Acellular Dermis-Assisted Breast Reconstruction

BACKGROUND: In 2004, the authors reported their findings with placement of tissue expanders for breast reconstruction in the partial submuscular position, the equivalent of the "dual-plane" technique for breast augmentation. Limitations with subpectoral expander placement include difficulty controlling the lower pole of the pocket during expansion, unprotected device coverage by a thin inferior mastectomy flap, possible effacement of the inframammary fold, and limited control over the superior migration of the pectoralis major muscle. This study aimed to examine the safety and efficacy of an acellular dermal sling in providing inferolateral support to the device during immediate breast reconstruction and expansion. METHODS: This study prospectively investigated 58 breasts of 43 consecutive women who underwent immediate breast reconstruction with tissue expanders and acellular dermis. After completion of adjuvant therapy and expansion, the devices were exchanged for implants. The patients were tracked through January, 2007. The study parameters included demographic information, oncologic data, complications, and aesthetic outcomes. RESULTS: The mean time required to complete reconstruction was 8.6 months. The overall complication rate after expander/acellular dermis placement was 12%, whereas the complication rate after exchange to implants was 2.2%. The aesthetic outcome for reconstructed breasts did not differ significantly from that for the control subjects who had no surgery. CONCLUSIONS: Acellular dermis appears to be a useful adjunct in immediate prosthetic breast reconstruction. Acellular dermis-assisted breast reconstruction has a low complication rate, helps to reconstruct an aesthetically pleasing breast, and facilitates expeditious completion of the reconstruction.     

Multicenter Study on Breast Reconstruction Outcome Using Becker Implants

The use of tissue expanders and implants is the simplest option for breast reconstruction following mastectomy. In the 1980s, Hilton Becker introduced a round, inflatable breast implant that could be used as a permanent implant. Since then, the original implant has been improved in both design and architecture. The new Becker device consists of an anatomical implant composed of 35% cohesive silicone gel in the outer chamber and 65% normal saline in the inner chamber. This multicenter study describes our experience with the new anatomical Becker implants in a large series of patients, in both immediate and delayed breast reconstruction. We reviewed the clinical records of 204 patients who underwent a breast reconstruction with an anatomical Becker-type implant in the sub-muscular position between November 2004 and December 2006. Data on the patients’ characteristics, indications for reconstruction, operative technique, device size used, complications, and need for further operations were collected and analyzed. A total of 248 breast reconstructions were performed in 204 patients. One hundred forty-three patients (70%) underwent an immediate reconstruction; in the remaining 61 cases (30%), the breast reconstruction was performed later. The patients’ age ranged from 26 to 66 years, with a median age of 47.5 years. The implant was placed unilaterally in 160 women (78.5%) and bilaterally in the remaining 44 (21.5%). Complications occurred in 85 cases (34.2%), in both the immediate and delayed reconstruction groups, and were related to wound healing, bleeding, seroma, and problems with the inflatable expanders. Iatrogenic implant rupture was documented in one case (0.4%). Inflation was impossible in 7 cases (2.8%) as a result of valve obstruction (3 cases, 1.2%) and valve displacement (4 cases, 1.6%). Implant malposition was the most troublesome complication; indeed, 34 patients (13.7%) complained of device malposition. Capsular contracture was assessed in all the patients. Significant capsular contracture (Baker grade III and IV) was detected in 6 cases (2.4%) at the follow-up approximately 1 year after surgery. Breast reconstruction with permanent inflatable expanders is widely acknowledged as a useful technique for breast cancer patients undergoing simple or modified radical mastectomy. The use of this device eliminates the need to replace a temporary tissue expander with a breast implant, thus avoiding a second operation. Although we believe autologous tissues afford the best method of reconstruction in the majority of patients, the results of our study show that expander implant placement may yield a reasonable reconstruction.     

Aesthetic Breast Reconstruction

Breast reconstruction is fully justified only from an aesthetic perspective. A reconstructed breast, therefore, should be as aesthetically natural and similar to the contralateral one as possible, even if this means reproducing some little defects. The breast's profile (projection, ptosis, sulcus location, and superficial unevenness), symmetry, areola, and nipple are the characterizing aesthetic factors. The authors present their experience in prosthetic breast reconstruction seen with an aesthetic eye and an artistic touch, illustrating personal tips and technical adjustments: use of anatomical prostheses, pectoralis muscle treatment, sulcus stabilization or reconstruction, superficial irregularities correction, and nipple-areola complex reconstruction. Results are evaluated by both the surgeon and the patient using a score system, validating the method.     

Breast reconstruction by tissue expansion for congenital and burn deformities

We have used tissue expanders to treat 10 patients with breast deformities, 2 the result of burns and 8 congenital in origin. The expanders are placed in the subglandular plane and expanded incrementally until the desired amount of growth is obtained. In patients with congenital deformities, the desired size of the reconstructed breast (implant size) is determined during the expansion phase. Reconstructions of the nipple-areola complex are done either at the time of the exchange or as separate procedures. Patients with burn deformities present a variety of problems not seen with the congenital deformities. The expander is placed in the subglandular plane and filled to the desired volume. We have noted a marked permanent softening of the scar and grafts encasing the breast, which persists after the expander is removed and the breast reconstructed. The interval between expansion and definitive reconstruction is delayed for several months to allow scar softening to take place. If the parenchyma is not burned and pedicle tissue is not required, the expander can be deflated and the skin coverage observed to determine if it will remain soft. If it does, the expander can be removed and the breast reconstructed. In patients who require pedicle coverage in the reconstruction and who have unburned scar surrounding the breast, massive overexpansion is carried out. The pedicle skin is used to resurface the breast after removal of the appropriate areas of scar and skin grafts. In all burned patients, the inframammary fold must be reconstructed if the breast is to be protuberant. The nipple-areola complex also requires reconstruction. To date there has been great acceptance by patients with both congenital and burn deformities; however, we believe that tissue expansion techniques offer possibilities that have not as yet been fully explored.     

Inferior Dermal Flap in Immediate Breast Reconstruction

Background

The inferior dermal flap can be used in conjunction with implants or tissue expanders to avoid need for acellular dermal matrix in breast reconstruction and on occasion can serve as an alternative to an autologous flap by functioning as a reconstructed breast mound. Candidates for this procedure are women with high BMI or breast ptosis who desire a decrease in breast size at time of mastectomy with reconstruction. This procedure recruits the de-epithelialized excess skin inferiorly and laterally from a skin-sparing mastectomy and uses this to eliminate the need for acellular dermal matrix in a cost-conscious environment.

Methods

The skin-sparing mastectomy is performed, and the inferior skin flap is de-epithelialized to create the inferior dermal pedicle. A gel implant is placed retropectorally, and the inferior dermal flap is sutured to the inferior border of the pectoralis major muscle and laterally to a muscle-sparing serratus pedicle to provide support and coverage of the implant.

Results

We have performed this procedure in several patients and present a video outlining the technique of this procedure in a 54-year-old female diagnosed with left breast DCIS. Postoperative pictures taken at 6 weeks showed an excellent cosmetic result without complications.

Conclusions

The inferior dermal flap is a simple and reproducible procedure that can reduce cost by eliminating the use of acellular dermal matrix. It provides an excellent cosmetic outcome in women undergoing mastectomy with large BMI and breast ptosis seeking reduction in breast size.     

Skin-sparing mastectomy with staged tissue expander reconstruction using a silicone gel prosthesis and contralateral endoscopic breast augmentation

Women with an A or B cup-size breast with no ptosis or glandular ptosis underwent a skin-sparing mastectomy through a periareolar incision. A submuscular tissue expander was placed for immediate reconstruction. The periareolar incision was closed using a modified pursestring technique. The reconstructed breast was expanded to a C cup size. The expander was removed and replaced with a silicone gel prosthesis. At the time of tissue expander removal, the contralateral breast underwent endoscopic augmentation. Nipple-areolar reconstruction was performed during a third stage to cover the mastectomy scar. Implant reconstruction of the breast frequently results in a breast mound that has greater upper breast fullness than the opposite breast. By augmenting the opposite breast, better symmetry is achieved. Burden WR. Skin-sparing mastectomy with staged tissue expander reconstruction using a silicone gel prosthesis and contralateral endoscopic breast augmentation.     

Infection following breast reconstruction

Of 33 patients who underwent 49 breast implantations for reconstructive surgery, 8 (24%) patients developed implant infections. All 8 of these patients were among a subgroup of 15 having immediate breast reconstructions with tissue expander implants after simple or modified radical mastectomy (a 53% infection rate). The infection rate increased substantially when bilateral procedures involving implants were performed as opposed to unilateral implants. Nine implants were removed (an overall implant loss rate of 18%). Patients who underwent other breast reconstruction techniques (i.e., including immediate reconstruction with permanent implants or delayed reconstruction with or without tissue expanders) did not develop infection unless they had had simultaneous immediate reconstruction with a tissue expander in the contralateral breast. The most frequently isolated organism was the coagulase-negative staphylococcus. The study concludes that neither the tissue expander nor immediate reconstruction is a risk factor, but the combination may lead to an unacceptable infection rate, especially in the face of bilateral breast procedures.     

Breast Reconstruction: Complication Rate and Tissue Expander Type

Background  Limited literature exists regarding complication rates among women undergoing breast reconstruction and the association of these rates with tissue expander types (anatomic, round and Becker). Methods  A historical cohort study investigated all breast reconstructions performed at Hadassah Medical Center for 140 consecutive women. Analyses were performed using both logistic and Poisson regression multivariate methods. Results  At least one major complication occurred in each of the following groups: anatomic (41%), round (20%), and Becker (11.7%) (p = 0.015). Women reconstructed with anatomic expanders were at increased risk for at least one complication (odds ratio [OR], 3.96; 95% confidence interval [CI], 1.18–13.3; p = 0.026) and an average increase of 331% (95% CI, 102–817%; p = 0.0002) in the number of major complications. Conclusion  The results of this study suggest that integrated-valve expanders are associated with more complications than the distant inflation port. The benefits of an anatomic shape may perhaps be better exploited using devices with a distant port.     

BREAST RECONSTRUCTION USING PERMANENT TISSUE EXPANDERS

The breast is a variable organ and as such reconstructive surgeons need to use a variety of reconstructive techniques. Prosthetic reconstruction is a good technique for women who are either unsuitable for or not accepting of autogenous tissue reconstruction. We reviewed the last live years' experience at Monash Medical Centre with permanent tissue expander breast reconstruction. Forty patients underwent reconstruction of 54 breasts. Immediate reconstruction was performed in 70% with an overall average patient age of 45 years. The selection criteria. advantages. and disadvantages of this technique are discussed. Inflation of expanders took an average of 71 days and creation of breast mound (excluding nipple/areolar reconstruction) took an average of 2.3 operations. Overall aesthetic results have been judged to be good to excellent in 81%. Symmetry was more easily achieved in bilateral reconstructions. Capsular contracture rate was Baker Grade I or II in 83%. Minor complications occurred in 17% of patients. We believe that there still exists a significant number of women who are either unsuitable for or not accepting of autogenous tissue reconstruction. It is this group of women who, if well selected, can be reconstructed safely and efficiently by the use of permanent tissue expander breast prosthesis.     

Development of the inframammary fold and ptosis in breast reconstruction with textured tissue expanders

Tissue expansion has become the most important method for postmastectomy breast reconstruction. However, well-defined inframammary fold and ptosis are difficult to achieve with this technique. This study was performed to evaluate the inframammary fold and ptosis achieved in breast reconstruction using a textured tissue expander, later replaced by a textured implant. In ten postmastectomy patients, a textured tissue expander was inserted into a submuscular pocket. Every two to three weeks the volume of the expander was increased by about 30%. About three months after the last filling, the expander was removed and replaced with a permanent textured, gel-filled implant. The profile of the reconstructed breast was recorded before and after the tissue expansion, as well as before and after the change of the implant. The results showed that the inframammary fold did not move significantly upwards or downwards during the expansion period when a textured tissue expander was used. Waiting three months after the last inflation of the expander before replacing it with the permanent implant resulted in a more ptotic breast mound. Usually, however, no real ptosis was achieved, meaning that the angle between the lower part of the breast and the lower chest wall was more than 90 degrees. These findings indicate that a textured expander could help create a pronounced inframammary fold, but without ptosis. A three-month waiting period before inserting the permanent implant may improve the development of an inframammary fold.     

2020 special issue: Twenty years of breast reconstruction: Past,present, and future

Breast reconstruction has evolved in the last 25 years to provide women with better autologous and implant‐based options. The general trends of breast reconstruction have shifted to skin and nipple‐areolar complex preservation, resulting in improved aesthetics and patient satisfaction. Autologous reconstruction has made a dramatic movement toward microsurgical reconstruction by free tissue transfer and has addressed lymphedema and breast sensation. Using the patient's own tissues, several aesthetic refinements have led to optimizing the cosmetic appearance of the reconstructed breast. Implant‐based reconstruction has improved with the invention of form‐stable silicone implants, acellular dermal matrix, and fat grafting. These positive trends will continue into the future. We hope that all women with a diagnosis of breast cancer will have the option of a consultation with a reconstructive plastic surgeon, ideally prior to undergoing resective surgery, to ensure they are aware of all reconstructive options to maximize their reconstructive result.     

Early experience with the crescent expander in immediate and delayed breast reconstruction.

Traditional breast expanders have known drawbacks, such as undesirable fullness at the upper pole, inadequate expansion of the residual breast tissue, and poor ptosis of the reconstructed breast. Crescent-shaped expanders are thought to improve the result in that expansion is concentrated at the basal breast pole. The aim of this prospective pilot study was to evaluate our results with the crescent-shaped expander in immediate and delayed breast reconstructions. Twenty-five patients, median age 51 (27-75) years, underwent 28 operations. The median follow-up time was 8 (4-15) months. Four patients developed complications including superficial infections, capsular contractions (Baker III-IV), and fullness of the upper pole. Three of these patients had been given irradiation. Breast reconstructions with the crescent-shaped expander allowed expansion of the lower pole and led to an anatomical breast shape. Patients' satisfaction during expansion was good. Our data indicate a correlation between complications and radiotherapy.     

Early experience with the crescent expander in immediate and delayed breast reconstruction

Traditional breast expanders have known drawbacks, such as undesirable fullness at the upper pole, inadequate expansion of the residual breast tissue, and poor ptosis of the reconstructed breast. Crescent-shaped expanders are thought to improve the result in that expansion is concentrated at the basal breast pole. The aim of this prospective pilot study was to evaluate our results with the crescent-shaped expander in immediate and delayed breast reconstructions. Twenty-five patients, median age 51 (27–75) years, underwent 28 operations. The median follow-up time was 8 (4–15) months. Four patients developed complications including superficial infections, capsular contractions (Baker III–IV), and fullness of the upper pole. Three of these patients had been given irradiation. Breast reconstructions with the crescent-shaped expander allowed expansion of the lower pole and led to an anatomical breast shape. Patients’ satisfaction during expansion was good. Our data indicate a correlation between complications and radiotherapy.     

Breast implant alternatives

The use of implants is a basic technique in breast reconstruction after mastectomy, for the correction of breast abnormalities or even more in aesthetic breast augmentation. However, especially in difficult cases, implants can have inconveniences and insufficiencies (poor natural aspect, necessity of replacement, capsular contracture). To mitigate these, numerous alternatives were developed. These autologous techniques use mainly the pedicled or free musculocutaneous flaps, which were at first used in breast reconstruction. Their indications were then widened in surgery of breast abnormalities and in aesthetic surgery of the breast. Main alternatives, described, in the breast implants are envisaged by clarifying their advantages, inconveniences, indications and contraindications. The current place of the fat grafting in breast plastic surgery is defined by taking into account the most recent data.     

Aesthetic role of the surgically rebuilt inframammary fold for implant-based breast reconstruction after mastectomy.

The inframammary fold (IMF) represents one of the most important anatomic landmarks in defining a woman's breast ptosis and inferior quadrant shape. Therefore it is important to preserve it, if this is oncologically safe, at the time of excisional surgery. If it is sacrificed, dislocated cranially or caudally, or there is a thick panniculus adiposus with a poor definition of the fold, it is necessary to recreate it. We present our experience in the reconstruction of the IMF in patients suffering from post-oncologic mastectomy, reconstructed with silicone implants. From January 2000 to May 2004 at the Plastic Surgery Department of the University of Turin, 74 reconstructions of the IMF were performed through Nava's technique, partially modified by us. We believe that IMF reconstruction, through fixation of cutis, subcutis and fascia superficialis to VI rib, along with capsulectomy of periprotesic pocket inferior quadrants, is a milestone for achieving, in selected cases, a good aesthetic result in terms of shape, ptosis and projection of inferior pole. The comparison between patients' opinions (obtained through questionnaires) and surgeon's, at 1 year after the reconstruction, shows that both are satisfied with the achieved outcome in terms of shape, projection, symmetry, ptosis and IMF definition. Another comparison was made between cases of fold preservation and cases of fold reconstruction, with a remarkable similarity of aesthetic satisfaction. The technique proposed here appears to be the current method of choice for IMF reconstruction in all cases where it is necessary to recreate or redefine it.     

Immediate Breast Reconstruction After Skin- or Nipple-Sparing Mastectomy for Previously Augmented Patients: A Personal Technique

Background  

Breast reconstruction for previously augmented patients differs from breast reconstruction for nonaugmented patients. Many surgeons regard conservation therapy as not feasible for these patients because of implant complications, whether radiotherapy-induced or not. Despite this, most authors agree that mastectomy with immediate breast reconstruction is the most suitable choice, ensuring both a good cosmetic result and a low complication rate. Implant retention or removal remains a controversial topic in addition to the best available surgical technique. This study reviewed the authors’ experience with immediate breast reconstruction after skin-sparing mastectomy (SSM) and nipple-sparing mastectomy (NSM) with anatomically definitive implants.     

延迟——即刻乳房再造

延期—即刻乳房再造是在乳癌根治术后一期,于胸大肌后植入合适大小扩张器,定期注水扩张,二期置换为乳房假体,根据术后放疗与否选择二期手术时机。延期—即刻乳房再造为可能需要接受术后放疗的患者提供了更好的乳房再造效果,降低了并发症的发生率。本文就延期—即刻乳房再造的适应证及手术方法进行综述。     

乳癌术后的乳房再造

目的 探索乳癌根治术后3种不同乳房再造方法的最佳外观效果.方法 (1)乳癌切除Ⅱ期行扩大背阔肌肌皮瓣乳房再造.(2)乳癌切除即时腹直肌横行皮瓣乳房再造.(3)保留胸大肌乳癌切除,Ⅱ期乳房假体置入并行乳头、乳晕再造;对不保留胸大肌乳癌切除者,Ⅱ期皮肤扩张后乳房假体置入再造.结果 共计治疗12例,10例皮瓣全部成活,外观形态满意,优良率较高.2例不满意,其中1例扩张后,因局部皮肤皮下组织较薄,扩张程度不足,勉强置入140 ml乳房假体,外观形态明显偏小;另1例腹直肌肌皮瓣大部分坏死,经再次修复创面愈合,乳房再造失败.结论 乳房再造的方法选择得当,可使乳房形态更为自然.普通背阔肌皮瓣改用扩大的背阔肌皮瓣后,软组织量比前者增加1倍以上,使再造乳房与对侧相近.假体置入乳房成形后,Ⅱ期行单蒂乳头、乳晕再造,可给患者以心理和外观上的更多抚慰.     

Revisiting an Old Place: Single‐Surgeon Experience on Post‐Mastectomy Subcutaneous Implant‐Based Breast Reconstruction

Significant advances have been made to the reconstructive tools available to plastic surgeons allowing for the re‐exploration of subcutaneous breast reconstruction. The purpose of the current study is to examine the safety, efficacy, and aesthetic results of subcutaneous breast reconstruction by a single‐surgeon. A retrospective chart review was performed on all patients undergoing subcutaneous implant‐based breast reconstruction between April 2012 and September 2014. All implants were fully wrapped in Alloderm and placed in the subcutaneous (pre‐pectoral) plane. Primary outcome was a successful subcutaneous breast reconstruction. All complications were recorded. Aesthetics of the preoperative and postoperative photographs were examined. A total of 135 breasts (79 patients) were reconstructed. Direct‐to‐implant reconstruction was performed in 8 patients (10%). Successful breast reconstruction was achieved for 130 breasts in 76 patients (96%). Sixty‐nine patients (87%) had a course free of any unexpected event or complication. There were no patients with implant extrusion or skin necrosis requiring operative intervention. When comparing pre‐mastectomy breasts with post‐mastectomy reconstructions, there was an improvement in the overall aesthetic outcome. Subcutaneous post‐mastectomy breast reconstruction is safe and effective with comparable complication rates to standard techniques. Yet, this minimally invasive approach does not sacrifice the aesthetic results. Long‐term studies will be required to prove the durability of aesthetic results overtime.     

Appraisal of breast reconstruction with the tissue expansion technique

Our experience with 29 patients treated using the tissue expander technique at the Breast Unit, Longmore Hospital, Edinburgh, UK was evaluated. A morbidity rate of 19%, of minor complications only, was seen with expander insertion, tissue expansion and insertion of the permanent prosthesis. Twenty-two women completed questionnaires, two of whom had undergone bilateral reconstruction. In the opinion of the patients, the improved freedom of dress and improved naked appearance after reconstruction, compared with after mastectomy, more than compensated for the abnormal sensation over or around the reconstructed breast; 19 patients rated their clothed appearance as good as that before mastectomy. Twenty of these women were assessed by a four-person panel. A range of end results was noted; symmetry, cosmesis and size were generally better when wearing a brassiere. Lack of ptosis, surgical scars and firmness on the reconstructed side were the main reservations. Tissue expansion breast reconstruction is highly acceptable to patients and has satisfactory surgical results.