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IMPLANT-BASED BREAST RECONSTRUCTION

Overview

  • Evolution of implant-based breast reconstruction largely secondary to:

    • Earlier detection of lower stage breast cancer through screening

    • More conservative surgical resections of breast cancer​

    • Adjuvant and neoadjuvant therapies

    • Increasing recognition of the value of immediate reconstruction

    • Development of ADMs

    • Option of expander-implant
       

Overview

Breast tissue expanders

  • Commonly used in 2-stage implant-based breast reconstruction

  • Simple mastectomy – insufficient skin/soft tissue envelope for implant

  • Available with remote port

  • Once inserted, expansion delayed until wound healed and stable

  • 2nd stage required for replacement with implants

  • Disadvantage:

    • Pocket control important to ensure expansion occurs to achieve required pocket for implant

      • Expander migration may cause tissue expansion in the wrong place

    • Remote ports can flip

      • May require further procedure to reposition port

    • Infection from non-sterile expansion

    • Generally same problems as implants

  • ​Stress relaxation - The force required to maintain a state of stretch at a constant length gradually reduces

  • Creep - Continuous stretching and tissue thinning stimulate production of new epithelium, collagen, elastic fibers, and neovasculogenesis

  • Changes:

    • Epidermal thickening and dermal thinning.

    • Formation of a capsule around the expander.

    • Muscle thinning and reduction in mass.

    • Bone thinning and new bone formation peripherally.

    • Mechanical strain triggering DNA synthesis and cellular proliferation.

    • Increased vascularity
       

Breast tissue expanders

BREAST AUGMENTATION

Patient selection

  • Examination:

    • Bra cup size

    • Ptosis

    • Measurements (SN-N, N-N, N-IMF)

    • Skin quality and scars

    • General examination

  • Photographs

  • External gel “bra” sizers

    • Good to give the patient an estimation of volume

  • Pocket selection

    • Type of mastectomy (How much skin is left?):

      • Simple mastectomy

      • Skin sparing mastectomy

      • Nipple sparing mastectomy

    • Adjuvant radiotherapy?

      • What tissues available for internal pocket?
        ​​

Patient selection

Techniques

  • 2-stage expander-implant reconstruction

    • 1st stage - Immediate insertion of deflated expander in subpectoral pocket post mastectomy

    • Interim - Expansion as outpatient

    • 2nd stag - Replacement of expander with implant

  • 1-stage "direct to implant" subpectoral reconstruction

    • ​Implant placed directly into subpectoral pocket after SSM/NSM with ADM as inferior pocket

    • Advantages:

      • Additional protection against implant extrusion

      • Decrease in rippling

    • Disadvantages:

      • Deficiencies in upper pole contour

      • Animation deformity

      • Increased postoperative pain and recovery

  • 1-stage "direct to implant" prepectoral reconstruction

    • ​Implant placed directly into prepectoral pocket after SSM/NSM with ADM as pocket through “wrapping” or “tenting”

    • Improved understanding of mastectomy planes

    • Advances in biological mesh technology

    • Advantages: 

      • Reduces postoperative pain

      • Lower risk of animation
        ​​

Techniques
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