Case 11 (2024): Pushing the Limits of Unilateral Autologous Breast Reconstruction: Bilateral TMG Flap with Immediate Nipple-Areolar-Complex Reconstruction
Oliver Didzun1, Adriana Panayi1, Amir K. Bigdeli1
- 1BG Ludwigshafen, Germany
Abstract
A 59-year-old female with a history of an extensive ductal carcinoma in situ (DCIS, staged as pTis m(DCIS), pN0 (0/1, sn), L0, V0, Pn0, R0) of the right breast was subjected to a skin-sparing mastectomy and sentinel lymph node excision, accompanied by the immediate implantation of a tissue expander. Three months postoperatively, the patient presented at our institution seeking consultation for aut
BeforeAfterA 59-year-old female with a history of an extensive ductal carcinoma in situ (DCIS, staged as pTis m(DCIS), pN0 (0/1, sn), L0, V0, Pn0, R0) of the right breast was subjected to a skin-sparing mastectomy and sentinel lymph node excision, accompanied by the immediate implantation of a tissue expander. Three months postoperatively, the patient presented at our institution seeking consultation for autologous breast reconstruction due to a progressive and painful foreign body sensation in her right breast. The patient had no familial history of breast cancer and no prior incidents of thrombotic events. Notably, her medical history was significant for the presence of carotid artery plaques, with no other pre-existing conditions reported.
The preoperative planning stage involved precise delineation of the scar tissue designated for excision and positioning of the new nipple-areola complex as well as marking the bilateral TMG flap.
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TMG flap harvesting was carried out on both inner thighs, with the skin paddles each measuring 15 cm in length and 6 cm in width, to guarantee a tension-free wound closure and to maximize volume extraction. Simultaneously, a second surgical team prepared the recipient vessels after expander removal and capsulotomy, ensuring efficiency.
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The flaps were meticulously positioned to conform to the breast’s natural shape, ensuring tension-free anastomosis to the right internal mammary artery and vein. To mimic the physiological appearance of the breast, the muscle was folded, and the flaps were oriented horizontally and attached to each other. This configuration was achieved by positioning the contralateral TMG flap inferiorly and the ipsilateral TMG flap superiorly. A Charrière drain was then placed along the medial axillary line.
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To guarantee the adequate perfusion of both flaps, end-to-end arterial and venous anastomoses were performed to the right internal mammary artery and vein. The recipient vessels were bisected, and the inferior TMG flap was first anastomosed to the lower section. This was followed by anastomosing the superior TMG flap to the upper section. Prior to anastomosis, the vessels had been carefully prepared by excising the medial segment of the third costal cartilage up to the sternal joint, allowing for precise placement of the anastomoses and an optimal length of the vessels. For enhanced venous patency, venous coupler devices were employed.
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The subcutaneous fat, muscle, and dermal tissues of the flaps were adapted to one another using resorbable sutures (Monocryl 4-0). This technique significantly minimizes the risk of unintentional displacement.
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The TMG flaps were carefully inserted to achieve sufficient breast volume and ensure optimal positioning.
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Schematic illustration of the flap harvest technique, donor- site preparation, and its flap positioning.
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The position for the new nipple-areolar complex was marked out, and the design for the skate-flap was outlined for immediate reconstruction. Notably, the upper TMG flap was utilized for the upper portion of the NAC and the predominant portion of the nipple itself, while the lower TMG flap contributed to the lower portion. Additionally, the remaining skin was carefully deepithelialized. To maintain the integrity of the reconstruction and counteract the effects of gravity, holding threads were placed around the upper breast pole. This ensures the flaps remain securely in position, preventing postoperative volume loss in the upper breast.
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Wound closure was executed using resorbable sutures (Monocryl 4-0). Simultaneously, the skate flap was shaped for the reconstruction of the NAC. Adequate perfusion was confirmed, and ongoing monitoring of both TMG flaps was established through the new NAC.
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The TMG flaps and the reconstructed NAC have healed completely, showing no signs of wound healing disorders or flap necrosis. The patient reports being pain-free and expresses satisfaction with the aesthetic outcome of the right breast. Furthermore, both donor sites have healed well, with no complications or disturbances in wound healing observed. At the 3-month follow-up, the patient has successfully resumed daily activities without any limitations. However, due to a persistent asymmetry between the breasts (with the right being smaller than the left), a further reduction mammoplasty on the left breast is planned to achieve symmetry.
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13– Hourly flap perfusion monitoring by the surgical team for the initial 48 hours post-surgery. – Early mobilization with physiotherapy support from day one, complemented by compressive leg wrapping. – Drain removal once the flow rate decreases to less than 30ml per day. – Removal of holding threads scheduled for day seven post-operation. – Custom-made compression garments, including pants with a pad for the inner thigh region to prevent seroma and hematoma, and a compression bra, to be worn for 6 weeks postoperatively. – Patients are advised to avoid straining the right arm and thighs for 6 weeks to ensure optimal healing. – Outpatient monitoring with follow-up visits planned at two weeks, six weeks, three months, and 12 months post-surgery to assess recovery progress and address any concerns.
How to cite this article
Oliver Didzun, Adriana Panayi, Amir K. Bigdeli. Case 11 (2024): Pushing the Limits of Unilateral Autologous Breast Reconstruction: Bilateral TMG Flap with Immediate Nipple-Areolar-Complex Reconstruction. Journal of Plastic, Breast & Reconstructive Surgery. 2024.
Open access. © 2024 The Author(s). Published by the Journal of Plastic, Breast & Reconstructive Surgery. Copyright to this case is shared between the author(s) and the journal; authors may reuse their own case for education, presentations and social media.
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