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EJSO 40 (2014) 673e675 www.ejso.com

Technical article

‘Imbricated dermal flap’: A novel technique forautologous augmentation in immediate breastreconstruction 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 skinflap for amore aesthetic result in immediate autologous breast reconstruction.Forwomenwithmedium to large ptotic breasts, utilising the excess tissue following skin-sparingmastectomy as an auto-prosthesis, adds volume tothe breast and improves inferior pole aesthetics. This ‘imbricated dermal flap’ offers an excellent addendum to aesthetic breast reconstruction.� 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 mas-tectomy and axillary dissection for a T2N1M0 carcinomaof the breast with adjuvant chemo-radiotherapy. Two yearslater she presented for prophylactic left mastectomy withimmediate reconstruction and a delayed right breast recon-struction using bilateral free transverse rectus abdominismyocutaneous (TRAM) flaps.

On examination her left breast was large and ptotic. Herright chest wall was hyper-pigmented in the area of previ-ous radiotherapy, on either side of a well healed, obliquemastectomy scar. The irradiated tissue was soft and suppleto examine (Figure 1). She was assessed pre-operatively asASA 2 (mild systemic disease) with a significant back-ground history of smoking, although she had ceased sixweeks prior to her reconstructive surgery.

Technique

Pre-operative markings included the midline and the leftinfra-mammary fold (IMF) which was translated to the right

* Corresponding author. St Vincent’s Hospital, 390 Victoria Street, Dar-

linghurst, NSW 2010, Australia. Tel.: þ61 400436141(mobile).

E-mail address: haydonnick@hotmail.com (N. Haydon).

0748-7983/$ - see front matter � 2014 Elsevier Ltd. All rights reserved.

http://dx.doi.org/10.1016/j.ejso.2014.02.242

chest wall. A skin-sparing mastectomy was performed onthe left side with the third intercostal space internal thoracicperforating vessels identified as being sufficiently large formicro-vascular anastomosis. On the right side the skin flapswere raised and the fourth costal cartilagewas excised to facil-itate access to the internal thoracic vessels. The right freeTRAM flap was moved to the left chest wall and the leftfree TRAM flap to the right chest wall. The nipple-areolar-complex (NAC) of the left breast had been excised with thespecimen leaving an empty, redundant skin envelope.Viabilityof the mastectomy skin flaps was assessed by examining thecolour, capillary return and wound edge bleeding. Avascular-ised dermal flap was then created by de-epithelialising theinfra-areolar mastectomy flap, between the inferior edge ofthe NAC and IMF, in the pattern of a vertical scar breast reduc-tion. The incised edges of the dermal flap were then approxi-mated, burying and imbricating the dermal flap between theoverlying breast skin and the underlying TRAMflap Figure 2.

Discussion

Patient selection

� In women with mammary hyperplasia undergoing skin-sparing mastectomy, the redundant inferior pole skin

Figure 1. Pre-operative image demonstrating the large ptotic left breast and

previous right mastectomy scar & post-operative image at six months.

674 N. Haydon et al. / EJSO 40 (2014) 673e675

flap can be utilised to auto-augment the breast ratherthan being excised

� This dermal flap has been described in alloplastic breastreconstruction to provide a stable soft-tissue cover forthe tissue expander/implant and allows a larger pocketto be created with less tension in the inferior pole.1

The utilisation of the de-epithelised inferior pole breastskin as an ‘auto-prothesis’ has also been described dur-ing superior pedicle mastopexy.2

� This report describes the use of the ‘imbricated dermalflap’ for augmentation of an autologous breast reconstruc-tion (TRAM), but it can also be used for any other autolo-gous reconstruction when there is a larger breast withlonger NAC to IMF distance and larger skin envelope.

Advantages

� This auto-prosthesis acts as a buttress in the inferior poleof the breast, adding volume to the breast, enhancingprojection and the aesthetic curve of the inferior pole.

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.

It adds negligible time to the procedure and is very reli-able with a broad base.

� Another technique, the Wise-pattern skin reducing mas-tectomy, creates a dermal sling from the lower half ofbreast skin and is used instead of the ‘imbricated dermalflap’ when there is too much skin redundancy and aNAC to IMF distance of >7 cm. The ‘imbricated dermalflap’ is indicated for moderate sized breasts and may bejudged on the table once the flap volume and skin enve-lope is assessed. It’s benefits over the Wise-pattern tech-nique in these patients are; shorter scars, less chance ofdamage to the superficial vascular plexus, and avoidswound healing issues at the T-junction.

� The dermal sling technique uses de-epithelialised redun-dant breast envelope to complete the submuscular pocketand provides infero-lateral coverage and support to implantor tissue expander.3 The ‘imbricated dermal flap’ similarlyutilises inferior pole de-epithelialised skin, preserving thedermal plexus. It is not necessary for flap coverage in thisinstance but does provide a degree of support, improvesprojection and overall breast aesthetics.

Disadvantages

� The sole disadvantage of this approach is increased scar-ring similar to vertical breast reduction pattern, howeverthis is usually well tolerated. In patients with diabetes,previous radiotherapy and smokers, one need be mindfulof the flap vascularity and it may be prudent to reducethe flap dimensions.

Pitfalls

� In regard to the vascularity of the dermal flap, care dur-ing de-epithelisation preserves the dermal vascularplexus. Once the imbricated dermal flap is buried it isnot possible to monitor the viability of the flap, so thisneeds to be well established prior to closure. Closureof the elliptical edges involves only the superficialdermis of the flap so as to avoid damaging the deepdermal vascular plexus.

Conclusion

Our technique describes de-epithelialising redundantinferior pole mastectomy skin in a vertical breast reduc-tion pattern and burying the resulting dermal flap anteriorto the newly created breast mound to improve projectionand breast aesthetics. In women with medium to largeptotic breasts undergoing immediate reconstructionfollowing mastectomy the ‘imbricated dermal flap’ offersan autologous augmentation of the newly created inferiorpole.

675N. Haydon et al. / EJSO 40 (2014) 673e675

Conflict of interest

None identified.

Funding

None.

Ethical approval

Not required.

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–

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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.