Pre-op Diagnosis:
History of left breast cancer [Z85.3]
Acquired absence of breast and absent nipple, left [Z90.12]
Breast asymmetry between native breast and reconstructed breast [N65.1]
*
Post-op Diagnosis:
same
*
Procedure:
*
BREAST RECONSTRUCTION UNILATERAL
BREAST IMPLANT AND CAPSULE REMOVAL
MAMMOPLASTY AUGMENTATION
*
*
presents for delayed left breast reconstruction after mastectomy. She also presents for right breast implant removal and replacement.
Procedure:
Attention was first turned to the right breast. Incision was made through her prior augmentation scar. I dissected down through her breast tissue until identified a subglandular breast implant capsule. I circumferentially dissected around the capsule using electrocautery and a lighted breast retractor. I was able to completely dissect around the capsule and remove the capsule and the implant en bloc from the patient. On the back table I opened the capsule to identify ruptured silicone implants. The capsule was thickened and calcified in multiple places. The capsule was contracted and had taken on a football like elliptical shape. I then used a saline sizer measuring 380 to 450 cc in the subglandular pocket. I tried a variety of fill volumes from 400-450 to fill the pocket. Patient did remain ptotic but had an improvement in her overall breast appearance. I then removed the sizer irrigated the pocket with an antibiotic irrigation. Hemostasis was achieved using electrocautery. A 15 French round JP drain was placed in the pocket. I changed my gloves and placed a smooth round high profile saline implant 380 to 450 mL. It was filled with 450 mL’s of sterile saline. The capsule was then closed with 3-0 interrupted Vicryl suture. The skin was closed with interrupted 3-0 Vicryl dermal sutures and running 4 oh strata fix Monocryl.
*
I then incised the left mastectomy scar. I raised subcutaneous flaps to re-create the mastectomy defect. Care was taken not to ever dissect the pocket inferiorly or laterally. *On a sterile back table, a piece of 16 x 20 cm fenestrated thick alloderm was fenestrated and wrapped around a 475 cc high profile tissue expander. *The suture tabs were brought through the fenestrations and secured to the alloderm using 2-0 vicryl sutures. *Additional sutures were used to close the sides of the alloderm around the expander after a little trimming. **Then the wrapped expander was placed in the left breast defect and secured with 2-0 vicryl interrupted sutures to the pectoralis muscle and rectus fascia. *It was oriented to that the base of the expander lay along the IMF with midline centralized. *A tail of alloderm was secured over the superolateral pectoralis muscle headed toward the axillae. A 15 French JP drain was placed under the skin extending laterally superiorly medially and then inferiorly along the pocket. * It was secured using 4-0 nylon.. **Again, antibiotic irrigation was used. Hemostasis was achieved. The skin was closed in layers with 3-0 Vicryl in the dermis and 4-0 Monocryl subcuticular sutures. Next, a similar procedure was performed on the patient’s right side. Dermabond prineo*was placed. No on table expansion was performed today to avoid tension of the skin flaps. A surgical bra was placed. The patient was awoken from anesthesia without complication and transferred to the recovery room in stable condition. At the end of the case all the needle, sponge and instrument counts were correct x 2 and I was present for the entire*case.
*
*
*