Expander-Implant Breast Reconstruction Treatment & Management

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. [34, 35]

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. [36]

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. [37]

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. [38]

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. [39]

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. [40]

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. [41]

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). [42]

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. [43]

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. [44]

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.