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Immediate reconstruction using inframammary adipofascial flap of the anterior rectus sheath after partial mastectomy
The American Journal of Surgery 193 (2007) 789 –791
How I do it
Immediate reconstruction using inframammary adipofascial flap of the anterior rectus sheath after partial mastectomy Yuko Kijima, M.D.*, Heiji Yoshinaka, M.D., Tetsuhiro Owaki, M.D., Yawara Funasako, M.D., Takashi Aikou, M.D. Department of Surgical Oncology, Breast and Endocrine Surgery, Kagoshima University Graduate School of Medical and Dental Sciences 8-35-1, Sakuragaoka, Kagoshima 890-8520, Japan Manuscript received April 15, 2006; revised manuscript June 28, 2006
Abstract Treatment of early breast cancer using breast conservative therapy (BCT) usually ensures local control and acceptable cosmetic results. To repair defects caused by partial mastectomy in the lower region of the breast, some reconstruction should be used. We developed a procedure involving the cranial based adipofascial (anterior rectus sheath) flap from immediately below the inframammary area for the reconstruction of defect due to partial mastectomy for patients with early breast cancer. In this procedure, a skin incision is made at the inframammary line, and the inframammary skin area is undermined. A tongue shaped flap composed of the subcutaneous fat and the anterior sheath of rectus abdominis muscle is pulled up and a C-shaped flap is rotated, gathered, and inserted to reconstruct the breast defect. © 2007 Excerpta Medica Inc. All rights reserved. Keywords: Breast cancer; Breast conservative therapy; Technique; Immediate reconstruction; Adipofascial flap; Cosmetic results
Breast conservative therapy (BCT) has become a standard strategy for breast cancer and ensures local control and acceptable cosmetic results [1]. However, an insufficient resection margin may increase local recurrence if too much attention is paid to cosmesis. Immediate reconstruction after BCT has thus become increasingly popular even for earlystage breast cancer [2,3]. Compared with Western women, the breasts of Asian women, including Japanese, are commonly too small to maintain symmetry even after partial resection. Use of pedicle dermal-fat graft for defect reconstruction has proven useful for defects of the breast after mastectomy [4,5]. These techniques are useful for fatty patients who have excessive skin at the inframammary region with large breasts; however, it is difficult for patients with slim bodies and small breasts, like Japanese women. Here, we describe a simple technique for reconstruction of the defect on the lower part of the breast in 2 patients with early breast cancer using inframammary adipofascial flap without dermis.
* Corresponding author. Tel.: ⫹81-99-275-5361; fax: ⫹81-99-265-7426. E-mail address: [email protected]
Technique The curved incision is at the inframammary line. The tumor is removed with gross margins of 3 cm. No skin is removed unless leaving the skin would compromise the superficial margin. Fascia of the pectoral muscle is removed. The harvesting and implantation of the inframammary adipofascial flap involves 4 steps: (1) harvesting a tongue-shaped flap of fat and the anterior sheath of the rectus abdominis muscle; (2) pulling up the flap to the cranial defect; (3) trimming or gathering the flap to adjust to the shape of the contralateral breast; and (4) fixing the flap to the edge of remnant gland (Fig. 1). Even if the patient is not obese, we can obtain a large amount of fat. Attaching the sheath of the muscle to the adipose tissue makes the harvested tissue firm. We pull up, roll, or gather it to reconstruct the breast mound and to adjust the size of the contralateral breast. Fixation to the edge of the remnant gland was performed using polydioxane (PDS II; Ethicon, Inc, Somerville, NJ). For patients with an early breast lesion located in the lower outer region, we used a slightly different technique. We obtained a C-shaped flap and rotated it toward the cranial defect. Fixation was added between the flap and the remnant gland in the same manner as described above. A continuous closed suction drainage tube was added to the subcutaneous defect at the donor site for two days after the operation.
0002-9610/07/$ – see front matter © 2007 Excerpta Medica Inc. All rights reserved. doi:10.1016/j.amjsurg.2006.06.052
790
Y. Kijima et al. / The American Journal of Surgery 193 (2007) 789 –791
Fig. 1. Procedure for harvesting the tongue-shaped adipofascial flap and repair of the defect (case 1). (A) Using the same skin incision at the inframammary line, partial resection of the breast can be performed to obtain the adipofascial flap. Attaching the sheath of the muscle to the adipose tissue makes the harvested tissue firm. (B) The tongue-shaped flap was harvested. (C) The flap is pulled up to the cranial side to fill the defect. We sometimes roll or gather the flap to reconstruct the breast mound.
Comments In the 1980s, BCT rapidly became a first-line procedure for early-stage breast cancer, and ensures local control and acceptable cosmetic results [1,6]. Insufficient resection mar-
gins that occur from paying too much attention to cosmesis may increase local recurrence, and determining the amount of breast tissue that must be removed to obtain histologically negative margins is difficult. Early research suggested
Fig. 2. A 36-year-old woman with breast cancer located on the lower inner quadrant of the right breast (case 1). (A) The resected area of the breast was marked in the supine position with a gross margin of 3 cm. A tongue-shaped adipofascial flap was designed with the length of 8 cm. (B) Six months postsurgery. The deformity of both breast and donor site is inconspicuous.
Y. Kijima et al. / The American Journal of Surgery 193 (2007) 789 –791
791
Fig. 3. A 46-year-old woman with breast cancer located on the lower outer quadrant of the right breast (case 2). (A) An adipofascial flap was designed to be harvested in a C shape. (B, C) Ten months postsurgery.
that conservation or restitution of the breast might mitigate the negative effects of breast cancer on the sexual wellbeing of women, and cosmetic results exert a marked effect on subsequent psychological outcomes [7,8]. Japanese women typically have small breasts, and symmetry can be difficult to maintain when a tumor is located in the lower region of the breast, even with only partial resection. Removing a relatively large part of the whole breast can thus have a considerable impact on poor cosmetic outcome. BCT therefore cannot always provide satisfactory cosmetic results in patients with small breasts. Wide local excision without immediate volume replacement is associated with breast retraction leading to cosmetic failure in one third of patients [9]. Use of pedicle dermal-fat graft for reconstruction of the breast has been proven for Western patients who received subcutaneous mastectomy [4,5]. It seemed to be useful for women with large breasts, excessive skin on the inframammary area, and rich fatty tissue. Sakai et al used this technique to reconstruct the breast for Japanese patients with subcutaneous mastectomy [10]. They concluded that this technique was safely performed and that excellent outcomes were obtained. They also reported that the ideal patients were those that received subcutaneous mastectomy, reserved skin and nipple-areola complex, and whose contralateral breast was not too large. We modified this technique for patients with BCT to repair the defect immediately. We observed cystic degeneration of the graft by ultrasonographical examination 10 months after the operation; however, good cosmetic results and softness of the breasts was obtained without fat necrosis, volume loss, or firmness and contour irregularity (Figs. 2 and 3). This tech-
nique provides excellent cosmetic results even when it is performed by a breast surgeon instead of a plastic surgeon. Immediate volume replacement using the adipofascial flap at the time of BCT on the lower region can be useful with good cosmetic effect, particularly for patients with small breasts, such as Japanese women. References [1] Fisher B, Anderson S, Redmond CK, et al. Reanalysis and results after 12 years of follow-up in a randomized clinical trial comparing total mastectomy with lumpectomy with or without irradiation in the treatment of breast cancer. N Engl J Med 1995;333:1456 – 61. [2] Berrino P, Campora E, Santi P. Post-quadrantectomy breast deformities: classification and techniques of surgical correction. Plast Reconstr Surg 1987;79:567–72. [3] Cooperman AM, Dinner M. The rhomboid flap and partial mastectomy. Surg Clin North Am 1978;58:869 –73. [4] Longacre JJ. Correction of the hypoplastic breast with special reference to reconstruction of the “nipple type breast” with local dermo-fat pedicle flap. Plast Reconstr Surg 1954;14:431– 41. [5] Maliniac JW. Use of pedicle dermo-fat flap in mammaplasty. Plast Reconstr Surg 1953;12:110 –15. [6] Fisher B, Anderson SA, Bryant J, et al. Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. J Engl J Med 2002;347:1233– 41. [7] Rowland JH, Desmond KA, Meyerowitz BE, et al. Role of breast reconstructive surgery in physical and emotional outcomes among breast cancer survivors. J Natl Cancer Inst 2000;92:1422–9. [8] Al-Ghazal SK, Fallowfield L, Blamey RW. Does cosmetic outocome from treatment of primary breast cancer influence psychosocial morbidity? Eur J Surg Oncol 1999;25:571–3. [9] Raja MAK, Straker VF, Rainsbury RM. Extending the role of breastconserving surgery by immediate volume replacement. Br J Surg 1997;84:101–5. [10] Sakai S, Suzuki I, Izawa H: Adipofascial (anterior rectus sheath) flaps for breast reconstruction. Ann Plast Surg 1992;29:173–7.
How I do it
Immediate reconstruction using inframammary adipofascial flap of the anterior rectus sheath after partial mastectomy Yuko Kijima, M.D.*, Heiji Yoshinaka, M.D., Tetsuhiro Owaki, M.D., Yawara Funasako, M.D., Takashi Aikou, M.D. Department of Surgical Oncology, Breast and Endocrine Surgery, Kagoshima University Graduate School of Medical and Dental Sciences 8-35-1, Sakuragaoka, Kagoshima 890-8520, Japan Manuscript received April 15, 2006; revised manuscript June 28, 2006
Abstract Treatment of early breast cancer using breast conservative therapy (BCT) usually ensures local control and acceptable cosmetic results. To repair defects caused by partial mastectomy in the lower region of the breast, some reconstruction should be used. We developed a procedure involving the cranial based adipofascial (anterior rectus sheath) flap from immediately below the inframammary area for the reconstruction of defect due to partial mastectomy for patients with early breast cancer. In this procedure, a skin incision is made at the inframammary line, and the inframammary skin area is undermined. A tongue shaped flap composed of the subcutaneous fat and the anterior sheath of rectus abdominis muscle is pulled up and a C-shaped flap is rotated, gathered, and inserted to reconstruct the breast defect. © 2007 Excerpta Medica Inc. All rights reserved. Keywords: Breast cancer; Breast conservative therapy; Technique; Immediate reconstruction; Adipofascial flap; Cosmetic results
Breast conservative therapy (BCT) has become a standard strategy for breast cancer and ensures local control and acceptable cosmetic results [1]. However, an insufficient resection margin may increase local recurrence if too much attention is paid to cosmesis. Immediate reconstruction after BCT has thus become increasingly popular even for earlystage breast cancer [2,3]. Compared with Western women, the breasts of Asian women, including Japanese, are commonly too small to maintain symmetry even after partial resection. Use of pedicle dermal-fat graft for defect reconstruction has proven useful for defects of the breast after mastectomy [4,5]. These techniques are useful for fatty patients who have excessive skin at the inframammary region with large breasts; however, it is difficult for patients with slim bodies and small breasts, like Japanese women. Here, we describe a simple technique for reconstruction of the defect on the lower part of the breast in 2 patients with early breast cancer using inframammary adipofascial flap without dermis.
* Corresponding author. Tel.: ⫹81-99-275-5361; fax: ⫹81-99-265-7426. E-mail address: [email protected]
Technique The curved incision is at the inframammary line. The tumor is removed with gross margins of 3 cm. No skin is removed unless leaving the skin would compromise the superficial margin. Fascia of the pectoral muscle is removed. The harvesting and implantation of the inframammary adipofascial flap involves 4 steps: (1) harvesting a tongue-shaped flap of fat and the anterior sheath of the rectus abdominis muscle; (2) pulling up the flap to the cranial defect; (3) trimming or gathering the flap to adjust to the shape of the contralateral breast; and (4) fixing the flap to the edge of remnant gland (Fig. 1). Even if the patient is not obese, we can obtain a large amount of fat. Attaching the sheath of the muscle to the adipose tissue makes the harvested tissue firm. We pull up, roll, or gather it to reconstruct the breast mound and to adjust the size of the contralateral breast. Fixation to the edge of the remnant gland was performed using polydioxane (PDS II; Ethicon, Inc, Somerville, NJ). For patients with an early breast lesion located in the lower outer region, we used a slightly different technique. We obtained a C-shaped flap and rotated it toward the cranial defect. Fixation was added between the flap and the remnant gland in the same manner as described above. A continuous closed suction drainage tube was added to the subcutaneous defect at the donor site for two days after the operation.
0002-9610/07/$ – see front matter © 2007 Excerpta Medica Inc. All rights reserved. doi:10.1016/j.amjsurg.2006.06.052
790
Y. Kijima et al. / The American Journal of Surgery 193 (2007) 789 –791
Fig. 1. Procedure for harvesting the tongue-shaped adipofascial flap and repair of the defect (case 1). (A) Using the same skin incision at the inframammary line, partial resection of the breast can be performed to obtain the adipofascial flap. Attaching the sheath of the muscle to the adipose tissue makes the harvested tissue firm. (B) The tongue-shaped flap was harvested. (C) The flap is pulled up to the cranial side to fill the defect. We sometimes roll or gather the flap to reconstruct the breast mound.
Comments In the 1980s, BCT rapidly became a first-line procedure for early-stage breast cancer, and ensures local control and acceptable cosmetic results [1,6]. Insufficient resection mar-
gins that occur from paying too much attention to cosmesis may increase local recurrence, and determining the amount of breast tissue that must be removed to obtain histologically negative margins is difficult. Early research suggested
Fig. 2. A 36-year-old woman with breast cancer located on the lower inner quadrant of the right breast (case 1). (A) The resected area of the breast was marked in the supine position with a gross margin of 3 cm. A tongue-shaped adipofascial flap was designed with the length of 8 cm. (B) Six months postsurgery. The deformity of both breast and donor site is inconspicuous.
Y. Kijima et al. / The American Journal of Surgery 193 (2007) 789 –791
791
Fig. 3. A 46-year-old woman with breast cancer located on the lower outer quadrant of the right breast (case 2). (A) An adipofascial flap was designed to be harvested in a C shape. (B, C) Ten months postsurgery.
that conservation or restitution of the breast might mitigate the negative effects of breast cancer on the sexual wellbeing of women, and cosmetic results exert a marked effect on subsequent psychological outcomes [7,8]. Japanese women typically have small breasts, and symmetry can be difficult to maintain when a tumor is located in the lower region of the breast, even with only partial resection. Removing a relatively large part of the whole breast can thus have a considerable impact on poor cosmetic outcome. BCT therefore cannot always provide satisfactory cosmetic results in patients with small breasts. Wide local excision without immediate volume replacement is associated with breast retraction leading to cosmetic failure in one third of patients [9]. Use of pedicle dermal-fat graft for reconstruction of the breast has been proven for Western patients who received subcutaneous mastectomy [4,5]. It seemed to be useful for women with large breasts, excessive skin on the inframammary area, and rich fatty tissue. Sakai et al used this technique to reconstruct the breast for Japanese patients with subcutaneous mastectomy [10]. They concluded that this technique was safely performed and that excellent outcomes were obtained. They also reported that the ideal patients were those that received subcutaneous mastectomy, reserved skin and nipple-areola complex, and whose contralateral breast was not too large. We modified this technique for patients with BCT to repair the defect immediately. We observed cystic degeneration of the graft by ultrasonographical examination 10 months after the operation; however, good cosmetic results and softness of the breasts was obtained without fat necrosis, volume loss, or firmness and contour irregularity (Figs. 2 and 3). This tech-
nique provides excellent cosmetic results even when it is performed by a breast surgeon instead of a plastic surgeon. Immediate volume replacement using the adipofascial flap at the time of BCT on the lower region can be useful with good cosmetic effect, particularly for patients with small breasts, such as Japanese women. References [1] Fisher B, Anderson S, Redmond CK, et al. Reanalysis and results after 12 years of follow-up in a randomized clinical trial comparing total mastectomy with lumpectomy with or without irradiation in the treatment of breast cancer. N Engl J Med 1995;333:1456 – 61. [2] Berrino P, Campora E, Santi P. Post-quadrantectomy breast deformities: classification and techniques of surgical correction. Plast Reconstr Surg 1987;79:567–72. [3] Cooperman AM, Dinner M. The rhomboid flap and partial mastectomy. Surg Clin North Am 1978;58:869 –73. [4] Longacre JJ. Correction of the hypoplastic breast with special reference to reconstruction of the “nipple type breast” with local dermo-fat pedicle flap. Plast Reconstr Surg 1954;14:431– 41. [5] Maliniac JW. Use of pedicle dermo-fat flap in mammaplasty. Plast Reconstr Surg 1953;12:110 –15. [6] Fisher B, Anderson SA, Bryant J, et al. Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. J Engl J Med 2002;347:1233– 41. [7] Rowland JH, Desmond KA, Meyerowitz BE, et al. Role of breast reconstructive surgery in physical and emotional outcomes among breast cancer survivors. J Natl Cancer Inst 2000;92:1422–9. [8] Al-Ghazal SK, Fallowfield L, Blamey RW. Does cosmetic outocome from treatment of primary breast cancer influence psychosocial morbidity? Eur J Surg Oncol 1999;25:571–3. [9] Raja MAK, Straker VF, Rainsbury RM. Extending the role of breastconserving surgery by immediate volume replacement. Br J Surg 1997;84:101–5. [10] Sakai S, Suzuki I, Izawa H: Adipofascial (anterior rectus sheath) flaps for breast reconstruction. Ann Plast Surg 1992;29:173–7.