Total Muscular Implant Coverage in Alloplastic Breast Reconstruction

Sir:FigureIt was with great pleasure that we read the interesting article by Elliott et al.,1 recently published in this Journal, and we would like to congratulate the authors on their study. The authors described the use of the “scarless” latissimus dorsi flap to provide total well-vascularized coverage to implant or tissue expander in conjunction with pectoralis major muscle. The traditional tissue expander or implant placement requires complete muscular coverage by elevating both the pectoralis major and the serratus anterior. We agree with the authors that it is important to have vascularized and adequate coverage when implanting devices, but we believe that sacrifice of a large muscle such as the latissimus dorsi is not always justified, especially if radiotherapy has not been performed. The latissimus dorsi should be used for implant coverage in case of previous radiotherapy to reduce the risk of capsular contracture2; otherwise, the serratus anterior combined with the pectoralis major muscle usually provides full muscular coverage to the device, especially in the event of a partially inflated tissue expander (Fig. 1). Partial coverage with the pectoralis only is not recommended because of the possibility of expander exposure or migration. Excellent results in nonirradiated and thin patients can be achieved with complete muscular pocket by means of the pectoralis major and serratus anterior muscles (Fig. 2). Furthermore, dissecting the serratus can be performed more easily and more quickly than the latissimus dorsi muscle. While raising the serratus, care should be taken at the junction between the pectoralis and serratus musculature, where there are only tiny muscular fibers and sheath. Use of the serratus anterior muscle also has less impact on daily activities and is associated with lower morbidity than sacrifice of the latissimus dorsi muscle.Fig. 1: The pectoralis major muscle is elevated to establish part of the pocket for tissue expander insertion. The serratus anterior is elevated to allow for inferolateral coverage of the device. The partially inflated tissue expander is placed in the pocket with the serratus approximated to the lateral edge of the pectoralis major muscle.Fig. 2: Preoperative (above) and postoperative (below) appearance of a patient who underwent right expander replacement with anatomical cohesive silicone gel implant and contralateral augmentation mammaplasty.An option gaining popularity is anteromedial coverage with the pectoralis and lateral coverage with acellular dermal matrix.3,4 This obviates the need for serratus elevation and might make subsequent expansion less painful. Concerning the use of acellular dermal matrix instead of muscle for implant coverage, we believe that we should take into account the biological cost of the latissimus dorsi muscle sacrifice and the economic cost of acellular dermal matrix. In any event, despite an increased rate of infection and seroma with use of acellular dermal matrix,5,6 there is an increasing interest in use of this material for alloplastic breast reconstruction. Finally, we wonder whether the scarless latissimus dorsi might require wider undermining compared with the standard latissimus dorsi procedure, with the subsequent increased risk of donor-site seroma formation. Furthermore, as a large muscle has been elevated, providing total muscular device coverage, immediate permanent implant placement should be preferred rather than a tissue expander, particularly in cases of skin- or nipple-sparing mastectomies. This would bring effective reduced cost, sparing the patient the second step for tissue expander replacement. Stefano Bonomi, M.D. Andrè Salval, M.D. Fernanda Settembrini, M.D. Flavia Sorbi, M.D. Chiara Gregorelli, M.D. Department of Plastic Reconstructive Surgery and Burn Unit Center, Ospedale Niguarda Ca' Granda, Milan, Italy DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication.