INTRODUCTION
The National Cancer Institute1 shows that
57,960 new cases of breast cancer were expected in Brazil in 2016 (25% of all
cancers), accounting for 14,388 deaths of women in 20132. Excluding non-melanoma skin tumors, this cancer type is
the most frequent among women in Brazil and the second in the world. A surgical
approach is the main step in treating this cancer.
There are several options for breast reconstruction, and the indications for each
option have undergone some changes and evolutions. The use of flaps in
association with implants has been gaining attention. The main limitation of
using implants for breast reconstruction is inadequate soft tissue coverage.
With the advent of skin-sparing mastectomy and subcutaneous mastectomy,
immediate reconstruction, either with implants or autologous tissues, is now
considered as the first option in selected patients3,4.
Despite the high efficiency of these techniques, some local complications persist
with greater incidence in immediate reconstructions. Persisting complications
include increased risk of seroma formation, skin necrosis, extrusion and
exposure of the implants, and malfunctioning valve and leakage/deflation when
expanders are used.
The advent of skin-sparing mastectomy and immediate reconstruction has allowed
plastic surgeons and mastologists to achieve better results with all types of
breast reconstruction. As skin flaps resulting from mastectomy have become more
reliable, the rate of complications has decreased, and the satisfaction of the
medical staff has increased.
Approximately 30 years after introducing the skin-sparing techniques, we are now
able to face the challenge of achieving good aesthetic results in immediate
reconstructions without significantly interfering with adjuvant therapy5-8.
The technique presented here consists of creation of an arcuate and versatile
incision from the lateral end to the medial end of the breast, passing
tangentially below, in the middle, or above the nipple-areola complex (NAC).
This provides a wide exposure of the breast tissue to be accessed and
reconstructed during mastectomy, allowing good coverage for the implant and the
necessary skin adjustment for each case.
The technique is indicated for tumors of the upper or central quadrants, in which
the skin in the lower quadrants can be partially preserved. The NAC could be
preserved following the oncological treatment indicated by the mastologist. It
could also be maintained, when possible, by maintaining the superior or inferior
pedicle, depending on each case. An important aspect for the success of the
technique described here is a good integration between the mastectomy team and
the plastic surgery team.
OBJECTIVE
This article aims at presenting an approach for immediate breast reconstruction
by creating a cavity in the retropectoral plane in the upper pole and in the
mixed subcutaneous (subcutaneous and skin) plane in the lower pole, resulting
in
a less morbid dual-plane cover. This result is achieved by
creating an arcuate incision in the breast, with the main advantage of
protecting the prosthesis in cases of dehiscence of the wound, since the suture
line of the deep plane (pectoralis muscle with subcutaneous flap) does not
coincide with the skin suture.
METHODS
Our approach consists of creation of an arcuate and versatile incision from the
lateral end of the breast sulcus to its medial end, passing tangentially below,
in the middle, or above the NAC. This provides a wide exposure of the breast
tissue to be accessed and reconstructed during mastectomy, providing an adequate
coverage for the implant and the necessary skin adjustment for each case.
The technique is indicated for tumors of the upper or central quadrants, where
the skin in the lower quadrants can be preserved. The NAC could be preserved
following the oncological treatment indicated by the mastologist. It could also
be maintained, when possible, by maintaining the superior or inferior pedicle,
according to each case.
This retrospective study analyzed the medical records of patients operated for
breast cancer from 2012 to 2016 at the Plastic Surgery Service of the senior
author’s private clinic at Daher Hospital and the Armed Forces Hospital in
Brasília, DF. All patients with tumors located in the upper quadrants of the
breast and those with skin adequate to cover the lower third of the implant were
selected.
Patients were selected after a joint analysis with the mastology team. All
patients had a small amount of fat tissue in the lower quadrants; thus, an
agreement on the maintenance of this tissue was necessary. Thus, tumor location,
absence of microcalcifications or other suspicious changes, and blood viability
of the flap from the perforators of the 6th and 7th intercostal spaces9 and the subdermal plexus of the upper
abdomen were carefully analyzed.
All patients were operated on in a hospital setting, were discharged after
surgery, and received a prescription for antibiotic prophylaxis with cefadroxil
500 mg every 12 hours, a vacuum suction drain, and analgesia; they were informed
of the need for early ambulation. Enoxaparin sodium was only used for
prophylaxis of deep venous thrombosis in selected cases; however, all mechanical
preventive measures were routinely performed in all patients.
This research study followed the legal procedures determined by Resolution 196/96
of the National Health Council regarding research involving human beings. Data
collection and analysis started soon after the examination and approval by the
Research Ethics Committee of the Armed Forces Hospital (registration number
54273216.3.0000.0025 and opinion number 1,549,048).
Operative technique
The technique used consists of creating an arcuate incision in the breast
from the lateral end to the medial part of the sub-mammary sulcus, following
the marks shown in figure 1. It can be
performed bilaterally and simultaneously and for therapeutic or
risk-reducing purposes. The incision may be created across the infra-areola
or supra-areola region, outlining the upper or lower NAC or removing it
completely. Further marking on the excess skin may be created if skin
removal is required during mastectomy (Figures 2 to 4).
Figure 1 - Marking of the skin incision line.
Figure 1 - Marking of the skin incision line.
Figure 2 - Marking of the skin incision line.
Figure 2 - Marking of the skin incision line.
Figure 3 - Marking of the skin incision line with removal of the
nipple-areola complex.
Figure 3 - Marking of the skin incision line with removal of the
nipple-areola complex.
Figure 4 - Marking of the skin incision line with skin extension to
cover skin resection in mastectomy.
Figure 4 - Marking of the skin incision line with skin extension to
cover skin resection in mastectomy.
The entire lower base of the breast skin was maintained intact. The
dermis-fat flap had a minimum thickness of 1.5 to 2 cm (Figure 5) and was placed by the plastic surgeon or at
least under his/her supervision. Subsequently, mastectomy was performed by
the mastology team through a wide incision that facilitates the procedure.
After mastectomy, the plastic surgeon prepared the flap of the pectoralis
major muscle by releasing it upon insertion of the costal insertion (Figure 6) near the rectus sheath
aponeurosis and the costal insertion located at the junction of the
4th and 5th ribs.
Figure 5 - Preparation of the lower skin flap.
Figure 5 - Preparation of the lower skin flap.
Figure 6 - Creation of the pectoralis major cavity.
Figure 6 - Creation of the pectoralis major cavity.
Once the retromuscular cavity was dissected, the silicone implant was
inserted and covered by the pectoralis major muscle in the higher two-thirds
and the dermis-fat flap in its lower third (Figure 7). The caudal border of the major pectoralis muscle was
then sutured approximately 2 or 3 cm from the lower border of the dermis-fat
flap (Figure 8), ensuring that this
suture line does not coincide with the skin incision line (Figure 9) and thus providing greater
protection for the implant in the case of dehiscence of the external
suture.
Figure 7 - Insertion of the implant and closure of the cavity.
Figure 7 - Insertion of the implant and closure of the cavity.
Figure 8 - Appearance of the sutured cavity.
Figure 8 - Appearance of the sutured cavity.
Figure 9 - Side view of the implant in dual plane, with the skin
incision still open.
Figure 9 - Side view of the implant in dual plane, with the skin
incision still open.
The skin of the upper portion of the breast covered the pectoral muscle, and
its lower border was sutured at the upper edge of the lower flap, where the
necessary adjustments and resections of skin excess were made (Figure 10). Thereafter, the implant
remained well protected in a “dual plane” positioning
(Figure 11). A vacuum suction
drain was used routinely, and skin synthesis was conducted in two or three
suture planes.
Figure 10 - Final suture (only skin remaining).
Figure 10 - Final suture (only skin remaining).
Figure 11 - Side view of the implant in dual plane, with sutured skin
incision.
Figure 11 - Side view of the implant in dual plane, with sutured skin
incision.
The implants used were round shaped for slim patients and regular shaped for
patients with thicker adipose tissue; in other cases, they were selected
according to the thickness left by the breast cancer specialist at the time
of mastectomy. The volume selected was near 60% of the volume desired by the
patient and/or surgeon. The NAC, when preserved, can be maintained with
superior pedicle, inferior pedicle, or free graft, always according to
mastology.
RESULTS
The mean patient age was 59.57 years. Ductal carcinoma in situ
and infiltrating ductal carcinoma were the histological types found in the
biopsy. High blood pressure, diabetes, and obesity were the most common
comorbidities. Smoking was reported by five patients (15.78% of the total).
Neoadjuvant therapy was required in two patients (5.5%) and adjuvant therapy
in
four (11.11%). Postoperative radiotherapy was indicated and performed in four
patients (11.11%) without significant complications.
The complications in the 36 patients operated were NAC necrosis (one case; 2.7% -
Figure 12), skin dehiscence without
implant exposure (two cases; 5.5%), seroma (two cases; 5.5%), hematoma (one
case; 2.7%), liponecrosis (one case; 2.7%), superior displacement of the implant
(one case; 2.7%), and deep vein thrombosis (two cases; 5.5%). No case of implant
extrusion or necrosis of the flap skin was observed. No patient showed
recurrence of breast neoplasia in the breasts treated with the proposed
technique during the study period.
Figure 12 - Necrosis of the nipple-areola complex.
Figure 12 - Necrosis of the nipple-areola complex.
Necrosis was treated by area delimitation followed by debridement and
reconstruction of the NAC in a second procedure. The case that showed hematoma
was correlated with the postoperative use of enoxaparin sodium, which is not
part of the routine procedures performed by the senior author.
DISCUSSION
The results regarding oncological and esthetic safety were quite satisfactory.
The approach was also safe regarding possible complications of adjuvant
treatments (Figures 13 and 14). The rate of complications obtained by
the author while using the technique described here was lower than that reported
for most reconstruction techniques using implants10,11.
Figure 13 - Pre- and postoperative images.
Figure 13 - Pre- and postoperative images.
Figure 14 - Pre- and postoperative images.
Figure 14 - Pre- and postoperative images.
As breast reconstruction techniques have evolved and became more sophisticated,
the expectation for better aesthetic results by the patients followed. They want
plastic surgeons to provide a reconstructed breast with a more natural shape
and
texture and with minimal scarring.
With the increasing use of immediate reconstruction techniques, the search for
adequate coverage of the implants has increased. This may result in larger scars
distant from the primary site in the case of reconstructions using a large
dorsal or rectus abdominis flap. The technique presented in this paper results
in a single arcuate scar in the lower quadrants of the breast, leading to a less
stigmatizing aspect.
NAC necrosis was observed in 1.9% of the cases analyzed in the study by
Eskenazi12, in which several breast
reconstruction techniques were compared; it was found in 2.7% in our study.
Seroma was observed in 4% of the cases in the same study against 5.5% observed
in our study. In Eskenazi’s study, 7.1% of the cases had skin flap necrosis
against none of our cases.
The recovery of the patients subjected to this technique is quick because the
implant is not fully covered with the pectoralis major muscle, which contributes
to a lower perception of postoperative pain.
The dual plane is not an unprecedented technique. However, in
the technique presented, the pectoral muscle covers less than two thirds of the
implant, leaving it freer. This facilitates natural ptosis, in addition to
reducing the risk for superior implant migration, a common complication in
reconstructions and aesthetic surgeries with placement of the implant in the
retropectoral plane. Furthermore, there is a lower risk of implant extrusion
owing to the interposition of the viable tissue between the implant and the
skin13, and no incision is created in
the lower portion of the breast14.
This technique provides adequate coverage for the implant in patients with
recommendations for adjuvant therapy, providing adequate implant protection and
reducing the risk of extrusion and capsular contracture or need for implant
removal, complications found in some patients undergoing breast reconstruction
using implants15. If the patient develops
capsular contracture, reoperation is simple and with satisfactory results in
most cases.
The pectoralis muscle flap and lower cutaneous pedicle technique has more
advantages than techniques using acellular dermal matrix16,17,
since it does not require the use of a matrix, which, in addition to having a
high cost18,19, has a greater risk of infection20,21.
The technique presented here, compared with the pectoralis muscle with lower
dermis-fat pedicle technique14,22, has the
advantage of leaving a thinner flap without glandular tissue, which favors
greater oncological safety. Furthermore, it frees the patient from extensive
scars and risk of dehiscence with implant exposure and necrosis in the lower
portion of the breast.
Consideration should also be given to maintaining the integrity of the upper
abdomen, thoracolateral, large dorsal, and TRAM flaps for the possible need for
salvage surgery.
CONCLUSION
The technique proposed by the authors is a viable alternative for selected cases
and may be part of the portfolio of techniques available for breast
reconstruction, since it is easy and quick to perform, has low morbidity and
complication rates, is similar to other techniques, and provides satisfactory
esthetic results and oncological safety.
Moreover, it provides a broad field for mastectomy, allowing easy access to
sentinel lymph node or axillary dissection, without the need for further
incisions.
COLLABORATIONS
OMC
|
Final approval of the manuscript; conception and design of the study;
completion of surgeries and/or experiments; writing the manuscript
or critical review of its contents.
|
IRJ
|
Analysis and/or interpretation of data; conception and design of the
study; completion of surgeries and/or experiments; writing the
manuscript or critical review of its contents.
|
LGM
|
Writing the manuscript or critical review of its contents.
|
DASS
|
Writing the manuscript or critical review of its contents.
|
LMCD
|
Writing the manuscript or critical review of its contents.
|
MCAG
|
Writing the manuscript or critical review of its contents.
|
GCS
|
Writing the manuscript or critical review of its contents.
|
LDPB
|
Writing the manuscript or critical review of its contents.
|
PJC
|
Writing the manuscript or critical review of its contents.
|
MVSO
|
Analysis and/or interpretation of data; conception and design of the
study; completion of surgeries and/or experiments; writing the
manuscript or critical review of its contents.
|
LCE
|
Conception and design of the study; writing the manuscript or
critical review of its contents.
|
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p. 732-42.
1. Sociedade Brasileira de Cirurgia Plástica, São
Paulo, SP, Brazil.
2. Hospital das Forças Armadas, Brasília, DF,
Brazil.
3. Hospital Daher Lago Sul, Brasília, DF,
Brazil.
Corresponding author: Ismar Ribeiro
Junior
Av. Pau Brasil, lote 20 - Ed. Via Naturale, apt 2402-2
Brasília, DF, Brazil Zip Code 71926-000
E-mail: ismarjr@gmail.com
Article received: June 22, 2016.
Article accepted: May 17, 2018.
Conflicts of interest: none.