Immediate Reconstruction After Skin-Sparing Mastectomy Using the Omental Flap and Synthetic Mesh

João Carlos Sampaio Góes

Antonio Luiz V. Macedo

Introduction

Breast reconstruction after mastectomy has evolved significantly in the last few decades. Initially, most reconstructions were performed using local flaps or simply implants in the mastectomy site. However, complication rates were high, and the results may be considered less than optimal when compared with the current standards (1,2,3). Consequently, numerous reconstructive procedures employing cutaneous and/or myocutaneous flaps (with or without implants) were developed worldwide (4,5,6,7,8,9). Modern breast reconstruction has been executed with safety, longer-lasting results, and excellent aesthetic quality.

Various techniques that involve myocutaneous flaps have obviated the need for breast implants, reconstructing the breast only with autologous tissue. Some disadvantages of these methods include the high complexity, cost, and donor-site morbidity (10,11,12). In terms of breast implants, results have improved by the inclusion of expanders in the treatment plan (13,14,15). However, this type of reconstruction may also result in serious complications, and complementary operations to resolve asymmetries and capsular contracture are frequently necessary (16).

Utilization of the omentum has been previously described in reconstructive surgery (17,18,19,20,21,22,23,24). This flap, whose main blood supply includes the gastroepiploic vessels, was initially used in breast reconstruction to cover an implant; final coverage was obtained by skin grafting (25). The aesthetic result was unsatisfactory due to the final shape and the quality of the skin coverage. The omentum has already been employed as a pedicle to vascularize the lower abdominal skin flap, allowing its rotation into the mastectomy site (26). However, this technique requires multiple stages and includes the risks of complications related to laparotomy.

The technique presented in this chapter was developed based on the senior author’s experience with skin-sparing mastectomy and the use of mesh support in breast surgery (27,28,29,30). This procedure follows the basic principles of breast reconstruction in an original way. First, the new breast’s volume is obtained by insetting the laparoscopically harvested omental flap, based on the gastroepiploic vessels. Breast shape is defined and supported by an internal bra consisting of synthetic mesh that wraps and fixates the flap to the thoracic wall. Finally, the skin-sparing mastectomy technique offers high-quality coverage with native skin and reduced, well-positioned scars.

Surgical Technique

Mastectomy

Modified radical mastectomy is performed through a circumferential periareolar incision. The size of the incision is determined by the amount of skin that will be necessary to cover the reconstructed breast without tension (Fig. 57.1). During the dissection, a thin layer (at least 0.5 cm) of subcutaneous fat must be preserved under the skin to ensure preservation of the subdermal plexus and viability of the flap. Total lymphadenectomy is feasible through the same incision by using appropriate retractors and adequate lighting, without the need for separate axillary incisions.

Laparoscopic Harvesting of the Omental Flap

With the patient appropriately positioned, the abdominal cavity is inflated with CO₂ until the intraabdominal pressure is 10 mm Hg. A Veress needle is then inserted through the umbilicus, followed by a 0-degree fiberoptic camera. Under direct vision, two 12-mm trocars are inserted symmetrically 6 cm from the midline and 4 cm above the umbilicus. Two accesses for the surgeon’s instruments and one for the assistant are established 4 cm caudal to the costal margin, at the level of the right midclavicular line.

The surgeon, positioned between the patient’s legs, mobilizes the omentum using a forceps and an ultrasound-assisted dissector. Metallic clips are employed for hemostasis of vessels whose diameter exceeds 1 mm. Dissection between the omentum and colon progresses from left to right, exposing the posterior portion of the stomach (from the duodenum to the gastric fundus), keeping the omentum connected to the stomach by its gastroepiploic pedicles. The left gastroepiploic pedicle is ligated using a 30-mm linear endoscopic stapler.

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