Extended Submuscular Implant-Based Breast Reconstruction with Pectoralis-Serratus Sling and Acellular Dermal Matrix.

Abstract

Partial muscle coverage with the use of acellular dermal matrix (ADM) has become commonplace in implant-based breast reconstruction.1-8 Compared with total submuscular coverage,9-12 the advantages of partial muscle coverage and ADM have included greater primary implant fill volumes, quicker expansion, increased lower pole expansion, and improved breast aesthetics.5,8,13-15 Since Breuing and Warren’s 2005 description,1 ADM has been widely used as a “pectoralis extender” and “inferolateral sling.” Having amassed experience and largely favorable results with this classical technique,1 we have nevertheless found several limitations with this approach, primarily related to the incision of the lateral margin of the pectoralis major muscle and the requisite lateral inset of the allograft. First, the lateral ADM inset requires two suture lines, along both the incised pectoralis major muscle lateral margin and serratus fascia, which can be time intensive. Second, lateral allograft inset can be technically arduous, particularly through increasingly limited-length or inframammary mastectomy incisions. Finally, we had commonly noted lateralization of the breast pocket throughout the expansion process, with varying degrees of lateral breast prosthesis displacement, that have necessitated onerous and additional time-intensive lateral capsulorrhaphy maneuvers to re-define the lateral pocket at the second stage. The authors’ current implant-based breast reconstruction technique was devised to establish more robust definition of the lateral breast pocket, limiting potential implant displacement and minimizing the need for capsular modification at a second procedure. The technique, described below and demonstrated in Figure 1, is a hybrid approach that combines the advantages of ADM inferiorly with extended submuscular coverage laterally by elevating the pectoralis major muscle in continuity with the serratus anterior muscle and fascia. This technique provides more vascularized autogenous implant coverage, improves support and maintenance of breast shape and implant position, facilitates control of the lateral pocket through …