What are the initial steps in breast reconstruction with acellular dermis?

Updated: Jul 29, 2021
  • Author: John Y S Kim, MD, FACS; Chief Editor: James Neal Long, MD, FACS  more...
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Preoperative planning is completed as is normal for an expander-implant based reconstruction. Critical breast landmarks are identified, and evaluation of original breast ptosis, projection, and inframammary fold is documented. The size of the tissue expander is determined in the usual manner. The breast is marked to define the inframammary fold and the modified skin-sparing periareolar incision lines.

Placement of incision

Skin preservation is a key element of the mastectomy because a larger skin flap allows greater intraoperative expansion. The vertical component of the incision is the critical component in this regard, and minimizing that component will maximize skin flap size. Specifically, the incision pattern should be directed obliquely (“keyhole” incision) to give the breast surgeon access to all quadrants of the breast (the same surface area of exposure) while minimizing the vertical component of the incision. [31]

For a nipple-sparing mastectomy, the incisions should be directed in a lateral approach that avoids the actual areolar border. The reason is that the periareolar nipple-sparing approach has a higher rate of nipple necrosis and should generally be avoided. Inframammary incisions have been used on the grounds that they are less cosmetically conspicuous, but they are generally problematic on larger-breasted women because they provide only limited access to all of the breast tissue.

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