Safe and Efficient Implant-Based Breast Reconstruction

Albert H. Chao, MD


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

In This Article

Description of Most-effective Procedures

Total Submuscular Reconstruction

Although one of the earliest and most basic of implant-based techniques, 2-stage total submuscular reconstruction remains an important option in contemporary breast reconstruction. In particular, this approach may be considered in patients at high risk for healing complications. The ability to minimize pressure on the mastectomy flaps and avoid the use of ADM as an additional foreign body may be prudent in patients with diabetes, smokers, or tenuous mastectomy flaps. This is also the approach that is necessary in most cases of delayed reconstruction cases, where the preoperative chest wall contour is flat.

In the first-stage, the tissue expander is placed beneath 3 musculofascial structures (Figure 1). Typically, the subpectoral plane is developed first, and then this dissection is continued inferiorly in a submuscular plane beneath the anterior rectus sheath to the level of the inframammary fold as one contiguous plane. In some cases, individual patient anatomy may preclude continuing the subpectoral plane inferiorly contiguous with the anterior rectus sheath, in which case a dual-plane approach (described below) may be necessary. Laterally, the serratus anterior muscle or fascia is then elevated to complete creation of the expander pocket. After irrigation and hemostasis, the tissue expander is inserted, and the pectoralis major and serratus anterior muscle/fascia are approximated to achieve total submuscular coverage of the device (Figure 2). Intraoperative expansion is then performed while directly assessing the tension on the muscle closure and skin flaps. Approximately 10–14 days later, postoperative expansion is resumed.

Figure 1.

Intraoperative photograph demonstrating tissue expander placement beneath the pectoralis major muscle and the serratus anterior fascia. IMF, inframammary fold; TE, tissue expander. Adapted with permission from Plast Reconstr Surg. 2010;125:1057–1064.

Figure 2.

Intraoperative photograph demonstrating inset of the anterior border of the serratus anterior fascia to the lateral border of the pectoralis major muscle to achieve total coverage of the tissue expander. IMF, inframammary fold. Adapted with permission from Plast Reconstr Surg. 2010;125:1057–1064.

At the second stage, the tissue expander is exchanged for the permanent prosthesis. During this operation, capsule work is often performed to adjust breast shape and position. Capsulotomies are generally performed in locations where one desires proportionately a greater implant volume. For example, if performed along the inferior pole, there will be descent of the implant and greater ptosis. Capsulotomies can be performed both radially and longitudinally depending on the desired effect, taking into account that additional tissue stretching will occur postoperatively. In some cases, partial or total capsulectomy may be necessary. For example, capsule modifications performed inferiorly can help increase ptosis. The use of implant sizers is helpful to select the most appropriate implant and the adequacy of capsule modifications. Both saline and silicone implants are safe and effective, although silicone implants are associated with higher patient satisfaction.[1,12] In unilateral cases, symmetry procedures on the contralateral breast are usually performed at this time. When assessing the result intraoperatively, it is essential to sit the patient up and adduct the arms before making final decisions about implant selection and inset. Fat grafting can be a useful adjunct to optimize the aesthetic outcome to address contour deformities. However, since fat grafts require a well-vascularized recipient site, they generally should not be placed at the time of the mastectomy or concurrent with capsule work.

Dual-plane Direct-to-implant Reconstruction

Dual-plane direct-to-implant reconstruction (DP-DTI) entails placement of the implant within a combined subpectoral and sub-ADM pocket. A strength of this approach is the ability to complete the reconstruction in a single-stage, while maintaining similar rates of revision and complications as well as patient-reported outcomes compared with tissue expander/implant reconstruction.[13,14] Optimal candidates for DP-DTI reconstruction are patients with relatively smaller breasts who wish to maintain the same size.[10,15] In addition, it is best performed in patients who demonstrate well-perfused mastectomy flaps because ADM is fundamentally a graft that relies on revascularization by the overlying tissues. Thus, patients who are diabetic, smoke, or who have a history of radiation therapy are generally not suitable candidates.

Elevation in a subpectoral plane is initiated with disinsertion of the muscle inferiorly. ADM is then shaped to bridge the inferior border of the pectoralis muscle with the inframammary fold inferiorly, and the lateral border of the pectoralis muscle with the outer curvature of the breast laterally (Figure 3). The vertical and horizontal dimensions of the ADM should be designed to take into account the overlying skin envelope and desired amount of ptosis. Achieving a smooth contour to the ADM, meshing or use of a perforated variety of ADM, and drain placement are important measures to facilitate graft take. Partial inset of the ADM to the chest wall is then performed, most commonly along its inferior and lateral aspects to provide ready access to the pocket centrally for subsequent implant placement. At this point, sizers and mastectomy specimen weight are used to help select the implant. After irrigation and hemostasis, the implant is inserted and the superior aspect of the ADM is approximated to the inferior and lateral borders of the pectoralis muscle to close the implant pocket. In unilateral cases, symmetry procedures on the contralateral breast are usually performed at this time. If necessary, DP-DTI can be converted intraoperatively to a 2-stage reconstruction using a tissue expander, which is then managed postoperatively similar to total submuscular reconstruction. Doing so can relieve pressure on the mastectomy flaps, although this may not necessarily accelerate the rate of expansion compared with total submuscular tissue expander placement.[16]

Figure 3.

Intraoperative photograph demonstrating dual-plane implant placement beneath the pectoralis major muscle and ADM. Adapted with permission from Plast Reconstr Surg. 2012;130:44S–53S.

Two-stage Prepectoral Reconstruction

The modern-day technique of prepectoral breast reconstruction involves placement of the device entirely beneath a sub-ADM plane, which in turn is located subcutaneously. The use of ADM is advisable to provide support, control position, and to potentially reduce the risk of capsular contracture.[17] This approach has gained popularity relatively recently over the past few years.[18,19] While recent reports of prepectoral direct-to-implant reconstruction are promising, a 2-stage approach affords greater control over implant position and mastectomy flap perfusion.[20,21] Optimal candidates for prepectoral reconstruction have well perfused and suitably thick mastectomy flaps, which can help minimize rippling and palpability.

The key initial step in prepectoral reconstruction is creation of a subcutaneous implant pocket that has a hand-in-glove fit. This is critical to optimize the aesthetic outcome, including a smooth contour to the breast, as well as to maximize contact between the mastectomy flaps and the ADM. In this regard, anatomic landmarks such as the inframammary fold should be reconstructed, redundant mastectomy flaps revised, and a prosthesis with appropriate dimensions selected. Next, ADM is shaped to envelop the anterior surface of the tissue expander or implant (Figure 4). Like with DP-DTI, achieving a smooth contour to the ADM, meshing or use of a perforated variety of ADM, and drain placement are important measures to facilitate graft take. After irrigation and hemostasis, the tissue expander (preferably a tabbed variety that can be positionally secured) or implant is inserted. The previously prepared ADM is then inset circumferentially around the device to the chest wall to help control its subcutaneous position (Figure 5). In direct-to-implant cases, some authors have sutured the ADM to itself along the posterior aspect of the implant, and then inserted the ADM and implant as a single apparatus. This approach facilitates device placement, but entails greater reliance on the pocket to control position.[22] When a 2-stage approach is taken, postoperative expansion and eventual implant exchange are performed as described for total submuscular reconstruction.

Figure 4.

Two sheets of ADM are draped over the tissue expander to achieve a smooth contour. Adapted with permission from Plast Reconstr Surg. 2017;140:51S–59S.

Figure 5.

The tissue expander position is secured by utilizing its suture tabs to the underlying pectoralis major muscle. Adapted with permission from Plast Reconstr Surg. 2017;140:51S–59S.