Breast reconstruction with anatomical expanders and implants: our early experience

A Meta-analysis of Clinical, Patient-Reported Outcomes and Cost of DIEP versus Implant-based Breast Reconstruction

Comparative data on clinical outcomes and cost of deep inferior epigastric perforator (DIEP) and implant-based reconstruction (IBR) are limited. We conducted a Preferred Reporting Items for Systematic Review and Meta-analysis-compliant systematic review and meta-analysis to compare clinical, patient-reported outcomes (PROs) and cost.

A prospective analysis of dynamic loss of breast projection in tissue expander-implant reconstruction

Background

Breast projection is a critical element of breast reconstruction aesthetics, but little has been published regarding breast projection as the firm expander is changed to a softer implant. Quantitative data representing this loss in projection may enhance patient education and improve our management of patient expectations.

Methods

Female patients who were undergoing immediate tissue-expander breast reconstruction with the senior author were enrolled in this prospective study. Three-dimensional camera software was used for all patient photographs and data analysis. Projection was calculated as the distance between the chest wall and the point of maximal projection of the breast form. Values were calculated for final tissue expander expansion and at varying intervals 3, 6, and 12 months after implant placement.

Results

Fourteen breasts from 12 patients were included in the final analysis. Twelve of the 14 breasts had a loss of projection at three months following the implant placement or beyond. The percentage of projection lost in these 12 breasts ranged from 6.30% to 43.4%, with an average loss of projection of 21.05%.

Conclusions

This study is the first prospective quantitative analysis of temporal changes in breast projection after expander-implant reconstruction. By prospectively capturing projection data with three-dimensional photographic software, we reveal a loss of projection in this population by three months post-implant exchange. These findings will not only aid in managing patient expectations, but our methodology provides a foundation for future objective studies of the breast form.

Evolution and update on current devices for prosthetic breast reconstruction

Over the past decade, the leading breast reconstruction modality has shifted from autologous tissue to implants. This trend reversal is multi-factorial but includes increasing bilateral mastectomies and the more widespread acceptance of implants due to stringent quality and safety regulatory surveillance by the US Food and Drug Administration (FDA). Since 2012, the US FDA has approved several new implant styles, shapes and textures, increasing the choices for patients and surgeons. Predictable, superior aesthetic results after prosthetic breast reconstruction are attainable, but require thoughtful planning, precise surgical technique and appropriate device selection based on several different patient and surgeon parameters, such as patient desires, body mass index, breast shape, mastectomy flap quality and tissue based bio-dimensional assessment. This article briefly reviews historic devices used in prosthetic breast reconstruction beginning in the 1960s through the modern generation devices used today. We reflect on the rigorous hurdles endured over the last several decades leading to the approval of silicone gel devices, along with their well-established safety and efficacy. The various implant characteristics can affect feel and performance of the device. The many different styles and features of implants and expanders are described emphasizing surgical indications, advantages and disadvantages of each device.

Tabbed tissue expanders improve breast symmetry scores in breast reconstruction

Background

Achieving symmetry is a key goal in breast reconstruction. Anatomically shaped tabbed expanders are a new tool in the armamentarium of the breast reconstruction surgeon. Suture tabs allow for full control over the expander position and thus inframammary fold position, and, in theory, tabbed expanders mitigate many factors responsible for poor symmetry. The impact of a tabbed expander on breast symmetry, however, has not been formally reported. This study aims to evaluate breast symmetry following expander-implant reconstruction using tabbed and non-tabbed tissue expanders.

Methods

A chart review was performed of 188 consecutive expander-implant reconstructions that met the inclusion criteria of adequate follow-up data and postoperative photographs. Demographic, oncologic, postoperative complication, and photographic data was obtained for each patient. The photographic data was scored using a 4-point scale assessing breast symmetry by three blinded, independent reviewers.

Results

Of the 188 patients, 74 underwent reconstruction with tabbed expanders and 114 with non-tabbed expanders. The tabbed cohort had significantly higher symmetry scores than the non-tabbed cohort (2.82/4±0.86 vs. 2.55/4±0.92, P=0.034).

Conclusions

The use of tabbed tissue expanders improves breast symmetry in tissue expander-implant-based breast reconstruction. Fixation of the expander to the chest wall allows for more precise control over its location and counteracts the day-to-day translational forces that may influence the shape and location of the expander pocket, mitigating many factors responsible for breast asymmetry.

A novel quantitative measure of breast curvature based on catenary

Quantitative, objective measurements of breast curvature computed from clinical photographs could be used to investigate factors that impact reconstruction and facilitate surgical planning. This paper introduces a novel quantitative measure of breast curvature based on catenary. A catenary curve is used to approximate the overall curvature of the breast contour, and the curvature measure is extracted from the catenary curve. The catenary curve was verified by comparing its length, the area enclosed by the curve, and the curvature measure from the catenary curve to those from manual tracings of the breast contour. The evaluation of the proposed analysis employed untreated and postoperative clinical photographs of women who were undergoing tissue expander/implant (TE/Implant) reconstruction. Logistic regression models were developed to distinguish between the curvature of breasts undergoing TE/Implant reconstruction and that of untreated breasts based on the curvature measure and patient variables (age and body mass index). The relationships between the curvature measures of untreated breasts and patient variables were also investigated. The catenary curve approximates breast curvature reliably. The curvature measure contains useful information for quantifying the curvature differences between breasts undergoing TE/Implant reconstruction and untreated breasts, and identifying the effect of patient variables on the breast shape.

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.

Acellular dermis-assisted breast reconstruction with the use of crescentric tissue expansion: a functional cosmetic analysis of 40 consecutive patients

BACKGROUND

Crescentric tissue expanders have the potential to improve postoperative aesthetic results via selective lower pole expansion; however, limited data are available on their efficacy.

OBJECTIVES

The authors assess postoperative functional and cosmetic outcomes of acellular dermis-assisted breast reconstruction with crescentric tissue expansion.

METHODS

This study is a single-institution, retrospective review of 40 consecutive patients who underwent acellular dermis-assisted breast reconstruction with crescentric tissue expansion. Demographic data, operative details, and procedural outcomes were recorded and assessed. Cosmetic outcomes were assessed using the Breast Evaluation Questionnaire.

RESULTS

Fifty-eight breasts representing 36 bilateral and 22 unilateral reconstructions were analyzed. Of these, 45 (78%) underwent tissue expander (TE) to implant exchange. The mean interval between stage 1 and stage 2 was 92 +/- 20 days, with a total follow-up time of 141 +/- 16 days. The average intraoperative expander fill volume was 213.5 mL, with an average final fill of 285 mL (range, 180-740 mL). The average number of expansions was 1.6. Overall, there were five complications (8.6%). Eighty-three percent of patients participated in the breast evaluation questionnaire. Answers to each question were reported using a qualitative five-point scale that ranged from 1 (very dissatisfied) to 5 (very satisfied). For the bilateral reconstructions, the average score in all contexts was 4.5 +/- 0.3, 4.33 +/- 0.5, and 4.36 +/- 0.33 for size, shape, and firmness, respectively. For unilateral reconstructions, the average scores were 4.0 +/- 0.58, 3.93 +/- 0.38, and 4.13 +/- 0.21, respectively.

CONCLUSIONS

Crescentric expander-based reconstruction with acellular dermis assistance is well tolerated, especially in smaller breasted women. Functional and cosmetic outcomes were acceptable and comparable to previous reports of traditional expander-based reconstructions.

Post-mastectomy breast reconstruction: a history in evolution

Although the need for mastectomy has been evident for many years, postmastectomy reconstruction has been recognized as an achievable outcome for only a little over a century. A review of the evolution of both autologous and prosthetic options for reconstruction was undertaken. The earliest attempts at reconstruction used autologous techniques that were either unsuccessful, not reproducible, or were associated with significant morbidity. Prosthetic techniques became sought after, with silicone prostheses widely used until concerns about potential adverse effects led to the investigation of alternate options. With these concerns shown to be unfounded, silicone and saline prostheses evolved with successive generations of implants. Concurrent advances in reconstructive surgery led to a revival in autologous techniques for breast reconstruction, with microsurgical free-tissue transfer potentiating a new range of potential donor sites. The abdominal wall became the donor site of choice, and with the advent of perforator flaps, morbidity associated with flap harvest was minimized. In cases where the abdominal wall is unsuitable, flaps such as the superior and inferior gluteal artery perforator flaps, the musculocutaneous gracilis flap, and the "stacked" deep inferior epigastric artery perforator flap are frequently used options. The development of minimally invasive techniques for implant placement and flap harvest, such as endoscopy, continue to evolve, and research in tissue engineering offers a vision for a future without the need for a donor site.

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: complication rate and tissue expander type

BACKGROUND

Limited literature exists regarding complication rates among women undergoing breast reconstruction and the association of these rates with tissue expander types (anatomic, round and Becker).

METHODS

A historical cohort study investigated all breast reconstructions performed at Hadassah Medical Center for 140 consecutive women. Analyses were performed using both logistic and Poisson regression multivariate methods.

RESULTS

At least one major complication occurred in each of the following groups: anatomic (41%), round (20%), and Becker (11.7%) (p = 0.015). Women reconstructed with anatomic expanders were at increased risk for at least one complication (odds ratio [OR], 3.96; 95% confidence interval [CI], 1.18-13.3; p = 0.026) and an average increase of 331% (95% CI, 102-817%; p = 0.0002) in the number of major complications.

CONCLUSION

The results of this study suggest that integrated-valve expanders are associated with more complications than the distant inflation port. The benefits of an anatomic shape may perhaps be better exploited using devices with a distant port.

Les prothèses mammaires anatomiques en chirurgie esthétique et reconstructrice: une étude de 135 cas

The aim of this work is to precise the indications to respect and the pitfalls to avoid in prosthesis setting using anatomical cohesive silicone gel implants.135 patients that undergone a reconstructive or cosmetic prosthesis setting were reviewed. Patients satisfaction has been assessed basing on the breast shape, consistency and symmetry. Complications (both usual and specific) were assessed and analysed. The results for mammary reconstruction after expansion or autologous flap and for cosmetic submuscular breast augmentation were good. Complications were unusual as far as the appropriate surgical procedure had been performed rigorously. These implants are an interesting alternative solution to round shape prosthesis in reconstruction indication. In breast augmentation border line indications, a beautiful result may be expected using these implants.

Periareolar Skin-Sparing Mastectomy and Latissimus Dorsi Flap with Biodimensional Expander Implant Reconstruction: Surgical Planning, Outcome, and Complications

BACKGROUND

Although use of the latissimus dorsi myocutaneous flap associated with the Biodimensional anatomical expander implant system (McGhan 150) is a reliable technique, little information has been available regarding clinical outcome following periareolar skin-sparing mastectomy reconstruction. The purpose of this study was to analyze the feasibility of the technique, surgical planning, and its outcome following skin-sparing mastectomy.

METHODS

Thirty-two patients underwent immediate unilateral latissimus dorsi myocutaneous flap/Biodimensional anatomical expander implant system breast reconstruction. Mean follow-up was 18 months. The technique was indicated in patients with small- or moderate-volume breasts with or without ptosis, in whom the use of abdominal flaps was precluded. Flap and donor-site complications were evaluated. Information on anesthetic results and patient satisfaction was collected.

RESULTS

Seventy-two percent had tumors measuring 2 cm or less (T1) and 78 percent were stage 0 and I according to American Joint Committee on Cancer criteria. Breast skin complications occurred in 9.4 percent. Two patients presented small breast skin necrosis, and in one patient, a wound dehiscence was observed. Donor-site complications, all represented by seroma, occurred in 12.5 percent. The cosmetic result was considered good or very good in 84.4 percent, and the majority of patients were either very satisfied or satisfied. No local recurrences were observed. All complications except two were treated by conservative means.

CONCLUSIONS

The latissimus dorsi myocutaneous flap/Biodimensional anatomical expander implant system is a simple and reliable technique for periareolar skin-sparing mastectomy reconstruction. Success depends on patient selection, coordinated planning with the oncologic surgeon, and careful intraoperative and postoperative management.

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.

Reconstruction mammaire prothétique après expansion préalable prolongée. À propos de 247 cas

SUBJECT

The purpose of this study was to analyse the complications and the aesthetic results in case of slow tissue expansion in prosthetic breast reconstruction.

PATIENTS AND METHODS

We tracked 237 patients representing 247 mammary reconstructions operated between 1992 and 2004. These patients were distributed in two series, a series of 148 operated mammary reconstructions between 1992 and 2000 and a series of 99 reconstructions operated between 2001 and 2004. For every reconstruction, we analysed the progress of the expansion, the complications and the quality of the aesthetic results according to the radiotherapy and the type of implant used.

RESULTS

The radiotherapy increases the risk of failure of the breast reconstruction and degrades the quality of the aesthetic results. Capsular contractures are rare and their frequency does not depend on the irradiation. Prosthesis infections and exposure are more frequent on irradiated ground.

DISCUSSION

The tissue expansion in prosthetic breast reconstruction is a technique studied well in the literature, but few authors use a chronic expansion and compare the long-term results according to the radiotherapy. If our study confirms the noxious role of the radiotherapy as for the complications and for the aesthetic aspect of the results, it is not a question for us of an absolute contraindication. The weak rate of capsular contracture is attributable to the chronic character of the expansion, which allows the maturation of the capsule. The use of silicone gel implants decreases the deflations but does not improve the results.

CONCLUSIONS

The radiotherapy increases the risks of failure of the tissulaire expansion and decreases the quality of the aesthetic results. The chronic character of the expansion allows to obtain a rate of capsular contracture weak, even on irradiated ground. The silicone gel implants make it possible to obtain a perennial result.

Aesthetic breast reconstruction

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

Expandable anatomical implants in breast reconstructions: a prospective study

Following success with two-stage anatomical breast reconstructions, we started using expandable anatomical implants for breast reconstruction to achieve one-stage reconstruction. Sixty-three breast reconstructions were carried out with one-stage expandable anatomical implants over a period of 15 months, September 1995 to December 1996. To assess the performance of these implants, 20 patients with mean age 51.1 years (range 34-68 years), who were operated between February 1996 and June 1996, were entered into a prospective study. Overall, very satisfactory results were achieved, with a mean follow-up of 10.1 months (range 8-12 months). Minor complications were recorded in 3 patients and minor secondary adjustment was required in 7 patients.