Keywords
breast mound - ptosis - reconstruction - skin flap - sponge
Introduction
Breast reconstruction using autologous tissue after mastectomy is widely performed,
and breast symmetry is important for patient satisfaction. However, it is often difficult
to reproduce the symmetry of ptotic breasts owing to the insufficient volume of the
skin flap, the need to fix the skin flap on the cephalic side because of the vascular
anastomotic position, and inaccurate evaluation of the bilateral ptotic morphology
because of intraoperative posture problems.
To reproduce ptotic breasts, the skin flap volume has been increased or decreased,
and healthy breasts have been modified[1]
[2]; however, these methods are not minimally invasive. In Japan, revision surgery for
healthy breasts is not often performed owing to the psychological resistance to inserting
a scalpel in healthy tissue; additionally, it is not covered by insurance.
We developed and applied a novel method comprising early postoperative upper edge
dissection under local anesthesia and sponge compression for the downward correction
of the reconstructed breast mound after the primary two-stage reconstruction of ptotic
breasts.
Idea
We applied a method of downward correction comprising early postoperative upper margin
dissection under local anesthesia and sponge compression for the reconstructed breast
mound of four patients from 2017 to 2020. Primary two-stage ptotic breast reconstruction
was performed with an abdominal free flap for three patients, with a pedicle latissimus
dorsi flap for one patient. The anastomotic position (internal thoracic artery and
vein) in the reconstruction with an abdominal free flap was positioned cranially so
that the reconstructed breast mound was positioned above the contralateral side in
all cases. The pedicle latissimus dorsi flap was misplaced, causing the reconstructed
breast mound to be positioned above the contralateral side.
For two patients, we performed a revision procedure with upper margin dissection under
local anesthesia 3 weeks postoperatively ([Fig. 1A]). For three patients, sponge compression was applied from the head of the reconstructed
breast ([Fig. 1B]). For one patient, both procedures were applied. All patients had worn a corrective
brassiere for a year after flap transfer. We measured the downward movement of the
reconstructed breast mound with respect to its inferior margin with four patients
treated with this method. The xiphoid process was the reference point for the measurements.
Fig. 1 A comprehensive explanation and illustration showing the surgical procedure of early
flap dissection and compression. (A) We removed the fixation threads from the upper border of the flap by approaching
the upper skin suture line under local anesthesia and performed dissection around
the fixed skin flap. Refixation of the flap was not performed. The green area shows
the area of early flap dissection, and the dotted line shows the margin of the transferred
flap. (B) A sponge (Reston pad®; 3M, St. Paul, MN) is placed on the upper pole of the reconstructed
breast mound, and a breast band is placed over the sponge to compress and fix the
reconstructed breast mound downward. The blue area shows the area of compression using
the sponge, and the dotted line shows the margin of the transferred flap.
Patient characteristics and the results of all present cases are shown in [Table 1]. No complications were observed postoperatively. The reconstructed breast mounds
spontaneously and gradually dropped, and just right downward shifts were achieved;
consequently, all cosmetic results were much improved ([Figs. 2]
[3]
[4]
[5]). Furthermore, we also measured postoperative caudal skin flap migration 2 years
postoperatively with respect to the inferior margin of the reconstructed breast in
randomly selected cases involving transverse rectus abdominis musculocutaneous flaps
combined with tissue expander that were not indicated for our downward correction
method. For these cases, only corrective undergarments that held the entire reconstructed
breast in place were used for 6 months. The results are shown in [Table 2]. We compared the present four cases with these cases, and patients treated with
this method had more downward displacement of the flap than did patients treated without
this method.
Table 1
Patient characteristics and results of downward movement of reconstructed breast mound
in cases in which our method was performed
|
Breast size[a]
|
Regnault classification
|
Body mass index (kg/m2)
|
Kinds of flap used
|
Start date of upper margin dissection of the flap (A) or pressure correction (B)
|
Period of postoperative pressure correction with a sponge
|
Distance difference immediately after flap transfer (cm)
|
Distance difference immediately after upper margin dissection of the flap (cm)
|
Distance difference 2 years postoperatively
|
|
Case 1
|
Large
|
Grade 3
|
25.8
|
DIEP/TRAM
|
A: 3 weeks after flap transfer
|
–
|
2.5
|
1
|
0 cm
|
|
Case 2
|
Large
|
Grade 1
|
29.2
|
DIEP
|
B: 1 month after flap transfer
|
5 months
|
2
|
–
|
0 cm
|
|
Case 3
|
Medium
|
Grade 2
|
23.7
|
TRAM
|
A: 3 weeks after flap transfer
B: 1 month after flap transfer
|
5 months
|
3
|
1.5
|
0 cm
|
|
Case 4
|
Medium
|
Grade 1
|
26.0
|
LD
|
B: 3 weeks after flap transfer
|
3 months and 1 week
|
2
|
–
|
−0.5 cm
|
Abbreviations: DIEP; deep inferior epigastric perforator flap; LD; latissimus dorsi
musculocutaneous flap; TRAM; transverse rectus abdominis musculocutaneous flap.
Distance difference: distance difference between the lower edge of the breast mound
of the reconstructed side and that of the healthy side (+, the former is higher than
the latter, −, the former is lower than the latter).
a Small, A or B cup; medium, C or D cup; large, E cup or larger.
Fig. 2 Progression of case 1. (A) At 2.5 weeks postoperatively, the height of the upper margin of the reconstructed
breast and peak protrusion of the reconstructed breast are higher than those of the
healthy side. (B) Photograph after upper margin dissection and 1.5 years postoperatively.
Fig. 3 A photo of case 2. Photograph of downward pressure correction using a sponge, which
was started 1 month postoperatively.
Fig. 4 Progression of case 3. (A) At 3 weeks postoperatively, the height of the upper margin of the reconstructed
breast and peak protrusion of the reconstructed breast are higher than those of the
healthy side. (B) The patient underwent upper margin dissection at 3 weeks postoperatively. (C) Photograph obtained 1 week after upper margin dissection. (D) Photograph after upper margin dissection and subsequent pressure correction using
a sponge at 2 years postoperatively.
Fig. 5 A photo of case 4. This photograph was obtained when downward pressure correction
using a sponge was started 1 month postoperatively.
Table 2
Downward movement of reconstructed breast mound in cases in which our method was not
performed
|
Breast size[a]
|
Grade of Regnault classification, means (range)
|
Body mass index (kg/m2), means (range)
|
Distance difference immediately after flap transfer, means (range)
|
Distance difference 2 years postoperatively, means (range; cm)
|
|
Comparative group 1, N = 10
|
Small
|
0.0 (0–0)
|
20.3 (18.1–22.3)
|
0.7 (0.2–0.9) cm
|
−0.2 (−0.8 to 0.4)
|
|
Comparative group 2, N = 10
|
Medium
|
0.8 (0–2)
|
23.8 (22.0–25.4)
|
0.9 (0.4–1.1) cm
|
−0.2 (−0.7 to 0.3)
|
|
Comparative group 3, N = 10
|
Large
|
1.9 (1–3)
|
25.6 (23.1–30.3)
|
1.1 (0.7–1.3) cm
|
−0.3 (−0.6 to 0.3)
|
Distance difference: distance difference between the lower edge of the breast mound
of the reconstructed side and that of the healthy side (+, the former is higher than
the latter; −, the former is lower than the latter).
a Small, A or B cup; medium, C or D cup; large, E cup or larger.
Written informed consent was obtained from all patients for the publication of this
article and accompanying images.
Discussion
The initial corrective procedure that is commonly performed to achieve stronger expression
of the ptotic morphology of the reconstructed breast mound comprises the reduction
of cephalic fat and the addition of caudal fat of the reconstructed breast. The former
involves liposuction or direct visual fat removal,[3] whereas the latter involves fat injection grafting. Additionally, when a large increase
in volume, including that of the skin, is required, another skin flap, such as the
latissimus dorsi flap, intercostal artery perforator flap, or anterolateral thigh
flap, may be implanted.[4] In contrast, mastopexy or reduction mammaplasty may be performed to reduce the degree
of ptosis of the healthy breast,[1] and these methods may be performed in combination with the aforementioned reconstructive
breast surgery. These procedures are necessary if the volume of the reconstructed
breast mound is deficient compared with that of the healthy breast. However, if the
total volume of the reconstructed breast mound is approximately equal to that of the
healthy breast volume, then these procedures may be invasive; nevertheless, no minimally
invasive correction method has been reported.
For cases 1 and 3, we performed a revision procedure with upper margin dissection
under local anesthesia 3 weeks postoperatively, when the flap blood flow was stable,
and the flap adhesion to pectoralis major muscle seemed relatively mild. We believe
that removing the upper border threads and flap dissection of upper pole facilitates
caudal migration of the flap to create a drooping effect. This operative technique
is minimally invasive, easy, and effective. No similar procedure has been reported.
For cases 2, 3, and 4, at 1 month postoperatively, sponge compression with a breast
band was applied in the upper pole of the reconstructed breast until 4 to 6 months
postoperatively. Compression for flap repositioning of breast mound after breast reconstruction
by autologous tissue transfer may be clinically applied; however, there have been
no high-quality reports with detailed progress notes of this method. Compression therapy
using a sponge is often used to reduce the elevation of keloids and hypertrophic scars.[5] In the present cases, the sponge was used to apply continuous pressure to the cephalic
side of the reconstructed breast mound to allow gradual caudal migration. The sponge,
which was thick, slightly firmer, and slightly elastic, was considered more effective
for sustained pressure. One advantage of sponges is that they are inexpensive and
can be used repeatedly. Certainly, this technique is also minimally invasive, easy,
and effective, similar to our revision procedure for upper margin dissection.
A corrective brassiere that is designed to hold the breast in place is often used
to prevent abnormal downward and lateral deviations of the reconstructed breast. Its
effectiveness and importance have been advocated in Japan.[6] In the present cases, we suppose it contributed to preventing the downward migration
of the inframammary fold (IMF). Additionally, a breast band may be worn around the
upper edge of the breast to prevent upward deviation of the reconstructed breast mound
during expander insertion or for breasts reconstructed with implants. In the present
cases, a breast band was used for compression and fixation of the sponge. The breast
band is an excellent fixation device that is inexpensive (approximately $15), can
be used repeatedly, and has a fixation force that can be easily adjusted with hook-and-loop
tape to apply pressure to the sponge without shifting.
A downward shift of approximately 1.5 cm was achieved immediately after revision surgery
under local anesthesia. However, a downward shift of approximately 2 cm was achieved
by sponge compression alone, and a downward shift of approximately 3 cm was achieved
by the combination of dissection and compression. No complications, such as skin flap
damage, were observed. We reviewed previous cases of breast reconstruction followed
by the use of corrective brassieres alone and found that the average downward migration
distance was 1 cm in the small breasts group, 1.1 cm in the medium breasts group,
and 1.4 cm in the large breasts group ([Table 2]). The results suggested that this method contributed to more downward displacement
of the flap. This method may be applied appropriately when the lower edge of the reconstructed
breast mound is 2 cm higher than that of the contralateral breast mound, the total
flap volume is approximately equal to the volume of the contralateral breast, and
the height of the upper margin of the flap and most prominent part of the skin flap
is located higher than the contralateral side. A revision procedure with upper margin
dissection may be applied when the lower edge of the reconstructed breast mound is
2.5 cm higher than that of the contralateral breast mound. Additionally, when applying
this method, we recommend the reconstructed breast mound should be firmly supported
by corrective brassiere to prevent an IMF left–right difference and the duration of
sponge compression over the upper pole of the reconstructed breast should be adjusted
flexibly according to morphological changes. Since our method was employed only in
four cases, a larger case series is required to confirm these results, and the appropriate
timing of the upper margin dissection of the flap should be considered. Furthermore,
individual differences regarding the detailed surgical procedure, skin elasticity,
flap weight, and flap atrophy or in the rate of thoracic skin expansion may have affected
postoperative results, and this should be considered.
In conclusion, we performed early postoperative flap dissection and sponge compression
under local anesthesia to move the reconstructed breast mound downward in four patients
with ptotic breasts who underwent primary two-stage reconstruction with flap transfer.
Consequently, an average downward shift of 2.5 cm (with regard to the inferior margin
of the breast) of the breast mound was achieved.
Although it is often difficult to correct an upwardly positioned reconstructed breast
mound, this useful, minimally invasive, convenient, and inexpensive technique resulted
in satisfactory outcomes. Furthermore, we believe that the combination of early postoperative
upper edge dissection and sponge compression provides a greater corrective effect.
