Breast reconstruction in private practice

Abstract

Comprehensive breast reconstruction can be performed in private practice. Our practice philosophy is that autogenous tissue provides the best substrate for breast reconstruction; the deep inferior epigastric perforator flap is our primary method of breast reconstruction. Microsurgical training and a group practice model permit routine use of all autogenous tissue techniques. Office, operating room, and hospital teams must be assembled; these teams follow clinical pathways, which make the execution of reconstructive procedures consistent and efficient. The practice must implement a plan for physician and patient education. The practice must review clinical outcomes, making adjustments in operative techniques and pre- and postoperative clinical pathways so that the best results can be achieved with a low complication rate. Breast reconstruction is a core service of our practice. We have accrued an economy of scale including these features: intraoperative and clinical efficiency, low practice overhead costs, and a high patient satisfaction rate.

Keywords: Autogenous tissue; clinical pathways; efficiency.

Figure 1

A 33-year-old woman 2 years after immediate right breast reconstruction with a muscle-sparing free TRAM flap and left breast mastopexy.

Figure 2

A 51-year-old woman 1 year after immediate right breast reconstruction with a muscle-sparing free TRAM flap and right breast mastopexy. (A, B, C) Preoperative views. (D, E, F) Postoperative views.

Figure 3

A 46-year-old woman with a failed tissue expander implant 5 months after delayed left breast reconstruction with a muscle-sparing free TRAM flap and right breast mastopexy. (A, B) Preoperative views. (C) Preoperative view of abdominal wall; patient has a history of multiple surgical procedures. (D, E) Postoperative views.

Figure 4

A 38-year-old woman 6 months after delayed left breast reconstruction with a muscle-sparing free TRAM flap. (A, B) Preoperative views; note the radiation dermatitis of the left and central chest wall areas. (C, D) Postoperative views.

Figure 5

A 51-year-old woman 9 months after bilateral breast reconstruction with free DIEP flaps. (A, B) Preoperative views. (C, D) Postoperative views; the patient is 1 month status post—nipple-areola reconstruction.

Figure 6

(A–D) A 65-year-old woman 5 months after bilateral capsulectomy-implant removal with bilateral free DIEP flap reconstruction. The patient presented with capsular pain and contracture; she underwent bilateral subcutaneous mastectomies, through a Wise reduction pattern, followed by multiple implant reconstructions. Note the thin soft tissue envelope.

Figure 7

A patient with a left malignant phyllodes tumor who underwent a mastectomy, including a large portion of breast and chest wall skin, followed by immediate reconstruction with a muscle-sparing free TRAM flap. (A, B) Preoperative views. (C, D) Postoperative views.

Figure 8

(A) Preoperative and (B) 2-year postoperative views of a 38-year-old patient with left breast ductal carcinoma in situ (DCIS); the preoperative view shows the breast boundaries and skin-sparing pattern; the postoperative result shows the reconstruction with a free TRAM flap.

Figure 9

The venous microanastomosis set-up: the internal mammary and deep inferior epigastric vessels are immobilized in a double aneurysm clip; a running anastomosis is performed.

Figure 10

The microneurorrhaphy between the anterior branch of the fourth intercostal nerve and 11th intercostal branch of a DIEP flap; an nerve intubation technique using an arterial segment is shown.

Figure 11

A unilateral muscle-sparing free TRAM flap reconstruction complicated by necrosis of the native breast skin. (A) Preoperative view. (B) Postoperative view depicting native skin loss. (C, D) Long-term postoperative results following TRAM flap and native skin revision and nipple-areola reconstruction.

Figure 12

Partial dehiscence of a free TRAM donor site.

Figure 13

Decreases in reconstructive operative times follows implementation of surgical and operating room clinical pathways.

Figure 14

Decreases in flap ischemia times for three groups: 1996, 1999, and 2002.

Figure 15

A 28-year-old woman with severe symptomatic fibrocystic disease who underwent nipple-areola–sparing mastectomies and bilateral free DIEP flap reconstruction. (A) Preoperative view. (B) Postoperative view.