group:
A Questionnaire was applied for 50 patients with cancer breast: Subgroup A (10): Ten cases before mastectomy. Subgroup B (40): Forty cases after mastectomy: Thirteen cases (13): finish their adjuvant chemo-radiotherapy. Two cases (2) : finish their adjuvant chemo-radiotherapy and had already breast reconstruction after mastectomy by TRAM flaps. Twenty-five cases (25): still under adjuvant chemo-radiotherapy. The results of this questionnaire were as follow: All the patients were 20~60 years old. All the patients body weights ranged from 70 to 90 Kgms. All the patients of low to moderate social class The histopathological examination of biopsies were stage II and III breast cancer with 90% infiltrative duct carcinoma and 10% of other types of breast cancer.

 The patients with non-reconstructed breasts were frustrated and depressed in comparison to the patients (seven cases) with reconstructed breasts. The sexual life after mastectomy was impaired. In Subgroup A (10 cases): Seven cases (7) (70%) know the concept of the breast reconstruction after mastectomy. They know only one modality, which is the breast reconstruction by the silicone-filled implants. In addition, three cases (3) (30%) ignore any thing about the breast reconstruction. By discussion of the other modalities of the breast reconstruction with these patients, only one case (1) (10%) was content with the idea of the breast reconstruction. The nine cases (9) (90%) who refuse the concept of the breast reconstruction: Seven cases (7) (70%): refusal was due to fear of surgical trauma. Two cases (2) (20%): refusal was by their husbands. in Subgroup B (40 cases): Thirty-eight cases (38) (95%) know the concept of the breast reconstruction after mastectomy. They know only one modality, which is the breast reconstruction by the silicone-filled implants, except two cases those were already reconstructed by TRAM flaps. In addition, two cases (2) (5%) ignore any thing about the breast reconstruction. By discussion of the other modalities of the breast reconstruction with these patients, only seven cases (7) (17.5%) were content with the idea of the breast reconstruction but one case escape. The thirty-four cases (34) (85%) refuse the concept of the breast reconstruction: Twenty-seven cases (27) (67.5%): refusal was due to fear of surgical trauma. Three cases (3) (7.5%): adapted their life for that and they do not seek for any further beauty. Three cases (3) (7.5%): refusal was by their husbands. One case (1) (2.5%): the patient refused, as she knew a complicated case after the breast reconstruction.

B- Second group:

The second group was subdivided into three subgroups: Subgroup A (one case): the patients who came for immediate breast reconstruction. Subgroup B (four cases): the patients who came for delayed breast reconstruction. Subgroup C (two cases): the patients who came for secondary procedures of breast reconstruction. Their ages rang from 20 to 60 years. All of them were stage II cancer breast with full metastatic work up done (chest X-ray, bone scan, tru-cut needle biopsy, abdominal ultrasonography and tumour markers assay). The patients in subgroup B,C have been finished their adjuvant chemo/radiotherapy. All of them have no medical problems except one of the subgroup B. she had bilateral mastectomy and she was diabetic, hypertensive and obese. She came for bilateral ipsilateral pedicled TRAM flaps. The results of subgroup A (one case) were as follow: This case was unilateral IDC grade II of the left breast. She came for modified radical mastectomy with immediate breast reconstruction by contralateral pedicled TRAM flap. The flap survival rate was 100%. During the follow up after 2 months, she presented by a small nodule within the TRAM flap. Biopsy was taken and examined histopathologically and had been proved that it was fat necrosis. During the follow up after 6 months, she had a lump in the other breast, tru-cut needle biopsy was done to detect any lesion in the other breast, but histopathological examination was free. Both breasts were nearly symmetrical. The patient, here husband and the plastic surgeons were satisfied form the aesthetic results.

Preoperatively

4th day postoperatively

The patient is willing to undergo the second stage of the breast reconstruction to reconstruct here nipple and areola.

The results of subgroup B (4 cases) were as follow: Two cases with unilateral mastectomy of 4 and 5 years ago were candidates for delayed breast reconstruction by contralateral pedicled TRAM flaps.

A unilateral contralateral pedicled TRAM flap:

1st- Preoperatively. The flaps survival ratespostoperatively. the two cases. 2nd- Two weeks were 100% in

During follow up after one month, the second case developed abdominal bulge, which was due to laxity of the abdominal muscles. Both breasts were nearly symmetrical in a one case and in the other case ptosis of the normal breast was noted.

 The patients and the plastic surgeons were satisfied form the aesthetic results. The two patients are willing to undergo the second stage of the breast reconstruction to reconstruct here nipple and areola and to complete the reconstruction by mastopexy of the normal breast for the second case. A case with bilateral mastectomy of 4 years ago was a candidate for delayed breast reconstruction by bilateral ipsilateral pedicled TRAM flaps. This case was diabetic, hypertensive and obese but the results of duplex revealed no abnormalities in the inferior and superior epigastric vessels and both were of normal diameters. The flaps showed color changes in the form of mottling on the second day postoperatively. 60% of right TRAM flap was lost and 80% of left flap was lost. Also, there was sloughing of a part of the anterior abdominal wall with exposure of the mesh on the fourth day postoperatively. Debridment was done with application of split thickness skin graft for raw areas. The patient, here husband and the plastic surgeons were not satisfied form the results. The psychological state of the patient was very bad during the period of hospitalization but she was getting better when she was discharged from the hospital after 45 days. The case with bilateral mastectomy of 6 years ago was a candidate for delayed breast reconstruction by bilateral prepectoral breast siliconefilled implants. The patient and the plastic surgeons were satisfied form the aesthetic results. Both breasts were nearly symmetrical. The patient is willing to undergo the second stage of the breast reconstruction to reconstruct here nipple and areola.

The results of subgroup C (2 cases) were as follow: The case was previously reconstructed by pedicled TRAM flap of 1 year ago and she was operated upon for the second procedure for reconstruction of the nipple and the areola by Star-shape local flap and reconstruction of the umbilicus.

The patient and the plastic surgeons were satisfied form the aesthetic results. Both breasts were nearly symmetrical so there was no need for reconstruction of the normal breast.

Postmastectomy complex reconstruction with umblicoplasty.

TRAM flap

Nipple areola

 The case was previously reconstructed by pedicled TRAM flap of 2 years ago and she was operated upon for the second procedure for refashioning and debulking of the reconstructed breast and repair of the anterior abdominal wall bulge. Both breasts were nearly symmetrical. The patient and the plastic surgeons were satisfied form the aesthetic results. The patient refused to continue the second stage of the breast reconstruction to reconstruct here nipple and areola. In two cases were breast reconstruction had been done by TRAM flaps closure of abdominal defects were done by On-lay prolene mesh to strengthen the repair, and by direct closure in the other two cases.

In case where bilateral prostheses where used for breast reconstruction two portovacs were inserted for chest wounds for 3 days. Operative time was ranging from three to eight hours for TRAM flap and ranging from one to two hours for application of mammary prosthesis. All the patients were discharged from the hospital after 3-14 days with follow up except for one case of bilateral pedicled TRAM flaps, the patient was discharged after 45 days.

DISCUSSION
Regardless the timing of the breast reconstruction and the nature of mastectomy procedure, the goals of reconstruction still the same, which are: 6) Restoration of the breast mound and contour. 7) Achievement of symmetry between the reconstructed breast and the remaining natural breast. 8) Reconstruction of the nipple-areola complex, (Dinner,
1984).

However, Reconstruction of the breast after mastectomy is predominantly a demand of women in the western world and the well-developed countries. In addition, elective mastectomy with immediate breast reconstruction is done for high risk females in these countries. Nevertheless, in the developing countries, the women hardly demand breast reconstruction after mastectomy unless offered or motivated, (Vyas, 1998). In this study, we try to recognize and analyze the causes of these variations and to public the idea of breast reconstruction after mastectomy between Egyptian females. We were confronted with 16% of females (eight cases of fifty patients) ignore any thing about the breast reconstruction. By analysis the causes of this ignorance, lack of communication between the general surgeons, oncologists and the plastic surgeons was the main cause. Another factor is that, there is no publication of the idea of the breast reconstruction after mastectomy through the audiovisual aids. In 84% of females (forty-two cases of the fifty cases) who were acquainted with the concept of the breast reconstruction after mastectomy, they know only one modality, which is the use of silicone-filled implants. This another important factor led to decrease the rate of breast reconstruction after mastectomy in Egyptian females, as there is false belief that these silicone implants are carcinogenic. By talking to the patients, 86% of females (forty-three cases of fifty patients) refused the concept of the breast reconstruction after mastectomy. The causes of the refusal are: About 79.8% of women (thirty-four cases of the forty-three cases) were afraid to undergo any other operations.

1. About 11.7% of women (five cases of the forty-three cases), the refusal was by their husbands. 2. About 7.2% of women (three cases of the forty-three cases) accepted the result of mastectomy operation and they adapted their life for this condition so they did not seek for any further beauty. 3. About 2.3% of women (one case of the forty-three cases), the refusal was due to the occurrence of a complication in a similar case. In this study, only seven cases (14%) out of fifty patients who had been reconstructed. In this study, seven cases underwent breast reconstruction, only one case was reconstructed immediately, and six cases were reconstructed by delayed methods. Studies that deal with timing of the reconstruction have emphasized the positive effects of immediate reconstruction on emotional and sexual state, (Rowland et al, 1995). In immediate reconstruction, the patient is already anesthetized, the defect does not have to be recreated and the patient can recover from her breast reconstruction at the same time that she is convalescing from the mastectomy. Since then, immediate breast reconstruction after mastectomy becomes more popular, (Elkowitz et al, 1993). Kroll et al, 1995, have shown that the outcomes of immediate breast reconstruction tend to be aesthetically better than those of delayed reconstruction. Other reports have also found that immediate breast reconstruction is oncologically safe, (Noone et al, 1994) and does not mask tumour recurrence, (Slavin et al., 1994). Hence, the use of immediate breast reconstruction is considered the preferred approach in almost all cases in which breast reconstruction is planned. Despite all these advantages of immediate breast reconstruction, in addition to, it is a mean of reducing both the morbidity and cost of staged surgery. However, the Egyptian females still refuse the immediate breast reconstruction as their main target is to get rid of breast cancer not to seek for beauty. The choice of the breast reconstruction procedure chosen individually according to following parameters:

h) i) j) k) l) m)

The age of the patients. The desires of the patients. Histopathology results of cancer breast. The conditions of the local tissues and the donor sites. The experiences of the plastic surgeons. The facilities.

Also, during the choice of the technique one should concern that cases with unilateral breast cancer that will be candidates for immediate breast reconstruction, the other breast may be affected later on. Therefore, the technique of reconstruction should safe other modalities that one of them may be needed to reconstruct the other breast. In this study, we try to adapt all these parameters to reach the ideal procedure for every patient individually. So, four cases were reconstructed by pedicled TRAM flaps. One case was reconstructed by bilateral siliconefilled breast implants. In addition, two cases, who were already reconstructed by delayed TRAM flaps, came for secondary procedures for reconstruction of the nipple-areola complex and for refashioning of the reconstructed breast. Breast reconstruction can be achieved either by prostheses or by flaps those may be pedicled or free flaps. However, prosthetic reconstruction has many disadvantages like infection, extrusion, rupture, capsular contraction and difficult to be used in post-radiated or tight scarred chest wall, (Fisher et al, 1992). In this study, another two factors limited the use of the prosthetic breast reconstruction. The financial state of the patients that make them unable to buy the prosthesis. The second factor is the false belief among the patients that these silicone-filled prostheses are carcinogenic. However, only one case that was reconstructed by bilateral silicone-filled breast implants and she did not have any of the previous complications. The latissimus dorsi muscle flap can be used also for breast reconstruction after mastectomy. However, this flap has many drawbacks. It is small; thus, it may be insufficient to restore the volume of the reconstructed breast. The subscapular vessels may be ligated during mastectomy or affected by radiotherapy. In addition, the donor site scar of the latissimus muscle flap is aesthetically bad, (Kroll, 1996). Hence, the TRAM flap is the first option for most surgeons performing autogenous tissue breast reconstruction, due to:

1. 2. 3. 4.

The use of generally unwanted abdominal wall tissue. The scar that is placed in a relatively hidden position on the body. The contour changes that often result in improvement. The tissue that can be readily shaped into a variety of new breast configurations, (Elliott, 1994). However, the risk factors for TRAM flap are well established and should be strictly reinforced. These risk factors include smoking, diabetes mellitus, hypertension, obesity, radiation to the base of the flap, injury of the superior epigastric artery, old age, cardiovascular diseases, chronic obstructive lung diseases, (Hartrampf, 1988). The nightmare of the unipedicled TRAM flap, used for breast reconstruction after mastectomy, is the high incidence of flap ischemia especially affecting zone IV. No doubt, this is due to the fact that the epigastric archade might be deficient at the region of the umbilicus or the superior epigastric vessels might be tenuous, (Millory et al, 1960). In addition, the venous valves might prevent retrograde flow from the inferior to the superior epigastric tributaries, (Costa et al, 1987). In our study, six cases out of seven were reconstructed by TRAM flaps, including two cases that were already reconstructed. Only one case that suffered from flap complication. In this case, bilateral pedicled ipsilateral TRAM flaps were done for delayed breast reconstruction. This patient also had medical problems as she was diabetic, hypertensive, and obese. In addition, she had post-radiation tight scar of the chest wall. All these factors contribute in the complications in the form of ischaemia and sloughing of the flaps and disruption of the abdominal wound. However, we selected this modality for breast reconstruction on the following bases, the bilaterality, the desire of the patient as she refused to has scar on her back, the scar of the chest wall was tight, the bulky abdomen was a good donor site and the facilities. To combat such ischemic complications augmentation of the blood supply of the TRAM flaps was tried by:

Delaying of the flap, (Codner et al., 1995). Inclusion of superior epigastric pedicles, (Wagner et al, 1991). Free flap transfer, (Arnez, 1992). Retrograde vascularization of the pedicled TRAM flap, (Pernia et al, 1991). Delay of the flap has the limitation of being a staged procedure as well as it might not be beneficial to improve the blood supply of the distal part of the flap (the infra-umbilical portion) because the communication between the superior and inferior epigastric vessels are grossly absent in 60% of people, (Mathes and Nahai, 1997). Meanwhile, bipedicled TRAM entails the sacrifice of both recti which eventually, produce abdominal wall dysfunction and possibly an incisional hernia in 25-45% of cases, (Kroll, 1992). However, the presence of two pedicles may limit free rotation of the flap, (Harashina et al, 1987). Free flap does not ensure the viability of the whole the TRAM flap and it is dependent on the integrity of a single vessel that might suffer from anastmotic complication which may prove to be disastrous especially in high risk patients, (Ishii et al, 1985).

The augmentation of blood supply to the TRAM flap may be either by: A. Anastmosing of both inferior epigastric vessels together in unipedicled TRAM flap "Turbocharging" TRAM flap, (Kind et al, 1997). B. Anastmosing the inferior epigastric vessels with appropriate recipient vessels in the axilla "Supercharging" TRAM flap, (Harashina et al, 1987).

SUMMARY AND CONCL USION

The female breast is one of the most important physical expressions of femininity. Removal or deformity of this sexual organ can induce severe psychological effects. Therefore, breast reconstruction is an element of prime importance to mastectomized women. The goals of breast reconstruction are creating a breast that looks and feels like the normal breast, with achievement of symmetry by correction of the contralateral side. The aims of this thesis are to review the different modalities of breast reconstruction after mastectomy and to identify the causes of refusal of Egyptian women to reconstruct their breasts after mastectomy and to evaluate their compliance for breast reconstruction.

Breast reconstruction either can be immediate at the time of mastectomy, delayed (secondary breast reconstruction) after six months or late up to five years after mastectomy. Oncologically, there is no reason preventing immediate breast reconstruction unless the patient refuses the operation or the prognosis is very poor. Immediate breast reconstruction has many advantages. For the patient, it is easier, less expensive and psychologically more convenient. For the surgeon, it facilitates the reconstruction and improves aesthetic results. Disadvantages of immediate breast reconstruction are minimal and consist of prolongation of duration of the surgery, more severe postoperative pain and a higher complication rate. Delayed breast reconstruction is considered three to six months after mastectomy as by this time the soft tissue will have recovered from the operative trauma, also, adjuvant chemotherapy is usually finished. In addition, the patient lived with the deformity for sometimes, which made her accept any kind of breast reconstruction. Technically, simple methods should be used if possible. However, selection of the breast reconstruction procedure must be chosen individually depending on various conditions: Silicone implants should be used only in the case of locally abundant soft tissue coverage. By tissue expansion, soft tissue coverage can be expanded until the desired volume with or without subsequent application of silicone implants. Local advancement flaps in combination with silicone implants are used to replace lost skin. The LDM flap enables the breast reconstruction of a thick soft tissue with skin and muscle and with insufficient or irradiated soft tissue. The TRAM flap is the standard way for the breast reconstruction but the problem of distal necrosis and fat lysis (due to ischaemia of zone IV) has produced trends to find different modalities to overcome this problems. Generally, all methods are suitable for immediate as well as for delayed breast reconstruction procedures. The patients in this thesis were divided into two groups. The First group, that included fifty patients, who were selected to evaluate the breast reconstruction idea between Egyptian females. This was done in

General Surgery and Oncology Departments during 1999-2000.

(in El-Demrdash Hospital)

The Second group, this included the patients who underwent breast reconstruction. This was done in Plastic Surgery Department (in ElDemrdash Hospital) during 1999-2000. The study, showed that 16% of Egyptian females ignore any thing about the breast reconstruction. The most probable cause for this is the lack of communication between the general surgeons, oncologists and the plastic surgeons and the paucity of publications of the idea of the breast reconstruction after mastectomy through the audiovisual aids. The Egyptian females know only one modality for breast reconstruction, which is the silicone-filled implants, that is known to be carcinogenic by most of them. In addition, 86% of Egyptian females refused the concept of the breast reconstruction after mastectomy, due to, 79.8% of women were afraid to undergo any other operations, 11.7% of women the refusal was by their husbands and 7.2% of women adapted their life for their postmastectomy condition. Also, the Egyptian females still refuse the immediate breast reconstruction as their main target is to get rid of breast cancer not to seek for beauty. In this study, seven cases underwent breast reconstruction, one case was reconstructed immediately, and six cases were reconstructed by delayed methods. The choice of the breast reconstruction procedure chosen individually according to the age of the patient, bilaterality, the desire of the patient, the condition of the local tissues and the donor sites, the experience of the plastic surgeon and the facilities. The TRAM flaps still the most commonly used modality for breast reconstruction. As this modality was used in six cases out of the seven reconstructed cases with good results, except in the patient that has some risk factors. So, it is recommended to enhance the vascularity of the TRAM flap. The seventh case was reconstructed by bilateral silicone-filled implants. This is not demanded by many cases for financial causes and false belief of carcingenicity of the silicone.

By conclusion, we recommend the followings: Enhance the communication between the general surgeons, oncologists and the plastic surgeons to improve the quality of breast surgery for Egyptian females.

 Publishing of the breast reconstruction after mastectomy idea through the audiovisual aids. During mastectomy, the breast surgeons if possible should avoid injury or ligation of the subscapular vessels as it is the arterial blood supply of the LDMF and it can be used as recipient vessel for the free flaps. After mastectomy, the patient should have a full operative details report to help in choosing of the reconstructive method. Immediate breast reconstruction is recommended as it reduces both the morbidity and cost of staged surgery. Also, it avoids reconstruction in irradiated tissues with its hazards. TRAM flap should not be used for risky patients. But, To combat that augmentation of the blood supply of the TRAM has to be done.

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