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Simultaneous pectoralis major myocutaneous flap combined with breast reduction for sternal defect coverage
Journal of Plastic, Reconstructive & Aesthetic Surgery (2009) 62, 1076e1080
Simultaneous pectoralis major myocutaneous flap combined with breast reduction for sternal defect coverage Niklas Iblher*, Vincenzo Penna, Stefan Krischak, G. Bjoern Stark Department of Plastic Surgery, University of Freiburg Medical Center, Hugstetterstrasse 55, D-79106 Freiburg, Germany Received 15 September 2007; accepted 2 April 2008
KEYWORDS Pectoralis major flap; Chest wall defect; Breast reduction; Sternal defect; Musculo-cutaneomammary flap
Summary Background: The pectoralis myocutaneous island flap is a well established technique for tissue reconstruction. In female patients with concomitant breast hypertrophy there may be a simultaneous indication for breast reduction mammoplasty. The inferior pole of the breast and the inframammary fold coincide with the skin island territory of myocutaneous flaps supplied by the thoracoacromial artery. Methods: A technique is described where this tissue is preserved as the flap skin island in combination with a superior pedicle reduction mammoplasty. The technique is illustrated with two exemplary cases. Results and conclusion: The technique is suitable in women with relative unilateral or absolute bilateral large breasts with a combined sternal defect and should be taken into consideration for respective cases. ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Anatomy The pectoralis major island flap, supplied by the thoracoacromial artery, is a well established technique for head and neck as well as for chest wall reconstruction.1,2 The vascular axis of the flap runs along the thoracoacromial artery crossing the chest wall in the direction of the xiphoid. Its
* Corresponding author. Tel.: þ49 761 270 2401; fax: þ49 761 270 2501. E-mail address: [email protected] (N. Iblher).
territory extends well beyond the inframammary fold, especially when including the superficial muscle fascia and the exterior rectus sheath. Along its course the several branches of the thoracoacromial artery give off perforators ascending into the inferior pole of the breast between the lateral and medial quadrant. This area coincides with the main tissue territory discarded in reduction mammoplasty based on an inverted T-scar and a cranially pedicled areola transposition.3 Thus the skin (including mammary tissue of the inferior pole) of the area reaching from the inferior margin of the areola down to the inframammary fold and beyond may be used as the flap’s skin island. There are
1748-6815/$ - see front matter ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2008.04.023
Simultaneous pectoralis major myocutaneous flap female patients for whom a for breast reduction is simultaneously indicated with a vascularised tissue transfer for coverage of a chest wall defect. This includes, especially, breast cancer patients with radiation damage over the sternum and the chest wall or axilla. These patients have frequently received a contralateral mastectomy so that they will benefit from a breast reduction to balance weight or achieve symmetry with a contralateral breast reconstruction. Patients with defects after sternotomy for cardiovascular surgery, in combination with large breasts, are known to benefit from defect coverage with well vascularised muscle flaps4 and may also benefit from breast reduction as the sheer weight of the breasts may be a factor in wound dehiscence and in preventing wound healing.5 These forces are even more hazardous to the healing process if the bony thoracic aperture is unstable, as can be the case with radiogenic or infectious sternal osteomyelitis. The arch of rotation of this flap has been well described and reaches 360 from the inframammary fold up to the mid face.6 It will also reach the complete sternum, including the manubrium and the supraclavicular and shoulder area. The technique may be used in combination with all breast reduction techniques based on the concept of a superior pedicle where usually the major resection of skin, subcutaneous and breast tissue is between the areola and the inframammary fold, as described in the techniques of Pitangui.3 Since there are only scarce and episodic descriptions of a reconstructive procedure using the pectoralis major island flaps in combination with a breast reduction in the literature,7,8 the following will outline our one-step approach to the above-mentioned complex clinical situations.
Technique As in elective isolated breast reduction patients, all candidates for this procedure undergo preoperative breast cancer evaluation including mammography to rule out any suspicion of pathological breast tissue transformation. In essence, the preoperative marking is performed according to the description of Pitangui in a standing position3 (Figure 1). This includes the upper margin of the new nipple areola complex and the inframammary fold, thereby also marking the central inferior area to be resected for reduction. The axis of the thoracoacromial artery from its origin under the clavicle towards the xiphoid is marked. A template is made from the expected defect and drawn within this resectional area. In contrast to standard reduction mammoplasty, the tissue island of the muscle flap can be extended beyond the inframammary fold, taking into account that this will shift the fold to a lower position. In this case abdominal skin can be advanced cranially. If the reduction mammoplasty has to be performed on both sides, the standard design of the contralateral breast reduction should be adjusted accordingly. The operation is performed in supine position. The marked incision lines are infiltrated with diluted epinephrine solution. The cranial dermal pedicle to the nipple areola complex is designed and de-epithelialised, extending 1 cm below the inferior border of the new areola
1077
Figure 1 Preoperative markings, fat line indicating flap border, which can be adjusted to the defect size and shape.
margin. From there the skin (and breast tissue) flap as a part of the reduction mammoplasty is dissected en bloc straight down to the pectoralis muscle with the scalpel defining the superior margin of the island (Figure 2A, B). The inferior margin is elevated with the costal origins of the pectoralis major muscle. The anterior rectus sheath must be included, especially if the island is extended below the inframammary fold. After defining the flap margins, a tunnel is dissected directly on the pectoralis fascia along the vascular axis to a width of about 5e8 cm with the aid of headlights. Thereafter the fascia caudal to the flap is incised and elevated, including the muscular insertion from the ribs. After entering the subpectoral plane, the dissection is straightforward and may be done by finger dissection. The lateral margin of the pectoralis major muscle can be preserved to prevent distortion of the anterior axillary fold. Medially, the muscle may be included as far as its sternal origins to increase bulk. Then using headlights or lighted retractors the origin of the thoracoacromial artery is defined and the vessel isolated including a cuff of about 2 cm muscle tissue on both sides of the arteriovenous pedicle (Figure 2C). Once the upward dissection is complete a tunnel is dissected towards the defect. This tunnel should be just large enough to incorporate the flap pedicle without compromising the vascular supply to the breast. After the flap has been positioned (Figure 2D) the reduction mammoplasty may be completed in a standard fashion. The reduction of breast tissue is continued in the central infraareolar part of the breast. In the well established technique, according to Pitangui, the areola complex is further mobilised, the vertical suture closed and fixed at its deepest point in the inframammary fold (Figure 2E). Medial and lateral dog ears are resected along the inframammary fold. The nipple areola complex is then delivered to its new position.
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Figure 2 (A) Elevation of myoglandulocutaneous pectoralis island flap from the inframammary fold. (B) Schematic drawing of flap elevation. (C) Dissection of pectoralis major muscle and the vascular pedicle using a large retractor and headlights. (D) Transposition of flap. (E) Completion of horizontal suture. The nipple areola complex is then relocated to its new position by the black suture.
Cases Case 1 A 61-year-old lady presented to our clinic with a history of suffering from breast cancer 20 years earlier with breast amputation and radiation therapy. Five years after the initial operation she had suffered from a local recurrence in the parasternal scar which was excised. At this time no infiltration of the sternum had been visible on CT scan. On presentation to our clinic the patient complained of pain on palpation around the sternum (Figure 3A) and CT scans showed an osteolytic lesion infiltrating the manubrium and cranial part of the sternum. The resection of the proximal corpus sterni and manubrium, including the sternoclavicular joints and left medial clavicle, resulted in a 15 15 cm defect with unstable upper thoracic aperture. Following the breast reduction and transposition of the flap, a fixateur externe was inserted to stabilise the upper thoracic aperture (Figure 3B). Histology proved infiltration of the cranial sternum and left medial clavicle by an adenocarcinoma in accordance with the precedent breast cancer. Wound healing was uneventful apart from minor wound edge necrosis which healed by secondary intention without further intervention. The fixateur could be removed after 3 weeks. The patient was very satisfied with the breast reduction result. Figure 3C shows the patient 2 years
postoperatively. One year postoperatively the patient developed a partial paresis of the brachial plexus. MRI showed a 4 3 cm nodule behind the left clavicle. Since not amenable to surgical resection, chemotherapy was applied which did not lead to any reaction of the nodule. Since then it has not increased in size and 10 years postoperatively there is no sign of tumour recurrence.
Case 2 A 64-year-old woman presented with a chronic presternal radiogenic ulcer after receiving a mastectomy and radiotherapy for breast cancer many years before (Figure 4A). After radical debridement and defect coverage with a musculo-cutaneo-mammary flap, a stable defect coverage could be achieved (Figure 4B). The inframammary fold and lower part of the breast tissue was included and used to enhance the medial contour of the breast (arrow in Figure 4B). The patient was satisfied with the reduction mammoplasty and appreciated the reduced asymmetry. The patient did not desire a contralateral breast reconstruction.
Discussion It is not uncommon for patients who need a vascularised soft tissue reconstruction of the chest to also be candidates for reduction mammoplasty, especially breast cancer
Simultaneous pectoralis major myocutaneous flap
1079
Figure 4 (A) Case 2: 63-year-old patient with sternal radiodermatitis after mastectomy and radiation for breast cancer, preoperative. (B) Early postoperative view, black arrow indicating former inframammary fold.
Figure 3 (A) Case 1: 61-year-old lady with sternal metastasis after breast cancer 20 years before. Preopertive view. Line indicates the approximate axis of the thoracoacromial artery. (B) Postoperative day 2 shows small wound edge necrosis. Upper thoracic aperture stabilised by fixateur externe. (C) Two years postoperatively, stable defect coverage with acceptable cosmetic breast shape.
patients with radiation damage, local tumour recurrence or sternotomy wounds. There is evidence that female patients with breast hypertrophy (often in addition to further risk factors like diabetes and obesity) have a higher risk of sternal wound dehiscence and that the weight of the breasts further hampers defect coverage of these problem wounds.5,8
The vascular territory of the pectoralis major island flap has been well documented. The thoracoacromial artery supplies a robust flap along its axis extending down the thoracic aperture. Its vascular territory also includes the inferior pole of the breast, the inframammary fold and the lower chest wall skin. Safe elevation of the flap, including its vascular pedicle, is possible without removing the complete muscle which would lead to loss of the anterior axillary fold. Before the advent of vertical scar-only reduction mammoplasty, techniques using a superior dermal pedicle with an inferior resection resulting in an inverted T-scar were a common standard operation, especially in Europe and Latin America. As for most aesthetic breast reduction mammoplasties, we now prefer a vertical scar-only technique modified after Lejour.9 This technique not only avoids the horizontal scar in the inframammary fold but also produces better projection. In contrast, after contralateral mastectomy, a reduced projection may be well suited to accommodate a contralateral reconstructed breast or the mastectomy itself. Hence the inverted T-scar reduction mammoplasty is still the standard technique in most of these patients. In these techniques the inferior part of the reduced breast tissue (including the overlying skin) basically is located within the vascular territory of the
1080 pectoralis major flap. Thus it seems logical to use this tissue as the island based on the pectoralis flap to simultaneously reduce the breast and cover a defect in a one-step procedure. This procedure makes use of breast tissue present in the patient anyway and does not add an oncological risk. Although only the very inferior part of the breast, which is known to incorporate less glandular tissue and therefore shows the lowest incidence of breast cancer, is transposed with this flap, preoperative gynaecological consultation and breast cancer screening is imperative. Provided an unsuspicious screening result is obtained, we cannot see any increased oncological risk in transposing this flap compared to the residuant breast tissue in regular breast reduction. According to need, this area may also extend beyond the inframammary fold. If this leads to a problem of symmetry it can usually be easily handled in patient groups with a contralateral mastectomy and planned breast reconstruction or with bilateral reduction mammoplasties, both of which can be adopted to achieve a symmetrical level of the inframammary fold. Since this is not a myocutaneous flap but rather a myomammarycutaneous flap it may be quite voluminous. As there are regularly very strong perforators ascending from the inframammary fold, it is possible to stretch out the flap and thin out the breast tissue above this level without compromising a sufficient blood supply. As a matter of fact the thick tissue may be beneficial in certain cases to fill in deep wound cavities. The breast tissue also can be included to improve the breast contour along the sternal margin of the breast base (Figure 4B). As alternatives, or if in any doubt about oncological safety, flaps based on the superior epigastric arteries, perforator flaps from the lateral chest or back or conventional pedicled scapular/parascapular or latissimus dorsi flaps should be considered, although these solutions nullify the advantages of a single operative site, quick dissection, easy patient positioning and minimal extra donor site morbidity.
N. Iblher et al. The described technique combines an established flap dissection with an equally established breast reduction procedure which, when not performed simultaneously, destroys the skin island of this flap. If reduction and flap transfer are done in one step the patient is saved the risk of an extra operation and an extra scar. As the concomitant problem of unilateral relative or bilateral absolute breast hypertrophy and sternal defect is not uncommon this technique should be taken into consideration.
References 1. Ariyan S. The pectoralis major myocutaneous flap. A versatile flap for reconstruction in the head and neck. Plast Reconstr Surg 1979;63:73e81. 2. Tobin GR. Pectoralis major muscle-musculocutaneous flap for chest-wall reconstruction. Surg Clin North Am 1989;69: 991e1006. 3. Pitanguy I. Surgical treatment of breast hypertrophy. Br J Plast Surg 1967;20:78e85. 4. Castello JR, Centella T, Garro L, et al. Muscle flap reconstruction for the treatment of major sternal wound infections after cardiac surgery: a 10-year analysis. Scand J Plast Reconstr Surg Hand Surg 1999;33:17e24. 5. Copeland M, Senkowski C, Ulcickas M, et al. Breast size as a risk factor for sternal wound complications following cardiac surgery. Arch Surg 1994;129:757e9. 6. Mathes SJ, Nahai F. Pectoralis major flap. In: Reconstructive surgery e principles, anatomy & technique. New York City: Churchill Livingstone Inc; 1997. p. 441e65. 7. de Fontaine S, Devos S, Goldschmidt D. Reduction mammaplasty combined with pectoralis major muscle flaps for median sternotomy wound closure. Br J Plast Surg 1996;49: 220e2. 8. Copeland M, Senkowski C, Ergin MA, et al. Macromastia as a factor in sternal wound dehiscence following cardiac surgery: management combining chest wall reconstruction and reduction mammoplasty. J Card Surg 1992;7:275e8. 9. Lejour M. Vertical mammaplasty and liposuction of the breast. Plast Reconstr Surg 1994;94:100e14.
Simultaneous pectoralis major myocutaneous flap combined with breast reduction for sternal defect coverage Niklas Iblher*, Vincenzo Penna, Stefan Krischak, G. Bjoern Stark Department of Plastic Surgery, University of Freiburg Medical Center, Hugstetterstrasse 55, D-79106 Freiburg, Germany Received 15 September 2007; accepted 2 April 2008
KEYWORDS Pectoralis major flap; Chest wall defect; Breast reduction; Sternal defect; Musculo-cutaneomammary flap
Summary Background: The pectoralis myocutaneous island flap is a well established technique for tissue reconstruction. In female patients with concomitant breast hypertrophy there may be a simultaneous indication for breast reduction mammoplasty. The inferior pole of the breast and the inframammary fold coincide with the skin island territory of myocutaneous flaps supplied by the thoracoacromial artery. Methods: A technique is described where this tissue is preserved as the flap skin island in combination with a superior pedicle reduction mammoplasty. The technique is illustrated with two exemplary cases. Results and conclusion: The technique is suitable in women with relative unilateral or absolute bilateral large breasts with a combined sternal defect and should be taken into consideration for respective cases. ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Anatomy The pectoralis major island flap, supplied by the thoracoacromial artery, is a well established technique for head and neck as well as for chest wall reconstruction.1,2 The vascular axis of the flap runs along the thoracoacromial artery crossing the chest wall in the direction of the xiphoid. Its
* Corresponding author. Tel.: þ49 761 270 2401; fax: þ49 761 270 2501. E-mail address: [email protected] (N. Iblher).
territory extends well beyond the inframammary fold, especially when including the superficial muscle fascia and the exterior rectus sheath. Along its course the several branches of the thoracoacromial artery give off perforators ascending into the inferior pole of the breast between the lateral and medial quadrant. This area coincides with the main tissue territory discarded in reduction mammoplasty based on an inverted T-scar and a cranially pedicled areola transposition.3 Thus the skin (including mammary tissue of the inferior pole) of the area reaching from the inferior margin of the areola down to the inframammary fold and beyond may be used as the flap’s skin island. There are
1748-6815/$ - see front matter ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2008.04.023
Simultaneous pectoralis major myocutaneous flap female patients for whom a for breast reduction is simultaneously indicated with a vascularised tissue transfer for coverage of a chest wall defect. This includes, especially, breast cancer patients with radiation damage over the sternum and the chest wall or axilla. These patients have frequently received a contralateral mastectomy so that they will benefit from a breast reduction to balance weight or achieve symmetry with a contralateral breast reconstruction. Patients with defects after sternotomy for cardiovascular surgery, in combination with large breasts, are known to benefit from defect coverage with well vascularised muscle flaps4 and may also benefit from breast reduction as the sheer weight of the breasts may be a factor in wound dehiscence and in preventing wound healing.5 These forces are even more hazardous to the healing process if the bony thoracic aperture is unstable, as can be the case with radiogenic or infectious sternal osteomyelitis. The arch of rotation of this flap has been well described and reaches 360 from the inframammary fold up to the mid face.6 It will also reach the complete sternum, including the manubrium and the supraclavicular and shoulder area. The technique may be used in combination with all breast reduction techniques based on the concept of a superior pedicle where usually the major resection of skin, subcutaneous and breast tissue is between the areola and the inframammary fold, as described in the techniques of Pitangui.3 Since there are only scarce and episodic descriptions of a reconstructive procedure using the pectoralis major island flaps in combination with a breast reduction in the literature,7,8 the following will outline our one-step approach to the above-mentioned complex clinical situations.
Technique As in elective isolated breast reduction patients, all candidates for this procedure undergo preoperative breast cancer evaluation including mammography to rule out any suspicion of pathological breast tissue transformation. In essence, the preoperative marking is performed according to the description of Pitangui in a standing position3 (Figure 1). This includes the upper margin of the new nipple areola complex and the inframammary fold, thereby also marking the central inferior area to be resected for reduction. The axis of the thoracoacromial artery from its origin under the clavicle towards the xiphoid is marked. A template is made from the expected defect and drawn within this resectional area. In contrast to standard reduction mammoplasty, the tissue island of the muscle flap can be extended beyond the inframammary fold, taking into account that this will shift the fold to a lower position. In this case abdominal skin can be advanced cranially. If the reduction mammoplasty has to be performed on both sides, the standard design of the contralateral breast reduction should be adjusted accordingly. The operation is performed in supine position. The marked incision lines are infiltrated with diluted epinephrine solution. The cranial dermal pedicle to the nipple areola complex is designed and de-epithelialised, extending 1 cm below the inferior border of the new areola
1077
Figure 1 Preoperative markings, fat line indicating flap border, which can be adjusted to the defect size and shape.
margin. From there the skin (and breast tissue) flap as a part of the reduction mammoplasty is dissected en bloc straight down to the pectoralis muscle with the scalpel defining the superior margin of the island (Figure 2A, B). The inferior margin is elevated with the costal origins of the pectoralis major muscle. The anterior rectus sheath must be included, especially if the island is extended below the inframammary fold. After defining the flap margins, a tunnel is dissected directly on the pectoralis fascia along the vascular axis to a width of about 5e8 cm with the aid of headlights. Thereafter the fascia caudal to the flap is incised and elevated, including the muscular insertion from the ribs. After entering the subpectoral plane, the dissection is straightforward and may be done by finger dissection. The lateral margin of the pectoralis major muscle can be preserved to prevent distortion of the anterior axillary fold. Medially, the muscle may be included as far as its sternal origins to increase bulk. Then using headlights or lighted retractors the origin of the thoracoacromial artery is defined and the vessel isolated including a cuff of about 2 cm muscle tissue on both sides of the arteriovenous pedicle (Figure 2C). Once the upward dissection is complete a tunnel is dissected towards the defect. This tunnel should be just large enough to incorporate the flap pedicle without compromising the vascular supply to the breast. After the flap has been positioned (Figure 2D) the reduction mammoplasty may be completed in a standard fashion. The reduction of breast tissue is continued in the central infraareolar part of the breast. In the well established technique, according to Pitangui, the areola complex is further mobilised, the vertical suture closed and fixed at its deepest point in the inframammary fold (Figure 2E). Medial and lateral dog ears are resected along the inframammary fold. The nipple areola complex is then delivered to its new position.
1078
N. Iblher et al.
Figure 2 (A) Elevation of myoglandulocutaneous pectoralis island flap from the inframammary fold. (B) Schematic drawing of flap elevation. (C) Dissection of pectoralis major muscle and the vascular pedicle using a large retractor and headlights. (D) Transposition of flap. (E) Completion of horizontal suture. The nipple areola complex is then relocated to its new position by the black suture.
Cases Case 1 A 61-year-old lady presented to our clinic with a history of suffering from breast cancer 20 years earlier with breast amputation and radiation therapy. Five years after the initial operation she had suffered from a local recurrence in the parasternal scar which was excised. At this time no infiltration of the sternum had been visible on CT scan. On presentation to our clinic the patient complained of pain on palpation around the sternum (Figure 3A) and CT scans showed an osteolytic lesion infiltrating the manubrium and cranial part of the sternum. The resection of the proximal corpus sterni and manubrium, including the sternoclavicular joints and left medial clavicle, resulted in a 15 15 cm defect with unstable upper thoracic aperture. Following the breast reduction and transposition of the flap, a fixateur externe was inserted to stabilise the upper thoracic aperture (Figure 3B). Histology proved infiltration of the cranial sternum and left medial clavicle by an adenocarcinoma in accordance with the precedent breast cancer. Wound healing was uneventful apart from minor wound edge necrosis which healed by secondary intention without further intervention. The fixateur could be removed after 3 weeks. The patient was very satisfied with the breast reduction result. Figure 3C shows the patient 2 years
postoperatively. One year postoperatively the patient developed a partial paresis of the brachial plexus. MRI showed a 4 3 cm nodule behind the left clavicle. Since not amenable to surgical resection, chemotherapy was applied which did not lead to any reaction of the nodule. Since then it has not increased in size and 10 years postoperatively there is no sign of tumour recurrence.
Case 2 A 64-year-old woman presented with a chronic presternal radiogenic ulcer after receiving a mastectomy and radiotherapy for breast cancer many years before (Figure 4A). After radical debridement and defect coverage with a musculo-cutaneo-mammary flap, a stable defect coverage could be achieved (Figure 4B). The inframammary fold and lower part of the breast tissue was included and used to enhance the medial contour of the breast (arrow in Figure 4B). The patient was satisfied with the reduction mammoplasty and appreciated the reduced asymmetry. The patient did not desire a contralateral breast reconstruction.
Discussion It is not uncommon for patients who need a vascularised soft tissue reconstruction of the chest to also be candidates for reduction mammoplasty, especially breast cancer
Simultaneous pectoralis major myocutaneous flap
1079
Figure 4 (A) Case 2: 63-year-old patient with sternal radiodermatitis after mastectomy and radiation for breast cancer, preoperative. (B) Early postoperative view, black arrow indicating former inframammary fold.
Figure 3 (A) Case 1: 61-year-old lady with sternal metastasis after breast cancer 20 years before. Preopertive view. Line indicates the approximate axis of the thoracoacromial artery. (B) Postoperative day 2 shows small wound edge necrosis. Upper thoracic aperture stabilised by fixateur externe. (C) Two years postoperatively, stable defect coverage with acceptable cosmetic breast shape.
patients with radiation damage, local tumour recurrence or sternotomy wounds. There is evidence that female patients with breast hypertrophy (often in addition to further risk factors like diabetes and obesity) have a higher risk of sternal wound dehiscence and that the weight of the breasts further hampers defect coverage of these problem wounds.5,8
The vascular territory of the pectoralis major island flap has been well documented. The thoracoacromial artery supplies a robust flap along its axis extending down the thoracic aperture. Its vascular territory also includes the inferior pole of the breast, the inframammary fold and the lower chest wall skin. Safe elevation of the flap, including its vascular pedicle, is possible without removing the complete muscle which would lead to loss of the anterior axillary fold. Before the advent of vertical scar-only reduction mammoplasty, techniques using a superior dermal pedicle with an inferior resection resulting in an inverted T-scar were a common standard operation, especially in Europe and Latin America. As for most aesthetic breast reduction mammoplasties, we now prefer a vertical scar-only technique modified after Lejour.9 This technique not only avoids the horizontal scar in the inframammary fold but also produces better projection. In contrast, after contralateral mastectomy, a reduced projection may be well suited to accommodate a contralateral reconstructed breast or the mastectomy itself. Hence the inverted T-scar reduction mammoplasty is still the standard technique in most of these patients. In these techniques the inferior part of the reduced breast tissue (including the overlying skin) basically is located within the vascular territory of the
1080 pectoralis major flap. Thus it seems logical to use this tissue as the island based on the pectoralis flap to simultaneously reduce the breast and cover a defect in a one-step procedure. This procedure makes use of breast tissue present in the patient anyway and does not add an oncological risk. Although only the very inferior part of the breast, which is known to incorporate less glandular tissue and therefore shows the lowest incidence of breast cancer, is transposed with this flap, preoperative gynaecological consultation and breast cancer screening is imperative. Provided an unsuspicious screening result is obtained, we cannot see any increased oncological risk in transposing this flap compared to the residuant breast tissue in regular breast reduction. According to need, this area may also extend beyond the inframammary fold. If this leads to a problem of symmetry it can usually be easily handled in patient groups with a contralateral mastectomy and planned breast reconstruction or with bilateral reduction mammoplasties, both of which can be adopted to achieve a symmetrical level of the inframammary fold. Since this is not a myocutaneous flap but rather a myomammarycutaneous flap it may be quite voluminous. As there are regularly very strong perforators ascending from the inframammary fold, it is possible to stretch out the flap and thin out the breast tissue above this level without compromising a sufficient blood supply. As a matter of fact the thick tissue may be beneficial in certain cases to fill in deep wound cavities. The breast tissue also can be included to improve the breast contour along the sternal margin of the breast base (Figure 4B). As alternatives, or if in any doubt about oncological safety, flaps based on the superior epigastric arteries, perforator flaps from the lateral chest or back or conventional pedicled scapular/parascapular or latissimus dorsi flaps should be considered, although these solutions nullify the advantages of a single operative site, quick dissection, easy patient positioning and minimal extra donor site morbidity.
N. Iblher et al. The described technique combines an established flap dissection with an equally established breast reduction procedure which, when not performed simultaneously, destroys the skin island of this flap. If reduction and flap transfer are done in one step the patient is saved the risk of an extra operation and an extra scar. As the concomitant problem of unilateral relative or bilateral absolute breast hypertrophy and sternal defect is not uncommon this technique should be taken into consideration.
References 1. Ariyan S. The pectoralis major myocutaneous flap. A versatile flap for reconstruction in the head and neck. Plast Reconstr Surg 1979;63:73e81. 2. Tobin GR. Pectoralis major muscle-musculocutaneous flap for chest-wall reconstruction. Surg Clin North Am 1989;69: 991e1006. 3. Pitanguy I. Surgical treatment of breast hypertrophy. Br J Plast Surg 1967;20:78e85. 4. Castello JR, Centella T, Garro L, et al. Muscle flap reconstruction for the treatment of major sternal wound infections after cardiac surgery: a 10-year analysis. Scand J Plast Reconstr Surg Hand Surg 1999;33:17e24. 5. Copeland M, Senkowski C, Ulcickas M, et al. Breast size as a risk factor for sternal wound complications following cardiac surgery. Arch Surg 1994;129:757e9. 6. Mathes SJ, Nahai F. Pectoralis major flap. In: Reconstructive surgery e principles, anatomy & technique. New York City: Churchill Livingstone Inc; 1997. p. 441e65. 7. de Fontaine S, Devos S, Goldschmidt D. Reduction mammaplasty combined with pectoralis major muscle flaps for median sternotomy wound closure. Br J Plast Surg 1996;49: 220e2. 8. Copeland M, Senkowski C, Ergin MA, et al. Macromastia as a factor in sternal wound dehiscence following cardiac surgery: management combining chest wall reconstruction and reduction mammoplasty. J Card Surg 1992;7:275e8. 9. Lejour M. Vertical mammaplasty and liposuction of the breast. Plast Reconstr Surg 1994;94:100e14.