Staged use of soft-tissue expansion and lower thoracic advancement flap in breast reconstruction

A single patient is presented in whom breast reconstruction after mastectomy for breast cancer has been achieved by sequential use of soft-tissue expansion followed by permanent silicone implant placement and thoracic flap advancement to define the inframammary fold. This procedure may play a useful role in patients in whom other, more complex methods of breast reconstruction are not selected or indicated and in particular in patients in whom bilateral silicone implants are utilized.     

Eighty-four consecutive breast reconstructions using a textured silicone tissue expander.

Breast reconstruction utilizing smooth-surface silicone tissue expanders is associated with certain problems. Significant capsular contracture may develop around the expander with subsequent expander displacement necessitating repositioning or capsulectomy at the time of expander removal. Infection, pain on expansion, chest-wall compression, and complications related to the remote fill valve also have been reported. A textured-surface silicone expander with an integrated fill valve was developed to address these issues. Eighty-four consecutive breast reconstructions were performed by a single surgeon using textured expanders in 55 patients. Intraexpander pressures were measured during expansion for a group of these patients, and both initial and postinflation pressure readings were quite low (average initial pressure 2.88 mmHg; average postinflation pressure 12.87 mmHg). Eighty-one of the reconstructions have been completed without any expander losses and with minimal complications. Tissue expander volume averaged 580 cc, and the expansion duration averaged 5.6 months. Various types and configurations of permanent implants were used to complete the reconstructions. Eighty-four percent of our patients' completed reconstructions (including nippleareola reconstruction and opposite breast alteration, when necessary) were accomplished with just two procedures. Seventeen long-term adjustable textured-surface expander/implants with anatomic breast shape are still in place, all after only one operation. The inframmary fold has generally been established passively by the expansion process alone. Textured-surface silicone expanders have stayed where positioned, have expanded easily with minimal patient pain, and have created a noncontractile soft-tissue cover for the final implant. The textured expander with an integrated fill valve has simplified breast reconstruction by helping to limit the problems encountered with smooth silicone expanders. The resulting reconstructions have remained soft with a very acceptable aesthetic appearance. The patient office and hospital charts and photographs of this consecutive series were notarized and submitted to the Editor of this Journal, whose biostatistician randomly selected the cases illustrated.     

"Apron" flap and re-creation of the inframammary fold following TRAM flap breast reconstruction

To the best of our knowledge, the recreation of an inframammary fold after TRAM flap breast reconstruction has not yet been described. This article offers a technique for the creation of an inframammary fold as a secondary procedure. The technique has been performed thus far in two patients with good aesthetic outcomes and no postoperative complications. It may also be suitable for adding bulk to the TRAM flap, especially in bilateral breast reconstruction, and for other minor chest deformities.     

Reconstructing the breast mound employing a secondary island omental skin flap

We have shown in an initial animal study that omentum will adequately vascularize a skin flap and allow transfer of this tissue composite for use in surgical reconstruction of the breast. Based on this experimental procedure, a technique employing a two-stage operation has been developed and used in 21 female patients in reconstruction of the breast after radical mastectomy. In the first stage, the omentum, attached to one gastroepiploic artery and vein, is exteriorized to the subcutaneous tissue of the lower abdominal wall. In the second stage, the distal omentum, now vascularizing the overlying skin and soft tissue, is moved as a secondary island flap to the anterior chest wall to complete the breast reconstruction. In all but 1 of our 21 patients who have been followed for 1 to 8 years, reconstruction of large defects, including the chest wall, breast mound, and infraclavicular axillary fold depression, was performed without use of a prosthesis. In one patient, there was complete necrosis of the flap due to vascular impairment; there were three instances of delayed healing and a significant but partial loss of the flap in one patient. All complications were encountered in the first 10 patients of the series during the time the technique was being refined.     

Integrated breast mound reduction and nipple reconstruction with the wraparound flap.

A new method for nipple reconstruction is described that combines revision of an autologous tissue breast mound with creation of a projecting nipple. The method is applicable only to reconstructed breast mounds that must be reduced or lifted to achieve symmetry with the opposite breast. In this technique, the mound is reduced as if it were a normal breast, using an inverted-T or vertical mammaplasty pattern. In this way, breast projection can be increased and, if necessary, the inframammary fold can be elevated. A rectangular flap is created from skin and subcutaneous tissue that would normally be discarded during the breast reduction, and this flap is wrapped around on itself to form a projecting nipple. This new technique avoids the flattening of the breast mound usually seen after nipple reconstruction because it does not take tissue away from the completed breast mound to make the nipple. In appropriate patients who require reduction in size of their reconstructed breast mound, the wraparound flap nipple reconstruction is worth considering.     

Functional MRI To Evaluate “Sense of Self” following Perforator Flap Breast Reconstruction

Background

Breast reconstruction is associated with high levels of patient satisfaction. Previous patient satisfaction studies have been subjective. This study utilizes functional magnetic resonance imaging (fMRI) to objectively evaluate “sense of self” following deep inferior epigastric perforator (DIEP) flap breast reconstruction in an attempt to better understand patient perception.

Methods

Prospective fMRI analysis was performed on four patients before and after delayed unilateral DIEP flap breast reconstruction, and on four patients after immediate unilateral DIEP flap breast reconstruction. Patients were randomly cued to palpate their natural breast, mastectomy site or breast reconstruction, and external silicone models. Three regions of interest (ROIs) associated with self-recognition were examined using a general linear model, and compared using a fixed effects and random effects ANOVA, respectively.

Results

In the delayed reconstruction group, activation of the ROIs was significantly lower at the mastectomy site compared to the natural breast (p<0.01). Ten months following reconstruction, activation of the ROIs in the reconstructed breast was not significantly different from that observed with natural breast palpation. In the immediate reconstruction group, palpation of the reconstructed breast was also similar to the natural breast. This activity was greater than that observed during palpation of external artificial models (p<0.01).

Conclusions

Similar activation patterns were observed during palpation of the reconstructed and natural breasts as compared to the non-reconstructed mastectomy site and artificial models. The cognitive process represented by this pattern may be a mechanism by which breast reconstruction improves self-perception, and thus patient satisfaction following mastectomy.     

Breast reconstruction by superior gluteal microvascular free flaps without silicone implants

The author's experience with 10 gluteus maximus myodermal free flap breast reconstructions is reviewed against the current methods of reconstruction using silicone implants, latissimus dorsi flaps, regional skin flaps, and rectus abdominis myodermal flaps. The superior gluteal free flap can achieve a reliable, permanent, and aesthetic reconstruction of the breast without silicone implants. The softness, projection, natural appearance, and patient satisfaction are excellent compared with other methods. It is particularly useful in patients who object to the use of artificial implants, are not suitable for regional flaps, or have disappointing results from previous reconstructions. Technical modifications of the flap design and selection of the recipient vessels are important.     

Salvage of infected expander prostheses in breast reconstruction

Periprosthetic infection is a devastating complication following breast reconstruction with prostheses. Traditional surgical principles dictate removal of the prosthesis to control infection. Although successful salvage of prostheses in the presence of periprosthetic infections has been reported in the plastic and other surgical literature, salvage procedures remain seldom practiced. Reports in the plastic surgery literature have been limited to implant salvage following cosmetic breast augmentation and subcutaneous mastectomy with implants. Salvage of saline-filled expander prostheses used in breast reconstruction following mastectomy for cancer has not been previously reported. The authors review their experience with implant salvage in patients with periprosthetic infections following breast reconstruction for a 6-year period. Fourteen patients (13 with saline-filled expander prostheses and one with silicone prosthesis) underwent implant salvage. Salvage of the breast reconstruction was successful in nine patients. Staphylococcus aureus infection was associated with poorer salvage rate (p = 0.023). Previous radiotherapy to the chest wall did not affect the salvage outcome (p = 0.50). In selected patients, immediate salvage of a breast reconstruction in the presence of prosthesis-related infection remains an alternative to implant removal followed by delayed reconstruction.     

Management of first trimester breast enlargement with necrosis.

We describe our management of two patients who had massive breast enlargement with necrosis in the first trimester. First, a therapeutic abortion was done to stop the breast growth, then we skin grafted the large ulcerated areas on the breasts, and finally we did a simple mastectomy with silicone gel implants for reconstruction. The latter procedure was to prevent almost certain recurrence of the problem during any succeeding pregnancy.     

An improved technique for immediate retropectoral reconstruction after subcutaneous mastectomy

Subcutaneous mastectomy is becoming an operation of choice in certain cases of premalignant and other breast pathology. We describe a technique for simultaneous subcutaneous mastectomy and retropectoral implantation of a silicone prosthesis. Gentle blunt prepectoral, retromammary dissection is performed through an axillary incision as far inferiorly as the inframammary fold, where a fibrous bridge between the anterior surface of the pectoralis major muscle and the skin prevents dissection any lower. Through the same incision, the retropectoral space is dissected to about 5 cm below the inframammary fold. A second incision is made in the inframammary fold to join the retromammary plane of the first dissection. The gland is then dissected subcutaneously and removed through the inframammary incision. A silicone implant is introduced retropectorally through the axillary incision, thus avoiding splitting the pectoralis major. Satisfactory results have been obtained in 23 bilateral and 14 unilateral cases; it is important that the dissection be performed carefully in order to prevent the implant from riding up too high in its musculoaponeurotic sling.     

The silicone gel-filled breast implant controversy: an update

Learning Objectives: After studying this article, the participant should: 1. Be familiar with the medical uses of silicone. 2. Have a working knowledge of the most important epidemiologic studies regarding silicone gel-filled breast implants. 3. Be aware of the issues about which patients desiring breast augmentation or reconstruction with implants must be counseled.     

Modified autogenous latissimus breast reconstruction and the box top nipple

During the past 3 years, the authors have been using the modified autogenous latissimus myocutaneous flap (MALF) for breast reconstruction in increasing numbers because of occasional patient and surgeon dissatisfaction with other methods of breast reconstruction. They have found this method to have unprecedented reliability, making it preferable to other forms of reconstruction in many patients. Considering the very low morbidity, the high patient satisfaction, and current economic factors, the authors are strong advocates of this form of reconstruction. A procedural outline proposed by McCraw and coworkers is followed, with some useful modifications. An elliptical transverse skin paddle is centered over the back fat roll. The area of the skin ellipse measures approximately 8 +/- 2 cm vertically and 30 +/- 5 cm transversely. After making the skin incision, a feathering technique is used in all directions through the fatty layer overlying the latissimus and in the tissue beyond the anteroposterior borders of the latissimus (not beyond 5 cm from the skin incision). By means of feathering, the shape of a breast mound can be created in the allowable tissue supported by the latissimus. A 180-degree rotation of the flap allows dependentvenous drainage and more bulk in the inferior outer quadrant, where it is needed. In the current series of 47 modified autogenous latissimus breast reconstructions, seromas were common. Other complications included one wound infection, one ulnar neuropraxia, and one fat necrosis. There were no flap necroses (partial or complete) or hematomas. The rarity of complications supports the use of this technique in selected patients. An innovative new technique for nipple reconstruction is also described. The "box top technique" of nipple reconstruction consists of four deepithelialized local flaps covered with a skin graft from the groin.     

Breast reconstruction using an inflatable breast implant with detachable reservoir

An inflatable breast implant having a detachable filling reservoir is described. Once in position, the implant can be filled under controlled conditions postoperatively. The implant functions either as a tissue expander or as a delayed-filling implant in the initial stages of the procedure. Once the desired breast size is achieved, the reservoir is removed, leaving the filled implant in position. This implant has been used successfully in various types of breast reconstructive procedures, including both primary and secondary reconstruction following modified mastectomy, immediate reconstruction following subcutaneous mastectomy, secondary reconstruction following radical mastectomy combined with the latissimus dorsi flap, and following the removal of silicone gel implants with associated capsular contracture. A total of 23 patients, representing 34 breasts, are reported on. The results have been encouraging over a period of 20 months of follow-up.     

Capsular contracture in silicone gel and saline-filled breast implants after reconstruction

Comparisons between results with randomly allotted silicone-gel and saline-filled prostheses in breast reconstruction after mastectomy led to the following conclusions. Neither prosthesis type is ideal. Leakage from saline-filled implants occurred in 2 of the 37 implants, with resultant deflation. Silicone prostheses had a significantly higher rate of capsular contracture [surgeon's evaluation: 54 percent capsular contracture for silicone-gel compared with 20 percent for saline-filled prostheses (p = 0.006); patients' evaluation for the same figures: 54 percent compared with 29 percent (p = 0.03)]. Other authors have shown the presence of silicone in the tissue around silicone-gel-filled silicone implants, but less or none around saline-filled silicone implants. Since the only difference between the two groups was the randomly allotted implants, we assume that the free silicone around silicone-gel-filled prostheses is the major cause of capsular contracture. Since the saline-filled implants showed a 20 percent capsular contracture rate, there could be other causes of capsular contracture in this study. For prevention of contracture, improved implant encapsulation and use of a less reactive filling substance seem to offer possibilities. Surgical technique should aim to preserve the integrity of the prosthesis.     

Sensitive areolar reconstruction in using a neurocutaneous island flap based on the medial antebrachial cutaneous nerve.

Sensory reconstruction has recently been stressed in breast reconstruction. However, there are no reports concerning the reconstruction of a sensitive areola. The bilateral reconstruction of a sensitive areola using a neurocutaneous flap based on the medial antebrachial cutaneous nerve is reported. The flap was harvested from the distal third of the forearm as an island flap and tunneled to reach the apex of the new breast, which was previously reconstructed using a 135-cc, gel-filled, silicone prosthesis covered by a latissimus dorsi myocutaneous flap. Six months later, fine sensibility in the reconstructed areola was demonstrated. The patient could perceive light touch, pain, and 14 mm two-point discrimination. At 2 months after surgery, 50 percent of cutaneous faulty stimulus location was observed. However, at 4 and 6 months after surgery, faulty location disappeared. Six months after harvesting the medial antebrachial cutaneous nerve, the sensory deficit was minimal; it included a hypoesthesic zone of 4 to 7 cm and an anesthesic zone of 2.5 to 5 cm on the middle third of the forearm. Fifteen months after the procedure, no hypoesthesic zone was observed; only a 2 to 3 cm anesthesic zone on the proximal medial side of the forearm existed. This sensory deficit passed unnoticed by the patient. The technique developed here is a refinement in breast reconstruction, and we think it should be used in selected patients.     

Pectoralis major "trapdoor" flap for silicone breast implant medial knuckle deformities.

Loss of breast parenchyma through surgery and physiologic involution can lead to problems of subglandular silicone breast implant palpability and even contour irregularities. This can give rise to patient concern and detracts from the aesthetics of the breast augmentation, particularly when it occurs medially. We present a simple solution to this problem on the medial side of the breast in the form of a small segmental medially based pectoralis major "trapdoor" flap that augments the implant soft-tissue cover intracapsularly, at the site where it is deficient. The technique, which has been used with success in five patients over 3 years, is described.     

A method of reconstructing a pendulous breast utilizing the tissue expander

It is possible to reconstruct a breast mound of almost any size by utilizing tissue expansion. In order to produce a pendulous breast which is also ptotic, the tissue-expansion technique has been combined with two other procedures. A new technique is being introduced. It is that of elevating the lower third of the mature breast capsule surrounding the tissue expander at the time the permanent prosthesis is to be exchanged for the expander. The established techniques of inframammary fold reconstruction of Pennisi and Ryan are used to provide pedicle skin coverage for the undersurface of the breast and the bed of the elevated capsule. Internal and external surgical approaches are described, and two examples of each are illustrated. Breasts reconstructed in this manner have remained pendulous structures. Some loss of the initial degree of ptosis has been noted in some cases.     

The inferior gluteal free flap in breast reconstruction

The inferior gluteal musculocutaneous free flap usually provides a sufficient amount of autogenous tissue for breast reconstruction when adequate tissue is not present in the lower abdomen or back. Its arteriovenous pedicle is longer than the superior gluteal musculocutaneous free-flap pedicle and permits microvascular anastomosis in the axilla, avoiding medial rib and cartilage resection. In the thin patient, there is more available donor tissue than with the superior gluteal musculocutaneous free flap. Cadaver dissections confirm the greater pedicle length and the local area of the lower gluteus maximus muscle needed to carry the skin island and have helped define a safe approach to flap elevation. We have used four flaps for breast reconstruction without vascular compromise or the need for reexploration. The low donor-site scar in the inferior buttock fold has been acceptable, especially for a bilateral reconstruction. The anatomy of the gluteal region, the surgical technique for the inferior gluteal free-flap transfer, and a 3-year patient follow-up are presented.     

Reduction mammaplasty with the "owl" incision and no undermining

Reduction mammaplasty has traditionally been done using the Wise pattern of incision. Because of the box-like effect in breast shape, the lack of projection, and the long scars associated with the inverted T incision, two techniques have emerged as alternatives: the vertical reduction of Lassus/Lejour and the "round block" periareolar technique popularized by Benelli. Each of these techniques has its pros and cons.The "owl" incision combines the features of the large periareolar reduction (Benelli's) and the vertical reduction (Lassus/Lejour); the horizontal inframammary scar is either made very short or completely eliminated. Volume reduction is done through a heart-shaped parenchymal resection, leaving the nipple-areolar complex over a supero-central pedicle. Maintenance of the central parenchyma behind the nipple-areolar complex and mobilization of the vertical pillars toward the center of the breast give excellent projection and diminish the lateral fullness. Enlargement of the periareolar skin resection diminishes the length and pleating of the vertical scar; conversely, inclusion of the vertical component to the periareolar technique eliminates the pleating effect of the periareolar incision. The short horizontal excision eliminates any resultant "dog ears" in the new inframammary fold. Thus, the discrepancy in the length of scars is better distributed. There is no skin or parenchymal undermining, so drains are not needed. Excellent results are obtained immediately on the operating table, and large volumes of glandular resection and correction of severe ptosis can be accomplished without compromising vascularity of either the nipple-areolar complex or the skin flaps.Ninety-four patients in a 7-year period were operated upon using this technique. Seventy-two had bilateral reductions up to 1900 gm per breast, 12 had unilateral reduction for symmetry following breast reconstruction, and 10 were patients with severe ptosis. Complications were rare and of a minor nature. No conversion to free grafts was done, even in the larger resections. One case required minor revision under local anesthesia, one case required bilateral re-reduction, and another case required unilateral re-reduction for continued growth of breast tissue. Almost 90 percent of the patients underwent procedures as outpatients.The owl-type incision and the supero-central pedicle flap are elements of a reduction mammaplasty technique that provides excellent projection and shape with minimal visible scars. It takes advantage of the positive features of the periareolar and vertical reduction techniques and minimizes their negative features. The new design of parenchymal resection improves the vascularity of the residual flaps. Additionally, it may better preserve the sensation to the nipple-areolar complex and lactation is not compromised.     

Breast reconstruction with contralateral rectus abdominis myocutaneous flap

A transverse myocutaneous rectus abdominis flap from the contralateral side has been employed for breast reconstruction in 52 patients. This flap has the advantage of balancing the patient by utilizing skin from an area of relative excess. The blood supply to the flap is based on the superior epigastric vessel and its perforators. The scar of the donor area is acceptable because it falls in the submammary sulcus. The use of a silicone implant can be avoided in some patients because of the adequate bulk of skin, muscle, and fat that is available. Abdominoplasty of the superior abdomen can be obtained during the same operation and can enhance the overall aesthetic results. Breast reconstruction is now possible with either ipsilateral or contralateral upper-abdominal transfer flaps, and further refinement of operative technique using the contralateral upper-rectus abdominis myocutaneous island flap must await further experience.