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 [5–8]. 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
Full size table

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
Full size table

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
Full size table
Table 4 Tumour related factors
Full size table
Table 5 Adjuvant and neoadjuvant treatment and further surgery planned
Full size table

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
figure 1

Schematics step by step summary of surgical technique

Full size image
Fig. 2
figure 2

Illustrations of the step by step summary of surgical technique

Full size image

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
Full size table

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
Full size table

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.