Selective pectoralis major muscle denervation in breast reconstruction: a technical modification for more effective and cosmetic results

Abstract

The use of pectoralis major muscle (PMM) in breast reconstruction has been a mainstay for decades. In recent years, although, a novel approach, the so-called subcutaneous or pre-pectoral breast reconstruction, has been introduced advocating the advantages of sparing the pectoralis muscle. Such advantages include more natural implant ptosis and appearance, significant reduction of capsular contracture and also avoidance of implant animation and animation deformities. These are all drawbacks that the use of muscles in implant coverage inevitably involves overtime. Nonetheless, there are clinical situations which definitely require the use of a muscle coverage either for surgical safety or for a better cosmetic outcome.In such cases a slight and simple modification of the standard technique can be adopted to prevent these drawbacks. While performing the muscular pocket two of the three main nerve trunks of the PMM can be severed, thus leaving innervated only the upper portion of the muscle. The remaining two thirds, basically the part covering a tissue expander (TE) or an implant, will therefore retain a status of a viable soft tissue without any muscular contraction. A significant atrophy will definitely ensue, but a sufficiently vascularized and floppy cushion will cover the prosthetic breast reconstruction device, protecting and masking it.

“To use or not to use the muscle” that is the question in the capsular contracture dilemma

“…Another suggestion that might corroborate this hypothesis is related to a novel technical modification, which I personally described on this journal in 2017 (18) and which has been reported by other authors as well afterwards (19)(20)(21)(22). This is the denervation of pectoralis major muscle in case of a retro-pectoral approach.…”

“…As a consequence, a more natural ptosis of the reconstructed breast, which resembles a pre-pec IBBR, is obtained. But, most of all, this technical "trick" can really make the difference in case of a revising surgery done for a long-standing CC (18,22). Capsulectomy and implant changing are not always the solution and might be temporary, while pectoralis major muscle denervation allows an immediate and promising solution with a rewarding feeling for the patient and surgeon together.…”

Hyperspasticity After Partial Neurectomy for Treatment of Myospasms Following Subpectoral Breast Reconstruction

“…A similar, yet much more common, side effect of subpectoral implants is breast animation deformity (BAD). Pectoral denervation for BAD had been performed for decades, 10 and some surgeons routinely transect the MPN 11 or both nerves 12 for better implant projection. A different approach may be reattachment of pectoral muscle with supportive injection of BTX-A 13 .…”

Current Trends in Prepectoral Breast Reconstruction: A Survey of American Society of Plastic Surgeons Members

“…Animation deformity has traditionally been a frustrating problem to address, with previous solutions often proving ineffective or resulting in compromised muscle function. 11 – 13 Adoption of prepectoral techniques eliminates the possibility for this complication. Similarly, an additional 14.7% of respondents indicated in their free-text responses that they would consider prepectoral reconstruction in athletic patients for whom muscle function is paramount.…”