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Breast reconstruction following prophylactic mastectomy for smaller breasts: The superiorly based pectoralis fascial flap with the Becker 35 expandable implant G.L. Ross* Department of Plastic Surgery, The Christie, Wilmslow Road, Manchester M20 4BX, United Kingdom Received 16 May 2011; accepted 20 December 2011 KEYWORDS Breast reconstruction; Superiorly based pectoralis fascial flap; Prophylactic breast reconstruction Summary Introduction: Immediate reconstruction using tissue expander/implants following prophylactic mastectomy for smaller breasts is a reliable means of providing similar size, shape and symmetrical reconstructions. The superiorly based pectoralis fascial flap allows an imme- diate reconstruction of the inferior pole and may eliminate the need for tissue expansion. Methods: The superiorly based pectoralis fascial flap and implant was performed on 5 patients (10 breasts). The Becker 35 expandable implant was used in all cases and average size was 349 (range 290e400cc). Average age was 33 (range 21e43). The average BMI was 23 (range 20e26). One patient underwent further tissue expansion of the Becker 35 postoperatively. One patient developed a seroma in the abdominal fascial flap donor site that settled without the need for drainage. There were no other complications. Conclusion: The superiorly based pectoralis fascial flap provides a one-stop reconstruction of the lower pole and can eliminate the need for tissue expansion in patients with small breasts. ª 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. Introduction Uptake of patients for prophylactic mastectomy þ/ reconstruction is determined in our centre by strict criteria 1e4 in accordance with guidance from the UK National Institute for Health and Clinical Excellence. 5 An assessment of reconstructive options enables the patient and surgeon to discuss the various options available including tissue expander/implant based reconstruction, local flaps þ/ tissue expander implants and free flaps. For patients with minimal breast tissue a total autologous reconstruction is often not possible and an implant is invariably required. A further discussion with a breast care nurse allows patients to understand the normal pre and postoperative * Tel.: þ44 (0) 1619187054; fax: þ44 (0) 1614463365. E-mail addresses: [email protected], [email protected]. 1748-6815/$ - see front matter ª 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2011.12.016 Journal of Plastic, Reconstructive & Aesthetic Surgery (2012) 65, 705e710

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Page 1: Breast reconstruction following prophylactic mastectomy ...€¦ · Breast reconstruction following prophylactic mastectomy for smaller breasts: The superiorly based pectoralis fascial

Journal of Plastic, Reconstructive & Aesthetic Surgery (2012) 65, 705e710

Breast reconstruction following prophylacticmastectomy for smaller breasts: The superiorlybased pectoralis fascial flap with the Becker35 expandable implant

G.L. Ross*

Department of Plastic Surgery, The Christie, Wilmslow Road, Manchester M20 4BX, United Kingdom

Received 16 May 2011; accepted 20 December 2011

KEYWORDSBreastreconstruction;Superiorly basedpectoralis fascialflap;Prophylactic breastreconstruction

* Tel.: þ44 (0) 1619187054; fax: þ44E-mail addresses: gary.ross@christ

1748-6815/$-seefrontmatterª2011Bridoi:10.1016/j.bjps.2011.12.016

Summary Introduction: Immediate reconstruction using tissue expander/implants followingprophylactic mastectomy for smaller breasts is a reliable means of providing similar size, shapeand symmetrical reconstructions. The superiorly based pectoralis fascial flap allows an imme-diate reconstruction of the inferior pole and may eliminate the need for tissue expansion.Methods: The superiorly based pectoralis fascial flap and implant was performed on 5 patients(10 breasts). The Becker 35 expandable implant was used in all cases and average size was 349(range 290e400cc). Average age was 33 (range 21e43). The average BMI was 23 (range 20e26).One patient underwent further tissue expansion of the Becker 35 postoperatively. One patientdeveloped a seroma in the abdominal fascial flap donor site that settled without the need fordrainage. There were no other complications.Conclusion: The superiorly based pectoralis fascial flap provides a one-stop reconstruction ofthe lower pole and can eliminate the need for tissue expansion in patients with small breasts.ª 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published byElsevier Ltd. All rights reserved.

Introduction

Uptake of patients for prophylactic mastectomy þ/�reconstruction is determined in our centre by strictcriteria1e4 in accordance with guidance from the UKNational Institute for Health and Clinical Excellence.5

(0) 1614463365.ie.nhs.uk, [email protected].

tishAssociationofPlastic,Reconstruc

An assessment of reconstructive options enables thepatient and surgeon to discuss the various options availableincluding tissue expander/implant based reconstruction,local flaps þ/� tissue expander implants and free flaps. Forpatients with minimal breast tissue a total autologousreconstruction is often not possible and an implant isinvariably required.

A further discussion with a breast care nurse allowspatients to understand the normal pre and postoperative

tiveandAestheticSurgeons.PublishedbyElsevierLtd.All rightsreserved.

Page 2: Breast reconstruction following prophylactic mastectomy ...€¦ · Breast reconstruction following prophylactic mastectomy for smaller breasts: The superiorly based pectoralis fascial

706 G.L. Ross

care and recovery following the various reconstructiveoptions. Preservation of the nipple areola complex involvesa careful explanation of the potential oncological risk ofpreserving the nipple areola complex versus the potentialimproved aesthetic outcome and an informed decisionmade by the patient.3

The use of the superiorly based pectoralis fascial flapcan be performed following prophylactic mastectomy insmaller patients with minimal ptosis.

Figure 1 Undermining of the abdominal tissue.

Chest wall

Pectoralismajor muscle

Rectus muscle

Serratus muscle

Fusion of fascia(serratus, rectus, pectoralis)

Rectus fascia

Figure 2 Lateral view of chest prior to flap raising.

Procedure

Preservation of the nipple areola complex is technicallypossible for all patients with minimal breast tissue andminimal ptosis. The increased oncological risks versus theimproved cosmetic outcome provided by leaving the nippleareola complex needs to be discussed so that the patientcan decide whether to undergo nipple areola preservationor not. This decision will affect the incision pattern for thesubsequent mastectomy. In all cases the mastectomy andreconstruction was performed by the plastic surgeon.

An inframammary incision provides an excellent accessfor the superiorly based abdominal fascial flap but makesthe mastectomy access more difficult. In patients witha short sternal notch to nipple distance of 20 cm or lessmastectomy access is not compromised by this method andis the preferred access. Where there needs to be a lift ofthe areola for ptosis a periareolar incision is preferred.Where the nipple areola complex is to be removed the scaris placed according the size and shape of the nipple areolacomplex. The aim is to provide the smallest scar and this isoften in horizontal or oblique plane. Both the horizontaland oblique incision provides good access for harvest of thesuperiorly based abdominal fascial flap.

The breast is infiltrated with 20 ml of Marcaine withAdrenaline and1 L of normal saline. Following access throughthe incisions as discussed above the mastectomies are per-formed in the plane between subcutaneous fat and breasttissue. Where the nipple areola complex is to be preservedthe plane at the nipple areola location is not as easilydelineated and it is important to make sure that a uniformthickness is maintained. This is easier to perform througha periareolar incision than an inframammary incision. In thelatter it is important when performing the mastectomysuperior to the nipple areolar complex to maintain unifor-mity of thickness. During the mastectomy it is imperativethat the pectoralis fascia is left intact in its entirety.

Once the mastectomy has been performed dissectioncontinues from superior to inferior through the inframam-mary fold towards the umbilicus (Figure 1). This dissectionis above the rectus abdominis fascia and requires a wideundermining of the upper abdomen. The dissectioncontinues as far as possible inferiorly and should easilyprovide at least 15 cm of fascial flap. The lateral view ofthe chest wall is seen in Figure 2. Under lighted retractionthe rectus abdominal fascial is incised (Figure 3) and thenraised from inferior to superior (Figure 4). This dissectionproceeds with ease until the fusion of the rectus fascia, theserratus fascia and the pectoralis fascia. The fusion ofthese planes is variable and is most constant medially. Oneis able to raise the fusion of the rectus fascia and the

pectorialis fascia in a deep plane without violating thesuperficial fascial tissue. The medial insertions of therectus and pectoralis should be maintained at this point.Moving medially to laterally the serratus fascia is thenraised in continuity with the rectus abdominis fascia frominferior to superior. The pectoralis muscle is then raised.Following haemostasis the Becker 35 is inserted into thepocket unexpanded. Release of the pocket is then possibleto allow the Becker 35 base width to sit flush on the chestwall. It may be necessary to release at this point either the

Page 3: Breast reconstruction following prophylactic mastectomy ...€¦ · Breast reconstruction following prophylactic mastectomy for smaller breasts: The superiorly based pectoralis fascial

Pectoralismajor muscle

Rectus abdominis muscle

Serratus anterior muscle

Fusion of fascia(serratus, rectus, pectoralis)

Implant

Fasciaincision line

Figure 3 Fascial incision of superiorly based pectoralis fascial flap.

Breast reconstruction following prophylactic mastectomy for smaller breasts 707

medial attachments of the pectoralis/fascial flap and/orthe lateral serratus fascia. The lateral view of the chestwall following reconstruction is seen in Figure 5. The pocketof the implant comprises upper pole cover by pectoralismajor with and inferior pole cover by the fascia. Theunexpanded Becker 35 is positioned correctly and the portattached. The tunnel for the Becker has already been madebut needs to be secured onto the upper abdominal wall.Once the Becker has been secured in position the superiorlybased pectoralis fascial flap is draped over the Becker and

Figure 4 Raising of the superiorly based pectoralis fascialflap from inferiorly.

secured onto the inframammary fold using interrupted 3.0ethibond. These stitches need to be placed at the new foldand be attached to periosteum. The Becker is then inflatedto the recommended saline volume and the expansion ofthe pectoralis fascial flap is clearly visualised. At this pointit is easy to see any irregularities in the expander/implantand further release or repositioning of the superiorly basedpectoralis fascial flap may be required. A 12G drain is theninserted in the breast pocket and another 12G drain inser-ted above the superiorly based abdominal fascial flap belowthe skin. The skin is closed with 3.0 and 4.0 monocryl.

Results

The superiorly based pectoralis fascial flap was performedon 5 patients (10 breasts). See Figures 5e9. The Becker 35expandable implant was used in all cases and average sizewas 349 (range 290e400cc). The average age was 33 (range21e43). The average BMI was 23 (range 20e26). Onepatient underwent further tissue expansion post-operatively. Although we achieved a similar size to thatpreoperatively she wished to be larger and underwent onefurther expansion to achieve this (Figures 6e8) (Fig. 10).

One patient developed seroma in the abdomen wherethe abdominal fascial flap was harvested that settled

Page 4: Breast reconstruction following prophylactic mastectomy ...€¦ · Breast reconstruction following prophylactic mastectomy for smaller breasts: The superiorly based pectoralis fascial

Chest wall

Pectoralismajor muscle

Rectus muscle

Serratus muscleFusion of fascia(serratus, rectus, pectoralis)

Implant

Rectus fascia

Figure 5 Positioning of implant under superiorly based pectoralis fascial flap.

Figure 6 Patient 1 preop.

708 G.L. Ross

without need for drainage. There were no other compli-cations. The follow up is average 9 months (range 7e18months). Surgical times varied from 155 min to 195 min withan average of 160 min.

Discussion

Patients with minimal breast tissue are often not candi-dates for autologous only reconstruction. Implant basedreconstruction remains a good option for size, shape andsymmetry.

With traditional tissue expansion in a submuscular pocketexpansion of the lower pole is not possible during the initialmastectomy as the pocket is limited in terms of size inferi-orly. Repeated expansions may be required and this in itselfmay lead to irregularities, as the expansion of the pocketcannot be visualised directly. Often the expansion occurs inareas of least resistance that is often medially or laterallyrather than uniformly over the lower pole.6,7

To combat this some authors have shown excellentresults with artificial dermis allowing the possibility of one

Page 5: Breast reconstruction following prophylactic mastectomy ...€¦ · Breast reconstruction following prophylactic mastectomy for smaller breasts: The superiorly based pectoralis fascial

Figure 9 Patient 2 preop.Figure 7 Patient 1 postop following expansion.

Breast reconstruction following prophylactic mastectomy for smaller breasts 709

stage reconstruction and minimal/no need for tissueexpansion.8 Aside cost the superiorly based pectoralisfascial flap remains an alternative as it has the advantageof being autologous and vascularised. The choice of theBecker was made to give flexibility e even though only onepatient required further expansion. She felt unhappy withthe size of her initial reconstruction even though it waslarger than preoperatively, however the flexibility of theBecker 35 allowed us to make one further expansion. It ispossible to place a permanent implant at the initial oper-ation and this is something that we intend to explore in thefuture. The patients likely to benefit are those withminimal breast tissue.

The benefit of the Becker however is that it gives onethe ability to deflate the expander portion should there beany issues with vascularity of the mastectomy skin. It alsogives one the ability to achieve further expansion post-operatively as occurred in one patient and gives one theability to expand one side preferentially in the postopphase to aid symmetry.

The downside of the superiorly based pectoralis fascialflap is the donor site harvest and the potential for seromaformation. This occurred in one case although it settledwithout intervention. Another potential issue is that theinframammary fold has to be reconstituted. It is importantto use permanent stitches to reconstitute the inframam-mary fold however patients must be informed that these

Figure 8 Patient 1 postop.

periosteal stitches can be painful for a couple of weeksafter surgery. The inframammary fold was recreated usingthe superiorly based pectoralis flap unto the periosteumand the skin was simply redraped over the reconstructedbreast. In the case where an inframammary incision wasused the Inframammary Fold was partially recreated usingthe skin using 3.0 monocryl. This was not performed in theother cases. It was felt that reconstituting the inframam-mary fold with the skin through the oblique and horizontalmastectomy incisions may compromise the mastectomyskin flaps. So far there has been no migration of the infra-mammary fold in these cases.

In all cases the mastectomy and reconstruction wasperformed by the plastic surgeon. It is important when thecase is performed jointly with an oncological breastsurgeon that the mastectomy is performed preserving thepectoralis fascia. This procedure has only been performedin the prophylactic group of patients and only been per-formed bilaterally. In may be of use in unilateral recon-structions and for oncological cases. It is unclear how muchprotection to radiotherapy the superiorly based pectoralisfascial flap would give in this setting.

The superiorly based pectoralis fascial flap with theBecker 35 expandable implant provides an excellent meansof reconstructing the smaller breast following prophylacticmastectomy.

Figure 10 Patient 2 postop.

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710 G.L. Ross

Conflict of interest

None declared.

Funding

None declared.

Acknowledgement

Professor Evans, Professor Howell, Dr Laloo, Dr Clancy,Genetic Medicine, MAHSC, St. Mary’s Hospital, Oxford Road,Manchester, M13 9WL, UK.

Mr Baildam, Mr Barr, Miss Rose, Mr Wilson, Dr Rodgers,WythenshaweHospital, SouthmoorRoad,Manchester,M239LT.

References

1. Lalloo F, Baildam A, Brain A, Hopwood P, Evans DG, Howell A. Aprotocol for preventativemastectomy in women with an increasedlifetime risk of breast cancer. Eur J Surg Oncol 2000;26:711e3.

2. Hopwood P, Lee A, Shenton A, et al. Clinical follow-up afterbilateral risk reducing (‘prophylactic’) mastectomy: mental

health and body image outcomes. Psychooncology 2000;9:462e72.

3. Evans DG, Baildam AD, Anderson E, et al. Risk reducingmastectomy: outcomes in 10 European centres. J Med Genet2009;46:254e8.

4. Evans DG, Lalloo F, Hopwood P, et al. Surgical decisions made by158 women with hereditary breast cancer aged <50 years. Eur JSurg Oncol 2005;31:1112e8.

5. McIntosh A, Shaw C, Evans G, et al. Clinical guidelines andevidence review for the classification and care of women at riskof familial breast cancer. NICE guideline CG041. London:National Collaborating Center for Primary Care/University ofSheffield; 2004 [updated 2006]. Available from: http://www.nice.org.uk.

6. Cordeiro PG, McCarthy CM. A single surgeon’s 12-year experi-ence with tissue expander/implant breast reconstruction: partI. A prospective analysis of early complications. Plast ReconstrSurg 2006;118:825e31.

7. Cordeiro PG, McCarthy CM. A single surgeon’s 12-year experi-ence with tissue expander/implant breast reconstruction:part II. An analysis of long-term complications, aestheticoutcomes, and patient satisfaction. Plast Reconstr Surg 2006;118:832e9.

8. Salzberg CA, Ashikari AY, Koch RM, Chabner-Thompson E. An 8-year experience of direct-to-implant immediate breast recon-struction using human acellular dermal matrix (AlloDerm). PlastReconstr Surg 2011;127:514e24.