How is the first stage of breast reconstruction performed?

Updated: Jul 29, 2021
  • Author: Mark F Deutsch, MD; Chief Editor: James Neal Long, MD, FACS  more...
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Immediately following mastectomy, the surgeon may close the wound and delay reconstruction, place a tissue expander under the pectoralis muscle, [2] place an implant beneath a transferred latissimus myocutaneous flap, or perform immediate reconstruction with a large myocutaneous flap. Nevertheless, the surgeon often believes that the most difficult portion of the reconstruction has been achieved, although the breast mound does not resemble the opposite breast. Certain details should be addressed during this initial procedure to improve the final outcome.

  1. Restore the inframammary crease. Close cooperation with the oncologic surgeon can alleviate problems, since technically no breast tissue lies inferior to this plane. If it has been violated, reconstruct it with sutures before proceeding. Some surgeons prefer placing sutures through the skin at the inframammary fold (IMF), while others simply mark this area with a pen. It is important to mark the IMF and the medial border and lateral slope of the breast.

  2. Close the axilla. During axillary dissection and dissection of the thoracodorsal pedicle, the lateral border of the latissimus is lifted away from the chest wall. If left alone without closure, the flap or implant often drifts laterally in this area. Suture the latissimus-serratus unit back to the chest wall in an attempt to restore the natural slope of the lateral breast.

  3. Inspect the mastectomy flaps carefully. If vascular compromise is suspected, intraoperative use of the Wood lamp may help determine this. If uncertainty remains, several options are available, including delaying reconstruction, resecting the questionable skin with immediate reconstruction, and closing the questionable skin over a non–de-epithelialized skin paddle, which allows full demarcation of the questionable skin and definitive surgical repair 2-3 days later.

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