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Improving Outcome in Immediate Alloplastic Breast Reconstruction, an Algorithm for Operative Decision Making

Shay, Tamir, MD*; Cohen, Avi A., MD*; Ad-El, Dean, MD*,†

Plastic and Reconstructive Surgery – Global Open: October 2018 - Volume 6 - Issue 10 - p e1845
doi: 10.1097/GOX.0000000000001845

From the *Department of Plastic Surgery & Burns, Rabin Medical Center, Petah Tikva, Israel

Tel Aviv University School of Medicine, Tel Aviv, Israel.

Published online 2 October 2018.

Received for publication March 20, 2018; accepted May 7, 2018.

Submitted as a Video Plus article, the enclosed video narrates and illustrated a decision making algorithm frequently utilized in our department for applicable patients undergoing mastectomy and immediate alloplastic reconstruction.

Disclosure: The authors have no financial interest to declare in relation to the content of this article. The Article Processing Charge was paid for by the authors.

Supplemental digital content is available for this article. Clickable URL citations appear in the text.

Avi A. Cohen, MD, Department of Plastic and Reconstructive Surgery, Rabin Medical Center, Beilinson Hospital, 39 Jabotinski st., Petach Tikva, Israel, E-mail:

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

Implant-based breast reconstruction presently comprise the lion’s share of postmastectomy reconstructions,1 reflecting among other factors the increased requirement of bilateral reconstruction, the taxing requirements of autologous reconstruction, and financial implications thereof.2 Difficult to predict, the aesthetic outcome of immediate, postmastectomy, alloplastic breast reconstruction, may vary considerably across patients, especially in cases of skin-sparing or nipple-sparing surgery.3–5

The end-result skin flap viability and the dimensions of the resulting reconstructed breast skin envelope, which it defines, are challenging to assess during the initial operation,.6–12 Arguably, this warrants better means of preoperative and intraoperative assessment and decision making.13–15 We present here a possible tool as such, in the form of a simple algorithm, to improve the final outcome of breast reconstruction.

In any breast contouring surgery, reconstructive and aesthetic, correctly adjusting volume to skin envelop is paramount to creating an aesthetic and proportional breast mound.2 , 6–8 , 15–27

Our proposed algorithm for immediate alloplastic breast reconstruction hinges on 3 key factors (Fig. 1):

Fig. 1

Fig. 1

  1. The patient habitus
  2. The planned envelope
  3. The remaining viable skin flaps following mastectomy.
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Discussing with the patient, it is important to determine the desired size and shape of the reconstructed breast in comparison with its preoperative form. Where a larger breast is desired, a 2-stage reconstruction is planned using a tissue expander. If a smaller breast is intended, an envelope reduction procedure may be required following completion of mastectomy. When the remaining envelope matches the planned size and shape of the desired breast a “direct to implant” procedure can be performed.

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Following mastectomy, an implant pocket is created in a submuscular plane, raising a pectoralis major flap and utilizing an ADM to complete the inferior pole of the pocket as needed. The final desired implant is selected with regard to the final desired breast mound, via planning an appropriate sizer in said pocket. The skin envelope is then assessed for viability. If a sufficient viable envelope is uncertain, a 2-stage reconstruction will be performed via tissue expansion.

Given a sufficient envelope, the reconstructed breast is evaluated via a sizer in several key stages (ie, after mastectomy, after elevation of the pectoralis flap, and after creation of the final submuscular implant-pocket), allowing the surgeon to modify the skin envelope or the muscle coverage according to the desired shape and size before closure over the final implant (see video, Supplemental Digital Content 1, which discusses how to improve outcome in alloplastic breast reconstruction. This video is available in the “Related Videos”section of Full-Text article at or at



Notably the key novelty of our algorithm (as compared with the common practice reflected by recent literature) is that the implant is selected only with regard to the desired final breast mound, whereas the skin envelope is assessed afterward, having placed an appropriate submuscular sizer, electing the next step in reconstruction accordingly as mentioned.

None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this article.

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1. Albornoz CR, Bach PB, Mehrara BJ, et al. A paradigm shift in U.S. Breast reconstruction: increasing implant rates. Plast Reconstr Surg. 2013;131:15–23.
2. Cemal Y1, Albornoz CR, Disa JJ, et al. A paradigm shift in U.S. breast reconstruction: Part 2. The influence of changing mastectomy patterns on reconstructive rate and method. Plast Reconstr Surg. 2013;131:320e–326e.
3. Bezuhly M, Wang Y, Williams JG, et al. Timing of postmastectomy reconstruction does not impair breast cancer-specific survival: a population-based study. Clin Breast Cancer. 2015;15:519–526.
4. Bezuhly M, Temple C, Sigurdson LJ, et al. Immediate postmastectomy reconstruction is associated with improved breast cancer-specific survival: evidence and new challenges from the Surveillance, Epidemiology, and End Results database. Cancer. 2009;115:4648–4654.
5. Kronowitz SJ, Robb GL. Radiation therapy and breast reconstruction: a critical review of the literature. Plast Reconstr Surg. 2009;124:395–408.
6. Susarla SM, Ganske I, Helliwell L, et al. Comparison of clinical outcomes and patient satisfaction in immediate single-stage versus two-stage implant-based breast reconstruction. Plast Reconstr Surg. 2015;135:1e–8e.
7. Kronowitz SJ. Delayed-immediate breast reconstruction: technical and timing considerations. Plast Reconstr Surg. 2010;125:463–474.
8. Colwell AS, Tessler O, Lin AM, et al. Breast reconstruction following nipple-sparing mastectomy: predictors of complications, reconstruction outcomes, and 5-year trends. Plast Reconstr Surg. 2014;133:496–506.
9. Endara M, Chen D, Verma K, et al. Breast reconstruction following nipple-sparing mastectomy: a systematic review of the literature with pooled analysis. Plast Reconstr Surg. 2013;132:1043–1054.
10. Abedi N, Ho AL, Knox A, et al. Predictors of mastectomy flap necrosis in patients undergoing immediate breast reconstruction: a review of 718 patients. Ann Plast Surg. 2016;76:629–634.
11. Lam TC, Hsieh F, Boyages J. The effects of postmastectomy adjuvant radiotherapy on immediate two-stage prosthetic breast reconstruction: a systematic review. Plast Reconstr Surg. 2013;132:511–518.
12. Cordeiro PG, Albornoz CR, McCormick B, et al. The impact of postmastectomy radiotherapy on two-stage implant breast reconstruction: an analysis of long-term surgical outcomes, aesthetic results, and satisfaction over 13 years. Plast Reconstr Surg. 2014;134:588–595.
13. Ho AL, Bovill ES, Macadam SA, et al. Postmastectomy radiation therapy after immediate two-stage tissue expander/implant breast reconstruction: a University of British Columbia perspective. Plast Reconstr Surg. 2014;134:1e–10e.
14. Macadam SA, Ho AL, Cook EF Jr, et al. Patient satisfaction and health-related quality of life following breast reconstruction: patient-reported outcomes among saline and silicone implant recipients. Plast Reconstr Surg. 2010;125:761–771.
15. Rinker B. A comparison of methods to assess mastectomy flap viability in skin-sparing mastectomy and immediate reconstruction: a prospective cohort study. Plast Reconstr Surg. 2016;137:395–401.
16. Maxwell GP, Van Natta BW, Bengtson BP, et al. Ten-year results from the Natrelle 410 anatomical form-stable silicone breast implant core study. Aesthet Surg J. 2015;35:145–155.
17. Gdalevitch P, Ho A, Genoway K, et al. Direct-to-implant single-stage immediate breast reconstruction with acellular dermal matrix: predictors of failure. Plast Reconstr Surg. 2014;133:738e–747e.
18. Salzberg CA, Ashikari AY, Koch RM, et al. An 8-year experience of direct-to-implant immediate breast reconstruction using human acellular dermal matrix (AlloDerm). Plast Reconstr Surg. 2011;127:514–524.
19. Zhao X, Wu X, Dong J, et al. A meta-analysis of postoperative complications of tissue expander/implant breast reconstruction using acellular dermal matrix. Aesthetic Plast Surg. 2015;39:892–901.
20. Kim JY, Davila AA, Persing S, et al. A meta-analysis of human acellular dermis and submuscular tissue expander breast reconstruction. Plast Reconstr Surg. 2012;129:28–41.
21. Lee KT, Mun GH. Updated evidence of acellular dermal matrix use for implant-based breast reconstruction: a meta-analysis. Ann Surg Oncol. 2016;23:600–610.
22. Davila AA, Seth AK, Wang E, et al. Human acellular dermis versus submuscular tissue expander breast reconstruction: a multivariate analysis of short-term complications. Arch Plast Surg. 2013;40:19–27.
23. Matsen CB, Mehrara B, Eaton A, et al. Skin flap necrosis after mastectomy with reconstruction: a prospective study. Ann Surg Oncol. 2016;23:257–264.
24. Munabi NC, Olorunnipa OB, Goltsman D, et al. The ability of intra-operative perfusion mapping with laser-assisted indocyanine green angiography to predict mastectomy flap necrosis in breast reconstruction: a prospective trial. J Plast Reconstr Aesthet Surg. 2014;67:449–455.
25. Kanuri A, Liu AS, Guo L. Whom should we SPY? A cost analysis of laser-assisted indocyanine green angiography in prevention of mastectomy skin flap necrosis during prosthesis-based breast reconstruction. Plast Reconstr Surg. 2014;133:448e–454e.
26. Colwell AS, Damjanovic B, Zahedi B, et al. Retrospective review of 331 consecutive immediate single-stage implant reconstructions with acellular dermal matrix: indications, complications, trends, and costs. Plast Reconstr Surg. 2011;128:1170–1178.
27. Selber JC, Wren JH, Garvey PB, et al. Critical evaluation of risk factors and early complications in 564 consecutive two-stage implant-based breast reconstructions using acellular dermal matrix at a single center. Plast Reconstr Surg. 2015;136:10–20.

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Copyright © 2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Society of Plastic Surgeons. All rights reserved.