Expander-Implant Breast Reconstruction Treatment & Management

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. ^[22]

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. ^[23]

An intraoperative photograph is shown below.

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. ^[24]

An intraoperative photograph is shown below.

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. ^{[25, 26, 23, 27]}

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.

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.

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. ^[28]

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. ^[29]

Postoperative photos are shown below.

A study by Min et al found that in contrast to the use of a previous incision for replacement of an expander with a breast implant, the use of an inframammary fold incision for this purpose was associated with no cases of implant removal due to dehiscence or indeed any cases of wound dehiscence at all. ^[30]

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. ^{[31, 32]} 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. ^{[33, 34]} 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. ^[35]

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

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. ^{[36, 37]}

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.

A study by Chen et al indicated that in patients who undergo two-stage breast reconstruction, a larger distance between the nipple and the inframammary fold and, in patients treated with postoperative radiation, a faster tissue-expander enlargement rate reduce the likelihood of capsular contracture. The investigators found the risk of contracture to be greater in patients with a nipple–inframammary fold distance of under 10.5 cm and an enlargement rate below 240 mL/mo, although the impact of the enlargement rate was significant only in persons who had undergone postoperative radiation therapy. ^[53]

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. ^[38]

A retrospective study by Manahan et al indicated that in women who undergo expander-implant breast reconstruction, the chance of infection is significantly increased by the presence of seroma, older age, larger mastectomy volume, smoking, vascular disorders, and hypertension, with a patient’s body mass index also influencing risk. The overall patient complication rate in the study was 30%, with infection occurring in association with 14% of tissue expanders. ^[39]

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. ^[40]

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.

A longitudinal, multicenter, prospective cohort study by Bennett et al indicated that in patients undergoing postmastectomy reconstruction, the expander-implant technique is associated with lower 2-year complication rates than other procedures. The study evaluated women who had undergone reconstruction with the expander-implant technique, direct-to-implant (DTI) technique, latissimus dorsi (LD) flap, pedicled transverse rectus abdominis myocutaneous (pTRAM) flap, free transverse rectus abdominis myocutaneous (fTRAM) flap, deep inferior epigastric perforator (DIEP) flap, or superficial inferior epigastric artery (SIEA) flap.

The investigators reported that the odds of developing any complication were significantly higher for the autologous reconstruction procedures than for the expander-implant technique. It was also found that compared with the expander-implant method, the odds for reoperative complication were greater in all flap procedures except LD flap reconstruction. Moreover, the odds for infection were not significantly lower in any of the autologous reconstruction techniques, with the exception of the DIEP flap procedure, than in expander-implant reconstruction. However, the failure rate for the expander-implant and DTI techniques (7.1%) was higher than for the pTRAM flap (1.2%), fTRAM flap (2.1%), DIEP flap (1.3%), LD flap (2.8%), and SIEA flap (0%) procedures. ^[41]

In contrast to the above report, a study of 294 immediate breast reconstructions by Riggio et al found that the major complication rate associated with expander-based surgery was 12.5%, compared with 4.3% for DTI treatment. No clinical variables were found to be significantly associated with DTI complications, but multivariate analysis indicated that radiotherapy and body mass index have a significant impact on major complications in expander-based reconstruction. ^[42]

A study by Dicuonzo et al indicated that whether a women undergoes breast reconstruction with a permanent implant or with a temporary expander that is subsequently exchanged with a permanent implant, postsurgical radiotherapy increases the risk of reconstruction failure. While such risk was apparently no greater in the expander-implant group than in the permanent implant patients, the investigators found that radiotherapy in patients with an expander was associated with a shorter time to failure than was radiation treatment to patients who underwent reconstruction with the permanent implant alone (109.2 mo vs 157.7 mo, respectively). ^[43]

A study by Park et al indicated that in patients who have undergone immediate expander-implant breast reconstruction, contralateral augmentation mammaplasty can lead to higher complication rates in the reconstructed breast. In comparing patients who underwent contralateral revision with those who did not, the complication rates for the reconstructed breast were found to be 13.5% and 6.5%, respectively, while revision operation rates for the reconstructed breast after the second stage of reconstruction were 9.0% and 3.0%, respectively. ^[44]

Although textured breast implants have been associated with the development of breast implant–associated anaplastic large cell lymphoma (BIA-ALCL), a single-institution, retrospective study by Nelson et al suggested that temporary, short-term exposure to a textured tissue expander poses less risk of BIA-ALCL’s occurrence. The report looked at 3310 patients, in whom 5201 textured tissue expanders were employed for an average of 6.7 months; these were subsequently replaced with smooth implants. At average 6.8-year follow-up, the investigators found no cases of BIA-ALCL. ^[54]

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.

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. ^{[34, 45, 46]} 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. ^{[47, 48]} 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. ^{[49, 50]} 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). ^[51]

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. ^[52]

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. ^[45]

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. ^[36]