Correspondence and communications
433
Inframammary fold reconstruction: The “hammock” technique Dear Sir, The aim of post-mastectomy breast reconstruction is to obtain a natural shape and recreate the cosmetic appearance of the breast. The key point is to recreate symmetry with the controlateral breast, specially regarding the inframammary fold (IMF) and degree of ptosis. These characteristics are generally achieved by bringing cutaneous tissue to the thoracic area with an abdominal advancement flap and by recreating a new IMF. Numerous operative techniques for IMF reconstruction have been described.1e3 Most of them are difficult to perform, time consuming and have unpredictable outcomes. A new technique of suspended IMF has been described with an intradermal running suture.4 The benefit conferred to this is a stable and optimal long-term aesthetic result. The risk is to create cutaneous necrosis, which can lead to implant exposure and secondary infection. Radiation therapy is by far the most frequent cause leading to this adverse situation. We present here a modification of this technique, with the fixation of the superficial abdominal fascia to the thoracic wall in only two points, giving it a hammock appearance.
Figure 1 view).
6 months follow up post-op result (Antero-posterior
It is worth mentioning that the upper edge of the fascial incision is neither manipulated nor fixed through the whole procedure. If the final position of the neo-IMF is unsatisfactory, adding separate stitches between the subcutaneous fascia and the chest wall can make adjustments. The hammock technique offers many potential advantages: a short learning curve, it is easily reproducible and
Operative technique Three cutaneous markings are drawn preoperatively: (i) a curvilinear drawing at the level of the theoretical IMF, (ii) a parallel line located 4e5 cm below the first drawing (neoIMF line), (iii) a line representing the lower limit of the abdominal cutaneous flap that will be harvest. A cutaneous abdominal flap is created separating the subcutaneous fat from the aponeurosis of the rectus abdominis muscle. This dissection should exceed the lower costal margin to allow proper mobility of the flap. The superficialis fascia is then incised at the corresponding level of the neo-IMF, on the inner side of the flap, over the entire length of the neo-IMF line. The surgeon should pay attention to limit the depth of the facial incision in order to preserve the dermal vascularization and prevent secondary necrosis. The neo-IMF will be defined by a single running suture (absorbable, 1-0 suture). This entire suture will anchor the lower edge of the incised fascia to the chest wall in only two lateral and medial points, without any other fixation point on the chest wall. An evenly run suture with small intervals between needle passages will contribute significantly to a smooth and regular definition of the neoIMF. To achieve optimal cosmetic result, other anchoring points sometimes need to be added, and can be fixed on surrounding solid tissue (rectus abdominis aponeurosis).
Figure 2
6 months follow up post-op result (Lateral view).
434 rapid to perform. The hammock folding takes only five minutes to complete. The technique is less painful than multiple sutures involving the dermis. The “suspended” aspect of the running suture allows for better and more uniform distribution of the tension on the entire length of the neo-IMF. This suture evenly distributes the skin to the center of the breast and reduces the internal and external cutaneous “dog ears” phenomenon. The cosmetic result is rapidly seen in early post-operative days, and stable in time (Figures 1 and 2). We notice one single relative contraindication in obese patient, because the whole hammock relies on a single suture line that bears the risk of breaking down if put under excessive tension. In our experience, the hammock technique is applied in the majority of immediate or delayed breast reconstructions, using either prosthesis or autologous flap. In our opinion, this technique also allows the surgeon to achieve a proper degree of ptosis and a well-defined IMF in a one-stage procedure.
Conflict of interest/funding None.
Ethical approval N/A.
Appendix A. Supplementary data The following is the supplementary data related to this article:
Appendix A. Supplementary data Supplementary data related to this article can be found at http://dx.doi.org/10.1016/j.bjps.2014.10.035.
References 1. Bogetti P, Cravero L, Spagnoli G, et al. Aesthetic role of the surgically rebuilt inframammary fold for implant-based breast reconstruction after mastectomy. J Plast Reconstr Aesthet Surg 2007;60(11):1225e32. 2. White N, Khanna A. Marking the position of the inframammary fold during breast reconstruction. Plast Reconstr Surg 2006; 118(2):584. 3. Nava M, Quattrone P, Riggio E. Focus on the breast fascial system: a new approach for inframammary fold reconstruction. Plast Reconstr Surg 1998;102(4):1034e45. 4. Pompei S, Frascino LF, Marcasciano F, et al. Definition of the inframammary fold in breast reconstruction: a simplified option. Eur J Plast Surg 2012;35:723e9.
Benjamin Sarfati J.F. Honart Cathie Guimond Franc ¸oise Rimareix Gustave Roussy, Cancer Campus, Grand Paris, Plastic and Reconstructive Surgery Unit, Villejuif, France
Correspondence and communications ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2014.10.035
Harvesting huge bipedicled free flaps from the anterolateral and medial thigh: Combined saphenous-anterolateral thigh (SALT) flaps* Dear Sir, We report here the combined saphenous-anterolateral thigh (SALT) flap for large skin defects. Anterolateral thigh (ALT) flaps were first introduced in 1984 and are frequently used to reconstruct tissue defects.1 Of these flaps, 87% have musculocutaneous perforators; the remaining 13% have septocutaneous perforators.2 In most cases, the pedicle itself comes off the descending branch of the lateral circumflex femoral artery (LCFA). However, a different dominant pedicle is used in 16%e32% of ALT flaps, which can complicate the harvesting of the flap.3 In addition, ALT flaps are occasionally used as super-thin flaps. Another common flap is the descending genicular artery (DGA) perforator flap, which was first described as a ‘saphenous flap’ in 1981.4 In this flap, the main perforator arises from the saphenous branch of the DGA. Imaging methods have facilitated the concept of ‘freestyle free flaps’ and advances in anatomical analysis. These advances have allowed previously pedicled flaps to be transferred as free-style flaps. For example, the saphenous flap has been transferred as a free-style perforator flap.5 The developments not only suggest that free flap transfers are safe, they also indicate that blood supply patterns are independent.
Surgical technique for harvesting SALT flaps The two perforators coming from the LCFA and DGA are located by color Doppler ultrasonography or contrastenhanced multi-detector computed tomography and marked on the side. If a large perforator vessel (i.e., exceeding 0.7 mm) is found, it will provide sufficient blood circulation to their flap However, if only narrow perforator vessels are present, several will have to be included to ensure that the flap has adequate blood supply. The location of these perforators determine the design of the SALT flap, which has an oblique shape and is located on the anterolateral and medial thigh. Flap elevation is performed under general anesthesia in the supine position. During surgery, the DGA-perforator is *
This report was presented at the 57th annual meeting of the Japanese Society of Plastic and Reconstructive surgeons, April 10, 2014.
433
Inframammary fold reconstruction: The “hammock” technique Dear Sir, The aim of post-mastectomy breast reconstruction is to obtain a natural shape and recreate the cosmetic appearance of the breast. The key point is to recreate symmetry with the controlateral breast, specially regarding the inframammary fold (IMF) and degree of ptosis. These characteristics are generally achieved by bringing cutaneous tissue to the thoracic area with an abdominal advancement flap and by recreating a new IMF. Numerous operative techniques for IMF reconstruction have been described.1e3 Most of them are difficult to perform, time consuming and have unpredictable outcomes. A new technique of suspended IMF has been described with an intradermal running suture.4 The benefit conferred to this is a stable and optimal long-term aesthetic result. The risk is to create cutaneous necrosis, which can lead to implant exposure and secondary infection. Radiation therapy is by far the most frequent cause leading to this adverse situation. We present here a modification of this technique, with the fixation of the superficial abdominal fascia to the thoracic wall in only two points, giving it a hammock appearance.
Figure 1 view).
6 months follow up post-op result (Antero-posterior
It is worth mentioning that the upper edge of the fascial incision is neither manipulated nor fixed through the whole procedure. If the final position of the neo-IMF is unsatisfactory, adding separate stitches between the subcutaneous fascia and the chest wall can make adjustments. The hammock technique offers many potential advantages: a short learning curve, it is easily reproducible and
Operative technique Three cutaneous markings are drawn preoperatively: (i) a curvilinear drawing at the level of the theoretical IMF, (ii) a parallel line located 4e5 cm below the first drawing (neoIMF line), (iii) a line representing the lower limit of the abdominal cutaneous flap that will be harvest. A cutaneous abdominal flap is created separating the subcutaneous fat from the aponeurosis of the rectus abdominis muscle. This dissection should exceed the lower costal margin to allow proper mobility of the flap. The superficialis fascia is then incised at the corresponding level of the neo-IMF, on the inner side of the flap, over the entire length of the neo-IMF line. The surgeon should pay attention to limit the depth of the facial incision in order to preserve the dermal vascularization and prevent secondary necrosis. The neo-IMF will be defined by a single running suture (absorbable, 1-0 suture). This entire suture will anchor the lower edge of the incised fascia to the chest wall in only two lateral and medial points, without any other fixation point on the chest wall. An evenly run suture with small intervals between needle passages will contribute significantly to a smooth and regular definition of the neoIMF. To achieve optimal cosmetic result, other anchoring points sometimes need to be added, and can be fixed on surrounding solid tissue (rectus abdominis aponeurosis).
Figure 2
6 months follow up post-op result (Lateral view).
434 rapid to perform. The hammock folding takes only five minutes to complete. The technique is less painful than multiple sutures involving the dermis. The “suspended” aspect of the running suture allows for better and more uniform distribution of the tension on the entire length of the neo-IMF. This suture evenly distributes the skin to the center of the breast and reduces the internal and external cutaneous “dog ears” phenomenon. The cosmetic result is rapidly seen in early post-operative days, and stable in time (Figures 1 and 2). We notice one single relative contraindication in obese patient, because the whole hammock relies on a single suture line that bears the risk of breaking down if put under excessive tension. In our experience, the hammock technique is applied in the majority of immediate or delayed breast reconstructions, using either prosthesis or autologous flap. In our opinion, this technique also allows the surgeon to achieve a proper degree of ptosis and a well-defined IMF in a one-stage procedure.
Conflict of interest/funding None.
Ethical approval N/A.
Appendix A. Supplementary data The following is the supplementary data related to this article:
Appendix A. Supplementary data Supplementary data related to this article can be found at http://dx.doi.org/10.1016/j.bjps.2014.10.035.
References 1. Bogetti P, Cravero L, Spagnoli G, et al. Aesthetic role of the surgically rebuilt inframammary fold for implant-based breast reconstruction after mastectomy. J Plast Reconstr Aesthet Surg 2007;60(11):1225e32. 2. White N, Khanna A. Marking the position of the inframammary fold during breast reconstruction. Plast Reconstr Surg 2006; 118(2):584. 3. Nava M, Quattrone P, Riggio E. Focus on the breast fascial system: a new approach for inframammary fold reconstruction. Plast Reconstr Surg 1998;102(4):1034e45. 4. Pompei S, Frascino LF, Marcasciano F, et al. Definition of the inframammary fold in breast reconstruction: a simplified option. Eur J Plast Surg 2012;35:723e9.
Benjamin Sarfati J.F. Honart Cathie Guimond Franc ¸oise Rimareix Gustave Roussy, Cancer Campus, Grand Paris, Plastic and Reconstructive Surgery Unit, Villejuif, France
Correspondence and communications ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2014.10.035
Harvesting huge bipedicled free flaps from the anterolateral and medial thigh: Combined saphenous-anterolateral thigh (SALT) flaps* Dear Sir, We report here the combined saphenous-anterolateral thigh (SALT) flap for large skin defects. Anterolateral thigh (ALT) flaps were first introduced in 1984 and are frequently used to reconstruct tissue defects.1 Of these flaps, 87% have musculocutaneous perforators; the remaining 13% have septocutaneous perforators.2 In most cases, the pedicle itself comes off the descending branch of the lateral circumflex femoral artery (LCFA). However, a different dominant pedicle is used in 16%e32% of ALT flaps, which can complicate the harvesting of the flap.3 In addition, ALT flaps are occasionally used as super-thin flaps. Another common flap is the descending genicular artery (DGA) perforator flap, which was first described as a ‘saphenous flap’ in 1981.4 In this flap, the main perforator arises from the saphenous branch of the DGA. Imaging methods have facilitated the concept of ‘freestyle free flaps’ and advances in anatomical analysis. These advances have allowed previously pedicled flaps to be transferred as free-style flaps. For example, the saphenous flap has been transferred as a free-style perforator flap.5 The developments not only suggest that free flap transfers are safe, they also indicate that blood supply patterns are independent.
Surgical technique for harvesting SALT flaps The two perforators coming from the LCFA and DGA are located by color Doppler ultrasonography or contrastenhanced multi-detector computed tomography and marked on the side. If a large perforator vessel (i.e., exceeding 0.7 mm) is found, it will provide sufficient blood circulation to their flap However, if only narrow perforator vessels are present, several will have to be included to ensure that the flap has adequate blood supply. The location of these perforators determine the design of the SALT flap, which has an oblique shape and is located on the anterolateral and medial thigh. Flap elevation is performed under general anesthesia in the supine position. During surgery, the DGA-perforator is *
This report was presented at the 57th annual meeting of the Japanese Society of Plastic and Reconstructive surgeons, April 10, 2014.
