Surgery Spotlight: Secondary Breast Reconstruction-Surgery Spotlight: Secondary Breast Reconstruction

Surgery Spotlight: Secondary Breast Reconstruction

Video Transcription

Hi, we're in Ghent today, Ghent, Belgium. I am Philip Landil. Today we will be doing a case of a 52-year-old woman. This is going to be a secondary case after primary breast  reconstruction with a deep flap. And the whole intention of today is to create more symmetry  in both breasts. And as you will see, the basic result is not too bad, but we really need to tweak left and right and try to get things a little better. And I think it will  be a great resume of the different techniques that we can apply if we want to do a secondary correction. To summarize a little bit what the problem is, the right breast is a little  too big, but it's mainly too wide if we compare it to the other breast. The left breast is  drooping a little bit. The position of the nipple is pretty good, but it's mainly shape-wise  that's drooping. So if we can just do a minimal mastopexy with a vertical scar, this will probably correct the problem. Now, she just told me that she would prefer to have a minimal  reduction of this side. That is actually pretty convenient for us because by taking out a wedge of tissue in the middle here, we can not only reduce the size and get to  better symmetry with the other side, we can also narrow the breast a little bit more and get better symmetry between both sides. So that's what the plan is going to be. Slight  reduction here, narrowing of the breast. On the left side, we will do a minimal lift, mainly working on the envelope of the breast, so nothing to the footprint, not too much  to the conas either, just reducing the skin envelope a little bit to lift that side up.  For drawings, we're going to once again work with our three-step principle. So first, midline.  Footprint on both sides.  Pectoralis. Upper border. Contralateral side.  All right. Position of the inframammary crease.  So slightly lower on this side.  All right. Let's see if we can, with our reduction, reduce this a little bit and lift this up a little bit.  So we're going to work through this scar here, up to here.  All right. Also, the time will take somewhere between eight and nine centimeters from the midline to determine the midclavicular line.  This time, I'm going to take nine centimeters. So this is midclavicular line.  So here, it's a little bit like a breast reduction technique. The only thing you don't have to do is you don't have to reposition the nipple.  So like I said, you can just try to take out the wedge in the bottom and try to gently give it a twist here.  Determine the amount of resection.  Same thing for the other side. So this is a little bit of a guesstimation of how much to resect.  This will also give you a little bit more projection, the level of the nipple. There we go.  We'll verify that once she's on the table. We can sit her up and we can see if that works out.  But to me, that looks actually pretty good.  All right.  Now, there's just one little thing that I'd like to, although we're going to do a breast reduction, I do like to add a little bit of fat here in this area.  It's not much. It's not about volume. It's about shape in this case here.  So we're going to just do a little bit of lipofilling in this area just to have a nice slant here and fill it up.  The position of the nipple is pretty good.  There's not much we need to do, but we mainly want to reduce the amount of skin here.  That's what we want to do. It's going to give her a nice and round shape. So once again, we're going to try to get a good estimate of the amount of skin we want to take away.  As we don't have to move the nipple a lot, I will see during surgery if we really need to do any movements. Yes or no?  But in case of, especially the upper border, the upper border of the areola is very similar.  It's not worth even trying to change too much. Also, the position of the nipple is actually pretty good.  So we'll try to determine that during surgery.  But by doing it this way, just taking out skin, that will probably be sufficient. We'll see how things go.  And then the same thing here. If you do a mastopexy, if you push up the breast, you always get a little depression here.  Well, to fill that up, we'll do a little bit of lipofilling here. This always provides a very nice decollete, the social breast, like we like to call it.  I'm not going to work too much on the inframammary fold. Like I said, if I can get it up a little bit, I will.  I'm just going to do a little bit of lipofilling here.  I'm not going to work too much on the inframammary fold. Like I said, if I can get it up a little bit, I will.  Otherwise, we're not going to do too many movements on that point.  And then we'll just do a little correction here, a little dog ear.  Try to get this as good as we can in the first procedure, but sometimes there's still a little bit of skin excess.  And then we're going to take some fat off.  And then we're going to take some fat away here.  Let's do some liposuction.  Maybe to specify a little bit, she had an areola sparing mastectomy.  So the areola is originally hers. The nipple is actually abdominal skin.  So after the reconstruction, we leave a little skin paddle here that in the second stage can be used to do the nipple reconstruction.  And then whatever we don't need, we throw out and we finish off with a vertical scar.  And why do we use a vertical scar? Because like in this case, if you want to do a mastopexy, you will have a vertical scar here.  And now she will end up with two vertical scars.  While if you do any other incision, like a horizontal or oblique incision, and you have to do a mastopexy, then you will have a scar here and a scar there.  So we always do our skin sparing, areola sparing, nipple sparing mastectomies through a vertical scar.  That provides also a nice result.  And on top of that, if you want to do any corrections, you can always work through here.  So before I start my surgery, the only thing we've done until now, we've just injected our donor sites for the lipofilling with a little bit of xylocaine and adrenaline.  But what I'm going to do first is I'm going to just close this here without doing any incision and see where we get.  I might do an incision here because I'm afraid that we'll have a little bit too much projection of the areola.  Okay, let's sit her up and see what happens. It's a little bit what I expected was going to happen.  Shape-wise, she's fine here.  If I take out this amount of her skin envelope, there's not too much tension.  This is still nice and smooth.  But if I want to do some liposuction here, I'm going to do some direct incision here.  So I'm going to end up with a little bit too much of envelope. So I'm going to end up with a little bit too much of envelope.  But what is sure is that this incision here that I marked here is not exaggerated.  This is a safe incision.  We probably will have to resect more, but this is a safe incision.  So the lines that I've drawn, I'll use those now to approach this breast first.  Now if you look to the other side, like I said, the shape isn't too bad, but she'll have too much projection here in the nipple areola area.  So I probably will do a circumareolar incision, remove a little strip of skin here to get a little more tightness.  The big problem with an autologous reconstruction, actually in almost all the cases, is that insufficient projection.  You can get a nice breast, but the central projection is always moderate to limited.  So you don't want to create a breast on that side that is over-projecting. So we might just take out a little bit of skin here.  Three things are important if you look at a breast.  Three lines for me are important.  First is the line over the equator of the nipple.  The shorter this line is, so the more skin you remove here, the flatter a breast becomes and the tighter this line becomes, less projection you get.  So the more skin you add, the more projection you get. Second line, which is really important for me, is this line here.  So somewhere halfway the areola and inframaric crease.  The tighter you make this area here, the more the breast moves up.  To a certain extent, you can't overdo it.  If you pull too much, you get necrosis of your glands and obviously a lot of complication.  But the more skin you add here, the more drooping you will get.  The same thing for this direction as well. The more you put in here, the more skin you add, the more drooping you will get.  And the last line is actually the inframaric crease itself.  The more tension that you put on this line, the more the breast moves up.  Also to a certain extent, because there are ligaments that fix the inframaric crease here.  So to a certain extent, you can move the inframaric crease probably about a centimeter, maximum two centimeters, depending on the laxity of the patient.  But don't expect too much.  But anyway, by pulling here, you can give more definition to the inframaric crease and raise the inframaric crease if you want to.  So with this in mind, these three lines in mind, that's how we're going to go through this case as well.  So here, the inframaric crease is good.  We might want to do a little bit more tightening here to raise the inframaric crease because we have a little difference here in height.  Like I said, once we've done the reduction, we'll probably have to do more reduction of skin, of envelope in this direction.  But here, we want to leave everything that we have because we want to preserve as much projection as we can.  So we'll work on this and we'll work on this here in the right side.  We'll do this first, try to finish this off, and then we'll go to the left side.  We've just now injected a little bit of local anesthesia.  Xyla came with some adrenaline in this area here. We'll let it work for a couple of minutes here.  And meanwhile, we'll do some liposuction here to reduce the volume.  And I did not inject anything here.  I'm just going to do just pure liposuction.  The reason why I don't inject it here is because it will change the volume of the breast and will give me less of an appropriate estimation of volume right here.  And this volume plays an important role here. We're just going to liposuct this and we'll see what happens.  Anyway, we're going to use that fat.  We're going to recycle that fat for lipofilling up here and up here.  So this is just a three millimeter cannula.  And obviously, the nice thing about this flap is that liposuction is very easy.  Let's see what we got here.  Let's take that out first.  I'm going to close the deep flap again so I have the dermis so I can put some sutures too.  So as with conventional breast reduction, you have to remodel and reshape your breast on the inside.  So the conus needs to be shaped first and then you redrape your skin on top of it.  If you don't do that, if you now just close the skin, you have less stability in the long run.  So that's why we do the undermining.  It shows your edges, gives you a nice clear view.  I was going to say the glandular part, but obviously there's no gland anymore.  It's the flap part.  Put an extra suture here.  Remember, the more tension I put here, the more definition I get.  And we will improve definition by making a small horizontal incision in the skin.  You can appreciate the nice shape of the lower part of the breast.  And now the skin is just closed over it.  No tension, just like a facelift procedure.  No tension, nice and smooth.  And you immediately have your result.  Don't expect stretching and so on to make any big difference in your final shape.  You have to have your final shape almost here on the table.  The only thing you want is to put it a little higher and a little more medial because the breast always shifts this way.  Otherwise, it has to be perfect on the table. But see, our scar now is too long.  And a lot of people would say, oh, but just do a vertical and just bunch everything up.  No, we're going to take out a little bit here.  This will provide me two things.  First of all, she'll have a perfect scar from the beginning.  But also, I'll be able to give more definition to that lower part here.  And that's what I really want to do.  First, I'm going to suture this down a little bit.  And in contrast to the other side, like I said, limited projection is a problem of reconstructions.  Well, here you're improving your projection by doing this.  And that's actually what you want.  This is a good thing.  And if her areola becomes too small, that's good.  You can always go over it with tattooing.  You can go a little further if you want to, if it were to be too large.  But I don't think so.  In this case, I don't think we'll have an issue.  So, from the lower part of the areola, we already have six and a half, which to me is more than enough.  So, I'm going to give her a small horizontal scar.  I'm just going to sit her up for a moment again, and then we'll appreciate what we've done.  We now have, to my opinion, a very natural-looking breast.  The only depression here, but that's something we'll correct later on.  Now, it's just a matter of volume.  I always try to estimate a little bit by putting my fifth finger at the lateral border and my hand in the inframaric crease.  I try to estimate a little bit what the volume difference is.  There's still some volume difference, as you can see. This breast is still a little bigger than the other side.  We can do some lipofilling, but I think we'll have to reduce it a tiny bit more to get a good result.  I think I'm going to do it just by doing a little bit more of some liposuction and see where we get with that.  All right, we're going to let it be for a second.  We're going to work on the other side first.  We can always reduce the volume a little bit more if necessary.  It doesn't look too bad.  We've taken away most of the lateral fullness.  She's got a nice, good shape and proportion with her body, too.  She's not extremely skinny, so you need to have a little bit of proportion.  Let's see what we can do with this side first, and then we might even come back to this side later on.  I'm going to immediately draw a skin resection around the areola her right her left nipple was just a little  bit lower than the and the right one so we can allow ourselves to move it up a little bit I'm just going to draw two rings and then whatever is in between  we'll just take it out so that was a 38 and this is a 45 that is she still has some pigmentation of areola outside of that ring so actually that's not not too  bad because that will allow us to to have a scar within the areola I've only drawn the lower part but it would be the same thing as you would do a traditional  reduction or mastopexy means determining position of your nipple your upper incision and then a typical keyhole incision it's just that we're just doing  the drawings right now on the table once again some just some local with some adrenaline and we know that the lines that we've drawn here before  they're right so we don't have to worry about that so we had six and a half on the other side so from this point on six and a half it's here so this is the bit  of horizontal excision we might expect we'll see anyway we start just with the keyhole incision we don't we're not doing that the the full incision yet  all right and then we'll make an incision around the areola here goes another dogma in plastic surgery there is no such thing as dermal vascularization  of the areola you can always cut the dermis the vascularization by the dermis is really minimal the vascularization of the nipple areola complex comes from the  mainly from this second internal mammary artery perforator that's a medial branch and from lateral from your lateral thoracic or external thoracic I think  they call it in the United States lateral thoracic the the main branch that goes with the fourth intercostal nerve comes from here and runs through the gland so  there's no way you can destroy it so as long as leave your nipple areola complex on top of your gland you'll be fine nothing will happen you maintain sensitivity you  maintain vascularization and there are no risks so you can always cut the dermis and I really want to deep tell you lies that because the white dermis for me is a  marking of where that skin on was later on so it reminds me what how much skin I've removed next up will be a little bit undermining so here's going to be my new inflammatory crease  this level here so this part needs to come down there to do that I will have to do some  undermining so I'm going to undermine this part here subcutaneous undermining and then I'll do  some undermining underneath the gland because you want to roll in and roll over your your pieces  of gland I'll show that in this in a second extremely important here obviously it's not  to go underneath your inframammary crease the inframammary crease is like the holy cow in India  you don't touch it so now same don't pull too hard okay if she pulls too hard what's going to  happen is you're going to pull over that inframammary crease okay so you got you have to keep your  anatomy in its normal position and then with a scissor I'm about a centimeter above my inframammary  inframammary crease I'm going straight down now I've marked where I want to do my incision I'm  going to go straight down to the pectoralis fascia once I hit the pectoralis fascia I'll be going medial and lateral it's really imperative that you don't pull too hard  so that we you know we really can appreciate the normal anatomy so in a certain point you will cut the superficial fascia so scarpus fascia this is actually superficial fascia  that we've just got this is the superior part it goes to the breast and this here is the lower part  and it's here where we will fix our breast tissue again later on so not to the chest wall to the  superficial or scarpus fascia or continuation of scarpus fascia in this case we don't need to do  too much of an undermining we just want to fold this in this was actually protruding almost like  a tubular breast it's not tubular breast because it's no under development of those quadrants but  it's protruding here so this is what we want to fold in now there are two ways you can do it  remember here is this is what we do so this was the markings by a pen so what you can do so you  can just suture it together like this and you'll have a mastopexy and in really minimal mastopexy  that's what I'll do but in most of the cases and we'll do it here too where you have to we have to  invaginate almost this glandular tissue you create a lot of pressure under this area here and to avoid  any kind of pressure and risk of ischemia and hyper vascularization what you can do is you can  just split the gland here that's what we'll do today and once again there's no risk for  vascularization because vascularization comes from here internal mammary artery and from lateral  lateral thoracic and the intercostals and the perforators of the pectoralis muscle so it is  no harm that you can do also it's innervation comes from medial comes from lateral there's  nothing you can do is no harm you can do the only thing you can do wrong by just invaginating this  tissue is creating ischemia so you want to have I'm just going to undermine this a little bit  underneath the gland so I can I can really push those parts of the gland inwards and then I'm  going to split this to make it to make it all a little easier so this was the indication of the  new inframaric crease here I'm just going to mark it here so the problem of a breast that is  tautic is that there's too much length in this direction and there's too much length in this  direction so what we're going to do now is put our we're going to lower the well the inframaric  crease stays in the same place we're going to lower the gland and turn it a little bit inward  this way okay to get to get a less height in this direction so for that I'm going to first put two  stitches at the level that we indicated okay so here's the new inframaric crease the more you put  those stitches apart means the more that you pull your gland together the more you're going to narrow  this line remember the lower arrow that I've drawn and you will get more definition for inframaric  crease and your inframaric crease will raise rise a little bit now that's exactly what we don't want  here because this side is already a little higher than the other side so that's why I put my stitches  relatively close to each other so that will have no influence on the on the tightness of the  inframaric crease all right this helps us just to do the incision of the of the glands the  clencompass so I'm coming back to our edges that we have defined by deep to leave the materializing  the area that we have drawn pre-optically so the intention is that we do this pull it together and  you can see how the tissue actually rolls inside so the intention is that this rolls inside gentle  no tension no pressure you have your cavity down below here so everything can move in this way and  a tissue the old inframaric crease that was here will just go like this and like this that's how  actually you move your tissues you want to suture your glands to scarpus fascia you don't do not  want to suture this to to the chest wall it's a it's a big misunderstanding thing that you have  to suture this to the chest wall because a breast is just not fixed due to the chest to  the breath to the thorax in a natural situation either look very funny if a breast would be stuck  to the chest wall make sure that you got a good bite here now this is not a very major there are  no major movements in this mastopexy here but if you have to do major movements you you really  will see the benefit of this and undermining and the second thing you know you have herpes and  safety around vasculation of your glandular tissue so once again here's our deep dealized border so  I'm going to start by doing this I'm first going to take that and suture those together and see  where we got we can always add some some sutures later on to make it tighter so if I would put a  suture here and make this very tight you will get flatness of your of your of your breasts okay if  I'm with put more attention here which I probably will will raise the the the breast a little bit  more the more attention you put here the more definition and the higher your inframaric crease  so the only thing I want to achieve now is just a little bit more tension here I wanted to have  this to be a little flatter so it's very easy you just add some more some more sutures  now let's try to close the skin six and a half that's good shape-wise we've got a much closer to each other here I think  two things here on the on the on this side I think we can take a little bit more put a little bit  more tension up here there's a little flatter make it come up a little bit more and probably also lift the nipple a little bit more than we have done six and a half here  yeah six and a half two so that's good so we have the same roundness and on both sides now she still  has more fullness here so I want to take a little bit more away on that side and I think if I do  that that's probably going to be good one more thing I'm going to do is lift the areola just a  little bit more so this is um this is a little tighter than the other side which is fine I'd  like to have it this way because there's not going to be much movement anymore in this breast here  because it's a deep flap that's fixed to the chest wall and you know it's not much going to move this  will sag a little bit this will stretch a little bit so actually I'm fine I'm happy with the position  of the nipple that's good the only difference that we still have so shape wise actually this  is what I this is what I want to get this is what I want to do but volume wise I'm still not there  so I'm going to do two things we're going to do some lipofilling over here and we'll do some we'll  try to add her a little bit more especially on the side we'll try to inject a little bit more  here but I'm also going to come back on this side and do a little bit further over a section of the  lateral part to be able to move that part in a little bit more and to get better symmetry and  then we'll be done now for fine-tuning we can still resect a little bit more we can just still  do a little bit more liposuction but then we're just going to get a flatter breast so I just want  to get you know just if I can just move it up a little bit more here the footprint is fine so we  don't have to change anything in the footprint what I'm going to do is I'm going to just resect a  little bit more of the gland here and probably take a little bit more of the skin here so before  I do my resection I'm just going to undermine a little bit more here she still has a little  little asymmetry in volume but remember we still have to do lipofilling on the left side and I  think I can compensate that volume difference with the lipofilling otherwise I think we've got symmetrical distances here we've got good positioning of the nipple so we're ready an  asteroid about 100 CC from our flap pure fat I estimate not to need too much so we do we do  lipofilling with a just a 10 CC syringe and a small can a small long cannula it's relatively  rigid and here because it's all it's all a flap it's just no glandular tissue you can pass easily  here through incision and like I said I'm just going to give her a little bit of volume here  just to make that transition between the clavicle on the breast a little bit more natural we're  going to start with 40 and we're going to do lipofilling of the other side first see where  with how we end up I don't want to give her too much volume because we're trying to reduce the  volume on this side would be stupid to give her more now just see what we can do it's going to  move to the other side so here we're going to inject mainly this area and then also lateral  part here obviously there's a gland here so we need to be a little bit more careful so we're in  between the gland and the skin as deep as I can stay so you know you're not in the gland because  you can easily move back and forth once you get resistance you know that you're actually within  within the gland just trying to give her a nice repetition of the fat deeper and superficial layers then we'll come from two directions we'll come from the side as well and then  small aliquots of fat with multiple passages so here's our final results I find it actually a  pretty good pretty good symmetry both in volume and shape so I repeat what we did we actually  applied the three-step principle to analyze the problem remember this breast was too wide and  too heavy and the other side the base was a little narrow and we had too much envelope so we had  ptosis so we first started with this side reduce this side got the breast a little bit more narrow  and more projecting just by direct excision and some liposuction obviously with the concomitant  resection of skin and then the same thing on the other side where we actually did the opposite  we did we added volume by lipo filling and lift it first the gland and then removed skin as well  and by removing more skin here we improved the shape and got to a symmetrical shape between both  of them so now to finalize we put in two drains which I think are the most important we're just  going to put a cloth on top so no dressings we use dermabond which is a skin adhesive for the  wounds and then just a cloth on top and that's it and that will be so for the next 24 48 hours  until the drains come out and then we'll we'll just let the patient get up and she can wear  some clothing be careful nothing too compressive we don't want to compress the breast not here not  there because of the lipo filling and I was no specific post-op of instructions she's gonna she  only got one doses of antibiotics she will be wearing some stockings until she leaves the  hospital and but actually she will be mobilizing very quickly by this evening she will be on her  feet we will put a panty on or a compression over here where we did the liposuction I think we did  at the end got a really good result and I never felt as a surgeon that I was running into trouble  or I was not controlling my operation because I knew step by step what I was going to do so  especially for your younger surgeons maybe those have just finished their training this three-step  principle is a really easy way to approach your problems and find a good way to solve  you

Video Summary

In this video, Philip Landil performs a secondary breast reconstruction on a 52-year-old woman in Ghent, Belgium, aiming to achieve symmetry in her breasts following a previous deep flap reconstruction. The right breast is wider and slightly larger, and the left exhibits some droopiness. Landil plans to reduce the right breast's size and width by removing a wedge of tissue, enhancing symmetry. The left breast will undergo a minimal lift, involving a vertical scar to adjust the skin envelope for a better shape without altering the footprint significantly.<br /><br />The procedure includes liposuction on the right side to reduce volume and improve shape and lipo filling on the left side to enhance projection and contour. A vertical incision technique for the skin sparing mastectomy helps ensure a neat result and allows for future adjustments if necessary. Landil underscores a meticulous step-by-step approach, emphasizing the importance of maintaining a natural positioning.<br /><br />The video concludes with post-operative care instructions, emphasizing minimal breast compression and early mobilization, a recommendation particularly useful for newer surgeons to ensure a controlled and effective procedure.

Asset Caption

This Surgery Spotlight, filmed in Ghent, Belgium, features Phillip Blondeel, MD as he performs a secondary breast reconstruction with the goal of achieving symmetry. The primary surgery was DIEP reconstruction after mastectomy. The video illustrates the Three-Step Principle, which involves an analysis of the breast, comprehension of what is troubled with the size and shape, and a systematic execution of the surgical design. In this resume of different techniques, the right breast requires a reduction and a narrowing of the shape, and the right breast receives a minimal mastoplexy. Liposuction and lipofilling are also utilized.

Surgeon Phillip Blondeel, MD

Disclosure The Surgery Spotlight program was created to bridge a difficult gap between classroom theory and clinical application. Every month, PSEN seeks out experts in the clinical field to demonstrate their approach to a given surgical problem. By presenting the Surgical Spotlight program, the PSEN does not suggest that any one surgeon's operative method is the sole or only appropriate approach that should be considered. Every surgeon should use their own judgment in planning their operative approach to suit their own skill set and the needs of their patients. The views expressed in the Surgery Spotlight programs are the views of the operating surgeons and do not necessarily reflect the views of PSEN. This product is not certified for CME.

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VI. Plastic Surgery of the Breast

D. Traumatic Breast Deformities

1. Breast reconstruction following mastectomy

E. Aesthetic and Functional Problems of the Breast

3. Mammary ptosis

b. Surgical techniques

secondary breast reconstruction

symmetry

liposuction

lipo filling

vertical incision

post-operative care

Philip Landil