Shaped versus Round Implants for Breast Reconstruction: Indications and Outcomes

Background: With the reintroduction of shaped silicone gel implants in the United States, questions regarding indications and outcomes for each are likely. The purpose of this article is to review the author’s early experience using shaped and round implants for breast reconstruction over a 14-month consecutive interval. Methods: Breast reconstruction using shaped or round implants was performed on 69 women that included shaped silicone gel devices in 49 and round devices in 20. Patients were evaluated based on nipple-sparing vs skin-sparing mastectomy, 1-stage vs 2-stage, radiation therapy, unilateral vs bilateral, occurrence of complications, and follow-up. Results: Of the 49 patients (78 breasts) who had shaped implants, reoperation was necessary in 6 patients (12.2%) and in 7 breasts (9%). This was secondary to infection in 2 breasts, capsular contracture in 2 breasts, incisional dehiscence in 1 breast, asymmetry in 1 breast, and exposure in 1 breast. Of the 20 patients (28 breasts) who had round implants, reoperation was necessary in 2 patients (10%) and 2 breasts (7.1%) and included the removal of the device secondary to a late infection in 1 patient and the correction of a malposition (double bubble deformity) in 1 patient. There were no malpositions involving the shaped silicone gel implants. Conclusions: Both shaped and round silicone gel devices can result in natural aesthetic outcomes. Shaped devices are preferred for contouring the upper pole and for optimizing breast projection. Round devices are preferred when the upper pole is not deficient and the patient desires softer breasts. Longer follow-up studies will be necessary

SPECIAL TOPIC Breast Reconstruction: A Review and Rationale for Patient Selection

Summary: The importance of good patient selection is becoming increasingly appreciated as a predictor of good outcomes following mastectomy and reconstruction. There are many variables that should be considered when making these decisions. Patient variables include breast characteristics, age, body habitus, comorbidities, and expectations. Oncological variables include tumor size, cancer stage, and perioperative radiation. This article is structured to review the variables that are relevant when deciding upon a particular reconstructive option for a particular patient. (Plast. Reconstr. Surg. 124: 55, 2009.) T he importance of patient selection as a determinate of good outcomes in plastic surgery is well accepted. Its importance is becoming increasingly recognized in the patient with breast cancer who is interested in reconstruction. Although reconstructive in nature, the aesthetic importance of breast reconstruction following mastectomy cannot be underestimated. Achieving a highly desirable outcome can be difficult in many women. There are numerous variables that must be considered when selecting the appropriate operation. Patient-related factors include breast size, volume, and contour, as well as body weight and habitus. Oncological factors include tumor size, cancer stage, and previous or future radiation therapy, as well as whether the reconstruction is immediate or delayed. Psychological factors include an assessment of expectations, both realistic and unrealistic, as well as preconceived notions of the reconstructive option desired. Surgeon factors include the technical ability to perform the various reconstructive operations in a predictable and reproducible manner. These variables all contribute to the complexity of the reconstructive process. It is the intent of this article to review a single surgeon's approach to patient selection. The specific details of the article are based on personal experience dating from July of 2005 to June of 2007; however, the principles and concepts are based on having personally performed breast reconstruction in more than 1000 women over the past 10 years. The goal is to provide a framework for optimizing patient evaluation with the ultimate selection of the reconstructive option that will optimize outcomes. PATIENTS Between July of 2005 and June of 2007, a total of 236 women had primary breast reconstruction following mastectomy. The reconstruction was unilateral in 161 women and bilateral 75 women, totaling 311 breasts. The reconstruction was completed with prosthetic devices in 61 women (25.8 percent) and autologous tissue in 175 women (74.2 percent). Of those women with prosthetic devices, the reconstruction was unilateral in 39 women (63.9 percent) and bilateral in 22 women (36.1 percent), totaling 83 breasts. Of those women who had autologous tissue repair, the reconstruction was unilateral in 122 women (69.7 percent) and bilateral in 53 women (30.3 percent), totaling 228 breasts. The specific type of autologous reconstruction included the musclesparing free transverse rectus abdominis musculocutaneous (TRAM) flap in 26 women (34 flaps), the deep inferior epigastric perforator (DIEP) flap in 128 women (172 flaps), superior gluteal artery perforator flap in eight women (11 flaps), and the latissimus dorsi flap in 11 women

The Internal Mammary Artery and Vein as Recipient Vessels for Microvascular Breast Reconstruction: Are We Burning a Future Bridge?

Abstract: Clinical applications for the internal mammary artery include use as an arterial conduit for coronary revascularization and as a recipient artery for microvascular reconstruction of the breast. This study was completed in an attempt to resolve the controversy over which indication should have priority. Five hundred twenty women with breast cancer who underwent breast reconstruction were reviewed. Of these, 240 were 50 years of age or more and were evaluated for cardiac disease. Three components were studied that included analysis of factors related to cardiac function (prior cardiac surgery, specific cardiac disorders, and cardiac medications), analysis of risk factors related to cardiac disease (hypertension, diabetes mellitus, and tobacco use), and analysis of factors related to the reconstruction (selection of recipient vessels, type of reconstruction). The women were stratified based on age-50 to 59 years, 60 to 69 years, and older than 70 years-to analyze trends based on advancing age. Results demonstrated that the incidence of coronary artery disease was 2 in 240 women (0.8%) and that the incidence of factors related to cardiac function and the incidence of risk factors related to cardiac disease appear to increase with advancing age. The internal mammary vessels were used in 35 of 114 free tissue transfers with no adverse sequelae. No woman in whom the internal mammary artery was used has developed coronary artery disease. The 2 women with coronary artery disease were reconstructed with implants. Based on the results of this study, the author thinks that use of the internal mammary artery as a recipient vessel for microvascular reconstruction of the breast is justified. Options for future coronary revascularization would include the opposite internal mammary artery when available, a saphenous vein graft, or angioplasty. (Ann Plast Surg 2004;53: 311-316) C linical applications for the internal mammary artery (IMA) include use as an arterial conduit for coronary revascularization or as a recipient artery for microvascular reconstruction of the breast. 1-5 The principle argument supporting the use of the IMA as an arterial conduit for coronary revascularization is that it has been demonstrated to maintain a higher patency rate and prolong patient survival when compared with saphenous vein grafts. 3,4 Thus, use of the IMA as a recipient vessel for free tissue transfer is becoming increasingly controversial, especially because its use is becoming more widespread. A principle reason for using the IMA as a recipient vessel is that it eliminates the need to dissect the axilla, which has a well-defined risk of lymphedema and sensory nerve damage. Modified radical mastectomy for invasive breast cancer has been performed for many years. After the axillary dissection, the thoracodorsal artery and vein were easily visualized and little effort was required to prepare them for microvascular anastomosis. 6 However, with the increasing role of skin-sparing mastectomy and sentinel lymph node biopsy, modified radical mastectomies are becoming less common. The thoracodorsal vessels are usually poorly visualized and more difficult to access after this technique. In light of a partially dissected axilla, the reconstructive surgeon has 2 choices for recipient vessels: the thoracodorsal or the internal mammary artery and vein. 7 Use of the thoracodorsal vessels usually requires additional skin incisions and additional axillary surgery, whereas use of the IMA does not. The purpose of this study was to analyze women with breast cancer who were at least 50 years of age and to determine whether the use of the IMA as a recipient vessel for microvascular breast reconstruction would adversely impact future options for coronary revascularization. Women were identified and stratified into 2 groups: those who had a history of cardiac disease before the diagnosis of breast cancer and those who had various risk factors for coronary artery disease (CAD). A paradigm for selecting the type of reconstruction based on the cardiac history is discussed

Delayed versus Delayed-Immediate Autologous Breast Reconstruction: A Blinded Evaluation of Aesthetic Outcomes

Background The technique of delayed-immediate breast reconstruction includes immediate insertion of a tissue expander, post-mastectomy radiation, followed by reconstruction. The aesthetic benefits of delayed-immediate reconstruction compared to delayed reconstruction are postulated but remain unproven. The purpose of this study was to compare aesthetic outcomes in patients following delayed and delayed-immediate autologous breast reconstruction. Methods A retrospective analysis was performed of all patients who underwent delayed or delayed-immediate autologous breast reconstruction by the senior author from 2005 to 2011. Postoperative photographs were used to evaluate aesthetic outcomes: skin quality, scar formation, superior pole contour, inferior pole contour, and overall aesthetic outcome. Ten non-biased reviewers assessed outcomes using a 5-point Likert scale. Fisher's Exact and Wilcoxon-Mann-Whitney tests were used for comparative analysis. Results Patient age and body mass index were similar between delayed (n=20) and delayed-immediate (n=20) cohorts (P>0.05). Skin and scar quality was rated significantly higher in the delayed-immediate cohort (3.74 vs. 3.05, P<0.001 and 3.41 vs. 2.79, P<0.001; respectively). Assessment of contour-related parameters, superior pole and inferior pole, found significantly improved outcomes in the delayed-immediate cohort (3.67 vs. 2.96, P<0.001 and 3.84 vs. 3.06, P<0.001; respectively). Delayed-immediate breast reconstruction had a significantly higher overall score compared to delayed breast reconstructions (3.84 vs. 2.94, P<0.001). Smoking and the time interval from radiation to reconstruction were found to affect aesthetic outcomes (P<0.05). Conclusions Preservation of native mastectomy skin may allow for improved skin/scar quality, breast contour, and overall aesthetic outcomes following a delayed-immediate reconstructive algorithm as compared to delayed breast reconstruction

Central Mound Mastopexy for the Correction of Tuberous/Tubular Breast Deformity

Summary:. Tuberous and tubular breast deformity are well-recognized abnormalities in the plastic surgery community that incur severe physical and psychological consequences in affected patients. Current reconstructive options for the tuberous and tubular breasts favor the use of prosthetic implants and soft-tissue manipulation. We present a case of tuberous and tubular breast deformity treated with a central mound reduction technique and mastopexy with imbricating sutures without the use of prosthetic implants. The patient remained extremely pleased with her results at long-term follow-up. This represents a unique case of successful reconstruction in a patient with a tuberous and tubular breast deformity using a central mound reduction technique with mastopexy and without a prosthetic device

Recipient Vessel Analysis for Microvascular Reconstruction of the Head and Neck

Abstract: The selection of recipient vessels that are suitable for microvascular anastomosis in the head and neck region is one of many components that is essential for successful free tissue transfer. The purpose of this study was to evaluate a set of factors that are related to the recipient artery and vein and to determine how these factors influence flap survival. A retrospective review of 102 patients over a 5-year consecutive period was completed. Indications for microvascular reconstruction included tumor ablation (n ϭ 76), trauma (n ϭ 13), and chronic wounds or facial paralysis (n ϭ 13). The most frequently used recipient artery and vein included the facial, superficial temporal, superior thyroid, carotid, and jugular. Various factors that were related to the recipient vessels were analyzed and included patient age, recipient artery and vein, diabetes mellitus, tobacco use, the timing of reconstruction, the method of anastomosis, previous radiation therapy, creation of an arteriovenous loop, and use of an interposition vein graft. Successful free tissue transfer was obtained in 97 of 102 flaps (95%). Flap failure was the result of venous thrombosis in 4 and arterial thrombosis in 1. Statistical analysis demonstrated that anastomotic failure was associated with an arteriovenous loop (2 of 5, P ϭ 0.03) and tobacco use (3 of 5, P ϭ 0.03). Flap failure was not related to patient age, choice of recipient vessel, diabetes mellitus, previous irradiation, the method of arterial or venous anastomosis, use of an interposition vein graft, or the timing of reconstruction. 2004;52: 148 -155) T he selection of recipient vessels that are suitable for microvascular anastomosis within the head and neck is an important component affecting patency. The vascular anatomy of the head and neck is complex with numerous arteries and veins from which to choose. (Ann Plast Surg 1,2 The decision is usually based on the location of the defect and the proximity of a recipient artery and vein. Recipient vessels that are in close proximity to the defect are usually anastomosed to the donor vessels in an end-to-end or end-to-side fashion. However, in circumstances in which the local vascular access is not available or when the quality of the local vasculature is inadequate, remote vascular access could be required. 3,19 -21 Other factors such as the timing of reconstruction, 22 method of anastomosis, MATERIALS AND METHODS This is a retrospective review of 102 patients over a 5-year consecutive period. Included were 73 men and 29 women with a mean age of 53 years (range, 10 -85 years). Indications for microvascular reconstruction included tumor ablation in 76 patients, trauma in 13 patients, and chronic wounds or facial paralysis in 13 patients. The location of the defects, types of flaps, recipient arteries, and recipient veins are listed i