Advanced Technique Produces Less Scarring and More Natural Results
By Kymberly Taylor
The nightmare begins—a woman with breast cancer is scheduled for a life-changing ordeal—a double mastectomy. Just 50 years ago a woman was left with a flattened chest, scars and prosthesis after surgery. However, today, breast reconstruction is possible. In general, there are two methods: those that use implants and those that use the patient’s own body tissues. Each has its pros and cons but all have certain things in common—pain, scarring, some disability, and a healing process that varies from weeks to months. Cosmetic results can vary as well.
Luckily, there is something new for cancer patients who have had skin-saving and/or nipple-sparing mastectomies: prepectoral implant reconstruction. This procedure is growing in popularity because it is less invasive, not as painful, and looks better than conventional implant surgery. During conventional implant surgery, implants are buried underneath the muscles of the chest.
Dr. Devinder Singh, chief of Plastic Surgery at Anne Arundel Medical Center (AAMC) and medical director of Anne Arundel Medical Group (AAMG) Plastic Surgery, explains that in prepectoral implant reconstruction the implants are placed on top of the muscle. The expanders, or implants, are wrapped with a biological mesh called an acellular dermal matrix (ADM). The biomesh, commonly referred to as Alloderm, is all-important—it is regenerative. It fortifies and supports the remaining skin after mastectomy, promotes new tissue growth, and looks more natural.
“The patient’s body repopulates the mesh with cells and blood vessels and heals,” says Dr. Singh, who specializes in the technique. “There is less scarring and the cosmetic results are spectacular…it sometimes looks like a breast augmentation even though a breast surgeon has actually removed the breast to treat cancer. It’s pretty remarkable.”
Only a few hospitals and surgeons in the country perform this innovative procedure, which relies on leading-edge technologies that foster greater precision and encourage wound healing. Mounting evidence points to its success. According to a July 2015 article by Roland Reitsamer, M.D. in the Journal of Plastic, Reconstructive and Aesthetic Surgery, “prepectoral implant placement and complete coverage with porcine ADM represents a novel approach and a feasible alternative to subpectoral implant placement after NSM [nipple sparing mastectomy] and implant-based breast reconstruction for patients who prefer their PMM [Pectoralis major] to be left intact.”
A July 2017 study published in Clinical Breast Cancer by Raghavan Vidya, M.D. goes farther to report, “Acellular dermal matrix has revolutionized implant-based breast reconstruction. Breast reconstruction has evolved from the traditional sub muscular to the new prepectoral implant based (also known as muscle-sparing) reconstruction. The new technique is emerging as a highly popular surgery owing to its more minimal approach.”
To fully appreciate prepectoral reconstruction Dr. Singh notes that it is important to examine its precedents.
In the 1890s, breast cancer was treated by amputating both breasts and underlying chest muscles in a radical mastectomy. Developed by Johns Hopkins surgeon William Halsted, the procedure was incredibly invasive with severe scarring but the first operation of its kind to try to cure the disease. Then, in 1962, surgeons set out to reconstruct the breast by putting a silicone implant under whatever skin was left following surgery. Unfortunately, the procedure, called subcutaneous implant reconstruction, was plagued with problems, including a very high rate of infection, skin necrosis, and profound scarring around the implant.
To address these problems, in the 1970s, surgeons decided to bury the implants under two muscles in the chest: the pectoralis and the serratus anterior.
“We took a deep dive into the body wall a long time ago and that helped reduce the infection rate, it helped mask the problems of scarring around the implant but it caused a lot of other problems, a lot of bleeding, a lot of pain, and a lot of disability,” says Dr. Singh. This technique was called “total muscular coverage” or TMC.
To solve these problems, around the 1980s, surgeons began to bury the implant under just the pectorals. This technique is called partial muscular coverage or PMC. “Once again, it helped solve some of the problems but created others,” notes Dr. Singh. “There was less bleeding, less disability, a better cosmetic result…but window shading was occurring…when a woman moved the pectoral muscles, the implant moved up and down. Not a very attractive look.”
Then, in the late 1990s, the exciting biological mesh, commonly called Alloderm, came on the scene and was initially used to help heal severe burn victims. Eventually, it was adapted to support breast reconstructions. During partial muscle coverage implant surgery doctors use Alloderm as a kind of sling to hold muscles and implants in place. “It was a big advance, but wasn’t perfect because patients were still having muscle spasms. The main issue has been spasms…and what is called animation deformity…you can see the implants moving and it looks unnatural and doesn’t feel great,” says Dr. Singh.
Luckily, surgical technologies, medications and also the implants themselves have evolved to feel softer and look more natural. So today, with advanced treatments for wounds and infection, doctors can perform a prepectoral implant and patients can go home and get back to their lives faster. Dr. Singh notes that surgeons have come full circle. “We have returned to placing implants on top of the pectoral muscle in the same spot, but using regenerative mesh. The mesh reinforces weak skin, regenerates tissue and does not scar in the normal way, but instead helps support healing.”
There is still much that needs to be worked out, observes Dr. Singh. It’s early in the experience of this new technique, and new issues may arise, such as a higher rate of fat grafting around the implants to camouflage rippling.
But really good things are happening. He notes that following the procedure he has stopped prescribing Valium for spasms and using far fewer narcotics for pain. For a woman fighting breast cancer, the technique may make the journey a little easier, the nightmare not so dark.
Anne Arundel Medical Group Plastic Surgery (AAMG)
2000 Medical Parkway, Belcher Pavilion, Suite 200, Annapolis, MD 21401
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