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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1054_Библиотеки_им_академика_М_И_Перельмана
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30 Dermal Flap Based Breast Reconstruction
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• Careful tissue handling, haemostasis and thorough wash
• Minimizing thermal injuries to skin if diathermy is used for raising aps
• Uniform ap thickness avoiding exposing
dermis
• Avoiding tension on suture lines
• Managing T-junction to minimize risk of
T-junction necrosis
• Use of an adjustable implant if undue tension
on suture lines with xed volume
implantexpected
30.4 Pre-op Marking fortheProcedure
The marking is done in an upright position either
sitting or standing, maintaining a neutral position
of the patient with her shoulders relaxed. The
marking itself follows the principles of wise pattern mastectomy and is crucial to the entire outcome of reconstruction and hence cannot be
overemphasized. The creation of a dermal ap is
integral to this process.
Figure 30.1: Marking WPM and DF
• Mark the sternal notch and drawa line vertically down to mark the midline. This helps to
compare the distance between the midline
and the nipple as well as the breast meridian
and is always worth noting if there is a difference on the two sides. In a bilateral procedure, these distances fromthe midline should
be equal for symmetrical looking reconstructed breasts.
• Mark the breast meridian- a vertical line joining mid-clavicular point to nipple and traced
to inframammary fold, chest wall, and upper
abdomen in the same line. This line will often
Fig. 30.1 Pre-operative marking for DF based IBR.The
numbers indicate the order in which the marking is usually done. The IMF projection on the anterior breast on the
breast meridian lineis the point where the vertical limbs
start but can be higher (not less than 19 cm from SC
notch) or lower
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R. Verma and R. Parmeshwar
be slightly oblique in the lateral direction
starting from the mid-clavicular point. A practical way of drawing this line is to allow a long
measuring tape around the neck to hang on
either of the breasts and hold it across the nipple to draw the line.
IMF projection on the breast on the breast
meridian is marked. This forms the upper most
point of the vertical limbs (wings) drawn down to
the either side of the areola. This point becomes
the point of maximum projection and site of
future nipple reconstruction.
• Vertical limbs are then drawn; the length of
these vertical limbs should be ideally
10–12 cm to allow a degree of natural pto-
sisandat least 8cm to achieve an acceptable
aesthetic outcome. In contrast to a Wise pat-
tern breast reduction mammoplasty, the verti-
cal limbs are kept close to the areolar margins
to preserve skin. In some cases where the dis-
ease is peripheral, part of the areolar skin can
be preserved in the process too. The more
divergent the wings, the less projection the
reconstructed breast will have with serious
compromise of the aestheticoutcome.
From the inferior end of the vertical limb, the
lines are extended laterally and medially, respectively, to join the extremes of the IMF.
30.5 Operative Procedure
30.5.1 Patient Positioning andSkin
Preparationand antibiotic
prophylaxis
• Supine with both arms abducted at 90° on an
arm boards with straight spine and no rotation
of the torso shoulder or pelvis. An incorrect
position will lead to wrong intra-operative
assessment and hence altered outcome.
• Secure patients’ arms on the arm board and a
pillow below the knees to prevent patient slid-
ing whensat up during the surgery.
• Ensure that patient can be safely sat up to
60–70° to check for implant position and
shape of the reconstructed breast.
• Skin preparation from neck to umbilicus and
well beyond the shoulder joint so that once
drapes are placed both the clavicle and shoulder joints are visible within the draped area.A
single dose of IV Flucloxacillin 1g is given as
prophylaxis (Teicoplanin or Clindamycin in
case of penicillin allergy).
30.5.2 Skin Incision (Fig.30.2a)
• Wise pattern skin incision as shown in
Fig.30.2a. It is extremely important that the
incision is kept supercialand epidermis deep
along the IMF to prevent any compromise in
the vascularity of the DF.
30.5.3 Mastectomy andCreation
ofDF (Fig.30.2b, c)
• Before raising the mastectomy aps, the lower
pole skin is de-epithelialized to create the DF.
• Incision along the vertical limbs and lateral/
medial extensions are deepened to allow raising the mastectomy aps.
• Upper and lower mastectomy aps are raised,
taking care to preserve the vascularity of the
aps by identifying and preserving the perforators in second and third intercostals space
coming from internal mammary blood vessels, cutaneous branches from lateral thoracic
artery,branches along the IMF coming from
chest wall perforators.
• While raising the lower ap, care should be
taken to preserve the IMF.If the IMF is disturbed or is mobile, it is secured with 2'0'PDS
sutures.Strong sutures taken in the underlying
muscle aponeurosis aresufcient and it is not
necessary to take the sutures down to rib periosteum (painful and frought with risk of troublesome bleeding)
• Breast tissue is dissected off the Pectoralis
muscle, keeping the Pectoral fascia intact
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a
c
b
d
e
Fig. 30.2 (a) Incision ismade and the lower pole skin
isde-epithelialized. As emphasised above the incision in
the IMF must be kept supercial to avoid inadvertently
de-vascularizing the DF. (b) Mastectomy is completed
and the Pec major is detached from the infero-lateral
attachmentsby dividing it fromthe ribs inferiorly andPec
minor laterally. The sternal bres are divided up to 4
0’clock (right side) or 8 0’clock (left). The subpectoral
dissection is then carried out dividing the sub-pectoral
unless concerns of tumour being close to the
muscle.
• The Pectoralis major is then detached from its
attachment inferiorly(started with separating
lateral margin from Pec minor and retracting
the muscle forward to get hold of the muscle
costal bres to allow sufcient medial placement of the
implant. (c) Appropriate implant volume isassessed with
sizers. If needed adjustable implant used and placed in the
subpectoral space. (d) DF and Pec major margins stitched
together. The lateral part of the implant can be covered
with back cut of lateral one third of the DF or with a
mesh.(e) The medial and thelateral wise pattern mastectomy aps are closed over the Pec major and theDermal
ap covering the implant.
between ngers) and carried on mediallyto partially release from the low sternal
attachment. The muscle isthen elevated from
the chest wall and the deep medial costal
bres are carefully divided securing perforator blood vessels from intercostal arteries.
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R. Verma and R. Parmeshwar
The dissection is taken close to sternum. A
complete division must be avoided to prevent
synmastia which is a difcult problem to correct. For the same reason it is also important
to stop dividing lower bres of Pectoralis
major from their sternal attachment beyond 4
o’clock position (right breast) or 8 o’clock
position for the left side.
• Laterally, DF often is not adequate to cover
the implant and a Serratus anterior muscle ap
or small patch of acellular dermal matrix
(ADM) can be used to provide implant cover.
Alternatively, the part of the DF can then be
released by dividing it (a back cut) lateral to
medially [5]. This gives slightly more laxity
tothe DF to cover the lateral end of the implant
or to wrap underneath it. However, care should
be taken while making the back cut to keep it
short to avoid compromising the vascularity of
the DF.
30.5.4 Implant Insertion
(Fig.30.2c,d)
• The volume and projection of the implant is
estimated from pre-operative planning. This
can be aided by measuring the width and
height of the breast disc plate intra-operatively
after completing mastectomy. Weight of the
specimen is not the best guide to implant volume due to variation in the parenchymal
density.
• Implant sizers are very useful to assess the
appropriate implant size. The patient must be
sat up for this purpose.
• Good wash of the pocket to remove any debris
or loose fat is quite important along with
meticulous haemostasis.
• Two closed suction drains are inserted at this
stage (one subcutaneous and one submuscular) and tunnelled at a distance away
from the suture lines. This has got two advantages as it decreases the risk of infection backtracking through the drain site and allows
adequate space to apply negative pressure
dressings.
• Extreme precaution to maintain asepsis while
handling implant (change of gloves, minimizing handling, avoiding contact with skin).
• Implant is placed in the subpectoral space. See
Fig.30.2c.
• The free edge of the pectoral major is then
sutured to the free edge of the dermal ap
using a running monolament stitch such as
3'0' PDS.
• Depending on the size of the dermal ap and
the implant, additional lateral cover may or
may not be needed.
• For a lateral coverthe Pectoralis major lateral
margin can be sutured to the free edge of
Serratus anterior ap or a small patch of ADM
if the dermal ap does not cover the implant
completely.
30.5.5 Closure
• The two vertical limbs are sutured together.See
Fig.30e.
• The upper ap is then sutured to the IMF incision over the dermal ap. It is a good practice
to excise 5 mm of the ends of the vertical
limbs which along with preserved small extension of the skin at T-junction reduces the risk
of T-junction necrosis.
30.5.6 Post-Operative Care
• Adequate analgesia, maintaining good oxygen
saturation, good hydration, keeping patients
warm, and use ofappropriate thromboprophylaxis (TEDS and Low molecular weight heparin injections).
• Most patients are discharged home within
24h.
• The practice of post op antibiotics prophylaxisvaries from a single dose of antibiotics at
induction to two further doses after the surgery or continuing antibiotics till the drains
are taken out. There is no evidence that longer
use of antibiotics reduces infection rate.
Author’s own practice is to offer 5 days of oral
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Flucloxacillin 500mg qds or Clindamycin
450mg qds in case of penicillin allergy.
The drains are usually removed when it drains
less than 30ml in 24h which is usually between
5 and 7days. It is important that the drains are
removed only after an appropriate level of clinical input (usually operating surgeon) and
thatthere is an agreed policy in place for ateam
approach to peri-operative careincluding timely
clinical review if need be.
30.6 Complication andRisks
30.6.1 Early Post-operative Risks
andComplications
The early post-operative complications include
bleeding, seroma and infection leading to implant
loss. The implant loss rate with DF based IBR
should not be any higher than other forms of
implant based reconstructions with an added risk
of T-junction necrosis (see chapters on Implant
based reconstruction). The technique, despite
being a useful one, remains somewhat underutilised and thus there is arelative lack of outcome
data [10]. The authors have used the technique
and the outcome data between 2008 and 2018
indicate outcomes which are comparable to other
implant based reconstruction [11, 12]. The long
and thin superior skin ap approximated along
the breast meridian can increase wound related
complications at T-junction. The reported incidence of wound dehiscence varies between 5 to
7% in the literature [5, 7] and in our series; it was
around 6% [12]. The more serious complications
including ap necrosis (5–20%) and implant
extrusion resulting in loss of implant have been
reported variably in the literatures from 0 to 13%
[5–7, 9]. In our series, implant loss and T-Junction
necrosis occurred in 6% of the patients [12].
Most of the T-junction necroses can be managed
conservatively, if supercial and limited to mastectomy aps with the underlying DF remaining
healthy. If there is impending implant exposure,
it requires early wound debridement and closure
(with or without converting xed volume implant
to adjustable implant or tissue expander placement to reduce tension on suture lines). One can
minimize the incidence of T-junction necrosis by
using an inverted V extension of IMF skin at the
T-junction allowing the excision of the tip (most
at risk) of the medial and lateral wise pattern
mastectomy ap to be excised. In relatively high
risk patients, use of a negative pressure dressing
can minimize the wound related complication in
the early post- operative period [13, 14]. The incidence of seroma has been reported to varying
rates but is lower compared to IBR using ADM
and implant and this is mainly due to the fact that
the DF based technique does not require a biological or a synthetic mesh; both associated with
risk of seroma. Seroma can be managed by observation alone and aspiration is avoided to minimize risk of infection but a seroma compromising
wound healing can be aspirated under US guidance with utmost aseptic antiseptic precautions.
30.6.2 Delayed Risk
andComplication
Late complication with DF based IBR are mainly
related to the use of silicone implant such as capsular contracture, migration/rotation of the
implant, rippling, breast animation and in rare
cases BIA ALCL (Breast implant associated anaplastic large cell lymphoma). See the chapter on
Silicone implant(Chap. 28) for delayed complications in implant based reconstructions.
In authors experience the incidence of capsular contracture seem to be lower in DF based
reconstruction in comparison to other implant
and ADM based reconstruction.
30.7 Summary
The outcomes from DF based reconstruction are
consistent and good with high patient satisfaction
(Figs. 30.3a, b, 30.4a, b, and 30.5). A careful
patient selection, proper counselling, and meticulous surgical technique with a structured peri-
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R. Verma and R. Parmeshwar
Fig. 30.3 (a) Young female with large breasts with grade
3 ptosis, in need for bilateral mastectomy and opting for
immediate breast reconstruction with implant. (b)
9 months post-IBR showing signicant reduced reconstructed breast volume compared to original breast size
ab
Fig. 30.4 (a) Female in 60s with large breasts opting to have implant based reconstruction. Image shows the degree
of asymmetry resulting. (b) Post-left breast symmetrization reduction surgery
operative care play vital roles in the success of
this procedure as with most forms of IBR.
Patients should be informed about possible
need for further procedures related to contralateral symmetrization reduction and also the early
and late complications typically associated with
an implant based IBR. However, DF implant
based reconstruction do produce much more lasting results with a less frequent need for additional
procedures as compared to ADM implant based
reconstruction due to autologous nature of lower
pole support.
DF based IBR is an extremely useful tech-
nique for large ptotic breasts, bilateral cases, and
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Fig. 30.5 Long-term outcome from a DF ap based breast reconstruction (Left) in comparison to the right sided
autologous LD ap reconstruction
245
risk reducing procedures where women wish or
accept smaller reconstructed breasts and areprepared to have contralateral symmetrization procedure. The complication rates are low in
experienced hands with stable long-term
outcomes and there is high level of patient
satisfaction.
References
1. Bostwick J, editor. Total mastectomy with breast skin
and volume reduction using an inverted ‘T’ incision.
Plastic and reconstructive breast surgery. St Louis:
Quality Medical Publisher Inc; 1990. p.1048–54.
2. Hudson DA, Skoll PJ. Single-stage, autologous
breast restoration. Plast Reconstr Surg. 2001;108:
1163–71.
3. Hammond DC, Capraro PA, Ozolins EB, Arnold
JF. Use of a skin-sparing reduction pattern to create a combination skin muscle ap pocket in immediate breast reconstruction. Plast Reconstr Surg.
2002;110:206–11.
4. Nava MB, Cortinovis U, Ottolenghi J, et al.
Skin-reducing mastectomy. Plast Reconstr Surg.
2006;118:603–10.
5. Carstensen L. Visualized immediate breast reconstruction with dermal ap and implant. Gland Surg.
2019;8:S225–61.
6. Ellabban MA, Nawar A, Milad H, Ellabban
MG. Single-stage immediate breast reconstruction
using anatomical silicone-based implant and the ham-
mock technique of dermal-muscle ap in large and
Ptotic breasts: a multicenter study. World J Surg. 2020
Jun;44(6):1925–31.
7. De Vita R, Pozzi M, Zoccali G, et al. Skin-reducing
mastectomy and immediate breast reconstruction in
patients with macromastia. J Exp Clin Cancer Res.
2015;34:120.
8. Carlson GW.Technical advances in skin sparing mastectomy. Int J Surg Oncol. 2011;2011:396901.
9. Newman MK. Reconstruction of the Ptotic breast
using wise pattern skin de-epithelialization. Plast
Reconstr Surg Glob Open. 2016;4(11):e1077.
10. Jepsen C, Hallberg H, Pivodic A, Elander A, Hansson
E. Complications, patient-reported outcomes, and
aesthetic results in immediate breast reconstruction with a dermal sling: a systematic review and
meta-analysis. J Plast Reconstr Aesthet Surg. 2019
Mar;72(3):369–80.
11. Parmeshwar R, Chiu W, Rajan SS.Dermal ap based
single stage immediate breast reconstruction. Eur J
Surg Oncol. 2014;40(5):e658.
12. Verma R, Ali S, Parmeshwar R. Dermal ap and
implant based reconstruction- a useful technique. Eur
J Surg Oncol. 45(5):e898.
13. Mullapudi NA, Vinayagam R, Clayden-Lewis C,
Kothari A, Douvetzemis S, Sircar T, others. Negative
pressure wound therapy in high risk breast procedures
(negative pressure PICO study group). Eur J Surg
Oncol. 2020;46(6):e47.
14. Irwin GW, Boundouki G, Fakim B, Johnson R,
Highton L, Myers D, Searle R, Murphy JA.Negative
pressure wound therapy reduces wound breakdown
and implant loss in Prepectoral breast reconstruction. Plast Reconstr Surg Glob Open. 2020 Feb
24;8(2):e2667.
Two-Staged andSubpectoral
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Implant Breast Reconstruction
IqbalKasana
31
In US and UK implant-based breast reconstruction (IBBR) is the most commonly performed
breast reconstruction operation [1]. Techniques
have evolved rapidly in this area since late 1990s
especially with the technological advancement in
prosthesis and meshes [2–8]. Commonly used
techniques are:
• Two-staged implant reconstruction (immediate or delayed).
• Subpectoral implant using mesh (synthetic or
biological).
• Subpectoral implant using dermal sling (only
possible in large ptotic breast)-covered
elsewhere.
• Pre-pectoral implant (with biological) mesh-
covered elsewhere.
31.1 Two-Staged Implant
Reconstruction (Immediate
or Delayed)
31.1.1 Introduction
Two-stage implant reconstruction involves placing temporary expander to expand skin, soft tis-
sues, and pectoralis major muscle, to be replaced
with permanent implant later (second stage). It
can be done in immediate or delayed settings.
Expander is gradually inated in clinic to achieve
the desired pocket size. Results are mediocre at
best and this technique is being replaced by
reconstruction with acellular dermal matrix
(ADM) and dermal sling. In my own practice I
use expander implants (Picture 31.1, right) with
remote port (c/w pure expanders which have integrated port) which can be left as permanent
option if decent cosmetic result and symmetry is
achieved.
31.1.2 Indications
Subpectoral implant using meshes (synthetic or
biological) or de-epithelised lower pole ptotic
skin (dermal sling) has replaced two-staged submuscular implant reconstruction in the developed
countries. However, two-staged procedure is still
used when mesh is not available, patient not suitable for dermal sling (non-ptotic breasts) and
autologous options of Latissimus Dorsi Flap and
DIEP ap are not available.
I. Kasana (*)
Manor Hospital, West Midlands, UK
© 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_31
247
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Picture 31.1 Left-expander with integrated port. (Alllergan 133, Right-expander implant with remote port Allergan
150)
I. Kasana
are usually not suitable. Short well build patients
are more suitable for nding complete cover.
Patients slim to the extent that ribs are visible in
upright position are generally not suitable.
31.1.3 Contraindications
Two-stage implant reconstruction better be
avoided in the setting of radiotherapy. Previous
radiotherapy and anticipated future radiotherapy
are contraindications to two-staged implant
reconstruction. It is difcult to expand irradiated
tissues and radiotherapy subsequently causes
severe encapsulation and pushes implant higher.
In very slim patients it is difcult to provide 360
degrees cover due to scarcity of tissue and therefore leading to poor cosmetic result.
31.1.4 Patient Selection
In two-stage submuscular pocket is created with
intention to provide complete muscle cover.
Patient selection is important. Tall slim patients
31.1.5 Preoperative Marking
Extent of breast is marked with dotted line.
Midline and inframammary fold are marked. Aim
to lower implant pocket 2–3 cm below IMF
which need to be marked by second line below
IMF.For delayed reconstruction breast footprint
is marked as per extent of the other breast. In case
of previous bilateral mastectomy breast foot
plates are marked based on IMF remnants and
implant size chosen vis-a-vis patients over all
built and chest wall frame.
Picture 31.2
Preoperative marking for twostage implant reconstruction. IMF need to be
lowered, shown on the right breast.
31.1.6 Surgical Technique
Skin sparing mastectomy (SSM) is done taking
care not to disturb serratus fascia or serratus muscle in the lower half of the base of the breast.
After careful skin sparing mastectomy, pectoralis
major muscle is split in the middle leading to
subpectoral space. This step is like splitting internal oblique muscle during open appendicectomy.
31 Two-Staged andSubpectoral Implant Breast Reconstruction
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removed helps in choosing right volume of the
implant in A to C cup breasts. In larger breasts
approximate size is discussed and agreed between
patient and surgeon.
After Care/Second stage It is my practice to
use single redivac drain. Broad spectrum antibiotics are used till drain is in situ, usually 5–7days.
Prosthesis is expanded by injecting uid percutaneously until the desired size is achieved. It is my
practice to inate at 6–8 weekly intervals.
249
Picture 31.2 Pocket dissection is started from centre of
pectoralis muscle
Dissection is extended 360in subpectoral space
up to the extent of the breast marked preoperatively. Inferiorly dissection extends to 2–3 cm
below IMF, as marked preoperatively. Care is
taken to include all the tissue available (serratus
fascia, serratus muscle, and upper bres of
oblique muscles of abdomen) below the lower
and lateral edge of pectoralis major muscle keeping it continuous with pectoralis without inadvertently making a hole in it. Implant is placed in the
pocket and inated as much as muscle and skin
can accommodate without undue tension. Split
muscle bres are closed with absorbable sutures.
Drain is placed in implant pocket. Skin is closed
watertight in two layers. Steri-strips and waterproof dressing is applied which is left in place for
a week.
31.1.7 Implant Selection
The expander is then replaced by a xed volume implant at a second operation. There is no
xed timing of replacement, it can be done any
time after nishing cancer treatment and when
desired ination is achieved. The old scar is
opened, and the old implant is removed, capsulotomy is enough for grade 1-II encapsulation.
Capsulotomy is done by radial incisions. For
tough capsule 360 degrees anterior capsulectomy
is necessary. Inframammary fold is opened to
lower the implant to achieve symmetry. The
pocket is adjusted to ensure tension free closure.
The wound is closed meticulously in two layers
(Picture 31.3).
Two-stage technique is safe but time consuming. It is better to use combined expander implants
(“permanent expanders”) as a one-stage approach
to avoid a second operation. Overall, better
results are achieved with one sitting of fat grafting between the two stages to get better outcomes
especially with thin aps.
31.1.8 Complications
Expander implants (Allergan 150, Mentor’s
Becker 35) or expanders (Allergan 133 or Mentor
expanders) can be used. Expanders have integral
port and expander implants have remote port to
be xed in subcutaneous location on the side in
the mid-axillary line. Size of the implant is
selected based on height and width of breast foot
plate measured preoperatively and size of pocket
measured intraoperatively. Weight of breast
Bleeding Peri-implant haematoma is rare, in
most cases it does not need any intervention and
is managed conservatively. Large or expanding
haematoma will need washout under GA.
Flap Necrosis It is rare and happens in smokers
and diabetics. Debridement and watertight closure is necessary to avoid infection and implant
loss.
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