Background: Bra flap is a muscular-fascial balcony consisting with fibers of the inferior pectoralis flap, external oblique, serratus muscle, and the rectus aponeurosis. Bra-flap augmentation mammoplasty, which is also called triple plane breast augmentation, is an effective method in constricted lower pole and tuberous breast. In breast cancer reconstruction, lower and lateral soft tissue deficiency is always the major concern. Inadequate lower lateral pocket dissection may result in implant exposure, irregularity, and long-term capsular contracture. Since transient nipple areolar complex(NAC) ischemia or necrosis is still inevitable, complete viable soft tissue coverage will make reconstruction safer and better long-tern result.
Capsular contracture is one of the major complication after reconstruction. The incidence rate of significant contracture (Baker Grade III and IV) ranges from 3 to 25% in 2 to 10-year period. The incidence rate can be decreased to around 1.4% when applying with acellular dermal matrix (ADM), but it is not a popular method in Taiwan. In our study, we want to present the bra-flap coverage technique to decrease capsular contracture and prevent implant exposure.
Patient and Methods: From Nov, 2019 to May 2022, we intension to preserve the soft tissue surrounding the bra-flap during simple mastectomy if safe margin available. All patients (N=76) received direct to implant breast reconstruction with a modified dual plane with bra-flap supporting. Post-operative following up was arranged on 3, 6, and 12 months.
Results: A total 76 breast reconstructions in 70 patients were performed. Fifteen breasts were excluded due to loss of following or less than three months after reconstruction. Mean follow-up was 12.6 months (from 4 to 26 month). Significant capsular contracture (Baker III, IV) occurred in 4 breasts in overall patients (6.6%, 4/61) and 1 breast in non-irradiated group (1.9%, 1/52). Sensation recovering of NAC occurred in 25 breasts (47.1%, 25/53). Good dynamic results with clear breast cleavage creation occurred in 56 breasts (91.8%). Mean satisfaction scores of BREAST-Q (from 0-100) are as following: Breast (87.0, from 67 to 100), Outcomes (92.2, from 68 to 100), Physical (78.1, from 10 to 100), Psychosocial (90.3, from 60 to 100), Sexual (82.3, 40 to 100).
There is no case converted to tissue expander or autologous tissue during operation, and there is no explantation even when post-operative NAC necrosis occurred.
Summary: Bra flap contributes to not only a safer reconstruction, but also better static and dynamic cosmetics. With full tissue coverage in lower and lateral pole, the implant contour will be created as “Evident” breast-like shadow smoothly. The soft pocket with implant can mimic the natural breast contour and create natural “Motivation” and “Beauty”. In summary, E.B.M concept and bra flap technique will make a more promising and predictable results in breast reconstruction.

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