One of the most difficult malpositioning problems in implant-based breast reconstruction is superior malposition.1–3 Most commonly, this problem requires implant removal and replacement of a tissue expander in a lower position. This communication describes a novel technique to address this problem without sacrificing the gains of the initial reconstruction.
The patient is marked in the standing position, and the area of the lower pole insufficiency is marked. Measurements are then taken for the appropriately sized rectangular tissue expander. Intraoperatively, the old mastectomy scar is used for access to the lower pole and the lower flap is dissected in the subcutaneous, extracapsular plane. The implant is not visualized and the expander is placed 2 cm below the desired inframammary fold. The implant is placed with minimal fill, ensuring a tension-free reclosure of the mastectomy scar. Tissue expansion is then begun at 2 weeks and performed weekly.
After completion of expansion and 1 month of settling, the patient is returned to the operating room to remove the expander and the “wall” that is the combined capsule of the permanent implant and the tissue expander. This allows the original permanent implant to fill the lower pole. The superior extent of the pocket is cauterized or excised and sutured to prevent relapse. Postoperatively, a gentle breast band is worn for 2 weeks.
We present a 37-year-old woman who had a delayed breast reconstruction after right mastectomy and irradiation and prophylactic mastectomy on the left. Reconstruction was performed with a right latissimus myocutaneous flap and bilateral placement of low tissue expanders. These were ultimately exchanged for smooth silicone gel implants. The patient was unhappy with the left lower pole deficiency and high-riding upper pole. Two years postoperatively, the patient successfully underwent the procedure described (Fig. 1).
The problem of lower pole insufficiency in breast implant reconstruction can be addressed using capsular scoring and resection, abdominal wall advancement, and resetting the inframammary fold, and in cases where even more skin is required, the implant can be removed and the tissue expander replaced, repeating the expander-to-implant process that just failed.4 More radical approaches such as latissimus or transverse rectus abdominis musculocutaneous flaps can be used to add skin back to the lower pole or completely replace the implant. Placing a second expander in the superior pole for relocating the areola has been described in the aesthetic patient but not in the lower pole of an implant reconstruction patient.5
Extracapsular, subcutaneous placement of a tissue expander while leaving the original implant reconstruction intact is a novel approach to the common problem of inferior pole deficiency in breast implant reconstruction. The retained implant supports and aids lower pole expansion. The procedure was well tolerated and successful in the two cases attempted and is less morbid than the other surgical revision options that would have otherwise been required.
Michael R. Zenn, M.D.
Division of Plastic and Reconstructive Surgery, Duke University Medical Center, 126 Baker House, Trent Drive, DUMC 3358, Durham, N.C. 27710, firstname.lastname@example.org
1. Ramon Y, Ullmann Y, Moscona R, et al.. Aesthetic results and patient satisfaction with immediate breast reconstruction using tissue expansion: A follow-up study. Plast Reconstr Surg. 1997;99:686–691.
2. Clough KB, O'Donoghue JM, Fitoussi AD, Nos C, Falcou MC. Prospective evaluation of late cosmetic results following breast reconstruction: I. Implant reconstruction. Plast Reconstr Surg. 2001;107:1702–1709.
3. Alderman AK, Wilkins EG, Kim HM, Lowery JC. Complications in postmastectomy breast reconstruction: Two-year results of the Michigan Breast Reconstruction Outcome Study. Plast Reconstr Surg. 2002;109:2265–2274.
4. May JW Jr, Attwood J, Bartlett S. Staged use of soft-tissue expansion and lower thoracic advancement flap in breast reconstruction. Plast Reconstr Surg. 1987;79:272–277.
5. Colwell AS, May JW Jr, Slavin SA. Lowering the postoperative high-riding nipple. Plast Reconstr Surg. 2007;120:596–599.
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