Inframammary Fold Reconstruction That is Not Dependent on Firm Fixation to the Chest Wall

GOICHI HARAOKA, and HISASHI MOTOMURA

Citation Osaka City Medical Journal. Issue Date 2018-06 Type Journal Article Textversion Publisher © Osaka City Medical Association. Right https://osakashi-igakukai.com/.

Placed on: Osaka City University Repository

GOICHI HARAOKA, and HISASHI MOTOMURA. Inframammary Fold Reconstruction That is Not Dependent on Firm Fixation to the Chest Wall. Osaka City Medical Journal. 2018, 64, 55-61 Osaka City Med. J. Vol. 64, 55-61, 2018

Inframammary Fold Reconstruction That is Not Dependent on Firm Fixation to the Chest Wall

GOICHI HARAOKA, and HISASHI MOTOMURA

Department of Plastic and Reconstructive Surgery, Osaka City University Graduate School of Medicine

Abstract Background The inframammary fold (IMF) is an important component of the female . Previously, various methods for reconstructing the IMF have been reported. However, several problems remain, including the loss of depth of the IMF because of loosening or misalignment of the suture. Methods This method was performed at the time of immediate two-stage reconstruction in 18 patients with breast cancer. By making an incision from the covering of the pocket interior up to immediately above the subdermal vascular plexus beneath the predesigned IMF, the fold that forms naturally was used as the IMF. The soft tissue of the tail that was incised at that height was fixed into the chest wall without lifting the tissue of the thoracic wall. Results The median duration of follow-up was 7.0 months. With regard to aesthetic outcome, almost symmetrical were achieved in 17 patients. During the follow-up period, the shape was maintained. The reconstructed breasts in 13 patients had mobility. The influence of body mass index, amount of resected , volume injected to the tissue expander, and volume of silicone were statistically significant. It was suggested that the subcutaneous fat is thicker and the larger breast is more advantageous to reconstruct a mobile IMF. Conclusions In this method, firm fixation is not required. Thus, scalloped deformity, subduction, and other undesirable outcomes do not occur. In addition to excellent cosmesis and maintenance, this method has a high level of patient’s satisfaction. Moreover, mobility of the breasts can be expected. Key Words: Breast‌ cancer; Breast reconstruction; Inframammary fold reconstruction

Introduction The inframammary fold (IMF) is an important component of the female breast, and its shape has

Received September 1, 2017; accepted November 28, 2017. Correspondence to: Goichi Haraoka, MD Department of Plastic and Reconstructive Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka 545-8585, Japan Tel: +81-6-6645-3892; Fax: +81-6-6646-6059 E-mail: [email protected]

- 55 - Haraoka et al a great impact on breast cosmesis1). Depending on location of the tumor, resection including IMF may be required by oncological reason. In such a case IMF reconstruction is essential. However, IMF reconstruction has several problems that must be overcome. The most important issue is the loss of IMF depth due to loosening or misalignment of the suture2,3). We think that the use of thoracic wall tissue is the cause of suture loosening. In previous reports, the tissue is moved from the lower part of the thoracic wall and fixed to the chest wall or deep to give surplus tissue in the lower pole of the breast for creating deep IMF and ptosis1,2,4-8). However, loosening of the suture and poor fixation occurs by gravity and regression force acting on the moved flap and the IMF becomes shallow. To solve this problem, we developed a method that does not depend on the fixation of tissue to the chest wall without recruitment of thoracic wall tissue. Herein, we report this novel procedure.

Patients & Methods This method was performed for 18 breast cancer patients who received immediate two stage reconstruction between August 2016 and April 2017 at our institution. Nine patients had left breast cancer, and another nine patients had right breast cancer. Mastectomy and simultaneous insertion of a tissue expander were performed for all patients. Our method of creating IMF was performed during the exchange operation of the tissue expander to the breast implant. The surgical results were reviewed retrospectively. The patients who received breast reconstruction with this method were divided into two groups: the both reconstructed breast and unaffected breast moved upward symmetrically (group A), and the reconstructed breast remained fixed and unmoving (group B) in position of the both elevation. Influencing factors including age, body mass index, quantity of breast tissue excised, volume injected to the tissue expander, and volume of silicone breast implant were compared between two groups. This study was approved by the ethics board of Fuchu Hospital, and written informed consent was obtained from all patients. Statistical analysis Student’s t-test and Mann-Whitney U-test were used to difine stastical difference. Differences at p＜0.05 were considered significant. Statistical analyses were performed using the Statcel 4 software program (OMS, Saitama, Japan). Operative procedure (skin folding method) Before the operation, the surgeon drew a curve symmetric in the IMF of the unaffected breast in the standing position. Incision was made on the mastectomy scar to remove the tissue expander. Thereafter, the IMF was reconstructed at first. A tattoo was made from the skin to inside the capsule by using a 25G needle and pigment along the marked IMF line. Incision was made on the inner aspect of the capsule along the tattoo line across the superficial fascia until exposing the subdermal vascular plexus. A fold forming the new IMF was naturally created in the remaining dermis. The soft tissue of the IMF tail was fixed to the chest wall only by several stitches of interrupted absorbable suture (3-0 VICRYL, Ethicon). After fixing the IMF, the scar tissue was dissected extensively from the upper portion of the breast to the axilla, releasing contractures and allowing the tissue nutation. It made the reconstructed breast ptotic because the tissue descended to the lower pole.

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Finally, an implant was inserted and the shape and symmetry of the breasts was checked in the sitting position. The wound was closed after insertion of a single suction drainage tube.

Results The mean age of the patients was 49.3 years (range 35-78 years). A patient developed mild hematoma in the IMF tail; however, was recovered with conservative treatment. Serious complications such as infection or necrosis of the skin flap did not occur. Additional surgical procedures were performed; fat injection in eight patients and fat injection and of the unaffected breast in seven patients. An almost-perfect symmetry was achieved in 17 patients. However, in one patient who received mastopexy, of the unaffected breast recurred, resulting in asymmetry. In the 5-12 months follow-up (median, 7.0 months), the shape of the IMF was maintained, and scalloped deformity or subduction did not occur. In 13 patients, mobility of the reconstructed breast was confirmed such that when both arms were raised, the reconstructed breast could also move upward similar to the unaffected breast. The influence of body mass index, volume of resected mammary gland, volume injected to the tissue expander, and silicone breast implant volume were shown in Table 1.

Table 1. Factors influencing mobility of the IMF reconstructed with Skin Folding Method in 18 patients

variables Group A (n＝13) Group B (n＝5) p-value

age, years (means±SD) 50.9±13.0 45.2±4.8 p＝0.358 body mass index kg/m2 (means±SD) 24.2±3.33 18.7±1.53 p＝0.003 quantity of breast tissue excised, g (median [IQR]) 439 [369, 500] 177.5 [173.3, 235.5] p＝0.017 volume injected to the tissue expander, mL (median [IQR]) 450 [380, 500] 265 [260, 280] p＝0.005 volume of implant, mL (median [IQR]) 365 [330, 370] 220 [210, 240] p＝0.005

Case Reports Case 1 (Fig. 1): A 58-year-old woman underwent right mastectomy and immediate breast reconstruction with a tissue expander. Our method of creating IMF was performed during the exchange operation of the tissue expander to the breast implant. After 4 months, and reconstruction as well as mastopexy of the left breast were performed simultaneously. At 7 months after the IMF reconstruction surgery, the breasts showed a natural symmetrical form. Both breasts moved similarly upward in position of both elevation, indicating that both breasts have mobility. Case 2 (Fig. 2): A 38-year-old woman underwent right breast mastectomy and immediate breast reconstruction with a tissue expander. Our method of creating IMF was performed during the exchange operation of the tissue expander to the breast implant. After 5 months, areola and nipple reconstruction as well as mastopexy on the left breast and fat injection on the right breast were performed simultaneously. At 7 months, after the IMF reconstruction surgery, the breasts showed a natural symmetrical form. Both breasts moved similarly upward in position of both arm elevation, indicating that both breasts have mobility.

Discussion The shape of the IMF has a great impact on breast cosmesis. The IMF is an important constituent

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Figure 1. Case 1: A 58-year-old woman. a, Frontal view at 7 months postsurgery with symmetrical inframammary fold position and form. b, Both arms raised: both breasts move upward similarly. c, Right oblique view. d, Left oblique view.

Figure 2. Case 2: A 38-year-old woman. a, Frontal view at 7 months postsurgery with symmetrical inframammary fold position and form. b, Both arms raised: both breasts move upward similarly. c, Right oblique view. d, Left oblique view.

- 58 - Inframammary Fold Reconstruction of the breast; however, it is one of the most difficult structures to reconstruct1). Previously, various methods for reconstructing the IMF have been reported. These methods can be classified into external approaches1,4-6) and internal approaches2,7-9). In the external approach, a de-epithelialized flap is pulled in and fixed to the chest wall4,5), and the periosteum of the rib6), for reconstructing the IMF. If necessary, the tissue of the lower thoracic wall is moved to the upper portion of the breast for making ptosis6). It is difficult to use this method in patients with small breasts, as wounds might be visible2). In the internal approach, the dermis or superficial fascia is fixed to the deep fascia7) and chest wall2,8), for reconstructing the IMF. As scalloped deformity and subduction may occur, running suture2) and liposuction10) are additionally performed. Recently, a method with barbed suture was reported3,9). Terao et al reconstructed the IMF by using a barbed suture that penetrates and follows alongside the skin, enabling fine adjustment of height3). A common problem among all methods is loosening of the suture2,3). We consider the use of thoracic wall tissue to be one of the causative factors. Surplus tissue in the lower pole is needed to reconstruct ptosis. Thus, in most previous reports, emphasize that lifting and fixation of the tissue of the lower part of the thoracic wall is lifted and fixed to the chest wall, deep fascia, and the costal periosteum are necessary for increased lower pole tissue1,2,4-7). However, gravity and regression force acting on the lifted thoracic wall tissue result in loosening of the suture over time, then it causes the IMF shallowing (Fig 3. c and d). To solve this problem, we dissect the soft tissue from the capsule beyond the superficial fascia until exposure of the subdermal vascular plexus by using the internal approach. Then, we use a naturally formed fold of the remaining dermis to create the IMF. We named this method the“ skin folding method”. The soft tissue in the lower part of the fold is fixed in the chest wall, and ptosis could be created by moving the tissue from the upper portion of the breast (Fig 4. c and d). Overexpansion of a tissue expander results in adequate stretching of the tissue, enabling adequate release of the subdermal scars of the upper portion of the breast and the axilla.

Figure 3. Nava et al’s procedure. a, Expansion of tissue with a tissue expander and the scheme before its replacement with an implant. b, Incision from the interior through the internal approach. c, Tissue is raised from the thoracic wall (black arrow) and fixed to the chest wall (white arrow), thereby reconstructing ptosis. d, The suture loosens easily because of gravity and regression of the skin flap (white arrow).

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Figure 4. Skin Folding Method. a, Expansion of tissue with a tissue expander and the scheme before its replacement with an implant (same as in Fig. 3a). b, Incision from the interior through the internal approach (same as in Fig. 3b). c, Incision is continued until only the subdermal vascular plexus remains; the inframammary fold (IMF) is created using the fold (gray arrow). The tail of the soft tissue is lightly fixed to the chest wall (white arrow). Ptosis is reconstructed by pulling down the tissue from the upper portion of the breast (black arrow). d, Long-lasting IMF that is hardly affected by regression force can be reconstructed.

There are differences between the method used by Nava et al2) and our method (Figs. 3 and 4). (i) Nava et al make an incision extends to the point that exceeded the superficial fascia. Our incision goes deeper up to the point where the subdermal vascular plexus is exposed. (ii) As for creating a ptotic breast, Nava et al elevate the skin flap from the thoracic wall and suture to the higher level of the thoracic wall. We reconstruct ptosis using the surplus tissue obtained by expanding the tissue; by dissecting the subdermal scar in the upper portion of the breast, axilla, and external skin; and by releasing the contractures. To create ptosis, we do not use the tissue of the lower part of the thoracic wall. (iii) Nava et al use running suture. On the other hand, our method does not require firm fixation, thus we use interrupted suture with an absorbable polyfilament. The IMF reconstruction with this method does not rely on fixation. Therefore, unfavorable outcome such as scalloped deformity and subduction that are seen in conventional methods rarely occur. And achieves an IMF with a smooth curve and superior cosmesis. Moreover, tissue movement cannot be reversed by gravity and is not readily affected by regression force. Therefore, the shape can be maintained for the long term. In addition, the IMF reconstructed by this method was observed to have slight mobility (Figs. 1 and 2). Comparing with conventional methods, which fix the de-epithelialized flap and dermis to the chest wall, our method does not form adhesion between the IMF and chest wall, because only the soft tissue of the lower part of IMF is sutured to the chest wall. The presence of mobility like natural breast seemed to improve the level of satisfaction and lifestyle in patients receiving reconstruction surgery with implants (e.g., enabling the feeling of wearing underwear). Therefore, with an increase in such cases in the future, further long-term follow-ups are necessary. In patients with ptosis in the unaffected breast if appropriate amount of tissue could not be moved from the upper portion of the breast due to inadequate expansion, mastopexy of the unaffected breast would be necessary to obtain symmetry. The remaining tissue after mastectomy should be expanded furthermore to avoid additional procedure. Therefore, a tissue expander larger than normal

- 60 - Inframammary Fold Reconstruction projection should be selected and inserted in an appropriate position for adequate expansion. Since the number of patients included in this study was very small and follow-up period was short, further follow-up would be necessary for definitive conclusion.

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