Improving Equipment Setup While Preparing Acellular Dermal Matrix during Prepectoral Breast Reconstruction.

Prosthetic breast reconstruction remains one of the most frequently performed procedures in plastic surgery. Two-stage and one-stage implant-based reconstruction are both commonly offered with varying amounts of acellular dermal matrix (ADM) use dependent on surgeon preference. Advantages of ADM include potential lower incidence of capsular contracture, improvement in implant coverage particularly in the lower pole, and increased ability to define placement of the inframammary fold and expander/implant position.[1-3]

The dual-plane approach continues to be the most commonly performed method of implant-based breast reconstruction. However, recently, there has been increased use of prepectoral techniques in an effort to minimize undesired muscle animation deformity, morbidity related to muscle dissection, and operative time.[1] Commonly, ADM is used to wrap the expander/implant to ensure coverage of the anterior surface of the implant at minimum, usually requiring at least 2 ADM pieces sutured together. In an effort to decrease operating time and increase operating room ergonomics, we developed a safe and effective equipment setup technique for use during ADM preparation. This setup allows suturing of the ADM pieces to one another before wrapping of the expander or implant and placement inside the postmastectomy breast pocket.

Two pieces of ADM are opened and prepared in standard fashion on a sterile back table and stacked on top of each other, aligning the edges to ensure the “rough” dermal surface of each piece of ADM oppose one another. This in turn ensures the “smooth” surfaces of each ADM piece remain exposed on the outside surfaces. With 2 small sharp towel clamps, one at each end of the stacked ADM construct, the pieces of ADM are suspended using 2 additional Kelly clamps (or similar) attached to a large sterile plastic basin (Fig. 1). Tension can be adjusted accordingly by moving the towel clamps or Kelly clamps as desired. In this new suspended position, the 2 pieces of ADM can be sutured together quickly with minimal manipulation and handling of the ADM itself (Fig. 2). Once suturing is complete, the construct can be quickly taken down to perform subsequent steps including wrapping of the expander/implant, which we also perform on the sterile back table. Our technique ensures that all suture knots remain on the inner surface, along the implant surface interface, once the expander/implant is wrapped and secured.

Fig. 1.

Setup using the presented technique to suture 2 pieces of ADM before wrapping of prosthesis during prepectoral breast reconstruction. Two towel clamps are used at each end of the ADM pieces to suspend from a sterile basin.

Fig. 2.

Intraoperative photograph showing 2 pieces of ADM sutured together while suspended by towel clamps at each end.

Prepectoral breast reconstruction provides many clinical advantages. Our technique has allowed surgeons to continue preparing the ADM simultaneously during the mastectomy portion of immediate breast reconstruction cases while decreasing operating time and minimizing traumatic handling of the ADM. In addition, the benefits of surgeon ergonomics increase dramatically.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.