Focus on the breast fascial system: a new approach for inframammary fold reconstruction

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.

Comprehensive management of breast augmentation with polyacrylamide hydrogel injection based on 15 years of experience: a report on 325 cases

Background

As a permanent soft tissue filler, the use of polyacrylamide hydrogel (PAAG) has been banned due to its myriad complications. However, a large number of symptomatic and asymptomatic patients whose breasts were augmented with the gel injection have continued to seek medical advice. This study aimed to explore standardized clinical management of breast augmentation with PAAG.

Methods

The authors retrospectively collected the data of a total of 325 patients following PAAG injection for breast augmentation from 2003 to 2018. Magnetic resonance imaging (MRI) was performed preoperatively to disclose the general distribution of the gel and its infiltration into the muscle and gland. Debridement surgery, including the PAAG evacuation, pathologic tissue excision, and pocket irrigation via the periareolar incision, was performed. Immediate breast reconstruction (IBR) using silicone prostheses was carried out on 86 patients and delayed breast reconstruction (DBR) was performed on 35 patients.

Results

Most of the patients in the group were satisfied with their surgical outcome, their symptoms disappeared after the debridement surgery, and they experienced no relapse or recurrence. Unfortunately, for most of the cases, it was extremely difficult to remove the PAAG completely-however, improved quality of life as seen through the BREAST-Q evaluation.

Conclusions

With the guidance of MRI images, surgery, including PAAG evacuation, pathologic tissue excision, and pocket irrigation via the periareolar incision, was a reliable method to ensure the maximal removal of the PAAG. Immediate or secondary breast reconstruction with sub-glandular placement of silicone prostheses showed a satisfactory mid-term effect.

Novel 3-Dimensional Imaging Analysis of the Ryan Procedure for Inframammary Fold Elevation in the Reconstruction of the Revised Breast

The inframammary fold (IMF) can be challenging to reconstruct after disruption during mastectomy or breast reconstruction. The Ryan procedure is a previously described technique with little long-term analysis. Our goal is to analyze the long-term results of the Ryan procedure using 3-dimensional (3D) technology, with the hypothesis that 3D measurements will provide quantitative outcomes that add to the qualitative assessment of the reconstruction. We retrospectively reviewed consecutive breast reconstruction patients by a single surgeon from January 1, 2012 to January 31, 2015 to identify patients who underwent the Ryan procedure. Previously obtained 3D photographs were then analyzed to compare breast base diameter, breast projection, and inter-IMF distance pre- and postoperatively. A survey was then given to 15 health professionals in our department to assess the IMF and symmetry pre- and postoperatively. Eight patients were eligible for inclusion. Four patients were unilateral reconstruction and 4 were bilateral. The Ryan procedure resulted in an inter-IMF discrepancy reduction of 39% and a breast projection increase of 18%. Average length of follow-up was 2.82 ± 0.75 years. One patient required a secondary IMF revision. The majority of survey respondents felt that the IMF and IMF symmetry were improved or stable postoperatively. The Ryan procedure seems to be a reliable and durable technique for IMF reconstruction with increased projection, decreased IMF discrepancy, and increased symmetry. Additionally, 3D imaging provides a useful approach in the assessment of breast reconstruction outcomes, adding quantitative outcomes measures to its evaluation.

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.

Efficacy of STRATAFIX in Inframammary Fold Recreation in Autologous Breast Reconstruction

Supplemental Digital Content is available in the text.

Positional relationship between the pectoralis major and external abdominal oblique muscles for consideration during dual-plane breast augmentation

During dual plane breast augmentation (DPBA), the costal origin of the pectoralis major (the PM) should be cut to ensure appropriate coverage and positioning of an implant. However, surgeons sometimes make inappropriate planar incisions and insufficient muscular incisions because the external abdominal oblique (the EAO) muscle partially overlaps the lateral portion of the PM. The goal of this study was to clarify the positional relationship between the PM and EAO with the aim of improving the accuracy of implant and muscular incisions during DPBA. Forty sides of 20 embalmed and fresh cadavers were dissected. The midline and midclavicular line (MCL) were used as reference lines for measurements. We clarified the overlapping patterns between the PM and EAO, and measured the distances from the MCL to the borders of those two muscles. The costal part of the PM originated from the 5th (25%), 6th (70%), or 7th rib (5%), respectively. The distances from the MCL to the lateral border of the PM at the 4th, 5th, and 6th ribs were 49.8 mm, 30.5 mm, and 6.3 mm, respectively. In 90% of the specimens, the PM and the EAO overlapped near the MCL. The width of the overlapping portion between the PM and EAO was about 25 mm. This study is one of the first to suggest an innovative approach for explaining the positional relationships between the PM and EAO. Our findings can be useful for surgeons attempting to produce optimal outcomes in DPBA, especially in procedures that involve patients of different races. Clin. Anat. 31:339-346, 2018. © 2018 Wiley Periodicals, Inc.

How to optimize aesthetic outcomes in implant-based breast reconstruction

The evolution of breast reconstructive surgery keeps pace with the evolution of breast oncologic surgery. The reconstructive choice should always balance the optimal local control of disease and the best cosmetic result, reflecting an informed decision that is shared with the patient, who is always at the center of the decision-making process. Implant-based breast reconstruction following mastectomy represents a complex choice. In order to obtain optimal results, the following considerations are mandatory: thorough preoperative planning, a complete knowledge of the devices that are used, accurately performed surgery, and appropriate follow-up.

DIEP Flap Breast Reconstruction in Patients with Breast Ptosis: 2-Stage Reconstruction Using 3-Dimensional Surface Imaging and a Printed Mold

Background:

Autologous breast reconstruction can be performed for breasts with ptosis to a certain extent, but if patients desire to correct ptosis, mastopexy of the contralateral breast is indicated. However, accurate prediction of post-mastopexy breast shape is difficult to make, and symmetrical breast reconstruction requires certain experience. We have previously reported the use of three-dimensional (3D) imaging and printing technologies in deep inferior epigastric artery perforator (DIEP) flap breast reconstruction. In the present study, these technologies were applied to the reconstruction of breasts with ptosis.

Methods:

Eight breast cancer patients with ptotic breasts underwent two-stage unilateral DIEP flap breast reconstruction. In the initial surgery, tissue expander (TE) placement and contralateral mastopexy are performed simultaneously. Four to six months later, 3D bilateral breast imaging is performed after confirming that the shape of the contralateral breast (post-mastopexy) is somewhat stabilized, and a 3D-printed breast mold is created based on the mirror image of the shape of the contralateral breast acquired using analytical software. Then, DIEP flap surgery is performed, where the breast mold is used to determine the required flap volume and to shape the breast mound.

Results:

All flaps were engrafted without any major perioperative complications during both the initial and DIEP flap surgeries. Objective assessment of cosmetic outcome revealed that good breast symmetry was achieved in all cases.

Conclusions:

The method described here may allow even inexperienced surgeons to achieve reconstruction of symmetrical, non-ptotic breasts with ease and in a short time. While the requirement of two surgeries is a potential disadvantage, our method will be particularly useful in cases involving TEs, i.e., delayed reconstruction or immediate reconstruction involving significant skin resection.

Small refinements in breast reconstruction: a technique for inframammary fold creation

BACKGROUND

In breast reconstructive surgery, the inframammary fold (IMF) is an essential component of breast identity. The lack of the IMF following previous mastectomy requires restoration. We have developed a new IMF reconstruction technique using the posterior sheet (PS) of the expander capsule. This article presents our 10-year experience of performing this original technique during two-stage breast reconstruction.

METHODS

Preoperatively, the midline, lateral, and medial borders (MBs) of the implant pocket and the new IMF line were marked. After extracting the expander, the anterior sheet of the expander capsule was removed with the exception of its lowest 2-cm portion. Two needles were placed at the intersection of the new IMF line with the lateral border (LB) of the implant pocket and its MB. Within the pocket, horizontal dissection of the PS of the capsule was performed from one needle to another, after which the sheet was mobilized downward. The mobilized free border of the PS was pulled upward until the inframammary crease was at the new marked location, and then fixed with non-absorbable interrupted sutures to the underlying tissues. An implant was placed over this layer. The covering tissues were then closed.

RESULTS

A total of 321 patients were included. The median age was 38 years (range, 18-58 years). No serious wound complications were observed. Breast-thoracic angle decreased in 21 patients (6.5%), and the distance from the IMF to the lower border of breast segment III was greater than that of the contralateral breast in 14 patients (4.4%).

CONCLUSION

This technique provides a well-defined IMF without indentations or retraction. The results are stable on long-term follow-up and provide a sharp breast-thoracic angle, which is crucial in creating natural-looking ptosis of the reconstructed breast.

A New Septum in the Female Breast

BACKGROUND

Understanding the female breast fascial system is of paramount importance in breast surgery. Little was written about breast ligaments. Most articles refer to Cooper's work without further anatomical studies. Lately, a horizontal septum has been described conveying nerves and vessels to the nipple areola complex.

METHODS

During the surgical dissection of the lower part of the breast, in supero-medial technique for breast reduction operations, a fascial septum between the lower two quadrants was detected. This fibrous septum was studied through anatomic dissection of breast tissues during routine breast reshaping procedures that was done on 30 female patients. Magnetic resonance imaging (MRI) was performed preoperatively in all cases and correlated with the intraoperative findings. In the other five cases, outside the clinical study, the imaging was done during routine investigation for breast swellings.

RESULTS

A vertical septum was identified in the lower part of the breast, lying at the breast meridian between the two lower quadrants. It is a tough bi-laminated structure that extends from the middle of the infra-mammary crease caudally to nipple-areola complex cranially and from the pectoral fascia posteriorly to the overlying skin anteriorly. This was proved by MRI findings.

CONCLUSIONS

This study describes a new inferior vertical septum which separates the lower half of the breast into two definite anatomical compartments: medial and lateral.

Predictability of anthropomorphic measurements in implant selection for breast reconstruction: a retrospective cohort study

Background

Preoperative implant planning for breast reconstruction is often at risk of being changed perioperatively. This study examined which factors are associated with a change of implant selection.

Methods

Women who had unilateral two-stage breast reconstruction between 2002 and 2007 were studied. Inclusion criteria were photographic evidence of preoperative skin markings indicating breast dimensions and a selected implant model. Multivariable logistic regression was used to identify variables associated with a changed selection.

Results

Among the 496 women studied, 308 preoperative implant choices (62.1%) were changed during surgery. A change in plan was significantly associated with symmetrization surgery involving contralateral reduction mammaplasty (OR = 1.92; 95% CI, 1.12 to 3.29) and contralateral mastopexy (OR = 2.26; 95% CI, 1.29 to 3.96), but not with BMI. The required implant width changed more than 0.5 cm in 70 cases (14.1%) while height changed more than 0.5 cm in 215 cases (43.2%). The likelihood of a change was high for large preoperative widths (OR = 9.66 for 15.5 cm) and small preoperative heights (OR = 2.97 for 10.5 cm). At a mean follow-up of 16.6 months, patient satisfaction was good or average in 92.1% of cases and 5.9% of implants had been replaced with another model, indicating that the perioperative implant selection was usually appropriate.

Conclusions

This study documents the frequency with which implant choices, despite accurate preoperative planning, are changed perioperatively as a result of relatively small differences in anthropomorphic measurements. Perioperative recalculation of breast dimensions may have an advantage in terms of patient reoperation rates. Changes in width were less frequent than changes in height and projection. Contralateral surgery, large width, and small height were the most influential factors.

Level of Evidence: Level IV, risk / prognostic study.

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.

Inframammary Fold Reconstruction: A Biomechanical Analysis

Background:

Inframammary fold reconstruction has scarcely been evaluated in literature. No biomechanical analyses have been performed comparing different reconstructive methods. This evaluation compares the gold-standard suture reconstruction with an intrarib anchor system (Micro BioComposite SutureTak, Arthrex).

Methods:

Three analysis groups were compared including 8 Sawbone blocks, 22 embalmed cadaver, and 27 regular cadaver specimens (N = 57). Transient mechanical analysis was performed at 5 N/s using an Instron 5565 test frame.

Results:

Ultimate load favored the anchor system (compared with the gold-standard suture) by a factor of 9.8 (P < 0.0001) for the regular cadaver group and a factor of 1.7 (P < 0.038) for the embalmed cadaver group. A similar statistically significant benefit was shown for stiffness and load at 2-mm displacement.

Conclusions:

This analysis showed an anchor system to be the biomechanically superior fixation method in terms of ultimate load, fixation stiffness, and displacement at failure when compared with the gold-standard suture method in inframammary fold reconstruction. Because of superior stability in every aspect, an anchor system may be considered for inframammary fold reconstruction.

Skin-reducing mastectomy and immediate breast reconstruction in patients with macromastia

INTRODUCTION

In women with macromastia, a type IV skin sparing mastectomy is often required to achieve an aesthetically pleasing reconstruction. The introduction of "skin-reducing mastectomy", which inserts a permanent prosthetic device into a large pouch made by the pectoralis major muscle and an inferior pedicle dermal flap, allows the surgeon to achieve a safe oncologic result plus a cosmetically satisfying reconstruction.

OBJECTIVE

We report here our experience with the skin-reducing mastectomy with the aim of emphasizing the problems associated with the technique.

MATERIALS AND METHOD

A study was conduced from April 2009 to November 2012, 74 patients with breast cancer were selected then received a skin-reducing mastectomy. The enrolled women satisfied the criteria of Nava. Statistical analysis was conduced to estimate the significance of the outcome results and complication rate.

RESULT

A total of 88 SRMs were performed and the outcomes were as follows: excellent in 34 patients, good in 21, and poor in 8. We recorded 25 % of adverse events and statistic helped us to identify patient related factors whose can increase the complications onset.

CONCLUSION

Skin-reducing mastectomy is an indispensable procedure to treat cancer in large and pendulous breasts. The correct patient selection is mandatory to reduce the not negligible complication risk. Skin reducing mastectomy when is well conduced allow to obtain good results with patient satisfaction but, like other breast-conserving surgeries, in some case is not the ultimate solution, because it may require some revisions to maintain the optimum results. To day it be consider relatively safe in selected patient and the gold standard in macormastia immediate reconstruction.

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.

"Upside-down" augmentation mastopexy

BACKGROUND

The author's wide experience with postbariatric body contouring pushed him to find a technique suitable for correcting the two most common defects of the massive weight loss (MWL) breast: hypotrophy and ptosis. For these defects, a technique selection algorithm has been created. According to the algorithm, the "upside-down" technique was developed for those cases with a diagnosis of "minor ptosis" (<6 cm of vertical nipple-areolar complex correction).

METHODS

The upside-down technique is performed as follows. (1) Complete subcutaneous undermining of the glandular upper pole to the upper edge of the mammary gland is performed. (2) After rotation around the edge, upside-down retroglandular undermining is performed, with great care taken to leave the inframammary fold and 2 cm of the gland undetached. (3) Topside-bottom implant insertion is performed with a "mailbox posting" action. The inframammary fold and the undetached gland act as a bra to prevent implant ptosis. The upper one-third of the prosthesis can be placed beneath the pectoralis major muscle with the "dual-plane" technique if a round implant is used or left completely retroglandular if an anatomic implant is used. (4) The type of implant needed (round vs anatomic) basically depends on the type of aesthetic defect. Major upper pole defects need round implants, and major lower pole defects need anatomic implants. The patient's preferences are a primary factor in the decision. (5) Breast lifting is performed through strong anchorage to the fascia, muscle, and second rib periosteum. At least three stitches of threaded nonabsorbable 0 or 1 suture are positioned. The whole lower gland pole is left undetached to guarantee blood perfusion (only 1 or 2 cm of periareolar incision are undermined). (6) Periareolar suture is always performed with the "interlocking" technique according to Hammond.

RESULTS

From November 2001 to May 2010, 231 patients underwent surgery using the described technique. The patients all were Caucasian with an average age of 38 years (range, 31-53 years), and all underwent surgery bilaterally. The mean operating time was 150 min (range, 120-180 min), and the mean hospital stay was 3.5 days (range, 2-5 days) after surgery. The ptosis recurrence rate was evaluated. A recurrence is identified when the nipple-areola complex slides more than 2 cm 1 year after surgery. The recurrence rate was 27.6% for other techniques versus 9.1% for the upside-down technique.

CONCLUSIONS

Natural shape, stable position, and short scars are the main advantages of the upside-down technique. The typical breast flatness after periareolar access is best corrected by the last-generation dual-cohesiveness anatomic implants, which the author strongly recommends to obtain the best results with this technique. The Body Uneasiness Test (BUT) study showed 100% improvement of patient discomfort.

Layers of the abdominal wall: anatomical investigation of subcutaneous tissue and superficial fascia

INTRODUCTION

In recent times new surgical approaches have been developed, in which subcutaneous tissue is the primary object, such as flaps and fat removal techniques, but different descriptions and abundance of terminology persist in Literature about this tissue.

AIM AND METHODS

In order to investigate the structure of abdominal subcutaneous tissue, macroscopic and microscopic analyses of its layers were performed in 10 fresh cadavers. Results were compared with in vivo CT images of the abdomen of 10 subjects.

RESULTS

The subcutaneous tissue of the abdomen comprises three layers: a superficial adipose layer (SAT), a membranous layer, and a deep adipose layer (DAT). The SAT presented fibrous septa that defined polygonal-oval lobes of fat cells with a mean circularity factor of 0.856 ± 0.113. The membranous layer is a continuous fibrous membrane rich in elastic fibers with a mean thickness of 847.4 ± 295 μm. In the DAT the fibrous septa were predominantly obliquely-horizontally oriented, defining large, flat, polygonal lobes of fat cells (circularity factor: mean 0.473 ± 0.07). The CT scans confirm these findings, showing a variation of the thickness of the SAT, DAT and membranous layer according with the subjects and with the regions.

DISCUSSION

The distinction of SAT and DAT and their anatomic differences are key elements in modern approaches to liposuction. The membranous layer appears to be also a dissection plane which merits further attention. According with the revision of Literature, the Authors propose that the term "superficial fascia" should only be used as a synonym for the membranous layer.

Skin-reducing mastectomy with breast reconstruction and sub-pectoral implants

One of the difficulties of an immediate breast reconstruction with a sub-pectoral tissue expander is fashioning the lower, medial end of the pouch because of the insertion of the fibres of the pectoral muscle into the ribs. This often requires delayed corrections to provide a good cosmetic result with fullness of the lower medial quadrant of the reconstructed breast. Skin-reducing mastectomy (SRM) is a technique that potentially resolves this cosmetic problem by creating a dermomuscular pouch with adequate volume in the lower-medial quadrant and, at the same time, provides satisfactory coverage of the silicone implant. Much of the surgical scarring lies in relatively concealed areas of the breast. The risk of complications is reduced by use of permanent expanders and achieving compatibility between the length of the skin flaps and that of the dermomuscular pouch. The indications for this technique are the same as those of a skin-sparing mastectomy. The procedure is particularly useful for women with large breasts and in cases of bilateral prophylactic mastectomy for women at increased risk of breast cancer. We report our experience with 18 skin-reducing mastectomies carried out in 10 women. One had a complication (5%) (haematoma and infection) and one had poor long-term cosmetic result (5%) (fibrosis of the lower pole of the reconstructed breast). SRM is, from an oncological perspective, a skin-sparing mastectomy (type IV) that provides a good cosmetic result by creating a dermomuscular pouch.

Pocket work for optimising outcomes in prosthetic breast reconstruction

Implant breast reconstruction is a recommendable alternative for women who have undergone mastectomy and lack the necessary subcutaneous fat tissue for an autologous reconstruction. On the other hand, many women reject the morbidity of the donor site, prolonged recovery periods and muscular weakness associated with autologous reconstruction. Therefore, muscle and skin expansion has become one of the most popular approaches used in breast reconstruction. Nevertheless, the expansion process may be hindered by events like seroma formation, implant rotation, moving upward or downward altering the location or shape of the submammary crease, capsule contracture or extrusion. Since the advent of the anatomical expander, two-stage reconstruction with the expander/implant sequence has become the most popular choice in prosthetic breast reconstruction (PBR). The second surgical stage, in which the tissue expander is exchanged for the permanent implant, offers a unique opportunity for pocket work. Pocket work strategies and their indications should be known and applied by the surgeon who aims at optimising PBR aesthetic results.

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

The inframammary fold (IMF) represents one of the most important anatomic landmarks in defining a woman's breast ptosis and inferior quadrant shape. Therefore it is important to preserve it, if this is oncologically safe, at the time of excisional surgery. If it is sacrificed, dislocated cranially or caudally, or there is a thick panniculus adiposus with a poor definition of the fold, it is necessary to recreate it. We present our experience in the reconstruction of the IMF in patients suffering from post-oncologic mastectomy, reconstructed with silicone implants. From January 2000 to May 2004 at the Plastic Surgery Department of the University of Turin, 74 reconstructions of the IMF were performed through Nava's technique, partially modified by us. We believe that IMF reconstruction, through fixation of cutis, subcutis and fascia superficialis to VI rib, along with capsulectomy of periprotesic pocket inferior quadrants, is a milestone for achieving, in selected cases, a good aesthetic result in terms of shape, ptosis and projection of inferior pole. The comparison between patients' opinions (obtained through questionnaires) and surgeon's, at 1 year after the reconstruction, shows that both are satisfied with the achieved outcome in terms of shape, projection, symmetry, ptosis and IMF definition. Another comparison was made between cases of fold preservation and cases of fold reconstruction, with a remarkable similarity of aesthetic satisfaction. The technique proposed here appears to be the current method of choice for IMF reconstruction in all cases where it is necessary to recreate or redefine it.

Immediate prosthetic breast reconstruction: the ensured subpectoral pocket (ESP)

Implant exposure due to cutaneous necrosis is one of the most feared complications of mastectomy with immediate prosthetic reconstruction. A key issue is to ensure good blood supply to the skin and complete integrity of the submuscular pocket. The latter is created with the pectoralis major and supplemented with the serratus anterior, the rectus abdominis sheat, the obliquus mayor and the pectoralis minor. The main drawback is that those muscles, when sutured to create a complete pocket, only allow the setting of small-sized implants. The authors present the application of polyglycolic mesh in an original fashion, mimicking the anatomy of the muscles usually employed in pocket creation. The proposed technique has been denominated Ensured Subpectoral Pocket and has proved to be a valid strategy in immediate single stage prosthetic breast reconstruction. It allows the setting of bigger implants without previous tissue expansion while preventing implant displacement. In addition, it reduces emotional trauma on patients and lowers surgical costs.

Inframammary fold reconstruction with a deepithelialized skin flap

Sagging of the remaining breast behind the inframammary fold after breast reduction or breast augmentation may necessitate revisional surgery. The authors achieved inframammary fold reconstruction by reconstruction of the inframammary crease ligament through a deepithelialized skin flap that is anchored to the periosteum of the fifth or sixth rib. They present their simple and safe technique.