Breast Reconstruction Expander Implant


Article Author:
John-Paul Regan


Article Editor:
Adam Schaffner


Editors In Chief:
Tod Aeby


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Trevor Nezwek
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
4/10/2019 11:31:42 AM

Introduction

Breast reconstruction with implants was first described in the 1960s. It was initially a single staged placement of implant alone. It has now evolved into tissue expansion over several weeks to months with ultimately an exchange of the tissue expander for the permanent implant. They are common options for patients undergoing mastectomy because of the uncomplicated nature of the procedure which adds little extra time to the initial mastectomy. Patients can choose to have the expanders placed during the initial mastectomy or have the procedure as a delayed repair.[1]

Anatomy

Pertinent anatomy for the reconstruction is similar to that of the breast surgery itself. The position of the inferior mammary fold (IMF) is of critical importance to the reconstructive surgeon as it is a reliable landmark for how far to extend the envelope. Over dissection medially in the area of the sternum can cause symmastia. 

Indications

Most patients are candidates for expanders and implants. The ideal candidate is a thin female undergoing bilateral mastectomy or a thin female undergoing unilateral mastectomy with little to no ptosis on the remaining breast. This is simply for the benefit of symmetry. Obese patients and patients with very large contralateral breasts may complicate the results of the expander and implant. The expansion process may fail to obtain symmetry of the new breast pocket. The patient can undergo the procedure immediately following the mastectomy or in a delayed setting. The benefit of the immediate expansion is that the patient is undergoing two procedures but only one anesthesia administration. Also during immediate reconstruction, the plastic surgeon and breast surgeon can decide on the best technique to save as much of a skin envelope as possible. [2][3][4]

Contraindications

 With the increased use of radiation, careful patient selection for reconstruction needs to be undertaken. Placement of a tissue expander in patients who are undergoing concurrent radiation may fail to expand, have poor wound healing and have poor projection. Complication rates can be as high as 60% for tissue expanders are radiation. [5]

Patients who are active smokers are at high risk of infection and poor wound healing. These patients need to undergo counseling for smoking cessation. 

Equipment

Many surgeons will have multiple shapes and sizes of implants available while performing the surgery. The final decision as to which implant to use may be based on the pocket that is achieved during the dissection. Lighted retractors may add a benefit during dissection of tight post-pectoral pockets. 

Personnel

The surgeon may benefit from assistance during the procedure, but this is up to the discretion of the surgeon. 

Preparation

Patients should be educated on all their reconstructive options during their initial consultations. Many patients may even need to directed to survivorship group therapies prior to their procedure to gain insight on what to expect postoperatively. 

Antibiotics should be given during the immediate preoperative period to decrease the risk of contamination of the skin flora into the wound. 

Technique

The technique to create the submuscular pocket for expansion is similar regardless if the procedure is primary or delayed. If performed during the initial mastectomy, the skin flaps are used to access the inferior-lateral border of the pectoralis major. Taking care to keep the inferior mammary fold intact, the surgeon dissects the pectoralis major muscle away from the chest wall maintaining its attachments to the lateral sternal border. Many surgeons will augment the subpectoral pocket with the use of an acellular dermal matrix such as Alloderm. This may aid in the speed of expansion and decreased pain, but this is based on anecdotal information. A tissue expander is then placed into this subpectoral space, and the defect is closed.[5] These expanders have a port on the anterior side which is easily accessed in the clinic. A drain is then placed in the mastectomy pocket, and the skin closed. Tissue expansion occurs over weeks to months after the initial procedure with the intention to over-expand an envelope of tissue that will comfortably accommodate an implant. In the clinic setting, a magnetic marker is used to identify the subcutaneous port. Under sterile conditions, the tissue is expanded with saline. The patient is usually instructed to take over the counter NSAIDs to treat the pain associated with the expansion.[6] Expansion may concurrently occur while the patient is undergoing chemotherapy; however, the patient should wait until their white blood cell count has normalized to undergo their exchange to a permanent implant. Once tissue expansion is complete, the tissue expander is planned to be exchanged for a permanent implant. A thorough discussion with the patient is imperative to discuss their different options regarding what type of implant is best for them. [7]

Many different implants are available through the market. The implants are either smooth or textured, silicone gel or saline, and round or anatomically shaped. The benefits and risks of each should be discussed before proceeding. This portion of the procedure is straightforward; the previous incision is used to access the tissue expander, which is removed. If capsular contractures are present, a capsulectomy or capsulotomy can be performed at this time in order to achieve optimal symmetry. A disposable sizer may be used in order to identify the correct implant and achieve optimal base height, projection, and size. The implant of choice is carefully inserted into the pocket at this time taking care not contaminate it, and the pocket is closed. Further detailing such as moving the inferior mammary fold, fat grafting, or even contralateral mastopexy/mammoplasty can be performed at this time to obtain symmetry between the breasts.[8]

Implants do not increase the incidence of breast cancer. They are radiopaque which can cause difficulty on mammogram, therefore, additional views are necessary. It may be necessary to follow the patient with other studies such as sonography and MRI. 

Postoperative instructions and care are a vital resource to the patient. Patients should be instructed to avoid wearing bras with an underwire. Many surgeons will use surgical bras postoperatively to hold dressings in place and may augment this with a binding implant stabilizer to aid the position of the implant. Oral antibiotics are used at the discretion of the surgeon. 

Complications

Complications of tissue expanders and implants are similar to those of cosmetic implants. Care must be taken intraoperatively to achieve hemostasis. Hematomas have high rates of infections and can increase the chance of capsular contractures. Prompt removal of hematomas must be done once noted. Tissue expander and implant infection can lead to multiple procedures. Bleeding and infection are reported to occur at an incidence of 1% to 2%. [9]Skin flap necrosis can be devastating to patients and care must be taken to ensure adequate blood flow and not to be excessive when performing tissue expansion. Other complications can occur later down the line. Local complications are the most frequently encountered complications. These include skin rippling, capsular contracture, infection, and implant rupture. Follow up with these patients should be planned to monitor the implants.

Capsular contractures are a fibrotic scar that forms around the implant as a foreign body reaction. It causes tightening of the implant, may displace its location, make the breast feel firmer and can be painful. Contractures are graded based on the Baker grading scale. Baker Grade I is a normal, soft breast that appears to be in natural shape and size and therefore no discernable capsule is noted. Baker II is a slightly firm feeling implant with a normal appearance. Baker III is where the contracture causes the breast to firm and appears abnormal. In Baker IV, the breast is hard, distorted and painful. Surgical intervention should be considered for grade III and IV. It is difficult to maintain a Grade II to a Grade I; therefore, special consideration should be given to these patients. [10]

Recently, there has been a link with implants to T-cell Anaplastic Large Cell Lymphoma. Although most studies have been anecdotal, there seems to be linked to the textured implants because of the "salt-loss" technique causing chronic inflammation, bacterial biofilm or other causes which are unknown. This is a special area of interest at this time because fewer than 100 cases worldwide have been identified. [11]

Clinical Significance

Breast cancer patients are a specialized population, and the reconstructive surgeon has a wide variety of options to help the patients regain a sense of normalcy after their disfiguring surgery. Tissue expanders and breast implants play a key role in this. They are an easy option for many patients, and their use has been widely studied and described.  

Enhancing Healthcare Team Outcomes

Breast reconstruction is often done following breast cancer surgery. While the actual procedure is usually done by a plastic surgeon, the patient is often followed by a nurse practitioner or the primary care provider. Hence, it is important for these healthcare workers to know about the potential complications of the procedure. In addition prior to the procedure, they should advise the patient from discontinuation of smoking. In general, breast reconstruction is best done affter treatment for breast cancer is completed and the patient has no evidence of any residual cancer.


Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Breast Reconstruction Expander Implant - Questions

Take a quiz of the questions on this article.

Take Quiz
A 59-year-old female presents to the office complaining of swelling in the right breast. She underwent implant-based reconstruction of her right breast after mastectomy six years ago. On examination, she has a palpable fluid mass surrounding her intact implant. Which of the following laboratory results would be consistent with the Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL)?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 60-year-old female is referred to the office one year after total mastectomy of the right breast. She also underwent radiation to the right chest six months ago. She previously wore a 32 C bra and had a BMI of 29 kg/m2. She has no other surgical history. Which of the following is the least appropriate reconstructive option for this patient?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A patient is 2 weeks postop from a left mastectomy with immediate reconstruction using tissue expanders. She follows up in the office and notes that there is a 2x1 cm area of wound breakdown on the inferior portion of her breast. There is no evidence of exposed tissue expander or infection. Which of the following is the most appropriate management for this patient?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A patient with a tissue expander in her right breast returns to your office 6 hours after having her tissue expander filled. She complains of significant pain in her right chest. There is no evidence of infection or fluid collections, and the skin appears slightly blanched. Which of the following is the most appropriate management of this patient?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 48-year-old yoga instructor is referred to a plastic surgeon by her breast surgeon for her reconstructive options. She will be undergoing a bilateral mastectomy and will not require any adjuvant therapy. She is 5'8" with a BMI of 20. She currently wears a 32B bra. On examination, she is an extremely fit female with no previous abdominal surgical scars and negligible abdominal fat. What is her best option for breast reconstruction?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Breast Reconstruction Expander Implant - References

References

Are Prophylactic Postoperative Antibiotics Necessary for Immediate Breast Reconstruction? Results of a Prospective Randomized Clinical Trial., Phillips BT,Fourman MS,Bishawi M,Zegers M,O'Hea BJ,Ganz JC,Huston TL,Dagum AB,Khan SU,Bui DT,, Journal of the American College of Surgeons, 2016 Mar 4     [PubMed]
Age-dependent Characteristics in Women with Breast Cancer: Mastectomy and Reconstructive Trends at an Urban Academic Institution., Rodby KA,Robinson E,Danielson KK,Quinn KP,Antony AK,, The American surgeon, 2016 Mar     [PubMed]
Prosthetic breast reconstruction: indications and update., Quinn TT,Miller GS,Rostek M,Cabalag MS,Rozen WM,Hunter-Smith DJ,, Gland surgery, 2016 Apr     [PubMed]
Impact of Prior Tissue Expander/Implant on Postmastectomy Free Flap Breast Reconstruction., Roostaeian J,Yoon AP,Ordon S,Gold C,Crisera C,Festekjian J,Da Lio A,Lipa JE,, Plastic and reconstructive surgery, 2016 Apr     [PubMed]
Two-Stage Latissimus Dorsi Flap with Implant for Unilateral Breast Reconstruction: Getting the Size Right., Feng J,Pardoe CI,Mota AM,Chui CH,Tan BK,, Archives of plastic surgery, 2016 Mar     [PubMed]
Prophylactic use of pentoxifylline (Trental) and vitamin E to prevent capsular contracture after implant reconstruction in patients requiring adjuvant radiation., Cook M,Johnson N,Zegzula HD,Schray M,Glissmeyer M,Sorenson L,, American journal of surgery, 2016 Feb 22     [PubMed]
Locally Advanced Breast Cancer: Autologous Versus Implant-based Reconstruction., Tanos G,Prousskaia E,Chow W,Angelaki A,Cirwan C,Hamed H,Farhadi J,, Plastic and reconstructive surgery. Global open, 2016 Feb     [PubMed]
Analyzing Regional Differences over a Fifteen Year Trend of One-stage versus Twostaged Breast Reconstruction in 941,191 Post-Mastectomy Patients., Kamali P,Koolen PG,Ibrahim AM,Paul MA,Dikmans RE,Schermerhorn ML,Lee BT,Lin SJ,, Plastic and reconstructive surgery, 2016 Mar 16     [PubMed]
Optimizing Safety, Predictability, and Aesthetics in Direct to Implant Immediate Breast Reconstruction: Evolution of Surgical Technique., Kalus R,Swartz JD,Metzger SC,, Annals of plastic surgery, 2016 Mar 5     [PubMed]
Comparison of immediate postoperative pain in implant-based breast reconstructions., Gassman AA,Yoon AP,Festekjian J,Da Lio AL,Tseng CY,Crisera C,, Journal of plastic, reconstructive & aesthetic surgery : JPRAS, 2016 May     [PubMed]
Comparison of subcutaneous versus submuscular expander placement in the first stage of immediate breast reconstruction., Zhu L,Mohan AT,Abdelsattar JM,Wang Z,Vijayasekaran A,Hwang SM,Tran NV,Saint-Cyr M,, Journal of plastic, reconstructive & aesthetic surgery : JPRAS, 2016 Apr     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Ob Gyn-Medical Student. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Ob Gyn-Medical Student, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Ob Gyn-Medical Student, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Ob Gyn-Medical Student. When it is time for the Ob Gyn-Medical Student board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Ob Gyn-Medical Student.