Expander-Implant Breast Reconstruction Treatment & Management

Updated: Feb 18, 2016
  • Author: Jorge I de la Torre, MD, FACS; Chief Editor: James Neal Long, MD, FACS  more...
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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.

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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.

An intraoperative photograph is shown below.

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

An intraoperative photograph is shown below.

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

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 puncture of the implant during filling, yet left in an inconspicuous area that facilitates removal. As indicated previously, acellular dermal matrices can be used to provide coverage of the implant below the caudal edge of the pectoralis muscle. The dermal matrix is attached to the caudal border of the pectoralis major and then sutured to the inframammary fold, creating a sling for the implant. [17, 18]

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.

A view after wound closure is shown below.

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

An implant is shown below.

Expander-implant breast reconstruction. Textured s Expander-implant breast reconstruction. Textured saline expandable implant with built-in 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. [19]

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. Some reports describe the use of a single implant expander allowing a single-stage reconstruction. [20]

Postoperative photos are shown below.

Expander-implant breast reconstruction. Anterior v 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 vi Expander-implant breast reconstruction. Lateral view 6 weeks after removal of expanders and replacement with implants covered by latissimus dorsi muscle flaps.
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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. [21, 22] 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. [23, 24] 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. [25]

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

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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. [26, 27]

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.

A study by Woo et al indicated that in nonobese patients undergoing expander-implant breast reconstruction, mastectomy weight and adjuvant radiation are independent risk factors for complications. The study, which included 397 immediate expander-implant breast reconstructions (367 patients), reported an association between a 100 g increase in mastectomy weight and a 23% greater risk of overall complications, major complications, and skin flap complications and a 28% greater risk of seroma. Adjuvant radiation was associated with reconstruction failure. [28]

A study by Chen et al indicated that in patients undergoing immediate expander-implant breast reconstruction, preoperative external beam radiation therapy increases the risk of reconstruction failure. The study included 76 patients, with the reconstruction failure rate being 13.3% in patients who underwent no external beam radiation therapy, versus 50.0% in the preoperative radiation patients and 26.3% in those who underwent postoperative radiation. [29]

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.

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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. [24, 30, 31] 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. [32, 33] 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.

The use of expander-implants for immediate breast reconstruction and subsequent radiation of the chest wall has been evaluated. [34] 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). [35]

Another study of patients who underwent immediate reconstruction with expander-implants found a significantly higher rate of grade III and IV capsular contractures in irradiated breasts than in nonirradiated ones (21.7% vs 10%, respectively). Moreover, the chance of major complications was greater in the irradiated group (odds ratio of 4.2). However, the revision rate in the irradiated breasts was less than that in those that did not undergo postmastectomy radiation therapy (20.9% vs 30.2%). The investigators concluded that in the irradiated breasts, the capsular contracture rate was acceptable and the revision rates unexpectedly low, making immediate breast reconstruction with expander-implants a reasonable option even in patients undergoing radiation treatment. [36]

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. [30]

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. [26]

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