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S. S. Rajan and R. Parmeshwar
xed with either a prolene or a PDS suture.
It is worth bearing in mind that in a prepectoral reconstruction the lower pole bears the
weight of the implant and if the IMF is compromised, the implant can easily migrate
inferiorly.
• Preservation of the pectoral fascia during
removal of breast from the chest wall is worth
attempting unless there is an oncological reason to remove it.
• After completion of mastectomy, it is a good
practice to check the skin envelope for its uniform thickness, vascularity, and any injury. It
is worth bearing in mind that the mastectomy
ap thickness is not uniform throughout and is
usually thinnest around the areolar margin and
gradually gets thicker as one goes towards the
chest wall.
• Any doubtful areas of skin, particularly the
incision margins are best excised. Various
techniques such as Indocyanine green angiography and uorescein dye angiography
have been used for intra-operative assessment of ap vascularity, but there is no substitute for an appropriate case selection,
utmost attention to mastectomy technique
and a judicious intra-operative assessment
[23, 24].
• There is no conclusive evidence to support routine use of antibiotic wash of the pocket but is
still commonly practiced in various combinations; the commonly used agents being cefuroxime, gentamicin, and povidone iodine but
in the author’s experience, the latter is best
avoided because of its irritant nature [25].
29.3.5 Implant Selection
Implant based IBR relies on good assessment of
breast dimensions in the outpatient setting. Once
decided as to what style and volume of implant
(see chapter on silicone implant), it is a good
practice to order implants of a size above and
below the size including the one thought to be the
most appropriate. Association of Breast Surgeons
and British Association of Plastic and
Reconstructive surgeons recommends that breast
units offering implant based reconstruction have
a bank of commonly used implants. It allows the
surgeon a wider range to choose from.
• The width, height, and projection of the
implant should be estimated from preoperative planning. In addition the lower pole
arc length is also important. These measurements would give an estimate of the volume,
type, and style of implant of the implant
needed for breast reconstruction. This can be
aided by measuring the width and height of
the breast disc plate intra-operatively. It is
quite important to get the width of the implant
right to achieve good aesthetic outcome and is
by far the most important of the dimensions
to get right. Weight of the resected breast
specimen can also give some idea of the
required implant size, but it is not often the
best guide as the density of the breast is quite
variable and a similar weight of breast can
vary signicantly in volume depending upon
its density.
• It is recommended that sizers are used to
assess symmetry and aesthetics of the reconstructed breast. The subjective assessment
plays an important role in choosing the correct
implant. One should be prepared to try different sizers with the patient sitting up, before
making a decision on which implant to use.
The chosen implant should ll the pocket and
yet allow easy approximation of the skin
edges. It should be borne in mind that in a prepectoral reconstruction, a large piece of ADM
is needed to wrap the implant in, which adds
to the volume of the implant/ADM composite
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229
and if not factored into, can lead to undesirable tension on the suture line.
29.3.6 ADM Wrap
Subcutaneous placement of an implant has been
known to have unacceptably high incidence of
implant loss and poor aesthetic outcome [26].
Use of ADMs has been the sole catalytic factor in
the resurgence of interest in implant based reconstruction. In the initial years of ADM based breast
reconstruction, it was mainly for dual plane direct
to implant based reconstruction covering only the
lower pole of the implant, the upper part of the
implant being separated from skin by the pectoralis major muscle. In PPBR the ADM needed is
much larger as it needs to cover the entire implant.
There is no strong evidence that one biological
mesh is any better than other but it is important to
understand the various types of biological meshes
available for the purpose.
• The biological meshes are derived usually
from either a bovine or a porcine tissue and
processed to make them acellular. They are
commonly the dermis but there are biological
meshes derived from bovine pericardium and
many other animal sources too. They can be
pre-shaped or a at sheet, which can be
moulded around the implant and xed to the
chest wall to give the coverage. The coverage
using the ADM can be a complete wrap or
only anterior depending on the surgeon’s preferenceor the type of ADM make. The posterior layer is not essential as it overlies the
musclebut can make the wrapmuch simpler.
It is also important to understand that there are
synthetic meshes too which are used for prepectoral reconstruction. Synthetic meshes are
cheaper and they have varying degree of suc-
cess and aesthetic results as published in
literatures.
• No matter which type of wrap is used, the
appropriate case selection, quality of mastectomy, and appropriate implant matter more in
deciding the outcome than the type of mesh
used. The implant should ll the pocket comfortably without any tension on suture lines
and yet leave minimal dead space. Figure29.2
shows one of the techniques of implant wrap
and inserting it in the mastectomy pocket following a SSM. (Table29.2).
Table 29.3 Summarises the universal precau-
tions in theatrefor implant based procedures
29.3.7 Use ofDrain
• A closed suction drain is recommended and
tunnelled for at least 5cms through subcutaneous plane to reduce the risk of infection. The
exit point of the drain is protected with a
waterproof dressing. The purpose of the drain
is to prevent any seroma that could adversely
affect the integration of the ADM with the
skin. Use of quilting suture to minimize
seroma formation is well documented but
there is not sufcient evidence to recommend
its routine use and the technique is fraught
with leaving excessive tissue behind and possible inadvertent damage to the underlying
implant.
29.3.8 Skin Closure
• Skin closure is performed in double layer
using absorbable monolament suture. It is a
good practice to excise a very thin margin of
the wound edges to remove any devitalised
tissue which can risk poor healing, marginal
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S. S. Rajan and R. Parmeshwar
a
b
Fig. 29.2 (a) Pre-pectoral implant reconstruction using pre-shaped ADM (Braxon®). (b) Pre and post-oprative images
of 29.2a
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231
Table 29.2
implant based breast reconstruction
Minimize number of individuals inside theatre
Prevent all avoidable movements in and out of theatre
Use of masks by everyone in theatre
Change of gloves prior to handling implant
Prevent any contact with implant with skin
Theatre equipped with laminar ow system is
preferred
Table 29.3
Grade
I At or 1cm below the IMF
II >1cm to up to 3cm below the IMF
III >3cm below the IMF or at the lower pole
Pseudoptosis is breast ptosis (ptotic lower pole) with nipple above the IMF
Universal precautions in theatre for any
Regnault’s classication of breast ptosis
Nipple position in relation to infra-mammary
fold (IMF)
necrosis, wound dehiscence and infection, all
of which can lead to implant loss.
29.3.9 Post-Operative Care
at home. It is important that thepatient understand the optimal wound care along with
importance of drain care.
• The practice of peri-operative antibiotics varies from single dose of antibiotic at induction
to two further doses to antibiotics till the
drains are taken out. There is no evidence
that longer use of antibiotic reduces infection
rate [27, 28]. It often comes down to individual unit’s or surgeon’s preference.
• The drains are usually removed when it drains
less than 30ml in 24 hours which is usually
between 7 and 10days. It is advisable to keep
the drain in situ for longer period if there is
continued output to encourage integration of
the ADM, and in some cases can be kept in for
as long as 2weeks.It is quite important that
the timing of drain removal is decided by the
operating surgeon or designated team member
with good understanding of the pitfalls (such
as low output due to loss of suction or blocked
drain)
• Adequate analgesia, maintaining good SpO2
(above 97–98%), good hydration and keeping
the patients warm are very important.
Needless to say thatthese factors are equally
important during intra-operative period too
and apply to any procedure requiring prolonged GA.It becomes even more important
in implant based reconstruction where the
vascularity and oxygenation of the skin
envelop are so crucial to a satisfactory
outcome.
• Patients are encouraged to use a well tted
surgical bra as continuously as practicable to
minimise movement and encourage integration of the ADM with skin.
• Most patients are discharged home within
24hours in the American and European set up
with drain care arrangement by health workers
29.4 Complications andRisks
Pre-pectoral IBR carry similar post-operative
risks when compared to the sub-pectoral variant
of IBR [18]. The immediate complications can be
in most instances mitigated to some extent
through careful patient selection and meticulous
surgical technique, whereas most of the delayed
complications are inherent to implant based surgery and can be difcult to control. They, however, are negatively inuenced by any immediate
post-operative problems with healing and of
course wrong case selection. It is very important
that the patients understand when to seek help if
any concerns, and on the part of the clinician it is
always a good practice to review the patients in
case of any wound related issues reported by the
patient.
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S. S. Rajan and R. Parmeshwar
29.4.1 Immediate Complications
• Bleeding and early return to theatreDespite the best efforts, about 2–3% of PPBR
will have haemorrhagic complications in the
early post-operative period and will require
return to theatre [18, 19]. Any haematoma is
best handled by exploration, wash and control
of bleeding even if not progressive due to its
impact on healing and integration of ADM if
left to resolve with conservative measures.
• Red breast syndrome- It is an ADM specic
condition, affecting about 5–10% of the PPBR
where the reconstructed breast develops erythema and mimics cellulitis [18–20]. Typically,
there is an absence of constitutional symptoms and the inammatory markers such as
neutrophil count and CRP are normal. The
distribution of the erythema tends to be limited to the underlying ADM in red breast syndrome which is essentially a chemical
inammation in response to the ADM itself or
to the preservatives used for the ADM.Despite
these distinguishing features it can often be
difcult to rule out infection and unplanned
use of antibiotics remains an issue in PPBR
and in other implant based IBR with ADM
use. The incidence is decreasing due to better
understanding of its aetiology and preventive
measures adopted intra-operatively. This can
be avoided in most cases by diligent and
meticulous washing of the ADM as per the
manufacture’s guidelines and respecting mastectomy principles. Excessive subcutaneous
fat left behind can lead to fat necrosis and add
to the problem of inammation, typically
manifesting 5–6weeks after surgery.
• Seroma and Infection- The common predecessor of infection after implant based IBR is
the development of seroma. This adversely
affects the ADM integration with host tissue
resulting in a cascade of events leading to the
development of infection and cellulitis.
Clinically signicant seroma (requiring aspiration) occurs in 5–10% of cases and can be
avoided by careful patient selection, respecting and maintaining mastectomy plane, meticulous haemostasis, and careful drain
management. It is important to bear in mind
that infection can happen even in absence of a
seroma.
• Wound dehiscence and implant exposure-
This is a relatively avoidable complication and
reported to be around 3–5% in the literature
[15–19]. Diabetes remains to be the single
most important factor that has got a strong
correlation to wound dehiscence in a pooled
data [15]. However, it should be emphasised
that, a tension-free wound closure, adequately
perfused mastectomy skin aps, and management of seroma is vital in the prevention of
wound dehiscence after any form implant
based breast reconstruction but more so in the
PPBR due to absence of an otherwise relatively well perfused muscle underneath in
asub-pectoral implant IBR.
• Skin Necrosis (marginal, mastectomy ap,
Nipple areola complex) – Skin necrosis in
itsvarious forms is an uncommon but a wellrecognised complication and its incidence is
quoted anywhere from 2% to up to 20% but in
experienced hands with good case selection it
should be well below 5% [16–18]. This can be
in the form of supercial marginal necrosis in
its mildest form to full thickness skin envelope
or a nipple areola complex necrosis of varying
extent. A dry marginal necrosis in most cases
can be managed conservatively by careful
monitoring. A full thickness necrosis requires
an early excision and re-suturing if possible
without any undue tension. In case of signicant skin loss the implant requires removal
with or without a temporising placement of a
tissue expander to bank the skin. This can later
be exchanged with a permanent implant.
• Loss of implant- Implant loss can be devastating for the patient and can result in signicant psychological trauma. The risk has been
quoted as low as 1 to 2% in individual series,
whereas the National Mastectomy and Breast
Reconstruction Audit in the United Kingdom
found the overall incidence as high at 8.9% [8]
in overall implant based reconstructions.
However, many multicentric audits in the UK
and Europe have shown the implant loss rate
of 5–10% in prepectoral IBR [15–18].
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233
Considering its devastating impact, surgeon’s
own implant loss rate should be discussed during the pre-operative counselling to helpthe
patient make aninformed decision. The most
denite way to treat such cases infection is to
remove the implant, but sometimes it is possible to salvage the implant in some cases by
thorough pocket wash and use of implant or
tissue expander with an antibiotic cover over a
drain. There are techniques of continuous
closed antibiotics irrigation of the implant
with varying degree of salvage rate [25, 29].
29.4.2 Delayed Complications
• Capsular contracture- The true incidence of
capsular contracture with PPBR is not known,
due to the lack of long-term follow-up data. In
a recent systematic review with a median follow- up of 13 months, capsular contracture
was identied in 5.8% of patients (Chatterjee
etal. 2016). Currently there is no evidence to
suggest that the risk of capsular contracture is
increased with pre-pectoral compared to subpectoral implant-based breast reconstruction.
As expected the incidence of grade3/4 capsular contracture is signicantly higher in cases
where patient receives chest wall radiotherapy
post-reconstruction but possibly less severe
than in sub-pectoral counterpart where the
brosis of muscle in front of the implant tends
to make matter worse [29].
• Rippling- The subcutaneous placement of
implant can lead to palpability and rippling
over time. This can be partly prevented by
careful case selection and use of highly cohesive implants. Mild rippling is not unusual in
any form of implant based reconstruction and
patient should be informed about it. Signicant
rippling can be managed with lipolling with
varying degree of success.
• Rotation, migration and leak- These are
implant related issues and can happen in
PPBR too. These issues have been addressed
elsewhere in the book with silicone
implantand possibly this informationshould
be re-inforced to patients post surgery in the
follow upIssues related to rotation and migration acquire greater signicance in women
with active life-style and they should be
advised to use appropriate bra in the initial
months following the surgery to reduce the
risk.
• Breast Implant Associated Anaplastic
Large Cell Lymphoma (BIA-ALCL)- BIAALCL is a long-term complication of silicone
implant surgery and presents with delayed
seroma in the reconstructed breast typically
after a median of 6–8 years (Clemens et al.
2019). The true incidence is difcult to assess
due to the rarity of the condition and variance
with different types of implants but has been
reported to be between 1:3000 and 1:6000
(ref). This again is not a PPBR specic risk
but related to textured silicone implants discussed elsewhere in the book. The diagnosis
and management of BIA-ALCL is beyond the
scope of this chapter and details can be found
in the NCCN consensus statement [30].
29.5 Summary
Pre-pectoral technique is fast becoming the
method of choice of implant based IBR for
healthy young women with small to moderate
size breasts because of its simplicity, quick recovery, avoidance of animation of the breast, and
much better natural ptosis and movement. The
early outcomes appear to be encouraging in terms
of aesthetics and oncological outcomes
(Figs. 29.3 and 29.4). Most of the multicentre
audits suggest that the technique is at least as
good as a sub-pectoral dual plane implant based
IBR; so far the commonest technique. However,
PPBR is not free from its challenges which are
not necessarily unique to the technique but simply related to the use of silicone implants and
meshes (biological or synthetic). There are early
suggestions that PPBR might tolerate radiotherapy better and has issues of rippling due to its
supercial location. Long term follow-up and
properly designed studies along with assessment
of patient related outcome measures will be
important in the years to come.
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Fig. 29.3 Right PPBR with an UOQ radial incision NSM for extensive DCIS (left pre-operative and right post
operative)
S. S. Rajan and R. Parmeshwar
Fig. 29.4 Left PPBR with IMF incision NSM for G2 cancer with DCIS (Left pre-operative and right post-operative)
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Dermal Flap Based Breast
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Reconstruction
RashmiVerma andRishikeshParmeshwar
30
30.1 Introduction
Implant based IBR constitutes over 70% of
immediate breast reconstruction in the UK and
North America. Its use seems to be on the rise in
other parts of the world too. Generally, these
implant based IBRs are performed in small to
moderate size breasts by performing a skin sparing or a nipple sparing mastectomy and lling
the mastectomy pocket with a silicone implant in
association with a biological or a synthetic mesh.
For larger breasts total autologous technique
such as Latissimus dorsi (LD) ap or a Deep
inferior epigastric perforator (DIEP) ap is preferred. Immediate breast reconstruction using
autologous DF and implant, however, offers a
simpler alternative to those patients who opt not
to have a major reconstructive procedure such as
LD or DIEP ap. This technique was rst
described by Bostwick in early 90s for immediate breast reconstruction in patients undergoing
prophylactic mastectomy [1, 8]. Over a decade
later, the same technique was used for IBR in
breast cancer patients [2, 3]. Hammond etal. [3]
initially used it in a two stage IBR (expander to
implant) in breast cancer patients. This tech-
R. Verma
Royal Wolverhampton Hospital, Wolverhampton, UK
R. Parmeshwar (*)
University Hospitals of Morecambe Bay,
Lancaster, UK
nique was further modied and rened for IBR
in breast cancer patients by Nava etal. [4] and
popularized the term “skin reducing mastectomy” (SRM).
Skin reduction is essential in large breasts
because the size of the implants limits the volume
to which skin envelope can be lled after mastectomy. Wise pattern mastectomy is one such skin
reducing mastectomy technique, based on breast
reduction technique described by Robert Wise in
1956, which not only allows to create a reduced
size but also aesthetically pleasing and less ptotic
reconstructed breast. Use of Wise pattern incision
to perform mastectomyalso creates the opportunity for the lower pole skin to be used as a ap/
sling. The de-epithelialised lower pole skin ap
forms the support and provides cover for the
lower pole of the implant while the upper part of
the implant is covered by the Pectoralis major
muscle detached from its lower attachment.
Dermal ap hence acts as an autologous substitute for a biological or a synthetic mesh commonly used in other forms of implant based
IBR.The technique facilitates the use of smaller
volume implants than what otherwise would have
been necessary.As mentioned in the Chap. 28
use of large implants (>450cc–500cc) sharply
increases the risk of post-operative complications
such as infection, wound dehiscence, and implant
loss. However, in many of these patients, despite
skin reduction, there will still be a need of a fairly
large volume implant. To minimize the above-
© 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_30
237
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R. Verma and R. Parmeshwar
mentioned risks an adjustable implant, such as
Becker® prosthesis is often necessary in the
author’s experience.
30.2 Patient Selection
As with any other breast reconstruction, good
patient selection is the key to a satisfactory outcome from DF based reconstruction. This includes
host factors as well as patient’s expectations in
terms of aesthetic as well as functional outcomes.
Good information provision regarding immediate
and long-term outcomes along with issues related
to the use of silicone implants is quite important.
Implant based reconstructions are generally considered to be high maintenance reconstructions
with frequent need for revision surgery down the
line. It is also important to take into consideration
if post-mastectomy chest wall radiotherapy is
anticipated as it carries a high risk of capsular
contracture and suboptimal long-term outcome.
Patient selection criteria for DF and implant
are not too dissimilar to any other implant based
reconstruction. For keeping the discussion
focused on DF ap based IBR these criteria can
be regarded as.
1. Essential prerequisites
2. Suitable candidates
3. Poor candidates
30.2.1 Essential Pre-Requisite
DF based IBR relies on creating a lower pole deepithelialized dermal sling and hence can only be
used in large ptotic breast where nipple is located
well below the level of inframammary fold (IMF)
and sufcient lower pole skin is available to createa DF.It is hence quite obvious that the technique cannot be used in small and non-ptotic
breasts. Theobjective criteria in case selection is
to understand that the patients for DF IBR
require SRM using Wise pattern incision for
patients with grade3 ptosis (see Regnault’s classication of breast ptosis in the chapter on
Prepectoral breast reconstruction). It is also important that the nipple to inframammary fold dis-
tanceis long enough to allow creation of at least
6-8cm of DF in addition to long enough vertical
limbs to allowa natural shape to the reconstructed
breast. It is also vitally important that the patient is
willing to undergo contralateral symmeterization
reduction because the DF based reconstruction
leads to a signicantly smaller reconstructed
breast compared to the original breast size.
30.2.2 Suitable Candidates
• Young healthy women(<60 years) with good
quality skin
• Good subcutaneous fat (=/>1cm)
• Need for bilateralmastectomy
• Women wishing for a smaller reconstructed
breast and willing to have a contralateral symmetrization procedure
• No or minimal co-morbidities
• Non-smoker
30.2.3 Poor Candidates
• Heavy smokers
• Poorly controlled diabetics or women with
compromised micro-vascular state
• Previous radiotherapy
• Possible need for post-mastectomy chest wall
radiotherapy
• Obesity (BMI over 35), immunocompromised
status
• Poor quality skin (dry, sparse subcutaneous
fat, local conditions such as eczema, stretch
marks)
• Unwilling to have contralateral breast
reduction/symmetrization
30.3 Surgical Technique
30.3.1 Principles
The outcome of the reconstruction is hugely
dependent on the quality of mastectomy and
adherence to the principles of implant based
reconstruction. It is quite important to pay attention to:
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