I enjoyed the December issue of the Journal (Plast Reconstr Surg. 2009;124:1735-1827), which opened with a section entitled “Breast.” I write to offer your readers an alternative viewpoint to expander-based breast reconstruction. I have been performing breast reconstruction at Scott and White Clinic and Hospital in Temple, Texas, for 33 years, beginning with Ruben Snyderman's first efforts with implants placed in the mastectomy site after a wait of several days to assess skin viability. Shortly thereafter, the submuscular pocket was described as a pectoralis major muscle-splitting approach. I have used this approach for many years and have found it very dependable.
Using this approach for immediate breast mound production, I elevate the lateral portion of the pectoralis minor, the origins of several serratus slips, and the superior anterior fascia of the rectus abdominis along with the entire pectoralis major down to the original inframammary fold. This generous pocket will almost always allow for immediate placement of a 450- to 500-cc saline implant, even in small-breasted women. Use of saline implants facilitates secure closure of the pectoral muscle incision under no tension, before filling the implant. The pocket provides full coverage for the implant and allows for separation of the mastectomy site, which is drained, from the implant pocket. We use voluminous antibiotic irrigations of all spaces. Most of the time, if a contralateral or opposite mastectomy is required, the plastic surgeon may perform this operation while the general surgeon performs the mastectomy for cancer, after which both breast mounds are reconstructed. Often, the implant volume is adequate for a definitive breast mound. After 2 to 3 months, if breast mound issues require modification, they are addressed in the operating room at the time of nipple reconstruction using the bow-tie technique. If the breast mound is satisfactory, the nipple reconstruction is performed in the outpatient clinic.
Postoperatively, following placement of the submuscular implant, I use an aggressive compression massage, maintaining and expanding the implant pocket with the definitive implant in place. These reconstructed breast mounds are followed closely in the early postoperative weeks, by the surgeon, moderating and managing the massage program to customize the program in response to each patient's periprosthetic capsular development. I was somewhat surprised to see no mention of capsule management by these physical therapy massage principles in the “systematic review” on this subject.
As a result of this time-tested experience, I have not found the need to use tissue expanders except in the very heavy breasted patient, where I am trying to balance with a heavy remaining breast. This is not common for me. I also have not needed to enlarge the submuscular pocket by synthetic or alloplastic grafts.
In contrast with Drs. Sbitany, Spear, Nahabedian, and Chen (December 2009 issue of Plastic and Reconstructive Surgery) and other reconstructive surgeons who use expanders in immediate breast reconstruction, I most often need only the mastectomy trip to the operating room to achieve a good breast mound. This holds true for immediate breast mound reconstruction after mastectomy for cancer or in prophylactic mastectomy, with or without sparing the nipple. In delayed reconstruction patients with adequate skin, I use an inframammary incision to place a permanent implant, much like in an augmentation mammaplasty in the subpectoral plane, on an outpatient basis, and the compression massage is, again, vigorously applied postoperatively. In patients with severe skin tightness on the chest wall, I prefer to use the latissimus dorsi skin and muscle flap, with immediate placement of the permanent implant, often on an outpatient basis.
Perhaps I am an old dog who has not learned new tricks, but I have found that the new tricks only add more office visits for sequential expansions and more trips to the operating room to remove the expanders later, and both expanders and patch grafts add substantially more expense to breast reconstruction.
Raleigh R. White IV, M.D.
Texas A&M University
College of Medicine
Scott and White Clinic
2401 South 31st Street
Temple, Texas 76508
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