• Archives of Plastic Surgery
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• v.50 no.6
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• pp.541-549
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• 2023

Background Despite its many advantages, prepectoral breast reconstruction also carries the risk of implant rippling. The recent introduction of partial superior implant coverage using a pectoralis muscle slip in prepectoral direct-to-implant (DTI) breast reconstruction has shown the potential to minimize upper pole rippling. The purpose of this study was to identify factors associated with rippling and the effectiveness of our surgical technique. Methods In total, 156 patients (186 breasts) who underwent prepectoral DTI breast reconstruction between August 2019 and March 2021 were identified retrospectively. Patient data were analyzed from medical records. Univariable and multivariable logistic analyses were performed to contextualize the risks associated with rippling deformity relative to demographic characteristics and other clinical factors. Retrospective propensity-matched analysis was performed to identify the relationship between rippling deformity and the reconstruction method. Results Patients with body mass index (BMI; odds ratio [OR], 0.736; p < 0.001), those with a postoperative chemotherapy history (OR, 0.324; p = 0.027) and those who received breast reconstruction via the superior coverage technique (OR, 0.2; p = 0.004), were less likely to develop rippling deformity. The median follow-up period was 64.9 weeks, and there were no significant differences between patients in types of mastectomy, implant, or acellular dermal matrix. Patients who underwent superior coverage technique-based reconstruction showed significantly reduced rippling (OR, 0.083; p = 0.017) Conclusion Patients with higher BMI and prior postoperative chemotherapy were less likely to develop rippling deformity. The superior coverage technique can be effective in minimizing upper pole rippling.

• Archives of Plastic Surgery
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• v.38 no.4
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• pp.401-407
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• 2011

Purpose: A number of flap for nipple reconstruction have been well described in the literature. However, most of these techniques do not permit the reconstruction of a projecting nipple and all are hampered to some extent by long-term loss of nipple projection. The objective of this study is to evaluate the long-term result and clinical efficacy of nipple reconstruction using skate flap technique after breast reconstruction. Methods: A retrospective chart review was carried out on 23 patients who underwent 25 nipple reconstructions. In those patients with greater than 10 mm nipple projection, reconstruction with skate flap and full-thickness skin graft and/or tattooing was performed. Maintenance of nipple projection was then carefully assessed over one-year follow-up. The following factors were analyzed: type of breast reconstruction, type of areola reconstruction, followup period, decrease in nipple projection, complication, and whether secondary nipple reconstruction was necessary and/or performed. Results: Breast reconstructions were performed in 17 patients with free transverse rectus abdominis musculocutaneous flap, 3 patients with extended latissimus dorsi musculocutaneous flap, and 3 patients with expander and implant. The mean follow-up after nipple reconstruction was 17 months. Mean loss of projection were $17.0{\pm}13.99%$, $25.0{\pm}12.70%$, $30.0{\pm}12.57%$ and $30.8{\pm}12.49%$ at 3, 6, 9 months and over one year, respectively. The greatest decrease in projection was noted in the first 3 months following surgery. Conclusion: These results indicated that nipple reconstruction with skate flap showed about 70 percent of the projection achieved over one year postoperation. Therefore, the skate flap may be a reliable method of nipple reconstruction in those patients with greater than 10 mm nipple projection.

• Archives of Plastic Surgery
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• v.45 no.2
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• pp.185-190
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• 2018

Subpectoral breast reconstruction using implants and meshes have been used widely in Europe, the United States and the United Kingdom. Although this technique has several advantages, animation deformity is a well-documented problem. We propose a new grading system to classify breast animation in patients undergoing subpectoral implant based breast reconstruction. We also discuss different techniques to avoid and correct animation deformity.

• Archives of Plastic Surgery
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• v.37 no.1
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• pp.83-86
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• 2010

Purpose: Authors present the case of 2 patients who underwent extended Latissimus dorsi myocutaneous flap to reconstruct postburn breast deformity. Methods: A 39-year-old woman and 18-year-old woman with postburn breast deformity visited for reconstruction. The nipples were preserved but normal breast development did not occur due to scar contracture. Burn scar contracture was released by excision of the restricting burn scar and breast mound was reconstructed with extended Latissimus dorsi myocutaneous flap. Additional contracture release with multiple z-plasty was performed at the axillae and medial portion of breast. Results: Postburn breast reconstruction using Latissimus dorsi myocutaneous flap showed natural shaped breast mound and inframammary fold. There was no significant complication in both cases. Conclusion: Latissimus dorsi myocutaneous flap provide sufficient skin and soft tissue and it could be an effective method for reconstruction of postburn breast deformity.

• Archives of Plastic Surgery
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• v.41 no.3
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• pp.258-263
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• 2014

Background For early breast cancer patients, skin-sparing mastectomy or nipple-sparing mastectomy with sentinel lymph node biopsy has become the mainstream treatment for immediate breast reconstruction in possible cases. However, a few cases of skin necrosis caused by methylene blue dye (MBD) used for sentinel lymph node localization have been reported. Methods Immediate breast reconstruction using a silicone implant was performed on 35 breasts of 34 patients after mastectomy. For sentinel lymph node localization, 1% MBD (3 mL) was injected into the subareolar area. The operation site was inspected in the postoperative evaluation. Results Six cases of immediate breast reconstruction using implants were complicated by methylene blue dye. One case of local infection was improved by conservative treatment. In two cases, partial necrosis and wound dehiscence of the incision areas were observed; thus, debridement and closure were performed. Of the three cases of wide skin necrosis, two cases underwent removal of the dead tissue and implants, followed by primary closure. In the other case, the breast implant was salvaged using latissimus dorsi musculocutaneous flap reconstruction. Conclusions The complications were caused by MBD toxicity, which aggravated blood disturbance and skin tension after implant insertion. When planning immediate breast reconstruction using silicone implants, complications of MBD should be discussed in detail prior to surgery, and appropriate management in the event of complications is required.

• Archives of Plastic Surgery
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• v.49 no.5
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• pp.587-595
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• 2022

Background The incidence of breast animation deformity (BAD) is reported to be substantial after direct-to-implant breast reconstruction with subpectoral implant placement. It has, however, never been examined if BAD can occur following prepectoral implant placement. Our primary aim was to compare the incidence and degree of BAD after direct-to-implant breast reconstruction using either subpectoral or prepectoral implant placement. Secondary aim of this study was to assess and compare the level of pain between sub- and prepectoral reconstructed women. Methods In this randomized controlled trial, patients were allocated to reconstruction by either subpectoral or prepectoral implant placement in accordance with the CONSORT guidelines. The degree of BAD was assessed by the "Nipple, Surrounding skin, Entire breast (NSE)" grading scale 12 months after surgery. The level of postoperative pain was assessed on a numerical pain rating scale. Results We found a significant difference in the degree of BAD favoring patients in the prepectoral group (23.8 vs. 100%, p < 0.0001; mean NSE grading scale score: 0.4 vs. 3.6, p < 0.0001). The subpectoral reconstructed group reported higher levels of pain on the three subsequent days after surgery. No significant difference in pain levels could be found at 3 months postoperatively. Conclusion The incidence and degree of BAD was significantly lower in women reconstructed by prepectoral direct-to-implant breast reconstruction. Unexpectedly, we found mild degrees of BAD in the prepectoral group. When assessing BAD, distortion can be challenging to discern from rippling.

• Archives of Plastic Surgery
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• v.36 no.1
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• pp.29-32
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• 2009

Purpose: Introduction of the mammary implant through the abdominal route has been well known since late 1960s, but the use of transabdominal route for contralateral breast augmentation in transverse rectus abdominis musculocutaneous (TRAM) flap breast reconstruction patients has not been reported in Korean literature. The authors report their experience with technical points as well as the selection of the appropriate patients. Methods: Simultaneous contralateral augmentation mammaplasty through transabdominal route was performed in 11 patients who underwent TRAM breast reconstruction from August 2003 to May 2008 with a mean follow up of 27 months. The pocket was created under direct vision: 3 subglandular, 7 subpectoral, and 1 dual plane was dissected. Eight saline and 3 silicone gel implants were used with an average volume of 165 cc. Results: There were no complications such as infection, hematoma, implant displacement, and capsular contracture. The result was well maintained throughout the follow up period. Conclusion: Transabdominal route could be recommended in selected patients for contralateral augmentation in TRAM breast reconstruction.

• Archives of Plastic Surgery
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• v.48 no.1
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• pp.26-32
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• 2021

Background Although loss of sensation in patients with breast cancer after mastectomy followed by breast reconstruction is an important factor affecting patients' quality of life, the mechanism of sensory recovery is still unclear. Our study aimed to identify variables that affect sensory recovery, especially pain, in reconstructed breasts. Methods All patients with breast cancer who underwent mastectomy followed by immediate breast reconstruction, including nipple reconstruction or areolar tattooing, were included in this study. Sensation was evaluated in the nipple as an endpoint of sensation recovery of the whole breast. Patients rated pain severity using a 3-point verbal rating scale (VRS): grade 0, no pain; grade 1, mild to moderate pain; and grade 2, severe pain. The VRS was assessed by a single experienced plastic surgeon. Results In the univariate analysis, the odds ratio (OR) for sensation recovery was 0.951 for age (P=0.014), 0.803 for body mass index (P=0.001), 0.996 for breast volume before surgery (P=0.001), 0.998 for specimen weight after mastectomy (P=0.040), and 1.066 for the period between mastectomy and sensory assessment (P=0.003). In the multivariate analysis, the variables that showed a significant effect were age (OR, 0.953; P=0.034), the period between mastectomy and sensory assessment (OR, 1.071; P=0.006), and reconstruction using abdominal tissue instead of prosthetic reconstruction (OR, 0.270; P=0.004). Conclusions Based on our results, it can be inferred that aging has a negative impact on the recovery of sensation, breast sensation improves with time after surgery, and the recovery of sensation is better in prosthetic reconstruction.

• Archives of Plastic Surgery
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• v.40 no.1
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• pp.19-27
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• 2013

Background Acellular dermal matrix (ADM) allografts and their putative benefits have been increasingly described in prosthesis based breast reconstruction. There have been a myriad of analyses outlining ADM complication profiles, but few large-scale, multi-institutional studies exploring these outcomes. In this study, complication rates of acellular dermis-assisted tissue expander breast reconstruction were compared with traditional submuscular methods by evaluation of the American College of Surgeon's National Surgical Quality Improvement Program (NSQIP) registry. Methods Patients who underwent immediate tissue expander breast reconstruction from 2006-2010 were identified using surgical procedure codes. Two hundred forty tracked variables from over 250 participating sites were extracted for patients undergoing acellular dermis-assisted versus submuscular tissue expander reconstruction. Thirty-day postoperative outcomes and captured risk factors for complications were compared between the two groups. Results A total of 9,159 patients underwent tissue expander breast reconstruction; 1,717 using acellular dermis and 7,442 with submuscular expander placement. Total complications and reconstruction related complications were similar in both cohorts (5.5% vs. 5.3%, P=0.68 and 4.7% vs. 4.3%, P=0.39, respectively). Multivariate logistic regression revealed body mass index and smoking as independent risk factors for reconstructive complications in both cohorts (P<0.01). Conclusions The NSQIP database provides large-scale, multi-institutional, independent outcomes for acellular dermis and submuscular breast reconstruction. Both thirty-day complication profiles and risk factors for post operative morbidity are similar between these two reconstructive approaches.

• Archives of Reconstructive Microsurgery
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• v.19 no.1
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• pp.68-79
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• 2010

Lower abdominal tissue is regarded as an ideal donor site for the breast reconstruction because it provides large skin territory and huge amount of soft tissues enough to the breast size. However it is not easy for the surgeon to reconstruct the really natural breast, and needs the learning curve with long time experience. Author represent the various reconstruction procedures for the breast using lower abdominal tissue such as muscle sparing free TRAM, DIEP, and SIEA free flaps to reinsure like breast. Indications, and selection of reconstructive methods, surgical timing, selection of donor sites and recipient vessel of these flaps were reviewed. In addition, detailed procedures, surgical tips and secondary adjuvant procedures are described for more symmetry of reconstructed breast. The muscle sparing free TRAM, DIEP, and SIEA free flaps would be enough to provide supple, huge amount of well vascularized tissue for the breast, if these flaps were selected for the appropriate indication according to patient's general condition, obesity, the opposite breast and abdominal tissue condition. Lower abdominal tissue was able to provide versatile designs with sufficient adipose tissue without compromising the integrity of abdominal wall.