Immediate Breast Reconstruction with Tissue Expanders

Complications and patient satisfaction following expander/implant breast reconstruction with and without radiotherapy

PURPOSE

To compare the rates of complications and patient satisfaction among breast cancer patients treated with mastectomy and tissue expander/implant reconstruction with and without radiotherapy.

METHODS AND MATERIALS

As part of the Michigan Breast Reconstruction Outcome Study (MBROS), breast cancer patients undergoing mastectomy with reconstruction were prospectively evaluated with respect to complications, general patient satisfaction with reconstruction, and esthetic satisfaction. Included in this study was a cohort of women who underwent breast reconstruction using an expander/implant (E/I). A subset of these patients also received radiotherapy (RT). At 1 and 2 years postoperatively, a survey was administered which included 7 items assessing both general satisfaction with their reconstruction and esthetic satisfaction. Complication data were also obtained at the same time points using hospital chart review. Radiotherapy patients identified in the University of Michigan Radiation Oncology database that underwent expander/implant reconstruction but not enrolled in the MBROS study were also added to the analysis.

RESULTS

Eighty-one patients underwent mastectomy and E/I reconstruction. Nineteen patients received RT and 62 underwent reconstruction without RT. The median dose delivered to the reconstructed breast/chest wall, including boost, was 60.4 Gy (range, 50.0-66.0 Gy) in 1.8- to 2.0-Gy fractions. With a median follow-up of 31 months from the date of surgery, complications occurred in 68% (13/19) of the RT patients compared to 31% (19/62) in the no RT group (p = 0.006). Twelve of 81 patients (15%) had a breast reconstruction failure. Reconstruction failure was significantly associated with experiencing a complication (p = 0.0001) and the use of radiotherapy (p = 0.005). The observed reconstruction failure rates were 37% (7/19) and 8% (5/62) for patients treated with and without radiotherapy, respectively. Tamoxifen was associated with a borderline risk of complications (p = 0.07) and a significant risk of reconstruction failure (p = 0.01). Sixty-six patients of the study group completed the satisfaction survey; 15 patients did not. To offset potential bias for patients not completing the survey, we analyzed satisfaction data assuming "dissatisfaction" scores for surveys not completed. In the analysis of patients with unilateral E/I placement, reconstruction failure was significantly associated with a lower general satisfaction (p = 0.03). Ten percent of patients experiencing a reconstruction failure were generally satisfied compared to 23% who completed E/I reconstruction. In addition, tamoxifen use was associated with a significantly decreased esthetic satisfaction (p = 0.03). Radiotherapy was not associated with significantly decreased general or esthetic satisfaction.

CONCLUSION

Irradiated patients had a higher rate of expander/implant reconstruction failure and complications than nonirradiated patients. Despite these differences, our pilot data suggest that both general satisfaction and patient esthetic satisfaction were not significantly different following radiotherapy compared to patients who did not receive RT. Although statistical power was limited in the present study and larger patient numbers are needed to validate these results, this study suggests comparable patient assessment of cosmetic outcome with or without radiotherapy in women who successfully complete expander/implant reconstruction.

Immediate breast reconstruction after mastectomy for cancer

BACKGROUND

Immediate breast reconstruction after mastectomy has increased over the past decade following the unequivocal demonstration of its oncological safety and the availability of reliable methods of reconstruction. Broadly, it is undertaken in the treatment of breast cancer, after prophylactic mastectomy in high-risk patients, and in the management of treatment failure after breast-conserving surgery and radiotherapy. Immediate breast reconstruction can be achieved reliably with a variety of autogenous tissue techniques or prosthetic devices. Careful discussion and evaluation remain vital in choosing the correct technique for the individual patient.

METHODS

This review is based primarily on an English language Medline search with secondary references obtained from key articles.

RESULTS AND CONCLUSION

Immediate breast reconstruction is a safe and acceptable procedure after mastectomy for cancer; there is no evidence that it has untoward oncological consequences. In the appropriate patient it can be achieved effectively with either prosthetic or autogenous tissue reconstruction. Patient selection is important in order to optimize results, minimize complications and improve quality of life, while simultaneously treating the malignancy. Close cooperation and collaboration between the oncological breast and reconstructive surgeons is desirable in order to achieve these objectives.

The premature removal of tissue expanders in breast reconstruction

The role of tissue expanders in breast reconstruction is well established. Little information exists, however, regarding the incidence and etiology of premature removal of the tissue expander before planned exchange to a permanent breast implant. The purpose of this study was to review our 10-year experience with tissue expander breast reconstruction and identify factors relating to the premature removal of the tissue expander. This study is a retrospective review of 770 consecutive patients who underwent breast reconstruction with tissue expanders over the past 10 years. Breast reconstruction was immediate in 90 percent of patients. Patients were expanded weekly, and adjuvant chemotherapy was begun during the expansion process when required. Factors potentially affecting premature expander removal (chemotherapy, diabetes, obesity, radiation therapy, and smoking) were evaluated. Fourteen patients (1.8 percent) with a mean age of 47 years (range, 38 to 62 years) required premature removal of their tissue expander. Expanders were removed a mean of 3.2 months (0.1 to 8 months) after insertion. Causes for premature removal of the tissue expander included infection (7 patients), exposure (2), skin necrosis (2), patient dissatisfaction (2), and persistent breast cancer (1). Positive wound cultures were obtained in four of the seven infected patients (57 percent), requiring expander removal for infection. Tissue expanders were removed in 11 patients for complications directly related to the expander. Among these, six (55 percent) were receiving adjuvant chemotherapy, and one was a smoker. Diabetes, obesity, other concomitant medical illnesses, and prior mantle irradiation were not associated with expander removal. Premature removal of the tissue expander was required in only 1.8 percent of the patients in this series. Infection was the most common complication necessitating an unplanned surgical procedure to remove the expander. This study demonstrates that the use of tissue expanders in breast reconstruction is reliable, with the vast majority of patients completing the expansion process.

Aesthetic results and patient satisfaction with immediate breast reconstruction using tissue expansion: a follow-up study

Immediate breast reconstruction with the tissue expander is now established as an accepted procedure after mastectomy, and large series have been published concerning the technique and its complications. Unfortunately, only scarce information is available regarding the long-term aesthetic results and patient satisfaction achieved by immediate reconstruction using tissue expansion. In this study, we reviewed 52 patients who had undergone immediate breast reconstruction using the tissue expander with a follow-up of at least 1 year after completion of the reconstruction. We developed an objective assessment of patient satisfaction, aesthetic results, and the factors affecting them. The results show remarkable concordance of assessment by patient, surgeon, and independent observer: All gave good scores for aesthetic appearance (6.4 to 7.4 on a scale of 1 to 10). A total of 92.3 percent of patients rated their satisfaction as good to excellent. Symmetry was the main parameter influencing the patients' score, while the surgeon's score also was affected by the quality of the inframammary fold and capsular contracture. Breast size, chemotherapy, complications, time interval, and additional procedures had no relation to either scoring or patient satisfaction.

Achieving symmetry in the tissue-expanded breast reconstruction

Breast reconstruction has become such a commonplace procedure over the last ten years that we as plastic surgeons are no longer content to simply create a mound. Today's goal is to create a mound that not only looks like a breast, but also matches the opposite breast. The most commonly used procedures today include simple augmentation if adequate tissue exists, flap reconstruction with either the latissimus dorsi or the tram, and, finally, tissue expansion. Each technique has its own highlights and pitfalls. It is the purpose of this article to deal only with tissue expansion and to present a simple technique to produce symmetry with the opposite breast.

Late results and current indications of latissimus dorsi breast reconstructions

One hundred and fifty latissimus dorsi flaps were used in 145 patients out of a series of 483 breast reconstructions performed from 1977 to 1988. There were few immediate complications and a durable, good cosmetic result was obtained in two-thirds of the 103 cases reviewed after at least one year. The main reasons for dissatisfaction with long-term results were capsular contracture (grades III and IV) and upper displacement of the implant. The rate of these late complications was 30%, the same as found in the simpler subpectoral reconstruction. However, prostheses with a thick outer envelope induced only 10% of severe capsular contracture. Reconstructions with autologous tissue are currently replacing latissimus dorsi flap reconstructions unless local or general conditions contraindicate such major surgery or when the patient lacks motivation.

The use of tissue expanders in immediate breast reconstruction following mastectomy for cancer

From April 1985 to March 1987, 50 women had 56 mastectomies for documented cancer. A tissue expander was used for immediate reconstruction in each case. The patient records were used to determine morbidity and mortality, as well as to examine the effect of reconstruction on adjuvant therapy, cancer surveillance, adequacy of cancer surgery and patient satisfaction. The patients were followed up for an average of 13 months. Fifty-two of 56 expanders were successfully replaced with a permanent prosthesis. Forty-seven women remain alive. Local or regional recurrence did not occur in any women within the study period. Complications, of which superficial skin necrosis was most common, occurred in 35% of reconstructions and were investigated critically. Patient satisfaction was high. Dissatisfaction was not related to the incidence of complications but rather appeared to reflect the success of the patient's cancer treatment.

The use of tissue expansion for immediate breast reconstruction after mastectomy

A series of 139 patients who had a total mastectomy underwent breast reconstruction using the method of tissue expansion. In 127 patients a tissue expander was inserted at the time of mastectomy and in 12 patients this was done as a delayed procedure. The reconstruction was successfully completed in 87% of cases and the patient acceptance of this method of reconstruction has been high. We believe that tissue expansion should be offered to all women having immediate reconstruction after total mastectomy and that it also has a significant role in delayed breast reconstruction after mastectomy.

Tissue expansion and skin circulation. Simultaneous monitoring by laser Doppler flowmetry and transcutaneous oximetry

The skin circulation was examined in nine patients during filling of their breast expander prostheses. Despite the high expansion pressure, which was increased above the systolic blood pressure, the overlying skin showed good circulation both clinically and when measured with a laser Doppler flowmeter and a transcutaneous oximeter. We conclude that the expansion was therefore directed to the tissues between the expander and the skin--that is, the fibrous capsule surrounding the prosthesis. Nine subcutaneous tissue expanders located in different anatomical regions were overfilled to a pressure at which all skin circulation ceased. Sufficient saline was then removed to allow skin circulation to return. Oxygenation of the skin ceased at a relatively low pressure when measured by transcutaneous oximetry, whereas when the skin circulation was measured with a laser Doppler flowmeter it did not disappear until the expander pressure had been raised appreciably above that level.