|Year : 2019 | Volume
| Issue : 2 | Page : 528-533
Staged breast reconstruction after mastectomy using tissue expander followed by permanent prosthesis
Alaa A El Sisi1, Sherif M El Kashty2, Ahmed G El Tatawy1, Alaa M. El Shamly El Sayed Shoeib3
1 Department of General Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Plastic Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt
3 Department of Surgical Oncology, Ministry of Health, El-Obour Insurance Hospital, Kafr El-Sheikh, Egypt
|Date of Submission||09-Dec-2017|
|Date of Acceptance||18-Feb-2018|
|Date of Web Publication||25-Jun-2019|
Alaa M. El Shamly El Sayed Shoeib
Department of Surgical Oncology, Ministry of Health, El-Obour Insurance Hospital, Kafr El-Sheikh 33735
Source of Support: None, Conflict of Interest: None
The aim of this study was to evaluate immediate breast reconstruction after mastectomy, by using tissue expander, followed by insertion of permanent prosthesis, as regards advantages, its complications and patient satisfaction.
Social and psychological effects of mastectomy on women make breast reconstruction a great challenge for oncoplastic surgeons; hence, staged breast reconstruction depends on tissue expander, and a prosthetic device may provide a good solution for that challenge.
Patients and methods
This study included 20 patients admitted in Menoufia University Hospitals and El-Obour Insurance Hospital with a diagnosis of breast carcinoma in the 2-year period spanning from January 2015 to February 2017. The studied patients refused autogenous reconstruction, and all of them were classified as early staged breast cancer. The first stage of reconstruction included mastectomy with axillary clearance, submuscular expander insertion, and their regular expansion, whereas in the second stage, the expander was removed and replaced by permanent prosthesis.
Seroma formation occurred in two patients, wound infection in two patients, one patient had a ruptured implant and another had expander leakage, whereas one patient failed by capsular contracture. All postoperative complications were managed conservatively or by surgical intervention.
Staged breast reconstruction, by using tissue expander, followed by permanent prosthesis, is an excellent solution in some patients, provided they are carefully selected.
Keywords: breast neoplasms, mammaplasty, mastectomy, postoperative complications, tissue expansion devices
|How to cite this article:|
El Sisi AA, El Kashty SM, El Tatawy AG, El Sayed Shoeib AM. Staged breast reconstruction after mastectomy using tissue expander followed by permanent prosthesis. Menoufia Med J 2019;32:528-33
|How to cite this URL:|
El Sisi AA, El Kashty SM, El Tatawy AG, El Sayed Shoeib AM. Staged breast reconstruction after mastectomy using tissue expander followed by permanent prosthesis. Menoufia Med J [serial online] 2019 [cited 2019 Sep 16];32:528-33. Available from: http://www.mmj.eg.net/text.asp?2019/32/2/528/260933
| Introduction|| |
During the last century, breast reconstruction after mastectomy has become an important part of comprehensive treatment for patients with breast cancer. Breast reconstruction was initially created to reduce complications of mastectomy and to diminish chest wall deformities. Now, however, it is known that reconstruction also can improve the psychosocial well-being and quality of life of patients who have breast cancer. Silicone breast implants were introduced in the early 1960s, but, in 1992, the Food and Drug Administration (FDA) placed a moratorium on silicone implants because of concerns with regard to its safety of use in patients. Since then saline implants have been exclusively used in the USA, until recently. In November 2006, after an extensive scientific review revealed no significant risks, the FDA approved the use of silicone implants for breast reconstruction in women of all ages. Now that the silicone implant has been deemed safe, the FDA is requiring a 10-year follow-up to continue to monitor these implants, as part of a postapproval study.
Radovan and colleagues, introduced tissue expansion with placement of an uninflated implant under the residual skin and muscle, followed by intermittent filling of the implant. This process resulted in a gradual expansion of the overlying tissue. At the final stage of breast reconstruction, permanent implants replaced the expander implant. This technique remained plagued by complications such as capsular contracture. Breast reconstruction advanced further with the popularization of the transverse rectus myocutaneous flap by Radovan and colleagues,.
Breast reconstruction using implants often requires a tissue expander to create room for it before its implantation, as, after mastectomy surgery, there is less skin remaining at the site of the breast than was present preoperative. For an implant to be comfortably placed, the surgeon first surgically inserts a balloon-like tissue expander under the chest muscle. At weekly intervals – beginning 2 weeks after surgery – the surgeon injects saline solution into the tissue expander through a small valve located just below the surface of the patient's skin. Once the tissue expander has sufficiently stretched the skin, the surgeon replaces it with a breast implant.
The aim of our work was to evaluate immediate breast reconstruction after mastectomy, by using tissue expander, followed by insertion of permanent prosthesis, as regards advantages, disadvantages, and rate of complications.
| Patients and Methods|| |
This study was conducted at the Department of General Surgery, Menoufia University Hospitals, in a duration of 2 years from January 2015 to February 2017, with a follow-up period of an average of 6 months. The study was approved by the Ethical Committee of Menoufia Faculty of Medicine. All patients gave their written informed consent before inclusion into the study. The study included 20 patients with a mean age of 43.2 years.
The study included patients with early staged breast carcinoma and who refused autogenous reconstruction, and it excluded patients with advanced breast cancer or patients who had undergone previous mastectomy, and who projected autogenous reconstruction.
Patients were subjected to full history taking, clinical examination (general examination of the patient, and local examination of breast mass and axilla), routine laboratory investigations (complete blood picture, liver profile, kidney function tests, prothrombin time and activity, international normalized ratio, fasting blood sugar, hepatitis markers), breast mammography and ultrasound, and metastatic workup, which included chest radiography, abdominopelvic ultrasound, and bone scan.
The technique was performed under general anesthesia in all cases. Patients were placed on the operating room table in the supine position with the arm of the affected side extended on a side table at 90° angle from the body. Both breasts and axilla of the affected side were exposed. The incision line was drawn by a permanent marker. Sterilization was carried out, from the shoulder superiorly, up to the umbilicus inferiorly, including both breasts and arm of the affected side, up to the elbow. Skin incision was made with a scalpel, and the upper and lower flaps were developed using cautery; the dissection extended laterally to the anterior border of the latissimus dorsi muscle, medially to the border of the sternum, superiorly to the clavicle and subclavius muscle, and inferiorly to the inframammary line [Figure 1]. Surgical dissection of the breast tissue starting from its medial aspect to lateral one including pectoralis major's fascia. Following the lateral margin of the pectoralis major muscle and opening the clavipectoral fascia to enter the axilla, the axillary vein was identified, and dissection of axillary lymph nodes following the borders of the axilla and including level I, II, and III lymph nodes was carried out. (The axilla is bordered by the axillary vein superiorly, the latissimus dorsi laterally, pectoralis muscle medially, and the serratus muscle anteriorly.) Thoracodorsal nerve/vessels (thoracodorsal bundle) were identified and preserved, as they run in the axillary fat pad. The long thoracic nerve (runs related to chest wall posteriorly) is identified and preserved.
|Figure 1: Lifting the breast off the pectoralis muscle with the fascia in the specimen.|
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The axillary contents were dissected off the thoracodorsal bundle up to the level of the axillary vein. The contents were then retracted inferiorly, the medial attachments to the serratus muscle were divided, and the specimen was removed en-bloc with the breast. Progressive dissection was carried out beneath the pectoralis major muscle superiorly, medially, and inferiorly. The inferior part of the dissection included the anterior rectus sheath, and the aponeurosis of the external oblique, and continued beneath the serratus anterior muscle. Thereafter, dissection of the sternal attachments of the pectoralis major was performed, from the second intercostal space to the inferior edge of the pocket, and dissection of the lowermost attachments of the pectoralis major and the serratus anterior muscle at the same level as the contralateral inframammary fold. The pocket was completely submuscular, except at the inframammary fold, where it was extended into the deep fascial layer, avoiding direct continuity with the mastectomy site. The expander was immersed in povidone iodine solution, and complete evacuation of air with aspiration of any retained air within the inner expansion chamber was carried out. The expander was partially inflated with saline while ensuring there was no leakage [Figure 2]. A small amount of saline (up to 20% final volume) left within the expander as a degree of partial inflation will aid insertion. Insertion of the expander partially inflated and correctly orientated is carried out, followed by insertion of two suction drains in the submuscular pocket and axilla, following axillary dissection. The submuscular pocket is closed by interrupted sutures [Figure 3]. This is followed by closure of both skin and subcutaneous tissues.
Patients were discharged the next day of operation, and drains were removed when the output was less than 30 ml in a 24 h period. Patients were encouraged to ambulate early and begin arm stretches.
Regular visits were arranged for all patients weekly. The expander was inflated with 50–100 ml of saline according to expander total volume and until reaching the desired size.
The second stage (started after completion of adjuvant chemotherapy and radiotherapy) included the following:
- Removal of the temporary expander
- Insertion of permanent prosthesis.
Adjustments to the contralateral breast were carried out at this stage. Choosing an appropriate size and shape of prosthesis, width, height, and projection of the contralateral breast had been accurately assessed, as they are crucial parameters in planning the final stage of reconstruction. The skin incision was placed toward the lateral end of the postmastectomy scar, and an incision was made along the free edge of the pectoralis major muscle, or in the line of its muscle fibers. The tissue expander was removed. A pocket for the definitive prosthesis was prepared by creating multiple capsulotomies. The lateral, upper, and lower incisions of the capsule edges were tailored according to the specific requirements for enlargement of the pocket. Extension of the lower pole of the new breast was carried out through a combination of radial and transverse capsulotomies positioned relative to the inframammary fold.
Following capsulotomy, the superficial fascia was divided at the level of the inframammary fold, which is marked by needles inserted into the pouch through the skin. The lower edge of the superficial fascia is sutured to the chest wall musculature using continuous sutures of strong absorbable material (1/0). This is followed by insertion of drains. Following insertion of the definitive prosthesis, the final result is checked with the patient, once the patient was elevated to the sitting position. The wound was closed in two layers using soluble suture material.
Follow-up after final stage
Drains are removed when daily volumes are less than 30–40 ml. A well-fitting sports bra was advised to be worn following reconstruction. Intensive exercise was advised to be avoided for 2–3 weeks, although arm and shoulder mobilization was important following formal axillary dissection.
All data were collected, tabulated and statistically analyzed. The descriptive measures of central tendency (mean and median) and measures of dispersion (range, SD, minimum, and maximum), besides frequency and the percentage, were calculated by SPSS 20 statistical software package (SPSS Inc., Chicago, Illinois, USA).
| Results|| |
This study had included 20 patients who were divided into two groups of age: the first group consisted of patients aged between 29 and 45 years and comprised 65% of the studied patients, and the second group consisted of patients who were aged between 45 and 60 years and comprised 35% of the studied patients [Table 1]. The associated comorbidities were diabetes mellitus (15%) and hypertension (10%); however, these conditions were controlled preoperatively. Invasive ductal carcinoma was the common pathology among the studied patients (45%), followed by ductal carcinoma in situ, which represents 15% of the study result. Paget's disease and papillary carcinoma represent 10% of the results for each. Invasive lobular carcinoma, inflammatory carcinoma, lobular carcinoma in situ, and medullary carcinoma represented 5% of patients for each type [Table 2]. Variable sizes of breast mass were noticed, which were divided into three categories that ranged from 1.5 to 2.5 cm, in the first group, which represents 15% of the studied patients, in the second group the dimension ranged from 2.5 to 3.5 cm, which represented 5% of patients, and in the last group, the mass size was more than 3.5 cm, representing 35% of the studied patients. The study included patients with staging of T1and T2, N1and N2 and all of them were classified as M0; patients staged as T1 represented 30% of the study, whereas T2 represented 70%. N1 stage was presented by eight (45%) patients and N2 by 12 (55%) patients.
The majority of patients did not have any complications (75% of the studied sample), but, unfortunately, 15% of them had wound infection and seroma formation; one patient, who represents 5% of the study population, had capsular contracture [Figure 4], another 5% had rupture of the inserted implant, and lastly 5% had leakage from the tissue expander in the first stage [Table 3]. According to the patients, 95% were satisfied; however, 5% were not satisfied with the end shape of the breast.
| Discussion|| |
The quality of the breast reconstruction will depend not only on surgeon skills but also on the amount of missing tissue, the patient's general health condition, the size of the opposite breast, and technique of breast reconstruction. Additional radiotherapy, heavy smoking, chemotherapy, and obesity can all have significant effects. Each patient is unique, and each operation is different. For most patients, successful breast reconstruction is possible and can usually be achieved. In the past 20 years, there was a dramatical change in developing diagnostic procedures for breast cancer, its treatment and surgery also development of operative procedures for breast reconstruction. Regarding breast surgery, there is a change of the concept from “remove all you can to do” to “remove all what in necessary to do”. This means significant reduction in the extent of breast cancer operations, which is based on better diagnostic methods, puncture of breast tissue under control of ultrasound, nuclear magnetic resonance, mammography, a new method of locoregional treatment of breast cancer, and, finally, sentinel lymph node biopsy. The surgical protocol has also been changed when radiotherapy and chemotherapy started to play an important role in the primary treatment of breast cancer.
The modern era of breast reconstruction using tissue expansion was pioneered by Radovan in the late 1970s and early 1980s. Since that time, great advances have been made, not only in the technique of expander/implant breast reconstruction, but also in the devices themselves. Anatomic expanders provide a more natural shape to the reconstructed breast by allowing preferential expansion of the lower pole. Textured expanders have allowed for more complete expansion by decreasing the amount of capsular contracture and by creating expansion in the desired location without expander migration.
Prosthetic reconstruction is most appropriate in patients who do not have sufficient autologous donor tissue in the abdomen or buttock region, and in obese patients. The best candidates for prosthetic reconstruction are patients in whom breast volume is moderate, with minimal ptosis, and in whom there is adequate and healthy soft tissue coverage over the prosthesis. Candidates with large and ptotic breast typically require reduction with mastopexy, but, in case of bilateral prophylactic mastectomies, symmetry is more readily achieved. Patient preference is also a very important issue. High-risk patients with inherited predisposition genes such as breast cancer genes (BRCA1 and BRCA2) usually need bilateral prophylactic mastectomies.
Adjuvant radiotherapy followed by mastectomy significantly reduced the risk of local recurrence. Meta-analysis published by the Early Breast Cancer Trialists Collaborative Group found a two-third reduction in the risk of recurrences with the addition of adjuvant radiotherapy.
A study from the Sloan-Kettering Cancer Center included 542 women who underwent expander/implant reconstruction without irradiation as the control group for 81 women receiving postmastectomy reconstruction irradiation. For the nonirradiated patients, this study found a 6% total complication rate and a 99% reconstruction completion rate, compared with a 11% complication rate and only a 90% reconstruction completion rate for the irradiated group.
In this study, there was no evidence that the failure rate or complications that occurred were caused by radiotherapy that had been administered to all our patients except one.
Castello et al., in a series of 56 immediate reconstructions using anatomic integrated-valve expanders only, reported overall rates of 37% for complications and 7% for complete failures. Our findings are comparable with the rates reported by Castello et al., although our total failure rates are different, because we followed up all our patients to completion of treatment, including a second round of expander introduction. The difference between the anatomic expander complication rate and the others may result from its design, with the rigid inflation port pressing against the mastectomy flap, which is plausibly more hazardous during immediate reconstruction or among irradiated patients. In addition, because the inflation valve is integrated into the expander's body, injection is directed into the implant pocket, probably increasing the potential for infection in this pocket.
Nahabedian et al. worked on a series of 130 patients reconstructed with an integrated-valve biodimensional expander; a 7.7% infection rate was found, which was comparable with the rates stated for round and Becker expanders. They found that radiation treatment had a significant association with infections in implant breast reconstruction.
Cordeiro et al. found an overall reduced successful reconstruction rate and a rise in all complication components compared with nonirradiated patients.
The majority of our patients did not have any complications (75% of the studied sample), but, unfortunately, 15% of them had wound infection and seroma formation, one patient who represented 5% of the study population had capsular contracture, another 5% had rupture of the inserted implant, and lastly 5% had leakage from the tissue expander in the first stage. Fortunately, in our study, no patient needed replacement of the final prosthesis, and most of our patients were satisfied with the end result (95% of cases), with one case representing 5% of the study population not being satisfied with the end shape of her breast.
The emotional benefits of immediate breast reconstruction have been widely discussed by Vandeweyer et al., concluding that the technique is safe and does not alter the biological behavior of the tumor.
| Conclusion|| |
Staged breast reconstruction by tissue expansion is an important and excellent technique, in the mind of the reconstructive surgeon, but should be used carefully and thoughtfully to obtain optimal results with this technique, which has benefited in recent years from advances in implant design and technology.
Financial support and sponsorship was provided by Menoufia University Hospitals and El-Obour Insurance Hospital.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3]