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The “Empanada” Construct: Prepectoral Technique Refinement Utilizing a Composite Acellular Dermal Matrix Mesh Wrap

2021; Lippincott Williams & Wilkins; Volume: 147; Issue: 6 Linguagem: Inglês

10.1097/prs.0000000000007934

1529-4242

Farah Sayegh, Yasmina Zoghbi, Joseph B. Jacobs, C. Andrew Salzberg,

Body Image and Dysmorphia Studies

In this article, we describe a novel technique utilizing acellular dermal matrix anteriorly and ProGrip Self-Gripping Polyester Mesh (Medtronic, Dublin, Ireland) posteriorly to provide full device coverage in the prepectoral space. The posterior mesh provides structure and stabilizes the implant and the overlying acellular dermal matrix, thus reducing implant movement, rippling, and contour irregularities. A thorough consultation must first take place to ensure appropriate patient selection. Selection criteria include athletic patients and breasts with moderate ptosis requiring a device less than 700 cc. Furthermore, patients should have a healthy subcutaneous layer and be amenable to secondary fat grafting.1 After the mastectomy has been performed, SPY angiography (Stryker Corp., Kalamazoo, Mich.) is used to assess skin flap perfusion and determine whether the patient is a good candidate for prepectoral reconstruction. The implant is chosen to match the chest wall dimensions, breast weight, breast diameter, and skin envelope. The “empanada” composite wrap is constructed on a sterile back table by placing acellular dermal matrix over the anterior surface of the implant/tissue expander and suturing it to the mesh on the posterior surface using 2-0 Vicryl (Ethicon, Inc., Somerville, N.J.) horizontal mattress sutures placed approximately 2 cm apart (Figs. 1 and 2). This should result in a smooth contour over the device without anterior evidence of rippling or wrinkling. For direct-to-implant patients, the upper pole material is left intentionally longer, to be buried under a slip of pectoralis muscle in the upper pole, which gives a smooth contour and slope.2Fig. 1.: The empanada construct before suturing (above) and after (below).Fig. 2.: The empanada construct, illustrated. Printed with permission from © Mount Sinai Health System.The empanada construct is subsequently prepared with a triple antibiotic and povidone iodine solution, then placed above the pectoralis major muscle and seated in the desired position. It is then secured using 0-absorbable barbed suture along the lower pole, with the mesh tacked onto the chest wall. Given the gripping nature of the mesh posteriorly, once the construct is secured, there is little to no concern for postoperative shifting. A suction drain is then inserted subcutaneously, and the skin and subcutaneous tissues are closed in layers. With advances in mastectomy techniques, intraoperative perfusion assessment tools, and acellular dermal matrix and biologic meshes, the prepectoral approach has again become a possibility for select patients.1,3,4 We describe a novel technique using ProGrip mesh, which contains a coating of resorbable microhooks that serve to anchor the mesh to the underlying tissue in an atraumatic fashion.2 Utilization of this mesh on the posterior side of the implant serves to stabilize the implant onto the pectoralis muscle and improves control of the implant while decreasing the amount of fixation required by sutures. The advantages of the technique described include ease of assembly on the back table during the mastectomy, decreased operative time, cost savings, and the creation of an easily placed construct that holds the tightness of the acellular dermal matrix to the underlying mesh, preventing the “stretch” seen with other techniques. We have found this technique to be simple to perform and the outcomes over the past 18 months stable and more aesthetically pleasing. There has been less need for secondary subcutaneous tissue transfer to camouflage implant and acellular dermal matrix contours. DISCLOSURE The authors have no financial conflicts of interest to disclose.