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Immediate prosthetic breast reconstruction: theensured subpectoral pocket (ESP)

Hugo D. Loustau*, Horacio F. Mayer, Manuel Sarrabayrouse

Department of Plastic Surgery, Hospital Italiano de Buenos Aires, University of Buenos Aires,School of Medicine, Gascon 450 (C1181ACH), Buenos Aires, Argentina

Received 5 April 2006; accepted 6 November 2006

KEYWORDSProsthetic;Breast;Reconstruction;Mesh

Summary Implant exposure due to cutaneous necrosis is one of the most feared complicationsof mastectomy with immediate prosthetic reconstruction. A key issue is to ensure good bloodsupply to the skin and complete integrity of the submuscular pocket. The latter is created withthe pectoralis major and supplemented with the serratus anterior, the rectus abdominis sheat,the obliquus mayor and the pectoralis minor. The main drawback is that those muscles, whensutured to create a complete pocket, only allow the setting of small-sized implants.

The authors present the application of polyglycolic mesh in an original fashion, mimicking theanatomy of the muscles usually employed in pocket creation. The proposed technique has beendenominated Ensured Subpectoral Pocket and has proved to be a valid strategy in immediate sin-gle stage prosthetic breast reconstruction. It allows the setting of bigger implants without pre-vious tissue expansion while preventing implant displacement. In addition, it reduces emotionaltrauma on patients and lowers surgical costs.ª 2006 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive andAesthetic Surgeons.

Autologous breast reconstruction usually achieves excel-lent outcomes in terms of ptosis, contour and thepreservation of symmetry in the long run.1 Some womenseeking mastectomy and immediate breast reconstructionlack the subcutaneous fat tissue required for autogenousreconstruction. Moreover, many of these women are un-willing to accept donor site morbidity. For those patients,prosthetic breast reconstruction (PBR) is an appealing

alternative. PBR allows for surgical treatment, providesgood cosmetic results, diminishes physical and emotionaltrauma and avoids donor site morbidity. However, immedi-ate prosthetic reconstruction (IPBR) is just as good inthose cases with adequate thickness of mastectomy skinflaps for coverage and when the area has not been previ-ously irradiated.

In order to avoid implant exposure due to cutaneousnecrosis, it is of utmost importance to preserve a goodblood supply to the skin. Complete integrity of thesubmuscular pocket is the most crucial factor to preventimplant displacements. In 1981, Little described the

* Corresponding author. Tel.: þ54 11 49590506.E-mail address: [email protected] (H.D.Loustau).

1748-6815/$ - see front matter ª 2006 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons.doi:10.1016/j.bjps.2006.11.007

Journal of Plastic, Reconstructive & Aesthetic Surgery (2007) 60, 1233e1238


complete muscular pocket for immediate breast recon-struction and named it ‘the living bra’.2 In this technique,the pectoralis major is supplemented with the serratus an-terior, the rectus abdominis sheath, the obliquus major andthe pectoralis minor to provide total muscle coverage ofthe implant. According to the first author, who performedover 300 prosthetic breast reconstructions applying severaltechniques, the main drawback has been that such muscles,when sutured to create a complete pocket, only allow forthe setting of small implants, a maximum of 250 cc.

The aim of this paper is to describe the application ofpolyglicolic mesh as a supplement to the pectoralis major incases of immediate breast reconstruction, in order to allowthe setting of bigger implants without previous tissueexpansion, while preventing muscle retraction and implantdisplacements.

Material and methods

From January 2000 to September 2005, 24 patients (aged35e59 years with an average age of 41 years) underwenttotal mastectomies and immediate breast reconstructionthrough this procedure. All the procedures were carried outat the Hospital Italiano de Buenos Aires under generalanaesthesia.

Surgical technique

Three basic steps can be described:

(1) Mastectomy. All the breast tissue, nipple-areolar com-plex, previous biopsy incisions and skin overlying super-ficial tumours are removed. The oncological marginscorrespond to the anatomical boundaries of the breastparenchyma3,4 (Fig. 1a). During dissection, care shouldbe taken to preserve the inframammary fold ligament,as well as to ensure an adequate thickness of skin flaps,in order to reduce the risk of skin necrosis and eventualimplant exposure that is a permanent threat (Fig. 1b).

(2) Creation of the subpectoral pocket. Through the lateralborder of pectoralis major, the retro-pectoral areolarspace is undermined by electrocautery dissection andits costal and sternal insertions are severed. The pocketdissection begins towards the midline then sweeps lat-erally along the direction of the pectoralis fibres to es-tablish the lateral pocket. Medial pectoralis majororigins are completely divided to allow the expansionof the medial pocket (along the border of the sternum).Complete division of the pectoralis above the fourthinterspace is not advisable because it risks excessiveupward muscle retraction5,6 (window shading), edgepalpability and visibility of the implant (Fig. 2a). It is

Figure 1 Mastectomy. (a) The subcutaneous mastectomy is completed. (b) Preserving a good thickness of the subcutaneous fat.

Figure 2 Pocket creation. (a) Pectoralis major costal insertions from third rib are preserved in order to avoid upward muscleretraction. (b) The anatomical continuity between the pectoralis major and the rectus abdominis sheet is severed as low aspossible.

1234 H.D. Loustau et al.


also important to preserve the anatomical continuitybetween the pectoralis major and the rectus abdominissheath. In order to avoid the compression and deforma-tion of the inferioremedial quadrant of the recon-structed breast, the pectoralis should be severed aslow as possible almost at the rectus sheath level(Fig. 2b). Then, the implant is inserted into the pocket.

(3) Placement of the polyglicolic mesh. Two ribbons of pol-yglicolic mesh, 4e5 cm in width, one lateral and oneinferior, are placed mimicking the anatomy of the mus-cles usually employed in pocket creation: the serratusanterior (lateral ribbon) and the rectus abdominis (infe-rior ribbon). The inferior ribbon represents the distalstop and also determines the new inframammary fold.The inferior edge of the implant and the preserved in-framammary fold ligament should not necessarily beat the same level.7 The prosthesis chosen will conditionthe placement of the lateral ribbon.

If the prosthesis is rounded, the ribbon will havea rectangular shape and will be placed in an obliquefashion. Thus, the mesh will exert forces against theprosthetic displacement activated by the pectoralis majorcontraction (Fig. 3a).

If the prosthesis is anatomical, the lateral ribbon willhave a trapezoidal shape and will be placed at a higherposition holding the lateral-superior edge of the implant soas to avoid its displacement and rotation (Fig. 3b).

The sequence of fixation of the ribbons is of utmostimportance. At first, ribbons are sutured at their distalextremity to the corresponding muscles (serratus anteriorand rectus abdominis sheath) at the level of the pocket’sboundaries (Fig. 4a). Then the pectoralis major, which ispartially retracted, is stretched and the proximal end of

the ribbon is finally sutured to the pectoralis fibres(Fig. 4b, c), cutting the remaining ribbon off (Fig. 4d).

In order to ensure the success of the technique and toavoid muscle laceration, muscle paralysis during this stageof the surgical act is crucial. To promote a completeadherence of the different anatomical layers, drainagesare kept in place until output is minimal.8

Results

Thirty-four breast reconstructions were performed. Four-teen patients were diagnosed breast carcinoma (six caseswith in situ carcinoma, five cases with stage I and threecases with stage II). Unilateral reconstruction was per-formed in all cases (Figs. 5 and 6). In the other 10 patients,the suggested treatment was risk-reducing mastectomy andbilateral reconstructions were performed (Figs. 7 and 8).Out of this group there were five patients who were athigh risk due to a significant family history of breast cancer(first degree relatives with early onset and bilateral breastcancer). In three cases the early detection of BRCA1 andBRCA2 mutations was the indication, while in the remainingtwo cases, atypical breast hyperplasia with family history ofbreast cancer determined the procedure.

Fifteen patients chosen to undergo ESP were thin and hadlittle subcutaneous tissue over their back and abdomen. Ninepatients refused an alternative autologous breast recon-struction after a thorough discussion with the surgeon.

Patients in our series had implant sizes ranging from 270to 375 cc. Anatomic implants were used in 16 patients,while they were rounded in the rest of the cases. The me-dian follow-up time was 2.8 years, with a range of 6 monthsto 5 years.

Figure 3 Placement of the polyglicolic mesh. Schematic representation of the technique (a) employing a round implant and (b) ananatomical implant.

Immediate prosthetic breast reconstruction 1235


One case of unilateral haematoma, detected a few hoursafter the procedure, was immediately drained with a goodoutcome. One case of seroma formation and two cases ofpartial wound dehiscence without exposure of the implantwere also detected during follow up. The case of fluidcollection was not associated with fever or local signs of

infection and was treated with arm immobilisation, steroidsand prophylactic antibiotics. The wound dehiscence closedwith just local treatment within 10e14 days. No cases ofcapsular contracture, infection or local recurrence werefound. In addition, we obtained very good results in termsof symmetry and patient satisfaction.

Figure 4 Sequence of mesh fixation. (a) The mesh is sutured by its distal extremity to the serratus anterior muscle at the level ofthe pocket’s boundaries. (b,c) The proximal end of the mesh is sutured to the pectoralis fibres through a running suture. (d) Themesh excess is cut off.

Figure 5 Total mastectomy and unilateral IPBR through theESP technique in a 38-year-old woman with infiltrating ductalbreast carcinoma.

Figure 6 Total mastectomy and unilateral IPBR through theESP technique in a 47-year-old woman with multicentric ductalin situ breast carcinoma, who waits for nipple-areolareconstruction.



Discussion

Several techniques have been described to avoid muscleretraction due to the division of its origins during pocketcreation in IPBR. One such technique consists of suturing, asdistal as possible, the lateral border of the pectoralis to thesubcutaneous cellular tissue. The main drawback of thistechnique is the risk of releasing stitches when a smallamount of tissue has been included or creating skin dimpleswhen too much tissue has been taken.9

Another technique proposed by Spears10 is based on se-curing the inferior edge of the pectoralis major muscle.This is accomplished by the placement of several U stitchesof 2/0 polydioxanone suture through the skin, through theinferior edge of the muscle, and backing out the skin belowthe mastectomy incision but above the inframammary fold.These sutures were named ‘marionettes’ sutures. Althoughthey should be tied loosely, there is a risk of skin injuringand scarring. These risks should be borne in mind whenchoosing this technique.

Figure 7 Risk-reducing mastectomy and bilateral IPBR through the ESP technique with an anatomical implant.

Figure 8 Risk-reducing mastectomy and bilateral IPBR through the ESP technique with a round implant which yields a cup breastbigger than the original breast. (a) Preoperative frontal view. (b) Postoperative frontal view. (c) Preoperative oblique view. (d)Postoperative oblique view.

Immediate prosthetic breast reconstruction 1237


Another surgical alternative is the use of a relaxedrunning suture approximating the lateral border of thepectoralis major to the boundaries of the surgical lodge. Itsmain disadvantage is the low reliability and the risk oftissue laceration.

Recently and during the preparation of this paper,Breuing and Warren11 described the use of an acellular cry-opreserved dermal matrix (Alloderm) sling to re-establishthe lower pole of the pectoralis major muscle in IPBR. SinceAlloderm is derived from human tissue, it is extensivelytested and screened to assure patient safety. Nevertheless,the risks of disease transmission, although improbable,could be a matter of concern for some patients. On theother hand, the cost of Alloderm in developing countriescould also restrict its use for breast reconstruction.

The application of a mesh in breast reconstruction hasalready been reported for other purposes. In 1997, Rietjenset al.12 described the use of a non absorbable mesh to pullup and maintain the upper abdominal skin flap duringmastectomies with large skin excision and also to permita better definition of the inframammary fold. In 2002Amanti et al.13 reported the use of a polypropylene meshin breast reconstruction, limited to the restoration ofthe pectoralis major, which was partially torn duringmastectomy.

The authors present the application of a polyglicolicmesh in an original fashion, mimicking the anatomy of themuscles usually employed in pocket creation. The proposedtechnique has been called ensured subpectoral pocket(ESP) and has proved to be successful in simplifying IPBRin the authors’ experience. In a single stage it allows thesetting of bigger implants without previous tissue expan-sion, as well as preventing implant displacements. Areduction in surgical steps and costs with less physicaland emotional trauma for the patient are additionalbenefits. On the other hand, the use of a dissolvablemesh, as the polyglicolic mesh, implies a lesser risk ofextrusion or complications, such as sinus tract formation,usually observed during the late postoperative period ofmesh hernioplasties.14 Although there could be an increasein the rate of capsular contracture, this has not been ob-served in these patients.

Currently, the knowledge on genome and gene muta-tions has really improved the prognosis and life quality ofpatients undergoing prophylactic mastectomies. In view ofthis, when considering very aggressive surveillance asa consequence of preserving all the breast parenchymaversus the breast amputation and a reliable immediatereconstruction, the latter could be the best choice.15,16

The authors conclude that ESP is a valid strategy in singlestage IPBR, since it allows the setting of bigger implantswithout previous tissue expansion and prevents its dis-placement. ESP can be presented as another tool for IPBR

when more prophylactic mastectomies will be carriedout,16 thus being useful for patients who are reluctant toundergo more than one surgery and are in a range of im-plants between 270 and 370 cc.

References

1. Alderman AK, Wilkins EG, Lowery JC, et al. Determinants of pa-tient satisfaction in postmastectomy breast reconstruction.Plast Reconstr Surg 2000;106:769e76.

2. Little 3rd JW, Golembe EV, Fisher JB. The ‘living bra’ in imme-diate and delayed reconstruction of the breast following mas-tectomy for malignant and nonmalignant disease. PlastReconstr Surg 1981;68:392e403.

3. Hidalgo DA. Aesthetic refinements in breast reconstruction:complete skin-sparing mastectomy with autogenous tissuetransfer. Plast Reconstr Surg 1998;102:63e70.

4. Kroll SS, Ames F, Singletary SE, et al. The oncologic risks of skinpreservation at mastectomy when combined with immediatereconstruction of the breast. Surg Gynecol Obstet 1991;172:17e20.

5. Brar MI, Tebbetts JB. Early return to normal activities afterbreast augmentation. Plast Reconstr Surg 2002;110:1193e4.

6. Beasley ME. Two stage expander/implant reconstruction:delayed. In: Spear SL, editor. The breast, principles and art.Philadelphia: Lippincott-Raven; 1998. p. 387e98.

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

8. Spear SL, Howard MA, Boehmler JH, et al. The infected or ex-posed breast implant: management and treatment strategies.Plast Reconstr Surg 2004;113:1634e44.

9. Spear SL. Primary implant reconstruction. In: The breast, princi-ples and art. Philadelphia: Lippincott-Raven; 1998. p. 347e56.

10. Spear SL, Spittler CJ. Breast reconstruction with implants andexpanders. Plast Reconstr Surg 2000;107:177e87.

11. Breuing KH, Warren SM. Immediate bilateral breast reconstruc-tion with implants and inferolateral AlloDerm slings. Ann PlastSurg 2005;55:232e9.

12. Rietjens M, Garusi C, Lanfrey E, et al. Cutaneous suspension:immediate breast reconstruction with abdominal cutaneousadvancement using a non-resorptive mesh. Preliminary re-sults and report of 28 cases. Ann Chir Plast Esthet 1997;24:177e82.

13. Amanti C, Regolo L, Moscaroli A, et al. Use of mesh to repairthe submuscular pocket in breast reconstruction: a new possi-ble technique. G Chir 2002;23:391e3.

14. Rutkow IM, Robbins AW. The mesh plug technique for recurrentgroin herniorrhaphy: a nine-year experience of 407 repairs.Surgery 1998;124:844e7.

15. Loustau H. Reconstruccion mamaria y calidad de vida. Mono-grafıa de la materia, Antropologıa medica. Carrera de adscrip-cion a la docencia de la UBA; 2000.

16. Anderson K, Jacobson JS, Heitjan DF, et al. Cost-effectivenessof preventive strategies for women with a BRCA1 or a BRCA2mutation. Ann Intern Med 2006;144:397e406.


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