Breast Reconstruction Surgery Overview

Preoperative Considerations

• Chemotherapy regimens must be identified preoperatively.
• Anesthetic plans must address potential effects of these medications on the patient's physiology and response to anesthetic agents.
• Patient's medical history, including any genetic mutations like BRCA1/2, is crucial for risk assessment and personalized treatment planning.
• Comorbidities, such as diabetes, renal failure, stroke, liver disease, and prior cancer, significantly increase breast cancer mortality. Advanced age also increases mortality. Over 45% of new breast cancer cases occur in women over 65.
• Smoking and obesity increase flap failure and impair wound healing during reconstruction.
• Obesity, a significant comorbidity, is linked to increased estrogen production, potentially increasing breast cancer risk, and impacting anesthesia/surgery due to multiple pathophysiologic effects on:
  • Cardiovascular system: hypertension, dyslipidemia, concentric hypertrophy, coronary artery disease, decreased myocardial performance, increased oxygen demand, ischemia, infarction, heart failure.
  • Respiratory system: reduced chest wall compliance, restrictive lung disease, decreased lung capacity, rapid hypoxemia, premature airway closure. Redundant airway tissue can lead to ventilation or intubation difficulty. Obstructive sleep apnea and hypercarbia are also linked to obesity. Precise positioning and preoxygenation are crucial.
  • Endocrine system: increased risk of non-insulin-dependent diabetes, altered glucose metabolism, impaired insulin receptor sensitivity. Preoperative blood glucose assessment is critical.
  • Gastrointestinal system: decreased gastric emptying, gastroesophageal reflux disease. Preoperative prophylaxis (gastrokinetic agents, histamine receptor antagonists, nonparticulate antacids) for gastric aspiration risk.
  • Hepatic system: nonalcoholic fatty liver disease, hepatocyte infiltration, altered liver function tests. Hepatic dysfunction impacts anesthetic metabolism.

Surgical Technique Considerations

• Anesthesia considerations depend on the type of breast reconstruction.
• The chosen surgical approach is tailored to each patient's specific needs and preferences.
• Reconstruction techniques include prosthetic implant-based and autologous tissue-based options.
• The choice of technique considers several factors: cancer type/location, extent of resection, patient's medical/surgical risks, desired breast size/shape, and patient preference.
• Implant-based reconstruction can be a single-stage or two-stage procedure using standard or adjustable implants, or combined with autologous tissue.
• Single-stage reconstruction is ideal for smaller breasts and skin-sparing techniques, promoting symmetry. Two-stage reconstruction uses a tissue expander initially, then a permanent implant. A partial or complete capsulotomy can enhance breast projection and prevent ptosis.
• Combined implant and autologous tissue reconstruction facilitates complete wound closure, often utilizing latissimus dorsi myocutaneous flaps.
• Autologous tissue reconstruction provides a more natural look and feel, but is a more complex procedure, potentially requiring longer surgical times and convalescence. Common flaps include latissimus, TRAM, and DIEP flaps.

Comorbidities and Risk

• Patients with comorbidities (e.g., hypertension, diabetes, dyslipidemia, active smoking, obesity) are at higher risk for complications during and after breast reconstruction surgery.
• Family history, nulliparity, early menarche, advanced age, obesity, and personal history of breast cancer are risk factors for breast cancer.
• Women with BRCA1 or BRCA2 mutations have a significantly increased risk of breast cancer (40%-85%).
• Increased Body Mass Index (BMI), smoking, and radiation therapy increase the risk of TRAM flap failure.

Postoperative Complications

• Postoperative complications can include hematoma, seroma, infection, skin flap necrosis, and implant exposure, potentially necessitating reoperation for drainage or debridement.
• Prophylactic mastectomies are performed for women with certain genetic mutations, such as BRCA1 or BRCA2.
• TRAM flap hypoperfusion and failure can lead to surgical flap debridement or hematoma evacuation.
• Implant-based procedures typically last 2 to 9 hours (mean 4 hours).
• TRAM flaps require 5 to 12 hours (mean 7.5 hours).

Anesthetic Management Considerations

• Chemotherapeutic agents like bleomycin, Adriamycin, methotrexate, and tamoxifen impact anesthetic plans.
  • Bleomycin: Pulmonary toxicity. Avoid FiO2 >30%. Chest x-ray, arterial blood gas, and pulmonary function tests as indicated.
  • Doxorubicin: Cardiac toxicity (dysrhythmias, ECG changes, cardiomyopathy, heart failure). Increased risk with higher doses, prior radiotherapy, and female gender. Myelosuppression (thrombocytopenia, anemia, leukopenia). ECG, complete blood count (CBC) are necessary.
  • Methotrexate: Renal and hepatic dysfunction. Anemia. CBC, blood urea nitrogen (BUN), creatinine, liver function tests are required.
• IV placement considerations: Avoid mastectomy side for IV and blood pressure monitoring to prevent lymphedema. Consider alternative sites like lower extremities (especially for non-diabetic patients). Bilateral mastectomies/lymph node dissections require external/internal jugular cannulation.
• Blood pressure assessment: arterial line indicated for patients with heart disease, anemia, bilateral lymphedema, or other comorbidities for accurate monitoring. Consider lower extremity BP cuffs for upper extremity contraindications.
• Preoperative sedation: exercise caution in preoperative chest marking to prevent airway obstruction and hypoxemia. Excessive sedation may induce airway obstruction due to obesity-related airway changes.

Intraoperative Considerations

• Blood pressure control: Maintaining mean arterial pressure within 20% of preoperative values is crucial for adequate flap perfusion. Avoid extremes – hypertension leads to excessive bleeding, hypotension to hypoperfusion. Administer fluids, not vasopressors, to manage hypotension. Serial hemoglobin checks ensure adequate oxygen-carrying capacity. Blood, fresh-frozen plasma, platelets are given based on preoperative status, hemodynamic stability, lab values, and surgical hemostasis.
• Volume replacement: Albumin may be preferable to large volumes of crystalloid.
• Autologous blood donation/transfusion: Autologous blood donation is associated with a higher rate of postoperative transfusion most likely due to relative preoperative anemia. This type of donation is infrequent for reconstructive breast surgery.
• Nitrous oxide: Avoid nitrous oxide during TRAM flap reconstruction to prevent abdominal distention. This is vital for optimal cosmetic results.
• Normothermia: Maintain normothermia, as hypothermia restricts blood supply to the flap, compromises hemostasis causing hematomas, increases myocardial oxygen demand, and delays anesthetic recovery.
• Dextran: Dextran, while minimizing microvascular thrombus formation, carries risks of coagulopathy and anaphylaxis. It is not routinely used intraoperatively. The alternative approach is to prioritize implant-based techniques for high-risk patients.
• Patient positioning: Use supine position with mild flexion for mastectomies and reconstructions. Switch to lateral decubitus for latissimus dorsi flap harvest. Move to sitting position to assess breast symmetry after implant or flap construction. Secure both arms to prevent brachial plexus or ulnar nerve injury. Ensure endotracheal tube stabilization to prevent accidental extubation or right mainstem intubation.

Postoperative Considerations

• Postoperative pain management: Patient-controlled analgesia, thoracic epidural, intercostal nerve block, thoracic paravertebral nerve block, IV narcotics, and oral pain medication. Paravertebral block enhances recovery and provides analgesia throughout the immediate postoperative period.
• Long-term care: Subsequent surgeries may be needed due to implant issues (contractures, migration, leakage, rupture), scar revision, or nipple reconstruction. Advancements in nipple reconstruction include monitored anesthesia care for tissue reconfiguration and tattooing to match the areola color.

Explore essential considerations for breast reconstruction surgery, including preoperative, surgical, and postoperative factors. This quiz covers anesthesia considerations, the impact of comorbidities, and potential complications that may arise during and after the procedure.