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The Breast (2004) 13, 502–505

THE

BREAST

KEYWORDBreast-consurgery;BreastreconstrucBreast red

0960-9776/$ - sdoi:10.1016/j.b

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Wise pattern mastectomy with immediate breastreconstruction

P. Prathap�, R.N.L. Harland

Department of General Surgery, Royal Albert Edward Infirmary, Wigan Lane, Wigan, WN1 2NN, UK

Received 1 April 2004; received in revised form 8 June 2004; accepted 28 July 2004

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ee front matter & 2004reast.2004.07.008

ng author. Tel.: +44 194ess: prathap64@aol.com

Summary A new technique of immediate breast reconstruction is presented.This technique uses a silicone implant placed in a subpectoral pocket, usingde-epithelialised skin from the lower breast to augment the submuscularpocket, thus producing a compound myodermal flap. The technique is simple,and the resulting scar is cosmetically satisfactory; when combined with reduc-tion mammoplasty on the opposite breast, this technique produces satisfactorybreast symmetry.& 2004 Elsevier Ltd. All rights reserved.

Introduction

Since the introduction of breast-conserving surgery,the incidence of mastectomy has been on thedecline. Nonetheless, it is still inevitable in somewomen. Breast reconstruction is being offered tomore and more of these women, with an increasingproportion of surgeons supporting breast recon-struction after mastectomy.1 The lower psycholo-gical morbidity when reconstruction is performedimmediately after mastectomy is well documen-ted.2,3 That the aesthetic results of reconstructionperformed immediately after mastectomy arebetter than the results obtained with delayedreconstruction is well documented.4

Elsevier Ltd. All rights reserv

2822246.(P. Prathap).

There is a wide choice of reconstructive techni-ques. Breast implants were first used for postmas-tectomy reconstruction in 19655 and offer bothspeed and simplicity. Placement of these implantsin the submuscular plane is associated with fewercomplications than the placement of subcutaneousimplants6,7 and does not delay detection of anycutaneous and/or subcutaneous recurrence.8 Re-duction of the contralateral breast is still needed inmost cases to achieve symmetry.

A new technique of immediate breast reconstruc-tion is described in this paper, which avoidsmultiple procedures associated with the use oftissue expanders and the scarring associated withmyocutaneous flaps. A well-defined inframammaryfold is produced, and this avoids placement of theimplant under the skin incision. Contralateralbreast reduction done at the same time allowsthe achievement of breast symmetry.

ed.

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Wise pattern mastectomy with immediate breast reconstruction 503

Methods

Patient selection

This procedure was carried out in six patients withtumours that were not attached to skin or to thechest wall. Central/subareolar tumours and tu-mours in the upper half of the breast were judgedto be the most suitable for treatment with thisprocedure. Tumours in the lower half of the breastwere regarded as unsuitable. All patients werecandidates for contralateral reduction for symme-try. Patients were given information about otherforms of reconstruction, and only those willing tohave smaller breasts were selected.

Operative technique

The skin incisions are marked in a Wise pattern9

prior to surgery, as illustrated in Fig. 1, with thepatient sitting up.

The first point to be defined (point A) is theposition of the nipple in the reconstructed breast,which is determined according to the usual refer-ence points of inframammary line, suprasternalnotch and median line. Two lines each 8 cm long aredrawn caudally from this point about 701 apart topoints B and B0. Lines are then drawn from points Band B0 to two further points (C and C0), which are

Figure 1 (a) Point A represents the projected position of thethe lines along which skin incisions are made. The ellipse of skthe de-epithelialised skin flap is sutured to the freed lower boflap. The implant is placed in this pocket and held in place byby suturing the edges of the upper flap over the de-epithelia

equidistant from the median line of the breast atpoint D. These points will be above the existinginframammary line medially and laterally when thepatient is supine. The patients were also markedfor contralateral breast reduction, with the mainreference point being a matching position for thenipple.

An ellipse of skin represented by the shaded areain Fig. 1 is de-epithelialised. The skin incisions aremade as shown in Fig. 1, and the inferior flap israised first to give a semilunate flap of vascu-larised, de-epithelialised dermis. The superior flapis raised next, and a routine mastectomy withaxillary clearance is carried out.

The inferior origin of the pectoralis major isseparated from the chest wall by sharp dissection.Blunt dissection is then used to create a spacebehind the muscle. The edge of the de-epithelia-lised skin flap is sutured to the lower border of thepectoralis major muscle with 2/0 vicryl continuoussutures as far laterally as possible.

The inside of the de-epithelialised flap is suturedto the chest wall along the line of the inframam-mary fold with interrupted stitches. This preventscaudal migration of the implant.

The lateral contour is recreated by insertinginterrupted stitches tacking the inside of the skinflap to the lateral chest wall. Further stitchesbetween the inner aspect of the upper flap and thechest wall along the anterior axillary line may be

new nipple. Lines A–B, A–B0, B–C, B–C0 and C–C0 representin enclosed by C–C0–D is de-epithelialised. (b) The edge ofrder of the pectoralis major to produce a large compositea lateral tacking stitch as indicated. The wound is closedlised flap as shown, along C–D–C0.

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P. Prathap, R.N.L. Harland504

necessary later to enhance this contour. This isdone after placement of a temporary sizer in thesubmuscular pocket. The skin incision is closedtemporarily with skin staples.

A standard breast reduction is carried out on theopposite side. Any excised areolar skin is kept insterile saline solution for possible use later.

Figure 2 The breast at completion of surgery. The right brreconstructed breast.

Figure 3 Follow-up photographs. The right breast has b

The patient is placed in a sitting position toassess the symmetry of the breasts, the temporarysizer being replaced if necessary to determine theoptimum size of the prosthesis.

Two suction drains are placed, the medial onedraining the subcutaneous space and the lateralone, the axilla.

east has been reduced to match its size to that of the

een reconstructed, and the left has been reduced.

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Figure 4 Follow-up photographs. The right breast has been reconstructed, and the left has been reduced.

Wise pattern mastectomy with immediate breast reconstruction 505

The appropriate size for the textured siliconeprosthesis is selected, and after insertion of theprosthesis into the pocket one or two interruptedstitches are placed between the lateral chest walland the pectoralis major or de-epithelialised skinflap to close any space between the prosthesis andthe axilla.

The skin incision is closed with an intradermal 3/0 vicryl suture to produce an inverted ‘T’-shapedscar (Figs. 2–4).

Spare areolar skin from the reduced breast canbe used as a full-thickness graft at the new nipplesite on the reconstructed breast to provide thebasis of a nipple reconstruction at this time ifdesired.

Results

The six patients treated with this procedure havenow been followed up for a median of 5 years.

One patient developed Baker IV capsular con-traction after primary radiotherapy for high riskdisease. This was successfully treated by capsulot-omy. No other significant complications haveoccurred in any of the patients who have undergonethis procedure.

Discussion

We have been able to achieve acceptable breastsize and symmetry with this technique. We have

not encountered any complications. Though tried inonly a small number of patients, the technique hasyielded promising results, and with the increasingemphasis on breast conservation and more demandfor immediate breast reconstruction, this couldbecome yet another reconstruction technique thatcan be frequently used in suitable patients.

References

1. Spyrou GE, Titley OG, Cerquerio J, Fatah MFT. A survey ofgeneral surgeon’s attitudes towards breast reconstructionafter mastectomy. Ann R Coll Surg Engl 1998;80:178–83.

2. Francel TJ, Ryann JJ, Manson PN. Breast reconstructionutilizing implants: a local experience and comparison of threetechniques. Plast Reconstr Surg 1993;92:786–94.

3. Schain WS. Breast reconstruction: update of psychologicaland pragmatic concerns. Cancer 1991;68:1170–4.

4. Kroll SS, Coffey JA Jr, Winn RJ, Schusterman MA. Acomparison if factors affecting aesthetic outcomes of TRAMflap reconstruction. Plast Reconstr Surg 1995;96:860–4.

5. Corsten LA, Suduikis SV, Donegan WL. Patient satisfactionwith breast reconstruction. Wis Med J 1992;125–9.

6. Woods JE, Irons GB, Arnold PG. The case for submuscularimplantation of prosthesis in reconstructive breast surgery.Ann Plast Surg 1980;5:115–22.

7. Artz JS, Dinner MI, Foglietti MA, Sampliner J. Breastreconstruction utilizing subcutaneous tissue expansion fol-lowed by polyurethane covered silicone implants: a 6-yearexperience. Plast Reconstr Surg 1991;88:635–9.

8. Johnson CH, van Heerden JA, Donahue JH, Martin JK, JacksonIT, Ilstrup DM. Oncological aspects of immediate breastreconstruction following mastectomy for malignancy. ArchSurg 1989;124:819–24.

9. Robert J. Wise. Plast Reconstr Surg 1956;17:367–75.