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Journal of Plastic, Reconstructive & Aesthetic Surgery (2007) 60, 1233e1238 Immediate prosthetic breast reconstruction: the ensured subpectoral pocket (ESP) Hugo D. Loustau*, Horacio F. Mayer, Manuel Sarrabayrouse Department of Plastic Surgery, Hospital Italiano de Buenos Aires, University of Buenos Aires, School of Medicine, Gascon 450 (C1181ACH), Buenos Aires, Argentina Received 5 April 2006; accepted 6 November 2006 KEYWORDS Prosthetic; Breast; Reconstruction; Mesh Summary Implant exposure due to cutaneous necrosis is one of the most feared complications of mastectomy with immediate prosthetic reconstruction. A key issue is to ensure good blood supply to the skin and complete integrity of the submuscular pocket. The latter is created with the pectoralis major and supplemented with the serratus anterior, the rectus abdominis sheat, the obliquus mayor and the pectoralis minor. The main drawback is that those muscles, when sutured to create a complete pocket, only allow the setting of small-sized implants. The authors present the application of polyglycolic mesh in an original fashion, mimicking the anatomy of the muscles usually employed in pocket creation. The proposed technique has been denominated Ensured Subpectoral Pocket and has proved to be a valid strategy in immediate single stage prosthetic breast reconstruction. It allows the setting of bigger implants without previous tissue expansion while preventing implant displacement. In addition, it reduces emotional trauma on patients and lowers surgical costs. ª 2006 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. Autologous breast reconstruction usually achieves excellent outcomes in terms of ptosis, contour and the preservation of symmetry in the long run. 1 Some women seeking mastectomy and immediate breast reconstruction lack the subcutaneous fat tissue required for autogenous reconstruction. Moreover, many of these women are unwilling to accept donor site morbidity. For those patients, prosthetic breast reconstruction (PBR) is an appealing * Corresponding author. Tel.: þ54 11 49590506. E-mail address: hugo.loustau@hospitalitaliano.org.ar (H.D. Loustau). alternative. PBR allows for surgical treatment, provides good cosmetic results, diminishes physical and emotional trauma and avoids donor site morbidity. However, immediate prosthetic reconstruction (IPBR) is just as good in those cases with adequate thickness of mastectomy skin flaps for coverage and when the area has not been previously irradiated. In order to avoid implant exposure due to cutaneous necrosis, it is of utmost importance to preserve a good blood supply to the skin. Complete integrity of the submuscular pocket is the most crucial factor to prevent implant displacements. In 1981, Little described the 1748-6815/$ - see front matter ª 2006 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. doi:10.1016/j.bjps.2006.11.007

1234 H.D. Loustau et al. Figure 1 Mastectomy. (a) The subcutaneous mastectomy is completed. (b) Preserving a good thickness of the subcutaneous fat. complete muscular pocket for immediate breast reconstruction and named it the living bra. 2 In this technique, the pectoralis major is supplemented with the serratus anterior, the rectus abdominis sheath, the obliquus major and the pectoralis minor to provide total muscle coverage of the implant. According to the first author, who performed over 300 prosthetic breast reconstructions applying several techniques, the main drawback has been that such muscles, when sutured to create a complete pocket, only allow for the setting of small implants, a maximum of 250 cc. The aim of this paper is to describe the application of polyglicolic mesh as a supplement to the pectoralis major in cases of immediate breast reconstruction, in order to allow the setting of bigger implants without previous tissue expansion, while preventing muscle retraction and implant displacements. Material and methods From January 2000 to September 2005, 24 patients (aged 35e59 years with an average age of 41 years) underwent total mastectomies and immediate breast reconstruction through this procedure. All the procedures were carried out at the Hospital Italiano de Buenos Aires under general anaesthesia. Surgical technique Three basic steps can be described: (1) Mastectomy. All the breast tissue, nipple-areolar complex, previous biopsy incisions and skin overlying superficial tumours are removed. The oncological margins correspond to the anatomical boundaries of the breast parenchyma 3,4 (Fig. 1a). During dissection, care should be taken to preserve the inframammary fold ligament, as well as to ensure an adequate thickness of skin flaps, in order to reduce the risk of skin necrosis and eventual implant exposure that is a permanent threat (Fig. 1b). (2) Creation of the subpectoral pocket. Through the lateral border of pectoralis major, the retro-pectoral areolar space is undermined by electrocautery dissection and its costal and sternal insertions are severed. The pocket dissection begins towards the midline then sweeps laterally along the direction of the pectoralis fibres to establish the lateral pocket. Medial pectoralis major origins are completely divided to allow the expansion of the medial pocket (along the border of the sternum). Complete division of the pectoralis above the fourth interspace is not advisable because it risks excessive upward muscle retraction 5,6 (window shading), edge palpability and visibility of the implant (Fig. 2a). It is Figure 2 Pocket creation. (a) Pectoralis major costal insertions from third rib are preserved in order to avoid upward muscle retraction. (b) The anatomical continuity between the pectoralis major and the rectus abdominis sheet is severed as low as possible.

Immediate prosthetic breast reconstruction 1235 also important to preserve the anatomical continuity between the pectoralis major and the rectus abdominis sheath. In order to avoid the compression and deformation of the inferioremedial quadrant of the reconstructed breast, the pectoralis should be severed as low as possible almost at the rectus sheath level (Fig. 2b). Then, the implant is inserted into the pocket. (3) Placement of the polyglicolic mesh. Two ribbons of polyglicolic mesh, 4e5 cm in width, one lateral and one inferior, are placed mimicking the anatomy of the muscles usually employed in pocket creation: the serratus anterior (lateral ribbon) and the rectus abdominis (inferior ribbon). The inferior ribbon represents the distal stop and also determines the new inframammary fold. The inferior edge of the implant and the preserved inframammary fold ligament should not necessarily be at the same level. 7 The prosthesis chosen will condition the placement of the lateral ribbon. If the prosthesis is rounded, the ribbon will have a rectangular shape and will be placed in an oblique fashion. Thus, the mesh will exert forces against the prosthetic displacement activated by the pectoralis major contraction (Fig. 3a). If the prosthesis is anatomical, the lateral ribbon will have a trapezoidal shape and will be placed at a higher position holding the lateral-superior edge of the implant so as to avoid its displacement and rotation (Fig. 3b). The sequence of fixation of the ribbons is of utmost importance. At first, ribbons are sutured at their distal extremity to the corresponding muscles (serratus anterior and rectus abdominis sheath) at the level of the pocket s boundaries (Fig. 4a). Then the pectoralis major, which is partially retracted, is stretched and the proximal end of the ribbon is finally sutured to the pectoralis fibres (Fig. 4b, c), cutting the remaining ribbon off (Fig. 4d). In order to ensure the success of the technique and to avoid muscle laceration, muscle paralysis during this stage of the surgical act is crucial. To promote a complete adherence of the different anatomical layers, drainages are kept in place until output is minimal. 8 Results Thirty-four breast reconstructions were performed. Fourteen patients were diagnosed breast carcinoma (six cases with in situ carcinoma, five cases with stage I and three cases with stage II). Unilateral reconstruction was performed in all cases (Figs. 5 and 6). In the other 10 patients, the suggested treatment was risk-reducing mastectomy and bilateral reconstructions were performed (Figs. 7 and 8). Out of this group there were five patients who were at high risk due to a significant family history of breast cancer (first degree relatives with early onset and bilateral breast cancer). In three cases the early detection of BRCA1 and BRCA2 mutations was the indication, while in the remaining two cases, atypical breast hyperplasia with family history of breast cancer determined the procedure. Fifteen patients chosen to undergo ESP were thin and had little subcutaneous tissue over their back and abdomen. Nine patients refused an alternative autologous breast reconstruction after a thorough discussion with the surgeon. Patients in our series had implant sizes ranging from 270 to 375 cc. Anatomic implants were used in 16 patients, while they were rounded in the rest of the cases. The median follow-up time was 2.8 years, with a range of 6 months to 5 years. Figure 3 Placement of the polyglicolic mesh. Schematic representation of the technique (a) employing a round implant and (b) an anatomical implant.

1236 H.D. Loustau et al. Figure 4 Sequence of mesh fixation. (a) The mesh is sutured by its distal extremity to the serratus anterior muscle at the level of the pocket s boundaries. (b,c) The proximal end of the mesh is sutured to the pectoralis fibres through a running suture. (d) The mesh excess is cut off. One case of unilateral haematoma, detected a few hours after the procedure, was immediately drained with a good outcome. One case of seroma formation and two cases of partial wound dehiscence without exposure of the implant were also detected during follow up. The case of fluid collection was not associated with fever or local signs of infection and was treated with arm immobilisation, steroids and prophylactic antibiotics. The wound dehiscence closed with just local treatment within 10e14 days. No cases of capsular contracture, infection or local recurrence were found. In addition, we obtained very good results in terms of symmetry and patient satisfaction. Figure 5 Total mastectomy and unilateral IPBR through the ESP technique in a 38-year-old woman with infiltrating ductal breast carcinoma. Figure 6 Total mastectomy and unilateral IPBR through the ESP technique in a 47-year-old woman with multicentric ductal in situ breast carcinoma, who waits for nipple-areola reconstruction.

Immediate prosthetic breast reconstruction 1237 Figure 7 Risk-reducing mastectomy and bilateral IPBR through the ESP technique with an anatomical implant. Discussion Several techniques have been described to avoid muscle retraction due to the division of its origins during pocket creation in IPBR. One such technique consists of suturing, as distal as possible, the lateral border of the pectoralis to the subcutaneous cellular tissue. The main drawback of this technique is the risk of releasing stitches when a small amount of tissue has been included or creating skin dimples when too much tissue has been taken. 9 Another technique proposed by Spears 10 is based on securing the inferior edge of the pectoralis major muscle. This is accomplished by the placement of several U stitches of 2/0 polydioxanone suture through the skin, through the inferior edge of the muscle, and backing out the skin below the mastectomy incision but above the inframammary fold. These sutures were named marionettes sutures. Although they should be tied loosely, there is a risk of skin injuring and scarring. These risks should be borne in mind when choosing this technique. Figure 8 Risk-reducing mastectomy and bilateral IPBR through the ESP technique with a round implant which yields a cup breast bigger than the original breast. (a) Preoperative frontal view. (b) Postoperative frontal view. (c) Preoperative oblique view. (d) Postoperative oblique view.

1238 H.D. Loustau et al. Another surgical alternative is the use of a relaxed running suture approximating the lateral border of the pectoralis major to the boundaries of the surgical lodge. Its main disadvantage is the low reliability and the risk of tissue laceration. Recently and during the preparation of this paper, Breuing and Warren 11 described the use of an acellular cryopreserved dermal matrix (Alloderm) sling to re-establish the lower pole of the pectoralis major muscle in IPBR. Since Alloderm is derived from human tissue, it is extensively tested and screened to assure patient safety. Nevertheless, the risks of disease transmission, although improbable, could be a matter of concern for some patients. On the other hand, the cost of Alloderm in developing countries could also restrict its use for breast reconstruction. The application of a mesh in breast reconstruction has already been reported for other purposes. In 1997, Rietjens et al. 12 described the use of a non absorbable mesh to pull up and maintain the upper abdominal skin flap during mastectomies with large skin excision and also to permit a better definition of the inframammary fold. In 2002 Amanti et al. 13 reported the use of a polypropylene mesh in breast reconstruction, limited to the restoration of the pectoralis major, which was partially torn during mastectomy. The authors present the application of a polyglicolic mesh in an original fashion, mimicking the anatomy of the muscles usually employed in pocket creation. The proposed technique has been called ensured subpectoral pocket (ESP) and has proved to be successful in simplifying IPBR in the authors experience. In a single stage it allows the setting of bigger implants without previous tissue expansion, as well as preventing implant displacements. A reduction in surgical steps and costs with less physical and emotional trauma for the patient are additional benefits. On the other hand, the use of a dissolvable mesh, as the polyglicolic mesh, implies a lesser risk of extrusion or complications, such as sinus tract formation, usually observed during the late postoperative period of mesh hernioplasties. 14 Although there could be an increase in the rate of capsular contracture, this has not been observed in these patients. Currently, the knowledge on genome and gene mutations has really improved the prognosis and life quality of patients undergoing prophylactic mastectomies. In view of this, when considering very aggressive surveillance as a consequence of preserving all the breast parenchyma versus the breast amputation and a reliable immediate reconstruction, the latter could be the best choice. 15,16 The authors conclude that ESP is a valid strategy in single stage IPBR, since it allows the setting of bigger implants without previous tissue expansion and prevents its displacement. ESP can be presented as another tool for IPBR when more prophylactic mastectomies will be carried out, 16 thus being useful for patients who are reluctant to undergo more than one surgery and are in a range of implants between 270 and 370 cc. References 1. Alderman AK, Wilkins EG, Lowery JC, et al. Determinants of patient satisfaction in postmastectomy breast reconstruction. Plast Reconstr Surg 2000;106:769e76. 2. Little 3rd JW, Golembe EV, Fisher JB. The living bra in immediate and delayed reconstruction of the breast following mastectomy for malignant and nonmalignant disease. Plast Reconstr Surg 1981;68:392e403. 3. Hidalgo DA. Aesthetic refinements in breast reconstruction: complete skin-sparing mastectomy with autogenous tissue transfer. Plast Reconstr Surg 1998;102:63e70. 4. Kroll SS, Ames F, Singletary SE, et al. The oncologic risks of skin preservation at mastectomy when combined with immediate reconstruction of the breast. Surg Gynecol Obstet 1991;172: 17e20. 5. Brar MI, Tebbetts JB. Early return to normal activities after breast augmentation. Plast Reconstr Surg 2002;110:1193e4. 6. Beasley ME. Two stage expander/implant reconstruction: delayed. In: Spear SL, editor. The breast, principles and art. Philadelphia: Lippincott-Raven; 1998. p. 387e98. 7. Nava M, Quattrone P, Riggio E. Focus on the breast fascial system: a new approach for inframammary fold reconstruction. Plast Reconstr Surg 1998;102:1034e45. 8. Spear SL, Howard MA, Boehmler JH, et al. The infected or exposed breast implant: management and treatment strategies. Plast Reconstr Surg 2004;113:1634e44. 9. Spear SL. Primary implant reconstruction. In: The breast, principles and art. Philadelphia: Lippincott-Raven; 1998. p. 347e56. 10. Spear SL, Spittler CJ. Breast reconstruction with implants and expanders. Plast Reconstr Surg 2000;107:177e87. 11. Breuing KH, Warren SM. Immediate bilateral breast reconstruction with implants and inferolateral AlloDerm slings. Ann Plast Surg 2005;55:232e9. 12. Rietjens M, Garusi C, Lanfrey E, et al. Cutaneous suspension: immediate breast reconstruction with abdominal cutaneous advancement using a non-resorptive mesh. Preliminary results and report of 28 cases. Ann Chir Plast Esthet 1997;24: 177e82. 13. Amanti C, Regolo L, Moscaroli A, et al. Use of mesh to repair the submuscular pocket in breast reconstruction: a new possible technique. G Chir 2002;23:391e3. 14. Rutkow IM, Robbins AW. The mesh plug technique for recurrent groin herniorrhaphy: a nine-year experience of 407 repairs. Surgery 1998;124:844e7. 15. Loustau H. Reconstrucción mamaria y calidad de vida. Monografía de la materia, Antropología médica. Carrera de adscripción a la docencia de la UBA; 2000. 16. Anderson K, Jacobson JS, Heitjan DF, et al. Cost-effectiveness of preventive strategies for women with a BRCA1 or a BRCA2 mutation. Ann Intern Med 2006;144:397e406.