I would like to congratulate Dr. White on his long-term success in performing single-stage breast reconstruction. He has described his method of reconstruction, involving a pectoralis major muscle-splitting technique and immediate placement of a fully submuscular saline implant at the final desired volume. In his hands, this has rarely necessitated tissue expansion or adjunct techniques such as placement of acellular dermal matrix.
In many cases, it is difficult to perform immediate implant placement in this way because of mastectomy flap viability. The newly created flaps are often thin, and this tissue is deemed unable to tolerate the additional threat to its vascularity from the immediate tension of underlying implants. The clinical result of many of these situations would be mastectomy flap necrosis.
In situations where the oncologic surgeon has created thicker mastectomy flaps, with sufficient remaining subcutaneous tissue, it is possible to safely augment the breast flap to the final desired volume. However, we often find this situation to not be present. I must surmise that it is these situations, with thin mastectomy flaps, that lead Dr. White to use the latissimus dorsi myocutaneous flap for primary large-volume reconstruction. However, the fact that he is usually able to bypass this option and perform single-stage reconstruction with the final desired volume indicates that he must be consistently provided with very robust mastectomy flaps.
In terms of aesthetic outcomes, it can be challenging to produce a ptotic breast mound with a defined inframammary fold through the use of such fully submuscular single-stage techniques. The inferior portion of the submuscular pocket, underneath the rectus abdominis fascia, is often tight. This can result in a lack of lower pole volume in the reconstructed breast mound and a high inframammary fold; thus, a second-stage operation to lower the fold may be necessary. The use of an acellular dermal matrix as an inferior sling can help reduce such occurrences by ensuring more precise placement of the inframammary fold and preferential lower pole volume in the submuscular pocket.1,2
A compromise between the techniques may be immediate single-stage reconstruction with placement of a postoperatively adjustable saline implant.3 This offers the advantage of gradual filling of the permanent implant, thus improving viability of the mastectomy flaps. If no implant repositioning is required following achievement of final volume, the fill port can be removed as an office procedure, at the time of nipple reconstruction.
I applaud Dr. White's vigilant regimen of postoperative massage to minimize capsular formation and resultant contracture. Although this undoubtedly minimizes the formation of scar tissue, I find that this technique can potentially displace the implant within the large submuscular pocket. It is for this reason that a second-stage operation, with formal capsulectomy/capsulotomy before permanent implant placement, can often produce more predictable outcomes.
I would encourage Dr. White to publish his career series, as we would all undoubtedly benefit from his experience. He has been able to master a technique to prevent skin breakdown and optimize aesthetic outcomes that many of us often bypass. It would be intriguing to see both his aesthetic outcomes and the incidence of morbidity with such techniques.
Hani Sbitany, M.D.
University of Rochester
1. Sbitany H, Sandeen S, Amalfi AN, Davenport MS, Langstein HN. Acellular dermis-assisted prosthetic breast reconstruction versus complete submuscular coverage: A head-to-head comparison of outcomes. Plast Reconstr Surg.
2. Breuing KH, Colwell AS. Inferolateral AlloDerm hammock for implant coverage in breast reconstruction. Ann Plast Surg.
3. Eskenazi LB. New options for immediate reconstruction: Achieving optimal results with adjustable implants in a single stage. Plast Reconstr Surg.
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