NEW ORLEANSA new technique for breast
reconstruction, used after a new method of skin-sparing
mastectomy, offers patients a scar-free result, according to the
surgeon who developed the method, Gino Rigotti, MD, head of the
Plastic Surgery Department, Verona General Hospital, Italy.
The reconstruction involves insertion of a semilunar-shaped expander
followed by definitive implant with a purse-string skin closure, Dr.
Rigotti said at the 68th Annual Scientific Meeting of the American
Society of Plastic and Reconstructive Surgeons (now known as the
American Society of Plastic Surgeons).
From the reconstructive surgeons point of view, skin-sparing
mastectomy is a contradiction in terms. Skin-sparing mastectomy
is a surgical method that reduces scars in the breast area but still
requires very invasive reconstructive techniques, Dr. Rigotti said.
The most commonly used immediate reconstruction techniques after
skin-sparing mastectomyfree and pedicle TRAM flaps or
latissimus dorsi flap with implantare highly invasive and can
leave functional or esthetic complications in donor areas in these
patients, he said.
To avoid disfiguring scars, Dr. Rigotti developed the new technique
based on what he considers the simplest, least invasive
reconstruction method availableexpansion followed by definitive implant.
The modified reconstruction method uses a purse-string closure to the
central portion of the surgical wound, reducing the length and
appearance of the scar. Additionally, the expander is not the usual
round or oval shapeit is semilunar, a shape, Dr. Rigotti said,
that allows the physician to expand only the inferior pole and thus
achieve a more desirable shape and position.
In the Verona experience of Dr. Rigotti and his colleague Alessandra
Marchi, MD, the complication rate in patients undergoing this method
of reconstruction has been low. The major complication rate
(complications resulting in failure of the reconstruction) is 3%, and
the minor complication rate (complications that did not compromise
the reconstruction) is 9%. This low complication rate is due, he
believes, to the absence of the retracting longitudinal scars
normally present with use of the other methods.
The complication rate is higher in patients who underwent or will
undergo radiation therapy. For such patients, autologous tissue
procedures are probably a better choice, he said.
The Italian surgeons began using the technique in August 1997 and
described their experience in 90 patients over a 26-month period. Of
this group, 50 patients had mastectomy followed only by expander
introduction, and 40 patients completed the surgical procedure with
definitive implant and areola-nipple reconstruction.
Skin excision in these patients was 5 cm to 13 cm wide, and an
axillary dissection was made en bloc with the mammary gland when necessary.
Patients with central or paracentral infiltrating cancer or with
comedo-type simple or multifocal intraductal lesions received a
round, central skin incision, which always included the skin
overlying the lump. The only obvious scar left in these patients
after reconstruction was the one surrounding the newly reconstructed nipple-areola.
Patients with infiltrating cancer of the peripheral quadrants
received a drop-shaped incision, which included the nipple/areola
complex and the skin over the lump. The purse-string closure in this
group was applied to the central portion of the surgical wound,
reducing the length of the residual scar and preventing scar
involvement of the tumor-free quadrants.