Open Access

Early experience with implant based breast reconstruction for early breast cancer in ptotic breasts with non biological mesh and lower pole dermal sling

  • Rathinasabapathy Rathinaezhil1Email author,
  • Fiammetta Ugolini1 and
  • Hisham Osman1
Annals of Surgical Innovation and Research20159:3

https://doi.org/10.1186/s13022-015-0012-3

Received: 30 November 2014

Accepted: 11 May 2015

Published: 19 May 2015

Abstract

Aim

Evaluation of early experience with implant based breast reconstruction for early breast cancer in ptotic breasts with titanium coated polypropylene mesh and lower pole dermal sling.

Methods

A pilot prospective ongoing study where patients having immediate implant based reconstruction with non biological mesh and lower pole dermal sling are evaluated simultaneously. Patient, surgical, and tumour related factors are presented as well as the cosmetic outcome in five patients, two of whom underwent bilateral procedure for bilateral breast cancer and one who underwent simultaneous symmetrisation with reduction mammoplasty on the contralateral side.

Results

All five patients had good cosmetic outcome with minor complications. There was no delay in adjuvant treatment due to complications. All were satisfied with their results and would recommend this treatment to others.

Conclusion

Using a non biological mesh as well as a lower pole dermal sling, which covers the suture line and offers an extra layer of protection to the mesh, reduces the complication rate especially in patients who may be at higher risk of wound related problems such as those with increased body mass index. This procedure is also cost effective (non biological meshes are only 1/5th of the cost compared to biological meshes) and provides equivalent cosmetic outcomes in a select group of patients.

Keywords

Breast cancer Reconstruction Implant Mesh Lower pole dermal sling

Background

The incidence of breast cancer continues to increase throughout the world. In 2011, there were 50,285 new cases of breast cancer in the UK. 49,936 (99 %) in women and 349 (less than 1 %) in men [1]. Patients with early breast cancer who need to undergo mastectomy are offered immediate as well as delayed reconstruction routinely in the UK. Nearly 30 % of patients (national mastectomy breast reconstruction (NMBRA) audit) in the immediate reconstruction setting opted to have implant based reconstruction after weighing up all the options available to them. With the availability of various biological and non biological meshes, good cosmetic outcome can be achieved at the present time [2].

The cost of biological meshes can be a prohibitive factor in offering this to all patients requiring implant based reconstruction [3]. Non biological meshes as an alternative are cost effective and can be substituted for biological meshes [4].

There are several publications supporting the use of non biological meshes and claiming equivalent cosmetic outcomes to biological meshes [58]. In patients with significant ptosis where skin reduction is also necessary, a lower pole dermal sling (the patient’s own biological mesh) can be used for breast reconstruction [9, 10].

We would like to present our early experience of combining the non biological mesh with the lower pole dermal sling in patients with significant ptosis who need skin reduction as well as reconstruction using implants with good cosmetic outcome.

Patient details and methods

All patients consented to take part in the study and this study was fully compliant with the Helsinki declaration. The treatment that patients underwent was the standard of care for their disease and as this study only looks into an innovative surgical technique, ethics approval was not required.

We have done seven procedures in five patients (two bilateral procedures for bilateral breast cancer). The age distribution in this cohort was 42–62 and the mean age was 53 years. All of the patients made an informed decision to undergo implant based reconstruction after reviewing the reconstruction literature and detailed discussion with the specialist breast care nurse.

The details of patient related factors such as age, BMI, smoking status, co-morbidities, drug intake including steroid intake, alcohol consumption, skin quality, contralateral breast surgery, degree of ptosis, and knowledge about post-operative radiotherapy and its implications are given in Table 1.
Table 1

Patient related factors

 

Patient 1

Patient 2

Patient 3

Patient 4

Patient 5

Age

42

47

55

59

62

BMI

22

34

26

31

33

Smoking habit

Non smoker

Yes. Gave up at diagnosis

Yes. Gave up at diagnosis

Ex-smoker–stopped 15 years ago

Non smoker

Alcohol intake per week

Very occasional

None

Occasional

14 units/week

None

Drugs including steroids

None

None

None

None

None

Connective tissue and vasculitic disorders

None

None

None

None

None

Diabetes

No

No

No

No

No

Other co morbidities

None

Asthma

None

None

None

Skin quality

Very good

Good

Good

Good

Good

Degree of ptosis

3

3

2

3

3

Contra lateral breast surgery

Planned

NA

Patient not keen

Reduction for symmetry

Planned

Knowledge about post-operative radiotherapy

Aware of the possibility

Aware of the possibility on the right

Aware

Unlikely as DCIS

Aware of the possibility on both sides

BMI body mass index, DCIS ductal carcinoma in situ

Surgery related factors such as antibiotic prophylaxis (intra-operative and post-operative), skin prep used, method of dissection to raise the dermal sling and mastectomy flap, mastectomy specimen weight, cavity washout, change of gloves, laminar flow usage, type and number of drains used, duration for which drains were left in, frequency of post-operative follow up are detailed in Table 2.
Table 2

Surgery related factors

 

Patient 1

Patient 2

Patient 3

Patient 4

Patient 5

Antibiotic prophylaxisa

Yes

Yes

Yes

Yes

Yes

Duration of antibiotic prophylaxisb

7 days

14 days

7 days

7 days

10 days

Skin prep used

Chlorhexidine

Chlorhexidine

Chlorhexidine

Chlorhexidine

Chlorhexidine

Method of dissection to raise skin flaps and dermal sling

Diathermy

Diathermy

Diathermy

Diathermy

Diathermy

Cavity wash out

Saline and antibiotic solution

Saline and antibiotic solution

Saline and antibiotic solution

Saline and antibiotic solution

Saline and antibiotic solution

Change of gloves prior to implantation

Yes

Yes

Yes

Yes

Yes

Implant type

Permanent anatomical fixed volume implant

Permanent anatomical fixed volume implant

Permanent anatomical fixed volume implant

Permanent anatomical fixed volume implant

Permanent anatomical fixed volume implant

Type, number of drains used and duration

Exudrain

Exudrain

Exudrain

Exudrain

Exudrain

2

2

2

2

2 on each side

7 days

10 days

7 days

7 days

10 days

Laminar flow usage

Yes

Yes

Yes

Yes

Yes

Post-op follow up

1 week

2 weeks

1 week

1 week

1 week

Mastectomy specimen weight

496 g

R-905 g

600 g

1071 g

R-454 g

L-885 g

L-464 g

a2 g flucloxacillin and 160 mg gentamicin or in those with penicillin allergy; 600 mg teicoplanin and 160 mg gentamicin

bDuration decided by the operating surgeon

The details of the hospital stay, immediate postoperative issues, tumour related factors, adjuvant, neoadjuvant treatments as well as further surgery planned are given in Tables 3, 4 and 5.
Table 3

Hospital stay and complications within 30 days

 

Patient 1

Patient 2

Patient 3

Patient 4

Patient 5

No of nights spent in hospital

5

10

3

5

3

Inpatient concerns

None

Skin necrosis

None

None

None

Minor complications treated conservatively

Wound edge superficial necrosis

As above

None

None

None

Major complications requiring readmissionand/or reoperation

None

None

None

None

None

Table 4

Tumour related factors

 

Patient 1

Patient 2

Patient 3

Patient 4

Patient 5

Size (invasive + in situ)

83 mm

R-40 mm, L-8 mm

9 mm with ADH

7 mm invasive and 100 mm in situ

R-100 mm, L-55 mm

Grade

2

R-3, L-2

3

3

3

Type

Mixed ductal with lobular features

R-ductal, L-lobular

Invasive ductal

Invasive micropapillary

Invasive lobular carcinoma

LVI

Positive

Negative

Negative

Negative

Positive both sides

Lymph node status

1/1

R-0/4, L-0/3

0/2

0/2

R-2/4, L-2/4

ER status

7

R-2, L-7

8

0

R-8, L-8

PR status

8

R-NK, L-6

8

0

R-6, L-8

HER2 status

Negative

R-Positive

Negative

Positive

Negative on both sides

L-Negative

ADH atypical ductal hyperplasia, LVI lymphovascular invasion, ER oestrogen receptor, PR progesterone receptor, DCIS ductal carcinoma in situ

Table 5

Adjuvant and neoadjuvant treatment and further surgery planned

 

Patient 1

Patient 2

Patient 3

Patient 4

Patient 5

Neoadjuvant chemotherapy

No

Yes

No

No

No

Neoadjuvant endocrine therapy

No

No

No

No

No

Adjuvant chemotherapy

Yes

No

No

No

Yes

Adjuvant endocrine therapy

Planned

Yes

Yes

No

Yes

Adjuvant radiotherapy

Planned

Yes only to the right

No

No

Yes

Targeted therapy

No

Yes

No

No

No

Further surgery planned for cancer

Planned (completion axillary clearance)

Possible free flap reconstruction–patient choice

Patient not keen on symmetrisation

No

No

Surgical technique

The patients were marked with a standard Wise pattern incision, with a 7.5–9 cm vertical incision (depending on the patient’s body habitus). Once de-epithelialisation of the skin was done, skin flaps, and dermal sling were raised and the breast disc was lifted from the pectoralis major and the mastectomy was performed in the standard manner.

The pectoralis major muscle was then raised by dividing it inferiorly and medially at the level of the infra mammary fold and a sub pectoral pocket was created. The synthetic non biological mesh (Ti Loop®) was fixed to the pectoralis muscle with 2/0 absorbable sutures to complete the pocket. The permanent fixed volume implant chosen was placed in the pocket and the mesh was fixed to the inframammary fold as well as laterally along the anterior axillary line to prevent lateral displacement.

Finally the dermal sling overlying the mesh was fixed to the muscle and the wound closed in layers with two low pressure vacuum drains. Patients were advised to wear a support bra for 6 weeks.

The technique is summarized in Figs. 1 and 2.
Fig. 1

Schematics step by step summary of surgical technique

Fig. 2

Illustrations of the step by step summary of surgical technique

Complications

There were no major complications and the only minor complication encountered was “T” junction and skin edge necrosis which settled with conservative measures. Four out of the five patients have had 3 months follow up. The fifth patient had surgery less than 3 months ago.

Patient reported outcome measures (PROMS) were assessed in four patients with breast Q questionnaire after obtaining informed consent 3 months post-operatively. The details are given in Table 6. The last patient declined consent for evaluation.
Table 6

PROMS (Patient Reported Outcome Measures at 3 months)a

 

Patient 1

Patient 2

Patient 3

Patient 4

Information given about mastectomy and reconstruction including risks and benefits

Right amount

Right amount

Right amount

Right amount

Management of pain in the first 24 h and during the first week

Mild pain

Moderate to severe pain

Mild pain

Mild pain

Unplanned readmission or surgery

None

None

None

None

Complications requiring treatment on an outpatient basis since discharge from hospital

None

Oral antibiotics for infection

Oral antibiotics for infection

None

Number of visits to surgical outpatients since discharge

4

5

3

3

aPROMS not reported for patient 5 as she declined consent

Results

All five patients were satisfied with the care and information they received. They were also satisfied with the cosmetic outcome from the reconstruction at this early follow up although admittedly this may change with longer follow up as well as with adjuvant radiotherapy.

A random selection of 15 allied health professionals and administrative staff, who were not directly involved in patient care, were asked to score the cosmetic outcome in four patients (one patient declined post-operative photographs). They were shown photographs of the breasts 3 months post-op and asked to score them between 1 and 10, where 1 = poor cosmetic appearance and 10 = excellent cosmetic appearance. In general, the scores were very encouraging with the average rating being 7.4–7.7. However the small sample size should be taken into context. The full details are given in Table 7.
Table 7

Observer ratings of cosmetic appearance at 3 months (1 = poor, 10 = excellent)a

 

Patient 1

Patient 2

Patient 3

Patient 4

Mean

7.4

7.4

7.7

7.7

Median

7

8

8

8

Mode

7,8

8

8, 9

8,9

Range

6–9

5–9

4–9

4–9

aObserver ratings not reported for patient 5 as she declined further follow up pictures

Conclusion

The availability of biological and non biological meshes have improved the cosmetic outcome of implant based reconstruction. The use of the mesh as a hammock in the lower pole and attaching it to the divided pectoralis major muscle enables us to reconstruct the breast using with larger volume implants with much less discomfort, quicker recovery, and better cosmetic outcome. This also avoids donor site scar and its associated morbidity in patients who are not keen to have other forms of reconstruction.

Our initial experience suggests that this technical innovation is an excellent alternative for patients with ptosis where skin reduction is needed. This negates the need to raise the serratus anterior muscle as required when the dermal sling alone is used for implant based reconstruction. This increases the post-operative pain considerably compared to our technique. In this method, the patient’s own dermis can be used as a biological mesh to cover the non-biological mesh along the Wise pattern scar line, thereby protecting the mesh, and the implant in the unfortunate incidence of wound complications and providing an additional layer of protection with no increased morbidity from the procedure.

We accept that some critics might question the use of both the non biological mesh and the dermal sling and enquire what additional benefit is conferred by using both rather than one or the other. The answer is that with the dermal sling it is not always possible to achieve complete closure for the implant laterally and medially. This necessitates the need to raise the serratus anterior muscle which causes reasonable discomfort at least in the initial post-operative period. Our technique avoids the need to disturb serratus anterior. The use of a non biological mesh is also associated with lower rates of post-operative seroma formation which require aspiration. This is thought to be due to the perforations which most biological meshes lack with the exception of the fenestrated bovine acellular dermal matrix.

We acknowledge that no definite conclusion can be made from our initial experience of combining non biological mesh and dermal sling in patients having implant based reconstruction. However this procedure could be considered as an alternative to using biological mesh or dermal sling in implant based reconstruction in select suitable patients. This technique is also very cost effective in units where the use of a biological mesh is prohibitive due to high expenses.

We intend to publish our results with more numbers and longer follow up in the future as we will continue to offer this procedure to selected patients who opt to have implant based breast reconstruction.

Declarations

Acknowledgements

The authors acknowledge Jessica Turvey, graphic designer based at the Clinical Media Centre, Mr. Samy Shaheed, Associate Specialist Breast Surgeon, and Dr. Ioannis Chavekes, Clinical Fellow Breast Surgery, Brighton, and Sussex University Hospitals NHS Trust for their assistance with the technical aspects of the surgery. All have given permission to be acknowledged.

Authors’ Affiliations

(1)
Park Centre for Breast Care, Brighton and Sussex University Hospitals NHS Trust

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Copyright

© Rathinaezhil et al. 2015

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

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