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Pectoralis Major Splitting Approach in Immediate Breast Reconstruction: A Submuscular Tissue Expander Technique for High Risk Patients
IRENA KARANETZ, M.D., Benjamin D. Schultz, MD, Kevin Chen, MD, Neil Tanna, MD, MBA, Lyle Leipziger, MD.
Division of Plastic and Reconstructive Surgery, Hofstra Northwell School of Medicine, New Hyde Park, NY, USA.

PURPOSE:
Multiple studies demonstrate that traditional submuscular tissue expander coverage offers the best protection against implant exposure but restricts lower pole expansion. Recognizing these limitations, the authors present a pectoralis major splitting approach for complete submuscular coverage in high-risk patients or those with ischemic mastectomy skin flaps. The pectoralis major muscle is split longitudinally along the direction of its fibers and submuscular pocket is developed elevating serratus muscle and anterior rectus fascia in continuity. The objective of this study was to evaluate expansion characteristics and complications using this technique.
METHODS:
A retrospective chart review of patients who underwent two-stage immediate breast reconstruction over a six-year period (July 2007-June 2013) was performed. Patient demographics, intra-operative details, characteristics of expansion and complications were noted.
RESULTS:
A total of 113 consecutive patients underwent immediate breast reconstruction with placement of 214 tissue expanders. Following exclusion of patients who were not candidates for complete submuscular coverage, seventy-one patients (138 tissue expanders) remained in the study cohort. The mean age was 49 with average follow-up of 39 months. The mean expander size was 408cc with mean intraoperative fill volume of 260cc (63.7% expansion). The overall mean time to final implant placement was 5 months with a mean number of 2 fills (range 1-4). Complications included hematoma (1.4%), flap necrosis (2.8%), explantation (2.8%) and infection requiring antibiotics (11.3%).
CONCLUSIONS:
This study demonstrates that pectoralis splitting approach allows adequate intraoperative fill volumes and low incidence of post-operative complications. Thus, this approach should be considered in high-risk patients.


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