Wise-Pattern Breast Reconstruction: Pocket Augmentation using Alloderm and a Vascularized Dermal-Subcutaneous Pedicle
Christopher A. Derderian, M.D., Mihye Choi, M.D., Nolan S. Karp, M.D..
New York University, New York, NY, USA.
BACKGROUND: Immediate breast mound implant reconstruction offers many advantages over staged reconstruction techniques. A single-stage procedure provides the psychological benefit of recovering from mastectomy with a reconstructed breast. In women with large breasts desiring immediate implant reconstruction, the challenge to the surgeon is to restore breast volume and provide adequate implant coverage. In the large-breasted woman desiring a large volume reconstruction a Wise-pattern skin resection provides good aesthetic results, however the submuscular implant pocket is inadequate to cover the inferior pole of the breast. In this patient population, the risk of implant exposure from T-point breakdown is significant. We present our technique of Wise-pattern breast reconstruction after skin-sparing mastectomy using alloderm and a vascularized dermal-subcutaneous pedicle to augment the volume and quality of implant coverage.
METHODS: A series of twenty patients have been reconstructed using the following technique. The selection criteria were women with large breasts who required an immediate implant reconstruction of ≥400cc volume. We employed a Wise-pattern design for resection of skin identical to that of a reduction mammaplasty. An inferiorly-based dermal-subcutaneous flap was developed. The T-point of the Wise pattern skin pattern was closed over this flap and provided vascularized coverage of the implant and alloderm at this vulnerable point. All patients underwent the standard mastectomy by a surgical oncologist. The pectoralis major and seratus anterior muscles were released from their inferior and costal origins respectively, and as much alloderm as needed was sutured to these muscles to provide an adequate pocket for the desired implant volume. The dermal-subcutaneous pedicle was laid over the alloderm and sutured in place. The breast was then closed with the T-point overlying the dermal-subcutaneous pedicle. In unilateral reconstructions, a symmetrizing procedure using a Wise-pattern reduction mammaplasty was performed on the contralateral side.
RESULTS: The average volume of reconstruction in this study group was 458cc. Significant T-point breakdown occurred in 5 patients, and 3 of these would have had implant/alloderm exposure if the dermal pedicle were not present. These patients were treated with local wound care and healed with an excellent aesthetic result. None of these patients required implant removal, implant exchange or operative debridement.
CONCLUSIONS: Wise-pattern skin-reducing mastectomy is an excellent strategy to provide an aesthetically pleasing, large, immediate implant breast reconstruction. The reliability of this technique is significantly improved with the addition of alloderm to the muscular pocket and a vascularized dermal-subcutaneous pedicle to preserve the integrity of the reconstruction in the presence of T-point breakdown. This technique can be added to the armamentarium of the plastic surgeon to safely restore breast size in one stage, remove the morbidity of multiple operations, and provide patients with the psychological benefits of an immediate reconstruction.