ArticlePDF Available

Use of Deepithelialized Flap in Mammoplasties: Simple Method With Excellent Results

Authors:
Jan Mestak at Bulovka University Hospital
Jan Mestak
Andrej Sukop at Charles University in Prague
Andrej Sukop
Ondrej Mestak at Charles University in Prague
Ondrej Mestak
Download full-text PDF
Read full-text
Download citation

Abstract and Figures

A deepithelialized flap is used in almost all surgical fields, particularly in plastic, reconstructive, and aesthetic surgery. This article describes several operating techniques using deepithelialized flaps that in specific cases can improve silicone breast implant coverage. All the patients underwent surgery in our department. The operations described are subcutaneous mastectomies with immediate reconstruction using silicone implants, mastopexy with immediate augmentation using silicone implants in a patient with very thin skin, and reaugmentation with mastopexy and reimplantation of silicone implants in a patient with very thin skin and extremely thin pectoral muscles. In all the described operations, we used a superolaterally based deepithelialized flap from the lower part of the breast that we fixed to the thoracic wall to cover the inferior part of the implant. The authors have extensive experience using this flap in such specific cases. To date, they have performed more than 30 operations using this technique. Each patient was followed for 2-7 years, and the findings show excellent postoperative results. None of the patients had implant extrusions, flap extrusions, or infections. The long-term cosmetic results were outstanding. The use of deepithelialized flaps in patients with very thin skin or pectoral muscles is a safe and easy way to improve implant coverage and prevent implant extrusion. This technique provides an alternative surgical option that can be beneficial in certain mammary cases.
Figures - uploaded by Ondrej Mestak
Author content
All figure content in this area was uploaded by Ondrej Mestak
Content may be subject to copyright.
Content uploaded by Ondrej Mestak
Author content
All content in this area was uploaded by Ondrej Mestak
Content may be subject to copyright.
ORIGINAL ARTICLE
Use of Deepithelialized Flap in Mammoplasties: Simple Method
With Excellent Results
Jan Mestak •Andrej Sukop •Ondrej Mestak
Received: 31 December 2010 / Accepted: 24 April 2011
ÓSpringer Science+Business Media, LLC and International Society of Aesthetic Plastic Surgery 2011
Abstract
Background A deepithelialized flap is used in almost all
surgical fields, particularly in plastic, reconstructive, and
aesthetic surgery. This article describes several operating
techniques using deepithelialized flaps that in specific cases
can improve silicone breast implant coverage.
Methods All the patients underwent surgery in our
department. The operations described are subcutaneous
mastectomies with immediate reconstruction using silicone
implants, mastopexy with immediate augmentation using
silicone implants in a patient with very thin skin, and
reaugmentation with mastopexy and reimplantation of sil-
icone implants in a patient with very thin skin and extre-
mely thin pectoral muscles. In all the described operations,
we used a superolaterally based deepithelialized flap from
the lower part of the breast that we fixed to the thoracic
wall to cover the inferior part of the implant.
Results The authors have extensive experience using this
flap in such specific cases. To date, they have performed
more than 30 operations using this technique. Each patient
was followed for 2–7 years, and the findings show excel-
lent postoperative results. None of the patients had implant
extrusions, flap extrusions, or infections. The long-term
cosmetic results were outstanding.
Conclusion The use of deepithelialized flaps in patients
with very thin skin or pectoral muscles is a safe and easy
way to improve implant coverage and prevent implant
extrusion. This technique provides an alternative surgical
option that can be beneficial in certain mammary cases.
Keywords Breast reconstruction
Deepithelialized flap Mastopexy Reaugmentation
Subcutaneous mastectomy
Introduction
Free dermal grafts or pedicled deepithelialized dermal flaps
are used in almost all surgical fields [1–5]. In general
surgery, pedicled deepithelialized dermal grafts were his-
torically used for abdominal wall reconstruction. This
technique has been replaced by new biomaterials such as
acellular allografts and xenografts [6].
Currently, deepithelialized flaps are used frequently by
plastic surgeons, especially for mammoplasties. Most
breast reduction and mastopexy techniques use deepithel-
ialized dermoglandular flaps for protrusion of the nipple–
areolar complex (NAC) when it requires new placement
[7]. Longacre [8] was one of the first surgeons to use
deepithelialized flaps from the abdominal wall for breast
augmentation.
Bohmert and Gapka [9] described the use of an inferi-
orly based flap to duplicate coverage of the breast implant
under the nipple in cases of breast reconstruction with an
implant after subcutaneous mastectomy. Another option in
reconstructive cases is the use of serratus anterior fascia
[10]. Currently, acellular dermal matrices (e.g., Alloderm,
Strattice, Permacol) are more frequently used to enhance
J. Mestak (&)O. Mestak
Department of Plastic Surgery, 1st Medical Faculty of Charles
University in Prague, University Hospital Bulovka,
Prague 8 180 00, Czech Republic
e-mail: mestak@gmail.com
A. Sukop
Department of Plastic Surgery, 3rd Medical Faculty of Charles
University in Prague, University Hospital Kralovske Vinohrady,
Prague 10 110 00, Czech Republic
123
Aesth Plast Surg
DOI 10.1007/s00266-011-9745-5
coverage of the implant’s inferior portion in breast recon-
struction and augmentation [11]. Nevertheless, their high
cost prevents the widespread use of this technique.
We did not find any literature in common databases
(Medline, PubMed, or Ovid) describing the use of deepi-
thelialized flaps in these types of procedures. This report
describes several operating techniques that use a supero-
laterally based deepithelialized flap fixed to the thoracic
wall with several stitches to enhance breast implant cov-
erage in patients with insufficient amounts of soft tissue in
the inferior aspect of the breast (Fig. 1a–d). These tech-
niques are subcutaneous mastectomy with immediate
reconstruction using silicone implants, mastopexy with
immediate augmentation using silicone implants in a
patient with very thin skin, and reaugmentation with
mastopexy and reimplantation of silicone implants in a
patient with very thin skin and extremely thin pectoral
muscles. The vascular supply of this flap is provided
superiorly by lateral mammary branches of the lateral
thoracic artery and partly by medial mammary branches of
the internal thoracic artery [12]. This rich vascular supply
greatly diminishes the risk of ischemic complications [13].
When using the superolateral pedicle, we preserve sen-
sitivity of the NAC by sparing the anterior ramus of the
fourth intercostal nerve, which supplies it [12,14].
Patients and Methods
From more than 30 cases managed with this technique
(Table 1), we selected 3 to illustrate the procedure. We
used silicone implants in all cases.
The first patient underwent radical subcutaneous mas-
tectomy of the right breast with immediate breast recon-
struction using a silicone implant placed under the major
pectoral muscle (Fig. 2a). The inferior aspect of the implant
was covered by a superiorly based deepithelialized skin flap
acquired from the inferior aspect of the breast and fixed to
the thoracic wall with five stitches (Fig. 2b). The patient
was discharged from the hospital after the drain was
removed on postoperative day 3. The patient healed
uneventfully (Fig. 2c). We followed the patient for 14 years
and observed excellent long-term results (Fig. 2d).
With the second patient, we used a superiorly based
deepithelialized dermoglandular flap to cover the implant’s
inferior portion in a case that involved mastopexy using
immediate augmentation in a patient with very thin skin.
This patient was discharged from the hospital after the
drain was removed on postoperative day 2. Healing was
uneventful for this patient as well.
With the third patient, we used a deepithelialized flap to
correct a previous augmentation with 280-ml implants after
Fig. 1 a Diagram of the flap
after deepithelialization.
bDiagram of the raised
deepithelialized flap. The
implant under the pectoralis
muscle is shown. cScheme of
the flap fixed to the thoracic
wall. Direction of the closure is
shown. dScheme of the breast
after wound closure
Aesth Plast Surg
123
Table 1 Complete table of 30 patients who underwent the described procedure listing diagnosis, procedure, and complications
Diagnosis Procedure Complications
BRCA Prophylactic subcutaneous mastectomy with
modelation and immediate breast implant
reconstruction
Minor dehiscence of the vertical and
horizontal scar junction on both sides
BRCA Prophylactic subcutaneous mastectomy with
modelation and immediate breast implant
reconstruction
None
Fibrocystic mastopathy Prophylactic subcutaneous mastectomy with
modelation and immediate breast implant
reconstruction
Minor dehiscence of the vertical and
horizontal scar junction on both sides
BRCA Prophylactic subcutaneous mastectomy with
modelation and immediate breast implant
reconstruction
Capsulation in the right breast
BRCA Prophylactic subcutaneous mastectomy with
modelation and immediate breast implant
reconstruction
Minor dehiscence of the vertical and
horizontal scar junction on both sides
Fibrocystic mastopathy Prophylactic subcutaneous mastectomy with
modelation and immediate breast implant
reconstruction
None
Dysplastic changes of the right
breast
Prophylactic subcutaneous mastectomy of the right
breast with modelation and immediate breast
implant reconstruction
None
Dysplastic changes Subcutaneous mastectomy with modelation and
immediate breast implant reconstruction
Capsulation of both breasts
Asymmetric ptotic breast Mastopexy with augmentation (120 ml) Capsulation of the right breast, elevated left
submammar line
Augmented breast (180 ml) with
ptosis, asymmetry
Mastopexy with reaugmentation (180 cc) None
Asymmetric ptotic breast Mastopexy with augmentation (180 ml right, 120 ml
left)
None
Ptotic breast Mastopexy with augmentation (150 ml) None
Augmented breast (210 ml) with
capsulation and ptosis
Mastopexy with reaugmentation (150 cc) Implant elevation on the right side, minor
NAC dehiscention on the right side
Augmented large breast (260 ml) Mastopexy with reaugmentation using smaller
implants (150 ml)
None
Ptotic breast Mastopexy with augmentation (120 ml)
subglandular
None
Ptotic breast Mastopexy with augmentation (180 ml) None
Augmented breast (180 ml) with
capsulation and ptosis
Mastopexy with reaugmentation (180 ml) Minor dehiscention next to the left NAC
Augmented breast (300 ml) with
capsulation and ptosis
Mastopexy with reaugmentation (210 ml) Right NAC slightly elevated, corrected by
supra-areolar excision
Ptotic breast Mastopexy with augmentation (180 ml) None
Augmented breast (210 ml) with
capsulation and ptosis
Mastopexy with reaugmentation (180 ml) None
Augmented breast (180 ml) with
capsulation and ptosis
Mastopexy with reaugmentation (150 ml) None
Ptotic breast Mastopexy with augmentation (150 ml) None
Augmented large breast (280 ml) Mastopexy with reaugmentation using smaller
implants (210 ml)
None
Augmented breast (300 ml) with
capsulation and ptosis
Mastopexy with reaugmentation (210 ml) None
Ptotic breast Mastopexy with augmentation (180 ml) None
Augmented breast (210 ml) with
ptosis
Mastopexy with reaugmentation (210 ml) Minor dehiscence of the vertical and
horizontal scar junction on the left
Aesth Plast Surg
123
a significant weight loss (her weight was 38 kg) (Fig. 3a).
She had extremely thin skin and atrophic major pectoral
muscles that formed a very thin membrane (Fig. 3b). We
performed mastopexy and reaugmentation (210 ml), cov-
ering the implant with a superolaterally based deepitheli-
alized flap fixed to the thoracic wall (Fig. 3c). The patient
was discharged from the hospital on postoperative day 2.
Healing was uneventful. She was followed-up for 2 years
with excellent postoperative cosmetic results (Fig. 3d, e).
Discussion
The use of breast implants in an environment with insuf-
ficient amounts of soft tissue (skin and large pectoral
muscle) in the inferior aspect of the breast is challenging. It
can be associated with implant rippling, unsuitable shape
and contour of the breast, and at worst, implant extrusion.
A few surgical approaches and techniques can decrease
the risk of these complications. One is the use of acellular
Fig. 2 a Patient requiring
subcutaneous mastectomy on
the right and reconstruction of
the left breast with an implant.
Frontal view. bIntraoperative
view after subcutaneous
mastectomy and insertion of the
implant, which is covered with
the deepithelialized flap.
cPostoperative view of the
patient after subcutaneous
mastectomy of the right breast
with immediate reconstruction
using a silicone implant and
reconstruction of the left breast
with a silicone implant. Frontal
view. dCosmetic results
14 years postoperatively
Table 1 continued
Diagnosis Procedure Complications
Augmented breast (300 ml) with
ptosis
Mastopexy with reaugmentation (210 ml) None
Augmented breast (180 ml) with
capsulation and ptosis
Mastopexy with reaugmentation (150 ml) None
Augmented large breast (310 ml) Mastopexy with reaugmentation using smaller
implants (180 ml)
None
Augmented breast (180 ml) with
ptosis
Mastopexy with reaugmentation (210 ml) None
NAC nipple–areolar complex
Aesth Plast Surg
123
dermal matrices to enhance coverage of the inferior aspect
of the breast implant. However, the use of these allogenic
biomaterials carries a slight risk of additional complica-
tions such as infection or insufficient biocompatibility. In
addition, the high cost prevents their widespread use.
Another option in reconstructive cases is the use of serratus
anterior fascia [10].
The deepithelialized dermoglandular flap is currently
used regularly for breast reduction and breast mastopexy
[7]. Similar flaps can be used in certain cases to cover the
inferior portion of the implant in breast reconstruction after
subcutaneous mastectomy, as described by Bohmert and
Gapka in 1997 [9]. To our knowledge, the use of supero-
laterally based flaps fixed to the thoracic wall for coverage
of an implant’s inferior portion with breast mastopexy
using either augmentation or breast reaugmentation has not
been described previously in the literature.
The technique we describe is safe and easy to reproduce.
Unlike acellular dermal matrices, the flap consists of vas-
cularized autologous tissue. In none of the cases managed
with this technique did we experience major ischemic
complication such as nipple loss. The only complications
we experienced were a small wound dehiscence and
implant capsulation. Sufficient vascular supply is secured
by lateral mammary brunches of the lateral thoracic artery
[12,13].
Opinions about the best ways of preserving NAC
innervation vary. In our experience, the use of a supero-
lateral pedicle ensures sparing of the anterior ramus of the
fourth intercostal nerve that supplies the NAC, as described
in previous anatomic studies [12,14]. This method is very
useful in cases with breast tissue (skin and large pectoral
muscle) of insufficient quality that require adequate cov-
erage of the implant to decrease the risk of implant
Fig. 3 a Preoperative view of a
patient 4 years after subpectoral
augmentation with 280-ml
silicone implants and after
losing 8 kg of weight. This
patient required reaugmentation
with mastopexy. Frontal view.
bAtrophic major pectoral
muscles appearing as a thin
membrane. cDue to extremely
thin, atrophic skin and pectoral
muscles, a dermal
deepithelialized graft was used
to cover the lower part of the
implant. d, e The patient
12 months postoperatively
Aesth Plast Surg
123
protrusion. By supporting the breast, this flap helps to
improve the final cosmetic result of the operation.
Conclusion
The use of deepithelialized flaps in patients with very thin
skin or pectoral muscle is a safe and easy way to improve
implant coverage and prevent implant extrusion. It repre-
sents an autologous alternative to the increasingly popular
acellular dermal matrices (e.g., Alloderm, Strattice, Per-
macol). The method described in this article provides an
alternative surgical option that can be beneficial in certain
mammary cases.
Acknowledgment This study was supported by research Grant IGA
NT 11 392-6/2010 from the Ministry of Health of the Czech Republic.
Conflict of interest The authors declare that they have no conflict
of interest.
References
1. Fogh-Andersen P (1963) Repair of monstrous ventral hernias
with buried dermis or whole skin grafts. Acta Chir Scand
126:466–473
2. Hagstro
¨m P, Nyle
´n B (1976) Repair of incisional hernias and
defects in the anterior abdominal wall using dermal grafts: case
report. Scand J Plast Reconstr Surg 10:157–158
3. Hutan M, Salapa M, Jamriska J (1994) Corium transplantation in
reconstruction of ventral hernias (in Slovak). Bratisl Lek Listy
95:228–231
4. Korenkov M, Eypasch E, Paul A, Ko
¨hler L, Troidl H (1997)
Autodermal hernioplasty: a rare and unknown technique. Zen-
tralbl Chir 122:871–878
5. Shaffer JO (1956) Massive and recurrent hernias: use of dermal
grafts in carrying out repair. Calif Med 85:10–14
6. Catena F, Ansaloni L, Gazzotti F, Gagliardi S, Di Saverio S,
D’Alessandro L, Pinna AD (2006) Use of porcine dermal colla-
gen graft (Permacol) for hernia repair in contaminated fields.
Hernia 11:57–60
7. Bostwick J (2000) Plastic and Reconstructive Breast Surgery, 2nd
edn. Quality Medical Publishing, St. Louis
8. Longacre JJ (1954) Correction of the hypoplastic breast with spe-
cial reference to reconstruction of the ‘‘nipple type breast’’ with
local dermo-fat pedicle flaps. Plast Reconstr Surg 14:431–441
9. Bohmert H, Gabka CJ (1997) Plastic and Reconstructive Surgery
of the Breast. Thieme, Stuttgart
10. Saint-Cyr M, Dauwe P, Wong C, Thakar H, Nagarkar P, Rohrich RJ
(2010) Use of the serratus anterior fascia flap for expander coverage
in breast reconstruction. Plast Reconstr Surg 125:1057–1064
11. Gamboa-Bobadilla GM (2006) Implant breast reconstruction
using acellular dermal matrix. Ann Plast Surg 56:22–25
12. Macea JR, Fregnani HJTG (2006) Anatomy of the thoracic wall,
axilla, and breast. Int J Morphol 24:691–704
13. Tracy CA, Pool R, Gellis M, Vasileff W (1992) Blood flow of the
areola and breast skin flaps during reduction mammaplasty as
measured by laser Doppler flowmetry. Ann Plast Surg 28:
160–166
14. Farina MA, Newby BG, Alani HM (1980) Innervation of the
nipple–areola complex. Plast Reconstr Surg 66:497–501
Aesth Plast Surg
123
... Two types of DSs with a modified circulatory basis have been reported (Table 2). Two studies [55,56] have described a technique with a supero-laterally based de-epithelialized flap that is cut inferiorly and then sutured in the inframammary fold over the implant (Figure 13). The authors argue that a superiorly based flap has a richer vascular supply than an inferiorly based flap and that the sensitivity of the NAC is better preserved [55]. ...
... Two studies [55,56] have described a technique with a supero-laterally based de-epithelialized flap that is cut inferiorly and then sutured in the inframammary fold over the implant (Figure 13). The authors argue that a superiorly based flap has a richer vascular supply than an inferiorly based flap and that the sensitivity of the NAC is better preserved [55]. The other type of DS with a modified circulatory basis is laterally based flap [57]. ...
Breast reconstruction with a dermal sling: a systematic review of surgical modifications
Article
  • Dec 2018
A dermal sling (DS) is used to cover the implant with two layers of tissue when immediate breast reconstruction is performed in women with large and ptotic breasts. It works as an autologous acellular dermal matrix/mesh that can be used to control the implant pocket and inframammary fold, without inferring an extra foreign material and higher costs. There is relatively little published about the DS technique. The primary aim of this study was to systematically review published surgical modifications to the dermal sling (DS). The secondary aim was to investigate what implants have been used. Relevant databases were searched for articles and abstracts published between January 1990 and September 2018. Inclusion criteria were studied and case reports on DS meeting the criteria defined in a PICO. Review articles were excluded. Total evidence for the different types of DSs was graded according to GRADE. A total of 428 abstracts were retrieved. Of these 373 abstracts did not meet the inclusion criteria and were excluded, leaving 54 abstracts. Nine categories of surgical modifications could be identified: classic dermal sling (DS) with minor modifications, non Wise-pattern mastectomy DS, nipple areola complex bearing DS, DS in combination with a matrix/mesh, DS as a suture line protection technique, DS with a modified circulatory basis, DS without an implant, DS as an immediate-delayed technique and pre-pectoral DS. The evidence for DS as a surgical technique is very low (GRADE ⊕). The DS can be used with both permanent implants and tissue expanders (GRADE ⊕).
View
... This dermal flap forms a dermal barrier to the implant and also adds soft-tissue support. 3,4,10,11 Further tightening of the vertical incision can also be performed postoperatively without additional scarring if needed. Further elevation can also be achieved easily (Fig. 8). ...
Immediate Implant-based Prepectoral Breast Reconstruction Using a Vertical Incision
Article
Full-text available
  • Jun 2015
Ideally, breast reconstruction is performed at the time of mastectomy in a single stage with minimal scarring. However, postoperative complications with direct-to-implant subpectoral reconstruction remain significant. These include asymmetry, flap necrosis, animation deformity, and discomfort. We report on a series of patients who have undergone immediate single-stage prepectoral, implant-based breast reconstruction with a smooth, adjustable saline implant covered with mesh/acellular dermal matrix for support using a vertical mastectomy incision. This technique, when combined with an adjustable implant, addresses the complications related to subpectoral implant placement of traditional expanders. Our follow-up time, 4.6 years (55 months), shows a low risk of implant loss and elimination of animation deformity while also providing patients with a safe and aesthetically pleasing result. All patients who underwent immediate implant-based prepectoral breast reconstruction using a vertical mastectomy incision as a single-staged procedure were included. Charts were reviewed retrospectively. Adjustable smooth round saline implants and mesh/acellular dermal matrix were used for fixation in all cases. Thirty-one patients (62 breasts) underwent single-staged implant-based prepectoral breast reconstruction using a vertical mastectomy incision. Postoperative complications occurred in 9 patients, 6 of which were resolved with postoperative intervention while only 2 cases resulted in implant loss. There can be significant morbidity associated with traditional subpectoral implant-based breast reconstruction. As an alternative, the results of this study show that an immediate single-stage prepectoral breast reconstruction with a smooth saline adjustable implant, using a vertical incision, in conjunction with mesh/matrix support can be performed with excellent aesthetic outcomes and minimal complications.
View
... It is more than what has already been described as breast conserving surgery, cosmetic quadrantectomy, low pole tumor reduction mammoplasty, central tumor reduction, therapeutic mammoplasty, and tumor specific immediate reconstruction [2,19,62e64]. It concerns as well several different combinations including excision of the tumor by reduction mammoplasty, tumor excision followed by remodeling mammoplasty, partial mastectomy with reconstruction and mastectomy with immediate reconstruction [30,56]. OBS applies to breast reconstruction following SSM/SRM and more recently to areola or nipple areola complex preserving mastectomies [14] with or without contralateral mastopexy or reduction mammoplasty. ...
Skin sparing/skin reducing mastectomy (SSM/SRM) and the concept of oncoplastic breast surgery
Article
  • Aug 2014
  • Int J Surg
Introduction: With the better understanding of breast cancer history and biology, improved diagnostic modalities and the shift towards minimally invasive surgeries, indications for prophylactic mastectomy, skin sparing or skin reducing mastectomies (SSM/SRM) with nipple areolar complex (NAC) preservation coupled with immediate breast reconstruction are gaining popularity. The authors share their experience and conception with mastectomy and immediate alloplastic breast reconstruction with the esthetic circumvertical mammoplasty pattern combined with the dermal barrier buttress flap. Material and methods: The described technique was performed for 28 patients presenting for mastectomy and immediate alloplastic breast reconstruction. With close collaboration between the oncologic and plastic surgeons, mastectomy was performed in all cases with the esthetic circumvertical mammoplasty pattern. To achieve safe excision and optimal reconstruction, the standard incisions could be custom designed to fit oncologic requirements and allow the creation of a dermal barrier flap used as a buttress separating the implant from the suture line. Conclusion: The circumvertical mastectomy pattern combined with the dermal barrier buttress flap is a versatile option allowing safe reconstruction regardless of the tumor and necessary skin excision location.
View
Risk Comparison Using Autologous Dermal Flap and Absorbable Breast Mesh on Patient Undergoing Subcutaneous Mastectomy with Immediate Breast Reconstruction
Article
  • Feb 2022
In patients with large breasts undergoing a subcutaneous mastectomy with immediate implant-based reconstruction, is necessary to perform a mastopexy. The combination of these procedures increases the complication rate. To reduce it, it is necessary to cover the lower pole of the implant. Our study aimed to compare the use of an autologous dermal flap and an absorbable breast mesh. A total of 64 patients without previous breast surgery were divided into 2 groups, each with 32 patients. In the 1st group, the implant was covered with an autologous caudally based dermal flap, sutured to the great pectoral muscle. In the 2nd group, the implant was covered with a fully absorbable breast mesh, fixed caudally in the inframammary fold and cranially to the great pectoral muscle. The incidence of complications, the aesthetic effect, and patient satisfaction were evaluated in a one-year follow-up. In the 1st group, there were 2 cases of seroma, 2 partial nipple-areola complex necrosis, 4 cases of dehiscence in the T-suture, and the malposition of the implant in 2 patients. In the 2nd group, there were 2 cases of seroma, 2 cases of T-junction dehiscence, and 1 case of full nipple-areola complex necrosis, which resulted in implant loss. There was no significant difference in patient satisfaction between the study groups. The dermal flap is more suitable for breasts with pronounced ptosis. The use of the synthetic mesh is suitable for smaller breasts, where the possible dermal flap would be too small to cover the implant. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.
View
Layered Mastopexy with Augmentation in Muscle Splitting Biplane: A Modification for Lower Pole Safety and Stability
Article
  • Aug 2021
Background Single-stage mastopexy with augmentation is a commonly performed procedure. The single-stage procedure can be performed in primary cases or a secondary procedure in patients with previous history of augmentation, mastopexy or mastopexy with augmentation. The procedure is challenging and not without its risks.MethodsA retrospective chart review of all consecutive cases of layered mastopexy with augmentation mammoplasties, carried out from September 2015 to August 2019, was performed. All patients had their implants placed in muscle splitting pocket first and access for the pocket was closed prior to the commencement of mastopexy.ResultsDuring the period of 4 years, 102 consecutive layered mastopexy with augmentations were performed in muscle splitting plane. Of these 102 patients, 74 (72.5%) patients had it as a primary and 28 (27.5%) as a secondary procedure. Of these 102 patients, 53 (52.0%) had textured, 37 (36.3%) had smooth and 12 (11.8%) had microtextured implants and 72 (70.6%) patients had high profile and 30 (29.4%) had medium profile implants. Same size implant was used in 89 patients with a mean of 298 cc, and 13 patients had different size implants with a mean of 362 cc on the right and 395 cc on the left. In current study, bilateral periareolar, vertical scar cat’s tail and Wise pattern mastopexies were performed in 11, 51 and 27 patients, respectively. Of the 102 patients, 5 had unilateral right periareolar, 5 unilateral right vertical scar cat’s tail, 2 unilateral left periareolar and 1 patient had a combination of periareolar and vertical scar combination. There was no nipple loss or periprosthetic infection. There was a minor wound breakdown seen in 4 (3.9%), haematoma in 2 (2.1%), nipple sensation loss in 2 (2.1%) and 12 (11.8%) had layered mastopexy as a part of a combined procedure. Revision was performed in 6 (6.5%), drains were used in 14 (13.7%), and 92 (90.2%) had the procedure performed as a day case.Conclusion Layered mastopexy with augmentation is a safe procedure with added stability and safety to lower pole of the breast as well as nipple-areolar complex.Level of Evidence IVThis journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authorswww.springer.com/00266.
View
Dermal Autografts in Breast Reconstruction: A Review of Past and Current Trends
Article
  • Jan 2020
Breast cancer affects 1 in 8 women. As the treatment of breast cancer evolves, breast reconstruction does as well. Implant-based reconstructions are increasing, leading to increased use of acellular dermal matrix (ADM) for better implant positioning. Acellular dermal matrices are derived from cadaveric skin and are processed to be immunologically inert. However, ADM can be costly and can have complications such as seroma and infection. This has led to the development of dermal autografts. These were first used in postmastectomy breast reconstruction in women with redundant breast skin that was deepithelialized and used for lower pole coverage of tissue expanders and implants. This evolved into harvesting dermal autografts from the abdomen. Later studies evaluated the use of meshed dermal autografts. Histological analysis of ADM versus dermal autografts shows that there are increased vessels within dermal autografts compared with ADM. This potentially contributes to the decreased complication rate seen with autografts. In addition, one study showed equivalent results in aesthetic outcomes and capsular contracture between ADM and dermal autograft. Analysis of cost has shown that ADM is significantly more costly than harvesting a dermal autograft. Physician reimbursement is also higher for dermal autografts. This review article seeks to summarize key studies that highlight the feasibility of using dermal autografts in breast reconstruction.
View
The Tuck-in Mastopexy
Article
  • Jun 2018
Background: Breast ptosis is an inevitable consequence of gravity and time. Every breast tends to become ptotic in different shapes and degrees. Many surgical techniques were described to solve this problematic issue. The aim of this article is to describe a mastopexy technique used for grades 1 to 2 ptosis, "tuck-in" mastopexy technique. Methods: Keyhole pattern was used for skin markings. All the planned skin excision areas were de-epithelialized. Breast mound was elevated as a 1-piece flap with extensive subglandular dissection. Elevated breast flap was reshaped and repositioned. Skin incisions were sutured in 2 layers. Results: Seventeen patients were operated on with this technique; average follow-up time was 10.1 months. No major complications were seen. The results were pleasing for both the patients and the surgeon. Conclusions: The "tuck-in" mastopexy technique uses breast mound as 1-piece flap, which has great vascularity from medial, superior, and lateral pedicles. Large areas of de-epithelialization facilitate reshaping and repositioning. It permits simultaneous or secondary breast augmentation with silicone gel implants. This easy-to-do technique has low complication rates and a short learning period.
View
“Immediate breast reconstruction with a Wise pattern mastectomy and NAC-sparing McKissock vertical bipedicle dermal flap”
Article
  • Jun 2018
  • J PLAST RECONSTR AES
Preservation of the nipple–areola complex (NAC) in immediate reconstruction of ptotic and large breasts is surgically challenging. This article presents a modification of the inferior dermal flap (“dermal sling”) to a vertical bipedicle flap with NAC preservation. This flap is well described in breast reductions but has never been described in a mastectomy setting. The study reviews data for a case series of 17 breasts in 11 women who underwent breast reconstruction with the new technique. The complication rate was 12%, thus indicating that the vertical bipedicle NAC-sparing flap should be considered a feasible option for breast reconstruction in women with ptotic and/or large breasts.
View
Acellular Dermal Matrix Versus Inferior Deepithelialized Flap Breast Reconstruction: Equivalent Outcomes, with Increased Cost
Article
Full-text available
  • Jun 2017
Background Approximately 250,000 new cases of breast cancer are diagnosed yearly in the U.S. resulting in more postmastectomy breast reconstructions (PMBRs). The acellular dermal matrix (ADM) expander-implant method became popular in the mid-2000s, but newer techniques such as the inferior deepithelialized flap (IDF) has more recently been described. We hypothesize that ADMs and IDFs provide comparable aesthetic outcomes, with no difference in complication rates and operative characteristics. Methods A retrospective, single-institution study was performed between July 1, 2012, and June 30, 2014, examining all PMBR’s (ADM and IDF). Outcomes were categorized as clinical (e.g., complications requiring surgical intervention) or aesthetic. Results A total of 65 patients (41 ADM; 24 IDF; mean age, 53.4 ± 10.7 years) were included, with 101 PMBR’s evaluated (63 ADM and 38 IDF). Patients who underwent IDFs had higher body mass index (32 versus 25; P < 0.01) and higher grades of breast ptosis. Major complication rates were similar between ADM and IDF groups (22% versus 31.5%; P = 0.34). There were no differences in aesthetic outcomes between groups (rater intraclass correlation, 0.92). The average IDF breast reconstruction took nearly 30 minutes longer per reconstructed side (192 minutes versus 166 minutes; P = 0.02), but operative costs were more expensive for the ADM breast reconstruction. Conclusions The IDF procedure took 30 minutes longer for each reconstructed side, without significant differences in complications or aesthetic outcomes between the 2 PMBRs. IDF reconstructions may be more suitable for patients with grade 3 breast ptosis and higher body mass index. Further studies should focus on long-term outcomes and value-based approaches to PMBR.
View
Erratum to: Simplified skin excision pattern for skin-sparing/reducing mastectomy and direct-to-implant single-stage immediate (DISSI) breast reconstruction
Article
Full-text available
  • May 2015
Background One-stage implant-based breast reconstruction with minimal scarring is a highly appealing option to most patients. In fact, expander/implant reconstruction accounts for nearly 70 % of all breast reconstructions. We present our experience with a simplified skin-preserving/reducing excision pattern in association with immediate breast reconstruction using permanent expander or prosthesis. Methods Thirty-two patients with 45 reconstructed breasts (unilateral or bilateral) between February 2010 and March 2014 are included in this study. All implants, except for two reconstructed breasts, were placed in a dual plane. Implants used were either a permanent expander or permanent silicone prosthesis. Results Two patients developed postoperative infections requiring removal of the implants. Minor wound dehiscence without implant extrusion occurred in one breast. One breast had a late deflation of the permanent expander secondary to trauma. Another patient required postoperative revision with fat grafting to improve breast contour. Conclusions One-stage prosthetic-based immediate breast reconstruction is a safe option with gratifying outcomes provided adequate patients’ selection and enough surgeons’ expertise to perform it. Level of Evidence: Level IV, therapeutic study.
View
Anatomía de la Pared Torácica, Axila y Mama
Article
Full-text available
  • Dec 2005
For adequate treatment of patients with breast cancer, mastologists should have a complete understanding of the anatomy of the thoracic wall, axilla and breast. However, the classical anatomical descriptions in textbooks make it difficult to gain full mastery of this subject, because the books usually deal with its elements separately. In an endeavor to resolve this difficulty, the present authors have conducted an extensive review, to describe the muscles, blood vessels and nerves of the thoracic wall and in the axilla that are of interest to mastologists. The axilla was described in detail, with emphasis on its limits, walls and contents, and highlighting the lymph nodes in this region. Finally, the anatomy of the breast and its topography, innervation, vascularization and lymph drainage were described, making correlations between the anatomy and the lymph node group classification routinely used by mastologists.
View
Anatomy of the Thoracic Wall, Axilla and Breast
Article
Full-text available
  • Dec 2006
For adequate treatment of patients with breast cancer, mastologists should have a complete understanding of the anatomy of the thoracic wall, axilla and breast. However, the classical anatomical descriptions in textbooks make it difficult to gain full mastery of this subject, because the books usually deal with its elements separately. In an endeavor to resolve this difficulty, the present authors have conducted an extensive review, to describe the muscles, blood vessels and nerves of the thoracic wall and in the axilla that are of interest to mastologists. The axilla was described in detail, with emphasis on its limits, walls and contents, and highlighting the lymph nodes in this region. Finally, the anatomy of the breast and its topography, innervation, vascularization and lymph drainage were described, making correlations between the anatomy and the lymph node group classification routinely used by mastologists.
View
Plastic and Reconstructive Surgery in Breast Cancer Patients
Chapter
  • Jan 1989
The evolution of breast reconstruction mirrors the progress in the field of reconstructive surgery in general. Early breast reconstructive attempts included migration of local and distant tubed pedicle flaps into the mastectomy defect and sharing of the opposite breast. These procedures are of historical interest only, as such methods usually fell short of a pleasing and satisfying reconstruction. With the development of new and reliable techniques, particularly rotation and advancement flaps, in combination with synthetic breast prosthesis, results have improved tremendously. Recent advances in reconstructive surgery, particularly the application of the latissimus dorsi and rectus abdominis musculocutaneous flap, have made breast reconstruction possible for virtually any patient who has had a mastectomy. Microvascular free flaps were added to these techniques and earned a role in certain breast reconstructions difficult to accomplish with convential techniques. Furthermore, tissue expanders have enriched our armamentarium, especially for immediate breast reconstruction. Now there are different ways to rebuild the breast and the development of numerous procedures have resulted in the most dramatic and impressive improvements in confidence and self-esteem that have been seen in the field of plastic surgery during the past decade.
View
View
View
View
View
Use of the Serratus Anterior Fascia Flap for Expander Coverage in Breast Reconstruction
Article
  • Apr 2010
Postmastectomy partial submuscular tissue expander placement can prevent the upper pole fullness commonly seen with complete submuscular prosthesis placement. The resultant inferior and lateral margins require coverage to prevent prosthesis exposure. The fascial layer overlying the serratus anterior muscle can be used as an alternative to previously defined techniques to provide composite lateral coverage. This method offers adequate coverage, prevents expander lateralization, and minimizes use of allogenic material. This study reports the anatomy, surgical procedure, clinical outcomes, and aesthetics following use of the serratus anterior fascial flap for lateral expander coverage in postmastectomy expander-based breast reconstruction. Twenty-two patients (31 breasts) who underwent breast reconstruction with serratus fascia were included in a retrospective case-note analysis after approval by the institutional review board. Demographics, perioperative factors, postoperative complications, patient satisfaction, and aesthetics were recorded as relevant endpoints. Ten fresh cadaver hemichests were dissected, and the serratus fascia for each was measured for length and width. At a mean follow-up of 197 days (range, 71 to 370 days), seroma occurred in two breasts, wound infection occurred in one breast, partial mastectomy skin flap necrosis occurred in four breasts, and minor wound dehiscence occurred in one breast. There were no incidences of capsular contracture or hematoma. Four patients (five breasts) reported very mild tightness or banding in the lateral chest wall. The mean length of cadaver serratus fascia was 164.3 mm and the mean width was 122.8 mm. The serratus anterior fascia flap is a versatile and safe alternative for providing vascularized composite lateral prosthesis coverage in expander-based breast reconstruction.
View
View
Repair of Incisional Hernias and Defects in the Anterior Abdominal Wall Using Dermal Grafts
Article
  • Feb 1976
  • Scand J Plast Reconstr Surg
The technique and results of using autografts of dermis to repair defects in the anterior abdominal wall is shown. Dermal grafting was used in altogether 15 cases. 7 with extremely large incisional hernias, and 8 with defects after malignant abdominal wall tumours. The surgical method is described and the follow-up 1 to 4 years postoperatively has shown a very satisfactory result in 13 cases. In one case there was a postoperative haematoma with subsequent graft necrosis and in the other there was a residual hernial defect. We recommend this method as one of choice in cases with large abdominal wall defects.
View