Patients in this group have an absent pectoralis major muscle, rather tense cutaneous flaps, scars from very wide mastectomies, previous radiotherapy or a large, ptotic contralateral breast (Fig. 31.2). Such women need greater expansion and possibly require a contralateral breast procedure to improve the outcome.

Tissue expansion prior to the definitive implant is the first stage in the two-stage technique. The expander is used to distend the cutaneous flaps and to obtain more volume when the definitive prosthesis is inserted. It is indicated in a similar fashion to definitive implants. Also, older patients, those with significant medical comorbidity, and women with minimal abdominal tissue, in whom the autologous technique would be unsuitable, also benefit from this technique. Besides, the expander/implant technique is indicated for those patients devoid of sufficient skin or preserved subcutaneous tissue in flaps resulting from mastectomy. This may occur when there is little elasticity of the cutaneous flaps from mastectomy or in the case of a contralateral breast with a rather large volume. In these situations, the two-stage implant reconstruction usually yields esthetically superior results (Fig. 31.3).

These are basically the same as those for the use of definitive implants, with even more emphasis on the risk of expanders after radiotherapy [14]. A large number of authors have realized that several postoperative complications can ensue when attempting to distend previously irradiated tissues [12, 14–16], since the radiation decreases the elastic distension capacity of the tissue. In these cases, the most frequent complications are painful and difficult expansion with possible extrusion of the expansion device or periprosthetic capsule (Table 31.1). Even though one achieves the final stage of expansion, the cutaneous coverage of the prosthesis becomes too thin and fragile to protect the definitive implant (Fig. 31.4).

The primary objective in breast reconstruction is to obtain symmetry [17, 18]. For this reason, it is essential to prepare a preoperative plan that includes a detailed analysis of the healthy breast’s characteristics and the most suitable technique for treating this breast [19]. The aim is to obtain a breast with low projection in the upper pole, with no ptosis or tear shape. These characteristics are fundamental in order to achieve a successful reconstruction result (Fig. 31.5). Firstly, a clinical and radiologic preoperative evaluation is fundamental in order to properly choose the surgical technique. Secondly, apart from all the standardized examinations required in the anesthesiological preoperative appointment, it is also important that an oncologic evaluation be performed, surveying the following topics: type and size of tumor; number of positive lymph nodes; type of surgical procedure to be performed; chemotherapy, radiotherapy or hormone therapy procedures the patient is adherent; follow-up period; and the most recently performed radiologic examinations and blood tests. Furthermore, the evaluation of the contralateral breast is also mandatory in order to exclude bilateral neoplasm and should include mammographic and ultrasound examinations. It should also be noted that contralateral breast surgery—a reductive mastoplasty, a mastopexy, or an additive mastoplasty—is frequently required to obtain a pleasing symmetry. Moreover, the contralateral breast evaluation should also aim to examine any palpable nodule or any mammographic alteration, such as microcalcifications or imaging patterns consistent with a suspicious lesion. Finally, it is important to state that no therapy of any sort is permitted prior to the surgical procedure itself aside from the prophylactic endovenous antibiotic administration of a first-generation or second-generation cephalosporin before skin incision.