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• W2029972712 abstract "Sir: We read with interest the recent articles by Dr. Saint-Cyr and colleagues regarding the use of serratus anterior fascia and/or subpectoral fascia for expander coverage in postmastectomy breast reconstruction.1,2 As they highlighted, a key point in the two-stage prosthetic breast reconstruction is the expansion of the lower breast pole to achieve a pleasant breast shape once the definitive implant is placed. The authors underscored the importance of the pedicled serratus anterior/subpectoral fascia flap for inferolateral expander coverage and to prevent expander/implant lateralization. The technique reported would represent an alternative to muscle flap expander/implant coverage (with their higher donor-site morbidity) and to the use of allograft because of the cost and the increased risk of seroma formation.1 However, the authors are using a pedicled serratus anterior/subpectoral fascia flap for the lateral expander/implant coverage and the acellular dermal graft for inferior implant coverage.1,2 In the thoracic wall, we have to distinguish two different fascial layers that are at different depths at some levels and fuse at other levels. In this setting, we distinguish the pectoralis major fascia (more superficial) and the deeper coracoacromioaxillary or axillary fascia enwrapping the pectoralis minor, the subclavian, and the coracobrachial muscles and overlying the serratus anterior.3 The pectoralis major fascia consists of the superficial pectoralis fascia on the outer part of the pectoralis major, which continues caudad overlying the rectus sheath. The deep pectoralis fascia is located on the inner part of the pectoralis major and terminates at its inferior border.3 At the lateral border of the pectoralis major, the superficial pectoralis fascia and deep pectoralis fascia fuse, and overlie the axillary fascia, creating a unique fascial system.3 Thus far, the terms “serratus anterior” and “subpectoral fascia” represent a new nomenclature given to regional subdivisions of an already well-defined fascia, the coracoacromioaxillary or axillary fascia. We share with the authors the belief in the importance of the thoracic fascias in defining a partial submuscular pocket for postmastectomy implant reconstruction. However, we use a different approach. In our technique, the expander/implant is placed in the submuscular-subfascial pocket (Fig. 1). At the inferior edge of the pectoralis major, we undermine the superficial pectoralis fascia in continuity with the pectoralis major itself, up to the inframammary fold. At this level, the superficial pectoralis fascia is cut to release the fascial tension.4,5 In this way, we define the condition for the major expansion in the lower pole. No further coverage is needed in the inferior pole and laterally. In skin expander reconstructions, the skin at the lower pole will expand as the implant is filled. In case of skin-preserving mastectomy, when staged skin expansion is unnecessary, the major expansion is immediately gained at the lower pole when the definitive implant is placed.4,5Fig. 1.: Intraoperative view of an immediate definitive implant reconstruction after bilateral skin-reducing mastectomy with a T pattern. The mastectomy flaps are everted. The submuscular-subfascial pocket is shown. It has been dissected through the upper lateral border of the pectoralis major muscle (PM). The asterisk indicates the textured anatomical implant in place. The dotted line indicates the point of merging of the superficial pectoralis fascia (SPF) with the axillary fascia overlying the serratus anterior muscle. The fascial planes allow definition of the submuscular-subfascial pocket that is separated from the mastectomy plane.In conclusion, the thoracic fasciae should be taken into consideration as valuable structures that allow an easy and pleasant breast reconstruction, with few complications. Marzia Salgarello, M.D. Giuseppe Visconti, M.D. Department of Plastic and Reconstructive Surgery Liliana Barone-Adesi, M.D. Breast Unit Catholic University of “Sacro Cuore” University Hospital “A. Gemelli” Rome, Italy DISCLOSURE The authors have no financial interests to disclose." @default.
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• W2029972712 date "2011-02-01" @default.
• W2029972712 modified "2023-10-18" @default.
• W2029972712 title "Use of the Subpectoral Fascia Flap for Expander Coverage in Postmastectomy Breast Reconstruction" @default.
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• W2029972712 doi "https://doi.org/10.1097/prs.0b013e318200aff6" @default.
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