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Ramos LDSP, Biazús JV. Outcomes after elevation of serratus anterior fascia flap versus serratus muscle flap in direct-to-implant breast reconstruction following mastectomy: a prospective study. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2024; 46:e-rbgo13. [PMID: 38765542 PMCID: PMC11075384 DOI: 10.61622/rbgo/2024ao13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Accepted: 07/25/2023] [Indexed: 05/22/2024] Open
Abstract
Objective The purpose of this study was to compare postoperative pain between SF flap and serratus anterior muscle (SM) in direct-to-implant breast reconstruction. Methods This is a prospective cohort study that included 53 women diagnosed with breast cancer who underwent mastectomy and one-stage implant-based breast reconstruction from January 2020 to March 2021. Twenty-nine patients (54.7%) had SF elevation, and 24 patients (45.3%) underwent SM elevation. We evaluated patient-reported early postoperative pain on the first day after surgery. Also, it was reported that all surgical complications in the first month and patient reported outcomes (PROs) were measured with the BRECON 23 questionnaire. Results The serratus fascia group used implants with larger volumes, 407.6 ± 98.9 cc (p < 0.01). There was no significant difference between the fascial and muscular groups regarding the postoperative pain score reported by the patients (2 versus 3; p = 0.30). Also, there was no difference between the groups regarding early surgical complications and PROs after breast reconstruction. Conclusion The use of SF seems to cause less morbidity, which makes the technique an alternative to be considered in breast reconstruction. Although there was no statistical difference in postoperative pain scores between the fascia and serratus muscle groups.
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Affiliation(s)
- Lilian de Sá Paz Ramos
- Federal University of Rio Grande do SulPorto AlegreRSBrazilFederal University of Rio Grande do Sul, Porto Alegre, RS, Brazil.
| | - Jorge Villanova Biazús
- Federal University of Rio Grande do SulPorto AlegreRSBrazilFederal University of Rio Grande do Sul, Porto Alegre, RS, Brazil.
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Chen Y, Yang C, Yang S, Chen X, Huang L. Serratus Anterior Fascia for Immediate Implant-Based Breast Reconstruction: A Case Series of 65 Patients With Breast Cancer. Ann Plast Surg 2024; 92:169-173. [PMID: 38157477 DOI: 10.1097/sap.0000000000003769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
OBJECTIVE After immediate implant-based breast reconstruction (IIBR) after mastectomy, implant exposure or capsular contracture can occur. This study aimed to evaluate IIBR using serratus anterior fascia in patients with breast cancer. METHODS This retrospective case series study enrolled patients with breast cancer underwent IIBR using the serratus anterior fascia after mastectomy in the Department of Breast Surgery of Fujian Cancer Hospital between January 2021 and December 2022. RESULTS Sixty-five cases with breast cancer underwent IIBR using serratus anterior fascia were enrolled, with a median age of 39 years (range, 24-57 years) and body mass index of 21.32 kg/m 2 (range, 19-25 kg/m 2 ). The aesthetic outcomes of the reconstructed breasts showed good in 53 cases (81.6%), moderate in 11 cases (16.9%), and poor in 1 case (1.5%) due to offset position. Two cases showed poor wound healing, which improved after repeat suturing and 5 cases developed partial ischemic necrosis of the nipple, which scabbed and healed spontaneously. CONCLUSIONS Implant-based breast reconstruction using serratus anterior fascia may provide good aesthetic outcomes with few complications.
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Affiliation(s)
- Ying Chen
- From the Department of Breast Surgery, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fujian, China
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Chen AX, Chen X, Yu Y, Wang X, Zhang B, Cao XC. Immediate surgical mesh-free implant-based breast reconstruction with fascial flap in breast cancer patients after mastectomy. Arch Gynecol Obstet 2022; 307:1941-1948. [PMID: 36477273 DOI: 10.1007/s00404-022-06871-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 11/25/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE Surgical meshes are often used in retro-pectoral implant-based breast reconstruction (IBBR) to improve lower pole expansion. However, using of surgical meshes is associated with increased complications and costs. To solve this problem, we have adopted a modified fascia-based IBBR technique using fasciae of pectoral major, serratus anterior, and external oblique muscles to form a sling covering the lower pole of prosthesis since 2014. METHODS Data of 788 retro-pectoral IBBR cases, including 250 fascia-based IBBR cases (fascial group) and 538 traditional IBBR cases (control group), treated between 2014 and 2019 were retrospectively analyzed. The surgical outcomes of the fascial and control group were compared. The primary endpoint was the rate of post-operative complications requiring interventions. The secondary endpoint was the rate of explantation. The exploratory endpoint was the time from surgery to complication and explantation. RESULTS The fascial group had significantly lower rates of developing major post-operative complications (1.2 vs. 6.1%, p = 0.002) and losing prostheses (1.2 vs. 4.3%, p = 0.025), as compared with the control group. The median time from surgery to complication and explantation were 61 (range, 35-115) days and 92 (range, 77-134) days for the fascial group and 35 (range, 6-239) days and 63 (range, 23-483) days for the control group, respectively. CONCLUSION Fascia-based IBBR technique had low rates of major post-operative complications and explantation. Fascia-based IBBR technique could be considered as an alternative reconstruction method in properly selected patients.
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Klifto KM, Tecce MG, Serletti JM, Kovach SJ. Comparison of nine methods of immediate breast reconstruction after resection of localized breast cancer: A cost-effectiveness Markov decision analysis of prospective studies. Microsurgery 2022; 42:401-427. [PMID: 35355320 DOI: 10.1002/micr.30882] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 01/08/2022] [Accepted: 03/10/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND Women undergoing immediate breast reconstruction without radiation therapy have reconstruction methods available with uncertain long-term costs associated with complications requiring surgery and revisions. We evaluated cost-effectiveness of nine methods of immediate breast reconstruction for women with localized breast cancer. METHODS Markov modeling was performed over 10-years for unilateral/bilateral breast reconstructions from healthcare/societal perspectives. PubMed, Embase, Cochrane, Scopus, and CINAHL were searched to derive data from 13,744 patients in 79 prospective studies. Complications requiring surgery (mastectomy necrosis, total/partial flap necrosis, seroma, hematoma, infection, wound dehiscence, abdominal hernia, implant removal/explantation) and revisions (fat necrosis, capsular contracture, asymmetry, scars/redundant tissue, implant rupture/removal, fat grafting) were evaluated over yearly cycles. Reconstructions included: direct-to-implant (DTI), tissue expander-to-implant (TEI), latissimus dorsi flap-to-implant (LDI), latissimus dorsi (LD), pedicled transverse rectus abdominis myocutaneous (TRAM), free TRAM, deep inferior epigastric perforator/superficial inferior epigastric artery (DIEP/SIEA), thigh-based, or gluteal based flaps. Outcomes were incremental cost-effectiveness ratios (ICER) and net monetary benefits (NMB). Willingness-to-pay thresholds were $50,000 and $100,000. RESULTS From a healthcare perspective for unilateral reconstruction, compared to LD, the ICER for DTI was -$42,109.35/quality-adjusted life-years (QALY), LDI was -$25,300.83/QALY, TEI was -$22,036.02/QALY, DIEP/SIEA was $8307.65/QALY, free TRAM was $8677.26/QALY, pedicled TRAM was $13,021.44/QALY, gluteal-based was $17,698.99/QALY, and thigh-based was $23,447.82/QALY. NMB of DIEP/SIEA was $404,523.47, free TRAM was $403,821.40, gluteal-based was $392,478.64, thigh-based was $387,691.70, pedicled TRAM was $376,901.83, LD was $370,646.93, DTI was $339,668.77, LDI was $334,350.30, and TEI was $329,265.84. CONCLUSIONS All nine methods of immediate breast reconstruction were considered cost-effective from healthcare/societal perspectives. LD provided the lowest costs, while DIEP/SIEA provided the greatest effectiveness and NMB.
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Affiliation(s)
- Kevin M Klifto
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Missouri School of Medicine, Columbia, Missouri, USA.,Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Michael G Tecce
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Joseph M Serletti
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Stephen J Kovach
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Breast Reconstruction after Mastectomy with the Use of an Implant and Serratus Anterior Fascia Flap-Initial Clinical Evaluation. J Pers Med 2021; 11:jpm11111142. [PMID: 34834494 PMCID: PMC8623064 DOI: 10.3390/jpm11111142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 10/27/2021] [Accepted: 11/01/2021] [Indexed: 11/17/2022] Open
Abstract
Prosthesis-based techniques are the predominant form of breast reconstruction worldwide. The most performed surgical technique involves the placement of the expander in a partial submuscular plane. The coverage of the implant remains a difficult management problem that can lead to complications and poor outcomes. The use of the serratus fascia flap may be the best choice to create a subpectoral pocket for the placement of a tissue expander, with excellent results in terms of morbidity and cost-effectiveness. A total of 20 breast reconstructions with the inferolateral coverage with the serratus fascia were performed. Patients demonstrated a low overall complication rate (9.5%), such as seroma and infection, with complete resolution during the follow-up and no major complications. The US examination of the soft tissues over the implant reported thickness measurements that demonstrated a good coverage over the inferolateral area. Our study shows that using the serratus fascia flap to create a pocket with the pectoralis major for the placement of the tissue expander is an effective technique during two-stage breast reconstruction. The resulting low rate of morbidity and the US findings collected reveal the safety of this procedure. Its success relies on appropriate patient selection and specific intraoperative technique principles.
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Complications After Immediate 2-Stage Tissue Expander/Implant Breast Reconstruction: A Deeper Look at the Second Stage. Ann Plast Surg 2021; 84:638-643. [PMID: 31800563 DOI: 10.1097/sap.0000000000002126] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Complications after 2-stage tissue expander/implant breast reconstruction have been studied as outcomes of a single procedure. We separately evaluated complications after the second stage and assessed factors associated with the outcomes of the second stage of breast reconstruction. METHODS Patients who underwent immediate 2-stage breast reconstruction between February 2010 and April 2017 were retrospectively reviewed. Patient demographics, surgical factors of the first stage of breast reconstruction, and complications and number of revision surgeries after the second stage were recorded. Factors associated with postoperative complications were analyzed, and a risk-scoring system was devised. RESULTS We analyzed 619 patients who underwent 653 immediate 2-stage breast reconstructions. Multivariate analysis showed that complications were associated independently with smoking history, radiotherapy, and a final inflation volume of 450 mL or greater. Each factor contributed 1 point in the creation of a risk-scoring system. The overall complication rate was increased as the risk score increased (1.2%, 4.7%, and 16.0% for 0, 1, and 2 risk scores, respectively, P < 0.001). Revision operation rate was also significantly different across the 3 groups (0.2%, 1.6%, and 12.0% for 0, 1, and 2 risk scores, respectively, P < 0.001). The area under the receiver operating characteristic curve was 0.732 and 0.731 for the logistic regression model and risk-scoring system, respectively (P = 0.975). CONCLUSIONS In the second stage of immediate 2-stage tissue expander/implant breast reconstruction, the rate of complication and revision surgery can be predicted by a novel risk-scoring system. Greater attention and preventive measures for complications are needed for high-risk patients.
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Cristofari S, Bertrand B, Rem K, Revol M, Stivala A. The modified serratus anterior fascia flap improves satisfaction and long-term results in immediate implant-based breast reconstruction: A retrospective study. J Plast Reconstr Aesthet Surg 2020; 74:800-808. [PMID: 33189619 DOI: 10.1016/j.bjps.2020.10.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 08/02/2020] [Accepted: 10/10/2020] [Indexed: 11/16/2022]
Abstract
After immediate implant-based breast reconstruction (IIBR) following skin-sparing mastectomy, postoperative complications such as implant exposure or badly defined mammary folds can occur. Acellular dermal matrix can provide good esthetic outcomes but remain expensive. This study evaluates a new technique of one-stage IIBR by using a modified serratus anterior fascia flap (MSFF group), providing lower implant coverage, as compared to the classical submuscular technique. In this retrospective study, we included all patients who underwent IIBR using either the MSFF technique or the classic technique between November 2012 and February 2015. We collected data regarding demographics, perioperative factors, postoperative complications, patient satisfaction (Breast-Q score), and esthetic outcomes. One hundred twenty-three patients who underwent IIBR, of which 61 breasts (59 patients) using the MSFF and 67 breasts (64 patients) the classical technique, were included. The size of the implants used were significantly higher in the MSFF group (p = 0.036). There were no statistically significant differences between the two groups with regard to the immediate complications rate. After a mean follow-up of 43.9 months, we observed more capsular contractures in the classic group (p < 0.001). In the classic group, patients required more revision surgeries (p = 0.008), more implant changes (p < 0.001), and higher volume of additional lipofilling (p < 0.001). According to the Breast Q scores, patients' satisfaction was better in the MSFF group regarding their breasts (p = 0.001) and the outcomes (p = 0.009). The MSFF is a simple, safe, effective, and inexpensive autologous technique for IIBR, which improves implant coverage with a vascularized flap and provides satisfying outcomes as compared to classic IIBR, with less complications.
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Affiliation(s)
- Sarra Cristofari
- Plastic and Aesthetic Surgery Department, Hopital Tenon, Paris, France; Pierre et Marie Curie University, Paris, France
| | - Baptiste Bertrand
- Plastic and Reconstructive Surgery, Conception Hospital, 147 Boulevard Baille, 13005 Marseille, Paris, France
| | - Kessara Rem
- Pierre et Marie Curie University, Paris, France
| | - Marc Revol
- Plastic and Aesthetic Surgery Department, Hopital Tenon, Paris, France; Pierre et Marie Curie University, Paris, France
| | - Alessio Stivala
- Plastic and Reconstructive Surgery, François Mitterand Hospital, 14 rue Paul Gaffarel, 21079 Dijon, France.
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Faenza M, Di Pace B, Di Costanzo P, Brongo S, Pieretti G, Verdura V, Nicoletti GF, Rubino C. Serratus fascial flap in immediate breast reconstruction with tissue expander: Is all that glitters gold? J Plast Reconstr Aesthet Surg 2019; 73:391-407. [PMID: 31685403 DOI: 10.1016/j.bjps.2019.09.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 08/06/2019] [Accepted: 09/20/2019] [Indexed: 11/24/2022]
Affiliation(s)
- M Faenza
- Multidisciplinary Department of Medical and Dental Specialties - Università degli Studi della Campania "Luigi Vanvitelli" - Plastic Surgery Unit, Italy.
| | - B Di Pace
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana" - PhD School of Translational Medicine of Development and Active Aging - Università degli Studi di Salerno, Italy
| | - P Di Costanzo
- Multidisciplinary Department of Medical and Dental Specialties - Università degli Studi della Campania "Luigi Vanvitelli" - Plastic Surgery Unit, Italy
| | - S Brongo
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana" - Università degli Studi di Salerno - Plastic Surgery Unit, Italy
| | - G Pieretti
- Multidisciplinary Department of Medical and Dental Specialties - Università degli Studi della Campania "Luigi Vanvitelli" - Plastic Surgery Unit, Italy
| | - V Verdura
- Multidisciplinary Department of Medical and Dental Specialties - Università degli Studi della Campania "Luigi Vanvitelli" - Plastic Surgery Unit, Italy
| | - G F Nicoletti
- Multidisciplinary Department of Medical and Dental Specialties - Università degli Studi della Campania "Luigi Vanvitelli" - Plastic Surgery Unit, Italy
| | - C Rubino
- Department of Medical, Surgical and Experimental Sciences - Università degli Studi di Sassari - Plastic Surgery Unit, Italy
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Montag E, Okada A, Arruda EGP, Munhoz AM, Busnardo FF, Gemperli R. Serratus anterior muscle flap as a salvage procedure in exposed implant-based breast reconstruction. Int J Surg Case Rep 2019; 63:31-35. [PMID: 31546177 PMCID: PMC6796642 DOI: 10.1016/j.ijscr.2019.08.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 08/03/2019] [Accepted: 08/24/2019] [Indexed: 11/17/2022] Open
Abstract
Implant based breast reconstruction is the most popular form of breast reconstruction following cancer treatment. Implant exposure normally leads to the loss of reconstruction due to contamination and infection. The two case series illustrate an approach to implant exposure with a novel use of the serratus anterior muscle flap. We discuss the main indications and technical aspects which can be helpful for surgeons dealing with similar cases.
Background Implant-based breast reconstruction (IBR) is the most common approach to reconstruct mastectomy deffects. Infection following breast reconstruction can be devastating and lead to loss of the reconstruction due to the need of implant removal. The serratus anterior muscle flap is widely used during breast reconstruction to provide coverage of the implant/expander. Methods We present the application of the serratus anterior muscle flap to treat implant exposure after breast reconstruction. Cases presentation Two patients who experienced implant exposure after breast reconstruction were successfully treated with partial capsulectomy, pocket irrigation and implant coverage with a serratus anterior muscle flap. Results No post operative complications have been observed while implant retention was achieved in both cases. Conclusions The serratus anterior muscle flap is an option to treat implant exposure following breast reconstruction in selected cases. This flap could be used to prevent implant exposure in critical cases.
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Affiliation(s)
- Eduardo Montag
- São Paulo Cancer Institute - University of São Paulo, Brazil.
| | - Alberto Okada
- São Paulo Cancer Institute - University of São Paulo, Brazil
| | | | | | | | - Rolf Gemperli
- Division of Plastic Surgery, University of São Paulo School of Medicine, Brazil
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Complication analysis of complete versus partial coverage of tissue expanders using serratus anterior musculofascial flaps in immediate breast reconstruction. Surg Today 2018; 48:703-708. [PMID: 29504033 DOI: 10.1007/s00595-018-1645-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 02/06/2018] [Indexed: 10/17/2022]
Abstract
PURPOSE To prevent tissue expander (TE) exposure following mastectomy flap necrosis in immediate breast reconstruction, the TE is usually covered completely or partially with a musculofascial (MF) flap. This study compares the complications of the two coverage methods. METHODS We reviewed, retrospectively, 106 cases of immediate TE-based breast reconstruction. The patients were divided into two groups according to whether complete or partial TE coverage was done. In the complete coverage group, the serratus anterior MF flap was dissected and sutured to the pectoralis major muscle to cover the TE completely. In the partial coverage group, the serratus anterior MF flap was not dissected, and the lateral border of the pectoralis major muscle was sutured to the mastectomy skin flaps. RESULTS The TEs were covered completely in 60 breasts and partially in 46 breasts. The mastectomy flap necrosis rate was significantly higher in the complete coverage group (p < 0.01), but there was no incidence of TE exposure in either groups. The lateral migration rate was significantly higher in the partial coverage group (p = 0.033). There were no significant differences in the cranial migration rate (p = 0.133). CONCLUSIONS The complete coverage method is a better option if there is a high risk of mastectomy flap necrosis; however, surgeons should monitor carefully for cranial migration.
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Chai L, Zhang X. [Application of serratus anterior muscle flap combined with breast implants for breast reconstruction after modified radical mastectomy]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2017; 31:1098-1101. [PMID: 29798568 PMCID: PMC8458417 DOI: 10.7507/1002-1892.201704032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 08/15/2017] [Indexed: 11/03/2022]
Abstract
Objective To investigate effectiveness of the combination of serratus anterior muscle flap and breast implants for breast reconstruction after modified radical mastectomy. Methods Between January 2015 and December 2015, 25 female patients with breast cancer were enrolled, aged 24-62 years (mean, 40.6 years). The tumor located at left side in 9 cases and right side in 16 cases; 14 cases were in the left upper quadrant, 4 cases were in the left lower quadrant, 7 cases were on the top of the breast. All cases were invasive ductal carcinoma. According to TNM staging, 14 cases were at stageⅠand 11 cases were at stageⅡA. The diameter of lumps were all less than 3 cm. All those lumps were solitary and without distant metastasis. The sentinel nodes were all negative. After modified radical mastectomy, the breasts were reconstructed by serratus anterior muscle flap and breast implants. The nipples were spared in 22 cases. Results The operation time was 113-148 minutes (mean, 136 minutes). All breasts survived and incisions healed at stageⅠ. There was no complication such as hematoma, infection, etc. All patients were followed up 6-18 months (mean, 15 months). Except 1 case, the others were evaluated according to the criteria of the reconstructed breast at 12 months after operation. Among them, 23 cases were evaluated as good and 1 case as fair. There was no tumor recurrence during the follow-up period. Conclusion The combination of serratus anterior muscle flap and breast implants after the modified radical mastectomy is a handy approach of breast reconstruction which is less harmful with few postoperative complications. It also gains a high degree of satisfaction from patients for good breast shape.
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Affiliation(s)
- Lijun Chai
- Department of Breast, the Second Affiliated Hospital of Zhengzhou University, Zhengzhou Henan, 450014, P.R.China
| | - Xuehui Zhang
- Department of Breast Reconstruction, Tianjin Medical University Cancer Institute & Hospital, Tianjin, 300060,
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