Reply: Two-Stage Implant-Based Breast Reconstruction

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Drs. Chahine and Atiyeh have agreed and disagreed with some of the basic concepts that we have described in the article describing the evolution of a conceptual and technical approach to implant reconstruction over a two-decade period.1 They agree that maximizing lower pole expansion is one of the principal goals of two-stage breast reconstruction. To achieve this end, we have described total musculofascial coverage to both minimize complications and maximize the aesthetic results. Our experience has been that, if the expander is placed in the submusculofascial plane, a fasciotomy in the region of the inframammary fold is essential to allow lower pole expansion. We have found that placing the expander low maximizes expansion in this area by actual lower pole skin expansion but also through recruitment of some of the upper abdominal skin. This lower pole expansion is not as effective when the tissue expander is placed at the level of the infra mammary fold, which remains fixed in its natural position.
Chahine and Atiyeh’s suggestion that placing the expander in a purely subcutaneous position inferiorly allows for adequate expansion is not always reliable. Our early experience with placing the expander at the level of the of inframammary fold often resulted in the point of maximum expansion occurring much too high, and it also usually created significant overexpansion of the upper pole relative to the lower pole of the breast. One of the other principal benefits of placing the expander in the submusculofascial plane, below the level of the inframammary fold, is that once the expander is placed into the pocket, the muscle/fascia inferiorly is sutured and approximated back to the pectoralis major muscle superiorly, which prevents the pectoralis muscle from “window-shading.” This is very likely to occur if the inferior pole of the expander is placed only in the subcutaneous plane as suggested by Chahine and Atiyeh.
Finally, in our institution, the rate of mastectomy flap necrosis, which usually occurs at the edges of the mastectomy flaps, is approximately 10 percent. In this scenario, these areas can heal by secondary intention most reliably and safely when there is a well-vascularized layer of muscle and fascia overlying the implant. If the lower pole of the expander is situated just beneath the skin and subcutaneous tissue, as suggested by Chahine and Atiyeh, the potential for losing the expander to infection and exposure becomes extremely high because it is located directly below the incision. If the mastectomy flaps are extremely thick and well vascularized, one might potentially “get away” with placing an expander into the subcutaneous plane; however, this is not the case when aggressive oncologic procedures with thinner mastectomy flaps are performed.
Through experience gained from over 25 years and approximately 6000 two-stage breast implant reconstructions, we have determined that the techniques we have described—creating a total submusculofascial plane of dissection, performing the fasciotomy, placing the tissue expander below the inframammary fold, and following the steps outlined—will most effectively and safely permit successful outcomes. This approach minimizes complications and maximizes aesthetic results.

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