Optimal Timing of Expander-to-Implant Exchange after Irradiation in Immediate Two-Stage Breast Reconstruction

 

 

by Kim, Ara; Bae, Juyoung; Bang, Sa-Ik; Pyon, Jai-Kyong 

 

Plastic and Reconstructive Surgery: February 2022 - Volume 149 - Issue 2 - p 185e-194e

 

Background: Time intervals for expander-to-implant exchange from radiation therapy have been reported to reduce device failure. This study investigated the optimal timing of expander-to-implant exchange after irradiation in terms of short- and long-term outcomes.

Methods: This retrospective review enrolled consecutive patients who underwent immediate two-stage breast reconstruction and radiation therapy to tissue expanders from 2010 to 2019. Receiver operating characteristic curves and the Youden index were used to estimate the optimal time from radiation therapy to implant placement in terms of 49-day (early) and 2-year (late) complications. Logistic regression analysis was performed to identify the risk factors for each complication.

Results: Of the 1675 patients, 133 were included. The 49-day and 2-year complication rates were 8.3 percent and 29.7 percent, respectively. Capsular contracture was the most common 2-year complication. The Youden index indicated that implant placement at 131 days after radiation therapy was most effective in reducing the 49-day complications, but that the 2-year complication was less significant, with lower sensitivity and area under the curve. Modified radical mastectomy, expander fill volume at radiation therapy, and size of permanent implant increased the odds of 49-day complications; none of them was associated with the odds of 2-year complications.

Conclusions: To reduce short-term complications, the best time point for permanent implant placement was 131 days after radiation therapy. However, there was no significant time interval for reducing long-term complications. Capsular contracture was an irreversible complication of radiation injury that was not modified by postirradiation variables including the time from irradiation or size of permanent implant. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

 

A Comparison of Surgical Complications in Patients Undergoing Delayed versus Staged Tissue-Expander and Free-Flap Breast Reconstruction

 

by Shammas, Ronnie L.; Cason, Roger W.; Sergesketter, Amanda R.; Glener, Adam D.; Broadwater, Gloria; Hollins, Andrew; Le, Elliot; Marks, Caitlin; Atia, Andrew N.; Orr, Jonah P.; Hollenbeck, Scott T. 

 

Plastic and Reconstructive Surgery: September 2021 - Volume 148 - Issue 3 - p 501-509

 

Background: Patients undergoing mastectomy may not be candidates for immediate free-flap breast reconstruction because of medical comorbidities or postmastectomy radiation therapy. In this setting, flap reconstruction may be intentionally delayed or staged with tissue expander placement (“delayed-immediate” reconstruction). The optimal reconstructive choice and incidence of complications for these approaches remain unclear.

Methods: The authors retrospectively identified patients who underwent delayed [n = 140 (72 percent)] or staged [n = 54 (28 percent)] abdominal free-flap breast reconstruction between 2010 and 2018 and compared the incidence of postoperative complications.

Results: Patients undergoing staged reconstruction had a higher overall incidence of perioperative complications, including surgical-site infection (40.7 percent versus 6.5 percent; p < 0.001), wound healing complications (29.6 percent versus 12.3 percent; p = 0.004), hematoma (11.1 percent versus 0.7 percent; p < 0.001), and return to the operating room (27.8 percent versus 4.4 percent; p < 0.0001). These complications occurred predominately during the expansion stage, resulting in an 18.5 percent (n = 10) rate of tissue expander failure. Mean time from mastectomy to flap reconstruction was 476.8 days (delayed, 536.4 days; staged, 322.4 days; p < 0.001). At the time of flap reconstruction, there was no significant difference in the incidence of complications between the staged cohort versus the delayed cohort, including microsurgical complications (1.9 percent versus 4.3 percent; p = 0.415), total flap loss (0 percent versus 2.1 percent; p = 0.278), or fat necrosis (5.6 percent versus 5.0 percent; p = 0.875).

Conclusions: The aesthetic and psychosocial benefits of staged free-flap breast reconstruction should be balanced with the increased risk of perioperative complications as compared to a delayed approach. Complications related to definitive flap reconstruction do not appear to be affected by the approach taken at the time of mastectomy. 

Clinical Question/Level of Evidence: Therapeutic, III.

Does the Textured-Type Tissue Expander Affect the Outcomes of Two-Stage Prosthetic Breast Reconstruction? A Propensity Score Matching Analysis between Macrotextured and Microtextured Expanders

Does the Textured-Type Tissue Expander Affect the Outcomes of Two-Stage Prosthetic Breast Reconstruction? A Propensity Score Matching Analysis between Macrotextured and Microtextured Expanders

 

by Lee, Kyeong-Tae; Park, Hae Yeon; Jeon, Byung-Joon; Mun, Goo-Hyun; Bang, Sa Ik; Pyon,expander Jai Kyong 

 

Plastic and Reconstructive Surgery: March 2021 - Volume 147 - Issue 3 - p 545-555

 

Background:

 

In two-stage prosthetic breast reconstruction, two types of tissue expanders are used for the first stage: microtextured Siltex and macrotextured Biocell. Despite emerging concerns regarding the safety of macrotextured prostheses, the association between the use of macrotextured expanders and adverse outcomes remains unknown clinically. This study aimed to evaluate potential impacts of the type of tissue expander on the long-term outcomes of implant-based breast reconstruction.

 

Methods:

 

Patients who underwent immediate two-stage tissue expander/implant breast reconstruction between 2014 and 2018 were evaluated and categorized into two groups according to the expander type. Those two were propensity score matched for baseline characteristics and compared for complication rates after the first- and second-stage operations. The impacts of several variables, including type of tissue expander used, on outcomes were assessed using multivariable logistic regression analyses.

 

Results:

 

Of the 1391 cases in 1294 patients, 276 pairs (552 cases) were successfully propensity score matched. In the first-stage operation, the macrotextured group showed a significantly shorter drain indwelling period and lower rate of seroma than the microtextured group. These differences retained influences after adjusting for other variables. Incidence rates of other complications were similar between the groups. Regarding the second-stage operation, the use of macrotextured expanders showed a significant association, with an increased rate of severe capsular contracture on the multivariable analyses in cases using textured implants. Development of other complications was not affected by the expander type.

 

Conclusion:

 

The type of tissue expander might influence the outcomes of two-stage implant-based breast reconstruction, and generally acceptable safety of both microtextured and macrotextured expanders was shown. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III. 

Patient-Reported Outcomes after Irradiation of Tissue Expander versus Permanent Implant in Breast Reconstruction: A Multicenter Prospective Study

Patient-Reported Outcomes after Irradiation of Tissue Expander versus Permanent Implant in Breast Reconstruction: A Multicenter Prospective Study

by Yoon, Alfred P.; Qi, Ji; Kim, Hyungjin M.; Hamill, Jennifer B.; Jagsi, Reshma; Pusic, Andrea L.; Wilkins, Edwin G.; Kozlow, Jeffrey H.

Plastic and Reconstructive Surgery: May 2020 - Volume 145 - Issue 5 - p 917e-926e

Background: Whether to irradiate the tissue expander before implant exchange or to defer irradiation until after exchange in immediate, two-stage expander/implant reconstruction remains uncertain. The authors evaluated the effects of irradiation timing on complication rates and patient-reported outcomes in patients undergoing immediate expander/implant reconstruction.

Methods: Immediate expander/implant reconstruction patients undergoing postmastectomy radiation therapy at 11 Mastectomy Reconstruction Outcomes Consortium sites with demographic, clinical, and complication data were analyzed. Patient-reported outcomes were assessed with BREAST-Q, Patient-Reported Outcomes Measurement Information System, and European Organisation for Research and Treatment of Cancer Breast Cancer–Specific Quality-of-Life Questionnaire surveys preoperatively and 2 years postoperatively. Survey scores and complication rates were analyzed using bivariate comparison and multivariable regressions.

Results: Of 317 patients who met inclusion criteria, 237 underwent postmastectomy radiation therapy before expander/implant exchange (before-exchange cohort), and 80 did so after exchange (after-exchange cohort). Timing of radiation had no significant effect on risks of overall complications (OR, 1.25; p = 0.46), major complications (OR, 1.18; p = 0.62), or reconstructive failure (OR, 0.72; p = 0.49). Similarly, radiation timing had no significant effect on 2-year patient-reported outcomes measured by the BREAST-Q or the European Organisation for Research and Treatment of Cancer survey. Outcomes measured by the Patient-Reported Outcomes Measurement Information System showed less anxiety, fatigue, and depression in the after-exchange group. Compared with preoperative assessments, 2-year patient-reported outcomes significantly declined in both cohorts for Satisfaction with Breasts, Physical Well-Being, and Sexual Well-Being, but improved for anxiety and depression.

Conclusions: Radiation timing (before or after exchange) had no significant effect on complication risks or on most patient-reported outcomes in immediate expander/implant reconstruction. Although lower levels of anxiety, depression, and fatigue were observed in the after-exchange group, these differences may not be clinically significant. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Systematic Review of the Impact of Acellular Dermal Matrix on Aesthetics and Patient Satisfaction in Tissue Expander-to-Implant Breast Reconstructions

Systematic Review of the Impact of Acellular Dermal Matrix on Aesthetics and Patient Satisfaction in Tissue Expander-to-Implant Breast Reconstructions

by DeLong, Michael R.; Tandon, Vickram J.; Farajzadeh, Matthew; Berlin, Nicholas L.; MacEachern, Mark P.; Rudkin, George H.; Da Lio, Andrew L.; Cederna, Paul S

Plastic and Reconstructive Surgery: December 2019 - Volume 144 - Issue 6 - p 967e-974e

Background: Acellular dermal matrix is used in most postmastectomy implant-based breast reconstructions in the United States. It is believed to be safe, despite a slightly increased complication rate. Although never established in a unifying study, the primary advantage of acellular dermal matrix is believed to be an enhanced aesthetic result, thus justifying the added expense. The purpose of this study was to assess the aesthetic benefits of acellular dermal matrix in expander-to-implant breast reconstruction.

Methods: A systematic review adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology was performed including all original studies examining aesthetic outcomes of expander-to-implant breast reconstructions with acellular dermal matrix compared to muscular coverage. Direct-to-implant and prepectoral studies were excluded from the evaluation. The results were aggregated and reported as a summary.

Results: Among 883 studies identified, 49 full-text articles were reviewed and nine articles ultimately met inclusion criteria. All nine studies were not randomized. Of these, three articles (1448 total patients) evaluated reconstruction aesthetic outcomes by patient satisfaction, whereas six articles evaluated the aesthetic outcomes by external observer (504 total patients). None of the articles evaluating patient satisfaction reported a difference between acellular dermal matrix and muscular reconstruction. Five of the six articles using objective outcomes demonstrated significant improvement in aesthetic outcome in the acellular dermal matrix group.

Conclusions: Although little evidence exists evaluating the aesthetic benefits of acellular dermal matrix for expander-to-implant breast reconstruction, the data suggest that objective observers consider acellular dermal matrix–assisted expander-to-implant breast reconstructions aesthetically superior to reconstruction with only muscular coverage, but patients appear to be equally satisfied with both reconstructive options.

Complication Profiles by Mastectomy Indication in Tissue Expander Breast Reconstruction

Complication Profiles by Mastectomy Indication in Tissue Expander Breast Reconstruction

 by Chouairi, Fouad; Gabrick, Kyle S.; Avraham, Tomer; Markov, Nickolay P.; Alperovich, Michael  

Plastic and Reconstructive Surgery: April 2019 - Volume 143 - Issue 4 - p 682e-687e

Background: Two-stage implant breast reconstruction is the most commonly performed breast reconstruction procedure. Limited data exist regarding reconstruction complication rates examined by mastectomy indication.

Methods: Patients who underwent two-stage implant breast reconstruction at Yale New Haven Hospital from 2011 to 2017 were included in the study. Perioperative complications were compared. Chi-square analysis, t tests, and Fisher’s exact tests were used to determine significant associations. A binary logistic regression was used to determine variables with a significant impact on the likelihood of mastectomy flap necrosis.

Results: Between 2011 and 2017, complete perioperative records were available for 141 patients who underwent 226 mastectomies followed by two-stage tissue expander/permanent implant reconstruction. Of the 226 mastectomies, 134 were therapeutic and 92 were prophylactic. On regression analysis, there were no significant differences in demographics, comorbidities, or mastectomy and reconstructive details between the two breast groups except for there being more modified radical mastectomies in therapeutic breasts (p = 0.003). When comparing complications, there was a significantly higher risk of mastectomy flap necrosis in the therapeutic group (p = 0.017). Therapeutic mastectomies had a 9.5 times higher risk of mastectomy flap necrosis than prophylactic mastectomies when adjusted for confounding variables. There were no significant differences in other reconstructive complications between the two groups.

Conclusions: Patients undergoing therapeutic mastectomies have a significantly higher risk of mastectomy flap necrosis than those undergoing prophylactic mastectomies. Although the underlying cause still needs to be determined, differences in technique may be related to mastectomy flap necrosis. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Tissue Expander Complications Do Not Preclude a Second Successful Implant-Based Breast Reconstruction

Tissue Expander Complications Do Not Preclude a Second Successful Implant-Based Breast Reconstruction

by Poppler, Louis H.; Mundschenk, Minh-Bao; Linkugel, Andrew; Zubovic, Ema; Dolen, Utku C.; Myckatyn, Terence M.  

Plastic and Reconstructive Surgery: January 2019 - Volume 143 - Issue 1 - p 24–34

Background: Implant-based breast reconstruction is the most common method of breast reconstruction in the United States, but the outcomes of subsequent implant-based reconstruction after a tissue expander complication are rarely studied. The purpose of this study was to determine the long-term incidence of implant loss in patents with a previous tissue expander complication. Methods: This is a retrospective review of the long-term outcomes of all patients with tissue expander complications at a large academic medical center from 2003 to 2013. Patients with subsequent tissue expander or implant complications were compared to those with no further complications to assess risk factors for additional complications or reconstructive failure.

Results: One hundred sixty-two women were included in this study. The mean follow-up period was 8.3 ± 3.1 years. Forty-eight women (30 percent) went on to undergo a second tissue expander or implant placement. They did not differ from women who went on to autologous reconstruction or no further reconstruction. Of these, 34 women (71 percent) had no further complications and 38 women (79 percent) had a successful implant-based reconstruction at final follow-up. There were no patient or surgical factors significantly associated with a second complication or implant loss. 

Conclusions: Following tissue expander complications, it is reasonable to offer women a second attempt at tissue expansion and implant placement. This study demonstrates that long-term success rates are high, and there are no definitive patient or surgical factors that preclude a second attempt at implant-based breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Comparison of Outcomes with Tissue Expander, Immediate Implant, and Autologous Breast Reconstruction in Greater Than 1000 Nipple-Sparing Mastectomies

Comparison of Outcomes with Tissue Expander, Immediate Implant, and Autologous Breast Reconstruction in Greater Than 1000 Nipple-Sparing Mastectomies

Frey, J et al
Plastic & Reconstructive Surgery: June 2017 - Volume 139 - Issue 6 - p 1300–1310

Background: Nipple-sparing mastectomy permits complete preservation of the nipple-areola complex with excellent aesthetic results and with oncologic safety similar to that associated with traditional mastectomy techniques. However, outcomes have not been directly compared for tissue expander–, immediate implant–, and autologous tissue–based breast reconstruction after nipple-sparing mastectomy. Methods: All patients undergoing nipple-sparing mastectomy from 2006 to June of 2016 were identified at a single institution. Demographics and outcomes were analyzed and compared among different types of breast reconstruction. Results: A total of 1028 nipple-sparing mastectomies were performed. Of these, 533 (51.8 percent) were tissue expander–based, 263 (25.6 percent) were autologous tissue–based, and 232 (22.6 percent) were immediate implant–based reconstructions. Tissue expander–based reconstructions had significantly more minor cellulitis (p = 0.0002) but less complete nipple necrosis (p = 0.0126) and major mastectomy flap necrosis (p < 0.0001) compared with autologous tissue–based reconstructions. Compared to immediate implant–based reconstruction, tissue expander–based reconstructions had significantly more minor cellulitis (p = 0.0006) but less complete nipple necrosis (p = 0.0005) and major (p < 0.0001) and minor (p = 0.0028) mastectomy flap necrosis (p = 0.0059). Immediate implant–based reconstructions had significantly more minor cellulitis (p = 0.0051), minor mastectomy flap necrosis (p = 0.0425), and partial nipple necrosis (p = 0.0437) compared with autologous tissue–based reconstructions. Outcomes were otherwise equivalent among the three groups. Conclusions: Tissue expander, immediate implant, and autologous tissue breast reconstruction techniques may all be safely offered with nipple-sparing mastectomy. However, reconstructive complications appear to be greater with immediate implant– and autologous tissue–based techniques compared with tissue expander–based reconstruction.

Impact of Neoadjuvant and Adjuvant Chemotherapy on Immediate Tissue Expander Breast Reconstruction.

Impact of Neoadjuvant and Adjuvant Chemotherapy on Immediate Tissue Expander Breast Reconstruction.

Ann Surg Oncol. 2016 Mar 4. [Epub ahead of print]

Dolen UC et al

BACKGROUND: Delayed wound healing or infection leads to premature tissue expander (TE) explantation after immediate postmastectomy breast reconstruction. A large study with sufficient duration of follow-up focusing on the impact of chemotherapy (CT) on premature TE removal after immediate breast reconstruction is lacking.
METHODS: A retrospective review of patients undergoing immediate TE reconstruction was conducted. Multivariate analyses identified factors contributing to premature removal of TEs including neoadjuvant and adjuvant CT, specific chemotherapeutic regimens, and other factors like cancer stage, body mass index, smoking, radiation, and age. Kaplan-Meier curves were plotted to study the timing of premature TE removal.
RESULTS: Of 899 patients with TEs, 256 received no, 295 neoadjuvant, and 348 adjuvant CT. Premature removal occurred more frequently in the neoadjuvant (17.3 %) and adjuvant (19.9 %) cohorts than the no-CT (12.5 %) cohort (p = 0.056). Premature TE removal occurred earlier (p = 0.005) in patients who received no CT than those with adjuvant CT. Radiation in patients receiving neoadjuvant CT prolonged the mean time to premature removal (p = 0.003). In the absence of radiation, premature removal occurred significantly sooner with neoadjuvant than adjuvant CT (p = 0.035).

DISCUSSION: Premature removal of a TE occurs more commonly in patients treated with neoadjuvant or adjuvant CT and is most commonly observed 2-3 months after placement-well after the follow-up period recorded by the American College of Surgeons National Surgery Quality Improvement Program (NSQIP) database. These findings can be used to aid preoperative counseling and guide the timing of follow-up for these patients.