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

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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

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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."

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