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Physicians Update

 
Fall 2006: Plastic Surgery

Breast Microsurgery Techniques Create Dramatic Reductions in Patient Morbidity

The most significant recent advance in breast reconstruction—the ability to transfer patients’ own tissues at the time of mastectomy with minimal or no muscle loss—has been facilitated by new microsurgical techniques being used by specially trained plastic surgeons. At institutions where breast microsurgery is performed in high volume, morbidity has been dramatically reduced and success rates are as high as 99 percent.

Microsurgery involves disconnecting a tissue and its blood supply from the body and reattaching it, transferring the vessels and sewing them under the magnification of a microscope. The “free flap”—in which the tissue is completely disconnected and reattached—has become the predominant technique in breast reconstruction at the Revlon/UCLA Breast Center, and has made possible the transfer of the patient’s tissue from the lower abdomen or buttocks at the time of the mastectomy, with minimal risk and low morbidity. “Traditional techniques for autologous breast reconstruction would transfer the tissue on the muscle pedicle, and significant muscle function was lost,” explains James Watson, M.D., UCLA plastic surgeon. “Now, flaps can be transferred with the skin, fat and blood vessels with no muscle. This is only possible when microsurgery is used to re-vascularize the flap with blood vessels found in the mastectomy pocket. We can now reconnect the artery and vein of the flaps. Whereas in the past, such techniques were associated with significant flap loss, our flap-loss rate at UCLA is less than 1 percent. We no longer do transfusions or autologous blood banking with this technique, and hospital stays are shorter because patients have less pain.”

At UCLA, one of the highest-volume microsurgical breast-reconstruction centers, the techniques for obtaining the free flaps are constantly being refined. “Before, when we were moving tissue around, we sometimes had to take a small piece of muscle,” says Andrew Da Lio, M.D., UCLA plastic surgeon. “Now it’s almost solely fat and skin, so the functional downside has been reduced dramatically, to the point where patients rarely notice any difference. And every year, we’re getting better at it.”

The latest evolution in microsurgery incorporates the use of perforator flaps to minimize morbidity by sparing maximal amounts of muscle. “The pedicle flap, taking skin and some muscle from the lower third of the abdomen, has been considered the gold standard for breast reconstruction,” notes UCLA plastic surgeon Christopher Crisera, M.D. “But we found by studying the anatomy of that area that the better blood supply to the main vessels for that tissue comes off of some branches from the external iliac system. In order to use that tissue, you have to disconnect it from the abdomen. That moved us from the pedicle flap to the free flap. But we were still taking half of the rectus muscle with the tissue.” With perforator flaps, Dr. Crisera explains, more abdominal muscle can be spared, such that UCLA breast microsurgeons are typically able to split that muscle and take only the blood vessels, the skin and the fat. The same technology can be used to form a gluteal flap. “It’s a less morbid procedure that will be particularly important for the increasing number of women who require bilateral reconstructions,” Dr. Crisera says. “Taking rectus muscle from both sides of the abdomen would lead to a lot of weakness in these women if done in the traditional fashion.”

Brian Boyd, M.D., chief of plastic surgery at Harbor-UCLA Medical Center, feels strongly that every woman with breast cancer must be offered all the latest techniques of breast reconstruction—including perforator flaps— so that she can make fully informed decisions about her own care. “We hope that as more surgeons become proficient with this technique, other centers might also be able to offer such cutting-edge technology to give their patients the opportunity for the best possible long-term results” says Jay Granzow, M.D., M.P.H., associate chief of plastic surgery at Harbor-UCLA Medical Center. Microsurgical breast reconstruction requires special expertise and subspecialty training. At high-volume centers such as UCLA, which performs 200-250 of the procedures per year, there is a growing demand. “As the patient population becomes more educated about what’s available, people are looking for centers that will offer breast microsurgery,” says Jaco Festekjian, M.D., UCLA plastic surgeon. “In the future, more surgeons will need to be trained in this subspecialty.”




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