Safe and Efficient Implant-Based Breast Reconstruction

Albert H. Chao, MD

Disclosures

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

In This Article

Pearls and Pitfalls

Thorough assessment of the mastectomy flaps intraoperatively should be performed before committing to a particular technique. Preoperatively, patients should be counseled on the possibility of a change in plan as to the specific type of implant-based reconstruction that is ultimately performed. Fluorescent angiography performed both before and after implant sizer placement can aid in decision-making. When limited areas of the mastectomy flaps appear compromised, preemptive excision and closure within the controlled setting conferred by the operating room can be helpful.

Radiation therapy can adversely affect the outcomes of implant-based breast reconstruction, which can result in fibrosis, diminished vascularity and healing capacity, capsular contracture, and even reconstructive failure. These effects can be mitigated through careful planning. In patients undergoing tissue expander/implant reconstruction who will receive adjuvant radiation therapy, there are 2 reconstructive timelines to consider: implant exchange before radiation therapy versus subsequent to radiation therapy. Performing implant exchange before radiation therapy is generally feasible only if the patient will also be receiving adjuvant chemotherapy during which the expansion process can be completed. In this scenario, implant exchange is performed approximately 4 weeks after chemotherapy and 4 weeks before radiation therapy. This approach is associated with a lower risk of reconstructive failure (16% risk of explantation) but a higher incidence of capsular contracture compared with implant exchange after radiation therapy (32% risk of explantation).[35] When implant exchange is performed after radiation therapy, it is advisable to wait at least 6 months to allow radiation effects to subside. In these cases, conservative implant sizing and capsule work may be prudent. Both timing strategies are associated with similar patient-reported outcomes.

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