Journal Logo

LETTERS

Breast Reconstruction: An Alternative Viewpoint

White, Raleigh R. IV M.D.

Author Information
Plastic and Reconstructive Surgery: August 2010 - Volume 126 - Issue 2 - p 672-673
doi: 10.1097/PRS.0b013e3181df7173
  • Free

Sir:

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

Section Description

GUIDELINES

Letters to the Editor, discussing material recently published in the Journal, are welcome. They will have the best chance of acceptance if they are received within 8 weeks of an article's publication. Letters to the Editor may be published with a response from the authors of the article being discussed. Discussions beyond the initial letter and response will not be published. Letters submitted pertaining to published Discussions of articles will not be printed. Letters to the Editor are not usually peer reviewed, but the Journal may invite replies from the authors of the original publication. All Letters are published at the discretion of the Editor.

Authors will be listed in the order in which they appear in the submission. Letters should be submitted electronically via PRS' enkwell, at www.editorialmanager.com/prs/.

We reserve the right to edit Letters to meet requirements of space and format. Any financial interests relevant to the content of the correspondence must be disclosed. Submission of a Letter constitutes permission for the American Society of Plastic Surgeons and its licensees and asignees to publish it in the Journal and in any other form or medium.

The views, opinions, and conclusions expressed in the Letters to the Editor represent the personal opinions of the individual writers and not those of the publisher, the Editorial Board, or the sponsors of the Journal. Any stated views, opinions, and conclusions do not reflect the policy of any of the sponsoring organizations or of the institutions with which the writer is affiliated, and the publisher, the Editorial Board, and the sponsoring organizations assume no responsibility for the content of such correspondence.

©2010American Society of Plastic Surgeons