You are in: eMedicine Specialties > Plastic Surgery > BREAST Breast Reconstruction, Expander-ImplantArticle Last Updated: Dec 19, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 10
  Author: Jorge I de la Torre, MD, FACS, Professor of Surgery and Physical Medicine and Rehabilitation, Residency Program Director, Division of Plastic Surgery, University of Alabama at Birmingham; Director, Center for Advanced Surgical Aesthetics Jorge I de la Torre is a member of the following medical societies: American Association of Plastic Surgeons, American Burn Association, American College of Surgeons, American Medical Association, American Society for Laser Medicine and Surgery, American Society for Reconstructive Microsurgery, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, Association for Academic Surgery, and Medical Association of the State of Alabama Coauthor(s): Luis O Vasconez, MD, FACS, Chief, Professor, Division of Plastic Surgery, University of Alabama at Birmingham Editors: Geoffrey L Robb, MD, Chair, Professor, Department of Plastic Surgery, University of Texas MD Anderson Cancer Center; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Saleh M Shenaq, MD†, Former Director and Founder, The International Brachial Plexus Institute; Former Chief, Section of Plastic Surgery, Methodist Hospital, Houston; Nicolas (Nick) G Slenkovich, MD, Practice Director, Colorado Plastic Surgery Center at Swedish Medical Center; Al Aly, MD, FACS, Consulting Surgeon, Iowa City Plastic Surgery Author and Editor Disclosure Synonyms and related keywords: implants, expanders, saline-filled implants, breast reconstruction, breast implant INTRODUCTIONSection 2 of 10
  The goal of breast reconstruction is to recreate symmetric natural-appearing breasts while preserving patient safety and quality of life. Many techniques exist for breast reconstruction but rarely do these produce true symmetry with the contralateral breast. The safety of the patient is essential and always should remain the primary concern in reconstructive procedures. These procedures should be tailored to the individual patient, taking into account the ultimate aesthetic outcome and the impact the reconstruction may have on the patient's lifestyle. History of the ProcedureSilicone breast implants were introduced in the 1960s and offered the first opportunity to provide reconstruction of the breast following mastectomy. The extirpative surgery resulted in significant breast deformity, and the breast implant allowed recreation of a breast mound. In the late 1970s, the introduction of the latissimus dorsi myocutaneous flap provided improved results for breast reconstruction using the silicone implant. Instead of placing an implant under the thin skin flaps, using the latissimus muscle allowed replacement or augmentation of the pectoralis muscle to provide coverage of the implant. Radovan's subsequent introduction of tissue expanders allowed the implant to be placed beneath the residual skin and muscle while uninflated. Once the skin and muscle flaps recovered from the trauma of surgery and could tolerate the stress, the implants were inflated. This spared additional injury to the chest wall tissues and permitted overinflation of the expander. More volume was placed in the expander than needed by the permanent implant, which helped to create a degree of breast ptosis, resulting in a more natural-appearing breast mound. Permanent saline expander-implants or saline expanders replaced by permanent saline implants are currently used because, in the United States, silicone implants can be difficult to obtain. Since the Food and Drug Administration (FDA) issued a moratorium on the use of silicone gel-filled implants, the use of these implants as well as saline filled implants have raised concerns. Currently both types are available for postmastectomy reconstruction. Most of the concern regarding the use of breast implants has focused on claims of a link between silicone and autoimmune diseases. This affects both the silicone gel-filled implants and the saline filled implants, which also have a shell made of silicone elastomer. According to the American Society for Aesthetic Plastic Surgeons, both the FDA (1999) and the Institute of Medicine (1999) have indicated that no definitive evidence links breast implants to cancer, immunologic diseases, neurologic problems, or other systemic diseases. Despite the scientific data supporting the safety of breast implants, careful informed patient consent concerning these issues as well as other potential complications (see Complications) is essential prior to any procedure involving implants or expanders. ProblemThe use of expander-implants can lead to unsatisfactory outcomes if proper coverage of the implant is not obtained. Often, the only available coverage is a thin layer of skin and subcutaneous tissue. This predisposes to the formation of capsular contracture, producing an unnatural round breast mound. By ensuring that sufficient vascularized soft tissue is provided to cover the implant, capsular contracture is less likely, and, ideally, the excess skin and muscle redrapes in a shape that simulates the normal ptotic breast. FrequencyIn 2001, more than 81,000 breast reconstructions were performed in the United States, and approximately one third of these were performed at the time of mastectomy. The remaining two thirds were performed on a delayed or elective basis. These delayed cases can present a different set of criteria when determining options for reconstruction. Since the introduction of breast implants in 1962, approximately 1.5-2 million women in the United States have undergone procedures to place either silicone gel or saline filled implants breast prostheses. Of these, approximately 20% were placed for reconstructive procedures, while the remaining 80% were used in purely cosmetic cases. PathophysiologyThree concepts are essential when considering the problems that must be addressed to create symmetry in the reconstructed breast: the inframammary fold, ptosis, and projection. The inframammary fold is an important landmark that frequently is disrupted or destroyed by modified radical mastectomy. Ptosis is the natural teardrop shape of the breast that occurs with the effect of gravity on the normal breast tissue and usually is lost when a noncompressible saline implant is placed beneath the skin. Projection is the anteroposterior fullness of the breast; projection also can be diminished when expander-implants are used. Achieving an aesthetic outcome requires that each of these elements must be adequate and similar to the contralateral breast mound. INDICATIONSSection 3 of 10
Factors that can help determine whether expander-implant reconstruction is appropriate include the quality of the overlying skin, the condition of the pectoralis and serratus muscles, and available donor tissue for autologous reconstruction. Regarding patients with inadequate donor tissue, those who cannot tolerate the increased length of surgery required for either pedicled or free-tissue transfer reconstruction are candidates for expander-implant procedures. In addition, patients who are undergoing bilateral reconstruction but are otherwise candidates for transverse rectus abdominus muscle (TRAM) reconstruction may be considered for implant/expander reconstruction to avoid the morbidity of using both rectus muscles. Patients who are undergoing delayed reconstruction likely may require prolonged expansion to create a sufficient skin envelope for placement of the implant unless a latissimus dorsi flap with overlying skin is used to cover the implant. RELEVANT ANATOMYSection 4 of 10
The anatomic borders of the breast mound are the level of the second rib superiorly, the inframammary fold at the seventh rib inferiorly, the lateral border of the sternum medially, and the midaxillary line laterally. The breast parenchyma is within the superficial fascia of the chest wall superficial to the pectoralis major, serratus anterior, and superior portion of the rectus sheath. The arterial supply includes the internal mammary artery, posterior intercostal arteries, and lateral thoracic and thoracoacromial arteries. Venous return is primarily via the axilla and secondarily via the internal thoracic and posterior intercostal perforating branches. Most lymphatic drainage is to the axillary nodes. Sensory innervation of the breast is supplied by cutaneous branches of the second through sixth intercostal nerves. CONTRAINDICATIONSSection 5 of 10
Because any patient who is undergoing immediate reconstruction following mastectomy is already a surgical candidate, contraindications to expander-implant reconstruction are few. Implant reconstruction is contraindicated in patients who have insufficient skin, soft tissue, and muscle to cover the prosthesis. This population is better suited for an implant covered by a latissimus dorsi flap. If muscle coverage is sufficient but skin coverage is limited, an expander can be placed and inflated over time to create a proper skin envelope. An additional relative contraindication is significant ptosis of the contralateral breast. Implants are unable to achieve a natural ptotic appearance and either autologous tissue reconstruction or a contralateral symmetry procedure is indicated. TREATMENTSection 6 of 10
Surgical TherapyThe options for breast reconstruction using either implants or expanders include the use of a temporary tissue expander exchanged for a permanent implant following serial expansion, permanent expander-type implant requiring only valve removal following full expansion, and latissimus dorsi muscle flap for coverage of an implant or expander Preoperative DetailsPreoperative planning requires evaluation of the patient in the upright position. Breast ptosis, projection, and the location of the inframammary fold should be identified. The size of the tissue expander to be used is established by determining the base width and height of the intact breast and then allowing for overinflation of an additional one third of breast volume. Ideally, the planned incision of the oncologic procedure is delineated if a standard periareolar skin-sparing mastectomy is not an option. If autologous coverage for the implant, such as the latissimus dorsi, is to be used, the donor site also should be marked. Routine preoperative precautions, such as antibiotic prophylaxis and deep vein thrombosis (DVT) prevention therapies, should be used as needed. Intraoperative DetailsFollowing completion of the mastectomy, a submuscular pocket is created for placement of the implant. The pocket is created deep to the pectoralis major and the serratus anterior. The submuscular pocket can be entered by releasing the inferior origin of pectoralis major muscle and dividing the junction between the pectoralis major and serratus muscles. The implant is placed to allow the superior two thirds of the implant to be covered by muscle; however, the inferior portion is usually left subcutaneous. The integrity of the inframammary fold is maintained as an important aesthetic landmark. If an isolated fill port is used, it should be positioned far enough from the implant to avoid inadvertent injury during filling, yet left in an inconspicuous area that facilitates removal. If a skin-sparing mastectomy has been performed, the reconstructive surgeon must evaluate the skin margins and resect any that do not appear viable. The skin then can be closed in layers. Following complete expansion, the expander-implant is removed through a lateral incision of the mastectomy scar to expose the junction between the pectoralis major muscle and the periprosthetic capsule. The capsule is opened and the expander is delivered. If adjustments to the capsule pocket are needed, they are performed using the lighted retractor and electrocautery. The permanent implant is inserted and filled with saline. The wound should be closed in layers to minimize the appearance of rippling. Postoperative DetailsAfter the operative site has healed, 4-6 weeks after surgery, expansion can be initiated. Saline is injected using either the surface port of the expander-implant or the distant port. Additional saline can be injected to achieve rapid expansion but minimize complications. Factors that must be considered while expanding include skin tightness, blanching, and patient discomfort. The injection port can be placed in either the lower lateral thoracic position or, as has recently been described, in the parasternal position to facilitate the aesthetic outcome and decrease discomfort during needle placement or expansion. Once the expander volume matches the contralateral breast, an additional 30-35% of volume should be added. This enlarges the implant pocket to help create a more natural ptotic breast. Removal of the expander and exchange for a permanent implant are delayed 8-12 weeks following complete expansion to prevent tissue recoil. Follow-upFor excellent patient education resources, see eMedicine's patient education articles Mastectomy, Breast Lumps and Pain, Breast Self-Exam, and Breast Cancer. COMPLICATIONSSection 7 of 10
Exposure occurs most often at the site of the mastectomy scar, particularly if the implant is not successfully covered with muscle. If the skin edges become necrotic, the wound can be treated with Betadine. The wound either contracts and heals or progressively worsens. If intact muscle, such as a latissimus flap or a portion of the pectoralis, is present, the implant can be successfully left in place. If the muscle has retracted and the implant becomes exposed, removing the implant is preferable. If the reconstruction has been performed without the latissimus dorsi myocutaneous flap, the exposed implant should be removed and a delayed secondary reconstruction can be performed using the latissimus dorsi. Malposition of the implant usually occurs because the implant is placed too high at surgery, and subsequent capsular contracture brings the implant even higher on the chest wall. Once this occurs, lowering the implant using nonoperative methods is difficult. The operative approach consists of dividing the capsule inferiorly and extending the pocket at least 2-3 cm below the desired postoperative level so that as the capsular contracture reforms, the implant remains at the proper level. In patients in whom the implant has been placed too low and the inframammary line is lower than the contralateral normal one, manual elevation and taping can successfully elevate the inframammary fold to the proper level. An effective but hazardous approach is the percutaneous closure of the excessive inferior pocket. This technique risks puncture of the implant and should be avoided. If taping and nonoperative methods fail, reopening the incision and then closing the pocket under direct vision are preferable. A few nylon sutures are placed at the proper level to promote adherence of the capsule. Removal of the remainder of the capsule is not necessary. In almost every patient, a certain amount of capsular contracture is expected and occurs. Severe capsular contracture (ie, Baker classes 3 and 4) does not occur as often when the latissimus dorsi myocutaneous unit has been transposed; however, it is much more common if reconstruction involves minimal subcutaneous coverage. In a patient who has undergone reconstruction with an expander and without the benefit of the latissimus dorsi myocutaneous unit, treatment of capsular contracture should include this transposition as a secondary procedure. Conversely, in a patient who develops an asymptomatic capsular contracture despite having had a latissimus dorsi myocutaneous unit, not reoperating is preferable. More often than not, open capsulotomies or capsulectomies are followed by reformation of thicker capsules. Comparison of immediate reconstruction and delayed reconstruction using implants has indicated that no significant difference exists in capsular contraction in the two groups. Infection is relatively rare in patients with implants. When it occurs, removing the implant is best. Although the literature indicates that an implant can be salvaged by continuous irrigation of saline and antibiotic solution, with increased hospitalization cost, this method of treatment is not cost-effective; it is better to remove the implant, support the patient, and wait a minimum of 6 months before undertaking another reconstruction. The occurrence of complications using expander/implants can exceed 40% in published studies. However, despite a significant rate of complications, these are usually minor and do not prevent completion of a satisfactory reconstruction. In experienced hands, good to excellent aesthetic outcomes can be obtained in more than 80% of patients. Note that all modalities of breast reconstruction usually require multiple procedures to achieve the final outcome; however, the use of implants may actually decrease the number of procedures needed. This may be partly attributed to complications at the donor site in autologous reconstruction. FUTURE AND CONTROVERSIESSection 8 of 10
A variety of implant types have been developed. Although the fill material (saline or silicone) is the greatest difference in implant types, both smooth and textured surfaces and either round or anatomic-shaped implants exist. The use of saline facilitates adjustment of the implant size, particularly when the expander-implant prosthesis is used. The silicone-filled implants provide a more natural feel and shape but may be less accepted by the public. Controversies exist over whether textured or smooth implants are best. Currently, experience with the use of anatomic or biodimensional breast implants is not sufficient to evaluate their effectiveness. Because a capsule forms around the implant as it contracts, the surface area becomes smaller. Since the volume remains the same, the teardrop shape of the implants becomes spherical. A certain degree of spherical shape of the reconstructed breast must be accepted. To mask asymmetry, a small implant can be placed in the contralateral breast to create upper pole fullness. In the authors' opinion, in most patients, the smooth round implants offer reliable results, particularly when covered by a thick chest wall flap or a latissimus dorsi flap. Another problem that can present in patients who have permanent implants placed is the development of visible implant rippling. Patients with very thin skin are prone to this problem. Increasing utilization of the acellular dermal matrix products offers an alternative. This dermal matrix has been demonstrated to incorporate with surrounding breast tissue. It can be used either to cover the implant completely or to provide extension of the muscle coverage, whether the latissimus or pectoralis muscle is used. This limited soft tissue coverage can be performed with a minimal increase in operative time and decreases morbidity as compared with more extensive procedures. Recently, the use of expander-implants for immediate breast reconstruction and subsequent irradiation of the chest wall has been evaluated. While the rate of capsular contracture formation is higher than in the nonirradiated breast, patient satisfaction remains high. Cordeiro and colleagues indicated that expander-implants in nonirradiated breasts resulted in acceptable aesthetic outcomes in 88% of patients compared to 80% in the irradiated group (P = not significant). The safety of implants with regard to postoperative cancer surveillance is another area of controversy. While patients with implants have demonstrated no increased risk of carcinogenesis, the implants themselves may preclude satisfactory radiologic evaluation for breast cancer. Most of the literature on this topic is from the early 1990s and was gleaned from patients who had silicone implants placed for breast augmentation. More recent information indicates that even in patients who have silicone implants placed over the breast tissue, use of mammography (74% accuracy) and perhaps more importantly ultrasonography (91% accuracy) can yield effect cancer surveillance. In addition, following breast reconstruction, diagnostic evaluation with tools such as fine needle aspiration (FNA), ultrasound, and MRI can be helpful to distinguish palpable masses from fatty necrosis (in autologous tissue reconstruction) and to identify silicone implant failure. However, others have indicated that the use of mammography is unnecessary in the reconstructed breast. In general, routine postmastectomy surveillance, including physical examination, should suffice in patients who have undergone implant-expander reconstruction. MULTIMEDIASection 9 of 10
REFERENCESSection 10 of 10
Breast Reconstruction, Expander-Implant excerpt Article Last Updated: Dec 19, 2006 | ||||||||||||||||||||||||||||||||||||||||||
