BREAST RECONSTRUCTION
Breast reconstruction is a surgical procedure that aims to restore the shape, size, and appearance of one or both breasts following a mastectomy (complete removal of the breast), lumpectomy (partial removal of the breast), or congenital deformities. The goal of breast reconstruction is to help improve the patient's quality of life and self-esteem after breast cancer treatment or other breast-related surgeries.
There are several methods of breast reconstruction, and the most suitable option depends on the individual's needs, preferences, and medical history. The main types of breast reconstruction include:
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Implant-based reconstruction: This method involves the use of saline or silicone-filled implants to recreate the breast mound. A tissue expander may be placed under the chest muscle to stretch the skin and create space for the implant. Once the desired size is reached, the expander is replaced with a permanent implant in a separate surgery.
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Autologous tissue reconstruction: Also known as flap reconstruction, this method uses tissue (skin, fat, and sometimes muscle) from other parts of the patient's body, such as the abdomen, back, or thighs, to create a new breast mound. Common flap techniques include the TRAM flap (transverse rectus abdominis myocutaneous flap), DIEP flap (deep inferior epigastric perforator flap), and latissimus dorsi flap.
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Combined reconstruction: This approach involves using both an implant and a flap of the patient's tissue to reconstruct the breast. This can provide additional coverage and support for the implant.
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Fat grafting: In some cases, fat can be harvested from other parts of the patient's body, purified, and then injected into the breast area to add volume and shape.
Breast reconstruction can be performed immediately after a mastectomy (immediate reconstruction) or at a later time, after the patient has healed and completed additional cancer treatments (delayed reconstruction). Some women may also choose not to undergo breast reconstruction and instead opt for a prosthesis or embrace their new appearance.
Anesthetic Implications for Breast Reconstruction
Anesthesia type: General
Airway: ETT or LMA
Preoperative:
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Doxorubicin chemotherapy can cause cardiomyopathies
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Bleomycin carries the risk of pulmonary toxicity
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Avoid FiO2 > 30% in bleomycin patients
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Methotrexate can produce renal and hepatic dysfunction
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Tamofixfen can cause N/V and dehydration
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Check for anemia and thrombocytopenia after chemotherapy
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The blood pressure cuff and the peripheral IV should be placed on the nonoperative-side arm
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Ensure arm abduction is <90° to prevent brachial plexus injury
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Placed EKG leads away from the sterile field
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Patient anxiety associated with breast cancer and altered body image
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Larger tumors, lymph node involvement, and the lack of estrogen and progesterone receptors are associated with worse prognosis
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Smokers are advised to stop smoking for at least 4 weeks before surgery
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Smoking complications: Nicotine-induced vasoconstriction, carbon monoxide-induced tissue hypoxia, and hypercoagulability from increased platelet aggregation
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The duration of surgery may be > 8 hours
Intraoperative:
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Position: The patient is placed in the lateral decubitus position for latissimus dorsi myocutaneous (LDM) flap harvest, then supine.
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Position: For tissue expanders/implants, the patient may have to be placed in the sitting position during the procedure
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Maintain a stable blood pressure (MAP 70 mm Hg) for perfusion of the flap tissue
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A Doppler may be used to check for flap pulses
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Keep patient warm and hydrated for flap perfusion (minimize peripheral vasoconstriction)
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Hypothermia may impair flap perfusion
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It is preferred to maintain a stable BP with volume replacement
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Careful use of vasopressors
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IV fluorescein dye may be used to determine the viability of the flap with breast reconstruction
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Skin fluorescence correlates with flap survival
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Duration: Tissue expander 1-2 hours, latissimus dorsi flap 4 hours + mastectomy time, TRAM flap 4-8 hours + mastectomy time
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EBL minimal to 500 mL
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Primary ischemia of the flap occurs as blood flow ceases during flap transfer
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Reperfusionphase in free flap surgery begins with vessel declamping after completion of microvascular anastomosis
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Ischemia/reperfusion injury may occur
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Overzealous fluid administration can result in interstitial edema
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Avoid hypovolemia, vasoconstriction, and hypothermia to prevent flap compromise
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Hypocapnia will also lead to vasoconstriction
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Hypercapnia can cause sympathetic nervous system stimulation
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A hyperdynamic circulation (high cardiac output, peripheral vasodilation, and large pulse pressure) is the ideal to maintain adequate microcirculatory perfusion
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During the dissection stages of surgery, controlled hypotension can be requested
Postoperative:
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Smooth emergence
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Pain management
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PONV prophylaxis
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Higher incidence of flap loss in obese, smokers, and diabetics
Complications:
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PONV
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Flap loss
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Seroma
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Infection
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Pneumothorax
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Hematoma
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Injury to axillary neurovascular structures
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Psychological trauma
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Venous thromboembolism
Sources:
Macksey, L. F. (2011). Surgical procedures and anesthetic implications: A handbook for nurse anesthesia practice.
Jaffe, R. A. (2020). Anesthesiologist's Manual of Surgical Procedures (6th ed.).
N Nimalan, BSc MBBS FRCA, O Alexandre Branford, BA (Hons) MA (Cantab) MBBS (Lon) PhD (Lon) MRCS (Eng) FRCS (Plast), G Stocks, BSc MB BS FRCA, Anaesthesia for free flap breast reconstruction, BJA Education, Volume 16, Issue 5, May 2016, Pages 162–166, https://doi.org/10.1093/bjaed/mkv036
Singh-Radcliff, N. (2013). 5-Minute Anesthesia Consult.