Two-Stage Prosthetic Breast Reconstruction With Integrated Versus Remote Port Expanders

A Comparison of Complication Rates

Joshua H. Choo, MD; Mitchell J. Buller, MD; Michelle O'Brien, MD; Ron Hazani, MD; Adam Augenstein, MD; John P. Tutela, MD; Bradon J. Wilhemi, MD


ePlasty. 2019;19(e14) 

In This Article

Abstract and Introduction


Background: Ever since their introduction, tissue expanders for breast reconstruction have undergone a gradual evolution from remote port expanders to the integrated port expanders commonly in use today. Integrated port expanders have been widely adopted because of their ease of use and reliability, and though the convenience of integrated port expanders over remote port expanders is clear, a side-by-side comparison of complications has not been performed. A same-surgeon, same-institution study was conducted comparing the complication rates of remote versus integrated tissue expanders.

Methods: A retrospective review was conducted of 107 patients who underwent breast reconstruction with tissue expanders. Remote tissue expanders were used in 21 consecutive patients (n = 42) and integrated port tissue expanders in 86 consecutive patients (n = 128). Patients who had received prior or concurrent breast irradiation were excluded from the study. Overall complications were compared, followed by complications that were broken down according to mechanical and infectious complications.

Results: Fisher’s exact test demonstrated a statistically significant increase in the rate of overall complications in remote port expanders compared with integrated port expanders (19% vs 7%; P = .024). Similarly, a statistically significant difference in the rate of mechanical complications between the 2 groups was found (7% in remote vs 0.8% in integrated, P = .047). When the rates of infectious complications were compared between the 2 groups, however (12% in remote vs 6% in integrated), no significant difference could be found (P=.312).

Conclusion: In this retrospective review of prosthetic breast reconstructions, increased overall complicationswere observedwith remote tissue expanders that were mainly mechanical in nature. The higher rate of infection observed in the remote port group was not statistically significant. Our study shows that remote port expanders do in fact have a higher complication rate than integrated port expanders. This should be taken into account when considering the use of remote port expanders in certain clinical scenarios.


In the United States alone, an estimated 246,660 cases of invasive breast cancer in women were diagnosed in 2016.[1] Prosthetic reconstruction has become an increasingly popular treatment option, with the percentage of women choosing this method of reconstruction climbing from 11.6% in 1998 to 36.4% in 2011.[2] The number of breast reconstruction procedures performed annually is up 35% since 2000, with implant-based reconstruction accounting for 81% of the 106,338 procedures performed in 2015.[3]

While the introduction of skin and nipple-sparing mastectomies has permitted new methods of breast reconstruction, 2-stage reconstruction beginning with tissue expander placement is still the most common method of prosthetic breast reconstruction. Radovan was the first to describe the use of a tissue expander to allow serial volume expansion of the skin before the placement of a permanent implant. Early prototypes were smooth-walled and filled via remote ports, which made them susceptible to kinking, twisting, and leakage. Expanders with integrated ports were later introduced to eliminate these problems. Further refinements over time led to the introduction of textured surfaces to minimize capsular contracture. Ports are now larger with self-sealing peripheries to minimize the occurrence of errant needle access, and most also have suture tabs to allow for a higher degree of pocket control.

When integrated port expanders were first introduced, concerns existed over the method of access (ie, through thin and vascularly compromised mastectomy flaps) and its potential to raise infection and skin necrosis rates. There were also concerns about how the magnetic integrated ports would affect the delivery of radiation to the breast. Safety and reliability of integrated port expanders are now well-established,[4,5] and while concerns about dose attenuation and heterogeneity do exist, most studies have shown that these effects are small and can be compensated for through heterogeneity corrections.[6–8]

While it may be tempting to conclude that remote port expanders have little part in current prosthetic breast reconstruction, the use of a remote port expander has its advantages in certain subsets of patients. When combining autologous and prosthetic breast reconstruction, magnetic port localization becomes less reliable as the thickness of the intervening flap increases, and a remote port expander may be a preferred alternative in these patients.[9] The majority of expanders with integrated magnetic ports are magnetic resonance imaging (MRI)-unsafe,[10] and patients with an anticipated need for MRI during the expansion process may therefore benefit from remote port expander placement.[9] In addition, the Food and Drug Administration recommends caution when using integrated port expanders in patients with implantable defibrillators or pacemakers, as serious adverse interactions have been reported.[11–13] In these patients, the use of remote port expanders may also be justified. In light of these considerations, it is worthwhile to review the risk profile of remote tissue expanders in comparison with integrated port expanders.

A review of the literature shows no head-to-head comparisons of remote and integrated port tissue expanders and their respective complication rates. Integrated port tissue expanders have been shown to have lower complication rates than what was historically observed with remote port expanders, but it is difficult to determine which complications were inherent to expander design. The purpose of this study was to retrospectively assess the rates of complications and infection in remote versus integrated ports in our patients undergoing 2-stage prosthetic breast reconstruction.