Implant-based reconstruction is the most common form of breast reconstruction in the US and it carries with it a number of advantages over autologous techniques. These include a lower initial cost, reduced operating room (OR) time, reduced hospital stay, avoidance of a donor scar, and in most cases, the technique is technically simpler and microvascular skills are not required. In the longer term, many of the advantages may be lost because the need for subsequent revision is increased as a result of complications such as capsular contracture, implant malposition, or implant rupture. In addition, it is difficult to achieve satisfactory symmetry in unilateral reconstruction as the soft tissue characteristics of a natural breast cannot be recreated and natural ptosis does not develop over time in the implant reconstructed breast. This is a key point to highlight to patients undergoing unilateral reconstruction to ensure they are well informed preoperatively and have realistic expectations from surgery.1–4 A technique that may help both the appearance and feel of an implant reconstruction is fat transfer, as this alters the ratio of autologous to implant volume, although this will add further procedures and costs to the process.5
The use of ADM has dramatically increased for breast reconstruction during the past decade with a number of different sources providing the matrices (bovine, porcine, human) and many manufacturers producing it. However, its use remains “off-label” from the FDA perspective in breast reconstruction. There are many indications and it is certainly not limited only to immediate subpectoral reconstruction. It is useful for both immediate and delayed reconstruction and prepectoral and submuscular reconstructions. The matrix should be tightly adherent to a permanent implant; however, some laxity should be left in the setting of planned tissue expansion. The matrix acts as an internal bra to support the implant in the correct place and also provide more soft tissue cover for the prosthesis. A further proposed advantage is that single-stage immediate reconstruction can be performed with the ADM providing inferior and lateral cover for the implant where the pectoralis muscle fails to provide cover. This may be the case, but overlying tissue vascularity in the inferior pole will be reduced given the thickness of the postmastectomy skin flap and wound healing problems can occur. Care must be taken to carefully suture the ADM to the pectoralis muscle superiorly and to the inframammary fold (IMF) inferiorly. Postreconstruction animation can still occur with this technique and also there is unlikely to be much development of natural breast ptosis due to the rigid fixity of the reconstruction. ADM does not have a proven role in reducing capsular contracture rates nor the effects of radiation therapy. One major concern with ADM is the cost effectiveness of its use as it is expensive and generally costs more than the implants themselves.1–4 In patients with larger breasts, it is preferable to utilize a de-epithelialized inferior dermal pedicle to cover the implant caudal to pectoralis major as this often provides thicker soft tissue cover than a matrix, is vascularized, and saves the cost of the ADM. The procedure is performed in the same way as an inferior pedicle breast reconstruction is undertaken but is only really applicable to immediate reconstruction (ideally prophylactic skin-sparing mastectomies) in patients with large ptotic breasts.
Prepectoral breast implant reconstruction has grown in popularity over the past decade. Historically, implant reconstruction had been performed in the subcutaneous plane but poor implant support and high complication rates led to the change in favor toward submuscular implant placement. Due to the problems with animation and disruption of the pectoralis muscle, prepectoral placement has seen a resurgence in use. However, while there is some evidence to show that early results are reasonable, there is no long-term evidence to support its use and it may be that with time the procedure falls out of favor once more.1–3 The procedure itself is not especially difficult and breast animation is avoided. The procedure may be staged but can also be performed in a single stage. The requirement for any procedure to need ADM needs careful consideration as there are cost implications and the risk of seroma development may be increased. Prepectoral breast implant reconstruction most often involves completely wrapping the implant in ADM and then suturing this to the chest wall. The concern some plastic and reconstructive surgeons have with this approach is the use of nonvascularized tissue being placed in a poorly vascularized pocket in combination with an implant. The long-term outcome reports of these techniques will be useful to guide practice preferences in the future.
4. de Blacam C, Momoh AO, Colakoglu S, Slavin SA, Tobias AM, Lee BT. Cost analysis of implant-based breast reconstruction with acellular dermal matrix. Ann Plast Surg 2012;69(5):516–520
5. Salgarello M, Visconti G, Barone-Adesi L. Fat grafting and breast reconstruction with implant: another option for irra- diated breast cancer patients. Plast Reconstr Surg 2012;129(2):317–329
The adequacy of mastectomy flap vascularity is absolutely vital to successful breast reconstruction as the flaps provide the final soft tissue cover for the reconstructed breast. Mastectomy flaps by their very nature have compromised vascularity by the fact that they have been separated from the breast and thinned, sometimes close to the subdermal level. Flap vascularity is best assessed clinically with consideration given to tissue thickness, amount of exposed dermis, skin color, and capillary refill. Dark, congested flaps are likely to incur necrosis or wound dehiscence particularly if placed under additional stress and tension over an implant. In such circumstances, reconstruction is better delayed to allow for recovery or demarcation of the mastectomy flaps. Months down the line, the flaps may be progressively expanded safely and reconstruction still completed. Flap thickness following mastectomy varies considerably according to the patient and the surgeon performing the procedure. Clinical assessment is not the only way to assess the flaps and there are adjuncts including indocyanine green (ICG) fluorescence imaging and ICG laser angiography which may help to evaluate perfusion intraoperatively if uncertainty remains.1,2
The simplest approach to reconstruction for this patient is to utilize an implant-based technique. As she is disease free, her skin envelope is maintained and no postoperative radiotherapy will be needed. These factors support the use of a prosthetic device. It is important to provide complete soft tissue cover for the implants as the skin flaps will be thin in this patient. For such cases, the use of dermal matrix has become popular. Superiorly the implant/expander can be covered by the pectoralis major muscle and serratus anterior. Inferiorly the dermal matrix can cover the implant from the inframammary fold to the pectoralis muscle. In larger breasted patients, the use of a de-epithelialized inferior skin flap is favored to provide additional implant cover without a dermal matrix. This patient does not have sufficient breast tissue for this approach. To use bilateral pedicled TRAM flaps in this patient would be a poor choice, particularly given her age, because of the morbidity associated with sacrifice of both rectus muscles. In addition, given her BMI it is unlikely she will have sufficient tissue for autologous reconstruction. Bilateral LD flaps could be used to provide additional implant cover but there is no need for harvesting skin as the native breast skin is preserved. Use of LD muscle flaps would also involve significant back scarring, which can be avoided by using an implant and matrix combination.1–4
Radiation therapy is often utilized as a component of breast cancer treatment, particularly in patients with larger or more aggressive tumors or those with axillary lymph node involvement. Radiation has known detrimental effects on the skin and subcutaneous tissues, including altered vascularity, radiation dermatitis, atrophy, dryness, discoloration, and chronic fibrosis. Lee and Mun1 analyzed 20 different studies looking at complication rates with implant reconstruction in patients who had previously undergone radiation therapy. Pooled analysis showed a significant increase in complications after radiation therapy, including reconstructive failure, infection, seroma formation, and mastectomy flap necrosis. Complication rates were higher regardless of reconstructive method used, including use of ADM, one versus two stage reconstruction, immediate versus delayed reconstruction, or nipple-sparing mastectomy. Although radiation does therefore affect the cosmetic outcome in terms of the soft tissues, there is no evidence to show that it will reduce the longevity of the implant itself nor increase the risk of implant failure/rupture. The reason therefore for early revision being necessary in implant-based reconstruction after radiation is soft tissue related rather than device related. It may be that the negative effects of radiation on an implant-based reconstruction are more severe when an expander is in place as opposed to a permanent implant.2,3
The most common complication within the first year after implant-based breast reconstruction is infection1 and the rates are markedly higher following radiation therapy. This highlights the importance of meticulous surgical technique including adequate skin preparation with 2% alcohol-based chlorhexidine, use of systemic and pocket irrigation with antibiotics, and minimizing hematoma risk. Ensuring adequacy of mastectomy skin flaps and thereby minimizing risk of wound healing complications should also be a high priority as should swift management of seromas which could themselves become infected. The other options all represent risks in the first year with the exception of capsular contracture, which is a later complication and is estimated to be around 10% risk. In the long term, 88% of patients have good aesthetic outcomes1 and most are satisfied with the outcomes of their surgery.2