Expander–Implant and Nipple–Areolar Reconstruction

What factors are important in selecting the most appropriate procedure for breast reconstruction?

1. Laxity and thickness of the remaining chest skin

2. Condition of the pectoralis and serratus anterior muscles

3. Size of the opposite breast

4. Availability of flap donor sites

What are the benefits of immediate breast reconstruction?

1. Decreased psychosocial morbidity

2. Superior aesthetic outcome (inframammary fold and skin envelope maintained)

3. Decreased surgical morbidity (single general anesthetic and recovery period)

4. Reduced overall cost

What are the potential disadvantages of immediate breast reconstruction?

1. Higher-patient expectations

2. Higher-risk mastectomy skin flap necrosis (10%)

3. Delay in determination of final margins and need for additional surgery and/or radiation therapy

Who are candidates for immediate breast reconstruction?

Patients in good general health with stage I or stage II disease, determined by the size and location of the tumor. Reconstruction has also been described for the selected stage III patients with good prognosis. Some surgeons will perform immediate reconstruction even in cases when the patient will require radiation therapy.

When should delayed breast reconstruction be considered?

1. If tumor clearance is uncertain.

2. Patients in whom immediate postoperative chemotherapy and radiation is expected.

Who first described tissue expansion for breast reconstruction?

Radovan in 1982.

What types of tissue expanders are available for breast reconstruction?

Tissue expanders differ in their:

1. shape (round, oval, tear drop, anatomic, crescentic)

2. surface (smooth, textured)

3. duration (temporary, permanent)

4. fill characteristics (uniform, differential)

5. filling ports (internal port, remote external valve)

6. size or fill volume

7. number of chambers (single chamber, dual chamber)

What are the advantages of tissue expansion in breast reconstruction?

1. Creates new donor tissue of similar texture, color, and sensation

2. No additional scar

3. No additional donor site

4. Decreased operating time

5. Shorter recovery period

6. Technical ease

What are the relative indications for tissue expansion and implant reconstruction?

1. Small- or medium-sized breast

2. Nonobese patient

3. Patient not opposed to implant use

4. Patient prefers not to undergo more extensive surgery

5. Medical contraindications to a more lengthy operation

6. Patient objection to scars of flap reconstruction

7. Patient not a candidate for autogenous reconstruction (multiple scars, limited donor tissue)

8. Bilateral reconstruction

What are the relative contraindications to expander/implant reconstruction?

1. Prior or anticipated chest wall irradiation

2. Morbid obesity

3. Atrophic, tight skin with poor/no pectoralis muscle

4. Mastectomy skin flaps of questionable viability

5. Active infection at the expansion site

6. Residual gross tumor

What are potential problems with expander/implant reconstruction?

1. Pain/discomfort/pressure with expansion

2. Infection +/− prosthesis removal

3. Skin erosion or extrusion

4. Skin flap necrosis

5. Leakage or deflation

6. Malposition

7. Remote injection port malfunction or kinking

8. Internal valvular failure

9. Capsular contracture

10. Hematoma

11. Seroma

12. Implant folds, “knuckles,” or wrinkling

13. Indistinct inframammary fold

14. Longer reconstruction period (up to 1 year)

15. Need for multiple operative procedures +/− additional revisional surgeries

16. Rounder appearance without natural ptosis

17. Chest wall deformity

18. Pneumothorax

Where should the tissue expander be placed within the mastectomy pocket?

The expander should ideally be placed under muscle and may be either completely submuscular (under pectoralis major, serratus anterior, and the fasciae of rectus abdominis and external oblique) or partially submuscular (covered by pectoralis major at its upper pole alone).

Smooth expanders should be placed slightly below the level of the inframammary fold, as they tend to rise upward with expansion.

Textured tissue expanders can be placed at the level of the inframammary fold, as their adherent surface prevents migration and enables lower pole expansion and subsequent ptosis.

What is the blood supply to each of the three muscles in a “totally submuscular” placement of a tissue expander/implant?

Pectoralis major—pectoral branch of the thoracoacromial artery, pectoral branches of the lateral thoracic artery, perforators from the internal mammary artery and intercostal arteries

Serratus anterior—lateral thoracic artery, serratus branch of thoracodorsal artery

Rectus abdominis—deep superior epigastric artery, deep inferior epigastric artery

What are potential advantages and disadvantages of complete submuscular coverage?

Potential advantages include lower incidence of infection, exposure, and extrusion. Disadvantages may include ineffective expansion of the lower-pole of the breast mound. Complication rates have been found to be equal between these methods.

When does the expansion process begin after surgery?

At the time of closure, up to 300 mL of sterile saline is added to the expander, or as much as will allow tension-free closure without skin blanching. At 2 weeks, 50 to 100 cc is injected at weekly or twice weekly intervals. End points for inflation volume include blanching of the skin over the expander and/or patient discomfort; saline is removed until these conditions are reversed.

By how much should the breast pocket be overexpanded once the ideal size has been reached, and how long should overexpansion be maintained for?

Overexpansion is generally 20% to 30% above the final desired volume. The pocket and capsule are allowed to mature for 3 to 6 months in the overexpanded state before removal of the expander and replacement with a permanent prosthesis.

What types of implants are available for breast reconstruction?

All breast implants have a silicone-based shell. In North America, implants are either saline filled or silicone filled. Silicone implants may be cohesive gel (firm) or liquid/responsive gel (more viscous).

Which dimensional features must be considered when selecting an implant type?

1. Base diameter

2. Height

3. Projection

4. Volume

5. Surface characteristics

6. Shape

7. Fill material

Which implant types are associated with the formation of a fibrous capsule?

All foreign bodies induce a foreign-body reaction and formation of a discrete fibrous shell. Certain factors are associated with a higher incidence of capsular contracture, including:

1. older-generation silicone implants

2. subglandular rather than submuscular/subpectoral placement

3. postoperative hematoma

4. postoperative infection

5. smooth rather than textured surface

What is the Becker implant?

A permanent combined expander–implant for breast reconstruction or augmentation. This double-lumen prosthesis contains an outer silicone gel-filled lumen surrounding an inner expandable saline-filled lumen with removable filler tube. After achieving overexpansion, the saline reservoir can be deflated to its final desired volume and the filler tube removed under local anesthesia at the time of nipple reconstruction. The common types are Becker 25 (25% silicone outer lumen, 75% saline inner lumen) and Becker 50 (50% silicone outer lumen, 50% saline inner lumen).

Do breast implants interfere with chemotherapy or radiation postoperatively?

No. Chemotherapy may proceed as usual postoperatively, although tissues are usually allowed to heal for 4 weeks before starting therapy. Implants neither block nor enhance the absorbed radiation dose. However, the tissue expander port can interfere with radiation beams, depending on the targeted nodes and the method of radiation delivery.

How does radiation affect tissue expansion and skin flap viability?