Safe and Efficient Implant-Based Breast Reconstruction

Albert H. Chao, MD

Disclosures

Plast Reconstr Surg Glob Open. 2020;8(9):e3134 

In This Article

Goals of the Procedure

The objectives of implant-based breast reconstruction are to (1) create a natural and aesthetically pleasing breast; (2) attain symmetry; (3) complete the reconstructive process in the fewest number of procedures and least amount of time; and (4) minimize complications. To accomplish these goals, a number of variables need to be considered, as described next in this section. While this article will later describe 3 of the most effective techniques for implant-based breast reconstruction, it is important to emphasize that a multitude of combinations of these variables is possible, and that an individualized plan should be developed for each patient that considers all factors.

Mastectomy Type and Incisional Design

Preoperatively, the plastic surgeon should confer with the surgical oncologist about the type of mastectomy (traditional, skin-sparing, nipple-sparing), and to design the incision jointly to meet both reconstructive and oncologic needs. Preservation of as much of the native breast skin envelope as possible is preferable over tissue-expanded skin to maximize breast aesthetics. In patients with large breasts and significant ptosis, skin reduction techniques such as Wise pattern are useful.

Nipple-sparing mastectomy (NSM) is an oncologically safe option for many patients that can confer a good aesthetic result while obviating the need for nipple reconstruction.[3] Contraindications to NSM include tumor involvement with the nipple or subareolar tissues, and nipple discharge associated with malignancy.[4] Risk factors for complications with NSM include obesity, smoking, and a history of radiation therapy.[5] In patients at increased risk for complications, surgical delay of the nipple can be beneficial.[6,7]While many different types of incisions have been used in NSM, the inframammary incision is associated with lower rates of complications, including nipple necrosis.[8,9]

Number of Stages

One-stage techniques have the clear advantage of completing the breast reconstruction in a single operation. Optimal candidates for direct-to-implant breast reconstruction are patients with relatively smaller breasts (A-B cup) who wish to achieve a similarly sized reconstructed breast.[10] However, single-stage direct-to-implant breast reconstruction may not always be the most appropriate option. Situations where this might be the case include patients in whom perfusion of the mastectomy flaps is a concern, such as due to patient (eg, smoking) or surgical (eg, mastectomy) factors. In these cases, a 2-stage approach utilizing a tissue expander at the initial operation may be advisable to minimize pressure on the flaps by the implant.

Implant Plane

There are 3 possible tissue planes for implant placement: subpectoral, dual-plane (ie, subpectoral and sub-ADM), and prepectoral. Dual-plane and prepectoral techniques both allow for partial intraoperative filling of the expander or immediate insertion of the implant, and thus greater preservation of the native breast skin envelope. The dual-plane approach affords greater soft tissue coverage of the device and may reduce implant rippling and palpability. Prepectoral positioning avoids the possibility of a postoperative animation deformity and may reduce pain and spasm from muscle dissection.[11] Subpectoral placement allows for total muscle coverage of a tissue expander without ADM, and may be useful in patients in whom there may be concerns about healing capacity and tissue perfusion.

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