When a single perforator flap does not provide adequate volume or projection for satisfactory breast reconstruction, the addition of an implant may be considered at the time of second-stage revisions. Dissection of an implant pocket beneath the flap may lead to the inadvertent injury of the flap pedicle as the tissue planes have been obscured by tissue ingrowth. The authors present a technique in which the boundaries of the implant pocket are predetermined at the time of flap reconstruction allowing an implant to be inserted at the second stage in ideal position with greater ease of dissection and minimal risk to the flap pedicle.
Forty patients (80 bilateral perforator flap breast reconstructions) treated with the creation of central under flap pocket technique in anticipation of subsequent sub flap implant augmentation within an 18-month period were assessed retrospectively.
Sixty-eight patients with flaps (85%) went on to receive secondary augmentation with silicone implants. The average percentage increase in volume contributed by the implant was 41%. The undersurface of the acellular dermal matrix was readily identified, and its medial most extent safely determined, allowing the expeditious recreation of the predelineated central under-flap implant pocket. No flap pedicles were injured during the process, and the implants were placed in a favorable position providing maximum projection to the reconstruction. No subsequent development of fat necrosis was identified after augmentation.