"A Split-Muscle Support Technique for Direct-To-Implant Breast Reconstruction"

Many patients who undergo direct-to-implant breast reconstruction with subpectoral implant placement experience animation deformity, where implants move up toward the axilla with contraction of the pectoralis muscle. The deformity affects quality of life and prompts patients to seek revisionary surgery. 1 Prepectoral implant placement has gained popularity over the past decade as an alternative. However, prepectoral placement may increase implant visibility and rippling, and provide inadequate coverage. Additionally, the use of acellular dermal matrices (ADM) and other adjuncts in prepectoral reconstruction can lead to complications and higher costs. The split-muscle support (SMS) technique originally described for breast augmentation and augmentation-mastopexy divides the pectoralis muscle in the direction of its fibers and elevates the superior and inferior divisions to create an implant pocket. 2 Crucially, the lateral and inferior attachments of the pectoralis muscle are preserved, which create autologous inferolateral sling support for the implant. The superior portion of the split muscle provides superomedial coverage without window-shading. We present the first reported application of the SMS technique to breast reconstruction. In our modification of the technique, the anterior window between the muscle edges is interposed with a piece of ADM for implant coverage. The SMS pocket is designed to increase implant stabilization and reduce bottoming out over time owing to autologous support. The technique may also result in less animation deformity and flattening than subpectoral reconstruction, while still providing muscular coverage with less use of ADM than in prepectoral reconstruction. 2 We present our initial experience with this novel technique in this single-surgeon series of 30 consecutive patients.