IMMEDIATE BREAST RECONSTRUCTION IN TWO STAGES USING ANATOMICAL TISSUE EXPANSION

Over the last four years, 43 modified radical mastectomies and 13 simple mastectomies were done for 56 patients with breast cancer followed by immediate reconstruction in two stages using anatomical tissue expansion. In 49 patients a permanent prosthesis was successfully implanted while three patients refused a further operation, and four required removal of the expander. Complications were seen in 21 cases, including infection (n=4), Baker III-IV contractures (n=5), radiodermitis with breast distorsion (n=3), and seroma (n=2). Four patients required removal of the expander, and no further attempts were made to reconstruct the breast. All 10 patients given radiotherapy developed some kind of complication. After a mean follow up of 2.5 years (range 6-48 months), the aesthetic result was rated 6.9 and patient satisfaction 7.8 on a 0-10 scale. We concluded that immediate breast reconstruction with anatomical tissue expansion gives predictable aesthetic results, which satisfied most patients. Although the complication rate is high, it does not exceed complication rates associated with mastectomy alone or delayed reconstruction. At present, only patients undergoing preoperative or postoperative radiotherapy and hesitant patients are not considered to be candidates for this procedure.     

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.     

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.     

Areola-sparing mastectomy with immediate breast reconstruction

Skin-sparing mastectomy with immediate breast reconstruction is a proved option for patients with early-stage breast cancer requiring mastectomy. Based on the authors' recent pathologic analysis of mastectomy specimens showing less than 1% malignant involvement of the areola, they have begun to perform areola-sparing mastectomies (ASMs) on a select group of patients. They report their results from an ongoing study of ASM at their institution. During a 20-month period, 17 ASMs with immediate reconstruction were performed on 12 patients. Mastectomy was performed for breast cancer prophylaxis (n = 10), ductal carcinoma in situ (n = 4), and less than 2 cm of peripheral infiltrating carcinoma (n = 3). The most frequent incision performed was intraareola (n = 13). Thirteen patients were reconstructed with tissue expanders and 4 with pedicled transverse rectus abdominis musculocutaneous flaps. There was 1 postoperative complication, which consisted of a localized wound infection. Overall the authors found that ASM with immediate reconstruction provides excellent aesthetic results with infrequent complications.     

Radiotherapy and Immediate Expander/Implant Breast Reconstruction: Should Reconstruction be Delayed?

Chest wall irradiation is very common for mastectomy patients that have opted for immediate breast reconstruction. We reviewed a 6 year experience with tissue expander implant reconstruction with and without radiotherapy in 97 patients. All patients were evaluated with respect to aesthetic outcome, infection, implant exposure, capsular contracture, displacement and failure of the reconstruction; more than 50% of our irradiated patients resulted in a complication. The findings of this study demonstrate that the rate of complications and the rate of patients requiring corrective surgeries in irradiated patients is significant in early follow up.     

Results of immediate breast reconstruction after skin-sparing mastectomy

Skin sparing mastectomy (SSM) removes the breast, nipple-areolar complex, previous biopsy incisions, and skin overlying superficial tumors. Preservation of the native skin envelope facilitates immediate breast reconstruction. The procedure has been adopted for the treatment of breast cancer. All cases of SSM and immediate breast reconstruction performed by the senior author (G.W.C.) from January 1, 1993, through December 12, 1997, were reviewed. Patient demographics, cancer staging, treatment, types of surgery performed, and postoperative outcomes were examined. Aesthetic outcomes were measured using four 3-point subscales. A total of 100 patients underwent 118 SSMs during the study period. The American Joint Committee on Cancer staging was as follows: stage 0, 27 patients; stage I, 25 patients; stage II, 39 patients; stage III, 7 patients; stage IV, 3 patients; recurrent, 2 patients; and cystosarcoma phylloides, 1 patient. The mean follow-up was 42.7 months. Local recurrence occurred in 2 patients (2.7%). Reconstructive methods included the transverse rectus abdominis musculocutaneous flap (N = 82; pedicled, 73; free, 9), the latissimus flap (N = 18), and tissue expansion (N = 20). Two patients underwent contralateral delayed reconstruction. The aesthetic results achievable with the three methods were similar. The failure rate was higher for expander reconstruction (10%) than those observed for transverse rectus abdominis musculocutaneous (4.9%) and latissimus (5.6%) flaps. SSM can be used in the treatment of invasive breast cancer without compromising local control. The aesthetic results of the three methods were similar, but tissue expander reconstruction had a higher failure rate.     

Single-stage immediate breast reconstruction using a skin-sparing incision and definitive saline implants compared with a two-stage reconstruction using tissue expansion plus implants

BACKGROUND:

Losing a breast to cancer has significant psychological ramifications, and it has been shown that minimizing this loss can have a profound impact. As a result, breast-conserving therapy or mastectomy followed by breast reconstruction have become the preferred surgical treatments for breast cancer. Limited available breast skin following mastectomy has traditionally necessitated the use of autologous tissue or tissue expansion; however, when reconstructing larger breasts, autologous tissue grafts rarely provide enough tissue and tissue expanders can often take several months to achieve the necessary tissue volume. The skin-sparing mastectomy offers a solution to this lack of skin, and as a result many new options for immediate breast reconstruction have presented. The present pilot study looks at a new method of immediate breast reconstruction involving a Wise pattern skin-sparing mastectomy with placement of a definitive, submuscular saline implant as a way to maintain a large breast size without requiring the patient to undergo a long and painful tissue expansion process.

METHODS:

A retrospective, case-control study was performed on 12 women who had undergone bilateral mastectomies with immediate reconstruction either with a tissue expander and later placement of definitive saline implant (control group) (n=5) or who had undergone a single-stage reconstruction involving the placement of a definitive submuscular saline implant (experimental group) (n=7). Patients were compared with respect to change in breast size, number of reoperations and operations in total, as well as satisfaction with their reconstruction.

RESULTS:

Patient satisfaction in both groups was relatively high and there was no statistically significant difference found between the two groups. The experimental group decreased in bra size by 1.4 cup sizes on average whereas the control group experienced no change on average; however, one-third of patient data had to be discarded for various reasons, making the change in size measurement inconclusive. Finally, the average number of reoperations was higher in the experimental group than the control (1.57 versus 1.00); however, the total number of operations required was less (2.57 versus 2.80).

CONCLUSIONS:

Immediate breast reconstruction using a definitive submuscular saline implant is a viable option for reconstruction in women with larger breasts that deserves further study on a larger scale. Although limited by sample size, the present pilot study showed, with a large effect size, that this new procedure reduces the total number of operations required for reconstruction when compared with a tissue expander followed by an implant while maintaining an equally high level of patient satisfaction.     

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.     

Technical aspects of immediate breast reconstruction with implants: five year follow-up.

We describe the technical aspects of 249 patients who had immediate breast reconstruction with implants and a follow-up of at least five years. The type of reconstruction was permanent expander prostheses (n=208), permanent prostheses (n=32), and temporary expander prostheses (n=9). The median total number of operations required to complete the reconstruction was 3 (range 1-6) with nipple-reconstruction included. Thirty-two patients developed local complications (13%) and three had systemic complications (1%). Eighteen implants were lost, so the failure rate of reconstruction was 7%. The technique of immediate breast reconstruction with implants is associated with a low overall morbidity. This, combined with earlier reported psychological advantages, no increased risk of cancer relapse, and reasonable cost, indicates the importance of immediate reconstruction with implants in the treatment of breast cancer.     

Tissue expander with acellular dermal matrix for breast reconstruction infected by an unusual pathogen: Candida parapsilosis

Infections occur in approximately 2-5% percent of women undergoing breast reconstruction by tissue expansion depending on patient characteristics and timing of reconstruction. Bacteria, specifically Staphylococci, are the most common pathogens. Treatment varies depending on the surgeon and the aggressiveness of the infection. We report a case of unilateral tissue expander infection with Candida parapsilosis in an otherwise healthy female undergoing immediate tissue expander placement after bilateral nipple-sparing mastectomies. The patient was treated with a one-stage irrigation, debridement, and tissue expander exchange as well as a 21-day course of oral antifungal therapy. Her infection resolved and she was able to complete her implant-based reconstruction. C. parapsilosis is usually responsible for infections in critically ill patients found in association with central lines, peritoneal dialysis catheters and prosthetic heart valves. The affinity of C. parapsilosis for foreign material makes it a causative agent worth considering in difficult to treat tissue expander infections.     

Lateral intercostal artery perforator flap used in salvage of exposed tissue expander of breast: case report

Management of an exposed tissue expander in breast reconstruction patients remains a challenging problem. For large defects that cannot be repaired primarily, local flap options are limited. In this case report, we describe the use of lateral intercostal artery perforator (LICAP) flap in salvage of an exposed tissue expander of a patient who had delayed immediate breast reconstruction after mastectomy. The postoperative recovery was uneventful and tissue expansion followed by radiotherapy was well tolerated by the flap. We believe this is the first article to describe the use of LICAP flap in salvage of an exposed tissue expander of the breast due to mastectomy flap necrosis in the early postoperative period.     

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.     

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 reconstruction with tissue expanders: obtaining an optimal result.

A large personal experience with breast reconstruction using tissue expanders (149 patients with Radovans, and more than 150 patients with Beckers), with many suboptimal results especially in the early learning stages, has brought about changes in approach offering a much higher probability of acceptable breasts. This report attempts to combine multiple factors useful in yielding such results. Areas addressed include immediate versus delayed reconstruction, selection of candidates, selection of expander type, appropriate placement of expander at a site minimizing the requirement for pocket modification, choosing the optimal size expander, importance of maximal overexpansion to yield a good submammary fold, and means of determining adequate overexpansion to match an unmodified contralateral breast and the risks inherent in overexpansion. Timing, interval, and length of maintenance of hyperexpansion are described along with deflation and timing of port removal. Both the skate and star techniques of nipple and areolar reconstruction in the hyperexpanded patient yield very acceptable results despite thinned skin and minimal subcutaneous tissue. Good, satisfactory, and suboptimal clinical results will be presented. In our experience, tissue expansion reconstruction offers distinct advantages in a large majority of patients with the proviso that patients are willing to accept the time required for hyperexpansion and the waiting period for deflation.     

Skin-sparing mastectomy flap complications after breast reconstruction: review of incidence,management, and outcome

This study assesses the incidence and outcome of skin-sparing mastectomy (SSM) flap complications after breast reconstruction. The authors performed a retrospective review of 37 consecutive patients undergoing SSM and immediate breast reconstruction, focusing on preoperative demographics, management of complications, and early outcome. Univariate analysis comparing patients with and without complications was performed using Student's t-test and chi-square analysis. From July 2000 to December 2001, 37 patients (mean age 48.1, range 24-71 y) underwent SSM and breast reconstruction (unilateral 20, bilateral 17) via TRAM flaps (n = 18), latissimus flaps (n = 13), and expander/implants (n = 6). SSM flap complications occurred in nine patients (24.3%) and included mild (n = 2), moderate (n = 5), and severe (n = 2) skin loss, resulting in four cases of dehiscence, five reoperations, and no delay in postoperative adjuvant therapy (required in six patients). Previous irradiation (n = 5, p = 0.045) and diabetes (n = 3, p = 0.001) were associated with SSM flap complications, but age, smoking, previous breast cancer, and type of reconstruction were not. Patients with SSM flap loss had a higher body mass index (BMI) than those without complications (30.0 vs. 24.3; p = 0.025). Skin flap complications after SSM and breast reconstruction are not uncommon but did not delay the initiation of adjuvant chemotherapy or radiotherapy, despite the need for reoperation. Patients with elevated BMI, diabetes, and previous irradiation may be at increased risk for SSM flap complications.     

Skin-sparing mastectomy and immediate breast reconstruction: a prospective cohort study for the treatment of advanced stages of breast carcinoma

Background Recent published series demonstrate the safety and effectiveness of skin-sparing mastectomy (SSM) with immediate reconstruction for the treatment of early-stage breast carcinoma. Although several reports have retrospectively evaluated outcomes after breast reconstruction for locally advanced disease (stages IIB and III), no study has specifically considered immediate breast reconstruction after SSM for locally advanced disease. Methods From 1996 to 1998, 67 consecutive patients with breast carcinoma underwent SSM with immediate reconstruction and were prospectively observed. From this group of patients, those with locally advanced disease (stage IIB, n=12; stage III, n=13) were analyzed separately. Tumor characteristics, adjuvant therapy, type of reconstruction, operative time, complications, hospital stay, and incidence of local recurrence and distant metastasis were noted. Results Breast reconstruction consisted of a transverse rectus abdominis myocutaneous flap (n=22) or a latissimus flap plus an implant (n=4). The median operative time was 5.5 hours; the average hospital stay was 5.2 days. Complications required reoperation in three patients (12%): partial skin flap necrosis in two and partial abdominal skin necrosis in one. Surgery on the opposite breast for symmetry was required in one patient (4%). Postoperative adjuvant therapy was not significantly delayed (median interval, 32 days). With a median length of follow-up of 49.2 months (range, 33–64 months), local recurrence was present in only one patient (4%), with successful local salvage treatment, and distant metastasis was present in four patients (16%). Conclusions SSM with immediate reconstruction seems safe and effective and has a low morbidity for patients with advanced stages of breast carcinoma. Local recurrence rates and the incidence of distant metastasis are not increased compared with those of patients who have had modified radical mastectomies without reconstruction.     

Impact of neoadjuvant chemotherapy on rate of tissue expander/implant loss and progression to successful breast reconstruction following mastectomy

PURPOSE: We examined the frequency and causes of tissue expander (TE) and permanent implant (PI) reconstruction failure in patients undergoing neoadjuvant chemotherapy. METHODS AND MATERIALS: Charts were reviewed from 120 patients with clinical stage II/III breast cancer enrolled between 2004 and 2007 into a prospective clinical trial of neoadjuvant chemotherapy. Patient demographics, tobacco use, radiation treatment, and data relating to the loss of TE, as well as progression to PI and PI loss, were collected. RESULTS: Of 120 patients, 61 underwent 75 mastectomies. Twenty-six patients had 34 TEs placed at the time of mastectomy. Eleven (32%) TEs required removal prior to definitive reconstruction. Fourteen (41%) TEs successfully progressed to PI exchange. Four of the PIs required removal. TE loss occurred most frequently due to infection and extrusion. Radiation, smoking history, or elevated body mass index (BMI) did not significantly affect reconstruction loss. CONCLUSION: Thirty-eight percent of immediate TEs or PI placements at the time of mastectomy failed to progress to definitive reconstruction in patients receiving neoadjuvant therapy, suggesting that reconstruction with TEs or PI reconstruction should be used cautiously in this patient population.     

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。     

Breast reconstruction by tissue expander after radiotherapy: When the skin does not expand,the rib cage is at risk

Background

Expander-based breast reconstructions in irradiated chest walls have been documented to result in an increased risk of complications including skin necrosis, extrusion, displacement, and capsule contracture. In this article, thoracic cage deformity and rib fractures were investigated following breast reconstruction by tissue expansion.

Methods

A prospective series of 89 immediate postmastectomy tissue expander breast mound reconstructions in 81 patients, the patients were divided into two groups, reconstruction with radiotherapy (n?=?37) and without radiotherapy (n?=?52). The patients were observed for any sudden severe pain and development of capsule contracture; intraoperative assessment was done first during expander insertion then after exchange of expander with implant to detect any deformity of the chest wall. CT scans were done as an objective way to support the clinical findings in patients who developed flat or concave chest wall deformities.

Results

Patients who had reconstructions with radiotherapy developed severe capsular contractures causing severe pain and limitation in breast expansion in 35 % of reconstructions compared with 5.7 % in the control group. Twenty-six reconstructions (70.2 %) in the study group developed chest wall deformities; in four of them, the deformity was concave, and two patients (5.4 %) developed multiple rib fractures at the expander site. The overall rate of ribcage deformities in the control group was 32.6 %; all of them were simple flattening with no concave deformities. No fractures were noted in the control group.

Conclusions

Expander-based breast reconstruction in combination with radiotherapy and tight unyielding overlying skin and capsule can redirect the expansion force toward the thoracic ribcage rather than the skin causing rib deformities and possible fractures. Level of Evidence: Level IV, risk/prognostic study