OUR EIGHT-YEAR EXPERIENCE WITH BREAST RECONSTRUCTION USING ABDOMINAL ADVANCEMENT FLAP (207 RECONSTRUCTIONS)

INTRODUCTION

For many years we have known that mastectomy significantly influences quality of life (1). In recent years, more and more patients seek reconstructive procedures. Depending on local findings in the area after mastectomy, we can offer these patients a variety of procedures. All of them attempt to create an appearance which is as natural as possible when unclothed and normal while wearing clothes. The most common approaches to breast reconstruction are expander/implant, latissimus/implant, free TRAM and DIEP reconstruction (2).

Seventy percent of all breast reconstructions use alloplastic materials. The combination of expander and implant has become a gold standard, partly because it represents the least invasive procedure with rapid recovery (3). It is particularly beneficial for women desiring smaller breasts. The disadvantages of implant reconstruction are the risk of capsular contracture (4) and the impossibility of achieving symmetry in unilateral reconstruction with ptotic contralateral breast. In addition, it is likely that the patient will need an implant exchange at some period in the future.

An essential requirement for implant reconstruction, to achieve good volume, shape and symmetry, is a sufficiently large of skin envelope. We have several options when it comes to increasing the amount of skin in this area. As well as established methods such as the use of expander or latissimus flaps, we can use skin advancement from lower thoracic/upper abdominal area. This technique was described by Lewis as far back as in 1979 (5). Eventually it was modified by Ryan (6) or further combined with expansion (7), or latissimus flap (8). By using this method we can achieve a well-defined inframmamary fold with more ptotic shape as well as good match of skin color and texture of a new breast.

We perform breast reconstructions within our Centre of Complex Care for Women with Breast Cancer at Department of Plastic Surgery of 1^st Medical Faculty, Charles University in Prague. Eight years ago we added to our spectrum of procedures breast reconstruction using abdominal advancement flap in combination with breast implantation. By using this technique on patients with minor skin excess in the area after mastectomy we can perform breast reconstruction extremely simply and quickly with excellent results.

METHOD

The principle of breast reconstruction using abdominal advancement flap lies in acquiring several centimeters of skin by wide skin mobilization from the lower thorax and upper abdomen cranially (Fig. 1). Placing the mastectomy scar low during a primary operation is advantageous for the operation and final cosmetic effect. The submammar line is fixated by non-absorbable buried interrupted sutures. It is necessary to overcorrect the position of the submammar line since it will descend during the postoperative course. The extent of advancement is dependent on skin elasticity as well as the thickness of subcutaneous tissue. Therefore this technique is not suitable for overweight patients. Subsequently, we release the pectoral muscle caudally and medially, and we insert the silicone implant in the subpectoral plane. We prefer to use anatomical implants, which give the breast a better shape. In rare cases we use turn-over abdominal muscular flap sutured to lower edge of the pectoral muscle for coverage of the lower part of the implant. Nipple areola complex reconstruction is performed with at least a three-month interval, together with potential contralateral mastopexy.

RESULTS

We followed 157 patients in the course of one to six years, on whom 207 breast reconstructions using abdominal advancement flap were performed (Table 1), 171 (83%) non-iradiated and 36 (17%) irradiated. 107 patients underwent unilateral reconstruction and 50 patients bilateral reconstruction (Fig. 2, 3, 4). Postoperative results evaluating individual breasts were: excellent (n=156; 75.4%), good (n=31; 14.9%), sufficient (n=19; 9.2%) and unsatisfactory (n=1; 0.5%).

The most common complication in the followed group evaluating single breasts was implant capsulation, evaluated as Baker III-IV (n=58; 28%). From the group of implant capsulations 31 (55%) breasts were evaluated as Baker IV, 21 (37%) in irradiated patients and 10 (18%) in non-irradiated patients. Previous tissue irradiation is also connected with higher risk of prolonged healing (n=2; 1%), tissue edema, seroma, possibility of implant displacement (n=4; 1.9%) and skin necrosis (n=2; 1%). This condition can occur at non – irradiated patients as well, however.

DISCUSSION

The advantage of breast reconstruction using abdominal advancement flap in combination with silicone implant is its simplicity, short learning curve, short operative time (45 minutes), and the fact that this one-time procedure minimizes operative stress for the patient. Only post-mastectomy scars are used for the incision. The period of post-operative recovery is very short in comparison with other reconstructive procedures. In addition, cosmetic results for correctly indicated women are excellent.

This technique is suitable for reconstruction of small and firm breasts. However, it is not appropriate for reconstruction of large and/or ptotic breasts. We have to be careful with women after irradiation, which often leads to severe implant capsulation and negatively influences the cosmetic result of the operation.

Cooperation with a general surgeon performing the primary procedure is very beneficial, since he/she can preserve certain skin excess and place a final scar in an area best suitable for subsequent reconstructive procedure.

The abdominal advancement flap can be especially beneficial for immediate breast reconstruction after mastectomy. In a case of skin-sparing mastectomy with immediate reconstruction with breast implant, we can achieve tension-free coverage more easily.

CONCLUSION

The use of abdominal advancement flap in combination with silicone implant is not suitable for all patients after mastectomy. It is preferable for patients with slight skin excess after mastectomy and smaller contralateral breasts. This type of reconstruction can expand the number of possible techniques and facilitate the selection of the technique best suitable for a patient.

Address for correspondence:

Karel Urban, M.D.

Department of Plastic Surgery

1^st Medical Faculty, Charles University in Prague

University Hospital Bulovka

Budínova 67/2

180 81 Prague 8

Czech Republic

E-mail: urban.karel@seznam.cz