Improving Outcome in Immediate Alloplastic Breast Reconstruction, an Algorithm for Operative Decision Making.

Supplemental Digital Content is available in the text.

Implant-based breast reconstruction presently comprise the lion’s share of postmastectomy reconstructions,[1] reflecting among other factors the increased requirement of bilateral reconstruction, the taxing requirements of autologous reconstruction, and financial implications thereof.[2] Difficult to predict, the aesthetic outcome of immediate, postmastectomy, alloplastic breast reconstruction, may vary considerably across patients, especially in cases of skin-sparing or nipple-sparing surgery.[3-5]

The end-result skin flap viability and the dimensions of the resulting reconstructed breast skin envelope, which it defines, are challenging to assess during the initial operation,.[6-12] Arguably, this warrants better means of preoperative and intraoperative assessment and decision making.[13-15] We present here a possible tool as such, in the form of a simple algorithm, to improve the final outcome of breast reconstruction.

In any breast contouring surgery, reconstructive and aesthetic, correctly adjusting volume to skin envelop is paramount to creating an aesthetic and proportional breast mound.[2,6-8,15-27]

Our proposed algorithm for immediate alloplastic breast reconstruction hinges on 3 key factors (Fig. 1):

Fig. 1.

Proposed algorithm for immediate alloplastic breast reconstruction.

The patient habitus

The planned envelope

The remaining viable skin flaps following mastectomy.

PRESURGICAL PRINCIPLES

Discussing with the patient, it is important to determine the desired size and shape of the reconstructed breast in comparison with its preoperative form. Where a larger breast is desired, a 2-stage reconstruction is planned using a tissue expander. If a smaller breast is intended, an envelope reduction procedure may be required following completion of mastectomy. When the remaining envelope matches the planned size and shape of the desired breast a “direct to implant” procedure can be performed.

INTRAOPERATIVE PRINCIPLES

Following mastectomy, an implant pocket is created in a submuscular plane, raising a pectoralis major flap and utilizing an ADM to complete the inferior pole of the pocket as needed. The final desired implant is selected with regard to the final desired breast mound, via planning an appropriate sizer in said pocket. The skin envelope is then assessed for viability. If a sufficient viable envelope is uncertain, a 2-stage reconstruction will be performed via tissue expansion.

Given a sufficient envelope, the reconstructed breast is evaluated via a sizer in several key stages (ie, after mastectomy, after elevation of the pectoralis flap, and after creation of the final submuscular implant-pocket), allowing the surgeon to modify the skin envelope or the muscle coverage according to the desired shape and size before closure over the final implant (see video, Supplemental Digital Content 1, which discusses how to improve outcome in alloplastic breast reconstruction. This video is available in the “Related Videos”section of Full-Text article at PRSGlobalOpen.com or at http://links.lww.com/PRSGO/A811).

See video, Supplemental Digital Content 1, which discusses how to improve outcome in alloplastic breast reconstruction. This video is available in the “Related Videos”section of Full-Text article at PRSGlobalOpen.com or at http://links.lww.com/PRSGO/A811.

Notably the key novelty of our algorithm (as compared with the common practice reflected by recent literature) is that the implant is selected only with regard to the desired final breast mound, whereas the skin envelope is assessed afterward, having placed an appropriate submuscular sizer, electing the next step in reconstruction accordingly as mentioned.

None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this article.