Skin Banking Closure Technique in Immediate Autologous Breast Reconstruction

Abstract

I mmediate breast reconstruction has been facilitated by the use of skin-sparing mastectomy. 1,2 With preservation of the native breast skin envelope, various methods of autologous or prosthetic reconstruction can be performed. Numerous techniques have been described to evaluate skin flap viability, with clinical observation or fluorescein testing being the most commonly practiced methods. [3][4][5][6][7] Outcome studies of immediate breast reconstruction following skin-sparing mastectomy report mastectomy skin flap necrosis rates in the 10 to 16 percent range. 8 -14 Tobacco smoke, body mass index greater than 30, and prior breast irradiation were identified to be risk factors for mastectomy skin flap necrosis. In the series reported by Carlson et al., 97 percent of skin necrosis healed by secondary intention. 8 If skin flap necrosis results in significant full-thickness eschar, debridement and revision of the reconstruction may be required. These wound issues are especially problematic if postoperative irradiation is planned but must be delayed to allow healing of the reconstructed breast mound.We present a strategy to manage mastectomy skin flaps when the viability is unclear in immediate autologous breast reconstruction. This approach is based on the basic principle of delayed wound closure, with a planned second-look procedure, where the interval of time permits demarcation of nonviable tissue. TECHNIQUEOnce the skin-sparing mastectomy has been performed and the transverse rectus abdominis myocutaneous (TRAM) flap elevated, the mastectomy skin flaps are carefully inspected. If there is any doubt as to the viability of the mastectomy skin, a fluorescein dye test is performed as previously described. 5 Viability of the mastectomy skin flap is demonstrated by fluorescein with Wood's lamp examination of the fluorescein-perfused skin. Our clinical experience agrees with reports that the fluorescein test overestimates the ultimate area of tissue necrosis. 4,15,16 Areas determined to be nonviable, either by lack of capillary refill or by complete nonfluorescence, are aggressively debrided at the initial operation. With aggressive initial debridement of the mastectomy skin flap, only three of the 34 patients who underwent autologous breast reconstruction by a single surgeon (J.W.M.) in the years 2001 to 2005 required the skin banking technique to balance preservation of mastectomy skin with excision of ischemic skin (Table 1).In situations where the viability of significant areas of the mastectomy skin is in question, we propose the skin banking closure strategy. Here, the TRAM flap skin paddle is not fully deepithelialized. Instead, excess skin is "banked" on the TRAM flap skin paddle, which is buried under the vulnerable mastectomy skin flap and loosely closed to give the semblance of a breast mound (Fig. 1). Areas of the TRAM flap skin banked in this manner can vary. One can preserve the entire TRAM skin paddle, or only save the TRAM flap skin where the overlying mastectomy skin flap is suspected to be ischemic. T...

Nipple-Areola Complex Necrosis after Nipple-Sparing Mastectomy with Immediate Autologous Breast Reconstruction

“…Since the introduction of the skin-banking technique, it has been used with some frequency [ 13 14 15 16 17 ]. However, to the best of our knowledge, the risk factors for this procedure and its outcomes have been not been previously studied with an algorithmic approach.…”

Safety of long-term subcutaneous free flap skin banking after skin-sparing mastectomy

“…In situ skin banking was first described by Kovach and Georgiad [ 7 ] using the transverse rectus abdominis flap, and has since been widely adopted [ 5 , 6 ]. The DIEP flap used in this series is considered to be the gold standard for autologous breast reconstruction and is the preferred flap worldwide [ 11 , 12 ].…”

“…Subcutaneous in situ skin banking of free-flap skin paddles has been proposed as a feasible solution and as an effective method to ensure the possibility of quick skin defect repair in cases of borderline mastectomy skin flap perfusion or in patients with an elevated risk of secondary oncological resection. Nevertheless, to date, only case reports [ 5 , 6 ] and small series [ 7 , 8 ] have been published; these reports have demonstrated the advantages of short-term skin banking, but without a focus on safety or the prolonged use of this method.…”

Skin banking: Treatment option for native skin necrosis following skin‐sparing mastectomy and previous breast irradiation

“…Preventive subcutaneous positioning of the skin flap offers an opportunity to provide this patient population with optimal surgical supply. The excess tissue can be utilized not only in the event of skin flap necrosis, as it has been reported in the context of immediate breast reconstruction with a TRAM flap, 9, 10 but also in the case of a necessary second‐look resection. In this way, an optimal aesthetic result can be ensured even in previously irradiated patients presenting with local breast cancer recurrence.…”

“…The method of skin banking, in this context, has been described as an option to manage mastectomy skin flaps of unclear viability in immediate autologous breast reconstruction with a transverse rectus abdominis myocutaneous (TRAM) flap. 9, 10…”