In the past 10 years, the field of breast reconstruction has undergone tremendous changes that have resulted in our ability to more closely mimic the native breast. Our success is attributable in large part to the improved mastectomy techniques with nipple preservation and efforts to preserve a well-perfused skin flap following breast removal. In addition, there has been evolution and advancement in the tools surgeons have to recreate the breast, including supplemental fat grafting. This article outlines important components of successful implant-based breast reconstruction.
All women who have a mastectomy should be counseled on their options for breast reconstruction. Important components of the history include the general health of the patient and the ability to withstand the extra time of anesthesia attributable to the reconstruction. Consultations with other specialists are necessary to determine whether it is safe to hold anticoagulation medications and whether immunosuppressants/antimetabolites can be held. Diabetes should be controlled and smoking discontinued. In patients with prior breast irradiation, individual assessment of risk factors may help determine candidacy for immediate implant reconstruction. In general, a higher incidence of risk factors is associated with a higher chance for complications. Obesity is not a contraindication to immediate breast reconstruction; however, these patients are likely at higher risk for complications.1,2 If two or more risk factors exist, delayed reconstruction or a Goldilocks procedure to control the skin envelope and create a small breast are considered.3 Compared to autologous reconstruction, implant reconstruction has a lower rate of complications and reoperations but a higher rate of failure.4
Postmastectomy radiation therapy is the risk factor that adversely affects outcomes and increases complications more than any other in implant-based reconstruction.5–8 Although we do not understand the entire mechanism of injury, it is likely influenced by the health and vascularity of the mastectomy skin envelope and the dose/delivery of radiation. Other contributing factors to radiation injury include a possible advantage of acellular dermal matrix and textured devices and a potential negative role for pectoralis muscle contraction. Timing of radiotherapy continues to be debated. Lower rates of complications are reported with radiotherapy to the implant, and better cosmesis is reported with radiotherapy to the expander.9
INCISIONS WITH NIPPLE PRESERVATION OR REMOVAL
Nipple-sparing mastectomy procedures have become the default operation in many large centers, with preference over skin-sparing or skin-reducing procedures. Oncologic indications for nipple removal include involvement of the nipple on clinical or radiologic examination.10 From a plastic surgery standpoint, nipple preservation is considered if it will end up in the correct anatomical position postoperatively or for patient preference.11,12 Prior incisions on the breast are not contraindications to nipple-sparing mastectomy.13,14 The most common incisions include an inferolateral inframammary fold incision for the best cosmesis (Figs. 1 through 3), a vertical incision for the ptotic breast, and a lateral radial incision for the best preservation of nipple blood supply. A full-thickness incision around the areola is largely avoided to minimize nipple ischemia. A technical pearl for optimization of nipple position in the first-stage surgery is to choose a wider expander or implant than would typically be used in skin-sparing procedures to try to keep the nipple centered. Patients with grade I breast ptosis are universally good candidates to preserve the nipple. Most patients with grade II breast ptosis are also excellent candidates; however, if they would like a smaller, more uplifted breast, skin or areola sparing is sometimes preferred. With severe grade II and grade III ptosis, several options exist for nipple preservation, depending on therapeutic versus prophylactic, desire for number of operations, and patient preference for uplift of breast (Table 1 and Fig. 4).15 If a staged approach is chosen, it is best to wait 3 months after a superior/medial pedicle and 9 to 12 months after an inferior pedicle with a Wise pattern before mastectomy, which can be problematic for therapeutic procedures.
Table 1. -
Reconstructive Options for Nipple-Sparing Mastectomy and Severe Grade II or III Breast Ptosis
|Fill/overfill skin envelope
||Any incision, DTI often possible
||Less lift compared to other techniques
||Better centralization and lift than IMF incision, mastopexy at second stage
||DTI less likely secondary to more tension and ischemia to skin flap
|Staged mastopexy or reduction before mastectomy
||Best lift and contour
||Delay in treatment, need for lumpectomy with first-stage surgery, insurance coverage
||One of best options for size reduction, avoids delay
||Loss of native nipple
DTI, direct-to-implant; IMF, inframammary fold.
When nipple preservation is not possible, an areola-sparing procedure can be considered. This preserves more skin at the time of the mastectomy compared with skin-sparing procedures, which has advantages for direct-to-implant reconstruction, and may obviate the desire for nipple reconstruction. If nipple reconstruction is performed, the thickened pigmented areola makes an excellent nipple. Standard skin-sparing or skin-reducing mastectomies are typically closed horizontally; however, a vertical closure provides better shape in a large breast. Although a Wise pattern provides the best control of the skin envelope and the best cosmesis if it is successful, it is also associated with the most complications. If a Wise pattern is chosen, the inferior skin is typically deepithelialized to provide implant support and to act an additional barrier with skin breakdown.
DIRECT-TO-IMPLANT VERSUS TISSUE EXPANDER/IMPLANT RECONSTRUCTION
Implant reconstruction can be performed in one stage or two stages. In a one-stage direct-to-implant reconstruction, the final implant is placed at the time of the mastectomy, whereas in a two-stage approach, a tissue expander is placed immediately and then exchanged to the final implant in a second surgical procedure (tissue-expander/implant).16 With experience, there is no difference in complication rates or revision rates between direct-to-implant and tissue-expander/implant reconstruction.15,17
Direct-to-implant reconstruction is considered for patients desiring to stay approximately the same size, although with experience, some degree of size change is commonly possible.16,18,19 It is most frequently performed in nipple-sparing procedures. Patients in general are otherwise healthy with relatively symmetric breasts and volume less than 900 cc. The most critical component of successful direct-to-implant procedures is the health and vascularity of the mastectomy skin flap. With experience, physical examination alone is sufficient for assessing the flap; however, a perfusion assessment device gives additional objective information that may be particularly helpful for inexperienced surgeons or those working with many oncologic breast surgeons. To safely increase size in direct-to-implant reconstruction, the mastectomy technique must be perfect in its ability to remove all the breast tissue yet leave a well-perfused flap. In the senior author’s experience, this type of flap is only routinely seen with one breast surgeon, and the size increase is typically limited to 50 to 100 cc greater than breast volume. However, with continued improvement in technique, larger volume changes may be possible. Advantages to direct-to-implant reconstruction include the potential for one less operation and recovery period compared to tissue-expander/implant reconstruction.20 Furthermore, there is less thinning of the skin envelope, resulting in less need for fat grafting and more control of nipple position. At our center, direct-to-implant reconstruction is the procedure of choice if a patient needs postmastectomy radiotherapy secondary to decreased complication rates compared with tissue-expander/implant reconstruction.
Tissue expander/implant reconstruction is indicated for significant size changes, very large or very small native breast volumes, asymmetry, or if the vascularity of the skin envelope is insufficient to support a full-sized implant. In addition, for inexperienced surgeons, tissue expander/implant reconstruction is a safer choice until experience is gained determining skin perfusion. Advocates of tissue expander/implant reconstruction cite the ability to more precisely control symmetry and implant position when given two operations compared to one and the ability to fat graft at the second stage. At the first stage, it is important to avoid overfilling the tissue expander, which can lead to tension-induced ischemia. A technical pearl at the second-stage operation is to perform superior and medial capsulotomies if needed to accommodate an implant approximately 50 cc greater than the volume of the tissue expander at the time of exchange. This gives a nice hand-in-glove fit and makes up for the loss of projection seen with exchange to a softer, more mobile device.
With either direct-to-implant or tissue-expander/implant surgery, fat grafting has emerged as an integral tool for filling in upper pole divots and for masking contour irregularities. Fat is injected at the second-stage surgery or as a revision procedure. The optimal way to enhance fat graft take remains elusive but is likely influenced by the quantity injected, quality of the lipoaspirate, and vascularity of the recipient site.
SOFT-TISSUE SUPPORT OF THE BREAST RECONSTRUCTION
Options for soft-tissue support and coverage of the breast implant reconstruction include the pectoralis major muscle, serratus anterior muscle or fascia, rectus abdominis fascia, acellular dermal matrix products, and synthetic mesh. Excellent recent reviews of the support matrix materials available for breast reconstruction have been published.15,21 The ideal material should be flexible and soft, yet durable for long-term soft-tissue support. In addition, it is advantageous for the material to thicken the soft-tissue envelope for implant coverage without inducing capsular contracture. Finally, if the support matrix is biointegrated, it minimizes risk for matrix exposure and facilitates bacterial clearance in the setting of infection. Acellular dermal matrix is the most commonly used material for breast reconstruction; however, synthetic meshes have been used in attempts to reduce overall costs of the procedure either alone or in combination with acellular dermal matrix.22,23 Short-term absorbable mesh has inconsistent outcomes, as the soft tissues struggle to maintain support, which may result in either excessive scar/capsular contracture or bottoming-out from lack of support. Titanium mesh appears promising for its ease of use, long-term support, and stability. However, performance with smooth round implants in the prepectoral space and in the setting of radiotherapy is lacking.
TOTAL MUSCLE COVERAGE
In the technique of total or nearly total muscle coverage, the pectoralis major muscle covers the majority of the device, whereas the serratus anterior muscle or fascia covers the lateral aspect of the device. This is reserved in general for tissue-expander/implant reconstruction. The advantages of this technique are in having healthy muscle as a barrier over the device and reduced material cost. This technique has fallen out of favor secondary to poor shape of the reconstruction with lack of inferior pole projection and painful expansion. However, with technical expertise, this technique can give excellent results in selected patients.24
PARTIAL MUSCLE COVERAGE (SUBPECTORAL OR DUAL-PLANE RECONSTRUCTION)
Partial muscle coverage offers a more natural shape by releasing the inferior pole constriction of the pectoralis muscle. Control of pectoralis muscle contraction and “window shading” may be achieved by sewing the pectoralis muscle to the inferior skin flap or with spanning sutures to the chest wall. Lateral control of implant position may be obtained by minimizing lateral dissection of the mastectomy with soft-tissue contouring to the chest wall. However, partial muscle coverage with acellular dermal matrix offers more control, predictability, and reliability and is therefore the most common technique performed currently for one- or two-stage surgery25 (Fig. 5). [See Video 1 (online), which displays subpectoral (partial muscle coverage) tissue expander reconstruction. See Video 2 (online), which displays subpectoral (partial muscle coverage) direct-to-implant pocket creation. See Video 3 (online), which displays subpectoral (partial muscle coverage) direct-to-implant placement of implant and closure.] This is routinely referred to as “subpectoral” or “dual-plane” reconstruction. In this procedure, the pectoralis muscle is raised from its lateral and inferior border to approximately the 4- or 8-o’clock position on the chest wall. This allows simultaneous upper pole soft-tissue coverage with muscle and inferior pole expansion. To avoid pectoralis muscle retraction deformity, the muscle is held on stretch with acellular dermal matrix, which acts as an inferior extension of the pectoralis muscle to the chest wall or inframammary fold. The lateral dissection of the mastectomy often proceeds to the latissimus dorsi muscle. To control the lateral border of the reconstruction, acellular dermal matrix is sewn to the chest wall at the desired position. If the lateral skin flap is of adequate thickness, quilting sutures may be placed from the skin flap to the chest wall to close off dead space and improve lateral contour. However, if the skin flaps are thin, these sutures are typically avoided, as they lead to skin puckering that may be permanent. The advantages of subpectoral partial muscle coverage reconstruction include excellent soft-tissue coverage of the superior pole of the breast, which is most visible in clothing. The subpectoral reconstruction tends to lift the breast, analogous to a dual-plane breast augmentation, and has excellent long-term cosmetic and functional results. Compared to prepectoral reconstruction with acellular dermal matrix (Table 2), the costs of the reconstruction are lower. The main disadvantage is potential animation, which refers to distortion or movement of the implant with flexion of the pectoralis muscle. In the senior author’s (A.S.C.) personal experience of more than 1500 subpectoral implant reconstructions, most patient animation is minor and present only with pectoralis activity. However, in select patients, it can be severe and bothersome.
Table 2. -
Comparison of Subpectoral Partial Muscle Coverage and Prepectoral Breast Reconstruction
||Better soft-tissue coverage upper pole
||More implant visibility, rippling, and contour irregularity upper pole
||Less animation (implant may still move)
||Good symmetry for unilateral grade 1 ptosis; symmetry not as good for grade II to grade III ptosis
||Good symmetry for unilateral grade I to grade III ptosis
||More uplift of breasts
||Less uplift of breasts
||More acute pain than prepectoral (variable)
||Less acute pain than subpectoral (variable)
||Higher material cost
||No limit on implant size
||No limit on implant size
|Outcome with radiotherapy
||Variable outcome with radiation therapy
||Variable outcome with radiation therapy; avoids pectoralis contracture
||Lack of projection in very large breasts
||Better projection in very large breasts
||Excellent medial position of implants attainable except with wide sternalis muscle
||Excellent medial position of implants attainable in all cases, more risk for symmastia
NO MUSCLE COVERAGE (PREPECTORAL RECONSTRUCTION)
As the quality of mastectomy skin flaps began to improve, a movement began to place implants on top of the muscle (Figs. 6 and 7).26,27 In these “prepectoral” or “subcutaneous” reconstructions, implants may be supported by soft tissue alone (no external support), anterior coverage with acellular dermal matrix/mesh, or anterior and posterior coverage of the device.
In reconstructions with no external support, control of the device comes from soft tissue and tabbed expanders or textured devices. To increase predictability and for long-term tissue support, acellular dermal matrix is typically used to cover the entire anterior surface of the device, with or without posterior coverage. [See Video 4 (online), which displays prepectoral implant reconstruction with two sheets of acellular dermal matrix: pocket creation. See Video 5 (online), which displays prepectoral implant reconstruction with two sheets of acellular dermal matrix: implant placement and closure. See Video 6 (online), which displays prepectoral implant reconstruction with a 16 × 20-cm sheet of acellular dermal matrix.] Anterior coverage uses two contour pieces of acellular dermal matrix sewn together centrally or a single 16 × 20-cm piece (Figs. 8 and 9). A slip of muscle may be raised superiorly to allow enhanced superior support for the device, a smoother chest wall/implant transition in patients with a paucity of soft tissue, and less acellular dermal matrix for device coverage.28,29 Another modification includes a gutter of acellular dermal matrix inferiorly for enhanced protection against inferior descent. These modifications are particularly important in direct-to-implant reconstruction with smooth round implants.
Anterior and posterior device coverage is commonly known as the acellular dermal matrix wrap. The acellular dermal matrix wrap is an off-label use of the material. The acellular dermal matrix wrap is the easiest, fastest way to perform the reconstruction and may be performed with one or two pieces of acellular dermal matrix. If the posterior acellular dermal matrix integrates into the muscle, it may enhance long-term support of the device and prevention of bottoming-out, but there may also be animation/movement of the device with pectoralis flexion. The greatest disadvantages are increased material cost and possible device malposition when only limited points of fixation to the chest wall are used. Furthermore, an excess of acellular dermal matrix material may increase seroma rates.
Initial safety results with the prepectoral technique are promising for similar rates of complications compared to subpectoral techniques.30–32 The main advantage of the prepectoral technique is avoiding distorting animation. Prepectoral reconstruction may also improve projection for the large breast, where an 800-cc implant replaces only a portion of the breast size. Depending on the technique, prepectoral reconstruction may decrease surgeon operative time, which is likely one of the reasons for the increasing popularity of the procedure. The greatest disadvantages are in more superior pole implant visibility and rippling and greater material cost. The implant visibility can often be improved with fat grafting in subsequent procedures. With the prepectoral technique, the implant tends to sit lower on the chest wall compared with subpectoral implants. This can be an important advantage in unilateral breast reconstructions in patients with ptotic breasts. However, it can be a disadvantage in bilateral reconstructions. The senior author’s (P.D.N.) general preferences are subpectoral/acellular dermal matrix for bilateral and prepectoral acellular dermal matrix anterior coverage for unilateral reconstructions, with some notable exceptions (Fig. 10).
Many comparisons of prepectoral versus subpectoral reconstruction continue to be debated, including whether there is a difference in overall pain and recovery, and long-term outcomes of stability and capsular contracture. In their large series, Sigalove et al. discuss that patients have “less pain and a faster recovery” with prepectoral reconstruction,26 and in a small series of tissue expanders, Walia et al. found decreased pain with prepectoral placement.33 Conversely, Baker et al. measured pain scores and length of stay in their prospective study and found no difference in pain or length of stay between subpectoral and prepectoral procedures.34 Most likely, pectoralis muscle elevation contributes to pain in some but not all patients. Overall pain in both techniques may be secondary to nerve pain from excessive traction or dissection during mastectomy, which can be modified by enhanced recovery protocols including nerve blocks, gabapentin, and acetaminophen. Long-term outcomes may be influenced by technique and material.
Advances in tissue expander design have included texturing of devices for improved capsule quality and avoiding malposition. An integrated valve has eliminated remote valve dysfunction failures. Tissue expanders now focus on lower pole expansion for more natural shape. A new device (AeroForm; AirXpander, Inc., San Jose, Calif.) uses carbon dioxide instead of saline for controlled expansion. The advantages of patient and physician convenience for this device are offset by disadvantages of device bulk, permeation, and cost. With knowledge of breast implant–associated anaplastic large cell lymphoma (BIA-ALCL) and its association with textured implants, new smooth-walled tabbed expanders have resurfaced. The question remains of whether the new smooth-walled expanders can improve on problems of poor capsule quality and device malposition seen in the earlier generations of smooth-walled expanders.
Silicone gel implants have the advantage of a more natural appearance and feel compared with saline implants with similar safety profiles. Implants are chosen based on breast base diameter and breast implant volume. Lower projecting implants have a larger diameter-to-volume ratio, whereas higher projecting implants have a more narrow diameter. Cohesive shaped anatomical implants offer a stiffer gel to help minimize rippling. These implants also have a better cosmetic result in the prepectoral position compared to round implants and may have an advantage with postmastectomy radiation therapy. The main disadvantage includes the risk of BIA-ALCL, which is a rare low-grade lymphoma associated primarily with textured implants.35 Although uncommon, the risk of BIA-ALCL has led many surgeons in the United States to offer exclusively the smooth round implants. Other disadvantages for some patients include a risk of rotation and lack of upper pole projection. Modifications have subsequently been made to round devices to make them more cohesive. The first modification includes an increased fill ratio using the same gel, which makes the implant slightly stiffer to help minimize rippling. The second modification is a cohesive round silicone gel implant with all of the advantages of the cohesive shaped implants but without the risks of texturing. However, these implants naturally flip in the anterior/posterior position. With the highest projecting cohesive round implants, a posterior flip presents as a noticeable new flatness of the device. The device can often be flipped anterior in the office, but it may be a recurring problem for the patient, only treatable by exchange to a different device style.
POSTOPERATIVE MANAGEMENT AND OUTCOMES
Skin edges are trimmed or deepithelialized and meticulously closed in layers. Surgical glue seals the incisions and Tegaderm (3M, Maplewood, Minn.) coverage allows patients to shower. Drains sites are covered by BioPatches (Ethicon, Inc., Somerville, N.J.) or sterile gauze and Tegaderm to help prevent bacterial contamination. Devices may be stabilized by the addition of Microfoam (3M) tape or a foam dressing. Patients are followed weekly until drains are removed. The typical criteria for drain removal is less than 20 to 30 cc/24 hours. A light compressive bra or wrap is placed following surgery or before patient discharge.
Pain management planning begins before surgery. Enhanced recovery after surgery pathways using multimodal pain therapy are gaining traction and offer patients nonnarcotic options for pain control.36 A typical regimen includes 900 mg of acetaminophen and 600 mg of gabapentin given before surgery and a postoperative regimen of gabapentin 100 mg or 200 mg twice daily for 1 week or more after surgery. Furthermore, paravertebral or local nerve blocks may help minimize intraoperative and postoperative opioid use.
Controversy remains regarding continuation of postoperative antibiotics with literature support for and against.37,38 The authors promote risk stratification with potential advantages in prepectoral or partial muscle coverage techniques with drains in contact with devices or acellular dermal matrix and in high-risk patients or poor flap perfusion; conversely, there may be no advantage and even disadvantage in patients with total muscle coverage and an axillary drain without any specific risk factors. Good outcomes can be achieved with implant-based reconstruction, although complications can occur. The most common acute complications include skin and nipple necrosis, infection, and seroma. Acute complications are best managed aggressively with excision of necrotic tissue, drainage of seromas, and treatment of infections with antibiotics and/or device removal or replacement. Surgeons should strive for infection rates and explantation rates to be less than 5 percent.
Now more than ever, we have the ability to reconstruct breasts that often appear as good as or, in some cases, better than the native breast with implant-based reconstruction. Together with the patients, we can tailor the incision, device, and technique to meet their reconstructive goals.
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38. Colwell AS. Discussion: Do prolonged prophylactic antibiotics reduce the incidence of surgical-site infections in immediate prosthetic breast reconstruction? Plast Reconstr Surg. 2016;138:1150–1151.