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Picture 31.3 Final result of submuscular implants
I. Kasana
Seroma It is relatively uncommon with submus-
cular implants after drain removal. It is safer to
leave small seromas alone as it gets reabsorbed
by 4weeks. Large uncomfortable uid collection
need drainage under ultrasound guidance to prevent puncturing of implant with strict aseptic
precautions.
Infection Infection usually happens by the end
of the third week. Common organisms are staphylococci and pseudomonas. Longer course of
antibiotics is usually required.
In case of non-response to antibiotics implant
loss is inevitable. Various implant salvage techniques are used to prevent the loss of implant. In
our centre we remove the implant and ll the cavity with distilled water mixed with antibiotics and
re-insert the implant after 48–72h under antibiotics cover. For implant infection we use combination of teicoplanin and gentamycin till culture is
available.
Upward Migration of Implant Happens in
most cases of submuscular implant reconstruction and need to be factored in at the time of operation or symmetrisation surgery. In some cases,
revision surgery and lowering of implant is
require.
Other Complications Red breast syndrome,
capsular contracture, implant deation (saline
leakage), implant migration, implant ip over,
port ip over, pain (capsule contracture is common cause), rupture, nipple sensation changes,
implant extrusion, chronic pain, and radiotherapy
related severe contracture and scarring.
31.2 Subpectoral Implant Using
Mesh (Synthetic or
Biological)
The introduction of biological and synthetic
meshes in the early 2000s to augment the submuscular pocket has had a major impact on the
practice of immediate breast reconstruction. The
mesh can be used as a sling between the lower
edge of the pectoralis muscle and the IMF to provide coverage for the lower pole of the implant.
This creates a much bigger submuscular pocket
and enables a single stage procedure with the
desired size permanent implant placed at the time
of mastectomy. With the use of meshes cosmetic
outcomes are improved because of better lower
pole projection and improved control of the inframammary fold, which creates a more natural
looking shape. A wide range of biological (e.g.,
acellular dermal matrix) and synthetic (e.g., tita-
31 Two-Staged andSubpectoral Implant Breast Reconstruction
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251
nium coated polypropylene) meshes are available
in the market.
31.2.1 Indications
One-stage reconstruction for small to medium
sized non-ptotic breasts. For large ptotic breasts
reconstruction, lower pole is better supported
with dermal sling covered elsewhere in this
book. Previous radiotherapy and smokers have
higher risk of complications and implant loss
rate.
Patient Selection Most patients are suitable
except very obese. In very obese patents it is difcult to get desired projection of implant beyond
body’s thick skin and subcutaneous tissue. This
leads to at looking reconstruction despite using
implants with highest projection.
31.2.2 Preoperative Marking
The extent of breast is marked with dotted line.
Inframammary fold is marked. Both options of
nipple sparing (NSM) and skin sparing (SSM)
are available. My preference is to remove nipple
if the cancer is close to nipple, otherwise nipple is
preserved but biopsy of the tissue from underneath the nipple is taken to ensure clear margins.
Drain is placed in subcutaneous pocket. Skin is
closed watertight in two layers. Steri-strips and
waterproof dressing.
31.2.4 Implant Selection
Expander implants or implants can be used. 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 removed dictates volume
of implant.
31.2.5 After Care
Single redivac drain. Antibiotics till drain in situ,
usually 5–7days (Picture 31.4).
31.2.6 Complications
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.
31.2.3 Surgical Technique
Skin sparing mastectomy/NSM is done taking
care not to disturb IMF. Pectoralis muscle is
lifted along its lateral border to 3 ‘O’ clock or 9
‘O’ clock in right and left breasts, respectively.
Pectoralis major is lifted up to pre-marked extent
of breasts. Some of the inner strong medial bres
of pectoralis are divided to prevent implant being
pushed laterally. ADM is cut to D-shape. Rounded
side of the ADM is xed to Scarpa’s fascia at
IMF with PDS sutures. Implant is placed in the
pocket covered by muscle at the top and ADM
below. Freed edge of the muscle is stitched to
upper free edge of ADM to cover the implant.
Picture 31.4 ADM, nal result
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I. Kasana
Seroma It is quite common after drain removal.
It is safer to leave it alone as it gets reabsorbed by
4 weeks. Large uncomfortable uid collection
need drainage under ultrasound guidance to prevent puncturing of implant with strict aseptic
precautions.
Infection Infection usually happens by the end
of the third week. Common organisms are staphylococci and pseudomonas. Longer course of
antibiotics is usually required. In case of nonresponse to antibiotics implant loss is inevitable.
Salvage can be done as explained in the previous
section.
Upward Migration of Implant Happens in
most cases of implant reconstruction and need to
be factored in at the time of operation or symmetrisation surgery. In some cases, revision surgery
and lowering of implant is require.
Other Complications Red breast syndrome,
capsular contracture, implant deation (saline
leakage), implant migration, implant ip over,
port ip over, pain (capsule contracture is common cause), rupture, nipple sensation changes,
rippling (fat grafting can correct rippling),
implant extrusion, chronic pain, and radiotherapy
related severe contracture and scarring.
31.2.7 Conclusion
There are few options of implant reconstruction.
Choice is made between these based on cost,
availability of meshes, surgeon’s expertise, cosmesis, and post-op pain and recovery. Two-stage
submuscular implant is becoming obsolete now
due to inferior cosmesis, two operations involved
and postoperative pain and discomfort but is still
a decent option where expensive meshes are not
available or not affordable.
Subpectoral implant with meshes or total prepectoral reconstruction is debatable. Most surgeons in UK have shifted to pre-pectoral implant
reconstruction with ADM which is a quick and
easy operation but is most expensive option of all
(mesh costs ~£2000), nonetheless with less postoperative pain. The disadvantage is rippling and
rapid take-off at the top and is not suitable for
very slim patients.
Subpectoral implant is comparatively cheaper
(mesh costs~£800) and gives smoother take-off
at the top but more painful in the immediate postoperative period due to partial detachment of the
muscle. This is better option than pre-pectoral
implants in slim patients.
References
1. National Mastectomy and Breast Reconstruction
Audit. NHS Information centre. 48 page document.
2. Strock LL. Two-stage expander implant recon-
struction: recent experience. Plast Recontr Surg.
2009;124(5):1–7.
3. Spear SL, Pelletire CV.Immediate breast reconstruc-
tion in two stages using textured integrated-valve tis-
sue expanders and breast implants. Plastic Recons
Surg. 2004;113:2098–113.
4. Salgarello M, Seccia A, Eugenio F.Immediate breast
reconstruction with anatomical permanent expand-
able implants after skin sparing mastectomy: aes-
thetic and technical renements. Ann Plast Surg.
2004;52:358.
5. Roostaeian J, Pavone L, Da Lio A, etal. Immediate
placement of implants in breast reconstruction:
patient selection and outcomes. Plast Reconstr Surg.
2011;127(4):1407–16.
6. Scott L. Spear. Surgery of the breast, 3rd ed., vol. 1,
Chapter 30–37.
7. Mehrara BJ, Ho AY.Breast reconstruction. In: Harris
JR, Lippman ME, Morrow M, Osborne CK, editors.
Diseases of the breast. 5th ed. Philadelphia: Wolters
Kluwer Health; 2014.
8. Cutress RI, Summerhayes C, Rainsbury R.Guidelines
for oncoplastic breast reconstruction Breast recon-
struction. Oncoplastic Surg. 2013 April;95(3):161–2.
Thoraco-Abdominal Flap forLarge
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Post-Mastectomy Defects
inLocally Advanced Breast Cancer
S.V.S.Deo, ManojGowda, andJyotishmanSaikia
32
32.1 Learning Areas
• Applied anatomy of a thoracoabdominal (TA)
ap
• Patient selection for TA ap
• Advantages of constructing a TA Flap
• Complications of TA ap
32.2 Introduction
Breast cancer is the most common malignancy
globally and the leading cause of cancer death
among women. The ratio of early breast cancer
(EBC) to locally advanced breast cancer
(LABC) is 1:9in developed countries, whereas
it is 1:1in developing countries like India. Many
times, these patients can present with large fungating masses, bleeding tumors, extensive skin
involvement, and sometimes with chest wall
inltration. These patients need radical surgical
excision of soft tissues and involved skin to
achieve a R-0 status, resulting in large postmastectomy soft tissue defect not amenable for
primary closure. The primary aim in such scenarios is to offer a simple and reliable surgical
technique to facilitate early wound healing and
timely institution of adjuvant therapies. In addi-
S. V. S. Deo (*) · M. Gowda · J. Saikia
Department of Surgical Oncology, DR BRAIRCH,
All India Institute of Medical Sciences,
New Delhi, India
tion, the surgical option should be simple
enough to be carried out by a large number of
surgeons in developing countries dealing with a
high volume of LABC [1].
32.3 Surgical Anatomy ofTA Flap
Blood supply of the anterior wall of abdomen is
provided by complex-interconnected vascular
components that contribute blood supply to the
adjacent muscles and skin [2]. The viability of
the abdominal skin is based upon: The perforating trunks and subdermal plexus. The perforating
arteries are responsible for the origin of the blood
supply. Knowledge of their locations and distribution is the most important element for the success of a local ap [3]. The subdermal plexus is
comprised of an intricate network of microvessels dispersed throughout the skin of the
abdomen and thorax, which distributes the blood
supplied by the perforating arteries over an extensive skin surface. There are three perforating
branch systems that guarantee the irrigation of
the thoracic and abdominal wall: the epigastric
system, the anterolateral intercostal system, and
the groin system (Fig. 32.1). Thus, the most
important aspect in designing a local ap is
understanding the distribution of the perforating
arteries, which allows for ap planning, manipulation during surgery and viability in the postoperative period [4].
© 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_32
253
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S. V. S. Deo et al.
Fig. 32.1 Anatomical distribution of the perforating branches of the epigastric, groin, and intercostal posterior
system
The TA ap utilizes the skin and subcutaneous
tissue of the anterior abdominal wall and is a
rotation advancement fasciocutaneous ap
(Type-c). It is based on two sets of direct perforating segmental arteries arising from the
subcostal, lumbar, and deep epigastric pedicles
(Fig. 32.1). There are two sets of perforating
lateral side of the chest wall and axilla, a
medially- based ap based on the medial perforating branches should be used, whereas for medial
soft tissue defects of chest wall, a laterally-based
ap based on the lateral perforators should be utilized [6]. The vascular territory of the skin which
can be used in TA Flap is shown in Fig.32.2.
branches— the lateral, arising from lumbar and
subcostal arteries at the level of the anterior border of the latissimus dorsi, and the medial, arising
32.3.1 Patient Selection forTA Flap
from the deep epigastric arcade at the lateral border of the rectus abdominis [5]. Sub-facial anastomosis is present between the medial and lateral
perforators. For post-mastectomy defects on the
Following factors can guide selection of patients
needing radical surgical excision of soft tissues
and involved skin to achieve a R-0 status:
32 Thoraco-Abdominal Flap forLarge Post-Mastectomy Defects inLocally Advanced Breast Cancer
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maintaining a strict length–breadth ratio of
1:1 within the vascular territory as described
above.
2. The limits of the ap are:
(a) Medial: Midline
(b) Lateral: Anterior axillary line
(c) Inferior: a horizontal plane at the level of
anterior superior iliac spine.
3. The plane of dissection should be maintained
supercial to the rectus fascia and aponeurosis of the external oblique muscle.
4. The dissected ap can be advanced and
rotated into the defect without tension
(Figs.32.3 and 32.4).
5. The tip of the ap is trimmed in patients with
doubtful viability and the wound closed using
2–0 nylon interrupted sutures after placing
two closed suction drains one draining the
mastectomy site and the other draining the
donor area.
6. The lax abdominal skin can be adequately
mobilized to effect primary closure of the
donor site.
255
Fig. 32.2 Vascular territory of the area of skin and subcutaneous tissue that can be utilized for thoraco-abdominal
(TA) ap (dotted area)
• Tumor factors:
– large fungating masses,
– bleeding tumors,
– extensive skin involvement, and
– additional chest wall inltration
• Patient factors:
– previous abdominal incisions
– laxity of the abdominal wall
32.3.2 Surgical Steps
1. After completion of the mastectomy and
assessing the defect, the TA ap is marked,
32.3.3 Advantages ofTA Flap over
Other Flaps andSSG
1. Simple, reliable, and cost-effective
procedure,
2. Easy to learn and apply in daily practice,
3. No donor site morbidly,
4. Less chance of ap loss,
5. Well tolerated by patients,
6. Can undergo adjuvant treatment without
delay.
32.3.4 Complications
1. Supercial Flap necrosis: The tip of the ap
may sometimes undergo necrosis, which
should be managed by debridement and secondary suturing or SSG.
256
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S. V. S. Deo et al.
a
b
Fig. 32.3 (a)-post-radical mastectomy defect, (b) -Lateral-based TA Flap, (c)-TA ap covering post-mastectomy
defect, (d)-Donor site closure
2. SSI: Wound infections can occur when covering defects after mastectomy for fungating
and infected tumors. These can be managed
by using antibiotics. A ve-day course of
Amoxicillin–Clavulanic acid should be
3. Major ap loss: If planned properly, the
chance of major ap loss is very less. In such
cases antibiotic coverage and repeated
debridement followed by SSG or LD ap
should be planned.
enough to treat this condition.
32 Thoraco-Abdominal Flap forLarge Post-Mastectomy Defects inLocally Advanced Breast Cancer
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257
Fig. 32.4 Medially based TA ap to cover the post-mastectomy defect
32.4 Conclusion
TA ap is a simple, reliable, and cost-effective
procedure for managing large postmastectomy
soft tissue defects in a subset of LABC. It has
huge potential in developing countries dealing
with a large number of LABC patients because of
simplicity and short learning curve.
References
1. Leinster SJ, Webster DJ.Thoraco-abdominal and tho-
racoepigastric aps: alternatives to skin grafting after
mastectomy. Clin Oncol. 1982 June;8(2):145–8.
2. Suryanarayana Deo SV, Mishra A, Shukla NK,
Sandeep B.Thoracoabdominal ap: a simple ap for
covering large post-mastectomy soft tissue defects
inlocally advanced breast cancer. Indian J Surg Oncol.
2019 Sep;10(3):494–498. doi: https://doi.org/10.1007/
258
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S. V. S. Deo et al.
s13193- 019- 00927- 4. Epub 2019 May 2. PMID:
31496598; PMCID: PMC6707995.
3. Deo SS, Purkayastha J, Shukla NK, Asthana
S.Myocutaneous versus thoraco-abdominal ap cover
for soft tissue defects following surgery for locally
advanced and recurrent breast cancer. J Surg Oncol.
2003;83:31–5. https://doi.org/10.1002/jso.10236.
4. Brown RG, Vasconez LO, Jurkiewicz MJ.Transverse
abdominal aps and the deep epigastric arcade. Plast
Reconstr Surg. 1975 Apr;55(4):416–21.
5. Bohmert H. Experience in breast reconstruction with
thoraco-epigastric and advancement aps. Acta Chir
Belg. 1980 Mar-Apr;79(2):105–10.
6. Parkash S, Srinivasan R, Ananthakrishnan N.Primary
closure of excisional defects of the breast with local
aps: a problem in the treatment of advanced carcinoma of the breast in developing countries. Br
J Plast Surg. 1981 July;34(3):291–4. https://doi.
org/10.1016/0007- 1226(81)90011- 4.
Oncoplastic Breast
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Surgery- Common Complications
andManagement
S.P.Somashekhar, ArchaPrasad,
andSaiRamPillarisetti
33
33.1 Introduction
The goal of oncoplastic procedures is to resect
the breast cancer with negative histological margins while preserving the contour of the breast.
Oncoplastic surgery merges the principles of
oncology and reconstructive surgery, utilising a
spectrum of aesthetic enhancing techniques to
address tissue defects and optimise cosmesis
from breast cancer surgery. The core of oncoplastic breast management exists in four disciplines—
surgical oncology, plastic surgery, radiation
oncology and medical oncology—and the timing, efcacy and role of each modality considered concomitantly often in a tumour board or
multidisciplinary breast centre.
S. P. Somashekhar (*)
MHEPL, Bengaluru, India
Manipal Comprehensive Cancer center,
Manipal, India
Manipal University, Manipal, India
Breast Surgeon of India, Manipal Hospital,
Bangalore, India
A. Prasad
Manipal Comprehensive Cancer center,
Manipal, India
Manipal University, Manipal, India
S. R. Pillarisetti
University of Central Lancashire, Preston, UK
Oncoplastic breast surgery has traditionally
been a safe operation with low morbidity and
mortality. Although the incidence of postoperative complications is low, physicians should be
aware of the morbidity unique to it.
In one of the largest comprehensive literature
reviews to date on oncoplastic BCS. Outcome
After Oncoplastic Breast-Conserving Surgery in
Breast Cancer Patients by De La Cruz L, the systematic review reveals high rates of OS and DFS
with low LR, DR, PMR, RR, CMR and complication rates. This chapter reviews the common
complications encountered in these patients and
the approaches for management and goals to
anticipate and prevent adverse events and to
accelerate recovery [1].
(Depending on Time of Event)
Immediate Late Long Term
Bleeding Contour
deformity
Seroma/
Hematoma
Infection Volume loss Radiation
Delayed wound
healing
Wound dehiscence Flap necrosis Chronic pain
Pnemothorax Nipple areolar
Scar widening Fat necrosis
“Plugged in
appearance
necrosis.
Local
recurrence
brosis
Flap
contracture
Breast
asymmetry
© 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_33
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