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BREAST RECONSTRUCTION IN CONSERVING BREAST CANCER SURGERY

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BREAST RECONSTRUCTION IN CONSERVING BREAST CANCER SURGERY JAMAL MASAD MELHEM MD,FRCS ASSOCIATED PROFESSOR OF SURGICAL ONCOLOGY JORDAN UNIVERSITY

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Conserving Breast surgery combined with radiotherapy. proved the test of time as a sound oncological operation in term of survival and local recurrence .

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Survival Rates of Conservative Surgery Plus Radiation Therapy Compared with Mastectomy Alone

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Advantages of conserving Preservation of body image and wellbeing. Positive psychological balance. To achieve these objectives: A nearly normal anatomy should be the end results of breast conserving surgery.

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What is the normal breast anatomy Most Public Private Parts important to women then men!

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CUP A 15% CUP B 44% CUP C 28% CUP D 10% Size variation. assymetry Journal of sex research

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Satisfaction rate 20-30% of patient have unsatisfactory out come

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Important factors Tumor size Breast size Tumor location Tumor distribution

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Tumor location

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Tumor distribution Localized (55%) Segmentally extended (35%) Irregularly extended(10%) G Amano, N Ohuchi and T Ishibashi et al., Correlation of three-dimensional magnetic resonance imaging with precise histopathological map concerning carcinoma extension in the breast, Breast Cancer Res Treat 60 (2000), pp. 43–55

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Determination of tumor site and distribution for surgical planning Clinical palpation. Mammography. Ultrasound. MRI 3D CT (Japanese reports)

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3 D CT

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Factors predisposing for poor cosmetic results Volume of excised tissue (25%)*** Badly sited surgical incisions. Poor tissue handling (fat necrosis&infection). Radiotherapy.

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Surgical Atlas

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TYPES OF BREAST CONSERVING OPERATIONS WLE (SIMPLE)

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TYPES OF BREAST CONSERVING OPERATIONS Segmental ]’’’’’’’’’’]][[][[]€ mastectomy

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HOW to improve the cosmetic outcome? Volume displacement Glandular flaps Reduction mammoplasty Other techniques Volume replacement Latissmus dorsi flaps Local flaps

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Glandular flaps

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Reduction mastopexy lumpectomy Large Defects in Large Breasts

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Large Defects in Large Breasts

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Donut Mastopexy

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Oncological and cosmetic outcomes of breast reshaping

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Latssimus flap Large Defects in Medium-Sized or Small Breasts

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Oncological and cosmetic outcomes of volume replacement (lat dorsi)

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Local flaps The use of immediately adjacent tissue to cover post conserving breast cancer surgery defect. (skin and fat ± glandular) Medium-Sized Defects in Smaller Breasts

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Local flaps Local flaps usually used in conjunction with glandular displacement in majority of cases

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LOCAL FLAPS Several searching engines of the internet: Ann Surg Oncol. 1997 Oct-Nov;4(7):540-4.Related Articles, Links Local rotational flaps for breast conservation therapy as an alternative to mastectomy. Bold RJ, Kroll SS, Baldwin BJ, Ross MI, Singletary SE. Department of Surgical Oncology, University of Texas M. D. Anderson Cancer Center, Houston 77030, USA. METHODS: in 3 years, nine patients were treated with BCT using local rotational flap techniques... CONCLUSION: Local rotational flaps composed of adjacent breast tissue are an acceptable method of achieving satisfactory cosmesis in selected patients .

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Local Fascicutaneus Flaps in Managing Post Burn Breast Deformities. WAEL M.R. SAKR, M.D. The Department of General Surgery, Faculty of Medicine, Cairo University. Egypt. J. Plast. Reconstr. Surg., Vol. 26, No. 2, 2002: 233 - 239

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JUH experience Local flaps used in 43 patients Data 0f 25 patient were analyzed (minimum follow up 24 months) Local flaps practiced since 1998

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Local flaps Indications: Anticipation of bad cosmetic outcome -large tumors. -Small breast Excisional biopsy with positive margins before referral.

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Local flaps… Methods 1998-2004 25 women with established diagnosis of breast cancer were enrolled in the study. Pre operative assessment by history physical examination and appropriate laboratory and radiological investigations to assess tumor stage and the patient fitness for multimodality treatment by surgery, chemotherapy and radiotherapy.

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Local flaps… Methods Surgical treatment: Preoperative planning by clinical assessment, mammography review and ink marking 0f the surgical site.

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Local flaps… Methods All patients had undergone wide local excision with at least one centimeter safety margin, the skin overlying the tumor was excised only if it should be included in the safety margin as in superficial tumor location or if recent excisional or incisional biopsy was performed.

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Local flaps… Methods The specimen routinely sent to histopathology department after appropriate labeling to assess the margins by frozen section. Further excision of the margin of concern was performed.

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Local flaps… Methods Post operative care: Discharged from the hospital after removal of drains. All patients received adjuvant chemotherapy except one who was started on neo adjuvant drugs because of large tumor (6 cm) which was reduced to (3 cm). All patients received radiotherapy treatment after finishing chemotherapy. Regular follow up every month after first pos operative visit for one year, every three months in the second year and every six months there after.

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Cosmetic out come assessment Local flaps… Methods

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Local flaps Results 11 14 Site 15 5 5

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Local flaps Results Tumor size: 4 patients Tx. 21 patients range(2-6)cm mean 3.1 cm 1 patient had neo adjuvant chemotherapy AT.(6—3)cm

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Local flaps Results Histopathology results:

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complications Bruises 1 Fat necrosis 1

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Local flaps Results Follow up period: Mean 48 months. Range of (23—120) months. 22 patients were free. One patient developed local recurrence after four years. One patient developed concomitant local recurrence, lung and brain mets after 18 months ,died one year later. Local recurrence 8% Distant metastases 4% Death 4%

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Local flaps Results Cosmetic outcome:84% very good and good outcome.

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Very good Very good

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Good

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Good

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Fair

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Local flaps conclusion Useful technique especially for medium sized upper outer or upper central defect. Easy to perform using simple plastic surgery principles of local flaps. Using tissue next to defect will provide matching color and texture to the breast. It is complementary to glandular flaps when there is significant skin loss. It provides wide access to the axilla when the flap incision is made in continuity with that of axillary incision. Several advantages over latissimuss dorsi, less time consuming, one stage procedure, no loss of muscle, no change in position during surgery no further distant scar and more important is keeping the muscle as a potential reserve for future use in case of local recurrence.

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conclusion To achieve best oncological and cosmetic outcome in conserving breast surgery: Careful planning to determine the magnitude of resection to achieve safety margin. Applying the deferent techniques mentioned before to have the best possible out come.

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Thank you

	jmasad 8 Months ago. Category: Surgery

Tags:	almasad breast oncoplastic

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