Dr. Joel Aronowitz — Salvage of the Mastectomy Cripple with Lateral Chest Roll Flap and Porcine Xenograft
AUTHORS:
Dr. Joel Aronowitz, MD; David Feldmar, MD, Joshua Ellenhorn, MD
INTRO: The lateral chest roll flap is a fasciocutaneous flap consists of the roll of lateral skin and fat often persistant as a bothersome extension of the inframammary fold after mastectomy or weight loss. It is an axial flap based on perforators of the intercostal vessels. It is a reliable source of significant, autogenous volume to complement mastopexy in the deflated, ptotic breast after massive weight loss. The lateral chest roll flap is also useful to improve the thin, tight chest wall which results from aggressive mastectomy, chest wall radiation, or removal of an infected prosthesis. It is an attractive alternative for the patient who declines a more definitive myocutaneous flap. One problem with the use of this flap however is difficulty securing a maximum bulk of the flap on the anterior chest wall. The most generous volume of fat tissue occurs near the lateral inframammary crease, the rotation point of the flap. There is a tendency of this adipose tissue to escape from the anterior chest wall inset. The absence of fibrous tissue in the soft adipose tissue of this portion of the flap makes lateral migration of adipose tissue difficult to prevent with suture fixation.
The purpose of this report is to describe our experience with this obscure but useful flap and describe the use of a porcine xenograft reinforcement to improve bulk of the flap near the lateral rotation point.
METHODS: A total of 24 lateral chest roll flaps were used in a series of symptomatic postmastectomy defects and to autoaugment the breast in a series of postbariatric mastopexy patients. After flap rotation, a porcine allograft, was sutured to the serratus anterior and lateral border of the pectoralis major. The anterior border of the graft is sutured to the dermis of the lateral chest roll flap to create a strong, inelastic support sling to prevent lateral migration of the adipose tissue of the flap. The Biodesign graft fenestrations allow escape of serous fluid in the recipient site to the drain of the donor site.
Surgical results were assessed retrospectively for flap and donor site complications, length of surgery and subjective flap volume and lateral bulge assessment.
RESULTS: A total of 24 lateral chest roll flaps were performed on 18 patients for breast reconstruction or breast autoaugmentation. The rate of donor site seroma, flap necrosis and wound infection compared favorable to our historical series of patients who underwent chest roll flap without the porcine allograft bolster. Of note, lateral projection and displacement of the flap was not identified in any of the patients in whom the porcine allograft bolster was used.
CONCLUSIONS: The lateral chest roll flap is a useful, if neglected, axial skin adipose flap with application in difficult post mastectomy defects and post bariatric autoaugmentation. Lateral migration of flap volume at the rotation point is a problem addressed satisfactorily by modifying the flap with a pivot point suspensory sling. A thin, laminated and fenestrated porcine submucosa xenograft proved to be a suitable material for the sling resulting in volume of the flap and no increase in complication rate.
