Aesth Plast Surg (2015) 39:379–385 DOI 10.1007/s00266-015-0479-7
MULTIMEDIA MANUSCRIPT
BREAST
A New Method for Inframammary Fold Recreation Using a Barbed Suture Yasunobu Terao1 • Koichiro Taniguchi1 • Shoichi Tomita2
Received: 7 December 2014 / Accepted: 16 March 2015 / Published online: 1 April 2015 Ó Springer Science+Business Media New York and International Society of Aesthetic Plastic Surgery 2015
Abstract Background There are inherent limitations with previously reported inframammary fold (IMF) recreation methods. The IMF is firmly fixed to the chest wall, but not physiologically, and it is difficult to determine the correct IMF position in the supine position and in the absence of an implant. Methods With our new IMF reconstruction method (i.e., drawstring method), the IMF is recreated by drawing a barbed suture, penetrating the dermis, along the IMF. The barbed suture is fixed to the costal cartilage at the medial IMF, and the head is drawn and cut externally at the lateral IMF. The IMF level and depth can be finely adjusted by the tension, in a seated position after implant insertion. Furthermore, the approach can be from a small incision, and a smooth IMF curve is reconstructed. Results Our drawstring method was performed in 102 patients who underwent reconstruction using a breast implant (n = 95) or flap (n = 7). The mean patient age was 52.0 years (range 33–77 years) and the follow-up period was 12 months (range 3–18 months). Suture or implant infection or exposure did not occur. Suture slack occurred
Electronic supplementary material The online version of this article (doi:10.1007/s00266-015-0479-7) contains supplementary material, which is available to authorized users. & Yasunobu Terao [email protected] 1
Department of Plastic and Reconstructive Surgery, Tokyo Metropolitan Cancer and Infectious Disease Center, Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo 113-8677, Japan
2
Department of Plastic and Reconstructive Surgery, The Jikei University School of Medicine, Minato-ku, Tokyo, Japan
in ten patients with implant-based reconstruction; their IMF became shallow. Insufficient skin expansion (P \ 0.005) and strong traction of the barbed suture from the caudal side (P \ 0.05) were related to IMF slack. The total revision rate was 2.9 %. Conclusions With sufficient skin expansion, the drawstring method using a barbed suture enables smooth and symmetrical IMF reconstruction. Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266. Keywords Breast reconstruction Barbed sutures Inframammary fold Breast implants
Introduction The inframammary fold (IMF) is an important feature of the female breast. Therefore, it should be recreated when sacrificed oncologically. Although previously reported methods for IMF reconstruction have progressed, some problems still remain. Scarring is an issue with the external approach [1–4], and it is not suitable for patients with smaller breasts. With an internal approach [5–10], subduction or scalloped deformity of the IMF may occur [9]. The conventional internal approach is also difficult because of a recently reported tendency for small mastectomy scars. In all of these methods, it is difficult to determine the correct position of the IMF in the supine position and without an inserted implant.
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We devised a new method for IMF reconstruction, called the drawstring method, with the aim of solving these problems. This method recreates the IMF with a smooth curve in the correct position, through a small incision. Although it is mainly used with patients who undergo implant-based breast reconstruction after mastectomy, it can be used also for secondary repair after reconstruction with a flap. The present study aimed at determining if the drawstring method is effective for the recreation of a symmetrical and smooth IMF, as well as documenting the complications associated with and maintenance of the IMF.
Materials and Methods Our method was performed by a single surgeon with 102 patients who underwent mastectomy and breast reconstruction between April 2013 and July 2014. Even in cases with small breasts and an IMF that was not clear, this method was performed when the position of the IMF had shifted. All patients underwent conventional mastectomy, which included excision of the nipple and skin. A retrospective review of the surgical results was conducted. The relationships between complications and operative or patient factors were analyzed using Chi squared or Fisher’s exact tests. The factors influencing slack in the suture following surgery were compared for the 95 patients that underwent implant-based reconstruction. This study was approved by the ethics board of our hospital, and informed consent was obtained from all patients. Technique Before the operation and with the patient in the seated position, the IMF is marked at a level and in a shape that is symmetrical with the other breast. First, capsulotomy of the lower pole is performed following the removal of the tissue expander through the mastectomy scar. In obese patients, superficial fasciotomy and lipectomy below the IMF should be added. A number 1 or 0 non-absorbable barbed suture (V-LocTM, Covidien, Mansfield, Massachusetts) is fixed to the costal cartilage beneath the medial end of the IMF (Fig. 1a). Then, a barbed suture is used to penetrate the dermis along the IMF until the lateral end. At this time, the operation is simplified by guiding the barbed suture with an epidural needle, which is bent along the IMF and pierces the dermis from the approximate center of the IMF to the medial end of the IMF (Fig. 1b). Then, the inner needle is removed, and the barbed suture that is fixed to the costal cartilage is passed through the external cylinder (Fig. 1c). The barbed suture is not drawn after this first pass; instead, this maneuver is
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repeated three or four times for the barbed suture to penetrate the dermis along the entire IMF, and the head of the suture pierces the skin externally at the lateral end of the IMF. Finally, the head of the barbed suture is drawn to adjust the level and depth of the IMF and can be cut outside the skin without knot fixation because the barbed suture has inherent fixation to the tissue over its entire length. Therefore, IMF adjustment by drawing the suture is possible in a seated position after implant placement and wound closure (Fig. 1d, e). If a traditional suture is used for this method instead of a barbed suture, it has to be fixed to the deep tissue at the lateral end of the IMF. The transverse diameter of the new IMF line needs to be wide enough to allow for the IMF narrowing as a result of traction of the barbed suture. In patients with large breasts and a deep IMF, a barbed suture should penetrate the dermis a bit lower (\1 cm) than the preoperative marked line because the IMF moves up vertically as a result of strong suture traction. Because the IMF is recreated by drawing the sutures together, this method was named the drawstring method. The drawstring method can also be adapted for breast reconstruction using a flap. External fixation by taping or a brace (such as a bra) is required for several weeks after the operation, particularly in patients requiring strong traction for the creation of a deep IMF.
Results The mean age of the 102 patients was 52.0 years (range 33–77 years) (Table 1), and the mean follow-up period was 12 months (range 3–18 months). In 80 patients, the drawstring method was used when the tissue expander was exchanged for a breast implant, and, in 15 patients, for secondary repair after reconstruction with implants. In the remaining seven patients, it was used for secondary repair after reconstruction with flaps. The average expansion of the tissue expander was 120 % of the breast implant volume. In 12 patients, the skin around the IMF was not sufficiently expanded because of elevation of the tissue expander or the influence of postoperative radiotherapy. The breast implants were round (12 patients; range 125–175 cc; average, 152.1 cc) or anatomical (83 patients; range 120–430 cc; average, 243.9 cc) types. Infection and exposure of the suture or breast implant did not occur. Slack in the suture occurred in ten patients who underwent implant-based reconstruction with anatomical-type breast implants, and their IMF became shallow. A clear IMF was maintained in the remaining 92 patients (100 %, flap; 89.5 %, implant). Although there were no
Aesth Plast Surg (2015) 39:379–385
381
Fig. 1 a A barbed suture is fixed to the costal cartilage beneath the medial end of the inframammary fold (IMF), b An epidural needle bent along the IMF pierces the dermis from the approximate center of the IMF to the medial end of the IMF, c The suture, with its needle removed, is passed through the external cylinder of the epidural needle, d, e The head of the suture is drawn to adjust the level and depth of the IMF, and it can be cut outside the skin without knot fixation. This adjustment is possible in a seated position after inserting the implant
Table 1 Clinical characteristics of the patients who underwent surgery for placement of the inframammary fold Total
Breast implant
Flapa
Patients
102
95
7
Age, years
52.0 (33–77)
52.0 (33–77)
50.3 (44–58)
Body mass index, kg/m2 Implant size, cc
22.2 (14.4–34.6)
22.0 (14.4–34.6) 232.3 (120–430)
24.6 (20.3–33.0)
Postoperative radiotherapy
5
5
0
a
Transverse rectus abdominis musculocutaneous flap, n = 6; latissimus dorsi musculocutaneous flap, n = 1
Values are reported as n or mean (range)
differences in age, body mass index, implant size, and postoperative radiotherapy based on the occurrence of suture slack (P [ 0.05), there were significant differences in
the number of patients with insufficient expansion of the IMF skin (P \ 0.005) and strong traction of the barbed suture from the caudal side ([1 cm) (P \ 0.05) (Table 2).
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Of the ten patients that experienced slack, two patients with insufficient expansion of the IMF skin underwent correction by additional capsulotomy and conventional internal fixation, but their IMF became unclear again. One patient in whom the barbed suture was drawn strongly from the 2 cm caudal side underwent correction by the drawstring method in which the barbed suture was drawn from the 5 mm caudal side. A clear IMF was then maintained during the postoperative 6 months. The IMF that was slack by strong drawing from the caudal side could be revised with symmetrical position of the barbed suture if the skin of the IMF was expanded sufficiently. The other seven patients did not need revision. The total revision rate was 2.9 %. Patients Case 1 (Fig. 2): A 43-year-old woman underwent left side mastectomy and immediate breast reconstruction with a tissue expander. The drawstring method using a barbed suture (V-Loc PBT number 0) and right side mastopexy were performed simultaneously with exchange of the tissue expander for a breast implant. A natural and symmetrical figure was observed 12 months postoperatively. Case 2 (Fig. 3): A 42-year-old woman underwent left side mastectomy and immediate breast reconstruction with a tissue expander. The drawstring method using a barbed suture (V-Loc PBT number 0) and nipple plasty were performed under local anesthesia; the expander was exchanged for an implant. The postoperative follow-up at 13 months showed symmetrical IMF position and form. Case 3 (Fig. 4): A 52-year-old woman underwent right side mastectomy and immediate breast reconstruction with a free transverse rectus abdominis musculocutaneous flap. The volume of the lower pole was insufficient, and the IMF was shallow. Secondary repair was performed by the drawstring method using a barbed suture (V-Loc PBT
number 0). At 10 months postoperatively, a clear IMF resulted in a naturally appearing breast. Case 4 (Fig. 5): A 44-year-old woman underwent right side mastectomy and immediate breast reconstruction with a latissimus dorsi musculocutaneous flap. The drawstring method using a barbed suture (V-Loc PBT number 0) was performed for the left side breast. The barbed suture was fixed to the deep tissue at the lateral end of the IMF through the small incision and penetrated the dermis medially. A symmetrical figure was observed 7 months postoperatively.
Discussion The amount of the mammary gland that is included in IMF tissue and whether the IMF should be excised during a mastectomy remain controversial [11–13]. Although IMF preservation facilitates cosmetic breast reconstruction [11], the IMF should be resected when required oncologically. With IMF tissue resection, dislocation of the breast implant and an unnatural form that lacks a junction between the breast and thoracic wall occur, unless the IMF is recreated [1]. Various IMF plasty methods have been previously reported. The external approach is advantageous for acquiring rigid fixation but is difficult with smaller breasts because it leaves a noticeable scar [9]. With the internal approach, fixation is achieved between the dermis or superficial fascia and the deep tissue, including the rib periosteum [5], deep fascia [8], and thoracic wall [9, 10]. However, according to detailed anatomical research, this strong fixation does not exist in a normal IMF [9, 14, 15]. Therefore, an unnatural IMF form (e.g., scalloped deformity or unnatural subduction) sometimes occurs with IMF reconstruction by the internal approach [9]. To overcome these inherent limitations, Pinella introduced liposuction to
Table 2 Factors influencing slack in the suture following surgery to recreate the inframammary fold in 95 patients with implant-based reconstruction
Age, years (mean) 2
Slack (-) 85
Slack (?) 10
Statistical significance
52.2
50.8
ns*
Body mass index, kg/m (mean)
21.9
22.4
ns*
Implant, cc (mean)
231.1
243.5
ns*
Insufficient skin expansion, n
7
5
P \ 0.005**
Postoperative radiotherapy, n
3
2
ns** P = 0.084
Strong traction of the barbed suture from caudal side ([1 cm), n
7
4
P \ 0.05**
* Chi squared test ** Fisher’s exact test ns not statistically significant
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Fig. 2 a Frontal view of a 43-year-old woman who underwent immediate left breast reconstruction using a tissue expander that was placed in a low position, b Frontal view 12 months postoperatively with recreation of a clear IMF, c Oblique view
reduce lower thorax bulkiness [6], while Nava et al., to avoid a scalloped deformity, performed fixation between the superficial fascia and thoracic wall by running a suture [9]. Similarly, running a barbed suture between the dermis and deep tissue has been recently reported [16]. However, it is difficult to determine the correct position of the IMF in a supine position and in the absence of an implant. Furthermore, mastectomy incisions have become smaller, and the internal approach is difficult through a small scar.
383
Fig. 3 a Frontal view of a 42-year-old woman who underwent immediate left breast reconstruction using a tissue expander that was placed in a low position, b Frontal view 13 months postoperatively with symmetrical IMF position and form, c Oblique view
With the drawstring method, a smooth curve can be acquired easily because the IMF is recreated by a suture that penetrates and follows the line of the skin. Moreover, because firm fixation between the skin, dermis or superficial fascia, and deep tissues does not exist, the IMF is not likely to sink to a deep level. The approach through a small scar is simple because the surgical maneuver for IMF fixation is not necessary in the pocket. With the use of a barbed suture, adjustment of the IMF position by drawing
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Fig. 4 a Frontal view of a 52-year-old woman who underwent right side breast reconstruction with a transverse rectus abdominis musculocutaneous flap. The IMF was fuzzy, with an asymmetric breast form, b Frontal view 10 months postoperatively with clear IMF and symmetrical breast expression
Fig. 5 a Frontal view of a 44-year-old woman who underwent right side breast reconstruction with a latissimus dorsi musculocutaneous flap, b Frontal view 7 months after secondary repair with the drawstring method for the left breast. A symmetrical figure was observed. It appears that the left breast became a little large
the suture is possible in a seated position, after implant placement. Slack in the suture occurred in some patients, primarily owing to insufficient expansion. Insufficient expansion of the IMF skin occurred because of elevation of the tissue expander or postoperative radiotherapy. With a lack of IMF skin expansion, it is difficult to create a deep IMF using the drawstring method. However, the drawstring method is very effective in patients with skin that is expanded well or in a nipple-sparing mastectomy. A successful procedure also depends on the suture traction. Strong traction of the barbed suture from the caudal side ([1 cm) to create a deep IMF causes slack in the suture and deviation of the implant. Furthermore, when the suture is fixed at the medial end of the IMF, the anchorage point at the costal cartilage and insertion point at the dermis should meet. If not, a dimple in the skin will appear at the medial end of the IMF by drawing the suture. There is more than one approach that results in an attractive, natural IMF reconstruction; it is necessary to choose the most suitable method for each case. With sufficient skin
for the IMF, the drawstring method is very effective for recreating the IMF. It is particularly appropriate for smaller breasts, when the IMF can be seen from the front. This method makes it possible to recreate the IMF with a smooth curve in the right position, through a small incision.
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Acknowledgments We used V-LocTM barbed sutures from Covidien (Mansfield, Massachusetts, USA). Conflict of interest
There is no financial interest in this study.
Ethical standards All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
References 1. Pennisi VR (1977) Making a definite inframammary fold under a reconstructed breast. Plast Reconstr Surg 60:523–525 2. Ryan JJ (1982) A lower thoracic advancement flap in breast reconstruction after mastectomy. Plast Reconstr Surg 70:153–160
Aesth Plast Surg (2015) 39:379–385 3. May JW Jr, Attwood J, Bartlett S (1987) Staged use of soft-tissue expansion and lower thoracic advancement flap in breast reconstruction. Plast Reconstr Surg 79:272–277 4. Wechselberger G, Del Frari B, Pt‹ lzl P, Schoeller T (2003) Inframammary fold reconstruction with a deepithelialized skin flap. Ann Plast Surg 50:433–436 5. Versaci AD (1987) A method of reconstructing a pendulous breast utilizing the tissue expander. Plast Reconstr Surg 80:387–395 6. Pinella JW (1989) Creating an inframammary crease with a liposuction cannula. Plast Reconstr Surg 83:925 7. Dowden RV (1987) Achieving a natural inframammary fold and ptotic effect in the reconstructed breast. Ann Plast Surg 19:524–529 8. Handel N, Jensen JA (1992) An improved technique for creation of the inframammary fold in silicone implant breast reconstruction. Plast Reconstr Surg 89:558–562 9. Nava M, Quattrone P, Riggio E (1998) Focus on the breast fascial system: a new approach for inframammary fold reconstruction. Plast Reconstr Surg 102:1034–1045 10. Bogetti P, Cravero L, Spagnoli G, Devalle L, Boriani F, Bocchiotti MA, Renditorre S, Baglioni E (2007) Aesthetic role of the
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13.
14.
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16.
surgically rebuilt inframammary fold for implant-based breast reconstruction after mastectomy. J Plast Reconstr Aesthet Surg 60:1225–1232 Carlson GW, Grossl N, Lewis MM, Temple JR, Styblo TM (1996) Preservation of the inframammary fold: what are we leaving behind? Plast Reconstr Surg 98:447–450 Behranwala KA, Gui GP (2002) Breast cancer in the inframammary fold: is preserving the inframammary fold during mastectomy justified? Breast 11:340–342 Gui GP, Behranwala KA, Abdullah N, Seet J, Osin P, Nerurkar A, Lakhani SR (2004) The inframammary fold: contents, clinical significance and implications for immediate breast reconstruction. Br J Plast Surg 57:146–149 Lockwood TE (1991) Superficial fascial system (SFS) of the trunk and extremities: a new concept. Plast Reconstr Surg 87:1009–1018 Muntan CD, Sundine MJ, Rink RD, Acland RD (2000) Inframammary fold: a histologic reappraisal. Plast Reconstr Surg 105:549–557 Hirsch EM, Seth AK, Fine NA (2014) Reconstruction of the inframammary fold using barbed suture. Ann Plast Surg 72:388–390
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MULTIMEDIA MANUSCRIPT
BREAST
A New Method for Inframammary Fold Recreation Using a Barbed Suture Yasunobu Terao1 • Koichiro Taniguchi1 • Shoichi Tomita2
Received: 7 December 2014 / Accepted: 16 March 2015 / Published online: 1 April 2015 Ó Springer Science+Business Media New York and International Society of Aesthetic Plastic Surgery 2015
Abstract Background There are inherent limitations with previously reported inframammary fold (IMF) recreation methods. The IMF is firmly fixed to the chest wall, but not physiologically, and it is difficult to determine the correct IMF position in the supine position and in the absence of an implant. Methods With our new IMF reconstruction method (i.e., drawstring method), the IMF is recreated by drawing a barbed suture, penetrating the dermis, along the IMF. The barbed suture is fixed to the costal cartilage at the medial IMF, and the head is drawn and cut externally at the lateral IMF. The IMF level and depth can be finely adjusted by the tension, in a seated position after implant insertion. Furthermore, the approach can be from a small incision, and a smooth IMF curve is reconstructed. Results Our drawstring method was performed in 102 patients who underwent reconstruction using a breast implant (n = 95) or flap (n = 7). The mean patient age was 52.0 years (range 33–77 years) and the follow-up period was 12 months (range 3–18 months). Suture or implant infection or exposure did not occur. Suture slack occurred
Electronic supplementary material The online version of this article (doi:10.1007/s00266-015-0479-7) contains supplementary material, which is available to authorized users. & Yasunobu Terao [email protected] 1
Department of Plastic and Reconstructive Surgery, Tokyo Metropolitan Cancer and Infectious Disease Center, Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo 113-8677, Japan
2
Department of Plastic and Reconstructive Surgery, The Jikei University School of Medicine, Minato-ku, Tokyo, Japan
in ten patients with implant-based reconstruction; their IMF became shallow. Insufficient skin expansion (P \ 0.005) and strong traction of the barbed suture from the caudal side (P \ 0.05) were related to IMF slack. The total revision rate was 2.9 %. Conclusions With sufficient skin expansion, the drawstring method using a barbed suture enables smooth and symmetrical IMF reconstruction. Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266. Keywords Breast reconstruction Barbed sutures Inframammary fold Breast implants
Introduction The inframammary fold (IMF) is an important feature of the female breast. Therefore, it should be recreated when sacrificed oncologically. Although previously reported methods for IMF reconstruction have progressed, some problems still remain. Scarring is an issue with the external approach [1–4], and it is not suitable for patients with smaller breasts. With an internal approach [5–10], subduction or scalloped deformity of the IMF may occur [9]. The conventional internal approach is also difficult because of a recently reported tendency for small mastectomy scars. In all of these methods, it is difficult to determine the correct position of the IMF in the supine position and without an inserted implant.
123
380
We devised a new method for IMF reconstruction, called the drawstring method, with the aim of solving these problems. This method recreates the IMF with a smooth curve in the correct position, through a small incision. Although it is mainly used with patients who undergo implant-based breast reconstruction after mastectomy, it can be used also for secondary repair after reconstruction with a flap. The present study aimed at determining if the drawstring method is effective for the recreation of a symmetrical and smooth IMF, as well as documenting the complications associated with and maintenance of the IMF.
Materials and Methods Our method was performed by a single surgeon with 102 patients who underwent mastectomy and breast reconstruction between April 2013 and July 2014. Even in cases with small breasts and an IMF that was not clear, this method was performed when the position of the IMF had shifted. All patients underwent conventional mastectomy, which included excision of the nipple and skin. A retrospective review of the surgical results was conducted. The relationships between complications and operative or patient factors were analyzed using Chi squared or Fisher’s exact tests. The factors influencing slack in the suture following surgery were compared for the 95 patients that underwent implant-based reconstruction. This study was approved by the ethics board of our hospital, and informed consent was obtained from all patients. Technique Before the operation and with the patient in the seated position, the IMF is marked at a level and in a shape that is symmetrical with the other breast. First, capsulotomy of the lower pole is performed following the removal of the tissue expander through the mastectomy scar. In obese patients, superficial fasciotomy and lipectomy below the IMF should be added. A number 1 or 0 non-absorbable barbed suture (V-LocTM, Covidien, Mansfield, Massachusetts) is fixed to the costal cartilage beneath the medial end of the IMF (Fig. 1a). Then, a barbed suture is used to penetrate the dermis along the IMF until the lateral end. At this time, the operation is simplified by guiding the barbed suture with an epidural needle, which is bent along the IMF and pierces the dermis from the approximate center of the IMF to the medial end of the IMF (Fig. 1b). Then, the inner needle is removed, and the barbed suture that is fixed to the costal cartilage is passed through the external cylinder (Fig. 1c). The barbed suture is not drawn after this first pass; instead, this maneuver is
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repeated three or four times for the barbed suture to penetrate the dermis along the entire IMF, and the head of the suture pierces the skin externally at the lateral end of the IMF. Finally, the head of the barbed suture is drawn to adjust the level and depth of the IMF and can be cut outside the skin without knot fixation because the barbed suture has inherent fixation to the tissue over its entire length. Therefore, IMF adjustment by drawing the suture is possible in a seated position after implant placement and wound closure (Fig. 1d, e). If a traditional suture is used for this method instead of a barbed suture, it has to be fixed to the deep tissue at the lateral end of the IMF. The transverse diameter of the new IMF line needs to be wide enough to allow for the IMF narrowing as a result of traction of the barbed suture. In patients with large breasts and a deep IMF, a barbed suture should penetrate the dermis a bit lower (\1 cm) than the preoperative marked line because the IMF moves up vertically as a result of strong suture traction. Because the IMF is recreated by drawing the sutures together, this method was named the drawstring method. The drawstring method can also be adapted for breast reconstruction using a flap. External fixation by taping or a brace (such as a bra) is required for several weeks after the operation, particularly in patients requiring strong traction for the creation of a deep IMF.
Results The mean age of the 102 patients was 52.0 years (range 33–77 years) (Table 1), and the mean follow-up period was 12 months (range 3–18 months). In 80 patients, the drawstring method was used when the tissue expander was exchanged for a breast implant, and, in 15 patients, for secondary repair after reconstruction with implants. In the remaining seven patients, it was used for secondary repair after reconstruction with flaps. The average expansion of the tissue expander was 120 % of the breast implant volume. In 12 patients, the skin around the IMF was not sufficiently expanded because of elevation of the tissue expander or the influence of postoperative radiotherapy. The breast implants were round (12 patients; range 125–175 cc; average, 152.1 cc) or anatomical (83 patients; range 120–430 cc; average, 243.9 cc) types. Infection and exposure of the suture or breast implant did not occur. Slack in the suture occurred in ten patients who underwent implant-based reconstruction with anatomical-type breast implants, and their IMF became shallow. A clear IMF was maintained in the remaining 92 patients (100 %, flap; 89.5 %, implant). Although there were no
Aesth Plast Surg (2015) 39:379–385
381
Fig. 1 a A barbed suture is fixed to the costal cartilage beneath the medial end of the inframammary fold (IMF), b An epidural needle bent along the IMF pierces the dermis from the approximate center of the IMF to the medial end of the IMF, c The suture, with its needle removed, is passed through the external cylinder of the epidural needle, d, e The head of the suture is drawn to adjust the level and depth of the IMF, and it can be cut outside the skin without knot fixation. This adjustment is possible in a seated position after inserting the implant
Table 1 Clinical characteristics of the patients who underwent surgery for placement of the inframammary fold Total
Breast implant
Flapa
Patients
102
95
7
Age, years
52.0 (33–77)
52.0 (33–77)
50.3 (44–58)
Body mass index, kg/m2 Implant size, cc
22.2 (14.4–34.6)
22.0 (14.4–34.6) 232.3 (120–430)
24.6 (20.3–33.0)
Postoperative radiotherapy
5
5
0
a
Transverse rectus abdominis musculocutaneous flap, n = 6; latissimus dorsi musculocutaneous flap, n = 1
Values are reported as n or mean (range)
differences in age, body mass index, implant size, and postoperative radiotherapy based on the occurrence of suture slack (P [ 0.05), there were significant differences in
the number of patients with insufficient expansion of the IMF skin (P \ 0.005) and strong traction of the barbed suture from the caudal side ([1 cm) (P \ 0.05) (Table 2).
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Of the ten patients that experienced slack, two patients with insufficient expansion of the IMF skin underwent correction by additional capsulotomy and conventional internal fixation, but their IMF became unclear again. One patient in whom the barbed suture was drawn strongly from the 2 cm caudal side underwent correction by the drawstring method in which the barbed suture was drawn from the 5 mm caudal side. A clear IMF was then maintained during the postoperative 6 months. The IMF that was slack by strong drawing from the caudal side could be revised with symmetrical position of the barbed suture if the skin of the IMF was expanded sufficiently. The other seven patients did not need revision. The total revision rate was 2.9 %. Patients Case 1 (Fig. 2): A 43-year-old woman underwent left side mastectomy and immediate breast reconstruction with a tissue expander. The drawstring method using a barbed suture (V-Loc PBT number 0) and right side mastopexy were performed simultaneously with exchange of the tissue expander for a breast implant. A natural and symmetrical figure was observed 12 months postoperatively. Case 2 (Fig. 3): A 42-year-old woman underwent left side mastectomy and immediate breast reconstruction with a tissue expander. The drawstring method using a barbed suture (V-Loc PBT number 0) and nipple plasty were performed under local anesthesia; the expander was exchanged for an implant. The postoperative follow-up at 13 months showed symmetrical IMF position and form. Case 3 (Fig. 4): A 52-year-old woman underwent right side mastectomy and immediate breast reconstruction with a free transverse rectus abdominis musculocutaneous flap. The volume of the lower pole was insufficient, and the IMF was shallow. Secondary repair was performed by the drawstring method using a barbed suture (V-Loc PBT
number 0). At 10 months postoperatively, a clear IMF resulted in a naturally appearing breast. Case 4 (Fig. 5): A 44-year-old woman underwent right side mastectomy and immediate breast reconstruction with a latissimus dorsi musculocutaneous flap. The drawstring method using a barbed suture (V-Loc PBT number 0) was performed for the left side breast. The barbed suture was fixed to the deep tissue at the lateral end of the IMF through the small incision and penetrated the dermis medially. A symmetrical figure was observed 7 months postoperatively.
Discussion The amount of the mammary gland that is included in IMF tissue and whether the IMF should be excised during a mastectomy remain controversial [11–13]. Although IMF preservation facilitates cosmetic breast reconstruction [11], the IMF should be resected when required oncologically. With IMF tissue resection, dislocation of the breast implant and an unnatural form that lacks a junction between the breast and thoracic wall occur, unless the IMF is recreated [1]. Various IMF plasty methods have been previously reported. The external approach is advantageous for acquiring rigid fixation but is difficult with smaller breasts because it leaves a noticeable scar [9]. With the internal approach, fixation is achieved between the dermis or superficial fascia and the deep tissue, including the rib periosteum [5], deep fascia [8], and thoracic wall [9, 10]. However, according to detailed anatomical research, this strong fixation does not exist in a normal IMF [9, 14, 15]. Therefore, an unnatural IMF form (e.g., scalloped deformity or unnatural subduction) sometimes occurs with IMF reconstruction by the internal approach [9]. To overcome these inherent limitations, Pinella introduced liposuction to
Table 2 Factors influencing slack in the suture following surgery to recreate the inframammary fold in 95 patients with implant-based reconstruction
Age, years (mean) 2
Slack (-) 85
Slack (?) 10
Statistical significance
52.2
50.8
ns*
Body mass index, kg/m (mean)
21.9
22.4
ns*
Implant, cc (mean)
231.1
243.5
ns*
Insufficient skin expansion, n
7
5
P \ 0.005**
Postoperative radiotherapy, n
3
2
ns** P = 0.084
Strong traction of the barbed suture from caudal side ([1 cm), n
7
4
P \ 0.05**
* Chi squared test ** Fisher’s exact test ns not statistically significant
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Aesth Plast Surg (2015) 39:379–385
Fig. 2 a Frontal view of a 43-year-old woman who underwent immediate left breast reconstruction using a tissue expander that was placed in a low position, b Frontal view 12 months postoperatively with recreation of a clear IMF, c Oblique view
reduce lower thorax bulkiness [6], while Nava et al., to avoid a scalloped deformity, performed fixation between the superficial fascia and thoracic wall by running a suture [9]. Similarly, running a barbed suture between the dermis and deep tissue has been recently reported [16]. However, it is difficult to determine the correct position of the IMF in a supine position and in the absence of an implant. Furthermore, mastectomy incisions have become smaller, and the internal approach is difficult through a small scar.
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Fig. 3 a Frontal view of a 42-year-old woman who underwent immediate left breast reconstruction using a tissue expander that was placed in a low position, b Frontal view 13 months postoperatively with symmetrical IMF position and form, c Oblique view
With the drawstring method, a smooth curve can be acquired easily because the IMF is recreated by a suture that penetrates and follows the line of the skin. Moreover, because firm fixation between the skin, dermis or superficial fascia, and deep tissues does not exist, the IMF is not likely to sink to a deep level. The approach through a small scar is simple because the surgical maneuver for IMF fixation is not necessary in the pocket. With the use of a barbed suture, adjustment of the IMF position by drawing
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Aesth Plast Surg (2015) 39:379–385
Fig. 4 a Frontal view of a 52-year-old woman who underwent right side breast reconstruction with a transverse rectus abdominis musculocutaneous flap. The IMF was fuzzy, with an asymmetric breast form, b Frontal view 10 months postoperatively with clear IMF and symmetrical breast expression
Fig. 5 a Frontal view of a 44-year-old woman who underwent right side breast reconstruction with a latissimus dorsi musculocutaneous flap, b Frontal view 7 months after secondary repair with the drawstring method for the left breast. A symmetrical figure was observed. It appears that the left breast became a little large
the suture is possible in a seated position, after implant placement. Slack in the suture occurred in some patients, primarily owing to insufficient expansion. Insufficient expansion of the IMF skin occurred because of elevation of the tissue expander or postoperative radiotherapy. With a lack of IMF skin expansion, it is difficult to create a deep IMF using the drawstring method. However, the drawstring method is very effective in patients with skin that is expanded well or in a nipple-sparing mastectomy. A successful procedure also depends on the suture traction. Strong traction of the barbed suture from the caudal side ([1 cm) to create a deep IMF causes slack in the suture and deviation of the implant. Furthermore, when the suture is fixed at the medial end of the IMF, the anchorage point at the costal cartilage and insertion point at the dermis should meet. If not, a dimple in the skin will appear at the medial end of the IMF by drawing the suture. There is more than one approach that results in an attractive, natural IMF reconstruction; it is necessary to choose the most suitable method for each case. With sufficient skin
for the IMF, the drawstring method is very effective for recreating the IMF. It is particularly appropriate for smaller breasts, when the IMF can be seen from the front. This method makes it possible to recreate the IMF with a smooth curve in the right position, through a small incision.
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Acknowledgments We used V-LocTM barbed sutures from Covidien (Mansfield, Massachusetts, USA). Conflict of interest
There is no financial interest in this study.
Ethical standards All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
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