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Immediate Implant-based Prepectoral Breast Reconstruction Using a Vertical Incision.

Becker H, Lind JG, Hopkins EG - Plast Reconstr Surg Glob Open (2015)

Bottom Line: This technique, when combined with an adjustable implant, addresses the complications related to subpectoral implant placement of traditional expanders.Adjustable smooth round saline implants and mesh/acellular dermal matrix were used for fixation in all cases.Postoperative complications occurred in 9 patients, 6 of which were resolved with postoperative intervention while only 2 cases resulted in implant loss.

View Article: PubMed Central - PubMed

Affiliation: Hilton Becker Clinic of Plastic Surgery, Boca Raton, Fla.; Department of Plastic and Reconstructive Surgery, Cleveland Clinic Florida, Weston, Fla.; Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Fla.; and Florida Atlantic University, Boca Raton, Fla.

ABSTRACT

Background: 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.

Methods: 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.

Results: 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.

Conclusions: 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.

No MeSH data available.


Related in: MedlinePlus

A, Preoperative view of a 40-year-old BRCA-positive patient. B, Adjustable implant placed beneath mesh support. C, Postoperative result at 6 months.
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Figure 7: A, Preoperative view of a 40-year-old BRCA-positive patient. B, Adjustable implant placed beneath mesh support. C, Postoperative result at 6 months.

Mentions: In our experience, to correct ptosis in skin reducing mastectomy, less skin needs to be resected compared with standard mastopexy or reduction mammoplasty. Exact skin tailoring along a wise pattern excision results in unacceptably high complication rates that may be easily avoided by adopting a versatile and a conservative vertical excision pattern.8 There are numerous advantages to a vertical incision over a horizontal incision.9 From the surgical excision perspective, the vertical incision allows for ease of access for the mastectomy, with comparable visualization to other incision patterns. There is less interference with the blood supply to the flaps as the incision runs parallel to the direction of blood flow, running in the watershed area of the lateral and medial blood supply to the breast. We also feel that this incision leads to a better cosmetic result. The scar resembles that of a breast lift procedure, resulting in a more natural projection of the reconstructed breast with improved nipple position. The nipple does not tend to drift laterally. Horizontal incisions tend to flatten the breast, particularly if tissue is excised or if scar contracture occurs. Should postoperative debridement of the flaps be necessary, further flattening and distortion occurs with horizontal incisions and lateral shift of the nipple is also common. By contrast, debridement of a vertical incision causes elevation of the breast without lateral distortion. This technique has applicability to small breasts and large ptotic breasts (particularly where reduction and/or elevation is necessary) (Figs. 7A–C). Large ptotic breasts require some degree of skin envelope reduction. With the vertical scar technique, rather than excising the skin, the delineated area is de-epithelialized and advanced medially. 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.

Becker H, Lind JG, Hopkins EG - Plast Reconstr Surg Glob Open (2015)

A, Preoperative view of a 40-year-old BRCA-positive patient. B, Adjustable implant placed beneath mesh support. C, Postoperative result at 6 months.
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC4494482&req=5

Figure 7: A, Preoperative view of a 40-year-old BRCA-positive patient. B, Adjustable implant placed beneath mesh support. C, Postoperative result at 6 months.
Mentions: In our experience, to correct ptosis in skin reducing mastectomy, less skin needs to be resected compared with standard mastopexy or reduction mammoplasty. Exact skin tailoring along a wise pattern excision results in unacceptably high complication rates that may be easily avoided by adopting a versatile and a conservative vertical excision pattern.8 There are numerous advantages to a vertical incision over a horizontal incision.9 From the surgical excision perspective, the vertical incision allows for ease of access for the mastectomy, with comparable visualization to other incision patterns. There is less interference with the blood supply to the flaps as the incision runs parallel to the direction of blood flow, running in the watershed area of the lateral and medial blood supply to the breast. We also feel that this incision leads to a better cosmetic result. The scar resembles that of a breast lift procedure, resulting in a more natural projection of the reconstructed breast with improved nipple position. The nipple does not tend to drift laterally. Horizontal incisions tend to flatten the breast, particularly if tissue is excised or if scar contracture occurs. Should postoperative debridement of the flaps be necessary, further flattening and distortion occurs with horizontal incisions and lateral shift of the nipple is also common. By contrast, debridement of a vertical incision causes elevation of the breast without lateral distortion. This technique has applicability to small breasts and large ptotic breasts (particularly where reduction and/or elevation is necessary) (Figs. 7A–C). Large ptotic breasts require some degree of skin envelope reduction. With the vertical scar technique, rather than excising the skin, the delineated area is de-epithelialized and advanced medially. 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).

Bottom Line: This technique, when combined with an adjustable implant, addresses the complications related to subpectoral implant placement of traditional expanders.Adjustable smooth round saline implants and mesh/acellular dermal matrix were used for fixation in all cases.Postoperative complications occurred in 9 patients, 6 of which were resolved with postoperative intervention while only 2 cases resulted in implant loss.

View Article: PubMed Central - PubMed

Affiliation: Hilton Becker Clinic of Plastic Surgery, Boca Raton, Fla.; Department of Plastic and Reconstructive Surgery, Cleveland Clinic Florida, Weston, Fla.; Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Fla.; and Florida Atlantic University, Boca Raton, Fla.

ABSTRACT

Background: 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.

Methods: 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.

Results: 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.

Conclusions: 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.

No MeSH data available.


Related in: MedlinePlus