Breast Mound Research Articles

Les asymétries constitutionnelles en chirurgie d’augmentation mammaire esthétique : incidence, satisfaction et applications chirurgicales

The clinically observable, constitutional breast asymmetries are frequent and physiological in the general population. Although there has been a preponderance of literature concerning breast augmentation, a conspicuous lack of data exists regarding the preoperative breast and chest wall asymmetries seen in the patient seeking consultation for aesthetic breast augmentation. These asymmetries can lead to postoperative dissatisfaction in patients.An independent plastic surgeon analysed the data of 200 patients who had a primary aesthetic breast augmentation. The mean follow-up was 36 months. All patients had pre- and postoperative standardized pictures of the anterior chest wall. The clinical examination was achieved using an original evaluation form. Patients were also asked to fill an exhaustive satisfaction form. Breasts and chest wall asymmetries were diagnosed by clinical examination and photographic analysis. Mastopexy-augmentations, breast reconstructions, breast malformations (tuberous breasts and Poland syndrome) and patients with incomplete data were excluded from the study. Stastical analysis was done using SPSS software version 15.There were 77% of chest wall and breast asymmetries and 69,5% of breasts asymmetries (26,5% of breast mound volume asymmetry and 62,5% of shape asymmetry). An isolated chest wall asymmetry was found in 17% of patients. Scoliosis was the main cause of asymmetry (52,9% of chest wall asymmetries) as it is often associated with chest wall rotation, chest wall depression, submammary depression or rib asymmetry. Patients often noticed an asymmetry postoperatively (28%). Among the patients complaining from a postoperative asymmetry, 83,3% had a constitutional breast or chest wall asymmetry. Asymmetry was the third cause of dissatisfaction and the third argument for revision surgery (after volume dissatisfaction and ptosis). Thirty per cent of patients asking for a surgical revision and 35.3% of unsatisfied patients complained about asymmetry, which was preoperative in 83.3% of cases.The asymmetry rate of our study is compared with the others studies found in the literature. In the daily practice, asymmetry can be diagnosed by a complete clinical examination and standardized chest wall pictures. Patients with constitutional asymmetry should be educated, helping to increase postoperative satisfaction. The authors propose and discuss a surgical pattern for the handling of the different types of asymmetries in breast augmentation.

Modified Wise-Pattern Reduction Mammaplasty, a New Tool for Upper Quadrantectomies: A Preliminary Report

Quadrantectomy is an oncological safe procedure for early breast cancer, but it often results in poor aesthetic results such as breast shape deformity, more visible if the tumor is located in the upper pole. We suggest the use of a modified Wise-pattern breast reduction in patients with moderate to severe breast hypertrophy and tumor located in upper quadrants that keeps the oncological advantages of the quadrantectomy but with better aesthetical results. Quadrantectomy of the upper quadrant, immediate breast reconstruction and contralateral breast reduction to obtain symmetry was performed on 11 patients affected by early breast cancer with bra cup size from C to E. To replace the skin area removed with mastectomy from the upper quadrants, a similar-size area from the lower pole was preserved. All patients healed uneventfully within 15 days, and no local or distant recurrences occurred with mean follow-up of 26.5 months (range 19-39 months). In all cases natural breast shape was achieved. The scars were similar to a reduction mammaplasty, and the medial or lateral scar on the upper quadrant did not aesthetically disfigure the décolleté. Modified Wise-pattern reduction mammaplasty is a valid technique as immediate breast reconstruction to obtain a natural breast mound after upper quadrantectomies on patients with medium/large breasts.

Invasive Breast Cancer after Mastectomy and Autologous Breast Reconstruction

Recurrence or new breast cancer after mastectomy and autologous breast reconstruction is a rare occurrence. We present a case series of four patients with this rare phenomenon and describe their presentation, workup, and surgical and adjuvant therapy. We discuss the possible physiologic mechanisms leading to tumor recurrence in a reconstructed breast along with literature review. A new palpable mass in a reconstructed breast mound warrants tissue diagnosis to avoid delay in treatment. The surgical options for breast cancer in tissue reconstructions depend on the location and extent of the tumor, involvement of the vascular pedicle, stage of disease, and adjuvant therapy options.

Long-Term Outcomes after Primary Breast Reconstruction Using a Vertical Skin Pattern for Skin-Sparing Mastectomy

Preservation of the breast skin envelope in skin-sparing mastectomy is the key component for superior aesthetic results. Breast mound disproportions in primary breast reconstruction caused by a mismatch between retained skin envelope and donor-tissue volume provokes breast shape asymmetries. A skin-sparing mastectomy using a vertical pattern can address these breast mound imperfections by adjusting this mismatch in a vertical direction. A retrospective chart review was conducted over a 10-year period for patients who underwent skin-sparing mastectomy using a vertical pattern for malignant, premalignant, benign, and deformational disease of the breast. Reconstruction was performed primarily with free muscle-sparing transverse rectus abdominis musculocutaneous or deep inferior epigastric perforator flaps. Seventy-two patients, aged 31 to 69 years (mean, 51.5 years), underwent 106 skin-sparing mastectomies using a vertical pattern and primary reconstruction with 38 unilateral and 34 bilateral free flaps (muscle-sparing transverse rectus abdominis musculocutaneous or deep inferior epigastric perforator flaps). The mean follow-up period was 42 months, without any local or systemic recurrences of the breast cancer. The complication rates of 8.49 percent at the donor site and 6.60 percent at the flap site show a direct correlation to smoking but no correlation to body mass index, cancer stage, or diabetes. Skin-sparing mastectomy using a vertical pattern improves the aesthetic outcome in primary breast reconstruction without compromising oncologic safety and demonstrates low morbidity. Elimination of the disharmony between skin flap and breast volume in the vertical direction while respecting the inframammary crease produces a youthful, symmetrical conical breast shape with medial fullness.

Breast Sculpturing: Overcoming the Limits of Traditional Approaches in Breast Reduction

A technique based on original refinements of the vertical breast reduction was developed in our department. The aim of the technique was the safe and aggressive sculpture of an attractive breast mound with minimal scarring and long-lasting results that is easy to perform and suitable for teaching purposes in a surgical training unit. Fifty consecutive patients who were to undergo bilateral breast reduction were prospectively enrolled in the study. Accurate standard anthropometric measurements and photographs were taken preoperatively and postoperatively at 2, 6, 12, 24, and 36 months. A selective breast liposuction plus a superior pedicle breast reduction with a vertical scar skin pattern was performed in all cases. Nipple lifting ranged from 5 to 14 cm; reduction of the distance between the inframammary fold and the nipple ranged from 0.5 to 7 cm; breast base width reduction ranged from 0 to 7 cm. This technique further contributes to vertical mammaplasty refinements, enhancing the key role of selective liposuction prior to surgical dissection of the breast. The basic principle is to convert a large breast into a middle-sized one, making vertical scar breast reduction the most appropriate technique for all cases. A thorough and selective liposuction of the breast mound reduces the breast cone base width safely and with virtually no limitations, thus breaking a taboo of traditional breast reduction techniques.

Immediate Single-Stage Breast Reconstruction Using Implants and Human Acellular Dermal Tissue Matrix With Adjustment of the Lower Pole of the Breast to Reduce Unwanted Lift

Breast reconstruction using implants remains an aesthetic challenge toward achieving symmetry and natural appearance. Closing the areolar defect results in a vertically elevated breast mound. The use of human acellular dermal tissue matrix has been reported to provide coverage and durability over breast implants while allowing for improved shape of the reconstructed breast. This study reports the operative technique used in a series of breast reconstructions using saline implants and human acellular dermal tissue matrix in an immediate one-stage procedure. Complications and appearance were evaluated for all reconstructions. Indications for inframammary fold reconstruction and lower pole breast enhancement using chest skin advancement were discussed. Twenty-three patients were included in the study; 11 had unilateral reconstruction and 12 had bilateral reconstruction for 35 total reconstructions. All patients had immediate reconstruction following skin-sparing mastectomy. Nine patients had inframammary fold reconstruction and 11 patients had a lower chest advancement flap with fold reconstruction. The mean follow-up was 9.5 months with a range of 1 to 24 months. Complications occurred in 3 patients. Human acellular dermal tissue matrix can successfully be used in conjunction with breast implants to achieve an aesthetically pleasing breast reconstruction in one stage at the time of skin-sparing mastectomy. The use of a tissue expander and its associated risks and costs are eliminated. The complication rate is low. In addition, either inframammary fold reconstruction or lower chest advancement and fold reconstruction to augment lower pole skin coverage can improve symmetry with the opposite breast.

Are augmentation mammaplasty and reconstruction of the burned breast collateral lines? Experience in performing simultaneous reconstructive and aesthetic surgery

Anterior chest burns in young females frequently result in complicated problems such as scar contracture, damage to the nipple–areolar complex and breast tissue. Furthermore, an absent breast mound, hypoplasia or disfigurement of developed breasts can result in breast asymmetry and psychological problems. So we presented an alternative procedure that combines burn scar reconstruction and augmentation mammaplasty performed during one operative session. We believe patients who have either smaller natural breasts or burned breast with anterior chest scar contracture can earn both functional and aesthetical benefits via this simultaneous operation.

Quantitative Effects of Tumescent Infiltration and Bupivicaine Injection in Decreasing Postoperative Pain in Submuscular Breast Augmentation

In submuscular breast augmentation, the muscle is transected along its inferior and medial border to allow the implant to rest beneath the breast mound and supply adequate cleavage. This leads to significant pain in the postoperative period. This study was undertaken to quantitatively document the effectiveness of tumescent infiltration and bupivicaine with epinephrine injection in controlling postoperative pain in primary submuscular breast augmentation and its effect on operating time, narcotic use, and complications. A retrospective chart review of 150 primary submuscular augmentation mammaplasties performed by 2 surgeons was conducted. Seventy-five consecutive augmentations performed by each physician during the same time period were studied. One surgeon used tumescent infiltration, using a syringe and a blunt infiltration cannula, placing 50 mL of standard tumescent solution in the planned pocket area of each breast before dissection. In addition, all cut muscle ends were injected with 0.25% bupivicaine with epinephrine (1:100,000, 40 mL per patient) under direct vision. The other surgeon omitted these steps. Patients evaluated pain subjectively using a 0 to 10 numeric pain intensity scale reported to the recovery room staff at specific times in the postanesthesia care unit. Postoperatively, the initial and discharge average pain rating was significantly different between the groups. The group that received tumescence and bupivicaine with epinephrine entered the recovery room with a significantly lower average pain score: 0.5 as compared with the pain score of the control group, which was on average 3.3. In addition, the highest average pain rating was 2.6 in the infiltrated group compared with 5.4 in the noninfiltrated group. Pain at discharge between the groups was also seen to be markedly lower with a subjective average rating of 2.0 in the infiltrated group compared with 4.0 in the control group. No difference was seen in operative time or complications. This is the first report to quantitatively show a pain reduction regimen that is effective in significantly decreasing postoperative pain and decreasing the use of narcotics in the recovery room. The authors conclude that its advantages are significant, and they advocate its use in all breast augmentations.

A New Approach to Nipple Reconstruction: The Modified S-Flap

Sir: Many different techniques have been described by plastic surgeons to achieve nipple reconstruction. The most important aspect of nipple reconstruction is persistence in nipple projection and its comparison to the contralateral nipple.1,2 In an attempt to maintain nipple projection and aesthetics, we have devised a new approach to nipple construction using what we call a modified S-flap. The S-flap nipple reconstruction technique was designed to address certain characteristics of other nipple reconstruction techniques that may lead to unwanted contraction of nipple or loss of projection, shape, and size. The S-flap nipple reconstruction was performed on all patients requesting nipple reconstruction following breast reconstruction over a 5-year period (July of 1999 through July of 2004). The technique was described to our patients as a modified S-flap reconstruction. An elliptical incision was performed down to the subcutaneous fat layer with modified S-flap extensions to prevent constriction of the randomized bare skin flaps. The faces of the randomized skin flaps were opposed to each other. These flaps are then assimilated to the contralateral nonoperative nipple during suturing. Figures 1 and 2 illustrate the design of our proposed reconstruction. Areola tattooing was performed approximately 8 to 10 weeks after surgery if satisfactory wound healing was achieved. The base of the nipple was also tattooed, but the S-flap walls and tip of the nipple were left untattooed to decrease injury and contraction. This would preserve the nipple projection.Fig. 1.: The modified S-flap design. A 4 × 2-cm elliptical incision was performed down to the subcutaneous fat layer with modified S-flap extensions to prevent constriction of the randomized bare skin flaps. Each letter corresponds to the specific points of angulations of the S incision. (Reprinted with permission from Frank Papay, M.D.)Fig. 2.: The modified S-flap design. The faces of the randomized skin flaps were opposed by matching A to A′ and B to B′ as described in Figure 1. These flaps are then assimilated to the contralateral nonoperative nipple during suturing. (Reprinted with permission from Frank Papay, M.D.)As the final stage of breast reconstruction, nipple reconstruction changes the breast mound into a complete anatomical breast by achieving the aesthetics of the contralateral breast. Nipple reconstruction also increases self-esteem in the patient.1,3 Nipple projection, areola color, and symmetry are extremely vital for complete nipple reconstruction.4 A number of flap designs for nipple reconstruction have been well described in the literature. The techniques that have withstood the test of time are those that are surgically reliable and maintain nipple projection. The main obstacle in achieving acceptable nipple shape and size is contraction.4 The current standard of nipple-areola reconstruction is a technique that includes pulled-out flaps or star flaps to increase nipple projection and intradermal tattooing for areola pigmentation.1,2,4,5 Some authors believe that there should be stratification of nipple reconstruction depending on the type of breast reconstruction used. 5 Moreover, some authors believe that nipple projection is determined by the quality of the reconstructed skin dermis, namely, its thickness and vascularity. Our proposed method of the modified S-flap nipple reconstruction has not only preserved size and shape of the nipple-areola complex but also proved to be aesthetically acceptable to our patients. Kiran Narra, M.D. Department of General Surgery L. Michael Diaz, M.D. Department of Plastic Surgery Louisiana State University Baton Rouge, La. Frank A. Papay, M.D. Department of Plastic Surgery The Cleveland Clinic Foundation Cleveland, Ohio

Nipple Areola Reconstruction

Nipple areola reconstruction is often considered the "finishing touch" in the process of breast reconstruction after surgery for breast cancer. Attention to detail with respect to patient selection, timing of reconstruction and surgical technique must therefore be paid to avoid an unsatisfactory result that may taint an otherwise successful reconstructive sequence. There are many surgical techniques available to recreate the nipple areola complex, but each of the various techniques is designed to accomplish similar goals. In every case, regardless of the technique chosen, the surgeon seeks to reconstruct a nipple areola complex that is esthetically pleasing in its color, symmetry, position on the breast mound, and projection.

Ectopic Fibrogenesis Induced by Transplantation of Adipose-Derived Progenitor Cell Suspension Immediately After Lipoinjection

Adipose tissue has its own tissue-specific progenitor cells, a subpopulation of which has been shown to have multipotency and called adipose stem cells or adipose-derived mesenchymal stem cells (1,2). During a clinical trial in which soft tissue is augmented by transplantation of progenitor-enriched adipose tissue (cell-assisted lipotransfer), we have encountered incidence of an unexpected complication: local ectopic subcutaneous fibrogenesis. Patients participating in the trial did so under informed consent approved by individual review boards. Cell-assisted lipotransfer was designed based on the finding that aspirated fat tissue contains many fewer vessels and adipose progenitor cells than intact fat tissue. This may explain the tendency of transplanted aspirated fat tissue to atrophy during the first 6 months posttransplantation (3). In the relevant clinical trial, the stromal vascular fraction (SVF) comprising 10% to 40% adipose progenitor cells was freshly isolated from aspirated fat by means of collagenase digestion and transplanted together with aspirated fat tissue grafts (4). In 146 cases, SVF cells were used as a cell pellet, mixed with and attached to aspirated fat tissue grafts before injecting into fatty and muscular layers of breast mounds. On the other hand, in two cases, SVF cells isolated from 600 mL aspirated fat were separately injected as a cell suspension in 60 mL of saline into both breast mounds (30 mL/side) immediately after conventional lipoinjection. Although grafted fat survived well and fibrogenesis in the breasts or surrounding tissues was not seen in the former group, fibrous tissue formation was observed in both cases of the latter group 3 months after treatment. In the two cases, breast mounds were somewhat hard to the touch; inspection by CT scan detected unexpected fibrosis in the subcutaneous fat layers. In the thinner patient of the two (Fig. 1), fibrous tissue approximately 10 mm thick had formed on the sternum and caused anterior elevation of the skin, which was treated with local injections of triamcinolone acetonide at 6 and 8 months. Furthermore, lymphadenopathy was seen at the left abdominal wall and the left inguinal region at 3 months and gradually disappeared by 12 months.FIGURE 1.: CT scan images taken before (Pre) and 3, 6, 12, and 36 months after treatment. Normal mammary glands and the thin fatty layers around them are visible before treatment. Substantial fibrosis had occurred, both diffusely in the transplanted fat surviving around the mammary glands and in the subcutaneous layer over the sternum, at 3 months. The fibrotic mass over the sternum was treated twice with local injections of triamcinolone acetonide at 6 and 8 months and dissipated, but diffuse fibrosis in the breasts remains at 36 months.Fibrogenesis results from persistent inflammation, in which tissue remodeling and repair processes are impaired and injured cells are replaced not with cells of the same type but with connective or scar tissue (5). As fibrogenesis was seen only when SVF cells were injected separately as a cell suspension, a nonphysiological microenvironment in which adherent adipose progenitor cells are suspended in saline solution may give rise to the unexpected differentiation and migration of the cells. After large-volume lipoinjection, tissue injury, edema, hemorrhage, and local inflammation are commonly seen, and transplanted adipose progenitor cells are temporarily placed in and stimulated by ischemic and inflammatory microenvironments. These findings provide some insights into a therapeutic strategy for future cell-based therapies involving adherent stem/progenitor cells. Previous experimental studies demonstrated that transplanted bone marrow-derived mesenchymal stem cells differentiated into myofibroblasts and contributed to liver fibrosis after acute or chronic liver injury (6,7). In cell-based therapies using adherent mesenchymal stem cells, the possibility of unfavorable behaviors such as differentiation into myofibroblasts should be taken into account, even if the cells are derived from adult tissue and have not been substantially manipulated. It may be a resolution to adhere adipose-derived adherent stem or progenitor cells to cells, tissue, extracellular matrix, or biological scaffold before administration to avoid their unexpected behaviors. Kotaro Yoshimura Noriyuki Aoi Hirotaka Suga Keita Inoue Hitomi Eto Department of Plastic Surgery University of Tokyo School of Medicine Tokyo, Japan Katsujiro Sato Cellport Clinic Yokohama Yokohama Excellent III Building 2F Kanagawa, Japan Masakazu Kurita Kiyonori Harii Department of Plastic Surgery Kyorin University School of Medicine Tokyo, Japan Toshitsugu Hirohi Ritz Cosmetic Surgery Clinic Tokyo Shinagawa-ku, Tokyo, Japan

A New Application for Increasing Breast Projection in Free-Nipple-Graft Reduction Mammaplasty

Free-nipple-graft reduction mammaplasty is the procedure of choice in patients with massive breast hypertrophy. Breasts that have undergone free-nipple-graft reduction mammaplasty usually cannot maintain projection. Many modifications of free-nipple-graft reduction mammaplasty have been described to treatment this problem. We describe our modification of the free-nipple-graft reduction mammaplasty. The technique includes two key points: The first is the fold of the midportions of the breast. The second is suturing the midportion of the breast to the fascia of the pectoral muscle. The fold increases breast projection and the suturing helps to obtain long-lasting breast projection. A total of 16 patients underwent free-nipple-graft reduction with the modified technique between 2003 and 2008. Mean follow-up was 21 months (range = 3-60 months). An average of 2016 g of tissue per breast was excised (range = 1250-2700 g per breast). An average of 4031 g of tissue per patient was excised. All patients had long-lasting, pronounced breast mound projection. Satisfactory breast projection was maintained. No "bottoming out" was seen. The level of satisfaction felt by all patients was very high. Long-term projection can be maintained by suturing the half-trianges to each other and to the fascia of the pectoral muscle. One more useful alternative technique for increasing projection in free-nipple-graft reduction has been added with the technique presented.

Paget Disease of a Nipple Graft Following Completion of a Breast Reconstruction With a Nipple-Sharing Technique

Surgical treatment of breast cancer can have a profound impact on patients both physically and psychologically. Postmastectomy breast reconstruction can significantly decrease the psychologic distress that a breast cancer patient experiences. Whereas breast mound reconstruction was initially thought to be sufficient, surgeons and patients have recognized the importance of nipple-areolar reconstruction. The following is a case report of a patient who developed Paget disease of a left nipple graft after left mastectomy and reconstruction with a TRAM flap and nipple sharing from the right breast. This case report provides a unique 14-year retrospective review of a clinical course and to our knowledge is the first reported case in the English literature of Paget disease developing in a nipple reconstructed from the contralateral nipple using the nipple-sharing technique.

Immediate Nipple Reconstruction on a Free TRAM Flap Breast Reconstruction

Reconstruction of the nipple-areola complex is usually deferred until breast mound reconstruction is complete. The authors review their experience with a technique that allows for shaping of a free transverse rectus abdominis myocutaneous (TRAM) flap and immediate nipple reconstruction and compare this technique with delayed nipple reconstruction. A retrospective chart review demonstrated 21 patients who underwent immediate nipple reconstruction, 10 of whom had complete photographs and records for review. Ninety patients underwent delayed nipple reconstruction. Twenty of these patients were chosen for comparison, 15 of whom had complete photographs and records. Age, body mass index, comorbidities, procedures required, complications, and time to completion were reviewed. A multiobserver, multicharacteristic, standardized photographic review of cosmetic outcomes was conducted. Time from mastectomy to completion of reconstruction, not including areolar tattooing, was 1 day (median) versus 125 days (median) in the immediate and delayed groups, respectively (p = 0.003). The number of procedures required to complete reconstruction before areolar tattooing was one (median) in the immediate group and two (median) in the delayed group (p < 0.001). Complication rates were similar in both groups. Subjective review demonstrated no difference in the aesthetic outcome of the breast mound or nipple-areola complex reconstruction. Patients having immediate nipple reconstruction in the setting of a free TRAM breast reconstruction completed their reconstruction earlier, required fewer procedures, and had aesthetic results comparable to patients having traditional delayed nipple reconstruction. Complications and revision rates were comparable.

Versatility of the Superomedial Pedicle in Managing the Massive Weight Loss Breast: The Rotation-Advancement Technique

Management of the breast following massive weight loss is challenging. Specific issues include an unstable envelope (skin laxity) and an unstable mound (decent and volume loss). The evolution of a technique is presented. A retrospective review of all massive weight loss patients who underwent superomedial pedicle mastopexy techniques was performed. The current procedure involves incorporating the lower pole of the breast and rotating it superiorly. The lateral breast flap is then advanced medially and plicated. This essentially (1) autoaugments the upper pole, (2) narrows the wide breast, (3) provides an internal sling, and (4) redefines and secures the inframammary fold. Thirty-five patients were included in the series. The average body mass index was 26.5, and the average weight loss was 121 pounds. Six patients (17 percent) had mastopexy augmentation. Wise pattern skin takeout was performed in 89 percent of patients. The revision rate for the series was 11 percent. The average follow-up was 1.7 years. The superomedial pedicle is a versatile, well-vascularized pedicle that allows for glandular plication of the lower pole and autoaugmentation of the upper pole once rotated. Parenchymal shaping through plication and suspension of the breast mound should improve breast shape over time, theoretically reducing the incidence of recurrent ptosis as breast shape relies less on the often inelastic skin envelope. It applies a familiar and reliable technique, with certain modifications, to improve results and maintain shape in the long, deflated, massive weight loss breast.

A new approach to correction of truncal redundancy after massive weight loss—The lateral thoracoabdominoplasty

Problems after massive weight loss include residual transverse abdominal laxity, which is not well addressed by abdominoplasty or circumferential lipoplasty, and the lateral descent of the breast mound and inframammary fold, which is not well addressed by mastopexy. The authors report a new approach, the lateral thoracoabdominoplasty, that uses a concealed mid-axillary incision to simultaneously address both of these issues. Redundant tissue was resected from the lateral aspect of the trunk rather than through a traditional midline abdominal incision. The anterior abdomen was left unblemished, and the scars were concealed along the mid-axillary line from the axilla to the iliac crest. The patient had no complications after more than 1 year follow-up and was satisfied with the results. The lateral thoracoabdominoplasty effectively corrects the vertical abdominal laxity and lateral breast descent seen after massive weight loss. The procedure is intended for patients who have undergone minimally invasive bariatric surgery or lost weight by diet and exercise and thus lack an existing midline incision. It provides only limited benefits with respect to improvement of upper midline abdominal fullness.

Simultaneous Endoscope-Assisted Contralateral Breast Augmentation with Implants in Patients Undergoing Postmastectomy Breast Reconstruction with Abdominal Flaps

Sir: We thank Drs. Di Lorenzo and Cordova for their interest in our article.1 We will try to explain our opinions on each item. To the best of our knowledge, there are no scientific data showing the detriment of biopsies or surgical manipulation of the contralateral breast. Conversely, since a woman with cancer in one breast has a 3- to 4-fold increased risk of developing a new cancer in the other breast, a perioperative biopsy of the other breast has been advocated to detect an occult tumor earlier. Anastasiadis et al.2 performed blind biopsies on the upper outer quadrant of the opposite breast in 195 patients and found malignancy in 12 of them (6.2 percent). We agree that the balancing procedure with random biopsies on the opposite breast is not a way to exclude a secondary breast cancer. The superiority of using autologous tissues over breast implants is well established. However, the use of autologous tissue is associated with increased operative time, increased cost, and additional donor-site morbidity. Therefore, we prefer to use it for “reconstruction” and not for purely “aesthetic” (symmetrization) purposes. We do not agree with the necessity of using the same type of tissue for reconstruction and augmentation, as Di Lorenzo and Cordova advocate. If the contralateral breast augmentation is performed using autologous tissue, the disadvantages include an additional scar located at the inframammary fold, additional operative time for flap dissection and anastomoses (usually 4 to 6 hours), the risk of re-exploration, and flap failure (2 percent). Most importantly, in our series, the residual deep inferior epigastric perforator flap volume of 81 ml (mean volume of total deep inferior epigastric perforator flap, 608 ml; used flap volume, 527 ml) seemed inadequate for augmenting a contralateral breast mound (mean implant volume of 189 ml was required). At a mean follow-up period of 29.2 months, the shape and size match were good and overall patient satisfaction was high. The opposite breast is one of the keys to planning breast reconstruction. If the size and shape of the contralateral breast are aesthetically unpleasant, recreation of it may be desirable. In our study, all the contralateral breast augmentation procedures were requested by the patients, not suggested by the surgeons. Then, as reconstructive and aesthetic surgeons, we were able to discuss with the patient that, of course, an intervention to the contralateral breast could be an option to obtain the best result. Please refer to answer 2. Betul Gozel Ulusal, M.D. Ming-Huei Cheng, M.D., M.H.A. Chang Gung Memorial Hospital Taipei, Taiwan

Breast Mound Salvage Using Vacuum-Assisted Closure Device as Bridge to Reconstruction With Inferolateral AlloDerm Hammock

Breast Mound Salvage Using Vacuum-Assisted Closure Device as Bridge to Reconstruction With Inferolateral AlloDerm Hammock

Reconstrucción del complejo areola-pezón: revisión de 60 casos

The creation of the nipple-areola complex is the latest time in breast recons-truction, transforming the reconstruction of the breast mound into a real breas...

Use of AlloDerm in Primary Nipple Reconstruction to Improve Long-Term Nipple Projection

The objective of this study was to demonstrate the use of the authors' technique to improve long-term maintenance of nipple projection by using AlloDerm (LifeCell Corp., Branchburg, N.J.) as a central core in nipple reconstruction. The nipple reconstruction technique involved the use of a modified star dermal flap pattern measuring 5 cm in length and 1.0 to 1.5 cm in width, depending on the amount of desired projection to match the opposite nipple. Then, a 1.5 x 4.5-cm piece of AlloDerm was placed into the core of the newly reconstructed nipple and sutured closed. After the incisions were closed, an ocular eye bubble protector was used to prevent compressive forces on the newly reconstructed nipple, and strict postoperative use of this protector was maintained for 6 weeks. A total of 30 nipple reconstructions were performed [14 transverse rectus abdominis musculocutaneous (TRAM) flaps and 16 tissue-expanded breast mounds]. Caliper measurements of nipple projection were recorded at the time of surgery and at 3, 6, and 12 months postoperatively. Twelve-month average maintenance of nipple projection was 56 percent for the TRAM flap group and 47 percent for the tissue-expanded group. There were no infections or associated complications. The authors' results demonstrate that the use of a modified star dermal flap pattern with the placement of an AlloDerm graft core is a safe, easily performed, and reproducible technique for improving the long-term maintenance of projection in reconstructed nipples.