TITLE:

TITLE : =20 POST MASTECTOMY BREAST=20 RECONSTRUCTION &nbs= p; =20 =20 =20 LOOKING BACK = AND=20 MARCHING AHEAD.

AUTHORS =20 : =20 * = =20 BHATTACHARYA = S.

&nbs= p; =20 =20 ** =20 BHATNAGAR =20 S.K.

&nbs= p; =20 =20 *** =20 BHATNAGAR ANKUR

INSTITUION: =20 * =20 Lucknow Plastic Surgery, Lucknow India.

&nbs= p; =20 =20 ** =20 Department of Plastic Surgery, Lucknow. India.

&nbs= p; =20 =20 *** =20 Prof. King George=92s Medical University, Lucknow

&nbs= p; =20 =20 =20 India.

&nbs= p; =20 =20 =20 SMS Medical College, Jaipur

ADDRESS OF CORROSPONDENCE=20 :

&nbs= p; =20 =20 Dr.S.K. Bhatnagar F- 2314, Rajaji Puram, Lucknow- 226 017

email : =20 =20 sirajitb@sancharnet.in

&nbs= p; =20 =20 skbhatnagarlko@hotmail.com

SUMMARY:

The last two = decades has=20 seen a dramatic evolution in the quality, predictability and = complication rate=20 in post mastectomy breast reconstruction. Early detection, better = understanding=20 of the disease and better adjuvant therapy has prompted the surgical = oncologist=20 towards tissue conservation. Historical concerns that immediate breast=20 reconstruction may compromise tumour ablation, alter survival or impede=20 detection of recurrences, has been most convincingly addressed. Now we = know for=20 certain that the reconstructed breast tolerates Radiotherapy better than = skin=20 grafted chest wall.

Our=20 experience of Post Mastectomy Breast Reconstructions, using mostly TRAM = flap and=20 LD flap and sparingly Lateral Thoracic Region Flap, Inferior Gluteal = artery flap=20 and recently DIEP flap has over the last two decades helped us to evolve = a=20 method of symmetrical breast reconstruction if the uninvolved breast is = not too=20 big or too pendulous. Nipple areola reconstructions have also improved = all these=20 years from tattooing to nipple sharing to reconstruction with pigmented = skin but=20 nipple areola sparing mastectomies have made it possible to give = excellent=20 cosmetic results.

INTRODUCTION:

Even=20 though medical, surgical, and radiation therapy treatments for breast = cancer=20 have increased the number of breast-sparing procedures available, some = breast=20 cancer patients, particularly in India still require a mastectomy as an = ablative=20 mode of treatment. In addition, mastectomy for other diseases with no = concern=20 for long-term survival like Cystosarcoma Phylloides also adds to the = list of=20 indications for reconstruction. Breast reconstruction surgery involves = creating=20 a breast mound that comes as close as possible to the form and = appearance of the=20 natural breast. The goal is to create a breast mound that matches the = opposite=20 breast and to achieve symmetry. If both breasts have been removed, the = goal of=20 breast reconstructive surgery is to create both breast mounds = approximately the=20 size of the patient's natural breasts.

INDICATIONS AND=20 CRITERION:

In=20 general, all women undergoing a mastectomy are candidates for immediate = or=20 delayed breast reconstruction. However, there are criteria for selecting = the=20 best candidates for the procedure:

1. =20 The = size and=20 location of the cancer - which determines the amount of skin and tissue = to be=20 removed in the mastectomy - are primary factors when making = recommendations for=20 reconstruction.

2. =20 Whether tissue=20 has been damaged by radiation therapy or aging, and is not sufficiently = healthy=20 to withstand surgery.

3. =20 Other=20 considerations include:

potential for complications=20
patient's desires =
the amount of tissue removed = from the=20 breast
the health of the tissue at the = planned=20 operation site
whether radiation therapy is = part of=20 treatment
the patient's general health and = physique=20
past medical history =
co-existing illnesses =
other risk factors such as = cardiac=20 disease, diabetes mellitus, smoking, and obesity=20

TIMING OF BREAST=20 RECONSTRUCTION:

The=20 patient should ideally be educated and counseled in breast = reconstructive=20 possibilities prior to mastectomy, so that she can make the decision for = or=20 against reconstruction before going into surgery. Based on the personal = medical=20 history of each patient, a recommendation will be made for=20 either:

immediate=20 reconstruction = - reconstructive=20 surgery performed at the same time as mastectomy. =
delayed=20 reconstruction = =96 reconstructive=20 surgery is performed after recovery from the mastectomy and adjuvant=20 therapy.

The timing = should be=20 decided in close consultation between the patient, the oncologist and = the=20 reconstructive surgeon.

Immediate = Breast=20 Reconstruction (IBR) =96 There are = no evidences=20 to suggest that IBR, whether by prosthesis or by autogenous tissue, in = any way=20 causes delay in recurrent cancer detection or interferes in any way with = its=20 prognosis (Fraizer TG et. al, 1985). It however certainly lessens the=20 psychological trauma associated with mastectomy (Jamison et. al, 1978, = Maguire=20 et.al, 1978, Naguchi et. al, 1994). Historical concerns that IBR might=20 compromise the extent of tumour ablation, alter survival or impede with=20 detection of recurrences have not been realized (Trabulsy P.P et. al, = 1993). As=20 the postoperative complication rates after mastectomy alone and = mastectomy + IBR=20 have not been significantly different (Johnson C.H et. al, 1985), the = notion=20 that IBR might delay adjuvant therapy has also been conclusively = falsified.=20 Furthermore, IBR reduces the number of operations, thus saving time and = money=20 for the patient, and as complication rates of both IBR and delayed=20 reconstructions are not significantly different, whether by prosthesis = or by=20 autogenous tissue, it is being more and more=20 accepted.

Delayed=20 Breast Reconstruction (DBR)=20 =96 This can be performed after the skin flaps of mastectomy have healed = and=20 become supple, after the completion of adjuvant therapy or after 2 years = disease=20 free survival. Planning is better and so better symmetry is achieved = than in=20 IBR. The patient has more time to adjust to her diagnosis and recover = from=20 adjuvant therapy. She is = better=20 able to research her options, and to formulate realistic goals for=20 reconstruction. Some reconstructive surgery requires blood transfusions. = With=20 DBR, the patient can donate her own blood ahead of time (autologous=20 transfusion), and/or arrange to have family and friends donate blood for = her use=20 (directed donation).

TYPES = OF=20 RECONSTRUCTION

There are two basic types of = reconstructive=20 techniques: Reconstruction with Breast Implants and that with Autogenous = tissue.=20 The choice of one or other route is influenced by various = factors: the=20 patient's preference; surgeon's competence; the availability of = resources; short=20 and long term morbidity associated with these procedures; the need for = adjuvant=20 therapy especially radiotherapy; patient's fitness. With the = availability of=20 more surgical skills, resources towards reconstruction of the breast, = the=20 refinements in the techniques which limit the morbidity, the increase in = the use=20 of post mastectomy radiotherapy and the developments in anaesthesiology, = the use=20 of autologous reconstructions are on the rise.

Breast = Implants:

In=20 general, implant procedures take less time, and are less expensive than=20 autogenous tissue transfer. Implants are breast shaped pouches. They are = made of=20 silicone outer shells, which may be smooth or textured. These pouches = may be=20 silicone gel filled or saline filled. Consequently they may be a fixed = volume=20 type as the silicone gel filled ones or inflatable ones, which look like = tissue=20 expanders and hence can be inflated to achieve both symmetry with the = opposite=20 breast and patient=92s desires and expectations.

The=20 initial procedure for any implant insertion uses the mastectomy incision = to make=20 a pocket of tissue, usually underneath the chest wall muscle. In DBR, = the=20 mastectomy scar may be re opened and used for this purpose, or a more = cosmetic=20 incision may be made. The implant is inserted into the pocket; the skin = is=20 stretched as needed and sutured.

If=20 there is inadequate tissue to achieve the desired size, or a naturally = sagging=20 breast is desired, a tissue expander is used. It resembles a partially = deflated=20 balloon, with an attached valve or port through which saline can be = injected.=20 After the initial surgical incision is healed, the patient comes back = for=20 follow-up on a weekly or bi-weekly basis, to have small amounts of = saline=20 injected through the port site into the expander. Injections can = continue for=20 about six to eight weeks, until the preferred size is obtained. In some = cases it=20 may be overfilled, and later partially deflated to allow for a more = pliable,=20 natural result. The temporary tissue expander is now removed after = several=20 months and replaced with a permanent implant.

IBR surgery=20 using an implant takes approximately two to three hours, and usually = requires up=20 to a 4-5 days hospital stay. Implant insertion surgery, as part of DBR, = takes=20 one to two hours with even shorter hospitalization. The choice of volume = and=20 shape of the implant is critical. The pocket created to receive it must = be=20 tailored with care to prevent displacement.

Implants=20 have some unique problems that may develop. A thick scar, also called a = capsule,=20 forms around the implant, as part of the body's normal reaction to a = foreign=20 substance. Capsular contracture occurs in 10 =96 15% of the patients = when the scar=20 becomes firm or hardened. This may cause pain and/or change the texture = and=20 appearance of the breast. Implants can rupture and leak, deflate, or = become=20 displaced. The chances of capsular contracture or rupture increase with = the age=20 of the implant. These complications can usually be remedied surgically = by=20 loosening the capsule or removing and/or replacing the implant as = needed. There=20 is some evidence that using implants with textured surfaces may decrease = the=20 incidence of these problems, as is their placement in the sub-muscular = plane=20 (Grunber R.P, 1981). An implant tends to remain firm indefinitely. It = will not=20 grow larger or smaller as the woman's weight changes. Asymmetry can = develop if a=20 woman gains or loses a large amount of weight.

Autogenous=20 Tissue Reconstruction:

Consequent=20 to the controversies, which the breast implants have attracted somewhat=20 undeservingly, more and more breast cancer patients have opted for = autogenous=20 tissue reconstruction. More natural breast contour and symmetry with the = opposite breast can be achieved, in both shape and feel. Early detection = of the=20 cancer is resulting in skin sparing mastectomies without any added risk = of local=20 recurrences, now means that there is often enough skin envelope and = autogenous=20 soft tissue filling is all that is require, thus totally avoiding the = patch like=20 appearance of reconstruction.

Besides=20 patient preference, the other indications for autogenous tissue = reconstruction=20 are

=B7 =20 patients=20 planned for adjuvant loco-regional radiotherapy

=B7 =20 radiation=20 necrosis of chest wall

=B7 =20 recurrent=20 capsular contracture

=B7 =20 peri-prosthetic=20 infections

=B7 =20 Immune=20 deficiency status

Autogenous=20 tissues used in breast reconstruction can be either pedicled flaps or = free laps=20 (microvascular tissue transfer). They may be used alone or in = conjunction with=20 implants, and they may be myo-cutaneous flaps, adipo-muscular flaps or=20 fasciocutaneous flaps.

Myocutaneous=20 Flaps:

1. =20 Pedicled=20 =96

=B7 =20 Latissimus=20 Dorsi Myocutaneous Flap

=B7 =20 Transverse=20 Rectus Abdominis Myocutaneous Flap (TRAM flap)

2. =20 Microvascular=20 (free flaps):

=B7 =20 Deep=20 Inferior Epigastric Perforator Flap (DIEP flap)

=B7 =20 Inferior=20 Gluteal Artery flap

=B7 =20 Superior=20 Gluteal Artery flap

Fasciocutaneous=20 Flaps:

1. =20 Lateral=20 Thoracic Region Flap =96 along with implant (Fig 3 & = 4)

Latissimus=20 Dorsi Myocutaneous Flap: ( Fig 1 & 2)

For=20 patients undergoing tissue sparing mastectomy and desiring immediate=20 reconstruction, this flap, based on Thoracodorsal vessels, is the flap = of=20 choice. As there is not much adipose tissue between the muscle and the = skin, it=20 does not bring a lot of volume to the recipient site, but the latter can = be=20 provided by an implant. It is a useful practice to stitch the muscle in = the flap=20 to the lateral border of Pectoralis Major, in order to completely = envelope the=20 implant. After a total mastectomy however, the flap fails to provide = enough=20 volume, especially frontal projection, without an implant.=20

The=20 Latissimus Dorsi flap necessitates a change in position of the patient = after=20 mastectomy, but its harvesting is technically easy, less time consuming, = and=20 with limited blood loss. The skin paddle can be both oblique and = horizontal, but=20 it is the latter, which gives us a better donor scar easily hidden by = our=20 dresses. A tissue expander can increase the size of this flap and then = it can be=20 used for large radiation necrosis cases.

TRAM=20 Flap:

Since=20 its introduction by Hartrampf et.al in 1978, the TRAM flap has remained = the most=20 commonly used flap for breast reconstruction. The pedicled TRAM is = superiorly=20 based on Superior epigastric artery and vein and transports tissue = originating=20 from contralateral abdominal wall. This was then a revolutionary = concept, which=20 permitted a totally autologous reconstruction of the breast, while = utilizing the=20 excess in the abdominal pannus. It is of note that this method of = microsurgical=20 free tissue transfer superseded the published reports of pedicled = transfers=20 (Hartrampf et.al 1982, 1987). However, the pedicled transfers, gained = popularity=20 in the 80's due to the limitations of both availability and = predictability of=20 microvascular techniques.
The understanding of the vascular supply = to the=20 abdomen was the key to limiting the flap loss, partial or total. The = most=20 significant contribution was from the work of Taylor et al (1984). The = role of=20 subdermal plexus in the abdominal pannus was crucial to the design of = the flaps=20 from the abdomen.There are numerous articles discussing the vascular = anatomy of=20 the lower abdominal wall. Most of these dwell on the arterial anatomy = with=20 limited reference to the venous drainage. The work of de Costa et al = (1987) on=20 the venous drainage has provided us with some understanding in this = area. The=20 vascular supply of the abdominal wall is from the Deep Inferior = Epigastric=20 system, Superficial Inferior Epigastric system, Superior Epigastric = system and=20 the Intercostal vessels. The deep system is the most dominant and = consistent=20 arterial supply to the abdominal wall. The superior and Deep Inferior = Epigastric=20 systems arborise within the Rectus Abdominis and anastomose with each = other.=20 This anastomoses is at the supra umbilical level. There are large = perforating=20 vessels, arising from the Deep inferior Epigastric system, which pass = through=20 the Rectus muscle, anterior Rectus sheath and the abdominal fat, to = arborise in=20 a plane parallel to the skin, at a subdermal level. The perforators are = more=20 consistent around the umbilicus, within a concentric circle of 8 cms. = radius=20 around the umbilicus. The perforating vessels also proceed through the = Scarpa's=20 fascia and provide a network of anastomotic channels at this level. The = sub=20 dermal anastomosis is far more dominant between these two levels of = anastomoses,=20 and this is especially so across the midline. The Superficial Inferior=20 Epigastric system with its many anatomical variations also contributes = to the=20 subdermal plexus, as do the intercostal vessels.

The=20 Superior Epigastric system provides supply to the lower abdominal skin = and fat=20 through its anastomoses with the deep inferior system and the peri = umbilical=20 perforators. This leads to a fall in the arterial perfusion pressures in = the=20 subdermal plexus, when compared with the pressures of a flap supplied = through=20 the deep inferior system. Whereas the pedicled TRAM is based on the = Superior=20 Epigastric system, the Free TRAM and the DIEP flap are harvested on the = Deep=20 Inferior epigastric vessels. The advantages of the more robust perfusion = of this=20 tissue via the Deep Inferior Epigastric pedicle, as compared to the = Superior=20 Epigastric pedicle and the limitation of the abdominal wall morbidity = makes the=20 Free TRAM and DIEP flaps better than the pedicled TRAM (Grotting et.al, = 1989,=20 Feller, 1994 and Shusterman et.al, 1994)

The=20 Muscle sparing TRAM Flap: =20 In=20 an effort to limit the morbidity to the abdominal donor site many = refinements to=20 preserve more of the Rectus muscle have been designed. The = muscle-sparing TRAM=20 allows the retaining of a medial and a lateral strip of Rectus muscle = while=20 removing a small piece of the mid segment with the deep inferior = Epigastric=20 artery and vein. The assumption here is that the lateral slip of muscle = is=20 innervated and functional. However, contrary to this belief one = routinely=20 denervates a lateral slip while harvesting a muscle sparing TRAM in view = of the=20 fact the intercostal pedicles enter the muscle not along it's lateral = margin but=20 in it's posterior surface. In fact the entry point of the nerves and = vessels=20 from the intercostals is between the junction of the middle and the = lateral=20 segment of the muscle. This results in denervated muscle in this=20 area.

DIEP=20 Flap:=20 (Fig 5 & 5A)

Since=20 the first description of a perforated base flap from the lower abdomen = by=20 Koshima et.al 1n 1989, there have been numerous publications (Allen = et.al 1994,=20 Blondeel et.al 1997) and DIEP flap reconstruction of the breast is today = considered the gold standard in reconstruction. This has been refined to = minimize morbidity to the abdomen while the predictability of the = transfer has=20 increased. As with other perforator-based flaps, pre-operative = assessment of the=20 perforators facilitates the identification of the perforators = pre-operatively.=20 Although most people use a handheld Doppler probe to do this, some = authors have=20 recommended coloured Doppler mapping of the abdominal wall as a routine. = Although experience of the surgeon helps in deciding which perforator to = choose,=20 it is usual to choose the largest of the perforators identified as they = exit=20 through the anterior Rectus sheath. These perforators may be from the = medial or=20 lateral branch of the deep inferior Epigastric arteries. It is usual to = find=20 them close to the umbilicus. Choice of a perforator at the lower part of = the=20 flap limits the length of the Deep Inferior Epigastric pedicle. Hence, = the more=20 cranial the perforator is, the longer the length of the vessel = available.=20 Further to identification of a perforator, the Rectus sheath is = carefully opened=20 and a course of the perforator is traced through the=20 muscle.

As=20 with most perforator flaps trans-mural dissection is the most difficult = part of=20 the procedure. This involves dissection of the muscle fibers close to = the=20 perforator in order to allow a tunnel to be created through which the = source=20 vessel (DIEA and V) could be reached. Twitching of the muscle is a = constant=20 problem in these cases. Instillation of Lignocaine over these fibers = prior to=20 dissection helps to suppress twitching in the muscle. The initial part = of the=20 dissection involves elevation of the lateral component of the muscle = away from=20 the perforators. This allows the dissection of the perforator and = identification=20 of its route through the muscle without having to elevate the = contra-lateral=20 side. The next step of the dissection would be to free the perforator = from the=20 medial segment of the muscle. Damage to the fine branches of the = perforating=20 Venae Commitantes is of great concern in the dissection of the = perforator=20 complex through the muscle.
Once the posterior Rectus base is free = there are=20 three ways to proceed with the dissection. Dissection of the Deep = Inferior=20 Epigastric artery and it's branches along the posterior surface of the = Rectus=20 muscle could be undertaken either through a linear opening in the muscle = (trans-mural), or, through mobilization of the muscle off the posterior = Rectus=20 sheath via the medial route, or through a lateral route. Dissection = through the=20 lateral border of the muscle has to be undertaken very carefully in view = of the=20 intercostal nerves entering along the side. Especially denervation of = the muscle=20 below the arcuate line would produce at least an abdominal bulge despite = the=20 fact that most of the muscle or all of the muscle is left behind.Closure = of the=20 abdomen is by suturing the anterior Rectus sheath only. No mesh repair = is=20 required in this instance. In view of the fact that anterior Rectus = sheath is=20 not resected, there is limitation of the shift of the umbilicus to one = side or=20 the other which is quite common when forming a standard TRAM = flap.
The=20 pedicle in a DIEP flap is long and is of a very small caliber close to = its entry=20 point into the flap, the problem of torsion and avulsion are higher in = these=20 flaps compared to the conventional free tissue transfers. It is = essential that=20 the torsion be corrected prior to inserting the flap. It is common = practice to=20 use the thoracodorsal pedicle if one was doing an immediate = reconstruction using=20 a skin sparing mastectomy technique. If a delayed reconstruction is = undertaken=20 it is more often the internal mammary that is the pedicle of = choice.
There=20 has been much debate about the use of either recipient vessels. The = proponents=20 of the internal mammary vessels as the choice recipient suggest that = this allows=20 for the medialisation of the breast mound and that this artery has = higher=20 perfusion pressures. However, approach to this pedicle may be difficult = if the=20 mastectomy was carried out through a peri areolar incision. Further, if = the=20 axillary clearance had been carried out through a separate axillary = access, this=20 allows excellent exposure to the thoracodorsal pedicle. With longer = pedicle=20 lengths available with a DIEP flap, it is possible to place the flap = more=20 medially, and provide an acceptable result.

The=20 Survival of both TRAM and DIEP Flaps can be enhanced to near perfection = by=20 supercharging the flap or delaying the flap thereby the vascular input = is given=20 a boost.

Superior=20 and Inferior Gluteal Artery Flap: (Fig 6 & 7)

These=20 are free myo-cutaneous units, the superior or inferior part of gluteus = maximus=20 muscle along with its overlying fate and skin paddle can be harvested on = either=20 the superior or the inferior gluteal artery. The superior Gluteal artery = flap is=20 technically demanding because of a very short vascular pedicle. The = inferior=20 gluteal artery flap is technically simpler, has a longer vascular = pedicle, can=20 transport more soft tissue and the donor site scar can lie hidden in the = inferior gluteal crease with negligible functional morbidity (Kroll S.S. = et.al,=20 1991).

Lateral=20 Thoracic Region Flap: (Fig 3 & 4)

The=20 lateral thoracic region flap (Bhattacharya et.al, 1990a and b) is a=20 fasciocutaneous flap from the lateral chest wall, vascularized by two or = three=20 of these vessels =96 thoracodordal, lateral thoracic, accessory lateral = thoracic=20 and fasciocutaneous branch of the pectoral branch of the = acromino-thoracic axis.=20 Being devoid of muscle, it can only resurface large chest wall defects = of=20 mastectomy or radiation necrosis, but can not add bulk to the breast. It = however=20 forms an excellent cover for a silicon prosthesis. Its donor site can be = primarily closed, and it remains hidden in common Indian=20 dresses.

Nipple-areola=20 reconstruction: (Fig 8)

Nipple-areola=20 reconstruction is safe, simple and predictable. Although an optional = procedure,=20 it significantly improves patients' satisfaction with breast = reconstruction. It=20 is being performed as a second operation to ensure symmetry of nipple = position,=20 a fundamental requirement for a good result. Areola is flat and is = reconstructed=20 by tattooing, using banked areola (in Cystosarcoma Phylloides), areola = sharing=20 with contraclteral breast, and grafting hyperpigmented skin from labia = minora or=20 medial thigh. The most challenging aspect of nipple reconstruction is = the=20 creation of a 3-dimensional projecting structure with texture, = dimensions, and=20 contour similar to the contralateral nipple. Moreover, the = reconstruction has to=20 last. Nipple reconstruction enhances the realism of breast = reconstruction, and=20 the more projecting and 3-dimensional the structure, the more lifelike = the=20 reconstruction. Various options have included banking, nipple sharing, = grafting,=20 and local flaps. Nipple reconstruction with local flaps is achieved with = various=20 techniques, each with its own proponents and benefits. These include the = skate=20 flap, bell flap, double opposing tab flap, star flap, top-hat flap, twin = flap,=20 propeller flap, S flap, rolled dermal-fat flap, and autologous = cartilage.=20 Successful=20 nipple-areola reconstruction is expected to maintain nipple projection = and=20 areola size; however, longevity of this reconstruction is highly = variable and is=20 influenced by factors such as scar contracture, tissue thickness, = radiation, and=20 trauma.

CONCLUSION

Over the past 25 = years, surgical=20 reconstruction of the breast following mastectomy has become an = important aspect=20 of the cancer patient's rehabilitation process. While the surgical = emphasis=20 remains on a cure for the cancer, experience with breast reconstruction = has not=20 demonstrated any increased rate of cancer recurrence, even when = reconstruction=20 is performed immediately following tumor resection. Advances in surgical = technique and biotechnology have made post-mastectomy reconstruction = possible.=20 The development of silicone gel and saline-filled implants as well as = tissue=20 expanders has revolutionized breast reconstruction. The elucidation of=20 musculocutaneous flaps now provides the surgeon with the ability to = transfer=20 adequate quantities of vascularized tissue to reconstruct the surgical = defects.=20 The advent of microsurgical techniques has provided an additional = reconstructive=20 option, with free tissue transfer allowing the plastic surgeon to move=20 musculocutaneous flaps from remote or distant sites to reconstruct the = defect=20 with negligible donor site morbidity.

The=20 search for the ultimate flap donor site for the reconstruction of the = breast has=20 come to rest in the lower abdomen. Scott Spear in his textbook =93The = Surgery of=20 the Breast=94 says ' the only procedure that I can imagine that will = ever replace=20 this procedure (i.e. The DIEP flap) would be the transfer of homologous = tissue=20 from a tissue bank, where there is no morbidity whatsoever associated = with the=20 operation'. The subtle refinements to increase the ease of transfer and=20 limitation of the donor morbidity will continue. The wider acceptance of = microvascular procedures to reconstruct the breast is only limited by = the=20 availability of skills and resources.

BIBLIOGRAPHY

1. Thomas G.Frazier, MD.FACS and R.Bassett Noone = MD.FACS :=20 An objective analysis of immediate simultaneous recontruction in the = treatment=20 of carcinoma of the breast. Cancer 55: 1202, 1985

2.=20 Naguchi M.Kitagawa H,Kinoshitak, Earashi M, Miyazaki I,Tatsukuchi S, = Saito=20 Y,Mizukami Y,Nonomura A , Nakamura S,et al : Psychological and cosmetic = self=20 assessment of breast consering therapy compared with mastectomy and = immediate=20 breast reconstruction.J.surg.Oncol.54 (4): 260 , 1994.

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Grunber=20 RP: Breast Reconstruction following mastectomy: A comparison of = submuscular=20 and subcutaneous techniques. Plast and Reconstr Surg 67:312, 1981=20
Jamison KR, Wellisch DK, = Pasnau RO.=20 Psychological aspects of mastectomy; Women's perspective. Am J=20 Psychiatry 1978; 135:432-6.=20
Maguire=20 GP, Lee EG, Bevington DJ, Kucherman SC et al. Psychiatric problems in = the=20 first year after mastectomy. Br J Med 1978;1:963-5. =20
Hartampf CR Jr, Scheflan M, = Black PW.=20 Breast reconstruction with a transverse abdominal island flap. = Plast=20 and Reconstr Surg 1982; 69:216-21=20
Hartrampf CR Jr, Benett GK.=20 Autogenous tissue reconstruction in the mastectomy patient. A = critical=20 review of 300 patients. Ann Surg 1987;205:508-14=20
Taylor=20 GI, Corlett RJ, Boyd JB. The versatile deep inferior epigastric flap. = Br J=20 Plasr Surg 1984;37:330-50.=20
Carramenhae=20 Costa MA, Carriquiry C, Vasconez LO. An anatomical study of the venous = drainage of transverse rectus abdominis musculo cutaneous flaps. Plast = and=20 Reconstr Surg 1987;79:208.=20
Grotting=20 JC, Urist MM, Maddox WA, Vasconez LO. Conventional TRAM flap versus = free=20 microsurgical TRAM flap for immediate breast reconstruction. Plast and = Reconstr Surg 1989;83:828-97=20
Feller=20 AM. Free TRAM. Results and abdominal wall function. Clin Plast Surg=20 1994;21:223-38.=20
Shusterman MA, Kroll SS, = Miller MJ, et=20 al. The free transverse rectus abdominis flap for breast=20 reconstruction-one center's experience with 211 consecutive cases. Ann = Plast=20 Surg 1994;32:234-45=20
Koshima=20 I. Soeda S: Inferior epigastric artery skin flaps without rectus = abdominis=20 muscle. Br J Plast Surg 1989;42:645-8.=20
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Blondeel=20 N, Vanderstraeten GG, Monstrey SJ, Van Landuyt K, et al. The donor = site=20 morbidity of free DIEP flaps and free TRAM flaps for breast = reconstruction. Br=20 J Plast Surg 1997;50:322-30.=20
Kroll=20 SS et.al: The oncologic risks of skin preservation at mastectomy when = cmbined=20 with immediate reconstruction of the breast. Surg Gynaecol Obstet = 172:17, 1991=20
Bhattacharya=20 S, Bhagia SP, Bhatnagar SK, Abdi SM and Chandra R: The anatomical = basis of=20 Lateral Thoracic flap: European J.Plast Surg:13 238-240, 1990a=20
Bhattacharya=20 S, Bhagia SP, Bhatnagar SK and Chandra R: The Lateral Thoracic Region = Flap:=20 British J. Plast Surg, 43: 162-168, 1990b =