CHAPTER 59 BREAST RECONSTRUCTION: PROSTHETIC TECHNIQUES
JOSEPH J. DISA AND NIMA P. PATEL
The use of prosthetic devices for breast reconstruction began in the early 1960s with silicone gel-filled implants. Over the years, implant technology and surgical techniques have evolved, resulting in improvement in the quality of the reconstructed breast. Currently, there are multiple methods of prosthetic breast reconstruction and various types of implants with different shapes, textures, and fill materials from which the plastic surgeon can choose.
The popularity of one-stage implant reconstruction has diminished over the years with the development of two-stage, expander–implant reconstructions. Early experience with tissue expanders used smooth surface, round devices with remote fill ports. These devices were fraught with problems, including capsular contracture, poor expansion of the mastectomy pocket, and mechanical problems with the fill port. Current tissue expanders for breast reconstruction have textured surfaces, are anatomically shaped, and have integrated valves. These devices have a semirigid back, allowing for preferential expansion in the anterior dimension. Device design also provides preferential expansion in the lower pole of the reconstructed breast to create a better match with a natural breast. Finally, the textured surface on the expander reduces the incidence of capsular contracture (Figure 59.1). These expanders are typically made in varying heights, widths, degrees of projection, and shapes, so that the optimal device can be selected for the individual patient’s needs.1,2
In general, most patients are candidates for prosthetic breast reconstruction. There are, however, limitations with the overall shape of permanent breast implants that dictate the quality of the final result. Factors to consider include unilateral vs. bilateral, body habitus, associated comorbidities, and the patient’s psychological profile. The ideal candidate for breast reconstruction with prosthetic implants is a thin patient with bilateral reconstruction, or a thin patient with a normal, nonptotic breast who requires unilateral reconstruction. In this situation, symmetry is relatively straightforward. As the patient’s breast size increases and the degree of ptosis increases, the difficulty matching the opposite side with prosthetic reconstruction increases. In this situation, the patient may be a candidate for a contralateral symmetry procedure such as a mastopexy and a reduction mammoplasty. Even with such procedures, however, exact symmetry out of clothing may not be possible. The patient is educated that the goal is to achieve as much symmetry as possible, but that this may only be accomplished when she is in her brassiere and clothing.3 Although not an absolute contraindication, obesity makes implant reconstruction difficult. In patients with a broad chest wall and a large contralateral breast, the expansion process may fail to achieve a pocket of appropriate volume to obtain a meaningful and symmetric result. In this situation, the addition of autologous tissue to an implant-based reconstruction, or the use of autologous tissue alone, may achieve a more pleasing result. For patients with multiple medical problems, an implant-based reconstruction may be more efficient than an autologous tissue reconstruction. However, implant-based reconstructions may require more than one operation and may require revisions over time. Additionally, if the patient has a chronic respiratory illness, the pressure from the tissue expander on the chest wall during the expansion process may exacerbate that underlying condition. Finally, prosthetic-based breast reconstruction often requires multiple steps and multiple visits to the office. The patients must be reliable and stable enough from a psychological standpoint that they can manage the reconstructive process.
It is also important to explain to patients that prosthetic breast reconstruction does not hinder detection of local or regional recurrence. There is no difference in the incidence of locoregional recurrence in patients who have undergone prosthetic reconstruction versus those who have not had reconstruction.4
Breast reconstruction using prosthetic techniques can be accomplished either in the immediate or delayed setting. The advantage of immediate reconstruction is that the first step in breast reconstruction is accomplished at the time of the mastectomy under the same anesthetic. In this setting, maximum amounts of breast skin can be preserved as the prosthetic device will occupy some of the mastectomy space. In the setting of a single-stage breast reconstruction using a permanent implant, immediate reconstruction allows for the placement of an optimally sized device. Delayed breast reconstruction using a prosthetic technique is also possible; however, tissue expansion is almost always necessary. In this method, the mastectomy skin flaps are re-elevated and expanded to re-create a pocket for the ultimate placement of a permanent breast implant. In the setting of high-risk disease and patients who require chemotherapy and radiation therapy, a delayed reconstruction may be appropriate as it will not delay the initiation of adjuvant treatment.
FIGURE 59.1. Textured surface, integrated valve, biodimensional-shaped tissue expander with Magna-Finder (Allergan, Irvine, CA) fill port locating device.
With all types of breast reconstruction, the primary goal is to achieve a breast mound that is as symmetrical as possible with the other breast or to the contralateral reconstruction in the setting of bilateral mastectomies. Coordination and communication between the surgeon performing the mastectomy and the reconstructive surgeon is required. Ideally, mastectomy incisions are planned to minimize their impact on subsequent tissue expansion and their visibility in conventional clothing. Skin flaps should be of adequate thickness to maintain blood supply, and the site of the inframammary fold should be marked and preserved whenever possible (Figure 59.2). The position of the point of maximum projection of the breast should also be noted. At the conclusion of the mastectomy, if the inframammary fold has been detached, it should be repaired. After obtaining hemostasis within the mastectomy pockets, a submuscular pocket for the placement of the tissue expander is prepared. The lateral border of the pectoralis major muscle is elevated from the chest wall and from the underlying pectoralis minor muscle. Care must be taken to adequately coagulate perforating vessels to the muscle to avoid hematoma formation. Expanders can be placed in a complete submuscular or subfascial pocket by elevating the medial border of the serratus anterior muscle and/or fascia and elevating the pectoralis major from lateral to medial and bringing both the subserratus and subpectoral pocket into communication at the level of or slightly below the inframammary fold (Figure 59.3). Final coverage of the expander occurs by suturing the lateral border of the pectoralis major muscle to the serratus anterior muscle. This technique completely separates the tissue expander from the mastectomy space (Figure 59.4A, B).5 In the setting of a very thin mastectomy skin flap, caution is recommended because there may be inadequate soft-tissue coverage over the inferior pole of the expander. Exposure of the expander either through the skin flap or through a poorly healed mastectomy incision does occur in some cases. In general, if soft-tissue coverage of the expander is questionable, any mastectomy skin flap necrosis should be treated aggressively with excision of devitalized tissue and closure of the wound. Occasionally, saline needs to be temporarily removed from the expander to accomplish closure.
An alternative to using the serratus anterior muscle and/or fascia for total submuscular coverage of the tissue expander is to use acellular dermal matrix. Once a subpectoral pocket is created for the expander, a sheet of acellular dermal matrix is tailored to the defect. It is placed in the inferior and lateral portions of the expander pocket and sutured to the pectoralis major muscle superiorly and to the chest wall or inframammary fold inferiorly (Figure 59.5). One to two closed suction drains are placed. Postoperative expansion starts in 10 to 14 days.
FIGURE 59.2. Intraoperative appearance of bilateral mastectomy defect. Original position of inframammary folds and planned lower position of the new inframammary fold are marked.
FIGURE 59.3. Submuscular dissection of tissue expander pocket. Lateral border of pectoralis major muscle (black arrow) is retracted medially while the medial boarder of serratus anterior muscle (white arrow) is retracted laterally.
It has been suggested in many case series that the use of acellular dermal matrix in tissue expander/implant reconstruction allows for quicker expansion, decreased pain caused by dissecting the serratus for submuscular coverage, and improved cosmesis. However, this is based on anecdotal reports. Initially, it was shown at our institution that there was no difference in the mean rate of postoperative tissue expansion with the use of acellular dermal matrix.6 More recently, however, increased rates of expansion due to larger initial fill volume in patients with acellular dermal matrix have been observed. Additionally, a recent study evaluated 153 immediate expanders placed using acellular dermal matrix versus 2,910 expanders placed without the acellular dermal matrix over a 4-year period.The acellular dermal matrix group had a higher incidence of overall complications, specifically seroma (7.2%) and reconstructive failure (5.9%) mostly due to infection.7
Choosing the appropriate expander is based on several factors, including breast volume, breast dimensions (height, width, and projection), breast shape, and the patient’s body habitus. In general, an anatomically designed, textured surface, integrated valve tissue expander is preferred (see Figure 59.1). The expander comes in various heights, widths, and amounts of projection that either can be compared with the contralateral breast or can be matched to another expander if a bilateral procedure is performed. Final considerations in choosing an expander include the amount and quality of remaining breast skin after the mastectomy and the impact of planned contralateral symmetry procedures (augmentation, mastopexy, and reduction) on the shape of the opposite breast. The expander typically comes partially filled with air. The air is evacuated from the expander and a small amount of saline solution is infiltrated into the expander to confirm the functioning of the port. The expander is then placed into the pocket with the appropriate anatomic orientation. The expander can be filled to match the available space in the submuscular/submastectomy pocket. A closed suction drain is placed in the mastectomy space, and the mastectomy wounds are closed. If there is redundant skin from the mastectomy, excision of this skin as much as possible prior to closure will improve the cosmetic result.
FIGURE 59.4. A. Tissue expander in place, covered by the pectoralis major muscle and serratus anterior muscle. B. Lateral border of pectoralis major muscle is sutured to medial border of serratus anterior muscle to provide complete submuscular coverage of the tissue expander.
DELAYED TISSUE EXPANDERS
Delayed breast reconstruction with a tissue expander is similar to immediate reconstruction. Typically, the mastectomy scar is excised and the mastectomy flaps are re-elevated, although not to the extent as was necessary during the original mastectomy. Once adequate pectoralis muscle is exposed, either the lateral border of the pectoralis muscle is identified and elevated from the chest wall, or the muscle is split in the direction of the muscle fibers and a subpectoralis major pocket is created. Similar to immediate expander placement, care is taken to avoid elevation of the pectoralis minor muscle. From this point, dissection beyond the pectoralis can be extended either into the subcutaneous plane inferiorly and laterally, or into the submuscular/subfascial plane as noted in the description of placement of an immediate tissue expander. Similar to immediate tissue expander placement, the importance of a careful dissection of the tissue expander pocket cannot be overemphasized. It is critical to free any scar tissue that will restrict expansion of the mastectomy flaps. The expander is placed such that the zone of maximum expansion is located in the lower pole of the reconstructed breast, allowing for preferential expansion of the lower pole, for a more natural shape of the reconstructed breast. Acellular dermal matrix may also be used for delayed reconstruction.
FIGURE 59.5. Tissue expander covered by the pectoralis major muscle superiorly sutured to the acellular dermal matrix (black arrow) inferiorly.
Intraoperatively, the tissue expander is filled to a volume that optimally obliterates dead space, but does not impart excessive pressure on the mastectomy skin flaps (Figure 59.6A–C). Because blood supply to the newly created mastectomy skin flap may be tenuous, overfilling the expander intraoperatively can impede circulation. Closed suction drainage tubes left at the time of expander placement are removed when output is ≤30 mL per 24 hours, which typically occurs within 2 weeks. Tissue expansion begins in the office approximately 10 to 14 days after surgery. A magnetic device is used to identify the site of the integrated fill valve under the patient’s skin. The area is cleansed with an antiseptic solution and a butterfly needle is used to gain access to the tissue expander. Approximately 30 to 120 mL of saline is injected into the expander during each expansion session. Expansion sessions can occur as frequently as once per week or as infrequently as once per month, although there is no set criterion to the expansion schedule. The final goal of the expansion is to achieve a volume that is approximately 25% to 30% greater than the expander volume (Figure 59.7). This allows for extra skin to be available at the exchange procedure, which can be used to create maximum breast ptosis and inferior pole projection. Overexpansion also allows for the removal of unsightly mastectomy scars, or scars that have resulted from delayed or poor wound healing. If the patient is to receive postoperative chemotherapy, the onset of this typically coincides with the expansion process. Patients can be safely expanded during chemotherapy, although it may be necessary to coordinate the expansion schedule with their chemotherapy schedule. Final replacement of the expander to a permanent implant is deferred until the patient’s blood counts have returned to normal after the conclusion of chemotherapy. Also after simulation for radiotherapy, it is important not to adjust the expander volume. In general, soft tissues are allowed to rest for at least 1 month between the time of the last expansion and the time of the exchange procedure.8
FIGURE 59.6. A. Magna-Finder (Allergan, Irvine, CA) device is used to locate the port intraoperatively. B. Saline solution instilled into tissue expander intraoperatively. The expander is filled to match the available space in the submuscular pocket. C. Intraoperative appearance of partially filled tissue expanders after wound closure.
EXCHANGE OF TISSUE EXPANDER FOR PERMANENT IMPLANT
The second stage in breast reconstruction using a prosthetic device involves exchanging the tissue expander to a permanent implant. This procedure can be accomplished at any time after the tissue expansion is completed. Typically, patients will wait at least 1 month following the last expansion before undergoing the exchange procedure. If the patient received chemotherapy as part of her management, then at least 3 to 4 weeks after the last chemotherapy session is allowed to pass so that bone marrow suppression induced by chemotherapy can resolve before undergoing an elective surgical procedure. The goals of the exchange procedure are to create a breast mound that has similar shape, volume, and position as the contralateral breast in a unilateral reconstruction, and to maximize symmetry and position in a bilateral reconstruction. The patient is positioned in the operating room such that the reconstruction can be accomplished in the sitting position, allowing for maximum ptosis of the natural breast. The permanent implant can then be placed with maximum symmetry.
The type of implant is chosen preoperatively: saline versus silicone, smooth versus textured. Once the type of device is chosen, then the shape of the device is selected: anatomic versus round. Round implants, whether they are silicone or saline have varying projections: low, moderate, or high profile. With smooth implants, the point of maximum projection is in the center of the device. The smooth device is mobile within the implant pocket, whereas textured implants are not mobile within the pocket, as the textured surface adheres to the pocket. Anatomic shaped form stable cohesive gel devices (Allergan/Inamed/McGhan 410, Irvine, CA, and Mentor CPG implant, Santa Barbara, CA) that were marketed in Europe in 1993 are not available in the United States at the time of this writing except at centers that are IRB (Institutional Review Board) approved for FDA (Food and Drug Administration) investigations (Figure 59.8A–C). This implant will maintain its dimensions and form in any position. These devices are available in a matrix of sizes with varying base diameters, projections, and heights. The clinical implication of this implant compared with a round implant is that with the shaped implant, careful dimensional planning is essential. Also the pocket dissection must be precise and overdissection is avoided.9 Patients should be educated on all implants and informed consent should be obtained prior to surgery.
FIGURE 59.7. Unilateral right breast reconstruction with tissue expander. The expander is intentionally overfilled to maximize projection and inferior pole skin.
The selection of the proper final implant is aided by measuring the dimensions of the normal breast. Specific measurements include base diameter, breast height, and projection. The step in choosing the appropriate breast implant is matching the volume of the contralateral breast. There are various techniques that can be used to facilitate this process. One involves comparing the weight of the breast removed at the time of mastectomy to the volume of the tissue expander. This technique will help in approximating the mass and volume needed for the reconstruction. Another technique is to partially empty the expander (which typically is overexpanded so as to maximize inferior pole skin and projection) prior to removing the expander (Figure 59.9A–D). The expander is emptied to a point where its volume approximates the contralateral breast. The volume of the remaining fluid in the expander, the base dimension of the pocket from which the expander came, and the height and projection of the contralateral breast determine the appropriate size and shape of the implant. Disposable sizers corresponding to particular permanent implants are also available and can aid in permanent implant selection (Figure 59.10A, B).
Perhaps, the most important step in placement of the permanent implant for breast reconstruction is accurate positioning of the inframammary fold. The placement of the inframammary fold on the breast mound should be marked preoperatively with the patient in the upright position. This marking then can be confirmed with the patient in the supine position. Depending on the degree of ptosis and whether a contralateral symmetry procedure will be performed on the opposite breast, the marking will help determine the final location of the inframammary fold. In general, the position of the inframammary fold of the reconstruction should match the normal side or the contralateral side in the setting of a bilateral reconstruction. If a contralateral symmetry procedure (augmentation, mastopexy, or reduction) is to be performed, care should be taken to match the symmetry procedure to the reconstruction. In the setting of a more ptotic breast, where the breast gland descends below the level of the inframammary fold, it may be desirable to place the bottom of the implant at the level of the bottom of the breast on the natural side. In this circumstance, the inframammary fold on the reconstructed side may be slightly lower than it is on the contralateral side; however, the overall position of the breast mounds is similar. Multiple techniques for recreating the inframammary have been described: internal placement of capsulorraphy sutures, external marionette sutures as described by Spear,10 liposuction of the inframammary fold to allow the external skin to stick to the chest wall, and advancement of the upper abdominal skin flap, suturing this internally to the chest wall to define the fold. The combination of appropriate positioning and definition of the inframammary fold, along with ample inferior pole skin expansion, will create the desired pocket for prosthetic breast reconstruction. Maximizing projection of the reconstructed breast can be further accomplished by performing internal capsulotomies positioned either circumferentially, radially, or both, or by performing a capsulectomy (Figure 59.11). Care is taken to ensure adequate thickness of the mastectomy skin flaps when performing these procedures. An inferior pole capsulectomy or capsulotomy will allow for maximizing inferior pole projection and ptosis in the reconstructed breast.
FIGURE 59.8. A. Anatomic shaped, form stable cohesive gel implant. B. Cut anatomic shaped, form stable cohesive get implant. C. Round silicone gel implant.
FIGURE 59.9. Exchange of tissue expanders to permanent implant. A. Excision of mastectomy scar. B. Mastectomy skin flaps elevated off pectoralis major muscle. C. Pectoralis muscle incised in the direction of its muscle fibers, exposing the tissue expander. D. Removal of fluid from tissue expander to estimate planned volume of permanent implant.
FIGURE 59.10. A. Disposable saline-filled sizers can be used to determine appropriate permanent implant. B. Intraoperative appearance of sizer in implant pocket.
FIGURE 59.11. Releasing an implant capsule aids in maximizing projection and ptosis of permanent implant.
If the patient desires a contralateral symmetry procedure, this is typically accomplished at the time of the exchange of the tissue expander with the permanent implant (the second stage of breast reconstruction). Contralateral symmetry procedures include augmentation mammoplasty, mastopexy, or reduction mammoplasty. Performance of the symmetry procedure at the second stage gives the surgeon maximum opportunity to obtain symmetry with the normal breast (Figures 59.12 and 59.13). In the setting of a bilateral mastectomy and reconstruction, the same principles are applied; however, the use of capsulotomy, capsulectomy, and repositioning of the inframammary fold is performed to maximize the symmetry of the pockets and the overall symmetry of the reconstruction (Figures 59.11to 59.16).
BREAST RECONSTRUCTION WITH IMMEDIATE PLACEMENT OF AN IMPLANT
In select cases, immediate breast reconstruction can be accomplished with placement of an implant. The mastectomy skin flaps must be completely healthy, the pocket must be of adequate size so as to insert an implant of the appropriate size, and the appropriate implant must be selected. If the pocket is inadequate for a permanent implant of sufficient volume, then an expandable implant, such as an expandable saline device with a remote access port, can be used. The port is removed at a later stage. Alternatively, an expandable silicone/saline device can be used. The advantage of an expandable device is its adjustability during the postprocedure period prior to final port removal, which generally can be accomplished in the office setting. Acellular dermal matrix may be beneficial in single-stage reconstruction. The disadvantage of immediate reconstruction includes the risk of asymmetry with the contralateral breast, inadequate size and projection of the device, and the potential need for a revision to improve the quality of the overall reconstruction. In general, use of a two-staged reconstruction with a tissue expander placed at the first stage, followed by a permanent implant at the second stage, maximizes the surgeon’s control. Whenever reconstruction in a single stage is performed with an implant, patients should be made aware that there may be a need for a revisionary procedure to improve the overall result.11,12
FIGURE 59.12. A. Unilateral right breast reconstruction with saline implant and left mastopexy for symmetry. B,C. Oblique views.
FIGURE 59.13. A. Unilateral left breast reconstruction with anatomic-shaped cohesive gel implant and right breast augmentation with anatomic-shaped cohesive gel implant. B,C. oblique views.
BREAST RECONSTRUCTION AFTER NIPPLE-SPARING MASTETOMY
The goal of breast reconstruction is to create a natural appearing breast. An improved cosmetic result can be attained by preserving the original nipple. Despite efforts to reconstruct the nipple using various flaps, a reconstructed nipple cannot compete with the aesthetics of a normal nipple. Nipple-sparing mastectomies, however, have raised questions about oncologic safety even though the nipple–areola complex is an uncommon site for breast cancer development. In a retrospective review of 115 consecutive nipple-sparing mastectomies from Memorial Sloan Kettering Cancer Center (MSKCC), occult disease was found in 5.2% of the nipples.13 In the same study, after a nipple-sparing mastectomy and prosthetic reconstruction, 3.5% of nipples were lost due to wound complications.
It is important to consider the incision placement for the mastectomy when planning a nipple-sparing mastectomy: periareolar, lateral, inframammary, omega type, or transareolar. Our preferred incision is the periareolar with lateral extension. The lateral extension allows for lateral access to the breast as well as to the axilla for either a sentinel node biopsy or axillary dissection. Multiple studies have shown increased patient satisfaction after preserving the original nipple. However, proper patient selection is essential (Figures 59.17 and 59.18).
FIGURE 59.14. A. Unilateral right breast reconstruction with saline implant after nipple-areola reconstruction. The reconstructed inframammary fold was intentionally lowered so that the lower pole of the reconstructed breast was symmetrical to the natural breast. B. Oblique views.
FIGURE 59.15. A. Bilateral breast reconstruction with saline implants after completion of nipple-areola reconstruction. B,C. Oblique views.
FIGURE 59.16. A. A 6-year postoperative follow-up on bilateral breast reconstruction with round silicone gel implants. B,C. Oblique views.
FIGURE 59.17. Postoperative after exchange to bilateral anatomic-shaped cohesive gel implants. The patient had bilateral breast reconstruction with acellular dermal matrix for tissue expander coverage after a bilateral nipple-sparing mastectomy.
After placement of a tissue expander, or after exchange of an expander for a permanent implant, the patient is placed in a surgical bra, which helps to hold dressings in place and provides a place for drains to be fastened. The use of oral antibiotics after surgery is discretionary. The use of a conforming breast binder to hold the implant position may be advantageous. Patients are instructed to avoid the use of an underwire bra for several weeks after surgery and, depending on the type of implant used, may be instructed to massage their implants. Implant massage is usually reserved for patients with smooth implants rather than shaped, anatomic implants where massage may lead to implant malposition. Pain medication is prescribed as needed.
Complications specific to prosthetic breast reconstruction are similar to those associated with breast implant surgery in general. Bleeding in the immediate postoperative period resulting in hematoma warrants re-exploration. Hematomas under the mastectomy skin flap and around the tissue expander or permanent implant increase the risk of infection and predispose to capsular contracture. Consequently, if a hematoma is recognized, it should be promptly evacuated. Infection of the prosthetic device can occur early in the postsurgery period, or late, occurring even years after the placement of the permanent implant. Infections typically present as cellulitis of the skin flaps over the implant. Occasionally, an abscess is identified. In a large series of tissue expanders placed at our institution, the incidence of infection requiring expander removal was approximately 2%.8 Typically, if the patient presents with cellulitis of the mastectomy skin flaps, a course of intravenous antibiotics or, occasionally, oral antibiotics are initiated. If the cellulitis fails to resolve with antibiotic therapy, or a frank abscess develops, removal of the implant is indicated.14 In rare circumstances, cellulitis of the skin flaps can be adequately managed with antibiotics without implant removal.
Another early complication includes mastectomy skin flap necrosis. Factors such as the length of the mastectomy skin flap, the patient’s overall medical condition, the thickness of the mastectomy skin flap, and whether or not the patient is a smoker can contribute to the development of mastectomy skin flap necrosis. Superficial- or partial-thickness flap necrosis is usually managed conservatively with local wound care. Occasionally, small areas of full-thickness necrosis can also be managed with local wound care, particularly if the expander is in a complete submuscular location, thus having an interface of normal healthy tissue between the device and the area of skin necrosis. When the eschar resolves, the underlying tissue granulates and heals as a scar that can be revised later. However, in the setting of larger areas of mastectomy skin flap necrosis or questionable soft-tissue coverage of the implant, resection of necrotic skin with immediate wound closure is indicated. If a tissue expander that has been partially expanded is in place, fluid can be removed from the device, which might allow for tension-free closure of the remaining mastectomy skin flaps. If mastectomy skin flap closure is not possible after resecting devitalized tissue, either the device can be removed and the skin subsequently closed, or a skin graft can be applied, which later can be expanded along with the skin flaps and eventually resected to allow for closure.
FIGURE 59.18. Bilateral two-stage breast reconstruction after nipple-sparing mastectomy with anatomic-shaped cohesive gel implants.
Late complications of prosthetic breast reconstruction include asymmetry, implant wrinkling, implant malposition, implant deflation, capsular contracture, and infection. Infection is discussed above. In almost every case of unilateral breast reconstruction, and even in certain cases of bilateral breast reconstruction, some degree of asymmetry is expected. The development of capsular contracture around a reconstructed breast may lead to implant malposition, changes in projection of the implant, and, occasionally, pain and discomfort. All of these factors may lead to the patient’s desire for a revision.15Implant wrinkling or ripple formation is a common sequela of breast reconstruction with implants. Unlike the setting of an augmentation mammoplasty, where a breast implant is covered by the skin, breast tissue, and often muscle, the reconstructed breast is covered by the skin and muscle, or perhaps only the skin, subcutaneous tissue, and implant capsule. Normal contour irregularities because of the compliance of the implant are transmitted through the skin and appear as a ripple on the reconstructed breast. As a consequence of gravity, these ripples tend to occur most commonly on the upper pole of the reconstruction, where they are most visible to the patient. Strategies to improve rippling include overfilling of saline implants (although this will lead to a more firm-feeling implant reconstruction) and the use of smooth wall devices. Textured surface breast implants tend to be associated with rippling more commonly than smooth surface devices. In the current era of implant reconstruction and with current implant design, it is unknown whether the risk of capsular contracture differs between smooth surface and textured surface implants. However, the only types of devices that are available in the smooth surface are round devices either in a low, moderate, or high profile.
Fat grafting can be used to improve many of the contour deformities that result from mastectomy and implant reconstruction. Fat grafting is typically accomplished during the exchange procedure and/or nipple areola reconstruction, but can be a separate procedure as well. The fat is injected in multiple different layers and feathered over the area that needs to be corrected. Some authors have described the use of acellular dermal matrix to correct rippling as well as capsular contracture.
IMPACT OF RADIATION ON PROSTHETIC RECONSTRUCTION
The indications and incidence of radiation therapy to the chest wall after mastectomy have increased significantly in the past decade. As a result of studies demonstrating a reduction of local recurrence in certain subsets of patients with breast cancer, radiation therapy is indicated after mastectomy for patients with tumors that are ≥5 cm in maximum diameter, four or more positive axillary lymph nodes, stage T3 or T4 disease, or positive margins. Additionally, the indications for radiotherapy seem to be expanding. Consequently, it is controversial in plastic surgery as to whether or not to perform immediate breast reconstruction in the setting of planned postoperative radiation therapy. Another controversial issue is management of the patient who has had a prior lumpectomy and radiation therapy for breast cancer and now for either reasons of local recurrence or prophylaxis requires a salvage mastectomy on the previously irradiated breast. Radiation therapy, whether it is delivered preoperatively or postoperatively, complicates breast reconstruction. With respect to preoperative radiation therapy, placement of a tissue expander at the time of the mastectomy may lead to failed expansion, poor expansion with lack of projection, poor wound healing, and an inability to achieve the desired result from this method of reconstruction. The rate of complications can be as high as 60%.16 Careful patient selection is mandatory when attempting to perform an expander-based reconstruction in a patient who has been irradiated. Ideally, the skin should show no evidence of prior radiation therapy and there should be no fibrosis within the pectoral muscle. A slow and careful expansion should be performed and the patient and the surgeon should be ready to convert to autologous tissue reconstruction if the expansion process fails.
Another approach to the previously irradiated patient with the use of a tissue expander is immediate placement of a latissimus dorsi myocutaneous transposition flap over the expander. The latissimus flap will have not been previously irradiated and thus is much more likely to expand without resistance. Additionally, the autologous tissue provided by the latissimus flap will increase the volume of skin for the breast reconstruction, thus enabling the reconstruction to have more projection and ptosis.
In patients who require postoperative radiation therapy, radiating the permanent implant leads to a higher incidence of capsular contracture and need for revision. One study from MSKCC examined 81 irradiated patients. Sixty-eight percent of the irradiated group had capsular contracture compared with 40% in the nonirradiated group.17 In another study, patient satisfaction was 70% with prosthetic reconstruction after irradiation despite having a one grade higher capsular contracture on the irradiated breast compared with the nonirradiated breast.18 On the other hand, a retrospective study performed on 1,037 patients showed that the complication rate increased from 21.2% to 45.4% with radiation. The most common radiation-related complications were implant extrusion and capsular contracture.19
In general, whether or not the patient needs postoperative radiation therapy after mastectomy is not known until the final pathology returns. If the tissue expander has been placed at the time of the mastectomy, then the protocol at MSKCC includes expansion of the tissue expander during chemotherapy, exchange of the tissue expander to the permanent implant as soon as possible after the conclusion of the chemotherapy, and beginning radiation therapy several weeks after the permanent implant is placed. In the setting where the surgeon and patient are aware that postoperative radiation therapy will be required, a frank discussion must be had regarding the increased complication rate associated with radiation and breast implants. A delayed reconstruction with autologous tissue, the use of autologous tissue primarily, or the use of a prosthetic-based reconstruction must be considered.
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