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BACKGROUND: Immediate breast reconstruction with tissue expander or implant has evolved to include use of acellular dermal matrix (ADM) or soft tissue support scaffolds (STSS). This material is expensive, has been linked to more potential complications and is often ineffective in very large or ptotic breasts. Increased BMI also significantly increases risks for breast reconstruction. Utilizing a lower breast pole de-epithelialized mastectomy flap and the modified Wise breast reduction pattern provides an excellent alternative to achieve tissue expander or implant breast reconstruction in women with macromastia or ptosis.
The use of a de-epithelialized mastecomy skin flap and a Wise pattern skin sparing mastectomy has been published. This technique is advantageous for breast reconstruction patients who are obese with macromastia or ptosis and are otherwise not good candidates for standard breast reconstruction options. This method precludes the need for exogenous soft tissue support material while preserving many of the benefits such as increased initial expander fill; healthy, easily expanded soft tissue coverage of the lower pole and a better positioned and shaped breast reconstruction mound.
METHODS: This technique uses a type IV skin sparing mastectomy/breast reduction pattern and a de-epithelialized fasciocutaneous flap inferiorly based along the inframammary fold (approximately 6-10 centimeters wide by 14-16 centimeters long depending on device base diameter). Following the mastectomy the de-epithelialization of the lower pole flap is completed and generally requires less than twenty minutes. The pectoralis major muscle is released inferiorly and elevated along with serratus anterior fascia laterally. The superior edge of the de-epithelialized flap is secured to the inferior border of the pectoralis muscle/serratus fascia flap above to create a well vascularized pocket for tissue expander or implant coverage. The skin flaps are then approximated in the standard inverted T pattern with marginal trimming as needed. In select cases, the nipple areola may be utilized as a composite graft placed in the proper position on the breast mound. A single donor nipple areola of sufficient diameter may be used to create two complete nipple areola reconstructions.
RESULTS: This technique was utilized for immediate breast reconstruction in twenty-six patients and forty-five breasts. There were seven unilateral and nineteen bilateral breast reconstructions performed immediately following mastectomy (three breasts direct to implant, the rest tissue expanders). In four cases small areas of superficial skin necrosis occurred at the T junction. One patient required debridement and STSG, the others healed with local wound care only. In two immediate nipple areola reconstructions, partial superficial graft desquamation with de-pigmentation of the areola occurred.
CONCLUSIONS: This procedure was well received and satisfaction was highest among patients who were suffering from macromastia symptoms prior to their breast cancer diagnosis. This technique does require some additional time to perform the de-epithelialization and inset of the fasciocutaneous flap, but in my experience this equals the time required for use of ADM or STSS. The overall morbidity associated with this procedure was acceptable. This technique provides a viable alternative choice for immediate tissue expander or implant breast reconstruction in patients with macromastia or ptosis.