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Dual-Plane Prosthetic Reconstruction Using the Modified Wise Pattern Mastectomy in Women with Macromastia

Salgarello, Marzia M.D.; Visconti, Giuseppe M.D.; Barone-Adesi, Liliana M.D.

Plastic and Reconstructive Surgery: April 2011 - Volume 127 - Issue 4 - p 1740-1742
doi: 10.1097/PRS.0b013e31820a66b8

Department of Plastic and Reconstructive Surgery; Catholic University of “Sacro Cuore”; University Hospital “A. Gemelli”; Rome, Italy

Correspondence to Dr. Salgarello, Via Massimi 101, 00136 Rome, Italy,

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We read with interest the recent article by Dr. Losken and colleagues regarding alloplastic breast reconstruction in women with macromastia that undergo skin-sparing mastectomy.1 In these patients, a type IV skin-sparing mastectomy is often required to achieve a more pleasant reconstruction than when approached using the safer transverse incision. However, the risk of skin necrosis, especially at the T-junction, is near 30 percent.1,2

The authors highlighted that a way of minimizing this would be to use autologous tissue reconstruction. However, patients with macromastia are often overweight or obese, and this can significantly raise the rate of complications and morbidity with this operation.

Skin necrosis at the T-junction following alloplastic dual-plane reconstruction using the recently introduced biological materials inferolaterally and pectoralis major muscle superiorly3 would invariably result in implant exposure and potential extrusion. In this setting, the authors feel that a technique already described, consisting of the use of the inferior deepithelialized mastectomy flap instead of the biological material, should be readdressed.

Using this technique, the implant pocket is defined superiorly by the pectoralis major and inferiorly by the deepithelialized lower pole mastectomy skin flap. So far, the dual plane consists of two vascularized flaps that would allow local wound care in the setting of skin necrosis.1

We share with the authors the concepts of a Wise pattern with a more conservative angle and longer vertical limbs and not to use biological materials to define implant pocket inferolaterally. However, we use a different approach (work in progress). In our technique, we do not create a dermal flap for lower pole implant coverage, but the expander/implant is placed in the submuscular-subfascial pocket (Figs. 1 and 2).

Fig. 1.

Fig. 1.

Fig. 2.

Fig. 2.

At the inferior edge of the pectoralis major muscle, we undermine the superficial pectoralis fascia, in continuity with the pectoralis major muscle itself, up to the inframammary fold (Fig. 1). At this level, the inner side of the superficial pectoralis fascia is cut to release the fascial tension.4,5 In this way, we define the condition for the major expansion in the lower pole.

The superficial pectoralis fascia represents the superficial layer of the pectoralis major muscle fascia, which overlies the pectoralis major muscle and continues inferiorly and laterally to the pectoralis major muscle. At the lateral border of the pectoralis major muscle, the superficial and deep pectoralis fascia fuse themselves and overlie the deeper axillary fascia, creating a unique fascial system that covers the serratus anterior and obliquus externus abdominis muscles. With our technique, no further coverage is needed inferolaterally, as this is anatomically provided by the thoracic fascias.

In skin-expander reconstructions, the skin at the lower pole will expand over time as the implant is filled. In case of skin-preserving mastectomy, when staged skin expansion is unnecessary, the major expansion is immediately gained at the lower pole when the definitive implant is placed.4,5

Using this technique, the expander/implant pocket is anatomically separated by the mastectomy space. In conclusion, the thoracic fascias should be taken into consideration as valuable structures that allow an easy and pleasant breast reconstruction with a low complication rate.5

Marzia Salgarello, M.D.

Giuseppe Visconti, M.D.

Liliana Barone-Adesi, M.D.

Department of Plastic and Reconstructive Surgery

Catholic University of “Sacro Cuore”

University Hospital “A. Gemelli”

Rome, Italy

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The authors have no financial interest to declare in relation to the content of this communication.

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1. Losken A, Collins BA, Carlson GW. Dual-plane prosthetic reconstruction using the modified Wise pattern mastectomy and fasciocutaneous flap in women with macromastia. Plast Reconstr Surg. 2010;126:731–738.
2. Carlson GW, Bostwick J III, Styblo T, et al. Skin sparing mastectomy: Oncologic and reconstructive considerations. Ann Surg. 1997;225:570–575; discussion 575–578.
3. Breuing KH, Warren SH. Immediate bilateral breast reconstruction with implants and inferolateral AlloDerm slings. Ann Plast Surg. 2005;55:232–239.
4. Salgarello M, Visconti G, Barone-Adesi L. Use of the subpectoral fascia flap for expander coverage in postmastectomy breast reconstruction (Letter). Plast Reconstr Surg. 2011;127:1010.
5. Salgarello M, Visconti G, Barone-Adesi L. Nipple-sparing mastectomy with immediate implant reconstruction: Cosmetic outcomes and technical refinements. Plast Reconstr Surg. 2010;126:1460–1471.

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