Trends in unilateral breast reconstruction and management of the contralateral breast: the Emory experience

Recent trends in breast reconstruction have transitioned toward the skin-sparing type of mastectomy and immediate reconstruction using autologous tissue. This study was designed to document trends in the management of patients with unilateral breast cancer and to determine how they influence management of the contralateral breast.All patients who underwent unilateral breast reconstruction at Emory University Hospitals from January of 1975 to December of 1999 were reviewed. The cohort was stratified by timing of reconstruction (immediate versus delayed), method of reconstruction, and mastectomy type (skin-sparing versus non-skin-sparing). The methods of reconstruction included implant, latissimus dorsi flap, and transverse rectus abdominis musculocutaneous (TRAM) flap. Contralateral procedures to achieve symmetry included augmentation, mastopexy, augmentation/mastopexy, and reduction. A total of 1394 patients were evaluated, including 689 delayed and 705 immediate reconstructions. Sixty-seven percent of delayed-reconstruction patients (462 of 689) had a symmetry procedure performed on the opposite breast, compared with 22 percent for the immediate-reconstruction patients (155 of 705) (p 相似文献   

Optimizing autologous breast reconstruction in thin patients

Breast reconstruction with a transverse rectus abdominis myocutaneous (TRAM) flap plus an implant has been proposed as an option for women with a thin body habitus who do not have sufficient abdominal tissue to permit reconstruction with a TRAM flap alone. The standard autologous tissue reconstructive procedure in these women is a combined latissimus dorsi myocutaneous flap and breast implant. We reviewed our experience performing TRAM flap/implant and latissimus dorsi flap/implant breast reconstruction to compare complication rates and aesthetic outcomes between these two types of reconstruction. Between 1992 and 1999, 88 breasts were reconstructed at our institution using an autologous tissue flap combined with a breast implant (44 with a TRAM flap/implant and 44 with a latissimus dorsi flap/implant). Recipient-site and donor-site complications for the two procedures were compared using Fisher's exact test; a panel of unbiased, blinded judges compared the aesthetic outcomes. The recipient-site complication rate was lower for the TRAM flap/implant group than for the latissimus dorsi flap/implant group (18 percent versus 34 percent, p = 0.09). Most recipient-site complications in the TRAM flap/implant group were related to fluid collection around the implant. In the TRAM flap/implant group, complications occurred in 37 percent of the reconstructions that had immediate implant placement and in none of the reconstructions with delayed implant placement (p = 0.01). In the TRAM flap/implant reconstructions with immediate implant placement, the recipient-site complication rate was 50 percent when implants were completely filled with saline, but no complications occurred with incompletely filled, postoperatively adjustable implants (p = 0.03). No microvascular complications occurred with immediate placement of breast implants under TRAM flaps. Donor-site complications included a hematoma, a seroma, and an umbilical necrosis in the TRAM flap/implant group and six cases of seroma formation in the latissimus dorsi flap/implant group. The comparison of aesthetic outcome was statistically significant for the TRAM flap/implant group, which had a higher overall mean score than the latissimus dorsi flap/implant group did (3.29 versus 2.85, p = 0.01). The results of this study suggest that the TRAM flap/implant breast reconstruction should be considered as an alternative to the latissimus dorsi flap/implant breast reconstruction in women with a thin body habitus.     

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.     

Symmetrical breast reconstruction: is there a role for three-dimensional digital photography?

Clinical applications of three-dimensional digital photography include assessments of breast volume and contour. It was hypothesized that knowledge of preoperative and postoperative breast volumes might facilitate obtaining symmetry after reconstructions with autologous tissue or implants. Breast reconstruction was performed for 382 women during a 4-year period. Of those women, 334 completed all phases of the reconstruction and underwent symmetry analysis. Reconstructive procedures included the use of pedicle transverse rectus abdominis musculocutaneous flaps, free transverse rectus abdominis musculocutaneous flaps, deep inferior epigastric perforator flaps, superior gluteal artery perforator flaps, or latissimus dorsi flaps or expanders/implants. Three-dimensional digital photographic images were obtained for 33 women, whereas the remaining 301 women were not digitally photographed. The differences in symmetry after the initial reconstruction and after the secondary procedures were compared for all women and for the groups with and without three-dimensional photographic images. For the group with three-dimensional imaging, initial volume symmetry was obtained for 73 percent, initial contour symmetry was obtained for 27 percent, secondary procedures were necessary for 70 percent, final volume symmetry was obtained for 88 percent, and final contour symmetry was obtained for 79 percent. For the group without three-dimensional photographic images, initial volume symmetry was obtained for 57 percent, initial contour symmetry was obtained for 34 percent, secondary procedures were necessary for 50 percent, final volume symmetry was obtained for 80 percent, and final contour symmetry was obtained for 71 percent. The results demonstrated that there was no significant difference in final contour and volume symmetry between women who had or did not have three-dimensional digital photographic images taken. However, the results demonstrated that autologous tissue reconstructions resulted in improved contour and volume symmetry, compared with implant reconstructions.     

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.     

Irradiation after immediate tissue expander/implant breast reconstruction: outcomes, complications, aesthetic results, and satisfaction among 156 patients

Chest wall irradiation is becoming increasingly common for mastectomy patients who have opted for immediate breast reconstruction with tissue expanders and implants. The optimal approach for such patients has not yet been defined. This study assesses the outcomes of a reconstruction protocol for patients who require irradiation after tissue expander/implant reconstruction. The charts of all patients who underwent immediate tissue expander/implant reconstruction at Memorial Sloan-Kettering Cancer Center between January of 1995 and June of 2001 and who had not previously undergone irradiation were retrospectively reviewed. A subgroup of patients who required chest wall irradiation after mastectomy and reconstruction was identified. Those patients were treated according to the following treatment algorithm: (1) reconstruction with tissue expander placement at the time of mastectomy , (2) tissue expansion during postoperative chemotherapy, (3) exchange of the tissue expander for a permanent implant approximately 4 weeks after the completion of chemotherapy, and (4) chest wall irradiation beginning 4 weeks after the exchange. All irradiated patients with at least 1 year of follow-up monitoring after the completion of radiotherapy were evaluated with respect to aesthetic outcomes, capsular contracture, and patient satisfaction. A control group of nonirradiated patients was randomly selected from the cohort of patients treated during the study period. During the 5-year study period, a total of 687 patients underwent immediate reconstruction with tissue expanders. Eighty-one patients underwent postoperative irradiation after placement of the final implant. A total of 68 patients who received postoperative chest wall irradiation underwent at least 1 year of follow-up monitoring after the completion of radiotherapy, with a mean follow-up period of 34 months. Seventy-five nonirradiated patients were evaluated as a control group. Overall, 68 percent of the irradiated patients developed capsular contracture, compared with 40 percent in the nonirradiated group (p = 0.025). Eighty percent of the irradiated patients demonstrated acceptable (good to excellent) aesthetic results, compared with 88 percent in the nonirradiated group (p = not significant). Sixty-seven percent of the irradiated patients were satisfied with their reconstructions, compared with 88 percent of the nonirradiated patients (p = 0.004). Seventy-two percent of the irradiated patients stated that they would choose the same form of reconstruction again, compared with 85 percent of the nonirradiated patients. The results of this study suggest that tissue expander/implant reconstruction is an acceptable surgical option even when followed by postoperative radiotherapy and should be considered in the reconstruction algorithm for all patients, particularly those who may not be candidates for autogenous 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.     

Use of a permanent tissue expander for breast reconstruction

The use of tissue expansion in breast reconstruction is a recognized alternative surgical approach. The second generation of tissue-expanding prostheses is the permanent reverse double-lumen expander. In a series of 100 breast reconstructions using a permanent tissue expander, the clinical benefits of producing a moderate degree of mound ptosis along with observed reduction in pain during expansion are discussed. Additional advantages to the use of the device are the cost savings realized, elimination of a second procedure and a second anesthetic exposure, and a high degree of patient acceptance and satisfaction. This study includes breast reconstruction following mastectomies for malignant and premalignant disease, as demonstrated in 75 delayed and 25 immediate reconstructions, with the longest follow-up being 3 years. Complications of infection (3 percent), significant capsular contracture (4 percent), and implant failure (3 percent) are the most frequent and major complications observed yet. In no instance was breast reconstruction rendered unachievable in the face of these complications. The demonstrated results achieved with permanent tissue-expanding prosthesis, complemented by the obvious benefits and a low rate of significant complications, endorse this method as a viable alternative approach in reconstructive breast surgery.     

Breast reconstruction using tissue expanders and implants in Hodgkin's patients with prior mantle irradiation.

Women treated for Hodgkin's disease with mantle irradiation have an increased risk for developing breast cancer. Typically, breast malignancy in Hodgkin's patients presents bilaterally in a younger age group. Skin flap ischemia, poor skin expansion, implant extrusion, capsular contracture, and poor cosmesis are common sequelae of tissue expander/implant breast reconstruction after breast irradiation for failed breast conservation therapy. This has led most surgeons to favor autologous tissue reconstruction in this setting. This study was performed to determine the efficacy of tissue expander/implant breast reconstruction in breast cancer patients who have been treated with prior mantle irradiation for Hodgkin's disease. A retrospective analysis of all breast cancer patients with a history of Hodgkin's disease and mantle irradiation treated with mastectomy and tissue expander/implant reconstruction between 1992 and 1999 was performed. There were seven patients, with a mean age of 35 years (range, 28 to 42 years). The average interval between mantle irradiation and breast cancer diagnosis was 16 years (range, 12 to 23 years). All patients underwent two-stage reconstruction. Textured surface tissue expanders were placed in a complete submuscular position at the time of mastectomy. Expansion was initiated 2 weeks after insertion and continued on a weekly basis until completion. Expanders were replaced with textured surface saline-filled implants as a second stage. Patients were evaluated for skin flap ischemia, infection, quality of skin expansion, implant extrusion, capsular contracture, rippling, symmetry, and final aesthetic outcome. Breast cancer was bilateral in five patients and unilateral in two. Two patients did not undergo simultaneous bilateral breast reconstruction because of metachronous cancer development. One of the patients had an initial transverse rectus abdominis muscle flap breast reconstruction, followed by a tissue expander/implant reconstruction of the opposite breast. The average follow-up was 3 years. Complications were limited to one case of cellulitis after implant placement that resolved with intravenous antibiotics. There were no cases of skin flap ischemia, poor skin expansion, or implant extrusion. Overall patient satisfaction was high and revisions were not requested or required. Symmetry was best achieved with bilateral implants. This study demonstrates the efficacy of tissue expander/implant breast reconstruction in patients treated with prior mantle irradiation. In this series, tissue expansion was reliable with low morbidity. Second-stage placement of permanent implants yielded good aesthetic results without significant capsular contracture. Mantle irradiation did not appear to compromise the prosthetic breast reconstruction. Tissue expander/implant breast reconstruction should remain a viable option in this category of irradiated patients.     

Evaluation of the factors related to postmastectomy breast reconstruction

A retrospective study was conducted in 75 consecutive patients requiring postmastectomy breast reconstruction over a period of 30 months. Each woman was offered one of the following four reconstructive options: free transverse rectus abdominis musculocutaneous flap (total number of reconstructions, n = 34); latissimus dorsi musculocutaneous flap (with or without expander and implant, n = 14); endoscopically assisted harvest of the latissimus dorsi muscle (with expander and implant, n = 13); and application of expander and implant only (n = 12).Of those patients originally selected for retrospective study, six did not meet the short-term prognostic criteria, and concerted attempts to contact two others proved unsuccessful. The remaining 67 patients were examined for the clinically assessed aesthetic appearance of the reconstructed breast(s), the subjective self-assessment of patient satisfaction, and the possible development of postoperative complications. Of these patients, six required bilateral surgery, which accounts for a final sample size of 73 individual breast reconstructions. The 67 individual patients were assessed after a minimum time of 6 months postreconstruction and became the sampling units for analysis.The free transverse rectus abdominis musculocutaneous flap procedure was the preferred method of breast reconstruction in 34 of 73 patients (47 percent), provided that it was generally agreed that the patient could endure a prolonged operation and that there was sufficient unscarred abdominal tissue available. Thereafter, postmastectomy radiotherapy at the chest wall became the primary criterion for assignment of a patient to a particular surgical procedure. Whenever radiotherapy resulted in poor-quality skin at the chest wall, endoscopically assisted transfer of latissimus dorsi muscle flap was considered to be the optimal treatment (13 of 73 patients, or 18 percent). Body mass index and smoking were secondary factors that were taken into account when this alternative technique was being considered.In the absence of radiotherapy, and provided that the chest wall was minimally scarred, patients who were reluctant to have reconstruction with autologous tissue were treated with expander and implant only (12 of 73, or 16 percent). This third procedure is a physically less arduous ordeal for the patient and was therefore the choice for all patients for whom a prolonged operation was not a realistic option. The fourth (and final) surgical procedure, latissimus dorsi musculocutaneous flap (with or without expander and implant), was selected for all patients with a better quality of skin over the chest wall, those whose abdomen was extensively scarred, and those who were on a general surgeon's operating list to undergo immediate breast reconstruction after mastectomy (14 of 73, or 19 percent).Equally good aesthetic results could be demonstrated with each of the four treatment options, provided that the reconstructive procedure selected was optimal for the individual patient and in accordance with the criteria described above. A variety of potential risk factors were considered for association with postoperative complications, including prescribed medication, obesity, smoking behavior, use of radiotherapy, and the recorded aggregated operative time. Of these, only body mass index (p < 0.001) and use of steroids (p = 0.016) were identified as having statistically significant effects on the incidence of adverse events.Finally, the general level of satisfaction expressed by the patient was highly correlated with a good appearance of the reconstructed breast, the physical comfort experienced while wearing a brassiere, and the general mobility of the unsupported reconstruction.     

Autologous breast reconstruction with the extended latissimus dorsi flap

The extended latissimus dorsi myocutaneous flap can provide autogenous tissue replacement of breast volume without an implant. Nevertheless, experience with the extended latissimus dorsi flap for breast reconstruction is relatively limited. In this study, the authors evaluated their experience with the extended latissimus dorsi flap for breast reconstruction to better understand its indications, limitations, complications, and clinical outcomes. All patients who underwent breast reconstruction with extended latissimus dorsi flaps at the authors' institution between January of 1990 and December of 2000 were reviewed. During the study period, 75 extended latissimus dorsi flap breast reconstructions were performed in 67 patients. Bilateral breast reconstructions were performed in eight patients, and 59 patients underwent unilateral breast reconstruction. There were 45 immediate and 30 delayed reconstructions. Mean patient age was 51.5 years. Mean body mass index was 31.8 kg/m2. Flap complications developed in 21 of 75 flaps (28.0 percent), and donor-site complications developed in 29 of 75 donor sites (38.7 percent). Mastectomy skin flap necrosis (17.3 percent) and donor-site seroma (25.3 percent) were found to be the most common complications. There were no flap losses. Patients aged 65 years or older had higher odds of developing flap complications compared with those 45 years or younger (p = 0.03). Patients with size D reconstructed breasts had significantly higher odds of flap complications compared with those with size A or B reconstructed breasts (p = 0.05). Obesity (body mass index greater than or equal to 30 kg/m2) was associated with a 2.15-fold increase in the odds of developing donor-site complications compared with patients with a body mass index less than 30 kg/m2 (p = 0.01). No other studied factors had a significant relationship with flap or donor-site complications. In most patients, the extended latissimus dorsi flap alone, without an implant, can provide good to excellent autologous reconstruction of small to medium sized breasts. In selected patients, larger breasts may be reconstructed with the extended latissimus dorsi flap alone. This flap's main disadvantage is donor-site morbidity with prolonged drainage and risk of seroma. Patients who are obese are at higher risk of developing these donor-site complications. In conclusion, the extended latissimus dorsi flap is a reliable method for total autologous breast reconstruction in most patients and should be considered more often as a primary choice for breast reconstruction.     

Breast reconstruction with implants and expanders

Breast reconstruction with expanders and implants provides an excellent option in the properly selected patient. Techniques for reconstruction have evolved significantly over the past 30 years with the development of more sophisticated devices and improvement in surgical procedures. Several options exist, each with its own advantages and disadvantages. Two-stage breast reconstruction using a textured device with an anatomic shape and integrated valve seems to provide the most consistent and reproducible results in most patients. Those patients with small, minimally ptotic breasts may be candidates for either single-stage implant reconstruction or reconstruction with an adjustable device. Advantages of expander and implant reconstruction over other techniques include relative ease of the procedure; no distant donor-site morbidity; use of tissue of similar color, texture, and sensation; reduced operative time; and more rapid postoperative recovery.     

An accelerated approach to tissue expansion for breast reconstruction: experience with intraoperative and rapid postoperative expansion in 370 reconstructions

Breast reconstruction with tissue expansion is a well-established technique that offers satisfactory aesthetic results with minimal patient morbidity. The traditional period of expansion, however, continues to be a significant source of patient inconvenience and dissatisfaction. The objective of this study was to develop and evaluate a protocol for rapid tissue expansion. A total of 370 breast reconstructions in 314 patients who underwent rapid tissue expansion were retrospectively reviewed. Contraindications to rapid expansion were considered to be previous radiation, mastectomy skin flaps of questionable viability, and an excessively tight skin envelope. All expanders were placed submuscularly and filled to 40 to 50 percent of tissue expander volume. Office expansion was undertaken within 10 to 14 days after the operation and continued on a weekly basis. Each expansion was limited by patient tolerance up to a maximal pressure of 40 mm of water or a volume of 120 cm3. Expansion was considered complete once the expanded breast was 30 to 50 percent larger than the contralateral breast. If required, postoperative chemotherapy was given during the expansion period. Mean patient age was 48 years (range, 23 to 73 years). Two hundred fifty-eight patients had unilateral reconstructions. Three hundred two patients had immediate reconstruction. Mean tissue expander size was 583 cm3 (SD, 108 cm3). Mean intraoperative expansion was 271 cm3, or 46 percent (SD, 9 percent) of the tissue expander size. The first expansion was started 12 days (SD, 3 days) after the operation. The mean volume of each expansion was 88 cm3 (SD, 23 cm3). Expansion was completed in 4.7 office visits (SD, one visit). Mean final expander volume was 672 cm3 (SD, 144 cm3). The expanders were overexpanded by 15.3 percent (SD, 8.4 percent). The mean time between expander placement and the final expansion was 6.6 weeks (SD, 3 weeks). The overall complication rate was 4 percent. Ten patients developed cellulitis, five patients had hematomas requiring drainage, and one expander became exposed. A total of eight expanders were removed: four for cellulitis, one for a hematoma, one because of locally recurrent disease, one because of expander exposure, and one at the patient's request for no medical reason. Intraoperative and rapid postoperative tissue expansion is a safe and reliable technique that offers a significant improvement over conventional techniques. In this accelerated protocol, expansion may be completed in less than 7 weeks. The result is decreased patient morbidity and delays in adjuvant therapy at no detriment to the final surgical outcome.     

Complete one-stage,immediate breast reconstruction with prosthetic material in patients with large or ptotic breasts

Immediate prosthetic breast reconstruction is a relatively simple, quick procedure with no donor site morbidity. This report discusses immediate one-stage breast reconstruction using prostheses in 18 patients (19 breasts) who also required a contralateral reduction or mastopexy. In all cases, an inverted-T pattern was applied to both breasts. The mean age of the patients was 49 years (range, 32 to 62 years), and the mean size of the gel implant used was 330 ml (range, 120 to 550 ml); the implant was inserted in a total submuscular pocket in seven patients and subcutaneously in 11 patients. In two patients with multiple risk factors, the prosthesis extruded, and one patient required removal for a periprosthetic infection. In 10 patients with early stage disease (T1 or T2) with tumors more than 5 cm from the nipple-areola complex, the original areola (n = 3) or nipple-areola complex (n = 7) was retained as a full-thickness skin graft.The breast shape after submuscular prosthesis insertion is different than that of the contralateral breast after a mastopexy or reduction, and nipple-areola complex symmetry was difficult to obtain; thus, this technique was abandoned in favor of the subcutaneous position (using a modified Wise keyhole pattern with a de-epithelialized portion, which still allows two-layer closure).In the subgroup of patients with large breasts or marked ptosis, a single-stage breast reconstruction procedure can be performed with symmetrical incisions. The subcutaneous position allows for symmetrical shape and nipple-areola complex symmetry to be obtained. When the tumors are small and situated in the periphery of the breast, the nipple-areola complex may be retained as a full-thickness graft.     

Prospective analysis of psychosocial outcomes in breast reconstruction: one-year postoperative results from the Michigan Breast Reconstruction Outcome Study

In the past decade, changing attitudes toward breast reconstruction among both patients and providers have led a growing number of women to seek breast reconstruction after mastectomy. Although investigators have documented the psychological, social, emotional, and functional benefits of breast reconstruction, little research has evaluated the effects of procedure choice on these outcomes. The current study prospectively evaluated and compared psychosocial outcomes for three common options for mastectomy reconstruction: tissue expander/implant, pedicle TRAM, and free TRAM techniques. In a prospective cohort design, patients undergoing postmastectomy reconstruction for the first time with expander/implant, pedicle TRAM, or free TRAM procedures were recruited from 12 centers and 23 plastic surgeons in the United States and Canada. Before reconstruction and at 1 year after reconstruction, patients were evaluated by a battery of questionnaires consisting of both generic and condition-specific surveys. Outcomes assessed included emotional well-being, vitality, general mental health, social functioning, functional well-being, social well-being, and body image. Baseline (preoperative) scores and the change in scores (the difference between postoperative and preoperative scores) were compared across procedure types using t tests and analysis of covariance. Preoperative and 1-year postoperative surveys were obtained from 273 patients. Procedure type was reported in 250 patients, of whom 56 received implant reconstructions, 128 pedicle TRAM flaps, and 66 free TRAM flaps. A total of 161 immediate and 89 delayed reconstructions were performed. Among women receiving immediate reconstruction, significant improvements were observed in all psychosocial variables except body image. However, no significant effects of procedure type on these changes over time existed. Similarly, delayed reconstruction patients had significant increases in emotional well-being, vitality, general mental health, functional well-being, and body image. Although the choice of reconstructive technique did not significantly impact most of these outcomes, significant differences existed among procedure types for three psychosocial subscales. Patients undergoing delayed expander/implant reconstructions reported greater improvements in vitality and social well-being relative to women receiving delayed TRAM procedures. By contrast, delayed TRAM patients noted significantly greater gains in body image compared with women choosing delayed expander-implant reconstruction. The authors conclude that both immediate and delayed breast reconstructions provide substantial psychosocial benefits for mastectomy patients. Although the choice of reconstructive procedure does not seem to significantly affect improvements in psychosocial status with immediate reconstruction, our data suggest that procedure type does have a significant effect on gains in vitality and body image for women undergoing delayed reconstruction.     

Capsular contracture after breast reconstruction with silicone-gel and saline-filled implants: a 6-year follow-up

A major problem after breast reconstruction with augmentation mammaplasty is contracture of the fibrous capsule around the prosthesis. In a series of 72 breasts in 65 women, silicone-gel and saline-filled implants were randomly selected prior to breast reconstruction. The results were judged with respect to consistency, tenderness, wrinkles, and sounds by two independent plastic surgeons according to the breast augmentation classification (BAC) and by the patients themselves. Capsular contracture was found by the surgeons in 50 percent of the gel implant group and in 16 percent of the saline implant group, which is in conformity with the results of the follow-up 5 years earlier. The incidence of deflation was 16 percent in the saline group and occurred in different sizes of both overinflated and underinflated prostheses. The degree of slow leakage from saline implants will be discussed. Despite the high rate of contractures in the gel group, 85 percent of all patients were satisfied with the result of the reconstruction.     

Long-term predictable nipple projection following reconstruction.

The creation of the nipple-areola complex is often the final step in the surgical treatment of breast cancer patients, and it consequently has important symbolic and aesthetic implications. Patient expectations and the need for symmetry make nipple projection a crucial aesthetic determinant of nipple reconstruction. We hypothesize that long-term nipple projection and shape can be achieved in a predictable fashion using the modified star dermal fat flap technique. Prospectively, 93 nipples were reconstructed by a single surgeon using a modified star dermal fat flap technique in 44 implant and 49 TRAM flap breast reconstructions. Flap dimensions (base diameter and flap length) were designed according to patient desire or to the base diameter and projection of the opposite breast nipple. A standardized, 3-month postoperative care regimen was observed in all patients. Nipple projection was assessed by the same observer at each follow-up examination. The average length of follow-up was 730 days (745 for TRAM reconstructions and 713 for implants). Consistently, an average of 41 percent of the intraoperative projection remained intact in both groups at final evaluation (SD 12 percent). The total flap length was strongly predictive of intraoperative and long-term projection (r = 0.64 and 0.86, p < 0.0001). Flap lengths ranged from 5.5 to 9.0 cm, and in a linear correlation, resulted in intraoperative projection of 1.0 to 2.1 cm, respectively, and long-term projection of 0.4 to 0.83 cm, respectively. Based on the linear relationship, every 1-cm increase in flap length could be expected to result in a 0.16-cm increase in projection. When controlled for flap length and intraoperative projection, there was no difference between TRAM and implant nipple reconstruction in predicting postoperative nipple projection. Intraoperative planning and execution are critical to achieve predictable nipple shape, size, and projection. The dimensions of the star dermal fat flap can be strategically modified to allow the surgeon predictable projection with a consistent 41-percent preservation of intraoperative nipple projection in both TRAM and implant patients at 2 years.     

Infectious complications following breast reconstruction with expanders and implants

The incidence of infection following breast reconstruction with expanders and implants ranges from 1 to 24 percent. Numerous factors associated with infection have been described; however, a one-variable at time setting and multifactorial analysis have not been performed. The purpose of this study was to analyze a set of factors that may predispose women to infection of the expander or implant. Between 1997 and 2000, a total of 168 implant reconstructions were performed in 130 women at a single institution. The mean age for all women was 48.2 years (range, 25 to 77 years). The factors that were analyzed included axillary lymph node dissection, chemotherapy, radiation therapy, tumor stage, timing of implant insertion, number of sides (unilateral versus bilateral), tobacco use, and presence or absence of diabetes mellitus. Statistical analysis was performed with stepwise logistic regression. Mean time to follow-up for all patients was 29 months (range, 12 to 47 months). Infectious complications occurred in 10 women (7.7 percent) and in 10 expanders or implants (5.9 percent). Infected implants were removed an average of 116 days following insertion (range, 14 to 333 days). Cultured bacteria included Staphylococcus aureus and Serratia marcescens. A significant association (p < 0.04) was detected between implant infection and radiation therapy. The chance for implant infection was 4.88 times greater for implants that were exposed to radiation therapy compared with those that were not. In addition, there was suggestive (p < 0.09) evidence that the chance of implant infection following lymph node dissection was 6.29 times higher than when no lymph nodes were removed. No significant association between implant infection and age, diabetes, tobacco use, tumor stage, timing of implant insertion, or chemotherapy was found.     

The premature removal of tissue expanders in breast reconstruction.

The role of tissue expanders in breast reconstruction is well established. Little information exists, however, regarding the incidence and etiology of premature removal of the tissue expander before planned exchange to a permanent breast implant. The purpose of this study was to review our 10-year experience with tissue expander breast reconstruction and identify factors relating to the premature removal of the tissue expander. This study is a retrospective review of 770 consecutive patients who underwent breast reconstruction with tissue expanders over the past 10 years. Breast reconstruction was immediate in 90 percent of patients. Patients were expanded weekly, and adjuvant chemotherapy was begun during the expansion process when required. Factors potentially affecting premature expander removal (chemotherapy, diabetes, obesity, radiation therapy, and smoking) were evaluated. Fourteen patients (1.8 percent) with a mean age of 47 years (range, 38 to 62 years) required premature removal of their tissue expander. Expanders were removed a mean of 3.2 months (0.1 to 8 months) after insertion. Causes for premature removal of the tissue expander included infection (7 patients), exposure (2), skin necrosis (2), patient dissatisfaction (2), and persistent breast cancer (1). Positive wound cultures were obtained in four of the seven infected patients (57 percent), requiring expander removal for infection. Tissue expanders were removed in 11 patients for complications directly related to the expander. Among these, six (55 percent) were receiving adjuvant chemotherapy, and one was a smoker. Diabetes, obesity, other concomitant medical illnesses, and prior mantle irradiation were not associated with expander removal. Premature removal of the tissue expander was required in only 1.8 percent of the patients in this series. Infection was the most common complication necessitating an unplanned surgical procedure to remove the expander. This study demonstrates that the use of tissue expanders in breast reconstruction is reliable, with the vast majority of patients completing the expansion process.     

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.