Complications of immediate breast reconstruction after total mastectomy using conical and non-conical prostheses
Complicações da reconstrução imediata da mama após mastectomia total com uso de prótese cônica e não cônica

INTRODUCTION

Breast cancer is the most common non-cutaneous malignancy among women worldwide, accounting for approximately 28% of new malignant tumor cases each year in Brazil. In the biennium 2016-2017, the Brazilian National Cancer Institute (Instituto Nacional do Câncer; INCA) estimated approximately 2,160 new cases in the state of Ceará and 57,960 new cases of breast cancer for every 100,000 women in Brazil¹.

The breasts represent one of the most eloquent symbols of female sexuality, adorning the female body, and any condition that compromises its structure brings serious consequences to the patient’s physical and psychological well-being.

The high incidence of breast cancer and the importance of the breasts for a good quality of life in patients made breast reconstructions after mastectomy an integral part of the cancer treatment plan.

In 1894, William Halsted published in the United States the technique known today as classical radical mastectomy, which relies on total withdrawal of the breast with an adequate margin of safety in the adjacent skin and subcutaneous tissue, in monobloc, by removing the pectoralis major and minor muscles and the adipose tissues in the region, which includes the axillary lymph nodes². However, this technique greatly compromised breast reconstructions as the skin was not preserved.

Over the years, more conservative techniques have emerged, such as the one advocated by Patey, which preserves the pectoralis major muscle, and the Madden technique, which preserves both the pectoralis muscles.

To progressively perform more conservative mastectomies, the skin-sparing mastectomy was developed, which may or may not preserve the nipple-areola complex (NAC) and emerged as a procedure that improved the reconstructed breasts, using no less complex techniques, but less debilitating for the reconstruction, through implants with alloplastic material. Preservation of the breast skin envelope provides a satisfactory color tone, texture, and contour of the reconstructed breast, either with a tissue expander, alloplastic implant, lipografting, or deepidermized flaps².

The use of prosthetic implants for breast reconstructions started in the early 1960s with implants filled with silicone gel. Over the years, implant technology and surgical techniques have evolved, resulting in an improved quality of the reconstructed breast³.

Alloplastic implants can be classified according to shape (round, natural, anatomical, and conical), texture (smooth, textured, and coated with polyurethane foam), and projection (high, extra-high, moderate, and low)⁴. The choice of implant is fundamental to the normal and natural shape, providing more femininity to the thorax.

Breast reconstruction with an alloplastic implant presents early and late surgical complications that are directly or indirectly related to the surgical technique used to perform mastectomy and implantation of a synthetic material.

OBJECTIVE

To analyze the complications found in a group of patients submitted for immediate breast reconstructions using conical and non-conical prostheses performed in our service from January 2016 to 2018.

METHODS

This is a cross-sectional, retrospective, observational cohort study that analyzed the medical records of patients who were submitted for skin-sparing total mastectomies due to breast cancer, with immediate breast reconstruction using an extra-high conical prosthesis coated with polyurethane or a non-conical prosthesis, performed by the Plastic Surgery and Reconstructive Microsurgery Service at the Walter Cantídio University Hospital of the Federal University of Ceará, in Fortaleza, CE.

Patients who had an outpatient follow-up of at least 6 months and whose reconstruction did not require local or distant skin flaps were included. Those who had an outpatient follow-up of <6 months or those who used local or distant flap for breast reconstruction were excluded.

All breast implants were placed in the submuscular position, using the pectoralis major muscle and serratus anterior muscle to create the pocket, followed by muscular suture to connect the edges after placing the prosthesis. To finish the procedure, the subcutaneous region was drained using a vacuum, which was removed after a daily rate of ≤30 mL of the sero-hematic secretion was achieved.

RESULTS

The mean age of the patients was 47.1 years, ranging from 27 to 71 years. Immediate total breast reconstruction using a direct prosthesis after mastectomy due to breast cancer was performed in 24 patients, with 13 (54.2%) reconstructions performed with non-conical prostheses and 11 (45.8%) with conical prostheses. The NAC was preserved in 8 (72.7%) patients with conical prostheses and in 8 (61.5%) with non-conical prostheses; however, the NAC in 3 (27.3%) patients with conical prostheses and in 5 (38.5%) with non-conical prostheses was not preserved (Figure 1).

Regarding the reconstructed side, 12 procedures were performed on the right breast and 12 on the left breast.

Figure 1 - Proportion of conical and non-conical prostheses in all analyzed patients who underwent breast reconstruction and their relation with the nipple-areola complex (NAC) preservation.

Figure 1 - Proportion of conical and non-conical prostheses in all analyzed patients who underwent breast reconstruction and their relation with the nipple-areola complex (NAC) preservation.

Complications occurred in 13 (54.1%) patients, with capsular contracture that occurred in 6 (25%) patients as the most common (Figure 2). In patients with conical prostheses, 3 experienced capsular contractures, 2 NAC dystopias (Figure 3) and 2 sore flaps with the formation of a hyperemic halo (Figure 4), similar to a pressure ulcer at the tip of the conical prosthesis, which resulted in extrusion (Figure 5) and prosthesis removal. In patients with non-conical prostheses, 3 capsular contractures and 3 NAC dystopias occurred (Figure 6).

Figure 2 - Capsular contracture.

Figure 2 - Capsular contracture.

Figure 3 - Dystopia of the nipple-areola complex (NAC).

Figure 3 - Dystopia of the nipple-areola complex (NAC).

Figure 4 - Hyperemic halo at the tip of the conical prosthesis.

Figure 4 - Hyperemic halo at the tip of the conical prosthesis.

Figure 5 - Extrusion of the prosthesis.

Figure 5 - Extrusion of the prosthesis.

Figure 6 - Frequency and types of complications in all analyzed patients who underwent immediate breast reconstruction and their relation with the use of conical and non-conical prostheses.

Figure 6 - Frequency and types of complications in all analyzed patients who underwent immediate breast reconstruction and their relation with the use of conical and non-conical prostheses.

No infection or death was found in this group of patients. Regarding the preservation of NAC, 8 (50%) patients with preserved NAC had complications, whereas 5 (62.5%) patients with no preserved NAC had complications.

No difference in the frequency of complications was observed between the right and left breasts, since both presented an incidence of 50% of complications. Conical prostheses presented the highest number of complications, with complications in 7 (63.6%) patients, whereas only 6 (46.1%) patients with non-conical prostheses had complications (Figure 7). In 6 patients submitted for radiotherapy, 2 (33.3%) had capsular contracture as a complication, whereas among the 18 patients who did not undergo radiotherapy, 4 (22.2%) had capsular contracture.

Figure 7 - Frequency of the use of conical and non-conical prostheses in the immediate and total breast reconstruction cases analyzed and the relation with the frequency of complications.

Figure 7 - Frequency of the use of conical and non-conical prostheses in the immediate and total breast reconstruction cases analyzed and the relation with the frequency of complications.

DISCUSSION

In the recent years, breast reconstruction for the treatment of breast cancer has become essential for mastectomized patients due to its proven psychological and physical benefits, because it allows faster return to social life, in addition to an improved immunity, thus contributing to a more favorable prognosis^5,6.

Choosing the format of the prosthesis directly influences the shape of the reconstructed breast, providing a better superomedial projection in round prostheses, a better anterior projection in conical prostheses and a more natural appearance in anatomical prostheses for more hypotrophic breasts.

In this study, complications occurred in 54.1% of patients using the alloplastic material, which is higher than most breast reconstruction services, with the incidence ranging from 30% to 43%^7,8.

The most common complication identified was capsular contracture, which occurred in 6 (25%) patients, which is similar to that found in the researched literature, ranging from 0.5% to 30%^9,10.

The most serious complication identified was prosthetic extrusion that required removal of the prosthesis that occurred in 2 patients who used the conical prosthesis, representing 18.1% of the patients. This incidence was higher than that of a previous study, which ranged from 1.2% to 5.3%, and higher than those using non-conical prostheses, in which no cases of prosthetic extrusion were observed¹¹.

Extrusions occurring in the conical prostheses initially evolved from a sore area (local hyperemic halo) formed in the myocutaneous flap on the tip of these conical prostheses, with characteristics similar to pressure ulcers (Figures 4 and 5).

CONCLUSION

Immediate breast reconstructions with silicone prostheses is an excellent option for selected patients, considering the low complexity of the procedure and short surgical time; however, the disease severity, associated with the surgeon’s experience in performing the mastectomy and the skin flap thickness, may weaken the cutaneous cover of the prosthesis, which promotes extrusion.

Our study showed a higher frequency of complications in immediate breast reconstructions with conical and non-conical prostheses when the NAC was not preserved and when the patient is submitted for radiotherapy, which were observed in patients using conical prostheses. This condition mainly occurs due to the formation of a sore area at the tip of the conical prosthesis that resulted in extrusion.