Journal of Aesthetic & Reconstructive Surgery

Keywords

Autologous dermal flap; Dermal sling; Breast reconstruction

Introduction

The use of an autologous dermal sling created from the deepithelialized skin of an inferior mastectomy flap is sometimes described as the Bostwick technique after it was described in a plastic surgery textbook in the 1990’s [1]. This description covered an immediate implant with 2 layers of vascularised tissue after a ‘Wise pattern’ mastectomy with a free nipple graft. However, publications describing the use of an ADF have been published as early as the late 1970’s [2]. A Medline search combined with reference list search was performed to describe the various published techniques in breast reconstruction using an ADF and the general benefits and pitfalls of the procedure.

Literature Review

Hannson et al. [3] published a systematic review on the number of techniques used and synthesised it down to 9 categories (Table 1). An ADF can be used in the technique above (‘classic’ dermal sling (DS)) or with a non-wise pattern mastectomy. It can be used in conjunction with a synthetic mesh or acellular dermal matrix (ADM), with or without an implant, or simply as a buttress for a suture line or T-junction. It can be used in a 1 stage or 2 stage reconstruction. One of the primary outcomes was to grade the level of evidence in the literature that used an ADF in breast reconstruction using Oxford Centre for Evidence-Based Medline 2009 guidelines. Generally, the level of evidence in most of the studies used was of low to very low quality being mostly case and cohort studies. They could not find any randomised controlled trials for the use of any of these flaps. This is inherently difficult as there is no established standard technique for the use of ADF as a comparison. Furthermore, randomisation of patients would be difficult as they are highly selected to undergo this technique in the first place. However, the main conclusions were that the ADF was a good option in the patient with macromastia and significant ptosis. An ideal nipple to IMF length of 8-15 cm was suggested however this depends on size of end result. Unfortunately, most of the studies on the use of ADF are low level across the literature, not just in this systematic review (Table 2).

Table 1: Summary of the participants’ demographics.

Table 2: Summary of access to breast reconstruction surgery services.

In many circumstances the use of an ADF negates the need for a synthetic mesh or matrix to provide implant coverage. These are often very expensive especially the human derived ADM. A literature review performed by a US group comparing ADM in patients undergoing a single staged immediate breast reconstruction demonstrated a cost benefit to using an ADF [4]. This cost benefit was durable with a complication rate of up to 20%. Most studies analysed in this paper quoted and average of 10.5% complication rate compared to 11% with an ADM. This benefit is further strengthened by the fact that most women undergoing an ADF have a higher BMI, which is an independent risk factor for complications [5]. This is because the breast needs to be sufficiently large in order to us the inferior mastectomy flap as an ADF. This study did demonstrate a reduced rate of infection, seroma and heamatoma rate with the use of an ADF however mastectomy skin necrosis and explanation were higher. An ADF was still not recommended in smokers, however smoking increasing the risks of complications in all breast cosmetic and reconstructive procedures [6].

Discussion

In general however, most of the reviewed literature supported the fact that using an ADF resulted in lower complications overall and was safe and effective in select patients [7,8]. Ladizinsky et al. [1] had an overall complication rate of 23.5%. The highest being in the patients who smoked, had a BMI>35 and had a direct to implant reconstruction. A further risk factor was a volume of breast excised >700 g [9]. The use of a tissue expander to reduce the tension on the mastectomy flap correlated with a lower flap necrosis rate. The patient population that benefited the most were the BRCA group undergoing bilateral prophylactic mastectomy. They surmised the lack of lymph node biopsy; younger age and less co-morbidities lended well to a good outcome and so may be ideal in this patient population. Other studies with smaller series published favourable results with low complication rates using an ADF [10-13]. The use of an non-autologous acellular dermal matrix has been associated with an increase in infection rate, especially in patients with a high BMI which is the patient population that usually benefit the most from and ADF [5] (Table 3).

Table 3: Summary of breast reconstruction surgery information.

The T-junction of a wise pattern mastectomy is prone to wound breakdown and loss or extrusion of implant if used to reconstruct the breast. An ADF can be used as vascularised tissue to cover the implant and provide a scaffold for epithelialization and a buffer to wound breakdown or flap necrosis particularly in the t-zone. The rate of implant exposure and extrusion was lower when an ADF was used in this circumstance [14]. Similarly, preservation of the nipple during a nipple sparing mastectomy in a large ptotic breast has a higher risk of nipple and skin flap necrosis. This is due to the excessive length of vascular pedicle to the extremity of the breast. Lavin et al. developed a novel technique using a bipedicle dermal flap. A skin reducing wise pattern utilising an inferior pedicle is marked. The inferior pedicle and usual area of skin excision is de-eplithelialised. The nipple sparing mastectomy is performed through an incision through the lateral edge of de-epithelialised skin. A subpectoral implant is placed and the skin flaps are sutured over the de-epithelialised skin. The vascularity of the ADF or nipple is rarely compromised due to the wide inferior vascular pedicle [15]. Most papers describing the use of an ADF preserving the nipple do so by a free nipple graft over de-eplithelialised skin in the upper flaps in the pre-marked position.

The disadvantage of ADF most often quoted is the limitation to the large and ptotic breast and this is true of the classic DS as a large amount of tissue is required to cover the implant. A nipple to inframammary fold distance of greater than 8 cm and a nipple to sternal notch greater than 25 cm are the ideal dimensions for an adequate ADF [10]. Nair et al. [16] however used ADF in medium and small non-ptotic breast but employed an expander rather than permanent implant to achieve the desired size subverting this limitation. There was no discussion however about later exchange of the expander implant, which leads one to think that they used the expander as a permanent implant. Modern expanders are not designed to stay in long term and need to be exchanged for a permanent implant. Hammond et al. [17] and others [18] also employed the use of ADF in a 2 staged reconstruction using a tissue expander in the early 2000. They reported using the lateral end of the inframammary wound to exchange to a permanent implant at a later stage. This did not appear to compromise the ADF or the implant.

Nava et al. [10] then adopted the single stage reconstruction with a direct to permanent implant in 2006 which is widely quoted in much of the following literature [7,19,20]. They have published further papers on this technique [21] always using a sub-pectoral pocket. The ADF is sutured to the lower end of the pectoralis major muscle. A pre-pectoral approach can be used if combined with a mesh or acellular dermal matrix. Caputo et al. [22] created a pocket using a porcine derived acellular dermal matrix to provide superior pole coverage to an implant sutured to an inferior ADF and the pec major muscle. Avoidance of dissection of the sub-muscular plane resulted in less postoperative pain with no animation artefact on contraction of pec major muscle while achieving a good cosmetic outcome. Implant loss due to T-junction breakdown was not experienced in this small study. This was again attributed to the coverage of the implant in the lower pole with well vascularised ADF.

The use of an ADF in patients who have had neoadjuvant or previous chemotherapy or radiotherapy has yet to be fully investigated and would be of great value with the increasing use of reverse sequencing. Autologous tissue reconstruction is usually favoured if reverse sequencing is used due to the perceived high rate of capsular contractures with implant-based reconstruction. Mongrial et al. recorded a 23% capsular contracture rate in their 5 year follow up after neoadjuvant radiotherapy [23]. A recent review however found that the rate of complications after neoadjuvant radiotherapy is no higher than adjuvant radiotherapy even when an implant based reconstruction is used [24]. Most were implants placed with a latissimus dorsi flap for coverage [25]. The use of an ADF may be beneficial in this circumstance; however it is still relying on coverage of the implant with irradiated tissue [26].

Conclusion

The use of an ADF in implant-based breast reconstruction is a cost effective, safe and reliable method in women with a range of breast sizes. The ADF can be tailored to breast size and reconstruction method using a wide variety of techniques with less complication rates and lower cost.

References

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