Email Alert | RSS

Journal of Peking University(Health Sciences) ›› 2020, Vol. 52 ›› Issue (1): 169-176. doi: 10.19723/j.issn.1671-167X.2020.01.027

Previous Articles     Next Articles

Techniques enhancement for tissue expander/implant two-stage breast reconstruction

Jian-xun MA1,You-chen XIA1,Bi LI1,△(),Hong-mei ZHAO2,Yu-tao LEI2   

  1. 1. Department of Plastic Surgery, Peking University Third Hospital, Beijing 100191, China
    2. Department of General Surgery, Peking University Third Hospital, Beijing 100191, China
  • Received:2019-04-11 Online:2020-02-18 Published:2020-02-20
  • Contact: Bi LI E-mail:libi0377@sina.com

RICH HTML

   

PDF (PC)

Abstract:

Objective: To investigate the outcomes of breast reconstruction with employing improved techniques throughout the tissue expander/implant two-stage breast reconstructed process, which involved the tissue expander placement, the saline filling intraoperatively and postoperatively, the implant selection, and the permanent implant replacement. Methods: In this study, 68 patients who had been provi-ded immediate or delayed tissue expander/implant two-stage breast reconstruction with autologous fat injection post-mastectomy in Peking University Third Hospital from April 2014 to September 2018 were involved, and the relevant information was analyzed retrospectively. The enhancements of the techniques, involving the incision selection, the expander placement, the principle of expansion, the management of capsule, the prosthesis selection, and the assisted reconstruction method were summarized, and the reconstruction outcomes were evaluated objectively through three-dimensional surface imaging. Results: Among the 68 patients in this study, immediate reconstruction was conducted in 25 patients and 43 patients underwent delayed reconstruction. The median time of tissue expansion was 7.0 (3.0, 20.0) months, and the average volume of expansion was (372.8±87.2) mL. The median size of breast implant was 215 (100, 395) mL. The median number of injections for fat grafting was 1 (1, 3), and the average volume of fat grafting was (119.3±34.1) mL. The median follow-up time was 7.0 (4.0, 24.0) months. During the process of breast reconstruction, the tissue expander leakage was observed in two patients, and one of them underwent expander replacement due to the secondary infection. In the immediate reconstruction cases, the volume symmetry of bilateral breasts after reconstruction got even better than that before mastectomy (t=4.465, P<0.01). And in the delayed reconstruction cases, the volume between bilateral breasts also achieved good symmetry after reconstruction (t=0.867, P>0.1). Conclusion: Good results of tissue expander/implant two-stage breast reconstruction could be achieved through the techniques enhancement, which involved the preferred transverse incision, the downward placement of expander, the rapid expansion of chest soft tissue, the release of capsule tension, the application of sizer in prosthesis selection, and the assisted autologous fat grafting.

Key words: Tissue expansion, Mammaplasty, Breast Implants, Autologous fat graft

CLC Number: 

  • R622

Table 1

Characteristics of 68 patients undergoing tissue-expander/implant two-stage breast reconstruction"

Items Data
Age/years 37.6±9.1
BMI 21.6 (16.8, 28.7)
Clinical stage (breast cancer)
Stage 0 9 (13.2%)
StageⅠ 32 (47.1%)
StageⅡ 27 (39.7%)
Final pathology
Invasive ductal carcinoma 57 (83.8%)
Ductal carcinoma in situ 8 (11.8%)
Mucinous adenocarcinoma 2 (2.9%)
Large cell neuroendocrine carcinoma 1 (1.5%)
Affected side
Right 26 (38.2%)
Left 42 (61.8%)
Nipple-areola preserving
Yes 3 (4.4%)
No 65 (95.6%)
Axillary lymph node dissection
Yes 54 (79.4%)
No 14 (20.6%)
Chemotherapy
Yes 62 (91.2%)
No 6 (8.8%)
Radiation
Yes 7 (10.3%)
No 61 (89.7%)

Figure 1

Three-dimensional surface imaging (VECTRA-XT) The device to harvest three-dimensional surface image through stereo-photogrammetry, and to calculate the data of the volume and morphology by the software contained."

Figure 2

The range of the pocket for the expander 2, the medial border was parasternal line, the lateral border was anterior axillary line, and the inferior border was 2.0 cm below the inframammary fold."

Figure 3

Judgment of bilateral breasts symmetry during the process of tissue expansion 3A, bilateral breast symmetry was evaluated by patients’ and surgeons’ visual assessment subjectively; 3B, bilateral breast symmetry was evaluated by three-dimensional surface imaging objectively."

Figure 4

The range of the fat to be transferred 4, the junction between the upper pole of the reconstructed breast and the chest wall, as well as the anterior axillary fold, were designed as an injection area for fat grafting."

Figure 5

Sizer-assisted observation of bilateral breasts symmetry intra-operation A, the breast implant sizer had the same volume and three-dimensional morphology as the related silicone gel prosthesis; B, the patient had the sitting position during operation after the placement of the sizer, presenting the actual reconstructed morphology, which was useful for surgeon to choose the ideal breast prosthesis."

Table 2

Relevant information on breast reconstruction of 68 patients"

Items Data
Reconstruction timing
Immediate 25 (36.8%)
Delayed 43 (63.2%)
Volume injected for expansion/mL 372.8±87.2
Period of expansion/month 7.0 (3.0, 20.0)
Implant
Anatomical 58 (85.3%)
Round 10 (14.7%)
Volume/mL 215 (100, 395)
Numbers of fat grafting 1 (1, 3)
Volume of fat grafting/mL 119.3±34.1
Follow-up/month 7.0 (4.0, 24.0)
Recurrence or metastasis of tumor 0 (0)
Complication 2 (2.9%)

Table 3

Volume measurement through three-dimensional surface imaging"

Items x?±s P
Immediate reconstruction
Affected/mL
Pre-operation 216.2±59.7
Post-operation 223.7±79.9
Contralateral/mL
Pre-operation 230.7±74.3
Post-operation 231.1±84.8
Bilateral difference/mL
Pre-operation 25.5±16.5
Post-operation 12.9±12.4
Breasts asymmetry/%
Pre-operation 11.1±6.4 <0.001*
Post-operation 5.3±4.3
Delayed reconstruction of post-operation
Contralateral/mL 240.1±63.8 0.392
Affected/mL 238.2±58.6
Bilateral difference/mL 10.3±7.5
Breasts asymmetry/% 4.2±2.6

Figure 6

Comparison of pre- and post-operation of immediate breast reconstruction A, before resection; B, three months after the reconstruction; C, 3D picture of breasts acquired three months after reconstruction, which indicated minimal volume difference between the two breasts."

Figure 7

Comparison of pre- and post-operation of delayed breast reconstruction A, before reconstruction; B, twenty-five months after the reconstruction; C, 3D picture of breasts acquired twenty-five months after reconstruction, which indicated minimal volume difference between the two breasts."

Figure 8

Tissue expander placement Gray dotted line: the desired lower pole for the maximal expansion; Red dotted line: the inframammary fold. A, early stage, the point of maximal expansion was located near the lower pole of the reconstructed breast; B, with the increase of the injection volume, the point of maximal expansion moved up, which was too high to reconstruct a natural breast contour; C, fixing the expander more inferiorly will make the point of maximal expansion at the desired lower pole of the reconstructed breast."

Figure 9

Spherical change of tissue With the increase of the injection volume, the diameter of the expander decreased, which would affect the placement of the prosthesis."

[1] Bertozzi N, Pesce M, Santi P . Tissue expansion for breast reconstruction: methods and techniques[J]. Ann Med Surg (Lond), 2017,21:34-44.
[2] Jabo B, Lin AC, Aljehani MA , et al. Impact of breast reconstruction on time to definitive surgical treatment, adjuvant therapy, and breast cancer outcomes[J]. Ann Surg Oncol, 2018,25(10):3096-3105.
[3] Susarla SM, Ganske I, Helliwell L , et al. Comparison of clinical outcomes and patient satisfaction in immediate single-stage versus two-stage implant-based breast reconstruction[J]. Plast Reconstr Surg, 2015,135(1):1e-8e.
[4] Lee KT, Mun GH . Comparison of one-stage vs two-stage prosjournal-based breast reconstruction: a systematic review and meta-ana-lysis[J]. Am J Surg, 2016,212(2):336-344.
[5] Hameeteman M, Verhulst AC, Maal TJ , et al. An analysis of pose in 3D stereophotogrammetry of the breast[J]. J Plast Reconstr Aesthet Surg, 2016,69(12):1609-1613.
[6] Liu C, Ji K, Sun J , et al. Does respiration influence breast volumetric change measurement with the three-dimensional scanning technique?[J]. Aesthetic Plast Surg, 2014,38(1):115-119.
[7] 刘荫华, 刘真真, 王翔 , 等. 乳腺癌改良根治术专家共识及手术操作指南(2018版)[J]. 中国实用外科杂志, 2018,38(8):851-854.
[8] Cordeiro PG, Jazayeri L . Two-stage implant-based breast reconstruction: an evolution of the conceptual and technical approach over a two-decade period[J]. Plast Reconstr Surg, 2016,138(1):1-11.
[9] Coleman SR, Mazzola RF. Fat injection: From filling to regeneration [M]. Florida: CRC Press LLC, 2009.
[10] 王振宇, 姜晓曼, 杜彤华 , 等. Ⅰ期乳房重建中扩张器的应用[J]. 中华内分泌外科杂志, 2019,13(2):93-96.
[11] 李尚善, 穆大力, 栾杰 , 等. 乳腺肿瘤切除术后二期组织扩张术假体植入乳房再造术的临床效果[J]. 中华医学美学美容杂志, 2018,24(1):32-34.
[12] Pacella SJ . Evolution in tissue expander design for breast reconstruction: technological innovation to optimize patient outcomes[J]. Plast Reconstr Surg, 2018,142(4S The Science of Breast Implants):21S-30S.
[13] Yang CE, Chung SW, Lee DW , et al. Evaluation of the relationship between flap tension and tissue perfusion in implant-based breast reconstruction using laser-assisted indocyanine green angiography[J]. Ann Surg Oncol, 2018,25(8):2235-2240.
[14] Kato H, Nakagami G, Iwahira Y , et al. Risk factors and risk scoring tool for infection during tissue expansion in tissue expander and implant breast reconstruction[J]. Breast J, 2013,19(6):618-626.
[15] Lam TC, Borotkanics R, Hsieh F , et al. Immediate two-stage prosthetic breast reconstruction failure: radiation is not the only culprit[J]. Plast Reconstr Surg, 2018,141(6):1315-1324.
[16] Woo KJ, Paik JM, Bang SI , et al. The impact of expander inflation/deflation status during adjuvant radiotherapy on the complications of immediate two-stage breast reconstruction[J]. Aesthetic Plast Surg, 2017,41(3):551-559.
[17] Sue GR, Sun BJ, Lee GK . Complications after two-stage expander implant breast reconstruction requiring reoperation: a critical ana-lysis of outcomes[J]. Ann Plast Surg, 2018,80(5S Suppl 5):S292-S294.
[18] Pusic AL, Cordeiro PG . An accelerated approach to tissue expansion for breast reconstruction: experience with intraoperative and rapid postoperative expansion in 370 reconstructions[J]. Plast Reconstr Surg, 2003,111(6):1871-1875.
[19] Liang X, Huang X, Zhou Y , et al. Mechanical stretching promotes skin tissue regeneration via enhancing mesenchymal stem cell homing and transdifferentiation[J]. Stem Cells Transl Med, 2016,5(7):960-969.
[20] Makiguchi T, Atomura D, Nakamura H , et al. Quantitative assessment and risk factors for chest wall deformity resulting from tissue expansion for breast reconstruction[J]. Breast Cancer, 2019,26(4):446-451.
[21] 刘晨, 栾杰, 丛中 , 等. 乳房再造手术对乳房缺失者的心理影响[J]. 中华医学美学美容杂志, 2008,14(3):187-189.
[22] Agochukwu-Nwubah N, Boustany A, Wetzel M , et al. Anatomic implants in breast reconstruction: a comparison of outcomes and aesthetic results compared to smooth round silicone implants [J]. Aesthet Surg J, 2019, 39(8): NP322-NP330.
[23] Petit JY, Maisonneuve P, Rotmensz N , et al. Fat grafting after invasive breast cancer: a matched case-control study[J]. Plast Reconstr Surg, 2017,139(6):1292-1296.
[24] Krastev T, van Turnhout A, Vriens E , et al. Long-term follow-up of autologous fat transfer vs conventional breast reconstruction and association with cancer relapse in patients with breast cancer[J]. JAMA Surg, 2019,154(1):56-63.
[25] Kim MS, Sbalchiero JC, Reece GP , et al. Assessment of breast aesthetics[J]. Plast Reconstr Surg, 2008,121(4):186e-194e.
[26] Lee WY, Kim MJ, Lew DH , et al. Three-dimensional surface imaging is an effective tool for measuring breast volume: a validation study[J]. Arch Plast Surg, 2016,43(5):430-437.
[27] Howes BH, Watson DI, Fosh B , et al. Magnetic resonance imaging versus 3-dimensional laser scanning for breast volume assessment after breast reconstruction[J]. Ann Plast Surg, 2017,78(4):455-459.
[28] O’Connell RL, Di Micco R, Khabra K , et al. The potential role of three-dimensional surface imaging as a tool to evaluate aesthetic outcome after breast conserving therapy(BCT)[J]. Breast Cancer Res Treat, 2017,164(2):385-393.
[29] Chae MP, Rozen WM, Spychal RT , et al. Breast volumetric ana-lysis for aesthetic planning in breast reconstruction: a literature review of techniques[J]. Gland Surg, 2016,5(2):212-226.
[30] Razdan SN, Panchal H, Albornoz CR , et al. Impact of contrala-teral symmetry procedures on long-term patient-reported outcomes following unilateral prosthetic breast reconstruction[J]. J Reconstr Microsurg, 2019,35(2):124-128.
[1] Xin-ling ZHANG,Zhi-yu LIN,Yu-jie CHEN,Wen-fang DONG,Xin YANG. Plastic and reconstruction surgery for non-healing wound after posterior spinal surgery [J]. Journal of Peking University (Health Sciences), 2023, 55(5): 910-914.
[2] ZHAO Jian-fang,LI Dong,AN Yang. Roles of ten eleven translocation proteins family and 5-hydroxymethylcytosine in epigenetic regulation of stem cells and regenerative medicine [J]. Journal of Peking University (Health Sciences), 2021, 53(2): 420-424.
[3] . [J]. Journal of Peking University(Health Sciences), 2015, 47(5): 891-封三.
Viewed
Full text


Abstract

Cited
  Shared   
  Discussed   
No Suggested Reading articles found!
Copyright © Journal of Peking University (Health Sciences), All Rights Reserved.
Powered by Beijing Magtech Co. Ltd