Strattice-Based Breast Reconstruction
New Strattice Reconstruction: Single Stage – Full Breast Reconstruction In Immediate Setting
Strattice-based breast reconstruction is a new technique of implant-based reconstruction which allows the use of a permanent implant to fill the breast envelope in one operation avoiding the need for tissue expansion.
It works especially well for A, B or small C cup breasts.
Strattice TM Reconstructive Tissue Matrix is a surgical mesh (acellular dermal matrix, ADM) that is derived from porcine skin and is processed and preserved. The product was developed by Life Cell, a KCI company.
This device is designed to perform as a surgical mesh for soft tissue repair while presenting a scaffold to the patient.
The structural properties minimise tissue attachment to the mesh. Use of Strattice provides for an implant which is strong, biocompatible and will incorporate into the recipient tissue with associated cell and microvascular ingrowth.
Porcine hides are obtained from a closed, disease-free isolated herd.
The hair is removed and the dermal tissue mechanically cut to a nominal thickness.
The prepared dermis is then processed to clear cells and other immunogenic material from the extracellular matrix while preserving the native architecture and key biochemical components of the matrix.
The resulting tissue is then packaged wet in a double foil package and terminally sterilized using electron beam irradiation.
The pectoralis muscle is extended using the Strattice graft, making a much bigger muscle pocket allowing the final breast implant to be placed. This technique was developed in the United States during 2003/4.
Implant-based ADM-aided breast reconstruction with fixed volume permanent implants
In my previous blog, I alluded to the fact that ADM-based breast reconstruction is gaining popularity amongst oncoplastic breast surgeons and patients. It is a method of choice for breast reconstruction due its relative ease of use, good cosmetic results and quicker recovery.
Surgeons, whilst performing implant-based ADM-aided breast reconstructions (IBAR), are using variable volume implants (expandable implants, a typical example being style 150 by Allergan of Beckers by Mentor). A fixed volume implant is seldom used and if it is, it tends to be in a highly selective group of patients.
When I started performing IBAR, my preference was variable volume implants as they gave me control over the volume and addressed some of the unpredictability of my breast volume assessment. As I have gained more experience in this technique over the last three years, I feel very confident in using fixed volume permanent implants for my ADM-aided reconstructions. This confidence has been boosted after attending a master class in Stockholm with Per Hedén. The master class was about choosing the correct implant for breast augmentation and it relies mainly on dimensions rather than guessing the volume. While flying back to the UK, it suddenly hit me that this principle of measurement can easily applied to IBAR.
Not all IBARs will be amenable to using fixed volume, but the majority will. Before I describe this technique, I want to discuss the merits and disadvantages of the use of variable volume implants.
Advantages of variable implants in ADM-aided reconstruction
Traditionally when performing IBARs, variable volume implants are used for the following reasons:
- It allows the surgeon to adjust the volume of the reconstructed breast to some extent, depending which implant has been used, e.g. Allergan style 150, Mentor Becker 50 or Becker 35. This is a good option, when you are concerned about the skin envelope and want to avoid excess pressure on the surrounding breast tissue.
- Preempting the precise volume of the final constructed breast has not been an exact science, and variable volume implants give the surgeon room to manipulate the volume for optimum cosmetic results.
- Conceptually it allows the surgeon to perform single-stage breast reconstruction.
Disadvantages of variable volume implants in ADM-aided breast reconstruction
- Although the cosmetic outcome is acceptable, it may lack certain aspects of good breast reconstruction e.g. the distance between the nipple and inframammary fold (IMF) lacks definition and the desired dimension in some of the cases, as there is less control on this aspect when using variable volume.
- Due to the fact that ADMs do not have give, they do not expand when variable volume implants are expanded, and as a result Pectoralis Major, which is more compliant, will expand and stretch. This, in 20-30% of cases, results in the thinning of the muscle and implant palpability over the upper pole.
- Although variable volume implants are used with the intention of providing patients with one-stage reconstruction, unfortunately due to the above mentioned reasons, either the implant has to be changed to permanent fixed volume, or the palpability of the implant has to be corrected with an additional sheet of ADM on the upper pole. The revision surgery rate can be as high as 35%.
Advantages of fixed volume silicone implants in ADM-aided breast reconstruction
Fixed volume permanent implants address most of the above issues. When used in accordance with the Akademikliniken system (AK system), fixed volume implants provide excellent cosmetic results and do not cause the thinning of the Pectoralis Major muscle, as no expansion is required. It is half the price of the variable volume implant and does not require replacement in most cases.
How to measure for fixed volume implants in ADM-aided breast reconstruction
Traditionally, surgeons have taken approximate values of breast volume, breast height and width to determine the implant size to be inserted in the reconstructed breast. In most instances it works and produces a good cosmetic outcome because the majority of surgeons prefer using variable volume implants, allowing them some freedom of error and secondly, the majority of these patients undergo skin-sparing, nipple-sacrificing mastectomy, thus eliminating the need for the centralisation of the nipple areola complex. Conversely, when doing ultra skin-sparing mastectomy, the nipple areola complex position becomes more relevant, and thus there is a need for more accurate measurements. Although in most instances the traditional way of assessing volume is enough to give a good cosmetic result, an exact science to determine the proper implant to give the optimum result is desirable.
It is very important to realise that IBAR works almost on the same principle as cosmetic breast augmentation. There are several systems available to assess implant size but the most accurate system backed by the science of numbers is, as previously mentioned, the Akademikliniken system (AK system), used and popularised by Per Hedén et al, plastic surgeons in Sweden.
I have been using the AK system for IBAR breast reconstruction with fixed volume permanent implants for some time now, and have been able to produce optimum results with minimum complications. I have been able to preserve the nipple areola complex in all of my patients. This obviates the need for multiple outpatient appointments to inflate an expander variable volume implant.
This also has the advantage of one-stage reconstruction eliminating the need for a second surgery to change the expander.
Pre-operative measurements start with measuring breast width. The next step is to ascertain the height of the implant. This is achieved by asking the patient to raise her arms above her head while the nipple level is marked on the sternum (A). Now arms are dropped down and the lower pole of the breast is marked in the midline (B). The distance measured between A and B is half of the height of the implant. This measurement is marked in the midline from point A, giving the superior pole of the implant. The next step is to decide the desired projection. This is achieved as shown in the figure. All these measurements are used to determine the implant size. Allergan provides tables for all their implant products which makes this easy.
The next step is to determine the site of incision under the breast, if doing ultra skin-sparing mastectomy through IMF approach. This is determined by calculating the lower ventral curvature (LVC) of the selected implant. This is taken on the anterior surface of the implant from the mid height point of the implant to the inferior edge. Again, this has been made easy by tables provided by Allergan, in which the LVC has been calculated for implants including style 410, 510 and Inspira. One centimetre (the thickness of the mastectomy flap) is added to the LVC of the implant to give you (C). Once again, the patient is asked to raise her arms above her head and C is taken from the nipple to the lower part of the breast: this is the site of the incision (figure). If I use a vertical approach, I will double breast the incision by de-epithelisation of one of the edges.
The results are invariably optimum and reproducible. I strongly recommend this system to oncoplastic breast surgeons, who are doing ultra skin-sparing mastectomies with immediate implant-based ADM-aided reconstructions.
This technique has been used in immediate breast reconstruction on both sides of the continent for some time now.
Delayed One Stage Reconstruction Using Strattice And Permanent Implant
Delayed one-stage Strattice-based breast reconstruction is a novel technique which has been used by Mr. Sheikh Ahmad with some modifications to the original immediate reconstruction technique. One-stage delayed reconstructions thus avoid the need for two-stage breast reconstruction.
This technique is suitable for patients who have had a mastectomy in the past but want to avoid major flap reconstruction without compromising aesthetic and natural looking breasts.
This type of reconstruction is most suitable for patients who either did not require post-operative chest radiotherapy or who have minimum post-radiotherapy skin damage.
Mr. Ahmad was the first surgeon to start this technique and to his knowledge no other surgeon is practicing this technique in the country in delayed settings.
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Differential compliance muscle sparing ADM bases implant aided immediate breast reconstruction
New innovative technique for immediate breast reconstruction which allows a very natural looking breast with added advantage of minimal post-operative pain.
This technique takes advantage of newly devoted ADM by Life cell cooperation, Artia, which is more companies and soft. A combination of differential complaints ADMs are used without mobilising Pectoralis major muscle. These ADMs form pocket in from of the muscle which encompasses the impact, giving a natural looking reconstructed breast.
This type of reconstruction is most suitable mastectomy of small to medium volume breasts. Mastectomy is done sparing the entire breast envelope, including nipple areola complex.
Mr Ahmad has been using this technique selectively for the past one year with excellent aesthetic results. Mr Ahmad has observed following advantages:
- Most natural looking reconstruction
- One stage reconstruction
- Minimal post-operative pain
- Minimal downtime
- Patient satisfaction
Mr Ahmad has an extensive experience in ADM based implant aided reconstruction and in his experience differential compliance immediate breast reconstructions provide the most natural looking reconstructed breast.