37 Pectoral fascia preservation in oncological mastectomy INTRODUCTION Over the past decades, there has been a tendency toward less extensive oncological breast surgery. Mastectomy procedures changed from Halsted’s radical mastectomy, including removal of the pectoralis major muscle (PM) toward the simple mastectomy, in which the PM was preserved and only the pectoral fascia (PF) was resected. This resulted in less postoperative pain and better biomechanical outcomes.1-3 Increased focus on long-term outcomes subsequently led to the introduction of skin and nipple sparing mastectomies, as well as the emergence of breast-conserving surgery as an oncological equivalent alternative for mastectomy in many cases. Furthermore, the axillary lymph node dissection has been largely replaced by the sentinel node procedure.3-5 Most of these changes are driven by the realization that more extensive surgery does not necessarily result in better oncological outcomes, and may worsen long-term cosmetic results and quality of life (QoL). Removal of the PF is still widely performed in the Modified Radical Mastectomy (MRM) and simple mastectomy. However; the necessity of this procedure is questionable. The PF is part of the muscular anatomy instead of the breast glandular tissue, and therefore, it seems theoretically of no oncological benefit to excise the PF except in those cases of tumor invasion in the PF. There is a strict adherence of the PF to the underlying PM. No separating epimysium is present between the PF and the PM, in contrary to the deep fascia in many other body parts (limbs, thoracolumbar fascia, rectal sheet and neck fasciae).6 The PF and PM should therefore be viewed as one myofascial unit in which the PF has a role in proprioception, due to its many nerve endings. Therefore, excision of the PF is both from a functional and surgical technical point of view not the most obvious choice. 7, 8 It is hypothesized that preservation of the PF has several advantages. It may reduce postoperative bleeding complications by preventing injury to the PM itself. Studies showed that 50% of postoperative bleeding requiring reoperation following mastectomy originated from the PM.9 Furthermore, PF preservation may decrease postoperative seroma formation due to its function in lymph drainage.10 From a reconstructive point of view, the strong fibro-elastic layer, although thin (mean thickness 151 µm ± 37), can be a valuable aid in implant coverage.8 The previously described subfascial breast reconstructions that have been applied emphasize the strength of the PF as an extra layer covering the breast implant.11, 12 . PF preservation may therefore reduce the rates of postoperative implant extrusion. Previous studies even described the use of the PF in the mediocaudal lower pole to improve projection making direct-to-implant reconstruction possible 3
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