Aesthetic role of the surgically rebuilt inframammary fold for implant-based breast reconstruction after mastectomy

Maximizing Aesthetic Outcomes in Delayed Breast Reconstruction: the Be.A.U.T-I.F.U.L. DIEP® Step-by-Step Inset Technique

INTRODUCTION

In microvascular breast reconstruction, the focus has shifted to achieving aesthetically pleasing results. Delayed breast reconstruction poses challenges such as ensuring natural ptosis and avoiding a "patch" effect. The Be.A.U.T-I.F.U.L. deep inferior epigastric perforator (DIEP) flap inset, presented here, offers a systematic and sequential seven-step method to optimize breast reconstruction outcomes.

METHODS

This approach emphasizes safety during flap harvest using the best (Be.) perforator identified via computed tomography angiography to minimize dissection and ensure solid perfusion. The flap is placed obliquely, directing its tail to the axilla (A.), enhancing upper (U.) pole volume and ptosis. The flap base is tucked-in (T-I.) to increase the projection of the breast mound, and its lateral portion is split as a fishtail (F.): the upper (U.) fin is used to define the lateral inframammary fold and prevent lateral displacement of the reconstructed breast, while the lower (L.) fin is turned under the flap to further improve projection.

CONCLUSION

This structured approach, focusing on key breast aesthetics, ensures optimal cosmetic outcomes and can serve for most delayed microsurgical breast reconstruction scenarios.

LEVEL OF EVIDENCE IV

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 .

Primary management of the inframammary fold in breast reconstruction using the thoracoabdominal advancement flap: Surgical technique

Our experience in breast reconstruction confirms the significant importance of reconstructing the inframammary fold in achieving overall aesthetic satisfaction. We describe our technique for primary fixation of the inframammary fold in breast reconstruction using a thoracoabdominal advancement flap. This technique is suitable for patients with a vertical skin laxity of at least 5cm in the future inframammary fold. Prior to the procedure, it requires preparation through physiotherapy, the use of adhesive external breast prosthesis, and skin expansion using an inflatable prosthesis in extreme cases. The surgical approach follows the existing mastectomy scar. After subfascial dissection of the thoracoabdominal advancement flap, the surgeon proceeds to create two separate rows of sutures. The first row mimics the deep attachment of the inframammary fold, fixing the superficial fascia of the flap to the rib periosteum. The second row mimics the superficial attachment of the inframammary fold, fixing the dermis of the flap to the rib periosteum. The main advantage of this technique is its applicability to all breast reconstruction programs.

Defining the Inframammary Fold by Liposuction: An Essential Tool in Aesthetic Shaping of the Reconstructed Breast. Technique and Long-term Results in a Series of Patients

Background

A good inframammary fold (IMF) definition and position is essential to achieve a satisfactory and natural result in breast surgery. This structure can be damaged, especially during mastectomies. Multiple methods are reported in the literature to restore IMF or improve its definition. In this study, we present the results achieved in a series of patients treated with subdermal liposuction.

Methods

We report on all our patients who underwent IMF liposuction between January 2016 and June 2020. Subdermal liposuction was performed with a blunt 3 mm cannula along the new IMF to promote skin retraction and adherence between skin and fascia. Results were evaluated subjectively by the patients and objectively by 8 individuals not involved with the treatment.

Results

We performed IMF liposuction in 88 breasts (69 patients), aged 21–74 (mean 52) years for 82 implant-based reconstructions, 2 tuberous breasts, and 4 contralateral breast augmentations. Mean follow-up was 28 months (6–64). Subjective results: the overall result evaluated with the VAS scale reached 86.6/100. All the 22 patients interviewed judged as well defined the new inframammary fold. Objective results: in 83% of cases the definition of the inframammary fold was judged as good or excellent, while symmetry with contralateral IMF, natural appearance, and overall aesthetic outcome were judged as good.

Conclusion

Based on our long-term satisfactory results, we recommend the technique of subdermal liposuction to improve the definition of IMF in breast reconstruction after mastectomy and other breast procedures. It is effective, easy to perform, minimally invasive, and durable.

Level of Evidence IV

This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. 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.

Making the upper edge of a silicone breast implant invisible by fat onlay-grafting harvested from the affected inframammary fold

Background

In silicone breast implant (SBI)-based breast reconstructions, aesthetic outcomes are often low due to the visible upper edge of the SBI. To ameliorate this, grafting fat harvested from the SBI operative field has not been reported to date. Therefore, we aimed to develop a novel technique for fat onlay-grafting, harvested from the inframammary fold (IMF) of the reconstructed breast, and investigate its usefulness.

Methods

A total of 90 patients who underwent SBI-based breast reconstruction after a simple mastectomy were included in this study. The harvested fat was recorded by weight and grafted evenly to the medial and median upper edge of the SBI on the pectoralis major muscle. We applied this technique to 30 patients (fat onlay-grafting group) and compared them with the 60 patients (no-grafting group) who did not undergo our technique using the postoperative 1-year aesthetic outcome scores of the medial and median upper edge of the SBI. Furthermore, we investigated the correlation between the weight of harvested fat and body mass index.

Results

No postoperative wound complications occurred, and infection, hardened fat, and fat lysis were not found in the fat onlay-grafting group. The medial and total aesthetic outcome scores in the fat onlay-grafting group were significantly higher than those in the no-grafting group (P<0.05). The average weight of harvested fat was 11.9 [5-32] g. The correlation between the weight of the harvested fat and body mass index was significantly positive (R²=0.7119, P<0.05).

Conclusions

Our technique made the upper edge of the SBI invisible. Further, it was simple and less invasive with safe augmentation. Therefore, we believe that this technique can contribute to better aesthetic outcomes in SBI-based breast reconstruction.

A Simple and Scarless Method for Inframammary Fold Correction Using a Barbed Suture

Background:

In the typical procedure for secondary correction of the inframammary fold (IMF) following breast reconstruction, a large incision is often required, and this increases surgical invasiveness. The “drawstring method” is a simple procedure for recreating a smooth IMF. We modified the drawstring method and developed an essentially scarless method for IMF correction from small stab incisions.

Methods:

Patients at our hospital who presented with IMF ptosis or loss of definition after breast reconstruction and required IMF correction, as well as those who requested IMF recreation for the contralateral breast, during the period spanning May 2016 to June 2019 were considered for this study. We collected and analyzed demographic data, as well as complications and postoperative outcomes.

Results:

The new method was performed on 20 patients, with the following breakdown: IMF recreation after breast reconstruction with a deep inferior epigastric artery perforator flap (11 patients), IMF recreation after breast reconstruction with a breast implant (2 patients), IMF recreation after breast reconstruction with fat graft (5 patients), and IMF recreation for the contralateral breast (2 patients). Overcorrection of the IMF stabilized by 2–3 months postoperatively, resulting in a smooth and well-defined IMF. For non–breast implant cases, the implant volume increased at the lower pole. Slack in the suture was observed in only 2 patients of the deep inferior epigastric artery perforator group and in 1 patient of the breast implant group after 6 months postoperatively.

Conclusions:

Our new method allows for the recreation of an essentially scarless, smooth, and well-defined IMF. IMF definition can be adjusted by altering the depth of the barbed suture. Since this method can be performed under local anesthesia, it offers the benefits of reducing medical costs and physical burden on patients.

The island-type pedicled TRAM flap: Improvement of the aesthetic outcomes of breast reconstruction

BACKGROUND

The pedicled transverse rectus abdominis myocutaneous flap (TRAM) remains an effective and widely-used method for breast reconstruction despite well-documented donor-site morbidity. We present the island-type pedicled TRAM flap as a way to obtain better and more reliable outcomes in breast reconstruction.

METHODS

A retrospective chart review of patients who underwent breast reconstruction with an island-type pedicled TRAM flap was performed. Patient demographics and complications were reviewed. In the island-type pedicled TRAM flap, we transversely resected the upper ipsilateral rectus muscle surrounding the origin of the superior epigastric vessels, preserving only a 1-cm muscle strip including the vascular pedicle to prevent epigastric bulging and inframammary fold (IMF) disruption. The flap was turned over into the ipsilateral breast pocket. The IMF was repaired except for the portion where the pedicle was placed.

RESULTS

From January 2013 to November 2017, 88 patients underwent surgery using the island-type pedicled TRAM flap. The etiology of the defect was breast cancer with mastectomy in 86 cases, and paraffinoma in two cases. Seventy-seven patients underwent unilateral reconstruction, and 11 patients underwent bilateral reconstruction. Minor fat necrosis occurred in eight cases. Mild inframammary or epigastric bulging was observed in five cases, and neither partial nor total flap necrosis was observed. The aesthetic outcome of the IMF was evaluated in 55 cases, and 53 cases received good overall scores.

CONCLUSION

Although the island-type pedicled TRAM flap is technically challenging because careful dissection and pedicle identification is required, it can provide more reliable and better aesthetic results without an increased risk of vascular compromise.

Inframammary fold subcutaneous cushion assessment using MRI (magnetic resonance imaging)

Background

The inframammary fold (IMF) is one of the most important elements in the determination of the aesthetic of the female breast. During mastectomies, it is important to preserve the subcutaneous portion nearby the IMF, attempting that, this preservation will greatly facilitate reconstruction allowing more satisfying aesthetic results. The aim of the present study is to evaluate the thickness of the subcutaneous IMF cushion using magnetic resonance imaging (MRI) acquisition images.

Methods

We have gauged the right breast IMF subcutaneous cushion from patients (all the cases without previous surgery in this topography) who were submitted to MRI in a diagnosis radiology center, between January and February of 2017. MRI images were analyzed in T1 fat saturated sequences. The assessment of the fold cushion was realized in the projection of axial measurements in sagittal plane.

Results

Among the 50 evaluated patients, the median measure of breast base was 9.91 cm. The median measure of the subcutaneous IMF cushion assessment in the sagittal projection of the breast base meridian was 2.40 cm (varying from 1.34 to 4.05 cm, with percentile 5% of 1.51 cm and percentile 95% of 3.55 cm).

Conclusions

Other studies indicate the negligible amount of breast tissue and the low incidence of neoplasia in this topography, the preservation of the IMF seems feasible. The measurements of the IMF thickness, evaluated by MRI in this study, provide reference values for maintaining a desirable inframammary crease.

[Acellular dermal matrix and synthetic mesh in implant-based immediate breast reconstruction: Current concepts]

The use of acellular dermal matrices and synthetic meshes is gaining popularity in direct-to-implant breast reconstruction, allowing the complete coverage of the prosthesis with greater pocket control and improved cosmesis. In this concise review, we present the advantages of acellular dermal matrices and resorbable or nonresorbable synthetic meshes in implant-based breast reconstruction, we discuss the risk of postoperative complications, and we raise their contribution in the growing interest of prepectoral breast reconstruction.

Percutaneous Purse-String Suture: An Innovative Percutaneous Technique for Inframammary Fold Creation and Improved Breast Projection in Reconstructive Surgery

BACKGROUND

Lipofilling for breast reconstruction has become increasingly common. Creation of a well-defined inframammary fold (IMF) is integral to achieving symmetrical aesthetic results. This has traditionally been done under direct vision through an open incision.

OBJECTIVES

The authors present their experience in reconstructive breast surgery with a novel percutaneous technique for IMF creation and improvement of projection without the need for large incisions.

METHODS

From June 2011 to January 2015, 180 patients underwent a percutaneous purse-string suture (PPSS) to enhance their IMF and improve breast projection. After completion of lipofilling, a curved cannula is tunneled subcutaneously. The suture is placed into the cannula and passed around the circumference of the breast footprint. After the completion of two passes in different anatomic levels around the footprint, the suture is tightened at the breast's tail zone to achieve the desired IMF definition and breast projection. Surgical technique, results, and follow up are presented.

RESULTS

The PPSS technique was combined either with lipofilling only or as part of flap breast reconstruction in 30 and 150 patients, respectively. The average follow-up time was 34 months (range, 11-48 months). PPSS was redone in 25 patients to further improve breast projection. One patient complained of postoperative pain. No other PPSS-related complication was reported.

CONCLUSIONS

PPSS is an innovative technique designed to complement the emerging field of lipofilling for breast reconstruction. The technique is safe, easily reproduced, and provides excellent results. Breast IMF and projection are immediately improved without the need for open incisions.

LEVEL OF EVIDENCE 4

A new percutaneous method for inframammary fold reconstruction in implant-based breast reconstruction: Vertical pendulum suture

Several operative techniques for inframammary fold (IMF) reconstruction have been described and have resolved the shortcomings of conventional methods. However, there are still difficulties with IMF reconstruction, that is, performance through small mastectomy scars, creation of a smooth IMF curve, transfer of external IMF markings to the interior chest wall, or determining correct IMF without an implant in place. We have used a type of anchor suture with a completely percutaneous approach, the vertical pendulum suture (VP suture), to reconstruct the IMF easily in implant-based breast reconstruction.The VP suture requires a pair of skin incisions a few millimeters in length (incisions A and B). The needle passes through the subcutaneous tissue from incision A, the chest wall, again through the subcutaneous tissue, and exits from incision B. Then, the needle passes through the edge of the dermis from incision B, the superficial layer of the subcutaneous tissue, again through the other edge of the dermis, and exits from incision A. The knot is tied and buried in the subcutaneous tissue. The whole technique can be performed percutaneously without visualizing the inside of the pocket. A retrospective case series study of photographs and chart review was conducted for all cases of unilateral implant-based breast reconstruction performed from December 2016 to December 2017 at Ina Central Hospital, Ina, Japan.Nine consecutive patients underwent unilateral implant-based breast reconstruction. Five patients treated using the VP suture were included in this study. All 5 patients showed good esthetic results over the follow-up period (average, 11 months). Scalloped appearance was observed in all patients, but flattened spontaneously and disappeared within 3 months postoperatively. There were no complications, such as hematoma, infection, skin necrosis, pneumothorax, seroma, scar contracture, or implant injury.The VP suture is completely percutaneous, parallel to the IMF, and is easy to perform at any time during surgery regardless of whether the implant is in place or not. IMF reconstruction is facilitated by freeing the surgeon from the need to visualize the inside of the pocket.

The Inframammary Fold (IMF): A Poorly Appreciated Landmark in Prosthetic/Alloplastic Breast Aesthetic and Reconstructive Surgery-Personal Experience

The inframammary fold (IMF) is the most critical visual landmark that affects final aesthetic outcome of augmentation mammoplasty and even post-mastectomy alloplastic breast reconstruction. Unfortunately, structural integrity of this landmark is greatly overlooked and very often neglected. Excessive undermining of the lower breast pole with aggressive disruption/lowering and subsequent poor reconstitution of the IMF scaffold combined with imbalanced implant-tissue dynamics may result in downward implant displacement with creep bottoming and upward tilt of the nipples. The current report reviews the experience of the senior author (BA) over 30 years in breast aesthetic and reconstructive surgery with IMF reconstruction and fixation to the chest wall at the inferior border of the implant. Illustrative cases are presented.

LEVEL OF EVIDENCE V

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 .

Aesthetic outcomes of inframammary fold recreation in two-stage, implant-based, breast reconstruction

Background

When the inframammary fold (IMF) is excised in mastectomy procedures for oncologic reasons, it must be recreated to restore a natural breast shape. Despite refinements in surgical techniques, postoperative loss of a well-defined IMF can occur. This study aimed to assess the outcomes of IMF recreation after two-stage, implant-based breast reconstruction.

Methods

We retrospectively reviewed 75 consecutive patients who underwent unilateral, two-stage, implant-based breast reconstruction between 2013 and 2015 at the authors’ institution. Among them, IMF recreation was performed in 37 patients through a modified Nava’s internal method. Aesthetic outcomes of the recreated IMFs were evaluated by observer assessment of two criteria, and critical factors affecting IMF outcomes were also analyzed.

Results

We found that contralateral breast ptosis (p < 0.05) and lack of postmastectomy radiotherapy (PMRT, p < 0.01) were significant predictors of better IMF outcomes. Nipple-sparing mastectomy and skin-sparing mastectomy resulted in better IMF outcomes, as compared with non-skin-sparing mastectomy (p < 0.05 for each), while no significant difference was observed between them in patients who did not undergo PMRT (p = 0.19). Similarly, larger implant volume, but not projection of implant, was a predictor of better IMF outcomes when limited to patients who did not undergo PMRT (p < 0.05). Age, body mass index, timing of reconstruction, and extent of overexpansion had no significant effect on IMF outcomes.

Conclusions

Based on these critical factors, the shape of the reconstructed breast and the need for reshaping the contralateral breast can be predicted. Special attention should be paid to patients with non-skin-sparing mastectomy and PMRT. When these patients desire a medium- to large-sized ptotic breast, conversion to autologous reconstruction can achieve symmetrical breast reconstruction.

A new method for inframammary fold recreation using a barbed suture

BACKGROUND

There are inherent limitations with previously reported inframammary fold (IMF) recreation methods. The IMF is firmly fixed to the chest wall, but not physiologically, and it is difficult to determine the correct IMF position in the supine position and in the absence of an implant.

METHODS

With our new IMF reconstruction method (i.e., drawstring method), the IMF is recreated by drawing a barbed suture, penetrating the dermis, along the IMF. The barbed suture is fixed to the costal cartilage at the medial IMF, and the head is drawn and cut externally at the lateral IMF. The IMF level and depth can be finely adjusted by the tension, in a seated position after implant insertion. Furthermore, the approach can be from a small incision, and a smooth IMF curve is reconstructed.

RESULTS

Our drawstring method was performed in 102 patients who underwent reconstruction using a breast implant (n = 95) or flap (n = 7). The mean patient age was 52.0 years (range 33-77 years) and the follow-up period was 12 months (range 3-18 months). Suture or implant infection or exposure did not occur. Suture slack occurred in ten patients with implant-based reconstruction; their IMF became shallow. Insufficient skin expansion (P < 0.005) and strong traction of the barbed suture from the caudal side (P < 0.05) were related to IMF slack. The total revision rate was 2.9 %.

CONCLUSIONS

With sufficient skin expansion, the drawstring method using a barbed suture enables smooth and symmetrical IMF reconstruction.

LEVEL OF EVIDENCE IV

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 .

Systematic Review: Aesthetic Assessment of Breast Reconstruction Outcomes by Healthcare Professionals

BACKGROUND

Achieving an aesthetic outcome following postmastectomy breast reconstruction is both an important goal for the patient and plastic surgeon. However, there is currently an absence of a widely accepted, standardized, and validated professional aesthetic assessment scale following postmastectomy breast reconstruction.

METHODS

A systematic review was performed to identify all articles that provided professional assessment of the aesthetic outcome following postmastectomy, implant- or autologous tissue-based breast reconstruction. A modified version of the Scientific Advisory Committee's Medical Outcomes Trust (MOT) criteria was used to evaluate all professional aesthetic assessment scales identified by our systematic review. The criteria included conceptual framework formation, reliability, validity, responsiveness, interpretability, burden, and correlation with patient-reported outcomes.

RESULTS

A total of 120 articles were identified: 52 described autologous breast reconstruction, 37 implant-based reconstruction, and 29 both. Of the 12 different professional aesthetic assessment scales that exist in the literature, the most commonly used scale was the four-point professional aesthetic assessment scale. The highest score on the modified MOT criteria was assigned to the ten-point professional aesthetic assessment scale. However, this scale has limited clinical usefulness due to its poor responsiveness to change, lack of interpretability, and wide range of intra- and inter-rater agreements (Veiga et al. in Ann Plast Surg 48(5):515-520, 2002).

CONCLUSIONS

A "gold standard" professional aesthetic assessment scale needs to be developed to enhance the comparability of breast reconstruction results across techniques, surgeons, and studies to aid with the selection of procedures that produce the best aesthetic results from both the perspectives of the surgeon and patients.

Technique to achieve the symmetry of the new inframammary fold

The literature outlines several surgical techniques to restore inframmammary fold definition, but symmetry of the fold is often left to irreproducible procedures. We report our personal technique to restore the symmetry of the inframmammary fold during multistep breast reconstruction.

Determination of the accuracy of juxtacapsular dissection of the breast. What is left behind?

BACKGROUND

Resectional breast surgery has become less extensive. Dissection on plane of the superficial fascia covering the breast (juxtacapsular) is used during various procedures for retention of the appearance of the breast. The accuracy of this method and its ability to remove all glandular breast tissue has never been tested.

METHODS

Twenty patients with breast cancer were studied prospectively. Juxtacapsular dissection of the inferior flap was performed during mastectomy. Biopsies were taken on each side of the dissection plane at 3 sites: median, medial and lateral. Several histological slides were prepared from each biopsy and examined for the presence of breast parenchymal or dispersed glandular tissue.

RESULTS

Three hundred and forty nine histological slides were examined, 185 from the resected breast side and 164 from the subcutaneous side. Ninety four percent of the slides from the breast side contained glandular tissue. Breast glandular tissue was found outside the dissection plane in 16 of 20 cases and in 33% of slides. This was sparse and dispersed in 69% of slides. A mean of 81% of slides from individual cases revealed glandular tissue inside and the absence of glandular tissue outside the dissection plane ("expected result"), demonstrating predominantly accurate juxtacapsular dissection.

CONCLUSION

This study demonstrated that accurate juxtacapsular inferior flap dissection leaves behind glandular breast tissue in a greater proportion of cases than any previous study. While this tissue is sparsely-distributed, surgeons should be aware of the occurrence of glandular breast tissue outside the juxtacapsular dissection plane in the majority of cases.

Is ultracision knife safe and efficient for breast capsulectomy? A preliminary study

BACKGROUND

Silicone breast implants are used to a wide extent in the field of plastic surgery. However, capsular contracture remains a considerable concern. This study aimed to analyze the effectiveness and applicability of an ultracision knife for capsulectomy breast surgery.

METHODS

A prospective, single-center, randomized study was performed in 2009. The inclusion criteria specified female patients 20-80 years of age with capsular contracture (Baker 3-4). Ventral capsulectomy was performed using an ultracision knife on one side and the conventional Metzenbaum-type scissors and surgical knife on the collateral side of the breast. Measurements of the resected capsular ventral fragment, operative time, remaining breast tissue, drainage time, seroma and hematoma formation, visual analog scale pain score, and sensory function of the nipple-areola complex were assessed. In addition, histologic analysis of the resected capsule was performed.

RESULTS

Five patients (median age, 59.2 years) were included in this study with a mean follow-up period of 6 months. Three patients had Baker grade 3 capsular contracture, and two patients had Baker grade 4 capsular contracture. The ultracision knife was associated with a significantly lower pain score, shorter operative time, smaller drainage volume, and shorter drainage time and resulted in a larger amount of remaining breast tissue. Histologic analysis of the resected capsule showed no apoptotic cells in the study group or control group.

CONCLUSIONS

The results suggest that ventral capsulectomy with Baker grade 3 or 4 contracture using the ultracision knife is feasible, safe, and more efficient than blunt dissection and monopolar cutting diathermy and has a short learning curve.

LEVEL OF EVIDENCE II

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 at www.springer.com/00266.