PUBLICACIONES
EN REVISTAS CIENTIFICAS DE CIRUGIA ESTETICA Y
PLASTICA
CIRUGIA ESTETICA DE LA MAMA.
RECONSTRUCCION MAMARIA MEDIANTE EXPANSION TISULAR
CON DESINSERCION PARCIAL DEL MUSCULO PECTORAL
MAYOR.
Mammary Reconstruction Using Tissue Expander and
Partial Detachment of the Pectoralis Major Muscle
to Expand the Lower Breast Quadrants
José María Serra–Renom, MD,
PhD, Joan Fontdevila, MD, Jaume Monner, MD, and
Jesus Benito, MD, PhD
Abstract: The techniques commonly
used in breast reconstruction with tissue expanders
do not provide a good definition of the lower
breast quadrant. With the authors’ technique
a better profile of the breast is achieved. Partial
detachment of the pectoral muscle is
performed, suturing it to the lower skin flap
and thereby avoiding cranial migration of the
expander. In addition a rounded shape of the lower
quadrants is achieved and the expander remains
in a subcutaneous position. (Ann Plast Surg 2004;53:
317–321)
Since its introduction by Radovan1 more than
20 years ago, the use of tissue expanders in breast
reconstruction has become a classic technique.
Since then, the technique has
greatly improved with the introduction of double-lumen
expanders2– 6 and, later, differential expanders
with an integrated valve and anatomic prosthesis.7–9
To avoid expander extrusion, the expander should
be placed in a submuscular position. Thus, in
some patients, the serratus muscle is sutured
to the pectoralis major muscle or
the latter is sutured to the pectoralis minor
muscle. Complete submuscular placement favors
cranial migration of the expander and impedes
good breast definition, especially in the lower
quadrants.
Our technique consists of the detachment of the
pectoralis major muscle at a sternal level at
the lower medial limit and the sixth rib. A tissue
expander is placed in a submuscular
position to achieve definition of the upper quadrants
on an inclined plane, to avoid elevation of the
breast during tissue expansion, and to acquire
a round shape in the lower
quadrants of the breast with the placement of
the subcutaneous expander at this level.
METHODS AND MATERIALS
Technique
The site of the placement of the tissue expander
is designed first, as are the size of the pocket
and the situation of the new submammary fold.
The pocket is dissected up to
2 cm below the level of the submammary fold of
the contralateral breast.
The surgical approach is performed by mastectomy
incision. The upper subcutaneous flap is dissected
superiorly to the infraclavicular region, with
careful separation from the
pectoral major muscle to avoid lesions. The cutaneous
flap is dissected caudally until the sixth rib
above the pectoralis major and serratus muscles
and the rectoabdominal fascia.
Both upper and lower subcutaneous dissection are
important to achieve good adaptation of the cutaneous
flaps and the pectoralis major muscle. The pectoralis
major is then detached
from the sternum at its lower level from the area
located in the 3-o’clock to the 6-o’clock
position on the right side, and the area from
the 6-o’clock to the 9-o’clock position
on the left side.
The insertions of the pectoralis muscle are sectioned
at the level of the sixth rib (Fig. 1). It is
important not to detach a greater area of the
muscle at the sternal level to avoid retraction.
A pocket is then dissected by detaching the pectoralis
major muscle up to the clavicular margin. On preparation
of the surgical pocket, the anatomic expander
with an integrated valve, full height or low height,
is placed under the pectoral muscle, and the free
edge of the pectoral muscle is sutured to the
lower cutaneous flap at 2 cm with transfixing
stitches or in the fatty tissue (Fig. 2). We initially
sutured the muscle directly at the lower edge
of the incision; however, lumping was observed
at the level of the scar.
For the past 4 years, we have fixed the muscle
in the fatty tissue 2 cm below the lower edge
of the incision (Fig. 3) to avoid this lumping
effect. Lastly, cutaneous closure is undertaken
with absorbable subcutaneous stitches of 3–0
and 4–0, and intradermal
suturing is performed with 4–0 monofilament
(Fig. 4).
Expansion begins 15 days after the surgery, twice
a week, until a 20% overexpansion % is achieved.
Four months after surgery the expander is substituted
with the permanent prosthesis. When placing the
prosthesis it is important to avoid complete opening
of the incision to avoid denervation of the lower
segment of the pectoral muscle. Thus, only the
most lateral part of the incision is opened outside
the anterior axillary line.
During the postoperative period the patient should
not wear a brassiere, which may elevate the expander.
If pexia or reduction is performed in the healthy
breast, a brassiere may be worn on this breast
but not on the reconstructed breast. For this
purpose we have designed a brassiere that does
not raise the reconstructed side.
Patients
Seventy-five patients distributed into 4 groups
according to the type of surgery required in the
healthy breast underwent surgery: group 1, breast
reconstruction without surgery of the healthy
breast (n = 14); group 2, breast reconstruction
and contralateral pexia (n = 22); group 3, breast
reconstruction and contralateral breast reduction
(n = 31); and group 4, breast reconstruction and
augmentation of the contralateral breast (n =
8).
No significant complications were observed in
any of the patients (Figs. 5 and 6).
DISCUSSION
The main problem with tissue expanders in the
breast is that the expander becomes displaced
cranially during expansion or during the postoperative
period as a result of the use of subjective clothing
(Fig. 7), making it difficult to achieve good
reconstruction. Moreover, the reconstructed breast
should have a drop shape, presenting an inclined
plane on superior planes with good, rounded projection,
particularly of the lower external quadrant, on
the inferior planes. On placement of the expander
with this technique, the 2 upper quadrants remain
submuscular and the 2 lower quadrants are subcutaneous,
thereby achieving optimum expansion.
Cranial coverage of the expander with muscle makes
a more anatomic and natural shape, obtaining an
adequate inclined plane at the level of the upper
quadrants. In addition, this allows correct expansion
of the lower quadrants because the expander is
placed subcutaneously at this level and does not
have muscle resistance, thereby achieving maximum
efficacy of the differential expansion. With the
detachment of the lower half of the muscle, the
expander is not raised on contraction of the muscle
and this allows better expansion of the lower
quadrants, providing a more aesthetic, round profile
of the breast in its lower external quadrant.
The pectoral muscle flap sutured 2 cm from the
edge of the lower cutaneous flap protects the
mastectomy wound, avoiding the possibility of
expander extrusion.
We have performed this technique since 1993. In
the beginning we sutured the muscle at the edge
of the lower cutaneous flap. However, lumping
was observed at the level
of the scar and thus we decided to place transfixing
stitches of the muscle to the dermal flap, but
this occasionally led to a problem of cranial
migration of the muscle. Currently we
suture the free edge of the muscle 2 cm below
the cutaneous edge of the lower flap. It is important
to take into account that the pectoral muscle
should not be detached above the fifth rib because
this may also cause retraction.
The incision sectioning the muscle for placement
of the prosthesis should not be long because this
may denervate the distal portion of the muscle,
leading to problems
of extrusion of the prosthesis. We therefore recommend
that the incision in the mastectomy scar be placed
as lateral as possible.
REFERENCES
1. Radovan C. Breast reconstruction after mastectomy
using the temporary expander. Plast Reconstr Surg.
1982;69:195–208.
2. Argenta LC. Reconstruction of the breast by
tissue expansion. Clin Plast Surg. 1984;11:257–264.
3. Becker H. Expansion augmentation. Clin Plast
Surg. 1988;15:587–593.
4. Serra–Renom JM, Samayoa V, Valiente E.
Breast reconstruction and asymmetry corrections
by Becker’s expansive prosthesis. Rev Senol
Patol Mam. 1988;1:27–30.
5. Serra–Renom JM, Samayoa V, Valiente E.
Delayed breast reconstruction by tissue expansion
in subcutaneous mastectomy. Rev Senol Patol Mam
1988;1:23–26.
6. Serra–Renom JM, Samayoa V, Valiente E.
Breast reconstruction after mastectomy by tissue
expansion. Rev Senol Patol Mam. 1988;1: 31–39.
7. Maxwell GP, Falcone PA. Eighty-four consecutive
breast reconstructions using a textured silicone
tissue-expander. Plast Reconstr Surg. 1992;89:
1022–1034.
8. Maillard GF. McGhan style 410 anatomic breast
implants. Plast Reconstr Surg. 1995;96:495–496.
9. Serra–Renom JM, Vila R. Endoscopia en
Cirugía Plástica y Estética.
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