Rerouting of the pectoralis major muscle for breast animation deformity in sub-pectoral autologous breast reconstruction: A case report and review of the literature

Abstract

Introduction: Breast animation deformity (BAD) is a known complication of sub-pectoral implant placement that is usually corrected by simply repositioning the implant to a pre-pectoral position. However, when this complication occurs in the case of a sub-pectorally placed free-flap, the solution becomes a lot less straightforward: repositioning of the flap carries the risk of possible damage to the pedicle. In order to avoid having to re-do the anastomoses we opted for a rerouting of the pectoralis major muscle around the vascular anastomoses.

Presentation of case: We present a 26-year old patient with unsatisfactory aesthetic outcomes of her bilateral deep inferior epigastric perforator (DIEP) flap breast reconstruction. The flaps were placed sub-pectorally, in the already existing pocket that was created during her first breast reconstruction with silicone implants, resulting in severe BAD. Repositioning the free flap from the sub-pectoral to the pre-pectoral plane allowed for reinsertion of the pectoralis major muscle to its anatomical position without jeopardizing the vascular anastomoses. The patient was satisfied with the increased projection of the breasts.

Discussion: Changing the plane from sub-pectoral to pre-pectoral remains the best treatment option for patients experiencing BAD. In combination with an acellular dermal matrix, this would have been a good option for our patient. However, when choosing to perform autologous breast reconstruction instead, our recommendation would be to always place the flap in the pre-pectoral plane to avoid BAD.

Conclusion: The report shows that the plane of a flap can be successfully changed without jeopardizing the pedicle of the flap.

Keywords: Breast animation deformity; Breast reconstruction; DIEP flap; Pectoralis major muscle; Reinsertion.