Available online at www.sciencedirect.com
ScienceDirect EJSO 40 (2014) 673e675
www.ejso.com
Technical article
‘Imbricated dermal flap’: A novel technique for autologous augmentation in immediate breast reconstruction after skin-sparing mastectomy N. Haydon*, J. Southwell-Keely, E. Moisidis Department of Plastic & Reconstructive Surgery, St Vincent’s Hospital, Sydney, Australia Accepted 14 February 2014 Available online 7 March 2014
Abstract This case demonstrates use of a de-epithelialised inferior pole skin flap for a more aesthetic result in immediate autologous breast reconstruction. For women with medium to large ptotic breasts, utilising the excess tissue following skin-sparing mastectomy as an auto-prosthesis, adds volume to the breast and improves inferior pole aesthetics. This ‘imbricated dermal flap’ offers an excellent addendum to aesthetic breast reconstruction. Ó 2014 Elsevier Ltd. All rights reserved. Keywords: Autologous breast reconstruction; Immediate breast reconstruction; Dermal flap; Auto-augmentation; Skin-sparing mastectomy
Introduction At the age of 58 the patient had undergone a right mastectomy and axillary dissection for a T2N1M0 carcinoma of the breast with adjuvant chemo-radiotherapy. Two years later she presented for prophylactic left mastectomy with immediate reconstruction and a delayed right breast reconstruction using bilateral free transverse rectus abdominis myocutaneous (TRAM) flaps. On examination her left breast was large and ptotic. Her right chest wall was hyper-pigmented in the area of previous radiotherapy, on either side of a well healed, oblique mastectomy scar. The irradiated tissue was soft and supple to examine (Figure 1). She was assessed pre-operatively as ASA 2 (mild systemic disease) with a significant background history of smoking, although she had ceased six weeks prior to her reconstructive surgery.
chest wall. A skin-sparing mastectomy was performed on the left side with the third intercostal space internal thoracic perforating vessels identified as being sufficiently large for micro-vascular anastomosis. On the right side the skin flaps were raised and the fourth costal cartilage was excised to facilitate access to the internal thoracic vessels. The right free TRAM flap was moved to the left chest wall and the left free TRAM flap to the right chest wall. The nipple-areolarcomplex (NAC) of the left breast had been excised with the specimen leaving an empty, redundant skin envelope. Viability of the mastectomy skin flaps was assessed by examining the colour, capillary return and wound edge bleeding. A vascularised dermal flap was then created by de-epithelialising the infra-areolar mastectomy flap, between the inferior edge of the NAC and IMF, in the pattern of a vertical scar breast reduction. The incised edges of the dermal flap were then approximated, burying and imbricating the dermal flap between the overlying breast skin and the underlying TRAM flap Figure 2.
Technique Pre-operative markings included the midline and the left infra-mammary fold (IMF) which was translated to the right * Corresponding author. St Vincent’s Hospital, 390 Victoria Street, Darlinghurst, NSW 2010, Australia. Tel.: þ61 400436141(mobile). E-mail address: [email protected] (N. Haydon). 0748-7983/$ - see front matter Ó 2014 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ejso.2014.02.242
Discussion Patient selection In women with mammary hyperplasia undergoing skinsparing mastectomy, the redundant inferior pole skin
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N. Haydon et al. / EJSO 40 (2014) 673e675
Figure 1. Pre-operative image demonstrating the large ptotic left breast and previous right mastectomy scar & post-operative image at six months.
flap can be utilised to auto-augment the breast rather than being excised This dermal flap has been described in alloplastic breast reconstruction to provide a stable soft-tissue cover for the tissue expander/implant and allows a larger pocket to be created with less tension in the inferior pole.1 The utilisation of the de-epithelised inferior pole breast skin as an ‘auto-prothesis’ has also been described during superior pedicle mastopexy.2 This report describes the use of the ‘imbricated dermal flap’ for augmentation of an autologous breast reconstruction (TRAM), but it can also be used for any other autologous reconstruction when there is a larger breast with longer NAC to IMF distance and larger skin envelope.
It adds negligible time to the procedure and is very reliable with a broad base. Another technique, the Wise-pattern skin reducing mastectomy, creates a dermal sling from the lower half of breast skin and is used instead of the ‘imbricated dermal flap’ when there is too much skin redundancy and a NAC to IMF distance of >7 cm. The ‘imbricated dermal flap’ is indicated for moderate sized breasts and may be judged on the table once the flap volume and skin envelope is assessed. It’s benefits over the Wise-pattern technique in these patients are; shorter scars, less chance of damage to the superficial vascular plexus, and avoids wound healing issues at the T-junction. The dermal sling technique uses de-epithelialised redundant breast envelope to complete the submuscular pocket and provides infero-lateral coverage and support to implant or tissue expander.3 The ‘imbricated dermal flap’ similarly utilises inferior pole de-epithelialised skin, preserving the dermal plexus. It is not necessary for flap coverage in this instance but does provide a degree of support, improves projection and overall breast aesthetics.
Disadvantages The sole disadvantage of this approach is increased scarring similar to vertical breast reduction pattern, however this is usually well tolerated. In patients with diabetes, previous radiotherapy and smokers, one need be mindful of the flap vascularity and it may be prudent to reduce the flap dimensions.
Pitfalls Advantages This auto-prosthesis acts as a buttress in the inferior pole of the breast, adding volume to the breast, enhancing projection and the aesthetic curve of the inferior pole.
In regard to the vascularity of the dermal flap, care during de-epithelisation preserves the dermal vascular plexus. Once the imbricated dermal flap is buried it is not possible to monitor the viability of the flap, so this needs to be well established prior to closure. Closure of the elliptical edges involves only the superficial dermis of the flap so as to avoid damaging the deep dermal vascular plexus.
Conclusion
Figure 2. Schematic drawing demonstrating the ‘Imbricated dermal flap’ technique (Medici Graphics, St Vincent’s Hospital, Sydney, Australia) & Intraoperative photo series demonstrating the redundant inferior pole skin, the de-epithelialised dermal flap, and final scar pattern after the dermal flap has been buried and imbricated.
Our technique describes de-epithelialising redundant inferior pole mastectomy skin in a vertical breast reduction pattern and burying the resulting dermal flap anterior to the newly created breast mound to improve projection and breast aesthetics. In women with medium to large ptotic breasts undergoing immediate reconstruction following mastectomy the ‘imbricated dermal flap’ offers an autologous augmentation of the newly created inferior pole.
N. Haydon et al. / EJSO 40 (2014) 673e675
Conflict of interest None identified. Funding None. Ethical approval Not required.
675
References 1. Hammond DC, Capraro PA, Ozolins EB, et al. Use of a skin-sparing reduction pattern to create a combination skinemuscle flap pocket in immediate breast reconstruction. Plast Reconstr Surg 2002;110:206– 11. 2. Nava MB, Cortinovis U, Ottolenghi J, et al. Skin-reducing mastectomy. Plast Reconstr Surg 2006;118:603–10. 3. Goyal A, Wu JM, Chandran VP, et al. Outcome after autologous dermal sling-assisted breast reconstruction. Br J Surg 2011;98:1267–72.
ScienceDirect EJSO 40 (2014) 673e675
www.ejso.com
Technical article
‘Imbricated dermal flap’: A novel technique for autologous augmentation in immediate breast reconstruction after skin-sparing mastectomy N. Haydon*, J. Southwell-Keely, E. Moisidis Department of Plastic & Reconstructive Surgery, St Vincent’s Hospital, Sydney, Australia Accepted 14 February 2014 Available online 7 March 2014
Abstract This case demonstrates use of a de-epithelialised inferior pole skin flap for a more aesthetic result in immediate autologous breast reconstruction. For women with medium to large ptotic breasts, utilising the excess tissue following skin-sparing mastectomy as an auto-prosthesis, adds volume to the breast and improves inferior pole aesthetics. This ‘imbricated dermal flap’ offers an excellent addendum to aesthetic breast reconstruction. Ó 2014 Elsevier Ltd. All rights reserved. Keywords: Autologous breast reconstruction; Immediate breast reconstruction; Dermal flap; Auto-augmentation; Skin-sparing mastectomy
Introduction At the age of 58 the patient had undergone a right mastectomy and axillary dissection for a T2N1M0 carcinoma of the breast with adjuvant chemo-radiotherapy. Two years later she presented for prophylactic left mastectomy with immediate reconstruction and a delayed right breast reconstruction using bilateral free transverse rectus abdominis myocutaneous (TRAM) flaps. On examination her left breast was large and ptotic. Her right chest wall was hyper-pigmented in the area of previous radiotherapy, on either side of a well healed, oblique mastectomy scar. The irradiated tissue was soft and supple to examine (Figure 1). She was assessed pre-operatively as ASA 2 (mild systemic disease) with a significant background history of smoking, although she had ceased six weeks prior to her reconstructive surgery.
chest wall. A skin-sparing mastectomy was performed on the left side with the third intercostal space internal thoracic perforating vessels identified as being sufficiently large for micro-vascular anastomosis. On the right side the skin flaps were raised and the fourth costal cartilage was excised to facilitate access to the internal thoracic vessels. The right free TRAM flap was moved to the left chest wall and the left free TRAM flap to the right chest wall. The nipple-areolarcomplex (NAC) of the left breast had been excised with the specimen leaving an empty, redundant skin envelope. Viability of the mastectomy skin flaps was assessed by examining the colour, capillary return and wound edge bleeding. A vascularised dermal flap was then created by de-epithelialising the infra-areolar mastectomy flap, between the inferior edge of the NAC and IMF, in the pattern of a vertical scar breast reduction. The incised edges of the dermal flap were then approximated, burying and imbricating the dermal flap between the overlying breast skin and the underlying TRAM flap Figure 2.
Technique Pre-operative markings included the midline and the left infra-mammary fold (IMF) which was translated to the right * Corresponding author. St Vincent’s Hospital, 390 Victoria Street, Darlinghurst, NSW 2010, Australia. Tel.: þ61 400436141(mobile). E-mail address: [email protected] (N. Haydon). 0748-7983/$ - see front matter Ó 2014 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ejso.2014.02.242
Discussion Patient selection In women with mammary hyperplasia undergoing skinsparing mastectomy, the redundant inferior pole skin
674
N. Haydon et al. / EJSO 40 (2014) 673e675
Figure 1. Pre-operative image demonstrating the large ptotic left breast and previous right mastectomy scar & post-operative image at six months.
flap can be utilised to auto-augment the breast rather than being excised This dermal flap has been described in alloplastic breast reconstruction to provide a stable soft-tissue cover for the tissue expander/implant and allows a larger pocket to be created with less tension in the inferior pole.1 The utilisation of the de-epithelised inferior pole breast skin as an ‘auto-prothesis’ has also been described during superior pedicle mastopexy.2 This report describes the use of the ‘imbricated dermal flap’ for augmentation of an autologous breast reconstruction (TRAM), but it can also be used for any other autologous reconstruction when there is a larger breast with longer NAC to IMF distance and larger skin envelope.
It adds negligible time to the procedure and is very reliable with a broad base. Another technique, the Wise-pattern skin reducing mastectomy, creates a dermal sling from the lower half of breast skin and is used instead of the ‘imbricated dermal flap’ when there is too much skin redundancy and a NAC to IMF distance of >7 cm. The ‘imbricated dermal flap’ is indicated for moderate sized breasts and may be judged on the table once the flap volume and skin envelope is assessed. It’s benefits over the Wise-pattern technique in these patients are; shorter scars, less chance of damage to the superficial vascular plexus, and avoids wound healing issues at the T-junction. The dermal sling technique uses de-epithelialised redundant breast envelope to complete the submuscular pocket and provides infero-lateral coverage and support to implant or tissue expander.3 The ‘imbricated dermal flap’ similarly utilises inferior pole de-epithelialised skin, preserving the dermal plexus. It is not necessary for flap coverage in this instance but does provide a degree of support, improves projection and overall breast aesthetics.
Disadvantages The sole disadvantage of this approach is increased scarring similar to vertical breast reduction pattern, however this is usually well tolerated. In patients with diabetes, previous radiotherapy and smokers, one need be mindful of the flap vascularity and it may be prudent to reduce the flap dimensions.
Pitfalls Advantages This auto-prosthesis acts as a buttress in the inferior pole of the breast, adding volume to the breast, enhancing projection and the aesthetic curve of the inferior pole.
In regard to the vascularity of the dermal flap, care during de-epithelisation preserves the dermal vascular plexus. Once the imbricated dermal flap is buried it is not possible to monitor the viability of the flap, so this needs to be well established prior to closure. Closure of the elliptical edges involves only the superficial dermis of the flap so as to avoid damaging the deep dermal vascular plexus.
Conclusion
Figure 2. Schematic drawing demonstrating the ‘Imbricated dermal flap’ technique (Medici Graphics, St Vincent’s Hospital, Sydney, Australia) & Intraoperative photo series demonstrating the redundant inferior pole skin, the de-epithelialised dermal flap, and final scar pattern after the dermal flap has been buried and imbricated.
Our technique describes de-epithelialising redundant inferior pole mastectomy skin in a vertical breast reduction pattern and burying the resulting dermal flap anterior to the newly created breast mound to improve projection and breast aesthetics. In women with medium to large ptotic breasts undergoing immediate reconstruction following mastectomy the ‘imbricated dermal flap’ offers an autologous augmentation of the newly created inferior pole.
N. Haydon et al. / EJSO 40 (2014) 673e675
Conflict of interest None identified. Funding None. Ethical approval Not required.
675
References 1. Hammond DC, Capraro PA, Ozolins EB, et al. Use of a skin-sparing reduction pattern to create a combination skinemuscle flap pocket in immediate breast reconstruction. Plast Reconstr Surg 2002;110:206– 11. 2. Nava MB, Cortinovis U, Ottolenghi J, et al. Skin-reducing mastectomy. Plast Reconstr Surg 2006;118:603–10. 3. Goyal A, Wu JM, Chandran VP, et al. Outcome after autologous dermal sling-assisted breast reconstruction. Br J Surg 2011;98:1267–72.
