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.     

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.     

One-stage breast reconstruction using McGhan Style 150 biodimensional expanders: a review of 107 implants with six years experience.

Permanent expanders have revolutionised breast reconstructive surgery, allowing one-stage procedures and the development of increasingly sophisticated implants (textured, anatomically shaped) has played an important role in enhancing the aesthetic outcomes. It is important to evaluate the tolerability of the implant. The aim of this present study was to evaluate the survival curves for McGhan Style 150 permanent expanders, in a consecutive series of breast reconstructions. Complications rates were also examined. Between April 1997 and May 2003, 107 McGhan Style 150 expanders (either full height or short height depending on patients' requirements) were used in 97 consecutive patients for a variety of breast reconstructive procedures. Overall, 46 devices were used for immediate reconstruction, 15 for delayed reconstruction and 46 for implant exchange, respectively. The mean age at implantation was 48 years (min: 26; max: 71). The mean follow-up was 60 months (min: 12; max: 72). Explantation was considered the most objective outcome variable, therefore this parameter was carefully monitored and then analysed using the Kaplan-Meier method of survival analysis. Different curves were compared using the log-rank test. Long term complications were also recorded. Among complications the most frequent finding was Baker 3-4 capsular contracture, occurring in 26% of immediate reconstructions at six years. Explantations increased in an almost linear fashion, with an overall rate of 25%, with a statistically significant difference among immediate reconstruction group and the implant exchange group. The rate of explantations was high, if compared with other series, because the sample included patients undergoing strong adjuvant therapies, particularly in the immediate group (locally advanced disease). The overall rate of explantations and of capsular contracture was found to be significantly lower in the delayed and substitution groups, than the immediate group (p<0.05). In our hands, the McGhan Style 150 anatomically shaped permanent expanders were associated with acceptable results, especially when used as 'permanent prostheses' for second stage procedures.     

Operative risk stratification in the obese female undergoing implant‐based breast reconstruction

The prevalence of obesity is growing, and breast reconstruction in the obese patient is becoming the norm rather than the exception. Our aim was to evaluate implant reconstruction outcomes in the obese female in the presence of coincident surgical risk factors and identify potential risk‐reducing interventions. A review of consecutive obese women (BMI ≥ 30) who underwent mastectomy and implant breast reconstruction was performed. Patient demographics, comorbidities, oncologic treatments, and reconstructive procedures and their complications were recorded. A total of 151 women (242 breast reconstructions) were included with mean follow‐up of 28 months. Average BMI was 36. Eighty percent of cases were immediate and 20% delayed. ADMs were utilized in 58% of cases. About 25% of patients had diabetes with one‐third achieving perioperative glycemic control. About 18% of women were active smokers, and 33% had radiotherapy. Major and minor complications occurred in 42% and 11% of patients, respectively. About 24% of reconstructed breasts required implant removal. Obese patients with prior radiation were three times as likely to develop infection (P = 0.008) and 2.5× as likely to undergo explantation (P = 0.002). Skin flap necrosis was three times as likely in obese smokers (P = 0.01). Increased rates of wound breakdown were identified in obese patients with increasing age (P = 0.005), smoking (P = 0.0035), and radiation (P = 0.023). In the obese radiated and smoking patient subgroups, surgical modifications (use of autologous tissue, delayed breast reconstruction timing, and no ADM) were associated with reduction in the relative risk for implant complications. While obesity alone increases implant breast reconstruction complication rates, the presence of additional risk factors compounds these rates. The use of surgical modifications may reduce the occurrence of perioperative complications in the obese female with coincident surgical risk factors undergoing implant breast reconstruction.     

Inferolateral AlloDerm hammock for implant coverage in breast reconstruction

PURPOSE: Implant reconstruction is commonly performed to reconstruct mastectomy defects or to correct breast hypoplasia. We have been using an inferolateral AlloDerm hammock as an inferior extension of the pectoralis major muscle to provide a mechanical barrier between the implant and skin and to control implant position. METHODS: The inferior border of the AlloDerm hammock is attached inferiorly to the rectus abdominis fascia and laterally to the serratus anterior fascia to create the borders of the implant pocket. The AlloDerm is then sewn to the pectoralis major muscle to enclose the implant. RESULTS: The AlloDerm hammock was used in 43 patients and 67 breasts for immediate expander-implant reconstruction (10), immediate silicone implant reconstruction (30), delayed expander-implant reconstruction (4), and revisional implant reconstruction for capsular contracture following capsulectomy (23). The AlloDerm hammock allowed complete coverage of the implant and symmetric positioning of the inframammary fold. In delayed reconstructions with existing skin redundancy at the mastectomy site, inferior epigastric tissue was recruited and tissue expanders filled over 75% of the desired volume, thus decreasing the need for subsequent filling. Patients were overall satisfied with their results and had few complications. No capsular contracture, hematoma, or seroma was observed in 6 months to 3 years of follow-up. CONCLUSION: Implant reconstruction with an inferolateral AlloDerm hammock facilitates positioning of the implant in immediate or revisional breast reconstruction and simplifies expander-implant reconstruction. This safe technique is easy to learn and should be considered a viable option for breast reconstruction.     

The effect of timing of postmastectomy radiation on implant-based breast reconstruction: a retrospective comparison of complication outcomes

Background

The optimal timing of postmastectomy radiation for women undergoing delayed permanent implant exchange continues to remain controversial. The objective of our study is to compare complication rates when tissue expanders are exchanged for permanent implants pre- vs postradiation.

Methods

A retrospective review of 54 consecutive patients who underwent implant-based breast reconstruction and received postmastectomy radiation was conducted. Complications including infection, implant loss, and capsular contracture (measured in Baker score) were compared between the 2 groups.

Results

Of the patients studied, 32 patients had radiation before placement of permanent implants, whereas 22 patients received radiation after implant placement. There was no difference in individual complication rates between the 2 groups.

Conclusions

In our study of 54 patients, the timing of radiation did not affect individual complication rates for patients who underwent implant-based breast reconstruction after immediate tissue expander placement.     

Complications analysis of 266 immediate breast reconstructions.

The purpose of this study was to describe the complications of immediate breast reconstruction, to compare their rates with respect to the surgical procedure and to patient's characteristics, in order to improve surgical indications and patient information. We carried out a retrospective study of 266 immediate breast reconstructions (249 women) over a 12-year period (latissimus dorsi myocutaneous flap with implant 61%, autologous latissimus dorsi myocutaneous flap 15%, subpectoral implant 24%). Mean age was 48 and the median follow-up was seven years (2-14). The overall complication rate was 49% (128), and there were 10 reconstruction failures. The most frequent complications were dorsal seroma 26% (70), capsular contracture 10% (27), skin necrosis 8.3% (22), and haematoma 5.6% (15). The complication rate for immediate breast reconstruction with implant alone (39%) was lower than that associated with latissimus dorsi with or without implant (51%), but the difference was not significant (Chi-square: p=0.07). The risk factors for complications were smoking (skin necrosis, Fisher: p=0.02), obesity (infection, Fisher: p=0.004), and radiotherapy (capsular contracture, Chi-square: p=2.6 x 10(-5)). Smoking was found as the only risk factor of reconstruction failure (Fisher: p=0.015). Capsular contractures were more frequent when implants were used alone (25%) as well as when used along with a flap (6.8%) (Chi-square: p=2 x 10(-5)). Infections were also higher in the non-flap group than in the flap group (Fisher: p=0.02). In our opinion, latissimus dorsi myocutaneous flap with or without an implant is a good compromise between complication risk and necessity of good cosmetic result requirement. These results have led us to delay or contraindicate reconstruction in the case of obesity or heavy smoking. In the case of probable post-operative radiotherapy, we prefer to delay the breast reconstruction.     

TIGR® matrix surgical mesh – a two-year follow-up study and complication analysis in 65 immediate breast reconstructions

In recent years, it has become increasingly popular to use matrices, such as acellular dermal matrices, in implant-based breast reconstruction. To lower the cost and to avoid implanting biological material, the use of synthetic meshes has been proposed. This is the first study examining TIGR^® Mesh in a larger series of immediate breast reconstruction. The aims of the study were to examine complications and predictors for complications. All consecutive patients operated on with breast reconstruction with TIGR^® Matrix Surgical Mesh and tissue expanders (TEs) or permanent implant between March 2015 and September 2016 in our department were prospectively included. Exclusion criteria were ongoing smoking, BMI (kg/m²)?>?30, planned postoperative radiation, and inability to leave informed consent. Fifteen breasts (23%) were affected by complications within 30 d: four (6.2%) major complications and eleven (17%) minor complications. The major complications included two implant losses and one pulmonary embolism (PE). Predictors for a complication were age over 51 years, BMI over 24.5?kg/m², large resection weight, and the need for a wise pattern excision of skin. Four minor surgical complications occurred after 30 d (minimum follow-up 17 months). There were no implant losses. In addition, minor aesthetic corrections, such as dog-ear resection, were performed in 10 breasts. In conclusion, breast reconstruction with a TE in combination with TIGR^® Matrix Surgical Mesh can be performed with a low complication rate.     

Reconstrucción mamaria inmediata mediante implante prepectoral de poliuretano. Resultados preliminares del estudio prospectivo PreQ-20

IntroductionIn recent years, mastectomy and reconstruction techniques have evolved towards less aggressive procedures, improving the satisfaction and quality of life of women. For this reason, mastectomy has become a valid option for both women with breast cancer and high-risk women. The objective of this study is to analyze the safety of mastectomy and immediate prepectoral reconstruction with polyurethane implant in women with breast cancer and risk reduction.MethodObservational prospective study to evaluate the feasibility and safety of immediate reconstruction using prepectoral polyurethane implant. All women (with breast cancer or high risk for breast cancer) who underwent skin-sparing or skin-and-nipple-sparing mastectomy with immediate reconstruction with a prepectoral polyurethane implant were included. Women with breast sarcomas, disease progression during primary systemic therapy, delayed, autologous or retropectoral reconstruction, and those who did not wish to participate in the study were excluded. Surgical procedures were performed by both senior and junior surgeons. All patients received the corresponding complementary treatments. All adverse events that occurred during follow-up and the risk factors for developing them were analyzed.Results159 reconstructions were performed in 102 women, 80.4% due to breast carcinoma. Fourteen patients developed complications, the most frequent being seroma and wound dehiscence. Eight women required a reoperation (5.0%), seven of them due to implant exposure. Four reconstructions (2.5%) resulted in loss of the implant. Three patients progressed from their oncological process: a local relapse in the mastectomy flap, an axillary progression and a systemic progression.ConclusionsPrepectoral reconstruction with a polyurethane implant is a procedure with a low incidence of postoperative complications (8.8%) and implant loss (2.5%). Its use is safe with perioperative cancer treatments (neoadjuvant chemotherapy and radiotherapy).     

Retrospective case review of capsular contracture after two-stage breast reconstruction: is colonization of the tissue expander pocket associated with subsequent implant capsular contracture?

Periprosthetic capsular contracture is a common problem associated with implant-based breast reconstruction. The purpose of this study was to determine if bacterial colonization of the tissue expander contributes to contracture of the permanent implant. Medical records were reviewed for 86 patients (124 tissue expanders) between 1997 and 2001 in 1 institution. Three specimens taken from the expander were cultured. The overall incidence of colonization was 42.7%; 49.4% (38.8-60.0) of immediate and 28.2% (14.1-42.3) of delayed expanders had at least 1 positive culture site (P = 0.043). The most common organisms were Propionibacterium acnes (57.6%), Staphylococcus epidermidis (31.0%), and Peptostreptococcus (5.8%). Statistical analysis revealed no significant difference between colonization of the expander and capsular contracture of the permanent prosthesis (P = 0.59). 45.8% (25.9-65.8) of breasts irradiated preoperatively developed contracture versus 14% (7.2-20.8) with no irradiation (P = 0.0013). These results suggest that colonization of the expander occurs frequently, irradiation predisposes to contracture, and colonization did not contribute to secondary implant contracture in this study population.     

Immediate direct-to-implant breast reconstruction with acellular dermal matrix: Evaluation of complications and safety

ObjectiveImmediate direct-to-implant breast reconstruction with acellular dermal matrix (ADM) is the method of choice for many plastic surgeons and patients, but the use of ADM remains a controversial subject in the literature.This study aimed to investigate complications, reconstructive failure and possible risk factors in direct-to-implant breast reconstruction with ADM (primarily Strattice™).MethodsWe retrospectively examined all patients undergoing immediate direct-to-implant breast reconstruction with ADM, during a five-year period (2014–2019) at a university clinic. Study outcomes were all complications and explantations. Complications were stratified within and after 6 months postoperatively and subcategorized by type of intervention. Explantations were subcategorized into loss of implant or salvage with immediate insertion of a tissue expander, the same or a new implant.ResultsWe included 154 patients and 232 breasts. Complications within 6 months per patient included hematoma (4%), seroma (8%), infection (9%), necrosis, wound dehiscence and delayed wound healing (19%). The total complication rate per patient was 34%. Explantation occurred in 20 patients (13%) of which 9 (6% of all) had implant loss. Preoperative radiotherapy was a significant predictor of explantation (adjusted OR 4.9, 95% confidence interval (CI), 1.0–23.5; p = 0.045), and smoking was also associated with risk of explantation, although only borderline significant (adjusted OR 4.0, 95% CI, 1.0–15.8; p = 0.050).ConclusionThis study demonstrates acceptable rates of re-operations and implant loss compared to other studies but highlights the importance of proper patient selection with regards to risk factors to minimize complications.     

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.     

Breast reconstruction with polyurethane implants: preliminary report

Today, immediate breast reconstruction is widely accepted in breast cancer surgery. There are many reconstruction procedures that combine cancer indications with patient's expectations. Improved techniques in the use of textured or polyurethane-coated implants and tissue expanders, associated with increasingly more conservative mastectomy procedures, may result in better cosmetic outcomes and less complications, even in patients that require postoperative radiotherapy. From June 2002 to December 2008, 166 unilateral breast reconstructions were performed immediately using definite prosthesis with polyurethane-coated (6) or textured (24) implants, or later, after implant of 136 tissue expanders, using polyurethane-coated (113) or textured (23) implants. Eighty-six two-stage breast reconstructions were irradiated where later 63 polyurethane-coated implants and 23 textured implants have been inserted. Results were analysed evaluating complications associated with temporary expanders and with the two definite implants, with or without RT, respectively. Excluding capsular contracture, total complication rate was 14.7% with expanders, 5.0% with polyurethane implants and 12.8% with textured implants. In this study, severe capsular contracture was reported in 21.7% of cases with textured prosthesis and in 6.3% of cases with polyurethane implants in patients receiving RT. This difference was statistically significant. As of today, no case of clinically noticeable capsular contracture was seen in non-irradiated patients receiving breast reconstruction with polyurethane-coated implants. These results allow us to establish RT, which is not a severe contraindication to breast reconstruction with implants. Polyurethane implants have provided encouraging results either in terms of lower complication rate and likelihood of capsular contracture.     

Use of acellular cadaveric dermis and tissue expansion in postmastectomy breast reconstruction.

Tissue expander or permanent implant coverage in postmastectomy breast reconstruction is often challenging. Multiple authors have demonstrated the use of acellular cadaveric dermis (ACD) in nonexpansive, single-stage breast reconstruction. The literature also suggests that tissue expansion may be accomplished with ACD as well for stage reconstructions. In many cases tissue expansion is necessary to create a submuscular and subACD pocket to accommodate a subsequent permanent prosthesis. In this study we report the outcomes and complication rates of using ACD in staged breast reconstruction. We reviewed the charts of 41 patients (65 breasts) in whom ACD was used in staged reconstructions. We analysed the patients' charts and operative records to determine postoperative complication rates and results. Complication rates for wound infection, expander removal, haematoma, and seroma were: 3.1% (two of 65), 1.5% (one of 65), 1.5% (one of 65), and 4.6% (three of 65), respectively. The use of ACD in expansive postmastectomy breast reconstruction has an extremely low complication rate, results in good cosmetic outcome, and should be in the repertoire of plastic surgeons. Further follow up is needed to evaluate the long term outcomes of ACD use in postmastectomy breast reconstruction.     

即刻及延期乳房再造方法的选择

目的回顾总结乳腺癌根治术后应用单纯假体植入、Becker可扩张假体植入和单蒂腹部横形腹直肌肌皮瓣（TRAM）移植、扩大背阔肌肌皮瓣（ELDF）移植乳房再造术的经验,探讨手术的适应证、方法和效果。方法自2002年7月至2005年10月,共67例患者进行了乳腺癌根治术后乳房再造术。即刻乳房再造56例：单纯假体植入38例、Becker可扩张假体植入16例、单蒂TRAM移植2例。延期乳房再造11例：单蒂TRAM移植6例、ELDF移植4例、Becker可扩张假体植入1例。结果手术效果满意,优良率超过90％。5例患者出现轻微并发症：皮瓣局灶性坏死2例,保留的乳头乳晕部分坏死1例,血清肿2例。结论单纯假体植入用于即刻乳房再造,适用于乳房较小、行保留皮肤的乳腺癌根治术后的患者,不宜用于延期乳房再造;可扩张假体植入即刻乳房再造适用于乳房较大或改良乳腺癌根治术的患者,同时可扩张假体植入延期乳房再造可用于皮肤、肌肉保留较好的乳腺癌根治患者;TRAM和ELDF皮瓣移植乳房再造是自体组织移植,其安全性高,可用于即刻和延期乳房再造。     

Prospective evaluation of immediate reconstruction after mastectomy.

OBJECTIVE: The authors prospectively studied the impact of immediate breast reconstruction on patients undergoing mastectomy. SUMMARY BACKGROUND DATA: Despite the advocation of a breast-conserving approach to the treatment of breast cancer, many women continue to medically require or choose mastectomy for the treatment of breast cancer. In recent years, immediate breast reconstruction has become an alternative to either mastectomy alone or to delayed reconstruction. METHODS: A prospective database of 216 patients who underwent mastectomy with immediate reconstruction was established. In this series, 94 procedures involved implants or tissue expanders, and 124 tissue transfers were performed. RESULTS: The overall complication rate was 15.3%; only 9% of patients who underwent autologous tissue transfers required secondary procedures. When implants were performed, the overall rate of prosthetic loss was 8%. The majority of patients (n = 101) underwent transverse rectus abdominis musculocutaneous (TRAM) flaps. Twenty-six of the 38 (17.5%) patients who required transfusion were from this group. Partial flap losses in this group (7%) were correlated to a history of heavy smoking. With a median follow-up of 33.2 months, only two patients had recurred locally. According to patient opinion, autologous tissue transfers resulted in a statistically better cosmetic result. CONCLUSIONS: Immediate reconstruction can be performed safely and with excellent cosmetic results.     

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.     

Breast reconstruction by DIEP free flap: about 100 cases

Autologous breast reconstruction was stigmatised because the muscular sacrifice of the rectus abdominis muscle. This problem could be avoided by the DIEP flap as much for immediate as delayed reconstruction with the creation of an aesthetic and natural shaped reconstructed breast. This retrospective study about 100 cases performed between January 1997 and June 2002 concern 94 patients, 88 unilateral reconstructions and six bilateral. The reconstruction was delayed in 83%, immediate in 8% or realised after failed attempt to reconstruct the breast with implant in 9%. Risk factors were also present: smokers (66%), one or more abdominal scars (40%), obesity (30%). The recipient vessels were the internal mammary vessels (86%), the circumflex scapular vessels (10%) and the subscapular vessels (4%). We noted four total flap loss, 5% of partial loss and 2% localized liponecrosis. Mean operating time was 6 hours 28 minutes for unilateral reconstruction and 9 hours 30 minutes for bilateral reconstruction. Mean hospital stay was 7,3 days. Two moderated abdominal bulging were noted. The tedious dissection of small vessels of the DIEP flap allowed for a similar rate of complication as the free TRAM flap, by respecting of the integrity of the rectus abdominis muscle, to reduce morbidity of harvest with less postoperative pain, shorter hospital stay and faster recovery.     

Breast Reconstruction with Implants,Tissue Expanders and AlloDerm: Predicting Volume and Maximizing the Skin Envelope in Skin Sparing Mastectomies

Abstract: AlloDerm has been used as a tissue supplement in conjunction with the pectoralis major muscle to provide full coverage over an implant in breast reconstruction. While this method of reconstruction has shown promising results there is little known on the relationship of AlloDerm size and potential immediate expansion volume. A retrospective chart review was completed evaluating all tissue expander or primary implant reconstructions using AlloDerm. Data recorded included: The type/size of implant/expander, dimensions of the AlloDerm used, initial fill volume, number of expansions and time period of expansion. Statistical analysis was completed with a linear regression model. AlloDerm was used on 49 patients (72 reconstructions). Thirty‐four patients (50 reconstructions) underwent reconstruction with a tissue expander and 15 patients (22 reconstructions) underwent a single stage reconstruction with a permanent implant. The tissue expander volume filled (cc) could be predicted by 5 × surface area of AlloDerm (cm²) ? 12 (R² = 0.62) and 80 × height of AlloDerm (cm) ? 15 (R² = 0.59). The tissue expanders could be filled to an average of 75% of total size and required three to four injections in the postoperative period to reach full expansion. Obviously, a requirement for maximal implant expansion is an appropriate skin sparing mastectomy. There is a mathematical relationship between fill volume and surface area as well as height of AlloDerm used in breast reconstruction. This analysis provides a guideline for immediate implant expansion to surgeons using AlloDerm in reconstructive breast surgery.     

PR15THE BRANCHING PATTERN OF THE DIEA FOR PERFORATOR FLAPS: THE IMPORTANCE OF PREOPERATIVE CT ANGIOGRAPHY

Introduction Implant‐based breast reconstruction has evolved from two‐stage methods using round smooth expanders to single‐stage using definitive textured biodimensional anatomical expander‐prostheses. The aim of this study was to assess if single‐stage reconstruction is achievable using McGhan 150 expander‐implants with latissimus dorsi (LD) myocutaneous flaps and if so, at what cost. Methods Data was collected retrospectively on all women who underwent this type of breast reconstruction, between 1997–2005, with a minimum of 6 months follow‐up. Results 147 patients had 164 reconstructions (17 bilateral cases). Mean age 48 ± 9 years. The indications for reconstruction were mastectomy, breast asymmetry and Poland’s syndrome. 144 patients had pedicled flaps and 3 patients had contralateral free flaps. The majority were delayed reconstructions. Single‐stage reconstruction was achieved in 81/147 patients. The number of procedures per completed reconstruction was 2.2 or 1.9 if nipple‐areola reconstruction and contralateral surgery were excluded. The overall complication rate was 38%. Implants were removal for infection in 12% and exchanged for capsular contracture in 15%. LD/expander‐implant reconstruction failed in 3 patients. Conclusions Single‐stage reconstruction is an achievable goal but patients should be counselled that further surgery might be required to complete the reconstruction.