INTRODUCTION
For many years, breast reconstructions were performed late since it was believed that
immediate breast repair could delay the onset of adjunctive therapy or prevent the
diagnosis of future relapse. There was also great concern that this adjunctive therapy
could increase the incidence of postoperative complications that could even lead to
reconstruction loss. However, over the last few years, the benefits of immediate reconstruction
have become increasingly clear and documented in the literature1,2,3.
Today, with some exceptions, immediate reconstruction is the preferred surgical choice
for breast cancer patients. Many surgical breast reconstruction techniques are currently
available. Despite being considered a long-term standard treatment4,5, autologous tissue reconstruction techniques are often not recommended due to classic
contraindications, nonacceptance of donor-area morbidity by patients, longer recovery
time, or patient comorbidities (such as chronic obstructive pulmonary disease [COPD]
and morbid obesity). Patient profiles have been changing as cancer is diagnosed increasingly
earlier in younger women with no children but a longer life expectancy. Simpler and
faster recovery reconstructions were quickly accepted by these young women as the
result resembles that of an aesthetic implant. Thus, we started saving more elaborate
flaps for future procedures.
Implant reconstructions can be performed immediately, in which the prosthesis is inserted
immediately after mastectomy, or in two steps, in which breast tissue expanders are
used and subsequently replaced with implants.
A two-step reconstruction consists of placing a tissue expander immediately after
mastectomy. The expansion continues until the optimal volume for a new surgical procedure
is achieved. The expander is placed during the second procedure and an implant is
placed simultaneously with breast symmetrization procedures such as mastopexy, reduction
mammaplasty, or even a breast augmentation implant. The time interval between surgeries
is variable, ranging from 3 months to over 1 year depending on adjunctive radiotherapy
and chemotherapy and patient availability.
When possible, the use of an implant in the first surgery has some advantages, such
as the easier use of tissues “virgin” to treatment, fewer postoperative returns, shorter
convalescence time, and faster body image recovery.
The greater indication for nipple-areola complex (NAC)-sparing mastectomy has created
a great opportunity for immediate direct reconstruction with an implant. In addition,
the number of risk-reducing mastectomies has been increasingly growing, whether due
to formal indications, BRCA gene mutation screening, or at patient request. These NAC-sparing prophylactic mastectomies
are appropriate for this type of reconstruction since it is easier to achieve symmetry.
The main difficulty of immediate prosthetic reconstruction is limited adequate tissue
coverage, which can lead to implant exposure, the need for several reoperations, and
an inadequate aesthetic result. However, modern mastectomy techniques preserving the
skin, pectoral muscle, and subcutaneous tissue have facilitated and improved the results
of these reconstructions.
OBJECTIVE
To compare the results, advantages, and disadvantages of breast reconstruction with
direct breast implant placement and two-step expander-implant reconstructions.
METHODS
This retrospective study was conducted from January 1, 2013 to December 31, 2014 and
followed the norms of the Declaration of Helsinki. Each patient signed an informed
consent form. The study included all patients undergoing total mastectomy followed
by immediate breast reconstruction using an implant or a temporary expander at private
clinics belonging to the two main authors (Brasília-DF). The patients were divided
into a group undergoing direct implant reconstruction and a group undergoing two-step
expander-implant reconstruction.
Patients undergoing reconstructions using permanent expanders, local flaps, and autologous
tissues (transverse rectus abdominis myocutaneous flap or pectoralis major muscle
flap); salvage reconstructions; and partial mastectomy were excluded.
Surgical technique
Both groups underwent the same surgical technique. After mastectomy, all patients
underwent careful hemostasis testing, immediately following which a submuscular pocket
was created for implant placement using the pectoralis major muscle and the anterior
sheath of the rectus abdominis muscle and the anterior serratus muscle. After implant
placement, the muscle pocket was closed with Vicryl 0 to completely cover the implant.
All patients used a suction drain until a volume less than 50 mL was reached in 24
hours. Patients undergoing NAC-sparing immediate implant reconstruction did not use
a postoperative bra to avoid NAC compression, decreasing vascularization. The remaining
patients wore a bra from the first postoperative day. In expander reconstructions,
expansion started during surgery if the pectoral muscle and/or flap conditions allowed.
The remaining cases were treated in 2-3 postoperative weeks.
Data collection
Several data were collected. Demographic data such as age, body mass index (BMI),
comorbidities, tumor type, and mastectomy type were used to evaluate the groups.
The analyzed complications included hematoma, seroma, minor infection (defined as
cases of hyperemia in which the patient used antibiotics and the condition regressed),
major infection (resulting in implant loss), capsular contracture, and necrosis (flap
and/or NAC). Data such as postoperative return and number of surgeries were also evaluated.
Statistical analysis
The Shapiro-Wilk test was used to evaluate the normality of the variable distribution.
Normally distributed continuous variables were analyzed using Student’s t-test for
independent samples and are presented as mean ± standard deviation (SD). Non-normally
distributed continuous variables were analyzed using the Mann-Whitney U test and are
presented as median and interquartile range. Categorical variables were analyzed using
the chi-square (X2) or Fisher’s exact test and are presented as absolute numbers and percentages. P
values <0.05 were considered statistically significant.
RESULTS
During these 2 years of study, 102 of the surveyed patients were selected within the
established criteria for a total of 138 reconstructions (57 immediate and 81 expander-implant).
The mean patient age was 50.63 years for the immediate implant reconstruction group
and 47.64 years for the expander-implant group (p = 0.188). Patients undergoing immediate
implant reconstruction had lower mean BMI than those undergoing expander-implant reconstructions
(23.4 vs 25.51; p = 0.006). The groups presented similar results for all other variables.
The patients’ demographic data are presented in Table 1.
Table 1 - Comparison of the immediate implant and expander-implant reconstruction groups.
| |
Implant |
Expander-implant |
p |
| Number of patients (n) |
41 |
61 |
|
| Laterality (n) |
| Unilateral |
25 |
41 |
|
| Bilateral |
16 |
20 |
0,331 |
| Age, mean ± SD |
50,63 ±13 |
47,64 ±9,8 |
0,188 |
| BMI, mean ± SD |
23,4 ±3,06 |
25,51 ±3,84 |
0,006* |
| Comorbidities |
|
|
|
| Hypertension, n (%) |
13 (31,70% |
12 (19,67%) |
0,125 |
| Diabetes, n (%) |
3 (7,3%) |
5 (8,19%) |
0,592 |
| Smoker, n (%) |
4 (9,75%) |
5 (8,19%) |
0,525 |
| Former smoker, n (%) |
4 (9,75%) |
6 (9,83%) |
0,633 |
| Hypothyroidism, n (%) |
6 (14,63%) |
9 (14,75%) |
0,610 |
| Dyslipidemia, n (%) |
3 (7,31%) |
5 (8,19%) |
0,475 |
| COPD, n (%) |
2 (4,87%) |
0 |
0,159 |
| DVT (%) |
1 (2,43%) |
1 (1,63%) |
0,598 |
| Neoadjuvant chemotherapy, n (%) |
4 (12,19%) |
11 (18,03%) |
0,193 |
| NAC-sparing, n (%) |
20 (48,78%) |
19 (31,14%) |
0,056 |
| Histopathological |
| Absence of CA, n (%) |
2 (4,87%) |
0 |
|
| IDC, n (%) |
27 (65,85%) |
34 (55,73%) |
|
| DCIS, n (%) |
10 (24,39%) |
13 (21,31%) |
|
| ILC, n (%) |
0 |
3 (4,91%) |
0,331 |
| LCIS, n (%) |
0 |
1 (1,63%) |
|
| Lobular, n (%) |
1 (2,43%) |
5 (8,19%) |
|
| Not described, n (%) |
1 (2,43%) |
6 (9,83%) |
|
Table 1 - Comparison of the immediate implant and expander-implant reconstruction groups.
Many postoperative complication variables were evaluated, but no intergroup difference
was noted in minor and major infections, hematomas, seromas, contractures, or necrosis
rates. Data on postoperative complications are presented in Table 2.
Table 2 - Comparison of complications by group.
| Reconstruction technique |
| |
Implant reconstruction (n = 57) |
Expander (n = 81) |
p |
| Complications |
| Hematoma, n (%) |
2 (3,5%) |
1 (1,23%) |
0,367 |
| Seroma, n (%) |
11 (19,29%) |
16 (19,75%) |
0,947 |
| Minor Infection, n (%) |
6 (10,52%%) |
11 (13,58%) |
0,591 |
| Major infection, n (%) |
3 (5,26%) |
3 (3,7%) |
0,658 |
| Necrosis, n (%) |
7 (12,28%) |
8 (9,87%) |
0,655 |
| Contratura (%) |
4 (7%) |
5 (6,17%) |
0,843 |
Table 2 - Comparison of complications by group.
Postoperative complications in both groups were also evaluated for exposure to radiotherapy.
The individual analysis by reconstruction type showed that radiotherapy did not influence
capsular contracture complications (Tables 3 and 4).
Table 3 - Implant reconstruction complications due to radiotherapy.
| Complications |
RTx (n=12) |
W/RTx (n = 45) |
p |
| |
Contracture (%) |
2 (16,66%) |
2 (4,4%) |
0,141 |
Table 3 - Implant reconstruction complications due to radiotherapy.
Table 4 - Expander reconstruction complications due to radiotherapy.
| Complications |
|
RTx (n=29) |
S/RTx (n=52) |
p |
| |
Contracture (%) |
3 (10,3%) |
2 (3,84%) |
0,244a |
Table 4 - Expander reconstruction complications due to radiotherapy.
Table 5 shows the number of breast reconstructions completed using each technique and the
number of surgeries required to achieve this outcome. The patients undergoing immediate
implant reconstruction required fewer surgeries to achieve treatment completion than
the patients undergoing expander-implant reconstruction (1.78 ± 0.55 vs 2.54 ± 0.72; p < 001).
Table 5 - Number of surgeries required to complete breast reconstruction.
| |
Implant
reconstruction
|
Expander |
p |
| Number of surgeries, mean ± SD |
1,78 +- 0,55 |
2,54 +- 0,72 |
<0,001* |
Table 5 - Number of surgeries required to complete breast reconstruction.
The mean implant volume used in the immediate implant reconstruction group was 357.92
mL.
Table 6 shows the number of postoperative returns for both reconstruction techniques. Patients
undergoing immediate implant reconstruction required fewer postoperative returns than
those undergoing expander-implant reconstruction (8 ± 3.26 vs 11.75 ± 4.7; p < 0.001).
Table 6 - Number of returns by reconstruction type.
| |
Implant
reconstruction
|
Expander |
p |
| Returns, mean ± SD |
8 +- 3,26 |
11,75 +- 4,7 |
< 0,001* |
Table 6 - Number of returns by reconstruction type.
Figures 1-5 show the immediate breast reconstruction cases. Figures 1, 2, and 3 show the implant breast reconstructions, while Figures 4 and 5 show the expander-implant reconstructions.
Figure 1 - Immediate expander reconstruction. Pre- and postoperative photos of a patient undergoing
mastectomy with expander reconstruction subsequently replaced with an implant.
Figure 1 - Immediate expander reconstruction. Pre- and postoperative photos of a patient undergoing
mastectomy with expander reconstruction subsequently replaced with an implant.
Figure 2 - Immediate implant reconstruction. Patient undergoing immediate implant reconstruction.
Row A: Preoperative; Row B: Postoperative; Row C: After symmetrization.
Figure 2 - Immediate implant reconstruction. Patient undergoing immediate implant reconstruction.
Row A: Preoperative; Row B: Postoperative; Row C: After symmetrization.
Figure 3 - Immediate implant reconstruction. Row A: Preoperative; Row B: After first surgery; Row C: After symmetrization.
Figure 3 - Immediate implant reconstruction. Row A: Preoperative; Row B: After first surgery; Row C: After symmetrization.
Figure 4 - Immediate expander-implant reconstruction. Sequences after first, second, and third
expander reconstruction surgeries.
Figure 4 - Immediate expander-implant reconstruction. Sequences after first, second, and third
expander reconstruction surgeries.
Figure 5 - Immediate expander-implant reconstruction. Sequence of pre- and postoperative photos
after expander placement and finally after the third surgery with expander replacement,
nipple-areola complex reconstruction, and symmetrization.
Figure 5 - Immediate expander-implant reconstruction. Sequence of pre- and postoperative photos
after expander placement and finally after the third surgery with expander replacement,
nipple-areola complex reconstruction, and symmetrization.
DISCUSSION
Breast cancer is a major public health problem worldwide, with over 1.5 million new
cases in 2012 alone6. The US spent approximately USD 14 billion in 2006 in addition to USD 12 billion
due to the resultant loss of productivity7. Breast reconstruction is a vital step in treating these patients since it restores
body image and, consequently, improves personal and psychological satisfaction8,9,10,11.
Several breast reconstruction techniques have evolved over the last few years with
the objective of achieving more natural reconstructions with greater overall patient
satisfaction in as few surgeries as possible.
Implant reconstructions have become common worldwide12. They have been increasingly indicated in the US, especially after the advent of
dermal matrices12,13. Modern mastectomy techniques that promote better skin preservation with the use
of skin- or NAC-sparing mastectomies enabled immediate implant placement after a mastectomy
and are increasingly accepted by patients, especially those who do not wish to undergo
several surgical procedures or the postoperative expansion process. However, several
risks are associated with this technique due to total dependence on mastectomy flap
quality and difficulty adjusting volume.
Patients undergoing immediate implant and two-step expander-implant reconstruction
were evaluated in this study. The groups presented similar values except for mean
BMI, which was higher in the expander-implant group. However, this difference, although
significant (p = 0.006), differed little between groups when evaluated by the BMI
classification, which considers patients with a BMI of 18.5-24.9 as eutrophic (normal
weight) and those with a BMI of 25-29.9 as overweight. The patients in the expander-implant
group had a mean BMI of 25.51 kg/m2, very close to the eutrophic classification (normal weight).
The evaluation of postoperative complications presented no statistically significant
intergroup differences, showing that both techniques are extremely safe and comparable
when performed with clinical judgment and good patient selection. These data are corroborated
by several published studies7,14.
Some studies show that expander-implant reconstruction has some advantages over implant
reconstruction6,14, especially the possibility of adjusting breast volume by placing a larger implant
and correcting minor imperfections during the second surgery, such as implant pocket
and mammary groove adjustments. However, this was not seen in the present study.
In this study, the implant volume in immediate reconstructions ranged from 225 cc
to 495 cc, with a mean of 357.92 cc. The number of surgeries required to complete
reconstruction was also evaluated. Patients undergoing immediate implant reconstruction
underwent fewer surgeries than those undergoing expander-implant reconstruction (1.78
vs 2.54; p ≤ 0.001). Also, there were fewer postoperative returns in the immediate implant
reconstruction group than in the expander-implant group (8 vs 11.75; p < 0.001).
These results have several implications. First, when well indicated, immediate implant
reconstruction can result in complete reconstruction with one procedure, with fewer
postoperative returns, fewer surgeries, and less stress for the patient, who can return
sooner to their daily activities, among other implications. Additionally, even in
cases in which a new surgery is required, this new procedure is usually shorter, faster,
and has no influence on the patient’s overall satisfaction, as observed in a study
by Susarla et al. (2015)14.
Therefore, immediate implant and expander-implant reconstructions are viable, are
safe, have accurate indications, and should be options for breast reconstruction.
It is important to inform patients that immediate implant reconstruction will not
definitely result in complete reconstruction in a single procedure, although it is
possible. This technique depends on several factors already mentioned (mastectomy
quality and pectoral muscle viability, which can only be analyzed intraoperatively)
and sometime may not be possible. In such cases, the surgeon will need to use an expander.
This study’s retrospective nature created a limitation. Cost is also an important
factor to be evaluated in future studies, although it was not the objective of our
study.
CONCLUSION
Immediate implant and expander-implant reconstructions presented similar low postoperative
complication rates. Immediate implant reconstruction patients undergo fewer surgeries
to achieve the final outcome and have fewer postoperative returns.
COLLABORATIONS
|
MCC
|
Analysis and/or data interpretation, Conception and design study, Data Curation, Final
manuscript approval, Methodology, Project Administration, Realization of operations
and/or trials, Writing - Review & Editing
|
|
AB
|
Final manuscript approval, Realization of operations and/or trials, Writing - Review
& Editing
|
|
RQL
|
Analysis and/or data interpretation, Conception and design study, Conceptualization,
Data Curation, Final manuscript approval, Formal Analysis, Investigation, Methodology,
Project Administration, Realization of operations and/or trials, Supervision, Visualization,
Writing - Original Draft Preparation, Writing - Review & Editing
|
|
CMA
|
Realization of operations and/or trials, Writing - Original Draft Preparation, Writing
- Review & Editing
|
|
FTM
|
Formal Analysis
|
|
IRJ
|
Realization of operations and/or trials, Writing - Review & Editing
|
|
LGM
|
Realization of operations and/or trials, Writing - Review & Editing
|
|
JCD
|
Writing - Review & Editing
|
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1. Hospital Daher Lago Sul, Brasília, DF, Brazil.
Corresponding author: Marcela Caetano Cammarota SMH/N, Quadra 2, Bloco C, Edifício Dr. Crispim, Sala 1315, Asa Norte, Brasília, DF,
Brazil. Zip Code: 70710-149. E-mail: marcelacammarota@yahoo.com.br
Article received: February 17, 2019.
Article accepted: April 18, 2019.
Conflicts of interest: none.
