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.     

Primary and secondary breast reconstruction with a permanent expander

Summary The second generation of tissue expanding prostheses is the permanent expander. It has been used in a series of 88 breast reconstructions following mastectomy for malignant and premalignant disease in 49 secondary and 39 primary reconstructions, the longest follow-up being 45 months and the shortest 12 months. Pre- and postoperative radiotherapy (45 gy) has been the major source of complications: implant loss (11%), infection (2%); capsular contracture-Baker's grade III–IV (90%); and, improper positioning should also be mentioned. Primary reconstruction is no longer performed if postoperative radiotherapy is scheduled. The results were totally different if radiotherapy was omitted after primary reconstruction. The expansion was smooth, an attractive breast shape with mild ptosis was easily achieved, and only minor complications were encountered. A permanent tissue expander, either alone or covered with a latissimus dorsi flap, remains our first choice in breast reconstruction.     

Immediate breast reconstruction using the skin expander: a modification in technique

A modification in the technique of immediate postmastectomy reconstruction of the small to moderate-size breast using the skin expander is presented. The advantage of the technique is that it simplifies the replacement of the expander with the permanent prosthesis while establishing a symmetrical inframammary crease and a laterally supported breast mound. Representative cases are shown.     

Treatment of tuberous breasts utilizing tissue expansion

This article presents the tissue expansion technique for the treatment of the tuberous breast and its variant, the tubular breast. The treatment objectives are different in the two deformities, but, in general, one has to expand the base circumference of the breast, expand the skin of the lower hemisphere of the breast, release the skin tightness at the skin-areola juncture, lower the position of the inframammary fold, increase the volume of the breast skin envelope, reduce the size of the areola and correct its deformity, and perform a mastopexy when necessary. To achieve these objectives, we use a tissue expander introduced either beneath the breast or beneath the pectoral muscle through an incision along the inframammary fold. It is slowly expanded to the appropriate volume. The reconstruction is completed at the second stage when the size of the areola is reduced, the expander is exchanged for an implant, or the fill-port is removed. The tissue "herniation" is corrected and a mastopexy is performed when necessary. We treated seven tuberous breasts and three tubular breasts by the two-stage method. Eight reconstructions were completed successfully in two stages. An additional operation became necessary in two cases; one to treat an exposed expander, and another to correct a capsular contracture. The results have been uniformly good and compare favorably with those presented in the literature done by other methods. We recommend use of the combination expander/implant.     

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.     

Objective evaluation of two differently-shaped permanent expander prostheses used for breast reconstruction

When a breast is being reconstructed with an implant, a capsule of connective tissue always forms around the implant and a capsular contracture can develop. Radiotherapy increases the incidence of capsular contracture. To evaluate the results after breast reconstruction with differently-shaped textured implants, and the effect of radiotherapy on the softness of the reconstruction, 140 patients given permanent breast expander prostheses between 1994 and 2000 were studied. In 99 patients a round implant and in 41 an anatomically-shaped implant was used. Radiotherapy was given to 24 patients. For objective assessment, applanation tonometry was recorded when the desired breast volume was achieved, and 6 and 12 months later. This study showed that, regardless of the shape of the implant, the softness of the breast reconstruction was similar, as shown by the contact area of the applanation tonometry disc. Radiotherapy transiently reduced the softness of the breast.     

Update on one-stage immediate breast reconstruction with definitive prosthesis after sparing mastectomies

Immediate breast reconstruction after skin and nipple-sparing mastectomies is commonly performed as a two-stage procedure; to overcome the paradox of traditional two-stage tissue expander/implant reconstruction used to create a tight muscular pocket that needs expansion to produce lower pole fullness, while losing the laxity of the mastectomy skin flaps, the authors conceived a subpectoral-subfascial pocket by elevating the major pectoral muscle in continuity with the superficial pectoralis fascia up to the inframammary fold. This alteration allowed for the immediate insertion of the definitive implant.The authors present their experience in 220 cases of immediate one-stage breast reconstructions with definitive prostheses in sparing mastectomies. Immediate and long-term local complications were evaluated. Immediate breast reconstruction with definitive anatomical silicone-filled implants can produce excellent cosmetic results (78.6%) with a low rate of complications (17.7%); these results allow for agreement between oncologic, aesthetic and economic purposes.     

Objective evaluation of two differently-shaped permanent expander prostheses used for breast reconstruction.

When a breast is being reconstructed with an implant, a capsule of connective tissue always forms around the implant and a capsular contracture can develop. Radiotherapy increases the incidence of capsular contracture. To evaluate the results after breast reconstruction with differently-shaped textured implants, and the effect of radiotherapy on the softness of the reconstruction, 140 patients given permanent breast expander prostheses between 1994 and 2000 were studied. In 99 patients a round implant and in 41 an anatomically-shaped implant was used. Radiotherapy was given to 24 patients. For objective assessment, applanation tonometry was recorded when the desired breast volume was achieved, and 6 and 12 months later. This study showed that, regardless of the shape of the implant, the softness of the breast reconstruction was similar, as shown by the contact area of the applanation tonometry disc. Radiotherapy transiently reduced the softness of the breast.     

Elliptical breast reconstruction: an improved and simplified technique.

An improved and simplified postmastectomy reconstruction by tissue expansion is presented. Utilizing a uniquely designed matched tissue expander and prosthesis, the technique is based on an elliptical concept of breast shape and corresponding volumetric relationships and permits controlled expansion of the lower chest skin. Horizontal and vertical base dimensions and the volume of the contralateral breast are used to determine the size and volume of the appropriate elliptically shaped tissue expander and, subsequently, of the mammary implant. This approach permits surgeons to achieve symmetry more readily by matching the implant to the patient, rather than the patient to the implant.     

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.     

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.     

Acellular dermal matrices in breast surgery: tips and pearls

Acellular dermal matrices (ADMs) have been used for postmastectomy breast reconstruction, primary and secondary breast augmentation, and reduction mammaplasty. In postmastectomy breast reconstruction, ADMs can be used to either create an implant pocket in single-stage reconstruction or to create the inferolateral portion of the tissue expander pocket in two-stage reconstruction. Specific deformities after cosmetic breast augmentation such as contour irregularities and implant malposition can be addressed with ADMs. The use of ADMs is a safe alternative for the correction of breast deformities after reconstructive and aesthetic breast surgery.     

Treatment of tuberous breasts utilizing tissue expansion

This article presents the tissue expansion technique for the treatment of the tuberous breast and its variant, the tubular breast. The treatment objectives are different in the two deformities, but, in general, one has to expand the base circumference of the breast, expand the skin of the lower hemisphere of the breast, release the skin tightness at the skin-areola juncture, lower the position of the inframammary fold, increase the volume of the breast skin envelope, reduce the size of the areola and correct its deformity, and perform a mastopexy when necessary. To achieve these objectives, we use a tissue expander introduced either beneath the breast or beneath the pectoral muscle through an incision along the inframammary fold. It is slowly expanded to the appropriate volume. The reconstruction is completed at the second stage when the size of the areola is reduced, the expander is exchanged for an implant, or the fill-port is removed. The tissue herniation is corrected and a mastopexy is performed when necessary. We treated seven tuberous breasts and three tubular breasts by the two-stage method. Eight reconstructions were completed successfully in two stages. An additional operation became necessary in two cases; one to treat an exposed expander, and another to correct a capsular contracture. The results have been uniformly good and compare favorably with those presented in the literature done by other methods. We recomment use of the combination expander/implant.     

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。     

Reconstruction of a pendulous breast utilizing a shaped expander

Can a breast-shaped skin envelope that is pendulous be formed through the use of a shaped expander? Once formed, can its shape be maintained following the exchange of the expander for a round implant? My colleagues and I set out to answer these questions by constructing a breast-shaped expander by altering a standard round expander. It was introduced through an inframammary incision while performing a Pennisi-Ryan type reconstruction. The expander was placed in a limited pocket beneath the pectoralis major muscle. The lower pole of the expander was left in the subcutaneous plane. The skin expanded into a mature, pendulous breast shape that exhibited a slight degree of ptosis. The shape was maintained following the exchange of the expander for a high-profile round implant. If contracture occurred, the distortion detracted from the initial pleasing shape. We present our experience with the first 15 reconstructions using this method. The best results were seen in delayed reconstruction cases. The method is of no value in cases of primary reconstruction. Lessons learned from this small series of cases are detailed, and complications are discussed. The follow-up for these patients is a minimum of one year from the beginning of expansion.     

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.     

乳晕切口法解剖型假体隆乳术治疗轻度乳房下垂

目的探讨应用解剖型假体(又称泪滴型假体)隆乳术矫正轻度乳房下垂的可行性及临床效果。方法术前依据原乳房三维形态,测量胸乳距、乳房基底宽度、乳头至乳房下皱襞距离等数据,以确定所需采用的假体类型、容量及下垂乳房下皱襞距离,选用乳晕切口对36例轻度乳房下垂者应用麦格410解剖型假体行隆乳术。结果全部隆乳者术后乳房挺拔,下垂基本得到矫正,受术者均表满意。结论应用解剖型假体的隆乳术是目前矫正有增大乳房容积愿望的轻度乳房下垂者的最佳选择之一。     

Breast reconstruction with perforator-based inframammary de-epithelized flap: a case report

Patients with silicon gel-injected breasts sometimes appear even now, demanding removal of this foreign body. These requests are often challenging for us—the removal leaves distortion of the breast contour. Musclocutaneous flap transfer is a good method for reconstruction, but scar formation for flap harvest is a problem. Most patients are reluctant to accept these scars. Reconstruction with prostheses has been another method. But the absence of subcutaneous tissue and degenerated muscle make implantation difficult. For one of these patients, the authors applied a method for breast reconstruction with perforator-based inframammary flap. After the removal of the siliconoma with surrounding degenerated tissues, a crescent-shaped skin flap was designed on the inframammary area. Preserving perforators into the flap, it was elevated with adipose tissue. After the skin was de-epthelized, the adipose tissue and skin flap were turned over to make the breast protrusion. The donor site is closed primarily. Ten months after the operation, there was little atrophy of the reconstructed breast, and the patient is satisfied with the result, especially with the softness of the reconstructed breast. Although this method has limitation for volume, less morbidity for donor site and volume reduction in inframammary area are advantageous. In conclusion, this inframammary flap seems to be a good tool for breast surgery.     

Staged TRAM Breast Reconstruction: Combining the Advantages of Tissue Expansion with Surgical Delay

The TRAM flap has become the gold standard in breast reconstruction but suffers from the disadvantages of poor color match, different texture, and impaired sensation compared to the normal breast. This study reports on a two-stage procedure to address these problems. The first stage consists of insertion of a tissue expander and surgical delay of the TRAM flap. The second stage consists of removal of the tissue expander and transposition of a deepithelized TRAM flap into the tissue expanded cavity. (The capsule is excised.) Four cases of breast reconstruction are reported. The advantage of this procedure is that it offers the benefits of tissue expansion, viz., normal color match, texture, and sensation, and in addition, reconstruction is achieved with autologous tissue by a pedicled TRAM flap. The vascularity of the TRAM is enhanced by a surgical delay procedure.     

Textured Surface Silicone Breast Implants: Histology in the Human

Previous studies on the interaction of textured silicone breast implants has analyzed tissue expanders or used animal models. To date, the data on long-term results of the textured silicone breast implants have not examined permanent implants or in vivo effects in the human. A prospective study was designed to examine the interaction of textured silicone breast implants in a human over several years. A single surgeon, standard surgical technique, and single-type implant design were included. The results revealed 78% had silicone particles in the tissue immediately adjacent to the implant interface. No distant migration, metaplasia, or adverse effects were noted. Our results indicate that silicone fragmentation is common but appears to be confined to the local environment.