eMedicine Specialties > Plastic Surgery > Breast

Breast Reconstruction, Expander-Implant

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
Luis O Vasconez, MD, FACS, Chief, Professor, Division of Plastic Surgery, University of Alabama at Birmingham

Updated: Oct 5, 2009

Introduction

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 they 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.^1,2

History of the Procedure

Silicone breast implants were introduced in the 1960s and offered the first opportunity to provide reconstruction of the breast following mastectomy. During those times, extirpative surgery resulted in significant breast deformities due to the more radical approaches used, and the breast implant allowed for really nothing more that the recreation of a breast mound. In the late 1970s, the latissimus dorsi myocutaneous flap was re-introduced and combined with implant placement to provide notably improved results in breast reconstruction.³ Rather than simply placing an implant beneath thin skin flaps, the latissimus muscle served to replace or even augment 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.⁴ 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 was needed by the permanent implant, which helped to create a degree of breast ptosis, resulting in a more natural-appearing breast mound. (For more information, see Uses of the Postoperatively Adjustable Implant in Aesthetic Breast Surgery.) Until recently, permanent saline expander-implants or saline expanders replaced by permanent saline implants had been used because of the difficulty in obtaining silicone implants.

In November 2006, the Food and Drug Administration (FDA) reversed the moratorium on the use of silicone gel-filled implants.^5,6 Objective and medically grounded information has confirmed the safety of using both silicone gel-filled and saline filled implants for breast reconstruction and aesthetic breast surgery.^7,8,9 (For more information, see Breast Implants, Safety and Efficacy of Silicone.) Most of the concern regarding the use of breast implants has focused on claims of a link between silicone and autoimmune diseases, a supposition now known to have no scientific foundation. Despite the 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.

Problem

The 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.

Options to improve coverage of the implant include the use of the latissimus dorsi muscle, which reduces capsular contracture and improves outcomes.¹⁰ The development of suitable biologic materials such as decellularized dermal matrices has given surgeons the means to provide coverage of implants and expanders.¹¹

Frequency

In 2008, more than 79,000 breast reconstructions were performed in the United States.¹² Some of these reconstructions were performed at the time of mastectomy, and some were performed on a delayed or elective basis. Delayed cases usually present with a distinct set of problems 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 breast prostheses filled with either silicone gel or saline. Of these, approximately 20% were placed for reconstructive procedures, while the remaining 80% were used in purely cosmetic cases.

Pathophysiology

Three concepts are essential to considering the problems that must be addressed to create symmetry in the reconstructed breast: the inframammary fold, ptosis, and projection.¹³ 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 is visually similar to the contralateral breast mound.

Indications

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. Patients with inadequate in-situ donor tissue who cannot tolerate the increased length of surgery required for either pedicled or free-tissue transfer reconstruction may be candidates for expander-implant procedures.¹⁴

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 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 Anatomy

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.

For a detailed discussion, see Breast Anatomy.

Contraindications

Because any patient who is undergoing immediate reconstruction following mastectomy is already a surgical candidate, contraindications to expander-implant reconstruction are few.¹⁵ 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; in these patients, autologous tissue reconstruction or a contralateral symmetry procedure is indicated.

Treatment

Surgical Therapy

The 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 Details

Preoperative 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.

Expander-implant breast reconstruction. Intraoperative photograph following bilateral skin-sparing mastectomy.

Intraoperative Details

Following 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. Care must be taken to preserve or recreate the inframammary fold, an important aesthetic landmark.¹⁶

Expander-implant breast reconstruction. Intraoperative view of site ready for implant.

Expander-implant breast reconstruction. Intraoperative view of implant in place and wound closed.

Postoperative Details

After 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.

Expander-implant breast reconstruction. Textured saline expandable implant with built-in port.

Expander-implant breast reconstruction. Anterior view 6 weeks after removal of expanders and replacement with implants covered by latissimus dorsi muscle flaps.

Expander-implant breast reconstruction. Lateral view 6 weeks after removal of expanders and replacement with implants covered by latissimus dorsi muscle flaps.

Follow-up

The incidence of locoregional recurrence is the same in breast cancer patients who undergo immediate, tissue expander/implant reconstruction as inpatients who do not undergo reconstruction.²⁰ Cancer surveillance after breast reconstruction should be performed; however, mammographic imaging of the mastectomy site does not increase the detection of locally recurrent breast cancer.^21,22 The presence of breast implants (placed for reconstructive or cosmetic purposes) does not interfere with mastectomy or breast reconstruction; however, they may compromise the outcome of breast conservation therapy.²³

For excellent patient education resources, see eMedicine's patient education articles Mastectomy, Breast Lumps and Pain, Breast Self-Exam, and Breast Cancer.

Complications

Exposure occurs most often at the site of the mastectomy scar, particularly if the implant is not fully covered with muscle. If the skin edges become necrotic, the wound can be treated with topical Betadine ointment. 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 usually 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. The latissimus dorsi is effective to prevent not only exposure but also capsular contracture in the irradiated breast reconstruction.^{24 25}

Malposition of the implant usually occurs because the implant is set too high at the initial 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 visualization is 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 flap has been used for coverage; 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 flap, 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 flap, no reoperation is indicated. 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 2 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, the complications themselves 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 Controversies

Various types of implants have been developed. Although the fill material (saline or silicone) is the greatest difference in implant types, surface (smooth and textured) and shape (round or anatomic-shaped) also vary. The use of saline facilitates adjustment of the implant size, particularly when the expander-implant prosthesis is used. 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.^22,26,27 Currently, experience with the use of anatomic or biodimensional breast implants is not sufficient to evaluate their efficacy.

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, the smooth round implants offer reliable results in most patients, 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 use of the acellular dermal matrix products offers an alternative.^28,29 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 radiation 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).³⁰

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.²⁶

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), ultrasonography, 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.²⁴

Multimedia

Media file 1: Expander-implant breast reconstruction. Intraoperative photograph following bilateral skin-sparing mastectomy.

Media file 2: Expander-implant breast reconstruction. Intraoperative view of site ready for implant.

Media file 3: Expander-implant breast reconstruction. Intraoperative view of implant in place and wound closed.

Media file 4: Expander-implant breast reconstruction. Textured saline expandable implant with built-in port.

Media file 5: Expander-implant breast reconstruction. Anterior view 6 weeks after removal of expanders and replacement with implants covered by latissimus dorsi muscle flaps.

Media file 6: Expander-implant breast reconstruction. Lateral view 6 weeks after removal of expanders and replacement with implants covered by latissimus dorsi muscle flaps.

References

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Keywords

breast reconstruction, expander implant, breast implants, breast surgery pictures, breast expander, breast implant expander, breast recon, implants, expanders, saline-filled implants, breast reconstructions, breast implant, implant-expander, breast expander implant, breast surgery, inframammary fold, latissimus dorsi, latissimus flap, silicone implant, saline implant, breast symmetry, breast asymmetry, contralateral symmetry, contralateral breast

Contributor Information and Disclosures

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, MD, FACS 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
Disclosure: Nothing to disclose.

Coauthor(s)

Luis O Vasconez, MD, FACS, Chief, Professor, Division of Plastic Surgery, University of Alabama at Birmingham
Luis O Vasconez, MD, FACS 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 Aesthetic Plastic Surgery, American Society for Head and Neck Surgery, American Society for Reconstructive Microsurgery, American Society for Surgery of the Hand, American Society of Maxillofacial Surgeons, and American Surgical Association
Disclosure: Nothing to disclose.

Medical Editor

Pankaj Tiwari, MD, Assistant Professor, Division of Plastic Surgery, Ohio State University
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Saleh M Shenaq, MD†, Former Director and Founder, The International Brachial Plexus Institute; Former Chief, Section of Plastic Surgery, Methodist Hospital, Houston
Saleh M Shenaq, MD† is a member of the following medical societies: American Academy of Anti-Aging Medicine, American Academy of Pediatrics, American Association for Hand Surgery, American Association for the Advancement of Science, American Association of Plastic Surgeons, American Burn Association, American College of Physician Executives, American College of Surgeons, American Congress of Rehabilitation Medicine, American Medical Association, American Society for Aesthetic Plastic Surgery, American Society for Reconstructive Microsurgery, American Society for Surgery of the Hand, American Society of Gene Therapy, American Society of Law Medicine and Ethics, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, American Trauma Society, Association for Academic Surgery, International College of Surgeons, Lipoplasty Society of North America, Plastic Surgery Research Council, Society for Neuroscience, Society of Surgical Oncology, Southern Medical Association, Texas Medical Association, and Texas Society of Plastic Surgeons
Disclosure: Nothing to disclose.

CME Editor

Nicolas (Nick) G Slenkovich, MD, Director, Colorado Plastic Surgery Center
Nicolas (Nick) G Slenkovich, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Society of Aesthetic Plastic Surgery, American Society of Plastic Surgeons, and Colorado Medical Society
Disclosure: Nothing to disclose.

Chief Editor

James Neal Long, MD, Assistant Professor of Plastic and Reconstructive Surgery, Division of Plastic Surgery, University of Alabama at Birmingham and Kirklin Clinics
James Neal Long, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Medical Association, American Society of Plastic Surgeons, Plastic Surgery Research Council, Sigma Xi, Southeastern Society of Plastic and Reconstructive Surgeons, and Southeastern Surgical Congress
Disclosure: Nothing to disclose.

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