Correction of Rippling in Implant-based Breast Reconstruction with Serratus Fascia Flap

Summary:

Implant-based breast reconstruction represents the most popular procedure for the treatment of women undergoing skin-sparing mastectomy. In selected patients, it allows for obtaining an excellent appearance of the reconstructed breast with great satisfaction to the patient. However, aesthetic and functional results can be affected by complications requiring reoperation. Among them, rippling is an undesired occurrence associated with implant-based reconstruction. It consists of a cutaneous manifestation, visible and/or palpable, of the implant wrinkles and edge which appear mostly when the patient leans forward. To treat this contour deformity, several techniques have been described such as acellular dermal matrices and autologous tissues. In this study, we intend to add the serratus anterior fascial flap within the autologous options in the treatment of implant rippling, reporting our experience.

INTRODUCTION

A good aesthetic appearance of the breast in implant-based reconstruction is the most important goal the patients ask of surgeons after skin-sparing mastectomy.^1,2 Rippling is a possible complication following breast augmentation or implant-based reconstruction and results in significant patient dissatisfaction.^3,4 It consists of implant contour visibility through the skin and appears as irregularities or undulations underneath the skin surface. Both subpectoral and prepectoral (with or without acellular dermal matrices [ADMs]) reconstructions may hesitate in this complication, although it is more frequent in prepectoral implant-based reconstruction, because of the absence of soft tissue coverage and support of the pectoralis muscle. Regarding one-stage breast reconstruction achieved with ADMs and implants, rippling often occurs at the inferolateral aspect of the breast mound, where the implant is not adequately covered by the muscle.^5–8 Treatment commonly consists of replacing the implant, usually placing it in a subpectoral pocket to reduce the risk of recurrence. Other techniques, such as increasing the implant size or tightening the capsule, can also be used. Recently, alternative treatments such as fat grafting or insertion of an ADM have been proposed.^9–11 In this study, we intend to add the serratus anterior fascial flap to the autologous options in the treatment of implant rippling.

METHODS

This study was approved by the local institutional review board and approved as a nonsignificant risk study. A 42-year-old patient underwent implant-based reconstruction with subpectoral prosthesis and ADM to cover the inferolateral aspect of the implant. About a year later, rippling appeared (Fig. 1) and the patient was treated with our technique for its correction, with a 3-year follow-up. The ethical principles outlined in the Declaration of Helsinki were respected by all authors. The patient signed an informed consent form.

Fig. 1.

Preoperative photographs showing the rippling affecting the lateral aspect of a reconstructed breast with ADM-assisted direct-to-implant technique. A, Frontal view. B, Lateral view.

Surgical Anatomy

The serratus fascia is a thin layer of tissue overlying the serratus muscle, which has two dominant vascular pedicles. The lateral thoracic artery is a direct branch of the axillary artery that runs along the anterior border of the serratus muscle and the serratus branch of the thoracodorsal artery. The thoracodorsal artery gives off two to four branches just before entering the latissimus dorsi muscle, and the most distal branch is the dominant pedicle of the serratus muscle and fascia. The serratus pedicle gives several side branches as it courses caudally within the fascia. This provides good and reliable vascularization for a wide area of the fascial flap.

Operative Technique

All procedures were performed under general anesthesia, with the patient in the supine position and ipsilateral arm abducted to 90 degrees. The previous mastectomy incision was reopened, and the skin was undermined along the lateral chest wall posteriorly enough to expose the serratus anterior fascial flap, preserving the serratus branches of the thoracodorsal vessels, together with the long thoracic nerve. The fascia was then carefully harvested from the serratus anterior muscle and reflected for covering the lateral aspect of the implant as an onlay flap onto the ADM-capsular plane, using absorbable sutures¹² (Fig. 2). The aesthetic outcome was good and constant over time with high patient satisfaction. (See figure, Supplemental Digital Content 1, which displays the intraoperative image showing the serratus anterior fascia flap detached from the underlying muscle fibers. http://links.lww.com/PRSGO/C447.)

Fig. 2.

The same patient at 1-year postoperative follow-up. A, Frontal view. B, Lateral. view.

DISCUSSION

Rippling is a possible occurrence in implant-based breast reconstruction, both retromuscular and prepectoral, consisting of visible and sometimes palpable folds on the surface of the reconstructed breast mound due to scar adhesions between the implant capsule and subcutaneous tissues. The impact of this long-term complication on the final aesthetic and functional outcome of the whole reconstructive process has led to the identification of risk factors and the creation of a grading scale, just like for capsular contracture, another complication to which in some respects is related.³ To treat this contour deformity, several authors have described the use of ADMs both as a capsular onlay graft to increase the thickness of subcutaneous tissues and as a “hammock” fashioned support to the lower pole of the implant pocket.^13–16 Despite the good results achieved with these devices, the real limitation to their employment is represented by their cost. To overcome this setback, different autologous procedures have been proposed, such as fat grafting,¹⁷ fascia lata graft,¹⁸ capsular flap,¹⁹ scar tissue flap,²⁰ and pectoralis major “trapdoor” flap.²¹ In 2010, Saint-Cyr²² demonstrated how the serratus anterior fascial flap can be safely used as an alternative to ADMs in the coverage of the inferolateral aspect of implants in breast reconstruction. In subsequent years, many studies supported this autologous coverage technique in implant-based reconstruction both in single and two-stage with excellent results in terms of complications and aesthetic outcomes. The surgical technique is the same as described in other studies;²³ the only difference resides in the fact that when employed for treatment of implant rippling, the flap is sutured onto a preexisting pocket. It is important to underline that the investing fascia of the serratus anterior muscle is often preserved during mastectomy procedures, and for this reason can be safely approached from the previous mastectomy scar, without the need for further scars, as required for harvesting fascia lata graft or fat grafting. Moreover, in our experience the risk of delayed lateral displacement of the implant because of the lateral undermining required for this flap is negligible and it is more due to inadequate disinsertion of the pectoralis major fibers. The fascial flap has good vascular support, not requiring any intake process or incorporating process as for grafts and ADMs.²⁴ It increases the thickness of the prosthesis overlying skin, in contrast to ADMs, which are thin, and in skinny patients their incorporation can lead to scar adhesion between the implant capsule and the subcutaneous tissue, causing the rippling phenomenon. Furthermore, compared with other local flaps described, it does not require the opening of the implant pocket, as for the capsular scar tissue or pectoralis major trapdoor flaps; consequently, the fascial flap could be performed even without implant removal or change. For all these reasons, our approach using the serratus anterior fascial flap represents an affordable and effective technique for treating rippling after implant breast reconstruction, in comparison with other options (ie, ADM and fat grafting), and may be mentioned in the autologous alternatives for the treatment of this complication.

Supplementary Material

gox-11-e4862-s001.pdf ^{(437.6KB, pdf)}