31 Can Implants Correct a Breast-Conserving Therapy Deformity?
The old notion that breast implants and radiotherapy do not mix still holds true most of the time. With the exception of fat injections, all of the techniques described in previous chapters have focused on using well-vascularized tissue in the form of local or distant flaps to reconstruct BCT deformities. This concept is one of the basic principles in reconstructive surgery when it comes to irradiated wounds—namely, that they require adequate debridement and coverage with vascularized tissue.
This chapter addresses whether there is any role for reconstruction with implants after BCT in a scarred, irradiated breast. Based on our experience with breast reconstruction after a skin-sparing mastectomy (SSM) in previously irradiated breasts, it can be assumed that reconstruction using implants is less desirable. The complication rates are higher and cosmetic results are worse when expanders are used after an SSM in breasts that previously have been irradiated. These patients often require autologous tissue to achieve the desired outcome.
Using implants in previously irradiated breasts is always a concern. Although the irradiated skin envelope encountered when correcting the BCT deformity is often more favorable than random mastectomy skin flaps in patients with a failed BCT, extreme caution should still be used.
Although the general impression is that implants are not good options for correcting BCT deformities in women with irradiated breasts, there may be exceptions. However, available literature on this topic is essentially nonexistent.
When evaluating a patient who has a poor cosmetic result after BCT, the surgeon must confirm that at least 1 year has passed since the completion of radiotherapy, that the patient has been adequately screened for any potential recurrence, and that a mammogram of the contralateral breast has been obtained.
Although the incidence of unfavorable cosmetic results after BCT is lower in women with smaller breasts than in women with large breasts, a certain percentage of patients opt for delayed reconstruction to have the deformity corrected. Their wishes and goals might include correction of their asymmetry, correction of the actual deformity, shape improvement, and breast enlargement. These patients are potential candidates for reconstruction of their BCT deformity with implants. However, the patient’s wishes are not enough to determine her eligibility; the breast evaluation is the main factor.
The physical examination should include classification of the deformity, with close attention paid to the size of the breasts, breast symmetry, the location of the deformity, and the amount of skin retraction and volume loss. In addition, the quality of the skin envelope should be assessed; this is likely the most important factor for correction with implants. If breast skin has edema, tightness, or hyperpigmentation with a leathery feel—all evidence of significant radiation damage—then that patient is not a good candidate for implants.
The ideal patient has smaller breasts and minimal to no ptosis, with minor residual changes to the skin and breast from radiotherapy. The breast mound should be relatively soft, the skin retraction minimal, and the nipples symmetrical.
If a contour deformity is present, the breast mound needs to be soft for the implant to correct or improve the deformity. If the mound is firm or significantly fibrosed, an implant will not allow the remaining breast tissue to fill out or improve the deformity. The result will be a larger breast with a persistent contour irregularity, which may be even more pronounced because of the size enhancement. It is probably preferable to correct the deformity as long as possible after radiotherapy, because its effects persist.
Although it is often easier to achieve symmetry by placing implants bilaterally, some patients have a fairly significant size discrepancy and require only an ipsilateral implant. Generally, however, if a patient has extensive radiation fibrosis, she will not be an ideal candidate for using implant placement to correct a BCT defect.
Autologous fat grafting to the breast can be used in conjunction with placing a smaller implant, which might improve minor contour deformities and minimize implant-related complications. 1
The use of implants to correct BCT deformities in well-selected patients allows rectification of parenchymal loss by replacing volume and minor skin deficiencies and contour irregularities by stretching the skin.
A number of classification systems are used to describe the BCT deformity. The Clough classification system, presented in Chapter 24, has classifications that range from a breast with preserved shape, no deformity, and some asymmetry in volume (type 1), to a breast with severe retractile fibrosis of the entire breast (type 3). Another useful morphologic classification of partial deformities was described by Berrino et al 2 and is described in the following text.
Reasonable candidates for reconstruction of BCT deformities with implants should have the following:
A wish for some size enhancement
Clough type 1 or 2 cosmetic sequelae (see Chapter 24)
Small to medium breasts
No or minimal ptosis
Good nipple symmetry
A healthy skin envelope
Minimal skin retraction or volume void
A soft, supple breast mound
Contraindications to this type of correction include the following:
Clough type 3 or 4 cosmetic sequelae
A thick, tight skin envelope with persistent radiation changes
Marked breast fibrosis
A firm breast mound
Large or ptotic breasts
Significant nipple retraction or asymmetry
Type 1 Deformity: Localized Breast Distortion
In a type 1 deformity the NAC is distorted or displaced, mainly from fibrosis and scar contracture. The asymmetry and displacement of the NAC can be mild to severe, depending on the amount of tissue that has been removed; it may also lose its round contour and natural location at the apex of the breast mound.