Implant-based breast reconstruction is very effective, but some cases involve substantial patient-related risk factors. Adjuvant treatment planning can change after breast cancer resection because of the degree of tumor aggressiveness identified during the definitive pathological examination. In such cases, radiation therapy may be chosen as a supplementary treatment.1–3
Depending on the intensity of capsular formation, it may be necessary to change the reconstruction method so that autologous tissues are used. Rectus abdominis–based muscle flaps are often one of the first choices in these situations.4
An abdominal defect must be produced to harvest tissue for breast reconstruction, and tension-free closure is not always possible. In such cases, one can rely on muscular transposition, tension-relief incisions, or prosthetic materials to replace the abdominal wall.5–9 The use of allogeneic material to repair abdominal wall defects is not risk-free; infection, extrusion, herniation, and secondary bulging of the abdominal wall are all possible.
When an abdominal flap is being adapted to the recipient area, it is necessary to resect portions of the prosthetic capsule. The capsule is discarded after histopathological evaluation in all cases. Breast tissue expanders are mainly placed in a retromuscular fashion. After extensive institutional review, our team considered only the hypothetical possibility that viable tumor cells are present in the tissue expander capsule in the selected donor site underneath the pectoralis major muscle.
A 55-year-old female patient was diagnosed with ductal breast carcinoma as confirmed by open biopsy. She underwent mastectomy and sentinel node resection followed by tissue expander–based reconstruction. After definitive pathological analysis, radiation therapy was recommended. Expansion was thus delayed until termination of the radiation therapy. Autologous reconstruction was subsequently indicated because of difficulties in expansion and the development of significant capsular contracture. Then a deep inferior epigastric perforator flap was planned.10
During the surgical procedure, identification of a dominant perforator was not possible, and a muscle-sparing transverse rectus abdominis myocutaneous flap was designed. A small, concentrated area of perforators (5 × 5 cm) with minimal muscle volume was collected along with the anterior rectus abdominis fascia (Fig. 1). Primary closure of the defect would have involved excessive tension due to intra-abdominal adiposity. The abdominal muscle thickness was inadequate for performance of muscular transposition or creation of a tension-releasing incision. The future development of abdominal weakness was also a concern.
The use of allogeneic material to repair the abdomen was impractical due to social and economic issues and institutional logistics. Our team decided to use a retropectoralis portion of the tissue expander capsule for abdominal wall restoration (Fig. 2). We replaced the lost portion of the rectus abdominis muscle anterior fascia by placing the internal, smooth surface of the capsule toward the muscle and the external capsular surface in contact with the subcutaneous tissue. Macroscopic similarity between the capsular tissue and rectus abdominis fascia was noted (Fig. 3). Abdominal closure was performed using progressive tension sutures between the flap and the muscle fascia as described by Baroudi and Ferreira11 and Pollock and Pollock.12
The outcome was uneventful. There was no evidence of hernia formation, bulging, seroma formation, or surgical site infection. The abdominal wall contour was maintained during follow-up, and the patient resumed social activities with no major complaints. Magnetic resonance imaging 3 months after surgery demonstrated abdominal wall integrity (Fig. 4). Six months after the procedure, there was still no sign of abdominal weakness.
Uncertainty often surrounds adjuvant breast cancer treatment. The need for irradiation can be difficult to predict. Changes in reconstruction procedure plans must be explained to the patient in these situations. It is necessary to provide a detailed explanation of the repair options and the positive and negative aspects of each.
Although the use of biological material to reconstruct the breasts has been reported, our team has no knowledge of any previous report of breast capsule reutilization in the specific setting presented herein. This method may be a viable alternative, although further studies are needed. In the present case, we observed no adverse events during the initial postoperative healing period.13–16
The use of tissue expander capsule for reinforcement of the abdominal wall after the autologous breast reconstruction with a muscle-sparing transverse rectus abdominis myocutaneous flap has initially proved itself to be a safe and reliable option for abdominal wall restoration.
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3. Moyer HR, Pinell-White X, Losken A. The effect of radiation on acellular dermal matrix and capsule formation in breast reconstruction: clinical outcomes and histologic analysis. Plast Reconstr Surg. 2014;133:214–221
4. Lipa JE, Qiu W, Huang N, et al. Pathogenesis of radiation-induced capsular contracture in tissue expander and implant breast reconstruction. Plast Reconstr Surg. 2010;125:437–445
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7. Patel KM, Shuck J, Hung R, et al. Reinforcement of the abdominal wall following breast reconstruction with abdominal flaps: a comparison of synthetic and biological mesh. Plast Reconstr Surg. 2014;133:700–707
8. Fischer JP, Nelson JA, Wes AM, et al. The use of epidurals in abdominal wall reconstruction: an analysis of outcomes and cost. Plast Reconstr Surg. 2014;133:687–699
9. Zhong T, Janis JE, Ahmad J, et al. Outcomes after abdominal wall reconstruction using acellular dermal matrix: a systematic review. J Plast Reconstr Aesthet Surg. 2011;64:1562–1571
10. Nahabedian MY, Momen B, Galdino G, et al. Breast reconstruction with the free TRAM or DIEP flap: patient selection, choice of flap, and outcome. Plast Reconstr Surg. 2002;110:466–475
11. Baroudi R, Ferreira CA. Seroma: how to avoid it and how to treat it. Aesthet Surg J. 1998;18:439–441
12. Pollock H, Pollock T. Progressive tension sutures: a technique to reduce local complications in abdominoplasty. Plast Reconstr Surg. 2000;105:2583–2586; discussion 2587–2588
13. Selber JC, Clemens MW, Oates S, et al. Autoderm: an alternative bioprosthetic for breast reconstruction. Plast Reconstr Surg. 2013;131:985–987
14. Matros E, Disa JJ. Discussion: Fascia lata allografts as biological mesh in abdominal wall repair: preliminary outcomes from a retrospective case series. Plast Reconstr Surg. 2013;132:640e–641e
15. Ladizinsky DA, Sandholm PH, Jewett ST, et al. Breast reconstruction with the Bostwick autoderm technique. Plast Reconstr Surg. 2013;132:261–270
© 2014 American Society of Plastic Surgeons
16. Bengtson BP, Ringler SL, George ER, et al. Capsular tissue: a new local flap. Plast Reconstr Surg. 1993;91:1073–1079