An improved technique for creation of the inframammary fold in silicone implant breast reconstruction.

A "lipo-fascial" flap is described for creation of the inframammary fold in patients undergoing breast reconstruction with silicone implants. We have employed this technique in 13 patients. The fold has been enhanced in all cases, and we have not encountered any significant complications. This technique is a useful adjunct to breast reconstruction with a silicone implant, and we recommend that it be considered in appropriate patients.     

Breast reconstruction by superior gluteal microvascular free flaps without silicone implants

The author's experience with 10 gluteus maximus myodermal free flap breast reconstructions is reviewed against the current methods of reconstruction using silicone implants, latissimus dorsi flaps, regional skin flaps, and rectus abdominis myodermal flaps. The superior gluteal free flap can achieve a reliable, permanent, and aesthetic reconstruction of the breast without silicone implants. The softness, projection, natural appearance, and patient satisfaction are excellent compared with other methods. It is particularly useful in patients who object to the use of artificial implants, are not suitable for regional flaps, or have disappointing results from previous reconstructions. Technical modifications of the flap design and selection of the recipient vessels are important.     

The silicone gel-filled breast implant controversy: an update

Learning Objectives: After studying this article, the participant should: 1. Be familiar with the medical uses of silicone. 2. Have a working knowledge of the most important epidemiologic studies regarding silicone gel-filled breast implants. 3. Be aware of the issues about which patients desiring breast augmentation or reconstruction with implants must be counseled.     

Eighty-four consecutive breast reconstructions using a textured silicone tissue expander.

Breast reconstruction utilizing smooth-surface silicone tissue expanders is associated with certain problems. Significant capsular contracture may develop around the expander with subsequent expander displacement necessitating repositioning or capsulectomy at the time of expander removal. Infection, pain on expansion, chest-wall compression, and complications related to the remote fill valve also have been reported. A textured-surface silicone expander with an integrated fill valve was developed to address these issues. Eighty-four consecutive breast reconstructions were performed by a single surgeon using textured expanders in 55 patients. Intraexpander pressures were measured during expansion for a group of these patients, and both initial and postinflation pressure readings were quite low (average initial pressure 2.88 mmHg; average postinflation pressure 12.87 mmHg). Eighty-one of the reconstructions have been completed without any expander losses and with minimal complications. Tissue expander volume averaged 580 cc, and the expansion duration averaged 5.6 months. Various types and configurations of permanent implants were used to complete the reconstructions. Eighty-four percent of our patients' completed reconstructions (including nippleareola reconstruction and opposite breast alteration, when necessary) were accomplished with just two procedures. Seventeen long-term adjustable textured-surface expander/implants with anatomic breast shape are still in place, all after only one operation. The inframmary fold has generally been established passively by the expansion process alone. Textured-surface silicone expanders have stayed where positioned, have expanded easily with minimal patient pain, and have created a noncontractile soft-tissue cover for the final implant. The textured expander with an integrated fill valve has simplified breast reconstruction by helping to limit the problems encountered with smooth silicone expanders. The resulting reconstructions have remained soft with a very acceptable aesthetic appearance. The patient office and hospital charts and photographs of this consecutive series were notarized and submitted to the Editor of this Journal, whose biostatistician randomly selected the cases illustrated.     

Salvage of infected expander prostheses in breast reconstruction

Periprosthetic infection is a devastating complication following breast reconstruction with prostheses. Traditional surgical principles dictate removal of the prosthesis to control infection. Although successful salvage of prostheses in the presence of periprosthetic infections has been reported in the plastic and other surgical literature, salvage procedures remain seldom practiced. Reports in the plastic surgery literature have been limited to implant salvage following cosmetic breast augmentation and subcutaneous mastectomy with implants. Salvage of saline-filled expander prostheses used in breast reconstruction following mastectomy for cancer has not been previously reported. The authors review their experience with implant salvage in patients with periprosthetic infections following breast reconstruction for a 6-year period. Fourteen patients (13 with saline-filled expander prostheses and one with silicone prosthesis) underwent implant salvage. Salvage of the breast reconstruction was successful in nine patients. Staphylococcus aureus infection was associated with poorer salvage rate (p = 0.023). Previous radiotherapy to the chest wall did not affect the salvage outcome (p = 0.50). In selected patients, immediate salvage of a breast reconstruction in the presence of prosthesis-related infection remains an alternative to implant removal followed by delayed reconstruction.     

Reasons why mastectomy patients do not have breast reconstruction

Breast reconstruction after mastectomy is valuable, yet only a small percentage of eligible patients ever have reconstruction. Little has been done to determine why so few patients proceed with reconstructive surgery. A homogeneous population of mastectomy patients, some of whom underwent breast reconstruction while others did not, were surveyed regarding their attitudes about breast reconstruction. A total of 245 women were surveyed. One-hundred and fifty-eight (64 percent) responded, 71 of whom had been reconstructed while 87 had not. Comparison of the responses of the two groups suggests factors that play a role in determining whether the mastectomy patient will accept or decline the option of breast reconstruction. Considerations that made it less likely that a woman would pursue reconstruction included advanced age at the time of mastectomy, concern about complications from further surgery, uncertainty about outcome, and fear about the effect of reconstruction on future problems with breast cancer. Marital status, receiving chemotherapy, or knowing a patient who had a bad result from reconstruction did not affect the decision. An awareness and understanding of these factors may be helpful to physicians in counseling patients and in increasing the number of women who enjoy the benefits of breast reconstruction.     

Breast reconstruction using an inflatable breast implant with detachable reservoir

An inflatable breast implant having a detachable filling reservoir is described. Once in position, the implant can be filled under controlled conditions postoperatively. The implant functions either as a tissue expander or as a delayed-filling implant in the initial stages of the procedure. Once the desired breast size is achieved, the reservoir is removed, leaving the filled implant in position. This implant has been used successfully in various types of breast reconstructive procedures, including both primary and secondary reconstruction following modified mastectomy, immediate reconstruction following subcutaneous mastectomy, secondary reconstruction following radical mastectomy combined with the latissimus dorsi flap, and following the removal of silicone gel implants with associated capsular contracture. A total of 23 patients, representing 34 breasts, are reported on. The results have been encouraging over a period of 20 months of follow-up.     

Management of first trimester breast enlargement with necrosis.

We describe our management of two patients who had massive breast enlargement with necrosis in the first trimester. First, a therapeutic abortion was done to stop the breast growth, then we skin grafted the large ulcerated areas on the breasts, and finally we did a simple mastectomy with silicone gel implants for reconstruction. The latter procedure was to prevent almost certain recurrence of the problem during any succeeding pregnancy.     

Functional MRI To Evaluate “Sense of Self” following Perforator Flap Breast Reconstruction

Background

Breast reconstruction is associated with high levels of patient satisfaction. Previous patient satisfaction studies have been subjective. This study utilizes functional magnetic resonance imaging (fMRI) to objectively evaluate “sense of self” following deep inferior epigastric perforator (DIEP) flap breast reconstruction in an attempt to better understand patient perception.

Methods

Prospective fMRI analysis was performed on four patients before and after delayed unilateral DIEP flap breast reconstruction, and on four patients after immediate unilateral DIEP flap breast reconstruction. Patients were randomly cued to palpate their natural breast, mastectomy site or breast reconstruction, and external silicone models. Three regions of interest (ROIs) associated with self-recognition were examined using a general linear model, and compared using a fixed effects and random effects ANOVA, respectively.

Results

In the delayed reconstruction group, activation of the ROIs was significantly lower at the mastectomy site compared to the natural breast (p<0.01). Ten months following reconstruction, activation of the ROIs in the reconstructed breast was not significantly different from that observed with natural breast palpation. In the immediate reconstruction group, palpation of the reconstructed breast was also similar to the natural breast. This activity was greater than that observed during palpation of external artificial models (p<0.01).

Conclusions

Similar activation patterns were observed during palpation of the reconstructed and natural breasts as compared to the non-reconstructed mastectomy site and artificial models. The cognitive process represented by this pattern may be a mechanism by which breast reconstruction improves self-perception, and thus patient satisfaction following mastectomy.     

Autologous fat graft in nipple reconstruction

Reconstruction of the nipple is the penultimate step in breast reconstruction after mastectomy. A number of reconstructive techniques have been described for nipple reconstruction including skin grafts, composite grafts, and various local flaps. The authors' preferred reconstructive technique is the local C-V or modified star flap. This flap produces an excellent reconstruction, but it is dependent on underlying subcutaneous fat to provide bulk to the reconstructed nipple. In most instances, the subcutaneous tissue is adequate. However, under certain circumstances, the subcutaneous fat may be insufficient to produce a nipple of adequate projection. Two cases of bilateral nipple reconstruction after soft-tissue expansion and implant placement and subsequent nipple reconstruction with local flaps provided inadequate nipple projection. These instances, as well as a retrospective review of reconstructed nipples after mound restoration using a variety of techniques, led the authors to conclude that a more predictable alternative to sustain nipple projection was necessary. The authors identified two broad categories of breast reconstruction patients in whom this new technique would be beneficial. In the first category of patients, breast mounds are reconstructed with tissue expansion and implant insertion, and in the second category, breast mounds are reconstructed by any technique in which the nipple reconstruction subsequently flattens. This article describes the indications, techniques, and experience in 13 patients treated over a 10-month period with fat grafting for nipple reconstruction.     

Capsular hematoma as a late complication in breast reconstruction with silicone gel prostheses.

This paper presents a rare complication of breast reconstruction with silicone gel prostheses in which formation of intracapsular hematomas in the mammary region occurred 3 years after surgery. Treatment by bilateral capsular excision was successful. The rarity of this occurrence and the progress of the case are the major reasons for this publication.     

Obscure carcinoma encountered in subcutaneous mastectomy in silicone- and paraffin-injected breasts: two patients

Two patients are presented whose breasts were injected directly or indirectly with paraffin and silicone, respectively. Both patients had breast cancer that was obscured by the overwhelming granulomatous resection produced by both these foreign substances. It is suggested that paraffin could have been a causative agent in the development of cancer. The role of injected silicone in breast cancer is questionable.     

Sensitive areolar reconstruction in using a neurocutaneous island flap based on the medial antebrachial cutaneous nerve.

Sensory reconstruction has recently been stressed in breast reconstruction. However, there are no reports concerning the reconstruction of a sensitive areola. The bilateral reconstruction of a sensitive areola using a neurocutaneous flap based on the medial antebrachial cutaneous nerve is reported. The flap was harvested from the distal third of the forearm as an island flap and tunneled to reach the apex of the new breast, which was previously reconstructed using a 135-cc, gel-filled, silicone prosthesis covered by a latissimus dorsi myocutaneous flap. Six months later, fine sensibility in the reconstructed areola was demonstrated. The patient could perceive light touch, pain, and 14 mm two-point discrimination. At 2 months after surgery, 50 percent of cutaneous faulty stimulus location was observed. However, at 4 and 6 months after surgery, faulty location disappeared. Six months after harvesting the medial antebrachial cutaneous nerve, the sensory deficit was minimal; it included a hypoesthesic zone of 4 to 7 cm and an anesthesic zone of 2.5 to 5 cm on the middle third of the forearm. Fifteen months after the procedure, no hypoesthesic zone was observed; only a 2 to 3 cm anesthesic zone on the proximal medial side of the forearm existed. This sensory deficit passed unnoticed by the patient. The technique developed here is a refinement in breast reconstruction, and we think it should be used in selected patients.     

Polyurethane implants: a 6-year review of 416 patients

The author reviews 6 years of experience and 416 patients in whom polyurethane implants were used for augmentation and reconstruction of the breast. As with many other plastic surgeons, early use was confined to "salvage cases." Owing to the impressive results, use was extended to routine augmentation. Polyurethane implants are now used exclusively for aesthetic breast surgery. Results are evaluated for replacement of gel capsules and simple and radical mastectomy reconstruction. Gel capsules (Baker stages III to IV), in which prostheses were removed and replaced with polyurethane-covered implants, improved in 29 of 32 patients (87 percent). For reconstruction, placement of polyurethane implants in unscarred situations gives far superior results than following repeated procedures. The incidence of infection is no higher than with gel implants. Removal without capsulectomy was not a problem in most instances. However, on two recent occasions capsulectomy was extremely difficult.     

Deep inferior epigastric free flap for breast reconstruction after radical mastectomy

This case illustrates an unusual mastectomy patient in whom the standard alternatives for breast reconstruction were not available. A deep inferior epigastric transverse abdominal free flap was successfully employed. The abundance of tissue provided by this technique enabled reconstruction of a large breast to match the contralateral side.     

Breast cancer detection using magnetic resonance imaging in breasts injected with liquid silicone

Two patients who had received silicone injections in their breasts several years ago presented with breast complaints. Excluding cancer in these patients was very difficult. Mammograms were very difficult to interpret, as were the physical findings. Carcinoma was successfully detected by magnetic resonance imaging. When women who underwent the injudicious injection of silicone reach the cancer-prone age, the examining physicians should have a greater awareness of the detection and management of carcinoma coexistent with silicone mastopathy. We think that MRI is potentially valuable in the evaluation of the breast lesions; it plays an important role in the detection of breast cancer in breasts augmented with liquid silicone.     

The coincidence of TRAM flaps and prostheses in the setting of breast reconstruction

It is well known that transverse rectus abdominis myocutaneous (TRAM) flaps can be used to replace unsatisfactory prosthetic breast reconstructions; however, little has been written about the scope of breast implant use in TRAM flap patients. In this study, to ascertain the range of such therapeutic options, their frequency, and their clinical outcomes, the authors retrospectively reviewed the senior author's breast reconstruction experience from 1989 to 2000 with patients in whom both a TRAM flap and an implant were used for breast reconstruction. The authors examined the surgical indications, body habitus, bra size, chest wall irradiation history, flap type, implant type, complications, and outcomes for those patients with TRAM flap and breast implant combinations.Thirty-two women who had 50 (various) combinations of a TRAM flap and a breast implant were identified. There were more clinical scenarios than patients because many of the women had multiple scenarios. The 50 combination scenarios were then divided into six groups. Group I consisted of 14 patients who had elective prostheses placed beneath simultaneous TRAM flaps; group II consisted of 10 patients who had TRAM flaps with contralateral prosthetic reconstruction (in which two implants were received before the TRAM flaps, five implants were received simultaneously with the TRAM flaps, and three implants were received after the TRAM flaps); group III consisted of eight patients who had contralateral augmentation in addition to their TRAM flaps; group IV consisted of 11 patients who had TRAM flaps that were used to cover or replace previous prosthetic reconstructions; group V consisted of four patients in whom prostheses were used to augment or improve previous TRAM flap reconstructions; and group VI consisted of three patients who required prostheses to either reconstruct or salvage total or near-total TRAM flap failures. A broad range of implant types was used, although anatomic saline implants predominated. Forty-one percent of the patients in the review had undergone irradiation during the course of their treatment for breast cancer. Eight of the 32 patients experienced a total of twelve complications, four of which were related to the implants and eight of which involved the TRAM flaps and abdominal donor sites.Although complex, the wide variety of potential TRAM flap/breast implant combinations can be useful for patients with challenging reconstructive scenarios, particularly those that involve radiation therapy. In the group of patients reviewed by the authors, TRAM flaps were most often used in successful partnership either on the same side as or opposite to an implant reconstruction. A TRAM flap was used to salvage or replace an unsatisfactory implant reconstruction in less than a third of the patients. From a risk point of view, implants used opposite a TRAM flap reconstruction had a lower incidence of complication than did implants used beneath TRAM flaps.     

Long-term use of polyurethane breast prostheses: a 14-year experience

I have used polyurethane prostheses for the past 14 years, implanting 220 implants into 130 patients who desired breast reconstruction after subcutaneous mastectomy or cancer ablation or simply breast augmentation. I theorize that a polyurethane-covered implant resists contracture, retaining its compressibility because the fibroblasts proliferate into the polyurethane in many different directions. When the fibrils contract, the forces of contracture counterbalance one another, resisting contracture. However, when smooth prostheses are implanted, fibrils are directed in a circular fashion around the implant and naturally contract, leading to firmer breasts. There were 115 prostheses inserted following subcutaneous mastectomy, and 22 percent developed contracted capsules. Seven implants became exposed because of skin necroses; one was removed because of a Staphylococcus infection; and two patients developed a combination of polyurethane and silicone granulomas. These developed only with the earlier implant, where there was shedding of the polyurethane sponge layer and silicone bled from the low-viscosity silicone used in the earlier implants. No granulomas were noted with the currently used Surgitek Replicon implant. Eighty-five breasts were reconstructed after cancer ablation with polyurethane implants, and the contracture rate was 2.3 percent. Other complications were minimal. A smaller group of patients had augmentation mammaplasty, and 20 prostheses were placed in 10 patients. A 15 percent contracture rate was noted in this group. In this study, 82 percent of patients were followed for up to 14 years. Capsular contractures occurred in 30 implants between 1 and 11 years, for an average recurrence at 6.3 years. The overall contracture rate was 13 percent. Other complications were minimal. All implants were placed subcutaneously or subglandularly, and all were drained.     

Alternatives to subcutaneous mastectomy.

It is our belief that subcutaneous mastectomy often leads to complications, with poor results. In addition, because a considerable amount of breast tissue may be left behind, its value as a prophylactic operation must be questioned. Two alternatives are presented. In our experience, these lead to fewer complications with a more thorough removal of the mammary gland, and achieve a better appearance. The alternatives are (1) simple mastectomy with secondary reconstruction; (2) the type of mastectomy described by Spira--with primary reconstruction using a subpectoral silicone prosthesis covered by muscle and an inferiorly-based dermal flap.     

Staged breast reconstruction with saline-filled implants in the irradiated breast: recent trends and therapeutic implications

A retrospective review was performed of one surgeon's experience with 40 consecutive patients who had undergone two-stage saline-filled implant breast reconstruction and radiation during the period from 1990 through 1997. A randomly selected group of 40 other two-stage saline-filled implant breast reconstructions from the same surgeon and time period served as controls. This review was undertaken because of the absence of specific information on the outcome of staged saline implant reconstructions in the radiated breast. Previously published reports on silicone gel implants and radiation have been contradictory. At the same time, the criteria for the use of radiation in the treatment of breast cancer have been expanded and the numbers of reconstruction patients who have been radiated are increasing dramatically. For example, in a 1985 report on immediate breast reconstruction, only 1 of 185 patients over a 6-year period underwent adjuvant radiation therapy, whereas in this review, there were 40 radiated breasts with saline-filled implants, 19 of which received adjuvant radiation therapy during their expansion. The study parameters included patient age, breast cup size, implant size, length of follow-up, number of procedures, coincident flap operations, Baker classification, complications, opposite breast procedures, pathologic stage, indications for and details about the radiation, and outcomes. The use of radiation in this review of reconstructed breasts can logically be divided into four groups: previous lumpectomy and radiation (n = 7), mastectomy and radiation before reconstruction (n = 9), mastectomy and adjuvant radiation during reconstruction/expansion (n = 19), and radiation after reconstruction (n = 5). The largest and most rapidly growing group of patients is of those receiving postmastectomy adjuvant radiation therapy. A total of 47.5 percent (19 of 40) of radiated breasts with saline implants ultimately needed the addition of, or replacement by, a flap. Ten percent of a control group with nonradiated saline implant reconstructions also had flaps, none as replacements. Fifty percent or more of both the radiated and control groups had contralateral surgery. Complications were far more common in the radiated group; for example, there were 32.5 percent capsular contractures compared with none in the control group. The control nonradiated implant-only group and the flap plus implant radiated group did well cosmetically. The radiated implant-only group was judged the worst. The increasing use of radiation after mastectomy has important implications for breast reconstruction. The possibility for radiation should be thoroughly investigated and anticipated preoperatively before immediate breast reconstruction. Patients with invasive disease, particularly with large tumors or palpable axillary lymph nodes, are especially likely to be encouraged to undergo postmastectomy radiation therapy. The indications for adjuvant radiation therapy have included four or more positive axillary lymph nodes, tumors 4 cm (or more) in diameter, and tumors at or near the margin of resection. More recently, some centers are recommending adjuvant radiation therapy for patients with as few as one positive lymph node or even in situ carcinoma close to the resection margin. The use of latissimus dorsi flaps after radiation has proven to be an excellent solution to postradiation tissue contracture, which can occur during breast expander reconstruction. The use of the latissimus flap electively with skin-sparing mastectomy preradiation is probably unwise, unless postmastectomy radiation is unlikely. Skin-sparing mastectomy with a latissimus flap thus should be preserved for patients unlikely to undergo adjuvant radiation therapy. Purely autologous reconstruction such as a TRAM flap is another option for these patients, either before or after radiation therapy.