Mammary reconstruction using tissue expander and partial detachment of the pectoralis major muscle to expand the lower breast quadrants


The techniques commonly used in breast reconstruction with tissue expanders do not provide a good definition of the lower breast quadrant. With the technique described in this video a better profile of the breast is achieved. This technique was described by Serra Renom in 2004 (Ann Plast Surg 2004;53(4):317-21). Partial detachment of the pectoral muscle is performed, suturing it to the lower skin flap and thereby avoiding cranial migration of the expander. In addition a rounded shape of the lower quadrants is achieved and the expander remains in a subcutaneous position.

Technique. The upper subcutaneous flap is dissected superiorly to the infraclavicular region, with careful separation from the pectoral major muscle to avoid lesions. The cutaneous flap is dissected caudally until the sixth rib above the pectoralis major and serratus muscles and the rectoabdominal fascia. Both upper and lower subcutaneous dissection are important to achieve good adaptation of the cutaneous flaps and the pectoralis major muscle. The pectoralis major is then detached from the sternum at its lower level from the area located in the 3-o’clock to the 6-o’clock position on the right side, and the area from the 6-o’clock to the 9-o’clock position on the left side. The insertions of the pectoralis muscle are sectioned at the level of the sixth rib. It is important not to detach a greater area of the muscle at the sternal level to avoid retraction. A pocket is then dissected by detaching the pectoralis major muscle up to the clavicular margin. On preparation of the surgical pocket, the anatomic expander with an integrated valve, full height or low height, is placed under the pectoral muscle, and the free edge of the pectoral muscle is sutured to the lower cutaneous flap at 2 cm with transfixing stitches or in the fatty tissue

Patient. A 61-year-old woman diagnosed with a multifocal infiltrative carcinoma in the right breast. She performed a previous lumpectomy with involvement of margins. A type I skin-sparing massectomy and the placement of an expander were planned.