Pocket work for optimising outcomes in prostheticbreast … · 2011. 1. 14. · deeper, sectioning the fascia superﬁcialis, fat and cel-lular subcutaneous tissue (CST). Then, the

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FPocket work for optimising outcomes in prostheticbreast reconstruction

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Hugo D. Loustau*, Horacio F. Mayer, Manuel Sarrabayrouse
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PRPlastic Surgery Department, Hospital Italiano de Buenos Aires, University of Buenos Aires, School of Medicine,Buenos Aires, Argentina

Received 30 June 2007; accepted 30 August 2007

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KEYWORDSProsthetic breastreconstruction;Pocket work;Capsulotomy;Capsulectomy;Capsulorraphy;Myectomy

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* Corresponding author. Address: PHospital Italiano de Buenos Aires,School of Medicine, Gascon 450 (118Tel.: þ54 11 49590506.

E-mail address: hugo.loustau@hLoustau).

1748-6815/$ - see front matter ª 2008 Pdoi:10.1016/j.bjps.2007.08.037

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Please cite this article in press as: HuReconstr Aesthet Surg (2008), doi:10

RRECTED

Summary Implant breast reconstruction is a recommendable alternative for women whohave undergone mastectomy and lack the necessary subcutaneous fat tissue for an autologousreconstruction. On the other hand, many women reject the morbidity of the donor site, pro-longed recovery periods and muscular weakness associated with autologous reconstruction.Therefore, muscle and skin expansion has become one of the most popular approaches usedin breast reconstruction. Nevertheless, the expansion process may be hindered by events likeseroma formation, implant rotation, moving upward or downward altering the location orshape of the submammary crease, capsule contracture or extrusion. Since the advent of theanatomical expander, two-stage reconstruction with the expander/implant sequence has be-come the most popular choice in prosthetic breast reconstruction (PBR). The second surgicalstage, in which the tissue expander is exchanged for the permanent implant, offers a uniqueopportunity for pocket work. Pocket work strategies and their indications should be known andapplied by the surgeon who aims at optimising PBR aesthetic results.ª 2008 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive andAesthetic Surgeons.

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NCImplant breast reconstruction is a recommendable alterna-

tive for women who have undergone mastectomy and lackthe necessary subcutaneous fat tissue for an autologousreconstruction. On the other hand, many women reject themorbidity of the donor site, prolonged recovery periods and

lastic Surgery Department,University of Buenos Aires,1), Buenos Aires, Argentina.

ospitalitaliano.org.ar (H.D.

ublished by Elsevier Ltd on behalf of

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muscular weakness associated with autologous reconstruc-tion. Therefore, muscle and skin expansion has become oneof the most popular approaches used in breast reconstruc-tion.1 Tissue expansion recruits local tissue with similar tex-ture, colour and sensitivity, thus avoiding donor sitemorbidity and reducing operative time and enhancing post-operative recovery. Nevertheless, the expansion processmay be hindered by events like seroma formation, implantrotation, moving upward or downward, altering the loca-tion or shape of the submammary crease (SMC), capsulecontracture or extrusion.2,3 There are several options inprosthetic breast reconstruction (PBR) which could be

British Association of Plastic, Reconstructive and Aesthetic Surgeons.

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or optimising outcomes in prosthetic breast reconstruction, J Plast

mailto:[email protected]

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immediate (IPBR), delayed (DPBR) and at the same time ineither one or two stages (Table 1).4e7 Even though patientsmay prefer reconstruction with permanent expanders suchas the Becker type, or the most modern ones such as theMcGhan Style 150, to avoid a second surgery,6 the authorsdiscourage this practice because it does not allow adequatesymmetrisation if a displacement occurrs. Since the adventof the anatomical expander,8 two-stage reconstruction withthe expander/implant sequence has become the most pop-ular choice in PBR. During the second stage, expander re-moval and final implant placement provide an excellentopportunity to perform pocket work. Pocket work (PW) en-hances implant location and allows for strategic alterationsof soft tissue, if they are necessary. The authors aim atshowing the resources they currently use to optimise PBRsymmetry, similitude and natural look.

Materials and methods

Between January 1992 and January 2005, 310 patientswhose ages ranged from 27 to 72 years (average 46 years),underwent PBR (Table 1). All procedures were carried outunder general anaesthesia. The authors reviewed all thosecases in which PW was necessary during the replacement ofthe expander by the final implant in a two-stage recon-struction, or after the final implant placement in eithera second stage or a primary reconstruction (immediate ordelayed). Several causes for PW were analysed: inade-quately positioned implants, capsular or muscular restric-tions and capsular laxity that required surgery to correctthe disharmony. These situations were reviewed in patientswith either the expander or the final implant.

As previously defined by the authors,9 the reconstructedbreast shows some anatomical features determined notonly by the implant shape but also by the soft tissue includ-ing the capsule. Three distinctive features can be high-lighted in a reconstructed breast:

(a) The submammary crease (SMC) is the feature that uponevaluation ensures the best aesthetic impact. From anaesthetic point of view, SMC is enhanced by three fea-tures: height, shape and definition.

(b) The reconstructed breast projection is influenced bythe success of the expansion process and the implant’sfeatures.

(c) The upper mammary margin (UMM) defined as the transi-tion between chest and the implant’s cephalic boundary.

These factors determining the final outcome in breastreconstruction are always conditioned by the thickness and

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Table 1 Patients and modalities of PBR employed

One stage immediate reconstruction (primary)Immediate expander e implant sequencePermanent expander e implant immediate reconstruction (220 pOne stage delayed reconstruction (primary)Delayed expander e implant sequencePermanent expander e implant delayed reconstruction (90 patie

Total: 310 patients e 376 PBR

Please cite this article in press as: Hugo D Loustau et al., Pocket work fReconstr Aesthet Surg (2008), doi:10.1016/j.bjps.2007.08.037

EDPROOF

malleability of the soft tissues covering the implant, in-cluding the capsule, and by the position of the implant on thechest. When the expander or final implant is not located atthe right position to achieve symmetry or is having sectorialrestrictions, it will require pocket work. These cases can beorganised into eight categories and are listed in Table 2.There a number of solutions which can be applied either incombination or in isolation depending on the deformity:

(a) Capsulorraphies: the capsulorraphy is a resource aimingto reduce the pocket size at any margin. Most of thetime, it is executed at the level of the SMC and, lessfrequently, at the level of the anterior axillary linewhen the implant is lateralised. The technique pro-duces a re-definition of the SMC or the anterior axillaryline with a running suture preserving capsule integrity.Additionally, the creation of raw areas by electrocau-tery promotes a better adherence. This can be carriedout very superficially, creating just a shallow scoring, ordeeper, sectioning the fascia superficialis, fat and cel-lular subcutaneous tissue (CST). Then, the hypodermisis fixed to the thoracic wall with a permanent runningsuture, in order to achieve a better defined SMC.When an expander or implant is removed, the lowerboundary of the pocket folds itself, thus points of refer-ences are lost. Therefore, it is necessary to recreatethe real position of the SMC as if the expander were po-sitioned. Before deciding where to reposition the SMC,it is necessary to know what the original position was.This position is mimicked exerting traction andcounter-traction manoeuvres. The surgeon retractsand raises the flap by means of a retractor, while theassistant pulls the skin downwards. This way, the grav-itational effect and the presence of the implant insidethe pocket is simulated, which is very helpful for thesurgeon. Capsulorraphies almost always involve the lift-ing of the SMC. The lowest point of the capsular back-side, where a curve named C starts as the main pointof reference, is named point A (Fig. 1). This pointdoes not necessarily correspond with the SMC drawnon the skin with the patient in standing position. Thedifference in height between the SMC of both breasts,in centimetres, is transferred above point A, determin-ing point A0 Point A00 results from transferring the samedistance on the curve C, below point A. This way, thedegree of ascent results from transporting point A00 tothe back wall of the capsule, coinciding with point A0,and with point A being the turning point. When theimplant is lateralised, capsulorraphy of the anterioraxillary line should be complemented with the

17 patients (11 bilateral)198 patients (48 bilateral)

atients e 282 IPBR) 5 patients (3 bilateral)9 patients (1 bilateral)74 patients (3 bilateral)

nts e 94 DPBR) 7 patients

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ROOF

Table 2 Indications for pocket work

a) Downward migration of implant and SMC due to anexcessive capsular softness or laxity.

b) Lateral migration of implant due to an excessive capsularsoftness or laxity.

c) Upward migration due to capsular sectorial constrictionwith expander elevation.

d) Restriction of upper-medial quadrant by inadequaterelease of pectoralis major’s fibres from costal insertionsor by development of sectorial capsular contracture.

e) Axial rotation of the expander or implant (anatomicimplant dystopia) usually associated with seromaformation.

f) Fibrous capsular contracture after implantation of thepermanent breast implant.

g) Malpositioning of the implant (too high, too low orlateralised) by the surgeon.

h) Deliberate lower positioning of the expander in order torecruit extra soft tissue coverage.

Figure 2 Capsulotomy/myotomy for plane change. Thereare three levels of capsulotomy and undermining. At level I, af-ter capsulotomy, the undermining proceeds underneath themuscular plane. No relaxation is obtained. When performingcapsulotomies at level II moderate relaxation of the lowerpole is obtained, relaxation being maximal at level III. Thelast two always involve myotomies.

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enlargement of the pocket towards the midline in orderto avoid recurrence.

(b) Capsulotomies: the capsule is severed in order to releaseadhesions developed during the expansion process.

(c) Capsulotomies/myotomies for plane exchange: are in-tended to expand the pocket capacity, usually down-ward. This always implies the change of anatomicalplane towards a thinner plane lacking capsule and mus-cle (Fig. 2). This plane provides the required malleabil-ity to achieve an adequate projection of the implant’slower pole. The change of plane is executed at least2 cm above the SMC, incising capsule and muscle andthen undermining proceeds above the fascial layer.This way, the lower pole of the implant is just coveredby the SCT and skin, achieving enough enlargement and

UNCORR

Figure 1 Capsulorraphies. The original position of the SMC ismimicked exerting traction and counter-traction manoeuvres.The surgeon retracts and raises the flap by means of a retrac-tor, while the assistant pulls the skin downwards. The mainpoint of reference is named point A.

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EDPdistensibility without previous expansion. Neverthe-

less, if this manoeuvre was performed in isolation,two different tensions would be created and as a conse-quence a double bubble deformity would result.10 Asa result, capsulotomies/myotomies for plane changeare always associated with capsulotomies/myotomiesfor progressive relaxation.

(d) Capsulotomies/myotomies for progressive relaxation:previous to switching the anatomical plane, the en-largement of the pocket always involves performingcapsulotomies and radial myotomies in inverted fanshape, extending 2.5 to 3 cm above and finishing atthe level of the change of plane (Fig. 3).

(e) Capsulectomies/myectomies: involve the resection ofan important portion of the capsule or capsule andmuscle. They usually start as capsulotomies/myotomiesfor plane change and, once the inferior boundary isreached, a resection of a crescent-shaped portion ofcapsule and muscle (patch myectomy) is carried out(Fig. 4). Capsulotomies/myotomies for progressive re-laxation are always associated with this resource.

(f) Liposuction at the level of the SMC: although it cannotbe strictly considered pocket work, liposuction can re-ally improve SMC definition, therefore it has been in-cluded in this classification. In most of the cases it isassociated with capsulorraphy in order to provide bet-ter SMC definition.

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Results

During the 13-year study period, 105 of the total of 376 PBRcases (27.9%) required PW. Of the 282 IPBR, 81 cases (28.7%)needed PW. Of the 94 cases reconstructed through DPBR(25.5%), 24 required PW. The most frequent proceduresemployed in this series for PW are listed in Table 3 and itscomplications in Table 4. Results were very good in termsof mammary symmetry and patient satisfaction (Figs. 5e9).


TFigure 3 Capsulotomies/myotomies for progressive relaxa-tion. The enlargement of the pocket always involves perform-ing capsulotomies and radial myotomies in an inverted fanshape, previous to switching the anatomical plane.

Table 3 Most frequent procedures in pocket work

Capsulotomies/myotomies for planechange

67 casesa 63.8%

Capsulorraphies by lower SMC 30 casesb 28.5%Capsulectomies/myectomies 6 cases 5.7%Capsulotomies 2 cases 1.9%

Total 105 cases 100%a Ten cases also required capsulorraphy of anterior axillary

line.b Associated with defatting of the SMC in five cases.

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Discussion

The possibility of offering a relatively immediate solution tomastectomised patients, a reduction in surgical steps andpractice, has made PBR a very popular technique. However,its success will always depend on the immobility of theimplant and the absence of capsular contracture. The

UNCORRE

Figure 4 Capsulectomies/myectomies. The procedure in-volves the resection of an important portion of capsule or cap-sule and muscle.

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EDPROOFposition of the implant, where its backside contacts the

chest wall, is the most prominent factor in determiningsymmetry in PBR. The permanence and evolution of theimplant is conditioned by the interaction between humantissues and implant. After implant placement, there isalways a foreign body response to the capsule. Thus, thecapsule is the second most important factor determiningsymmetry in PBR. Capsular consistency ranges from totalsoftness to severe restriction (capsular contracture) andhas been matter of study since the introduction of siliconegel implants by Cronin and Gerow.12 Capsular contracture isa common problem, which produces implant distortion, dis-rupting PBR symmetry. On the other hand, total softness orlaxity can also be problematic. In cases of a strong pector-alis major muscle, its repetitive contraction can progres-sively promote downward displacement of the implant.This is the description of a scenario where the only distor-tive factors are random. Whereas, in some cases, the defor-mity may result from tactical or surgical errors whenplanning or executing surgery, in others postoperative com-plications such as fluid collection produce implant dystopia.All these situations require PW. Sometimes, in cases of bi-lateral reconstruction, it is hard to account for the factthat a meticulously planned reconstruction, after an expan-sion process, does not reach adequate symmetry. Hypo-thetically, if pockets and implant positions were strictlyidentical, the unfolding of the expander as the expansionprocess progresses would be responsible for more evidentasymmetries. An extremely soft unilateral capsule wouldwork in the same way. Sectorial capsular contractures donot usually modify implant position; perimetral shape andtridimensional results are altered though. In patients un-dergoing two-stage PBR, there is a second surgical stagewhich allows the surgeon to revise any problem in symme-try, thus preserving the patient-physician relationship.

PW aims at providing the reconstructed breast with ananatomical shape, which does not exclusively depend onthe implant. When considering PW, the problem should be

Table 4 Complications

Seroma 11 casesHaematoma 1 caseRotational dystopia 2 casesa

Recurrence of SMC lowering 5 casesb

a One case was associated with a previous fluid collection.b They required a new capsulorraphy, three of them executed

by the Nava’s technique.

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Figure 5 (a) A case of high restrictive pocket and insufficientlower pole expansion. (b) After capsulotomy/myotomy forplane change associated to radial myotomies in an invertedfan shape.

Figure 6 (a) A case of restrictive pocket and sectorial con-tracture at lower and upper pole. (b) After capsulotomy/myot-omy for plane change.

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approached focusing on the five layers of tissue coveringthe implant: skin, SCT, plane of fibrosis (which replacesbreast tissue), muscle and capsule. In cases of seroma, theimmediate adherence between SCT and muscle is impaired.Due to halstedian principles, the comunication betweenaxilla and the surgical lodge makes self-limited fluidcollections more frequent. Furthermore, in these casesthere is a higher deposit of collagen fibres producinga thicker and more rigid layer of fibrosis. As a consequence,capsulotomies/myotomies for plane change are not enoughto improve lower pole definition. The removal of a patch ofcapsule, muscle and fibrosis through the procedure namedcapsulectomy/miomectomy solves the problem.

Capsulotomies are needed when adherences betweenthe anterior and posterior walls of the pocket are created.These adherences are frequently founded at the level ofthe pocket covered by the serratus anterior muscle. Afterreleasing such adherences, a capsulorraphy to regularisethe perimeter is usually required.

The main indications for capsulorraphies are the descentor the lateralisation of the expander. It can also benecessary to improve SMC definition, without displacing


ROOF

the implant.13 In 1979, Lewis reported the use of an abdom-inal sliding flap to provide coverage in breast reconstruc-tions and its fixation as in internal capsulorraphies.14

Later, Ryan described a similar resource although ap-proaching through the crease itself.15 In 2001 Massiha pub-lished a SMC reconstruction technique through an internalapproach, which is similar to the method employed bythe authors.16 In this work, the authors present a novelmethod for the exact determination of the necessary SMClifting. According to this method, transferring the distancebetween two horizontal tangents to the creases of bothbreasts (difference in heights), above and below the pointof reference A, allows crease symmetry to be achieved.Point A, which has been defined as the lowest point ofthe posterior wall of the capsule, must be exactly locatedby means of traction and counter-traction manoeuvres. In1998 Nava proposed an approach for SMC definition throughan incision of fascia and TCS and suture of the posteriorwall of the pocket to the dermis.11 This approach was ap-plied in only three patients of this series, being indicatedfor recurrence of SMC lowering. In the remaining cases,the liposuction of the SMC achieved an adequate definition.


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Figure 7 (a) Lateralised expander and restriction at internallower quadrant. (b) After capsulotomy/myotomy for planechange associated with lateral capsulorraphy.

Figure 8 (a) A case of descent of the SMC. (b) After capsulor-raphy to mimic contralateral mammary ptosis.

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UNCORR

This is usually complemented by wearing a brassiere, whichexerts pressure on the SMC and 1.5 cm below.

The surgeon always works with delayed flaps at themoment of PW. These flaps provide safety in proceduressuch as capsulotomies/myotomies for plane change, cap-sulectomies and myectomies. The execution of thesemanoeuvres, involving dermal or dermofatty pedicles withlow risk of cutaneous necrosis, is evidence of that. Ryan’stechnique of thoracic advancement flap in bucket handlecan be cited as another example.15

In terms of postoperative seromas, they can be pre-vented by keeping drains in place until output is less than30 cc per day17 and providing inmobilisation through thewearing of tailor-made brassieres with medial, lateral andinferior reinforcements for 1 month. If fluid collection is de-tected, it should be treated with corticosteroids, prophy-lactic antibiotics and arm immobilisation. Surgicaldrainage is seldom necessary. In the sentinel node era theseseromas will probably diminish. The most feared effect offluid collection is implant malposition. The authors have re-cently described the application of polyglycolic mesh asa supplement to the pectoralis major in cases of IPBR in


order to allow the settings of bigger implants without pre-vious expansion, while preventing implant displacements.18

Not only does radiotherapy affect the capsule consis-tency but it also affects the plane of fibrosis of the surgicallodge and reinforces the collagen matrix of the SCT.Therefore, all tissue layers are affected. On the otherhand, flaps raised from radiated areas are not reliableenough. The most commonly accepted theory explainingthe effects of radiation has focused on decreased vascu-larity and hypoxia in affected tissues. More recently,impaired leukocyte function has been considered as anadditional factor in the pathophysiology of radiation in-jury.19 Patient’s clinical records should always be carefullyanalysed, focusing on radiotherapic events. Some of the pa-tients who have been radiated after conservative surgeryundergo mastectomy after cancer recurrence. Nowadays,radiated patients are seldom regarded as candidates forPBR. On the other hand, the current trend of radiating pa-tients with less involved axillary lymph nods will eventuallyincrease radiotheraphy indications.20 There is not a consen-sus about radiating mastectomised patients with a perma-nent breast implant21 or with a tissue expander in placebefore their permanent implant exchange.4


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Figure 9 (a) Patient with extracapsular contractur due topre-muscular fluid collection and subsequent fibrosis. (b) Aftercapsulectomy/myectomy.

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UNCORRIn conclusion, after analysing results obtained with thisgroup of patients, it is evident that two-stage PBR with the

sequence expander/implant has been, in the authors’hands, the best surgical option in order to optimise resultsin terms of symmetry and natural look.

The second surgical stage, in which the tissue expanderis exchanged for the permanent implant, offers a uniqueopportunity for PW. Pocket work strategies and theirindications should be known and applied by the surgeonwho aims at optimising PBR aesthetic results.

References

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2. Alderman AK, Wilkins EG, Kim HM, et al. Complications in post-mastectomy breast reconstruction: two-year results of theMichigan Breast Reconstruction Outcome Study. Plast ReconstrSurg 2002;109:2265e74.

3. Clough KB, O’Donoghue JM, Fitoussi AD, et al. Prospectiveevaluation of late cosmetic results following breast reconstruc-tion, I: implant reconstruction. Plast Reconstr Surg 2001;107:1702e9.

4. Kronowitz SJ, Hunt KK, Kuerer HM, et al. Delayed-immediatebreast reconstruction. Plast Reconstr Surg 2004;113:1617e28.

5. Spear SL, Pelletiere CV. Immediate breast reconstruction intwo stages using textured, integrated-valve tissue expandersand breast implants. Plast Reconstr Surg 2004;113:2098e103.

6. Camilleri IG, Malata CM, Stavrianos S, et al. A review of 120Becker permanent tissue expanders in reconstruction of thebreast. Br J Plast Surg 1996;49:346e51.

7. Ward J, Cohen IK, Knaysi GA, et al. Immediate breast recon-struction with tissue expansion. Plast Reconstr Surg 1987;80:559e66.

8. Maxwell GP, Falcone PA. Eighty-four consecutive breast recon-structions using a textured silicone tissue expander. Plast Re-constr Surg 1992 Jun;89(6):1022e34 [discussion: 1035e6].

9. Loustau HD, De Elizalde L, Sarrabayrouse M. ReconstrucciónMamaria Protesica: evolucion estetica. Rev Arg Cir Plast2003;9(2):15e21.

10. Massiha H. Augmentation in ptotic and densely glandularbreasts: prevention, treatment, and classification of double-bubble deformity. Ann Plast Surg 2000 Feb;44(2):143e6.

11. Nava M, Quattrone P, Riggio E. Focus on the breast fascial sys-tem: a new approach for inframammary fold reconstruction.Plast Reconstr Surg 1998 Sep;102(4):1034e45.

12. Cronin TD, Greenberg RL. Our experiences with the silastic gelbreast prosthesis. Plast Reconstr Surg 1970 Jul;46(1):1e7.

13. Pennisi VR. Making a definite inframammary fold under a recon-structed breast. Plast Reconstr Surg 1977 Oct;60(4):523e5.

14. Lewis Jr JR. Use of a sliding flap from the abdomen to providecover in breast reconstructions. Plast Reconstr Surg 1979 Oct;64(4):491e7.

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Pocket work for optimising outcomes in prosthetic breast reconstructionMaterials and methodsResultsDiscussionReferences

Pocket work for optimising outcomes in prostheticbreast … · 2011. 1. 14. · deeper, sectioning the fascia superﬁcialis, fat and cel-lular subcutaneous tissue (CST). Then, the

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