What Are the Pros and Cons of Breast Reconstruction after a Mastectomy?

Immediate breast reconstruction after breast cancer resection. Transverse rectus abdominis myocutaneous flap TRAM flap.

Immediate breast reconstruction after breast cancer resection

Immediate breast reconstruction after breast cancer resection. Transverse rectus abdominis myocutaneous flap TRAM flap.

Chinese name

Transplantation of rectus abdominis myocutaneous flap for breast reconstruction

Foreign name

TRAM

Immediate breast reconstruction after breast cancer resection

Transplantation of rectus abdominis myocutaneous flap for breast reconstruction; TRAM

ordinary

85.5401

Immediately after breast cancer resection, the rectus abdominis myocutaneous flap was transplanted into the breast.

Breast reconstruction after breast cancer resection can be performed immediately, or a two-stage breast reconstruction can be performed after the first operation, that is, after completion of chemotherapy. If it is a patient who needs radiation therapy after breast cancer surgery, it should be performed 6 to 12 months after stopping radiotherapy.

Applied Anatomy of TRAM Flap:

The blood supply of the TRAM flap comes from the anastomotic branches of the superior and inferior abdominal arteries. The continuation of the internal thoracic artery of the upper abdominal artery. The inferior abdominal wall artery comes from the external iliac artery. There are two accompanying veins in the superior and inferior abdominal wall. The outer diameters of the artery and vein are above 2mm. Form of anastomosis.

The breast is made up of glands, fat and fibrous tissue. The mammary glands are derived from the epidermis and are located in the reticular fascial tissue. The nipple is a local hyperplasia of the spinous layer of the epidermis. The physiological activity of the breast is restricted by various hormones, such as anterior pituitary hormone, adrenocortical hormone, and sex hormone, and produces corresponding changes in tissue structure. Adult female breasts are located in the sac composed of superficial fascia, with 4-5 intercostal spaces above and below, and the upper boundary is generally at the level of the second rib. Axillary midline on both sides. The upper part of the gland protrudes into the axillary cavity into the tail lobes of the breast.

The center of the mammary gland is the nipple, and the ring isola is around. The cyst of the breast is the superficial thoracic fascia, which extends deep into the breast and divides the mammary gland into about 20 lobes arranged radially, with cell-like adipose tissue between the lobes. Each mammary lobe has a corresponding lactiferous duct that opens into the nipple. The enlargement of the ducts near the nipple is called the ductus sinus. Cooper ligaments are connected to the skin and pectoralis major fascia.

The lymphatic vessels of the breast are very abundant, and the main returning channels are the axillary lymph nodes and internal mammary lymph nodes.

Axillary lymph nodes can be divided into 5 groups: outer, anterior, posterior, internal and central. The lateral group is around the axillary arteries and veins; the anterior group is located on the superficial surface of the anterior serratus, the lower edge of the pectoralis minor muscle, and the lateral thoracic artery. Breast cancer metastasis first invades this group of lymph nodes; the posterior group is located on the posterior side of the axillary arm, along the subscapular vessels Distribution; the central group is in the center of the axillary base, in the loose adipose connective tissue on the deep side of the axillary fascia, and the lymph nodes of each group meet here; the inner group is located on the deep side above the pectoralis minor muscle, and its output tube collection is the subclavian trunk and the lateral neck The lymph nodes are in communication, the subclavian lymphatic stem is injected into the chest duct on the left and the right lymph duct is injected on the right.

Parasternal lymph nodes are arranged along the blood vessels in the thorax. The superficial and deep lymphatic vessels of the medial breast and anterior thoracic wall merge into this group of lymph nodes, and then the intercostal lymph vessels enter the mediastinal or supraclavicular lymph nodes.

Lymphatic vessels on the underside of the breast pass through the anterior abdominal wall and into the hepatic lymphatic vessels in the subcondylar space. Lymph vessels on the deep side of the breast pass through the pectoral muscles into the subclavian lymph nodes. Superficial breast lymphatics have extensive connections with cutaneous lymphatics. Cancer can thus spread to the contralateral breasts and armpits.

The blood supply to the breast is mainly from the lateral thoracic artery, the intercostal branch of the internal thoracic artery, and the lateral branch of the intercostal artery.

The superficial veins of the breast are the subcutaneous veins, and the deep veins accompany the arteries of the same name, merge into the internal thoracic veins, axillary veins, odd veins, or semi-odd veins, and eventually flow into the pulmonary vascular network.

The innervation of the breast is mainly the lateral cutaneous branches and anterior branches of the 2nd to 6th intercostal nerves, and the supraclavicular and anterior thoracic nerves.

Immediate breast reconstruction after breast cancer removal is suitable for:

1. Non-invasive ductal carcinoma, invasive ductal carcinoma <1cm.

2. Breast cancer is located on the lateral side of the breast and there is no sign of axillary lymph node metastasis.

3. Eczema-like breast cancer, who can not reach a clear mass in the breast.

4. Mucinous carcinoma, medullary carcinoma, intrapapillary papillary carcinoma, phyllodes sarcoma, etc., those with late axillary lymph node metastasis.

1. Transverse abdominal incision surgery has been performed in the quarter-costal area, or lateral abdominal incision surgery has been performed.

2. After the midline incision or paramedian incision in the lower abdomen.

3. Preoperative radiotherapy, the arteries and veins of the chest wall have been damaged.

1. The nature of the tumor should be as clear as possible before radical operation. Fine needle aspiration can be used for cytological examination. Experienced doctors can draw tissue from larger lesions, and the diagnostic accuracy can reach more than 90%. However, for smaller lesions, such as cytology can not judge its nature, you should first open the suspicious tissue for quick biopsy or completely remove the smaller mass for pathological examination immediately. The excision site should be within the resection range of the radical operation.

When it is determined that radical surgery is performed for cancer, the instruments used for biopsy should not be repeatedly used in radical surgery. The surgical field should be re-sterilized and surgical gowns and gloves should be replaced.

There should also be correct estimates of the extent of local lesions and whether there are distant metastases in the lungs, bones or internal organs before surgery. If the primary lesion is large, there is regional lymph node metastasis, and cancer cells are hidden in the above areas, there will be obvious clinical manifestations shortly after surgery. Therefore, every patient with breast cancer should have a very detailed and comprehensive examination. Blindly expanding the indications for surgery cannot improve the quality of treatment. On the contrary, severe surgical trauma may damage the body's immune mechanism and adversely affect the patient.

2. Required tissue measurement.

The patient should be placed in an upright or sitting position during the measurement. The measurement contents are as follows: The distance from the midpoint of the clavicle to the nipple; The distance from the nipple to the midpoint of the underfold of the breast;

General anesthesia or optionally high epidural anesthesia. Elderly patients with abnormal heart and lung function and poor general condition can do chest intercostal nerve block.

The patient took a supine position, the upper limb of the affected side was abducted by 90 °, and a thin cloth was placed on the shoulder and chest sides to expose the posterior axillary line.

Thoroughly disinfect the skin of the chest. The affected side reaches the posterior axillary line. The contralateral side reaches the front axillary line, including the upper arm and axillary. The upper boundary starts from the neck root plane and the lower boundary reaches the umbilical plane. The surgical field needs to show the clavicle, acromion, sternal margin, rib margin, and midline of axillary chest.

1. Improved radical mastectomy for breast cancer.

2. Design TRAM flaps: TRAM flaps are generally spindle-shaped. The left and right ends are bounded by the anterior and superior condyles on both sides. The upper edge is 0.5 to 1 cm above the umbilicus and the lower edge is on the upper edge of the pubic hair.

3. Cut the skin and subcutaneous tissue at the upper edge of the TRAM flap to the rectus abdominis sheath and the external oblique aponeurosis, and lift the two wings of the skin on both sides of the external oblique tendon surface to the outside of the rectus abdominis sheath. Edge 2.5 3cm.

4. Cut the skin at the lower edge of the TRAM flap to reach the anterior sheath of the rectus abdominis and the oblique tendon of the external oblique muscle. An L-shaped incision is made on the anterior sheath of the rectus abdominis on the uninjured side. The presence of arteries and veins under the abdominal wall can be detected deep in the rectus abdominis and the posterior sheath of the rectus abdominis.

5. At the outer edge of the anterior sheath of the rectus abdominis, cut the anterior sheath of the rectus abdominis, and include the contralateral rectus abdominis anterior sheath and part of the ipsilateral anterior sheath together with the rectus abdominis in the flap to protect The percutaneous branch of the musculocutaneous blood vessel is made into a flap to protect the upper muscles for transplantation.

6. Make a tunnel in the upper abdomen and connect it with the chest incision, so that the TRAM flap can enter the chest incision smoothly.

7. According to the needs of the receiving area, trim the size and shape of the myocutaneous flap, branch the epithelium in some areas, and shape the breast body.

8. In order to avoid excessive twisting of the muscle pedicle during flap transfer, which affects the blood supply of the flap, the muscle pedicle of the contralateral rectus abdominis muscle is generally selected, and the muscle pedicle of the ipsilateral rectus abdominis muscle can also be selected.

9. Widely free the upper abdominal skin and subcutaneous tissue to the quarter ribs, make it pull down to the incision edge of the upper fold area of the pubic bone, and perform abdominal wall shaping. Do anterior sheath repair of rectus abdominis, reconstruct the umbilical foramen, and complete the shaping of the abdominal wall.

10. It can also be used as a safe operation for bilateral rectus abdominis and the abdominal wall arterial and vein pedicled. With bilateral abdominal arterial and venous pedicles, the success rate of surgery is improved. The surgical method is the same as that of single breast TRAM flap reconstruction.

11. Built-in negative pressure drainage in the chest and lower abdomen incisions.

When taking the lower abdominal muscle flap, the length of the blood vessel at the end of the muscle flap should be kept as much as possible, and the injury should be prevented. Anastomosis of the blood vessel can be performed if necessary.

In order to protect the strength of the abdominal wall, 25% to 30% of the lateral rectus abdominis anterior sheath and rectus abdominis are retained, so that the medial rectus abdominis anterior sheath and rectus abdominis are included in the flap.

After breast cancer resection, do the following immediately after breast reconstruction:

1. Closely observe the blood supply to the flap 3d after the operation and deal with the cause of the flap blood supply failure in time.

2. Keep the urination and urination unobstructed, and prevent abdominal wall hernia due to excessive intra-abdominal pressure.

3. The drainage tube was removed 4 to 5 days after the operation.

4. Bandage the abdomen within 1 month after the operation. Nipple reconstruction can be performed 3 months after the operation to complete the entire process of breast reconstruction.

1. Flap necrosis The insufficient blood supply of the single-muscle pedicle flap leads to ischemic necrosis of the tissue. When the flap is transferred, the superior abdominal wall arteries are twisted or angled. Postoperative compression bandaging causes compression of the pedicle.

2. Abdominal wall weakness and excessive care of the flap blood supply during abdominal hernia surgery, bring the entire rectus abdominis and its anterior sheath into the flap. Postoperatively, the abdomen was properly bandaged, and an elastic abdominal band was worn for 3 to 6 months to prevent abdominal wall weakness and hernia.

3. Fat liquefaction.

4. Incision splitting can occur both in the recipient area and the donor area. The reason for this is due to necrosis of the edge of the flap. In the donor site, it is caused by poor incision healing due to excessive incision tension.

5. The bad shape of reconstructed breast is mainly manifested by the asymmetry of both sides of the breast, the reconstructed breast is too small or lacks the normal structure of normal breast. The reason is that there are too many breast tissue defects, and the amount of tissue provided by the skin is small; the flaps are placed in the wrong direction, causing breast morphology.