Introduction

Breast cancer (BC) is the most common cancer in women (20.9% in 2018) [1]. Nevertheless, screening has reduced the number of patients with late stages of disease [2]. According to statistical data for 2017, breast cancer stage I was diagnosed in 26.0% of patients, stage II — 43.9%, stage III — 21.6%, stage IV — 7.9%, unclear stage — 0.6%. At the same time, the modern possibilities of drug treatment and radiotherapy of breast cancer have grown significantly in recent years. As a result, mortality rate within the first year after diagnosis has decreased up to 6% [3]. Improvement of life expectancy and quality of life in patients with breast cancer is followed by advanced interest of medical community and patients in reconstructive breast surgery. Psychologists analyzed psychological portrait of a woman with previous breast cancer. According to their data, borderline psychiatric disorders are detected in 70 out of 100 women; baseline mental disorders were found on other ones. These patients associate psychological disorders with loss of sexuality and attractiveness in addition to fear of their own health [4].

The above-mentioned aspects dictate the need for perfect methods of one-stage breast reconstruction with the best aesthetic outcome, minimal number of complications and optimal technical and economic availability.

Surgical treatment of breast cancer has undergone significant changes since the first description of radical mastectomy by W.S. Halsted in 1891. Various approaches to mastectomy with simultaneous breast reconstruction were developed (“expander-implant”, autotransplantation or their combination). We would like to emphasize the incidence of breast endoprosthesis implantation in the world (65% of all reconstructive interventions) [5]. This is due to relative technical simplicity and economic availability of this method.

However, breast endoprosthesis implantation has certain complications like all other methods. G. Edwin et al. [6] analyzed 1615 cases of breast reconstruction with endoprostheses (implants and two-stage reconstruction using “expander-implant” technology). Simultaneous reconstruction was performed in 92.9% of cases, delayed reconstructions — in 7.1% of patients. The authors did not consider anatomical location of endoprosthesis and its coverage. Follow-up period was 12 months. Complications of reconstruction with endoprostheses were as follows: hematoma — 56 (3.5%) cases; wound edge dehiscence — 26 (1.6%); infection — 162 (10.0%); skin flap necrosis — 107 (6.6%); seroma — 47 (2.9%); capsular contracture — 13 (0.8%); implant displacement — 8 (0.5%); implant integrity disruption — 18 (1.1%) cases.

G. Edwin et al. emphasized once again imperfection of simultaneous reconstruction with endoprosthesis and confirmed the need to modify these techniques.

Covering the lower slope is traditional problem in subpectoral placement of endoprosthesis during subcutaneous or skin-preserving mastectomy with simultaneous implant/expander implantation. Upper slope is covered by pectoralis major muscle [7–10]. Incomplete covering of endoprosthesis significantly increases the risk of complications, especially during subsequent radiotherapy [11–15].

To date, various methods of covering the lower slope of endoprosthesis have been developed (synthetic mesh materials, biological mesh materials, local autodermal flaps, as well as movement of musculocutaneous flaps with axial blood supply) [16, 17].

Acellular dermal matrix (ADM) is an expensive material for breast reconstruction. M. Scheflan and A. Colwell [10] analyzed 1170 cases of two-stage reconstruction (expander-implant technology) and compared the incidence of complications after surgery with/without ADM. Despite the contradictory data, most authors agree that ADM reduces the incidence of complications compared to methods without covering the lower slope of the breast. Nevertheless, the cost of ADM is currently high and surgeons in many countries refuse this technique. An approximate cost of ADM mesh 18 x 10 cm ranges from $ 3,000 to $ 3,500 in the United States [18–25].

H. Ellis et al. [26] compared synthetic mesh materials and ADM for breast reconstruction. According to their data, both methods are comparable regarding the number of complications with minor differences. Synthetic materials were somewhat better regarding the incidence of infectious complications, ADM ensured less incidence of capsular contracture. However, an important advantage of synthetic mesh materials is cost (about $ 500-800 in the USA (TiLOOP Bra 19.5×9.5 cm)). Most authors agree that covering the lower slope of implant with ADM ensures better aesthetic outcomes compared to synthetic mesh implants. This is due to better integration of ADM into tissues.

Another method of covering the lower slope of endoprosthesis is flaps with axial blood supply. Thoracodorsal flap (TDF) is the most common among them. The technology consists in harvesting a latissimus dorsi flap through an additional incision in subscapular area with or without an additional skin flap. TDF ensures complete covering the implants of any dimensions and reduces the incidence of complications after reconstructive surgeries with implantation of endoprosthesis. The main disadvantage of this technique is donor bed morbidity. TDF harvesting is often followed by seroma, significant functional impairment of latissimus dorsi muscle, as well as contour defects in thin patients. Nevertheless, TDL is considered as an alternative to synthetic mesh materials [27, 28].

In addition to 3 above-mentioned methods, autoderm is actively used in the world to cover the lower slope of endoprosthesis. This technique is devoid of disadvantages associated with cost and donor bed morbidity. Autoderm technique was first described by Bostwick in 1990 [5].

Autodermal flap technique includes the following stages:

1) incision and breast skin deepidermization by Weiss;

2) mastectomy via this approach;

3) implantation of endoprosthesis into the bed from major pectoralis muscle and de-epithelialized skin of the lower slope of the breast;

4) wound suturing in “T-inverse” fashion.

The purpose of the study was to develop the technique of implant lower slope coverage for reduction of the incidence of complications requiring redo surgery in subcutaneous and skin-sparing mastectomy with simultaneous breast implant reconstruction.

Material and methods

An experience of simultaneous breast reconstruction with implantation of endoprosthesis and covering the lower slope with deepidermized autodermal flap was accumulated at the department of reconstructive surgery for cancer. This method was applied in 72 patients with breast cancer stage I (34.72%) and IIa (65.28%) for the period from 2016 to 2019. Fourteen (19.44%) patients underwent preventive subcutaneous mastectomy and reconstruction with an implant due to BRCA1 and BRCA2 gene mutations.

Surgical technique

Marking. Marking is carried out in patient’s standing position. The midline connecting xiphoid process and jugular notch, inframammary grooves and middle nipple lines are marked. Marking in accordance with Weiss technique is performed around the nipple-areolar complex considering the new proposed position of upper edge of areola (Fig. 1).

Fig. 1. Preoperative marking in a patient with subcutaneous and skin-preserving mastectomy with simultaneous endoprosthesis reconstruction.

a — midline connecting xiphoid process and jugular notch, inframammary grooves, middle nipple lines and areola are marked; b — marking by Weiss round the nipple-areolar complex considering the new position of upper edge of areola.

Surgery. Intervention is carried out in patient’s supine position with outstretched arms. Operating table should ensure the possibility of patient’s sitting position for preliminary assessment of aesthetic result of surgery. Next, anesthetic procedures and surgical field dressing are performed. If indicated, sentinel lymph node biopsy (SLNB) is performed via additional incision 4–5 cm in axillary region. Then, skin incision by Weiss is performed according to preliminary marking. Surgeon performs deepidermization of superior or superior medial pedicle for subsequent translocation of nipple-areolar complex, as well as deepidermization of the flap of the lower slope of the breast (Fig. 2).

Fig. 2. The initial stage of the operation.

a — skin incision by Weiss according to preliminary marking; b — deepidermization of the upper pedicle for further translocation of nipple-areolar complex and the flap of the lower slope of the breast.

Deepidermized autodermal flap and pedicle with nipple-areolar complex are separated from the underlying breast tissue and covered with napkins soaked in saline solution (Fig. 3). Subcutaneous mastectomy is performed via this access. Next, major pectoralis muscle is elevated in accordance with preoperative marking (Fig. 4). An obligatory surgical stage is suturing of deepidermized autodermal flap to the chest at the level of putative submammary sulcus. Several interrupted slowly absorbable sutures are used to fix submammary sulcus.

Fig. 3. Separating of the deepidermized autodermal flap and the pedicle containing the nipple-areolar complex from the underlying breast tissue.

Fig. 4. Elevation of the pectoralis major muscle.

Hemostasis, insertion of drainage tubes in axillary area and endoprosthesis bed, additional scrubbing of surgical field with antiseptic solutions and changing gloves by the entire surgical team are followed by implantation.

An implant is covered by a combination of major pectoralis muscle and de-epithelized skin of the lower slope of the breast (Fig. 5). The wound is sutured in T-inverse fashion using cosmetic sutures (Fig. 6).

Fig. 5. Implantation.

Implant is covered with a pectoralis major muscle and autodermal flap.

Fig. 6. The final stage of the operation.

T-inverse suture.

Postoperative management

Antibiotic therapy with broad-spectrum drugs and analgesia are prescribed in postoperative period. Compression underwear is recommended for 1.5 months. Drainage tubes are removed after 6–8 days depending on discharge. Attending physician informs the patient about contraindications for physical exertion on shoulder girdle, as well as prohibition of raising the arms above shoulder level for 2 months after surgery. In addition, consultation of rehabilitation physician is recommended.

Results

Excellent postoperative aesthetic result was obtained in 49 (68.05%) patients, good outcome — in 15 (20.84%) patients.

There were no complications requiring redo surgery. Marginal necrosis of nipple-areolar complex was the most common complication (n=4, 5.55%). Total necrosis of nipple-areolar complex occurred only in 1 (1.38%) patient. In all cases, partial and complete necrosis of nipple-areolar complex resulted scar surface after scab discharge. Subsequently, these patients underwent cosmetic tattooing. All cases of necrosis were associated with advanced (over 4 cm) translocation of nipple-areolar complex. Partial necrosis of skin flap was observed in 3 (4.17%) cases. In all cases, treatment implied ointment dressings.

Clinical examples

A 42-year-old patient N. with BRCA2-associated right breast cancer (stage Ia, T1N0M0) underwent SLNB with bilateral subcutaneous mastectomy and simultaneous implant reconstruction (Fig. 7).

Fig. 7. Patient N., 42 years old, before (a) and after (b) bilateral subcutaneous mastectomy with simultaneous implant reconstruction.

A 46-year-old patient A. with BRCA1-associated left breast cancer (stage I, T1N0M0) underwent SLNB with bilateral subcutaneous mastectomy and simultaneous implant reconstruction (Fig. 8).

Fig. 8. Patient A., 46 years old, before (a) and after (b) bilateral subcutaneous mastectomy with simultaneous implant reconstruction.

A 39-year-old patient M. with BRCA2-associated left breast cancer (stage IIa, T2N0M0) underwent SLNB with bilateral subcutaneous mastectomy and simultaneous implant reconstruction (Fig. 9).

Fig. 9. Patient M., 39 years old, before (a) and after (b) bilateral subcutaneous mastectomy with simultaneous implant reconstruction.

A 51-year-old patient A. with cancer of the left breast (stage IIa, T2N0M0) underwent SLNB with skin-sparing left-sided mastectomy and simultaneous implant reconstruction, right-sided T-inverted mastopexy. Nipple-areolar complex was removed due to the presence of tumor cells in subareolar area (Fig. 10).

Fig. 10. Patient A., 51 years old, before (a) and after (b) skin-sparing mastectomy on the left with simultaneous implant reconstruction. T-inverted mastopexy on the right. Nipple-areolar complex was resected due to tumor cells in subareolar area.

Conclusion

Deepidermized autodermal flap for simultaneous breast reconstruction with endoprosthesis is valuable to prevent complications requiring redo surgery (protrusion and loss of endoprosthesis). This technique is advisable in patients with breast ptosis grade ≥ II and early stages of disease (stages I and IIa when no radiotherapy is scheduled). Correction of contralateral breast is required in all cases. Implantation of expander instead of implant is possible in case of lymph node metastases or if surgeon has doubts about sufficient blood supply of the skin flap.

Obvious advantages of this technique:

— aesthetic result following mastopexy and submammary sulcus fixation;

— more reliable covering of lower slope of endoprosthesis, in particular within suture zones.

The technique is not advisable if breast ptosis is mild or absent.

The authors declare no conflicts of interest.