Edward W. Knowlton, M.D.
Roseann Gorey, M.D.
Howard Taekman, M.D.

Drs. Roseann Gorey and Howard Taekman are general surgeons.

Table of Contents

Abstract   Introduction   Technique   Case Reports   Discussion   Conclusion   References

Abstract

A technique for immediate breast reconstruction is described that equally preserves the skin of both the mastectomy and remaining breast. Three cases are reported to illustrate both advantages and variations of skin preservation with this technique. Replacement of the excised nipple-areolar complex is provided by a round "peg" latissimus dorsi flap. The expanded prosthetic sub-muscular pocket of the pectoralis major and latissimus dorsi closely assimilates the volume of the skin envelope. Insertion of a permanent implant instead of an expander is possible. The nipple-areolar reconstruction can also be completed at this initial stage. In many patients, a total immediate breast re construction can be achieved. [Contemp Surg 41(3).15 19, 1992]

Introduction

The inherent limitations of radiation therapy for the treatment of large and multicentric breast cancers and the long-term effects of radiation therapy, especially in the young patient, have not been resolved. Therefore, there is a continuing need for modified radical mastectomy. Preservation of the pectoralis major muscle coupled with the gradually fading stigma of creating a Halsted deformity have encouraged an increasing number of women to opt for breast reconstruction while undergoing mastectomy.

The present challenge is to design a one-stage breast reconstruction technique that greatly limits the extent of the mastectomy scar while enlarging the volume of the sub-muscular prosthetic compartment commensurate with the volume of the original skin envelope. Whenever possible, the length of the mastectomy incision should be significantly shortened by limiting the mastectomy excision to the nipple-areolar complex.

If the skin excision of the mastectomy can be limited to the nipple-areolar complex, a one-stage breast reconstruction is possible with the use of a permanent implant and a modified latissimus dorsi flap (peg). Repositioning incisions on the contralateral breast are frequently avoided, as the skin envelope on the mastectomy site is completely preserved. The addition of a latissimus dorsi flap creates a larger sub-muscular compartment, which allows insertion of a permanent prosthetic implant instead of a breast expander.

Technique

A primary requirement of this procedure is for the general surgeon to limit the initial biopsy and subsequent skin excision of the mastectomy to the nipple-areolar complex. Immediately following the mastectomy and axillary node dissection, (usually through separate incisions), the round skin island latissimus dorsi flap (peg) is raised (Fig. 1). From the transverse back incision, additional latissimus dorsi muscle is included inferior to the skin island (Fig. 2).

Figure 1 Latissimus dorsi muscle is raised using axillary and back incisions.

Figure 2 Latissimus dorsi muscle inlaid to inferior aspect of pectoralis major.

Dissection is pursued from the back and axillary incisions, taking care to preserve the thoracodorsal vascular bundle. Inadvertently raising the serratus anterior muscle with the latissimus dorsi also must be avoided. This is best accomplished by first pursuing the dissection of the latissimus dorsi from the axillary incision. This approach also allows early identification of the thoracodorsal bundle along the anterior border of the latissimus dorsi muscle. The flap is transposed to the mastectomy defect after assuring the patency of the thoracodorsal artery and vein. The insertion of the latissimus dorsi muscle at the axilla can then be transected to allow further advancement of the flap.

Next the inferior border of the pectoralis major muscle is incised to create a sub-pectoral pocket. The superior margin of the latissimus dorsi muscle is sutured to the inferior margin of the pectoralis muscle, with the inferior margin of the latissimus dorsi muscle sutured to the inframammary fold. An appropriate size gel or saline inflatable textured implant is then inserted (Fig. 3). At this point, implant size is best determined with the patient placed in a sitting position.

Figure 3 Cross-section of reconstructed breast with sub muscular prosthesis and raised quadraped nipple flap.

Finally, the round peg skin flap is used to close the circular defect of the excised nipple-areolar complex. The nipple-areolar complex can be reconstructed immediately by creating the nipple mound as a superiorly pedicled quadraped flap from the skin of the peg (Fig. 4). The normally discarded areola can be defatted and placed as a full-thickness skin graft to the de-epithelialized peg (Fig. 5). An alternative donor site for the areola is the skin of the superior medial thigh.

Figure 4 Superiorly-based quadraped nipple flap marked on peg.

Figure 5 Raised nipple flap of peg. Remaining skin of peg is de-epithelialized. Refatted areolar skin is applied as full-thickness skin graft to de-epithelialized peg.

Drains are inserted at both the posterior flap donor site and the anterior mastectomy site. During the procedure, 1 gm of Vancomycin, the most effective antibiotic for suppressing Staphylococcus epidermis contamination from the breast tissue, is administered via IV piggyback.

Case Reports

Case 1: The patient is a 57-year-old Caucasian female who underwent a left modified radical mastectomy with axillary lymph node dissection. The skin excision was limited to a circumareolar resection. An immediate breast reconstruction was performed using a modified latissimus dorsi peg flap. A permanent textured silicone implant was placed into the combined submuscular compartment of the pectoralis major and latissimus dorsi. The nipple-areolar complex was reconstructed eight weeks later. The contralateral nipple-areolar complex was raised with excision of a superior periareolar ellipse of skin.

Case 2: The patient, a 44-year-old Caucasian female who had diffuse carcinoma in situ of the right breast, underwent a right modified radical mastectomy with axillary lymph node dissection. The skin excision was limited to a circumareolar resection. An immediate breast reconstruction with a peg latissimus dorsi flap was performed (Fig. 6).A permanent textured saline implant was placed into the combined sub muscular compartment. The nipple-areolar complex was reconstructed immediately using a quadraped flap for the nipple. The ipsilateral areola was harvested as a full thickness skin graft to the recipient areolar site of the peg flap.

Figure 6a Preoperative: right areola marked.	Figure 6b Preoperative: Peg flap marked.
Figure 6c Postoperative: prior to nipple tattoo.	Figure 6d Postoperative: after nipple tattoo.

Case 3: The patient, a 46-year-old Caucasian female with moderate lyptotic breasts with large areolae, underwent a right modified radical mastectomy with axillary lymph node dissection. Due to the increased width of the nipple-areolar complex and ptosis of the breast, the skin excision for both the right mastectomy and contralateral breast consisted of a modified Wise keyhole-shaped resection.

A peg from the right latissimus dorsi replaced the excised nipple-areolar complex, thereby matching the area of the remaining left nipple areolar complex. Both the peg and the left nipple-areolar complex were elevated to comparable and slightly higher positions. A permanent silicone implant was inserted into the combined sub muscular compartment of the pectoralis major and latissimus dorsi. The right nipple-areolar complex was constructed immediately using a quadraped flap for the nipple. The ipsilateral areola was harvested as a full-thickness skin graft to the recipient areola site of the peg flap.

Discussion

Limiting the skin excision to the nipple-areolar complex allows complete preservation of the breast skin envelope, as if putting a round peg into a round hole. The sub-pectoral pocket is expanded with an inlay of the latissimus dorsi muscle along the inferior border of a pectoralis major muscle. With the insertion of a permanent implant introduced through the excised nipple-areolar complex, an immediate, complete, one-stage breast reconstruction was performed. Using this approach, the typical transverse mastectomy scar is avoided. The posterior flap donor scar is an excellent trade-off to the characteristic mastectomy deformity. In many cases, the frequent requirement of a mastopexy on the contralateral side can be eliminated.

The reconstruction technique described in this report is appropriate for the complete range of breast sizes. In patients having smaller breasts, the need for an implant may be eliminated altogether. While larger breasts will require a permanent implant, in most cases it will not be necessary to use a breast expander.

Extremely large breasts may require a Wise pattern (keyhole) skin reduction combined with the peg breast reconstruction. In those cases, the contralateral breast would undergo a similar Wise pattern breast reduction. In other words, both breasts would have typical breast reduction incisions: the nipple-areolar complex of the mastectomy site is reconstructed with the circular peg of the latissimus dorsi flap, while in the contralateral breast the nipple-areolar complex is transposed to the same level as the peg flap of the mastectomy site.

An appropriate size permanent implant is used to substitute for the missing breast tissue on the mastectomy side, thereby matching the volume of the contralateral breast. Smaller, moderately ptotic breasts would not require correction of the contralateral side since the skin on the mastectomy side remains completely intact.

Conclusion

If the skin excision of the mastectomy can be limited to the nipple-areolar complex, an immediate one-stage breast reconstruction can be performed immediately using a modified peg latissimus dorsi flap. The larger sub-muscular compartment created with the latissimus dorsi flap allows insertion of a permanent prosthetic implant instead of a breast expander. Complete preservation of the skin envelope on the mastectomy site frequently makes it possible to avoid repositioning incisions on the contralateral breast.

References

1. Grossman PH, Novack BH, Karlan SR, Uyeda RY, "An Alternative Technique for Modified Radical Mastectomy with Immediate Reconstruction." Contemp Surg 38(6): 20-24, 1991.

2. Knowlton EW, "Release of Axillary Scar Contracture with a Latissimus Dorsi Flap." Plast Reconstr Surg 74:124-126, 1984.

3. Schneider WJ, Hill Jr HL, Brown RG, "Latissimus Dorsi Myocutaneous Flap for Breast Reconstruction." Br J Plast Surg 30:277, 1977.

4. Bostwick III J, Vasconez LO, Jurkiewicz MJ, "Breast Reconstruction After Radical Mastectomy." Plast Reconstr Surg 61:682, 1978.

5. McCraw J, Papp CH, "Fleur-de-Lis Breast Reconstruction." Hartrampf's Breast Reconstruction with Living Tissue, pp 211-248. Hampton Press, Norfolk, VA, 1991.

6. "Efficacy of Bilateral Prophylactic Mastectomy in Women with a Family History of Breast Cancer." New England Journal of Med. 2:340, 1999

Illustrations by Meg Bennett.

Reprinted with permission from Contemporary Surgery, Vol.41, September 1992.