We can see here that this patient has well perfused mastectomy flaps with a consistent thickness. ICG angiography can be used to evaluate flap perfusion as needed. The expander size is based on the width of the pocket and the mastectomy weight. After the expander has been chosen, it is temporarily filled with air to the estimated fill volume. Next, a piece of acellular dermal matrix is chosen based on the expander volume. It is sutured to the edge of the tabs of the expander with a rapidly absorbable suture, starting with the supralateral tab. Next, the ADM is stretched along the lower pole of the tab where it is fixed with additional sutures. In some cases, the ADM will reach across to the opposite upper medial tab. When this is not possible, a spanning stitch is placed. Here we see the acellular dermal matrix has been sutured to the upper lateral, inferior, and upper medial tabs. In this case, a rectangular piece of ADM has been used, which is now trimmed along the inframammary fold. When using a contoured piece of ADM, this trimming is not necessary. The remaining tabs are then sutured to the acellular dermal matrix. Finally, a spanning stitch is used to ensure that the free edge of the ADM does not descend along the inframammary fold. Here's the completed construct in which the acellular dermal matrix is providing support to the lateral and inferior poles of the implant. The spanning stitch prevents descent of the ADM. In this case, the construct would be placed on the patient's right side. The expander is then deflated of air and placed into the pocket. The inferior, superior, and medial tabs are sutured to the chest wall with longer-lasting sore wall or even permanent suture. Here we can see that the superior, superomedial, inferomedial, and inferior tabs have been sutured to the chest wall. We find in most cases it is not necessary to suture the lateral tabs, and we believe these create more discomfort. Next, the acellular dermal matrix is sutured along the border of the expander using interrupted polydioxin on suture. The expander is then filled with injectable saline to the desired volume. Here we can see the polydioxin on suture along the lateral and inferior mammary folds. The drain is woven through the acylid dermal matrix to prevent seroma formation between the ADM and the skin. The skin is then approximated in the usual fashion.

mastectomy flap reconstruction

expander implants

acellular dermal matrix

sutures

seroma prevention