Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1054_Библиотеки_им_академика_М_И_Перельмана
.pdf
218
https://t.me/medicina_free
S. H. Ali and R. Parmeshwar
While it is still a standard practice to decide
the implants on the basis of measurements taken,
there are now 3D cameras with integrated software which can aid in deciding the implant style
and volume and also give a visual impression of
the likely appearance of the reconstructed or augmented breasts. They should be an adjunct to surgeons’ own assessment rather than a
substitute. The same applies to the practice of
using weight of the mastectomy specimen
andcertain mathematics formulae by some surgeons to calculate implant volume.
28.7 Complications Related
toSilicone Implants
Implant based reconstructions, although technically simpler to an autologous reconstruction to
perform, a consistently good and lasting outcome
can be hard to achieve. This is related to use of
prosthetic material as opposed to autologous tissue even though the results are now much
improved because of the use of biological meshes
[20]. A total subcutaneous placement is associated with very high risk of failure and is not recommended [21].
28.7.1 Early Complications
Seroma
Infection
Skin necrosis
Implant loss
In the rst few weeks, the seroma and infection are the biggest challenges in implant based
reconstruction [22–24]. These two often go
together and can be minimized by appropriate
case selection and meticulous surgical technique
(careful tissue handling, judicious use of diathermy, minimizing the use of retractors, thorough wash of pocket, use of drains and
prophylactic antibiotics). Theatre environment
(keeping patient warm, use of masksbyeveryone
inside the theatre, minimizing movement in and
out of theatre and number of people within theatreand preferable use of laminar ow) and care-
ful implant and biological mesh selections are
also very important. Most of the large series on
implant based reconstruction will show an
implant loss rates of at least5–10%, overall complication rates of 25% with a90day readmission
rates of about 10% and reoperation rates
of 10–15%. Skin necrosis has a direct relationship with smoking, diabetes and high implant
volume [19, 25–27].
28.7.2 Delayed Complication
Asymmetry
Rotation
Migration
Leak/rupture
Capsular contracture
Breast associated anaplastic large cell lymphoma
(BIA ALCL)
The long-term issues with implant based
reconstruction are related to changes happening
in the reconstructed breast as well as in the host.
Implants can also rotate, migrate, leak or rupture. Rotation of an anatomical implant can lead
to altered shapes of the reconstructed breasts.
Even inthe absence of any compromise in position or integrity of the implant, asymmetry is
quite common in unilateral implant based breast
reconstruction and tends to get more obvious
with time mainly owing to capsulation and also
because of change in body weight and ageing of
the contralateral normal breast.
Gel bleed is a phenomenon wherein the silicone gel (broken down short chain PDS) leaks
through the silicone elastomer shell which
behaves like a semi-permeable membrane. This
differs from implant rupture as gel bleed is microscopic leakage through an intact implant shell.
Both gel bleed and implant rupture can cause silicone migration to liver, lymph nodes, upper
limbs, pleural uid and synovium. Gel bleed in
most cases are just an incidental intra-operative
nding and on its own does not require intervention. Implant rupture on the other hand usually
occurs a decade after implantation (10–15years)
with incidence increasing with implant age.
28 Silicone Gel Breast Implants
https://t.me/medicina_free
Fig. 28.7 Ultrasound scan of axilla showing sand-storm echo pattern
219
Fig. 28.8 MRI scan of breasts showing gel bleed (left) and intracapsular rupture (right)
Diagnosis of implant rupture on clinical examination is challenging however most common presentations are pain, loss of breast shape,
asymmetry, inammation, swelling and mass formation. Physical examination alone fails to diagnose implant rupture in more than 50% of cases.
A leaked silicone implant can cast a typical
“sandstorm” echo pattern on ultrasound
(Fig.28.7) scan but in doubtful cases MR scan
(Fig.28.8) can be helpful which provides a better
denition of the shell and also whether the leak is
intra-capsular or extra-capsular. The latter obviously requires more urgent attention because of
the risk of silicone granulomas formation in the
parenchyma or lymphatic uptake into the axillary
lymph nodes.
The most common and well-known delayed
complication after breast implantation is capsular
contracture occurring in up to 30 per cent of
patients [28] and hence the need for revision surgery is not uncommon. The trigger for capsular
contracture remains uncertain. Bacteria invading
the surface of implants (biolms) may lead to
inammation of the adjoining tissue, causing
brosis and capsular contracture. The other risk
factors are axillary dissection and for obvious
reasons, radiotherapy to the reconstructed breast
is a major risk factor in the development of cap-
220
https://t.me/medicina_free
Table 28.2 Baker’s grading of capsular contracture
Grade Breast Firmness Implant Implant visibility
I Soft Not palpable Non-visible
II Minimal Palpable Non-visible
III Moderate Easily palpable Distortion visible
IV Severe and painful Hard, tender, cold Distortion marked
From Baker JL Jr.: Augmentation mammoplasty. In Owsley JQ Jr., Peterson RA, editors: Symposium on aesthetic
Surgery of the Breast, 1978, St Louis, 1978, CV Mosby
S. H. Ali and R. Parmeshwar
sular contracture and that too of grade 3/4.
Positioning of implants (sub-glandular or submuscular) or even chemical interference were
thought to be possible factors [29]. The Baker
classication is a common method to assess clinically increasing levels of capsular contracture
(Table28.2).
Breast ALCL occurs in the implant capsule
itself. A typical presentation is the development
of seroma usually a decade after silicone implant
placement (range 1–32years) [30]. Other notable
symptoms are presence of a palpable lump or
Bakers capsular contracture Grade III or
IV. Systemic symptoms are rare. Triple assessment with clinical examination, imaging and
cytology play a vital role in diagnosis. The diagnosis, however, can be difcult in the absence of
a mass. It is quite possible that the actual incidence of BIA ALCL could be higher than
reported. It is important to have a high index of
suspicion in appropriate cases. In suspected cases
of ALCL, clinicians and radiologists must specifythe suspicion and request for cytological evaluation of seroma uid for cluster of differentiation
(CD30) and anaplastic lymphoma kinase (ALK)
markers. Any capsulectomy performed for revision of reconstruction must be subjected to histological examination. In cases of diagnosed ALCL
majority of the women responds to surgery
(removal of implant and capsulectomy), chemotherapy and radiotherapy and the prognosis is
generally good.
28.8 Summary
Silicone implant based breast reconstructions are
the mostcommon technique in the western world
and its use seems to be on the rise because of the
developments around biological meshes which in
turn have lead to improved aesthetic outcomes.
These implant based reconstructions are easier to
perform and are far less invasive compared to the
autologous reconstructions such as a LD ap or a
free DIEP ap. They also offer quicker recovery
and avoid donor site related morbidities.
However, they are not free from immediate and
long-term problems and are certainly associated
with high incidence of readmission, reoperation
andneed for revisions.
They continue to bethe focus of passionate
debates because of their association with ALCL
and some of the less clear systemic manifestations. A careful patient selection, good surgical
technique with sound knowledge of appropriate
implants and the issues associated with them are
crucial to achieving a consistent good outcome.
It is absolutely essential to provide full information to the patient and make a truly shared
decision.
References
1. Goldwyn RM. Vincenz Czerny and the beginning of breast reconstruction. Plast Reconstr Surg.
1978;65:673–81.
2. Milojevic B. Complications after silicone injection
therapy in aesthetic plastic surgery. Aesthet Plast
Surg. 1982;6(4):203–6. https://doi.org/10.1007/
bf01570647.
3. Cronin TD, Gerow FJ.Augmentation mammoplasty:
new “natural feel” prosthesis. Excerpta Med Int Congr
Ser. 1963;66:41–9.
4. Estes AC. A brief history of breast implants. The
Atlantic 2013. https://www.theatlantic.com/technology/
archive/2012/01/brief- history- breast- implants/333230/
5. Fruhstorfer BH, Hodgson ELB, Malata CM. Early
experience with an anatomical soft cohesive silicone
gel prosthesis in cosmetic and reconstructive breast
implant surgery. Ann Plast Surg. 2004;53:536–42.
28 Silicone Gel Breast Implants
https://t.me/medicina_free
221
6. Becker H. Implant and inating construction. US
patent 4,944,749a. 1988. https://patents.google.com/
patent/us4944749a/en
7. Calobrace MB, Capizzi PJ.The biology and Evolution
of cohesive gel and shaped implants. Plast Reconstr
Surg. 2014;134(1S):6S–11S. https://doi.org/10.1097/
PRS.0000000000000347.
8. Tanne JH. FDA approves silicone breast
implants 14 years after their withdrawal. BMJ.
2006;333(7579):1139. https://doi.org/10.1136/
bmj.39048.332650.db.
9. Martindale V, Menache A. The pip scandal: an
analysis of the process of quality control that
failed to safeguard women from the health risks.
J R Soc Med. 2013;106(5):173–7. https://doi.
org/10.1177/0141076813480994.
10. Swerdlow SH, Campo E, Pileri SA, et al. The
2016 revision of the World Health Organization
classication of lymphoid neoplasms. Blood.
2016;127(20):2375–90.
11. Jones JL, Hanby AM, Wells C, Calaminici M,
Johnson L, Turton P, Deb R, Provenzano E, Shaaban
A, Ellis IO, Pinder SE.National co-ordinating committee of breast pathology. Breast implant-associated
anaplastic large cell lymphoma (BIA-ALCL): an
overview of presentation and pathogenesis and guidelines for pathological diagnosis and management.
Histopathology. 2019;75(6):787–96. https://doi.
org/10.1111/his.13932.
12. Hu H, Johani K, Almatroudi A, et al. Bacterial biolm infection detected in breast implant associated
anaplastic large cell lymphoma. Plast Reconstr Surg.
2016;137(6):1659–69.
13. Bjarnsholt T, Jensen PØ, Moser C, Høiby N, editors.
Biolm infections. NewYork: Springer; 2011.
14. Roger NW, Ross LS, Renee MB, Amy KM, Mark
AC. Risk of breast implant bacterial contamination
from endogenous breast Flora, prevention with nipple shields, and implications for biolm formation.
Aesthet Surg J. 2012;32(8):956–63. https://doi.org/1
0.1177/1090820X12456841.
15. Headon H, Kasem A, Mokbel K.Capsular contracture
after breast augmentation: an update for clinical practice. Arch Plast Surg. 2015;42(5):532–43. https://doi.
org/10.5999/aps.2015.42.5.532.
16. Groth AK, Graf R.Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) and the textured
breast implant crisis. Aesthet Plast Surg. 2020;44:1–
12. https://doi.org/10.1007/s00266- 019- 01521- 3.
17. Brown M, Shenker R, Silver S.Cohesive silicone gel
breast implants in aesthetic and reconstructive breast
surgery. Plast Reconstr Surg. 2005;116:768–79.
https://doi.org/10.1097/01.prs.0000176259.66948.e7.
18. Atlan M, Bigerelle M, Larreta-garde V, et al.
Characterization of breast implant surfaces, shapes,
and biomechanics: a comparison of high cohesive anatomically shaped textured silicone, breast
implants from three different manufacturers. Aesthet
Plast Surg. 2016;40:89–97. https://doi.org/10.1007/
s00266- 015- 0603- 8.
19. Chandarana M, Harries S, Parmeshwar R.Prepectoral
immediate implant-based reconstruction using
Braxon® acellular dermal matrix – multicentre
study from the United Kingdom. Eur J Surg Oncol.
2020;46(6):1–2. https://www.ejso.com/article/
s0748- 7983(20)30157- 8/fulltext
20. Salzberg CA.Nonexpansive immediate breast reconstruction using human acellular tissue matrix graft
(alloderm). Ann Plast Surg. 2006;57(1):1–5. https://
pubmed.ncbi.nlm.nih.gov/16799299/
21. Schlenker JD, Bueno RA, Ricketson G, Lynch
JB. Loss of silicone implants after subcutaneous
mastectomy and reconstruction. Plast Reconstr
Surg. 1978;62:853–61. https://pubmed.ncbi.nlm.nih.
gov/715039/
22. Chatterjee A, Nahabedian MY, Gabriel A, Macarios
D, Parekh M, Wang F. Grifn l, Sigalove S. early
assessment of post-surgical outcomes with prepectoral breast reconstruction: a literature review and
meta-analysis. J Surg Oncol. 2018;117(6):1119–30.
https://pubmed.ncbi.nlm.nih.gov/29346711/
23. Berna G, Cawthorn SJ, Papaccio G, Balestrieri
N.Evaluation of a novel breast reconstruction technique using the Braxon acellular dermal matrix: a
new muscle-sparing breast reconstruction. ANZ J
Surg. 2017;87(6):493–8. https://pubmed.ncbi.nlm.
nih.gov/25266930/
24. Vidya R, Berna G, Sbitany H, Nahabedian M, Becker
H, Reitsamer R, Rancati A, Macmillan D, Cawthorn
S. Prepectoral implant-based breast reconstruction: a joint consensus guide from UK, European
and USA breast and plastic reconstructive surgeons.
Ecancermedicalscience. 2019;13:927. https://asso-
ciationofbreastsurgery.org.uk/media/65096/ppbrguidelines.pdf
25. Li L, Yonghui S, Bingqiu X, Xiaoyan H, Weiru
C, Jianjing H, Yingying Z, Jinhui T, Jia W, Jiong
W. Comparison of prepectoral and sub pectoral
breast reconstruction after mastectomies: a systematic review and meta analysis. Eur J Surg Oncol.
2019;45(9):542–1550. https://www.sciencedirect.
com/science/article/pii/s0748798319304536#!
26. Li Y, Xu G, Yu N, Huang J, Long X. Prepectoral
versus sub pectoral implant-based breast reconstruction: a meta-analysis. Ann Plast Surg. 2020;10:1097.
https://journals.lww.com/annalsplasticsurgery/
abstract/9000/prepectoral_versus_subpectoral_
implant_based.96778.aspx
27. Vidya R, Masià J, Cawthorn S, Berna G, Bozza F,
Gardetto A, Kołacińska A, Dell’antonia F, Tiengo C,
Bassetto F, Caputo GG, Governa M.Evaluation of the
effectiveness of the prepectoral breast reconstruction
with Braxon dermal matrix: rst multicenter European
report on 100 cases. Breast J. 2017;23(6):670–6.
https://pubmed.ncbi.nlm.nih.gov/28481477/
28. Ersek RA. Rate and incidence of capsular contracture: a comparison of smooth and textured
silicone double-lumen breast prostheses. Plast
Reconstr Surg. 1991;87(5):879–84. https://doi.
org/10.1097/00006534- 199105000- 00012.
222
https://t.me/medicina_free
S. H. Ali and R. Parmeshwar
29. Embrey M, Adams EE, Cunningham B, Peters W,
Young VL, Carlo GL.A review of the literature on the
etiology of capsular contracture and a pilot study to
determine the outcome of capsular contracture interventions. Aesthet Plast Surg. 1999;23(3):197–206.
https://doi.org/10.1007/s002669900268.
30. Ye X, Shokrollahi K, Rozen WM, Conyers R, Wright
P, Kenner L, Turner SD, Whitaker IS. Anaplastic
large cell lymphoma (ALCL) and breast implants:
breaking down the evidence. Mutat Res Rev Mutat
Res. 2014;762:123–32. https://doi.org/10.1016/j.
mrrev.2014.08.002.
Pre-pectoral Implant Based Breast
https://t.me/medicina_free
Reconstruction
SreekumarSundaraRajan
andRishikeshParmeshwar
29
29.1 Introduction
Implant based breast reconstruction is the
most common technique used for immediate
breast reconstruction (IBR) in Europe and
America. Even though IBR with subcutaneous
placement of implant after radical mastectomy
was attempted almost 50years ago [1–3], it never
gained popularity due to the very high risk of
complications and at best a poor aesthetic outcome. In comparison the subsequently developed
totalsub-muscular technique remained the mainstay for implant based reconstruction for nearly
two decades and wasoften done in a delayed setting. In the sub-muscular breast reconstruction,
the implant is placed under the pectoralis major
muscle superiorly, serratus anterior muscle laterally and supported inferiorly by the upper most
aponeurosis of rectus abdominis. However, the
cosmetic outcomes from these IBRs were often
suboptimal due to the mismatch between the
outer lamella (the skin envelope) and the inner
lamella (the muscle cover overlying the implant),
resulting in projection of the reconstructed breast
like a mound on the chest which lacked natural
ptosis. These reconstructed breasts also lacked
S. S. Rajan
Queen Elizabeth Hospital, Birmingham, UK
R. Parmeshwar (*)
University Hospitals of Morecambe Bay, Lancaster, UK
movement and maintain a xed position on the
chest in contrast to a normal breast which is
meant to have a natural movement [4–6].
It was only after the introduction of various
acellular dermal matrices (ADM) and synthetic
meshes in the late 90s and the early 20s that led
to a renewed interest in implant based IBR
amongst plastic surgeons and oncoplastic breast
surgeons. Since the publication of rst series of
IBR with ADM in 2006 by Salzberg et al. [7],
the use of biological and synthetic meshes have
revolutionised the approach to IBR. The
National Mastectomy and Breast Reconstruction
Audit conducted in the UK between 2008 and
2011 showed only 30–35% of IBR were being
carried out with implants whereas the current
data suggest that implant based IBR now constitute about 70% of IBR in the UK and the USA
[8, 9]. The use of ADM provides the surgeon
with an internal hammock to support the implant
below the Pectoralis major muscle facilitating in
the natural ptosis of the reconstructed breast.
The use of ADM or a synthetic mesh thus helps
to compensate for the disparity arising between
the outer and theinner lamella. It also provides
a better denition of the infra and lateral mammary fold compared to a total sub-pectoral
technique.
In the early years of the introduction of
ADMsthe standard practice was to perform IBR
in dual planes by dividing and elevating the
Pectoralis major muscle along the lateral and
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023
S. V. S. Deo (ed.), Breast Oncoplasty and Reconstruction,
https://doi.org/10.1007/978-981-99-5536-7_29
223
224
https://t.me/medicina_free
S. S. Rajan and R. Parmeshwar
inferior borders and insert the implant in the
sub- pectoral position and interpose an ADM or a
synthetic mesh between the Pectoralis major
inferolateral margin and infra-mammary fold to
support the lower pole of the implant. Even
though this technique was superior to total submuscular placement of the implant, it still had
several signicant problems such as reduced
mobility of the reconstructed breast, pain from
the divided muscle, and animation of the restructured breast from involuntary strong contractions
of the Pectoralis major muscle [9, 10]. The
renewed interest in pre-pectoral subcutaneous
placement of implant in IBR has been a result of
the efforts by the professionals to overcome these
shortcomings of dual plane IBR. A substantial
development in the quality of ADMs and synthetic meshes over the last 2 decades have been
major factors in the process [11, 12].
Pre-pectoral implant based reconstruction
(PPBR) is thus a relatively novel technique. The
implant is placed in the pocket created after a
skin sparing or nipple sparing mastectomy in
front of the Pectoralis major muscle covered by
an ADM or a synthetic mesh [13, 14]. The cover
could be partial (anterior part opposed to the
skin surface) or a complete wrap. The early
reported outcomes from the PPBR technique are
encouraging, both in terms of aesthetics as well
as oncological outcomes with the added benet
of avoiding the issues arising from division of
the muscle. The evidences from the early publicationsdo indeed conrm that, at least in short
term, there is no difference in the occurrence of
seroma, infection, ap necrosis, and explantation between pre-pectoral and sub-pectoral
(dual plane) IBR techniques [15, 16]. The
European and UK multicentric audits support
these ndings [17–19]. The potential benets of
PPBR over a sub-pectoral technique are summarized in Table 29.1, and have led to a rapid
uptake of this technique of immediate breast
reconstruction both in Europe as well as in the
USA and is fast becoming the preferred technique in implant based IBR [20].
Table 29.1 Potential benets of Pre-pectoral Implant
based reconstruction over sub-pectoral
Anatomical in concept (replacing the breast volume by
implant with no other alterations)
Easier and quicker to perform
No compromise of muscle function
Less pain
Early discharge (can be done as day case)
Quicker recovery
No animation
Better movement
Possible better tolerance to post mastectomy
radiotherapycompared to subpectoral ADM and
implant IBR
29.2 Selection Criteria
Appropriate patient selection is paramount in any
form of breast reconstruction and this assumes
even greater signicance in implant based reconstructions as the safety margins are narrow. An
inappropriate selection can lead to implant loss and
suboptimal result. There are various patient related
factors that should be considered while considering
pre-pectoral implant-based reconstruction. Most of
these selection criteria for PPBR apply to any
implant based reconstruction. It is quite important
to understand that despite improved outcomes from
implant based reconstruction they are still not
equivalent to a total autologous IBR.Patients need
to be informed that the reconstructed breast with
PPBR will not have the same feel of a natural
breast,it will not have much sensation,can often
feel cold to touch and it will not change its volume
with patient’sweight loss or weight gain while the
normal contralateral breast would and hence
can lead to asymmetry. They will often change
with time for the worse aesthetically, requiring
revision surgery the incidence of which could be as
high as 20–40% [21, 22].
29.2.1 Good Candidates
• Small to moderate size breast with the maximum implant volume requirement of 450cc to
29 Pre-pectoral Implant Based Breast Reconstruction
https://t.me/medicina_free
225
500cc.Need for bilateral IBR is a good indication for PPBR.
• Mild to moderate (Grade 1–2) ptosis only. See
Table 29.3 for Regnault’s classication of
breast ptosis.
• Good quality skin.
• Subcutaneous fat thickness of 1cm or more.
Mediolateral oblique Mammograms can often
give a good objective idea about subcutaneous
fat thickness.
• Non-smokers.
• Young age (<50years).
• Realistic expectations with good understanding of likely outcome.
29.2.2 Relatively Unsuitable Candidates
• Obesity (BMI > 35)
• Smokers
• Diabetics
• Previous radiotherapy to the chest wall
• Likely need for post mastectomy radiotherapy
• Immuno-suppressed patients
29.3 Surgical Technique
29.3.1 Preoperative Marking
Pre-operative markings are crucial to any cosmetic or reconstructive procedure as they allow
the surgeon to work on a planned template. In a
reconstructive surgery the following markings
are accepted as standard.
The markings are always done in sitting
upright or standing position with back straight
and shoulders relaxed in neutral position. A tilted
posture changes the surface markings signicantly and should be avoided.
The breast margins including upper pole,
infra-mammary fold (IMF), and the lateral mammary fold (LMF) are marked with an indelible
marker pen as they help in mastectomy and also
give an idea of the required implant volume. It is
quite important to mark the contra-lateral IMF
and upper pole too as they help implant placement after mastectomy by means of offering a
comparable template. In addition, they also give
an idea if any signicant differences exist
between the two sides preoperatively. Any such
differences would be expected to have been noted
in outpatients and implications explained to the
patients. Similarly supra-sternal notch to nipple
distance, midline to nipple distance and nipple to
infra-mammary fold distances are important
landmarks and must be clearly recorded. It is a
good practice to keep a preoperative clinical photograph along with one showing the markings
followed by a series of post operative photographs at dened intervals. Figure29.1 shows a
typical preoperative marking in an implant based
IBR and applies to PPBR too.
29.3.2 Patient Positioning, Skin
Preparation andAntibiotic
Prophylaxis
This is no different than any implant based IBR
and focused on a supine neutral position, with
arms out on arm boards with a torso position
which allows sitting the patient up for subjective
assessment.
• As with any procedure involving prosthesis
placement, antibiotic prophylaxis is imperative in form of a single dose of penicillin based
antibiotic aimed at skin bacteria. It is best to
follow the local antibiotic prophylaxis policy
of the hospital. In authors practice this is 1gm
of Flucloxacillin or 600mg of Clindamycin in
case of penicillin allergy given at induction of
anaesthetic.
• Both arms are kept abducted at 90° on arm
boards and patient as straight as possible.
• Patient’s arms secured on the arm board and a
pillow below the knees to prevent patient sliding while sat up during the surgery.
• Position of the patient on the table should
enable safe propping up to 60°–70° to check
for symmetry. If not positioned properly, it
226
a
b
https://t.me/medicina_free
S. S. Rajan and R. Parmeshwar
Height
Width
Note left IMF lower than right
Fig. 29.1 (a) Pre-operative marking. (b) Position of the implant in relation to skin, ADM/mesh and chest wall
can cause awkward exion of the spine with
potential injury and the chest area does
Pectoralis major
Mesh
Biological or Synthetic
Implant
injection on admission and continued till
patient is fully mobile.
notallow proper assessment of the breasts.
• Skin preparation from umbilicus to neck and
wellbeyond the shoulder joint and mid arm so
29.3.3 Incision
that once drapes are placed both the clavicle
and shoulder joints are visible within the
draped area.
• Uniform single application of 4%
Chlorhexidine (in 70% ethyl alcohol) is
used and sufcient time is allowed for it to
evaporate and dry to maximize the antiseptic
function. It also allows drapes to stick to
skinproperly and prevents accidents from the
use of electro-cautery.
• It is essential to put thrombo-prophylactic
measures in place. This wouldusually be in
the form of a combination of thromboembolic
deterrent (TED) stockings, intra-operative
pneumatic intermittent calve compression
device, and low molecular weight heparin
The commonest technique of mastectomy used
for PPBR is of skin sparing (SSM) type where
the NA complex is sacriced. However, in
appropriate cases nipple sparing mastectomy
(NSM) is a valid option. It must be borne in mind
that NSM carries higher risk of complication due
to the added dimension of potential vascular
compromise to the nipple areola complex and
increased risk of infection due to natural colonization of nipple with bacteria. NSM is hence best
avoided in heavy smokers, poorly controlled diabetics and those with poor quality skin. From
oncological viewpoint extensive DCIS, cancer
within 20mm of the base of the nipple are generallytaken as contraindications for NSM.
29 Pre-pectoral Implant Based Breast Reconstruction
https://t.me/medicina_free
227
• A range of incisions are possible including but
not limited to elliptical central incision which
can be horizontal, oblique or vertical (in SSM)
and an infra-mammary fold incision, lateral
mammary fold or a radialouter quadrant incision (in NSM) depending on breast dimensions and patient’s preference. Surgeon’s own
expertise and skills with these incisions also
inuences the decision.
• If possible, peri-areolar incision is avoided
due to increased risk of wound breakdown and
infection.
• Use of nipple guard in cases of nipple sparing
mastectomy helps minimizing the risk of
infection.
29.3.4 Mastectomy
A good quality mastectomy is the key to a good
outcome in any breast reconstruction but is particularly important in implant based reconstruction. The fact that the implant is placed in a
subcutaneous position in PPBR, even though
with a mesh wrap, a well perfused mastectomy
ap acquires even greater signicance compared
to some other forms of implant based reconstruction such as a sub-pectoral or a dual plane
technique, where at least part of the implant is
separated from skin by muscle which is a much
better vascularised tissue. The attention to
the following details helps achieving an oncologically safe and yet a well perfused mastectomy envelope.
• Careful tissue handling using skin hooks in
preference to strong retraction on skin by relatively more traumatic instruments.
• Sharp dissecting is preferable to diathermy but
if the latter is chosen, its setting is kept to low
and excessive use avoided by use of careful
traction and counter traction.
• Chest wall perforators to the skin are identied and carefully preserved to ensure adequate perfusion of skin aps. In this regard
perforators from the second and third intercostals space coming from theinternal mammary artery, cutaneous branches from lateral
thoracic artery and from intercostal artery
perforators along the IMF and LMF are
worth noting. The sub-dermal network of
blood vessels must not be exposed or damaged by keeping the ap thickness uniform
and sticking to the mastectomy plane.
Exposure of dermis should be avoided at all
costs as this risks ap necrosis and even if
there is no ap necrosis, this results in adherence of skin to the capsule with poor aesthetic outcome.
• Meticulous haemostasis is quite crucial as
bleeding and haematoma can lead to risk of
infection and poor integration of the ADM.A
thorough wash of the pocket with saline/warm
water is done with normalization of the blood
pressure (normal for the patient) with the help
of the anaesthetist is quite useful to achieve
satisfactory haemostasis.
• It is important to recognise that unlike simple
mastectomy where superior and inferior skin
aps can be raised separately, when performing SSM using elliptical central incision, skin
aps should be raised all around simultaneously to allow enough exposure and for the
ease of dissection and hence reduce any inadvertent injury to the skin ap.
• In cases of nipple sparing mastectomy with
infra-mammary fold (IMF) incision, it is
quite important to have proper assistance to
get to the upper pole and perform a safe mastectomy. The use of a lighted retractor and
lighted head gear is very useful in performing
a safe NSM. It is quite important to choose
carefully a candidate for NSM and small B/C
cup breast with minimal ptosis are the best
candidate.
• Care should be given to identify and preserve the infra-mammary fold (IMF) and the
lateral mammary fold to achieve a stable
pocket and avoid implant migration or rotation. If the IMF is compromised it must be
Соседние файлы в папке Библиотека им академика М.И. Перельмана