One-stage Immediate

Breast Reconstruction

With Adjustable Implants

Hilton Becker

INTRODUCTION

Although autologous tissue is ideal for breast reconstruction, the magnitude of the surgery, the length of recovery, potential complications, and the resultant scarring are of concern to many patients.

The increased awareness of the risk factors and the availability of genetic testing have increased the incidence of bilateral mastectomies being performed on younger women. These patients are eager to have immediate reconstruction with minimal scarring and minimal downtime. Many of these patients are already dissatisfied with their breasts and may have, or are considering, breast implants.

The ability to have a one-stage implant reconstruction with minimal or no visible scarring, as well as the opportunity to correct prior hypomastia or ptosis with minimal surgical time and downtime, is often more preferable to these patients than the use of autologous flaps.

The technique involves the following:

Mastectomy performed using the skin-sparing technique Muscle release and inframammary fold reconstruction Use of adjustable implants

TECHNIQUE

Preoperative planning is done together with the general surgeon who will be performing the mastectomy. Infra-

mammary folds are marked, and the extent of skin resection and feasibility of areolar skin preservation are discussed.

It is advantageous for the plastic surgeon to assist the general surgeon, at least initially, with the mastectomy.

The skin-sparing mastectomy is performed by the general surgeon using the circumareolar incision. Fiber-optic lighting is used to facilitate dissection. Care is taken to avoid trauma to the skin flaps. If necessary, a medial and lateral extension can be made to the circular incision for better exposure, or a separate incision can be made in the axilla for axillary dissection. Both incisions are easily concealed.

Preserving the fascia, avoiding any damage to the muscle, and maintaining viable skin flaps is key to facilitating an optimal reconstruction.

After the general surgeon has completed the skin-sparing mastectomy, the drapes are changed and hemostasis checked. Dissection begins at the lateral border of the pectoralis major muscle. The muscle is elevated and detached inferiorly at its insertion. It is also partially detached medially. The serratus anterior muscle is elevated laterally and detached inferiorly at the level of the inferior margin of the pectoralis major. The two muscles are then sutured together with interrupted sutures, thus expanding the submuscular pocket.

If the fascia has been removed and the muscle damaged, it may be preferable to close the incision and perform a delayed reconstruction at a later date. Alternatively, a muscle flap or alloderm may need to be used.

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Chapter 27: One-stage Immediate Breast Reconstruction With Adjustable Implants

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Figure 27.1 The Becker 50/50 implant. A: Implant prior to insertion. B: Implant overexpanded. C: Volume reduced and injection dome removed.

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Figure 27.2 Diagrammatic drawing of reconstructive technique. A: Defect following mastectomy. B: Pectoralis major muscle elevated. C: Pectoralis and serratus sutured together. Adjustable implant inserted beneath muscle flap. D: Adjustable implant in position. Injection dome buried in subcutaneous pocket. Inframammary fold reconstructed with sutures from edge of muscle flap to fascia at inframammary fold location.

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Figure 27.3 Diagrammatic representation of immediate reconstructive technique. A: Patient prior to mastectomy showing circumareolar incision. B: Insertion of adjustable implant in submuscular position following pectoralis release and inframammary fold fixation, or reconstruction by suturing inferior edge of pectoralis major to fascia at point of inframammary fold. C: Implant partially expanded postoperatively. D: Implant overexpanded. E: Volume reduced. F: Final result—injection dome removal and nipple-areolar reconstruction. G: Enlarged view of inframammary fold area.

Chapter 27: One-stage Immediate Breast Reconstruction With Adjustable Implants   441

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Figure 27.4 A: Patient prior to mastectomy. B: Skin marking showing circumareolar skin incision with small medial and lateral incisions. C: Patient following mastectomy. D: Mastectomy specimen with attached nipple. E: Pectoralis major muscle and serratus anterior muscle elevated. F: Pectoralis and serratus sutured together, and the free inferior edge then sutured to the fascia at the level of the inframammary fold.

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Figure 27.4 (continued) G: Implant inserting into submuscular space. Implant partially filled, showing well-defined inframammary fold (Becker 500-cc 50/50 filled to 200 cc at time at surgery). H: Injection dome attached to fill tube. I: Closure of purse-string suture and completion of the procedure. J: Early postoperative result. K: Implant further expanded. L: Implant overexpanded. M: Final result with volume reduction and nipple-areolar reconstruction with tattoo (implant filled to 275 cc on the right and 185 cc on the left).

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Figure 27.5 A and B: Patient prior to bilateral mastectomy. C: Following skin-sparing mastectomy with areola preservation. Closure of purse-string suture 500-cc Becker 50/50 implant was used and filled to 150 cc. D: Early postoperative result. E: Further expansion of implant. F: Further expansion of implant.

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Figure 27.5 (continued) G: Implant overexpanded with 400 cc of saline on each side. H: Implant overexpanded with 400 cc of saline on each side. I: Injection dome retrieved through original incision. J: Injection dome clamped and ready for removal. K: Injection dome removal. L: Nipple reconstruction with saved areolar skin. M: Final result with 340 cc of saline on the right and 320 on the left. N: Final result with 340 cc of saline on the right and 320 on the left.

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Figure 27.6 A and B: Patient prior to bilateral mastectomy. C: Early postoperative result. D and E: Implant overexpanded. F and G: Final result following injection dome removal and nipple-areolar reconstruction. H: Close-up of scar following nipple reconstruction; no visible scar is seen.

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Figure 27.7 A: Patient prior to bilateral mastectomy. B: Skin markings. C: Defect following mastectomy. D: Following insertion of 375-cc smooth spectrum implant and placement of purse-string suture. E: Closure of purse-string suture. F: Early postoperative result. G: Final result following nipple-areolar reconstruction with no visible scarring.

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Figure 27.8 A: Patient prior to surgery. B: Skin incision. C: Following submuscular 475-cc smooth spectrum implant filled to 300-cc purse-string placement. D: Purse-string closure. E: Early postoperative result. F: Implants overexpanded.

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Figure 27.8 (continued) G: Long-term result with no visible scarring. H: Result following injection dome removal and nipple-areolar reconstruction. I: Long-term result with no visible scarring. J: Result following injection dome removal and nipple-areolar reconstruction.

An intraoperative expander is placed beneath the muscle and partially expanded to asses the size and position. The inferior edge of the muscle is then sutured to the fascia at the level of the inframammary fold.

The expander is then replaced with the selected adjustable implant. Further sutures are placed to secure the muscle to the fascia at the level of the inframammary fold. A small space is left between the muscle and inframammary fold to facilitate inferior pole expansion. The fill tube is attached to the injection dome and secured with two silk

sutures. It is then placed in a subcutaneous pocket lateral to the incision or in the axilla. The patient is placed in the upright position to check the position of the implant. The skin incision is then closed as a purse-string or V-Y closure in two layers. Partial delayed closure can be performed if there is a concern about healing.

The implant is usually underfilled initially, depending on the viability and tension on the skin flaps.

Expansion is started once pain has settled and viability of the skin flaps is assured, usually 2 or 3 days after surgery.

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A 23-g needle is inserted into the injection dome under sterile conditions, and 50 to 100 cc are injected once or twice weekly.

The implants are overexpanded and kept overexpanded for several weeks prior to volume reduction. This will help remove the skin folds and improve the shape. Temporary overexpansion may decrease the incidence of capsular contracture.

The injection domes are removed at approximately 3 to 6 months, at which time nipple-areolar reconstruction is performed. Prophylactic antibiotics are used when the injection domes are removed.

IMPLANT SELECTION

Adjustable implants are available in the following configurations in both smooth and textured surfaces:

Saline

25% gel and 75% saline 50% gel and 50% saline

I prefer to use the 50/50 implant for immediate breast reconstruction. The 25% gel implant is used if the tissues are tight or if there is a problem with skin flap tension. I use the saline adjustable implant for the patient who does not want silicone.

DISCUSSION

The general surgeon's comprehension of the reconstructive planning is essential in maximizing the aesthetic results of this procedure. The final result of the reconstruction largely depends on the status of the tissues after the mastectomy.

Complete muscle release and inframammary fold reconstruction allows for easier placement of the implant and less need for postoperative expansion. Furthermore, a more anatomic shape can be obtained because the tissues in the inferior pole of the breast will be thinner than the upper pole, allowing for selective inferior pole expansion.

Use of the adjustable implant essentially eliminates the need to replace a temporary tissue expander with a breast implant. The implant can be placed underfilled, thus decreasing tension and potential problems with large skin flaps. Overexpansion can be performed to improve shape, and size can be adjusted postoperatively to better enable the achievement of symmetry.

CONCLUSION

The ideal goals of breast reconstruction are as follows:

One-stage procedure performed at the time of mastectomy Minimal or no scarring

6! Patient should look as good as, if not better, than before mastectomy

No interference with chemotherapy or radiation

Short surgical time, low complication rate, and minimal downtime

One-stage immediate breast reconstruction can be performed in a high percentage of patients. The patients need to be carefully selected prior to surgery. The general surgeon should be familiar with both the technique of skin-sparing mastectomy and the reconstructive procedure.

Adjustable implants allow for a one-stage procedure, reduce the complication rate, and allow for optimal postoperative size adjustment.

Today, these goals can be achieved in selected patients.

Editorial Comments

Dr. Becker deserves tremendous congratulations for developing the "Becker" implant. I have found this device to be useful in a variety of situations, including single-stage reconstruction in women that have been appropriately selected. My preference is to use this implant as the permanent device following removal of a tissue expander in a two-stage reconstruction; however, its utility as a single-stage device is certainly appreciated. The ability to adjust the volume postoperatively has been a tremendous advancement, allowing the surgeon to obtain volume symmetry without having to surgically exchange the implant.

Currently, the Becker implant is available only in a round form in the United States, although a contoured or anatomic version is sold internationally. The surface of the implant comes in two varieties, smooth and textured. The smooth Becker implant is an excellent device that has delivered excellent breast ptosis. Limited personal experience with this version has so far been very favorable with high patient satisfaction. The Becker implants are currently available as a 25% or 50% device, based on the ratio of silicone gel to saline. A device that is 75% silicone gel will soon be available. The range in volume is variable, and for the Becker 25 is from 150 to 800 cc and for the Becker 50 is from 300 to 700 cc. This is important when selecting an implant of appropriate size, because although the Becker 50 is the preferred implant, it may be too large for the woman with small volume requirements.

M.Y. N.

REFERENCES

1. Becker H. Breast reconstruction following subcutaneous mastectomy using a delayed filling volume adjustable breast implant. Transaction 1983, VIII International Congress of Plastic Surgery, Montreal, Canada.

2. Becker H. Breast reconstruction using an inflatable breast implant with detachable reservoir. Plast Reconstr Surg 1984;73:678-683.

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3. Becker H, Maraist F. Immediate breast reconstruction after mastec-   6. Becker H. The expandable mammary implant: an update. Perspect

tomy using a permanent tissue expander. South Med I   Plast Surg 1989;3(1).

1987;80(2):154-160.   7. Becker H. Tissue expansion. In: Rolf E, Nordstrom MD, eds. Breast

4. Becker H. The permanent tissue expander. Clin Plast Surg   expansion augmentation, p. 145; The expander mammary

1987; 14 (3):10-13 .   implant for breast reconstruction, p. 163,1996.

5. Becker H. The expandable mammary implant. Plast Reconstr Surg   8. Becker H. The effect of Betadine on silicone implants. Plast Recon-

1987;79(4):631-637.   str Surg 2000; 105 (4):1570-1571.