In current standard practice, acellular dermal matrix is first sutured to the inframammary fold or to the inferior edge of the pectoralis major muscle and a deflated tissue expander is inserted.1 This can lead to problems such as breast asymmetry (e.g., if the acellular dermal matrix is not sutured identically on both sides in bilateral cases) and lack of lower pole projection (e.g., if the acellular dermal matrix is sutured with too much tension). We present a modified technique in which the acellular dermal matrix is draped to a fully expanded device ex vivo.
The pectoralis major muscle is released inferiorly and medially. The position of the lateral breast fold is then determined. The width of the pocket is measured and the expander is selected accordingly. On a back table, the tissue expander is inflated with air, to the maximal volume recommended by the manufacturer. The acellular dermal matrix is draped over the tissue expander at an oblique angle parallel to the orientation of the respective inferior border of the pectoralis muscle. The medial and lateral edges of the acellular dermal matrix are sutured to their respective tabs on the tissue expander with 2-0 polydioxanone suture, and the remaining suture and needles are left at full length to secure to the chest wall once the device is inserted into the subpectoral cavity (Fig. 1). The tissue expander/acellular dermal matrix prefabricated composite device is inserted in the subpectoral plane and secured medially first to shape the medial breast contour, then laterally using the residual suture and needles, ensuring that the inferior aspect of the device aligns with the infra mammary fold. Next, the acellular dermal matrix is secured to the inframammary fold at the lateral mammary fold. Finally, the inferior edge of the pectoralis major muscle is secured to the superior edge of the acellular dermal matrix with a running 2-0 Vicryl suture (Ethicon, Inc., Somerville, N.J.). The final air fill volume is decreased if necessary according to tension on the suture line of acellular dermal matrix with the pectoralis major muscle and the mastectomy skin flaps before layered closure of the skin. Two 15-French round channel drains are placed with the tips inserted medially under the acellular dermal matrix. A surgical bra is put on without tension for light compression to circumvent any seroma formation.
Our technique allows the surgeon to confirm the absence of rippling before tissue expander insertion, ensuring maximal contact with the mastectomy skin flap. This technique can be applied in subpectoral direct-to-implant cases. Instead of securing the acellular dermal matrix to tabs, acellular dermal matrix laxity on the posterior aspect of the draped permanent implant is sutured to itself. This is then sutured to the inferior aspect of the pectoralis major muscle in the typical fashion.
It is our opinion that this technique creates lower breast pole projection and improves breast symmetry in bilateral reconstructions, and is technique that is reproducible and can be taught to residents (Fig. 2). Furthermore, the device can be prefabricated while the mastectomy is performed, which can maximize operative efficiency. Finally, the second-stage procedure is simplified by nearly eliminating the need for capsulectomy or capsulorrhaphy and ultimately results in fewer revision operations.
The authors have no financial interest in any of the products or techniques mentioned and have received no external support related to this study.
Christine Oh, M.D., M.Sc.Division of Plastic and Reconstructive SurgeryMayo ClinicRochester, Minn.
Sebastian Winocour, M.D., M.Sc.Division of Plastic SurgeryBaylor College of MedicineHouston, Texas
Valerie Lemaine, M.D., M.P.H.Division of Plastic and Reconstructive SurgeryMayo ClinicRochester, Minn.
1. Nahabedian MY. Prosthetic breast reconstruction with acellular dermal matrices: Achieving predictability and reproducibility. Plast Reconstr Surg Glob Open 2016;4:e698.