CLINICAL PAPER
Immediate Permanent Implant Reconstruction Following Mastectomy With Capsule Preservation in Patients With Prior Augmentation Mammoplasty L. Franklyn Elliott, MD,*Þ Carrie K. Chu, MD,Þ Jarrod Daniel, MD,Þ Garrett Harper, MD,Þ and Patricia Bergey, PA-C* Abstract: Prior breast augmentation in patients desiring post-mastectomy reconstruction provides a unique opportunity for capsular preservation and immediate, single-step implant reconstruction. We report a case series of a single-surgeon experience with immediate implant reconstruction after skinsparing mastectomy in patients with prior subpectoral augmentation. Final implant volumes, complications, and outcomes were examined. Twenty patients (15 bilateral, total 35 breasts) were included. Eighteen (90%) patients were treated for cancer. Mean augmentation-to-reconstruction interval was 9 years (range, 3Y19 years). Mean patient age was 45.1 years (range, 37Y64 years). Eight patients (40%) received postoperative chemotherapy and two (10%) radiation. Mean mastectomy weight was 321 g. Mean weight of the implants removed was 346 g. Mean volume of new implants was 487 mL. All patients underwent capsulotomy (100% superior, 85% medial, 30% inferior, 5% lateral). Mean operative time was less than 1 hour for bilateral reconstruction. With average follow-up of 25.6 months, 2 patients were re-operated on for asymmetry (implant malposition, synmastia). Thirty-day complications included 1 implant loss due to infection, 1 drain placement with implant salvage, 1 hematoma requiring evacuation, and 1 cellulitis treated with antibiotics. There were no late complications and no capsular contractures. None have required further oncologic surgery. No cancer recurrences have been detected. In patients who desire prosthetic reconstruction similar to their original submuscular augmentation, capsule preservation and implant replacement with a larger prosthetic inserted within the old capsule is safe, fast, and aesthetically pleasing without compromising oncologic principles. Key Words: breast reconstruction, breast cancer, mastectomy, breast augmentation, implant, capsulotomy, capsule, immediate reconstruction (Ann Plast Surg 2014;72: S103YS106)
P
lastic surgeons are increasingly encountering patients with prior breast augmentation who now desire post-mastectomy reconstruction. Demand for augmentation mammaplasty, the most commonly performed cosmetic operation, continues to grow; the total number of procedures surpassed 300,000 in 2011 in the United States, representing an increase of 45% from 2000.1 Meanwhile, 1 in 8 women will be diagnosed with breast cancer during their lifetime.2 Breast reconstruction in previously augmented patients presents unique challenges. Younger age, lower body mass index, greater prevalence of smoking, ready acceptance of implant use, and reduced native breast tissue are all elements of consideration during reconstructive planning. Aesthetic emphasis may be of utmost importance Received November 8, 2013, and accepted for publication, after revision, November 13, 2013. From the *Atlanta Plastic Surgery, Atlanta, GA; and †Division of Plastic Surgery, Emory University School of Medicine, Atlanta, GA. Conflicts of interest and sources of funding: none declared. Reprints: Franklyn Elliott, MD, 975 Johnson Ferry Rd, NE, Suite 100, Atlanta, GA 30342. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0148-7043/14/7202-S103 DOI: 10.1097/SAP.0000000000000088
Annals of Plastic Surgery
& Volume 72, Supplement 2, June 2014
in this population. Total mastectomy is favored over breast conservation with radiation therapy as the latter approach may be associated with implant morbidity and poor cosmetic outcome.3,4 Skin-sparing mastectomy with immediate reconstruction has emerged as an attractive option. Though autologous tissue reconstruction has been described for previously augmented patients, the majority of approaches are implantbased procedures.5,6 Prior subpectoral augmentation has been proposed previously as a potentially advantageous scenario in which capsule preservation allows for in situ implant retention or immediate implant upsizing.6 However, no dedicated description of this technique and examination of its outcomes have been published. We present an experience with straight-to-implant reconstruction following capsule-preserving mastectomy in patients with pre-existing subpectoral augmentation.
METHODS Consecutive patients with prior augmentation who underwent immediate reconstruction by a single surgeon (L.F.E.) following mastectomy from January 2009 to September 2012 were identified for analysis in this retrospective case series. Patients with implants in the subglandular position were excluded, as the technique of capsule preservation was not possible. Data pertaining to demographics, familial history, pre-existing implant volume and type (saline, gel), preoperative ptosis (nipple-to-fold position), and contracture (Baker classification) were noted. Mastectomy indication and weight, implant-to-mastectomy interval, laterality, tumor staging, and adjuvant therapy were also examined. Capsulotomy extent and final implants features were observed. Outcomes of interest included reoperations and early (30-day) and late complications, inclusive of capsular contracture. Records were also reviewed for cancer recurrence and need for further oncologic surgery. Finally, completion of subsequent nipple-areolar reconstruction was noted.
Surgical Technique Skin-sparing mastectomy incisions are marked preoperatively after previous incisions and oncologic considerations are discussed with the general surgeon. Preoperative antibiotics are administered to all patients. Ample communication with the extirpative surgeon is key. The mastectomies must be performed with care not to disrupt or enter the implant capsule. Additionally, the mastectomy portion of this technique requires consideration of 3 major points. First, the dissection should start superiorly with adequate skin f laps raised until the pectoralis muscle is encountered. The breast can then be dissected off the muscle in a caudal direction with relative assurance that the capsule will not be entered (Fig. 1). Second, in a previously augmented patient, the inframammary fold is lowered away from the natural boundaries of the breast tissue. Tissue from the lower chest and upper abdomen is what is actually present in the new fold’s location, so with no actual breast tissue present, the resection can stop 2 to 3 cm cephalad to this existing fold. This helps prevent entering into the capsule inferiorly and preserves the inframammary fold, an www.annalsplasticsurgery.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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& Volume 72, Supplement 2, June 2014
FIGURE 1. Mastectomy dissection begins with an inferior periareolar incision and continues cephalad to the pectoralis muscle inferiorly. The dissection stops 1 to 2 cm cephalad to the inframammary fold.
important aesthetic consideration. The care taken in this manner has allowed for us to limit the use of acellular dermal matrix inferiorly to reestablish the fold. Third, extra care should be focused on the lateral mastectomy dissection. At this point, the removal of breast tissue is directly over the capsule with no intervening muscle. The mastectomy is completed, and explantation of the implant is performed through an anterior capsulotomy just caudal to the inferior edge of the pectoralis muscle. The mastectomy specimen and the implant are weighed and a new implant size is selected based on these values and patient desires. Further capsulotomies and/or capsulectomies are performed as needed in sequential order. They are first performed superiorly
and next medially towards the sternal midline. If necessary, capsulotomies can be done inferiorly if the inframammary fold needs to be relocated caudally. It is generally not necessary or encouraged to perform a capsulotomy laterally as the capsule is often quite thin in this area. All done in the described order, the extent of these capsule releases depends on existing capsular state and the difference between the pre-existing implant size and the required new implant dimensions. Controlled and conservative treatment of the capsule in this manner has generally in our experience obviated the need for acellular dermal matrix and its associated expense and potential morbidities. The thin lateral capsule represents a rare exception where dermal matrix use prevents excess lateral implant migration.
FIGURE 2. A, Forty-eight-year-old with right breast cancer, 19 years after bilateral breast augmentation. B, Three months after nipple-sparing mastectomy and immediate reconstruction with 425 mL high-profile gel implant. No procedures were performed on the left. S104
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* 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Annals of Plastic Surgery
& Volume 72, Supplement 2, June 2014
Reconstruction After Augmentation
FIGURE 3. A, Forty-year-old with left breast cancer with planned bilateral mastectomy 11 years after augmentation. B, Four months after bilateral skin-sparing mastectomies and immediate reconstruction with removal of 283-mL implants and replacement with 400-mL high-profile implants.
An implant sizer then offers a preview of the adequacy of the capsular releases to accommodate the new, larger, implant.
RESULTS Twenty previously augmented patients underwent mastectomy by our technique with immediate implant reconstruction. Fifteen (75%) of the cases were bilateral and 5 (25%) unilateral for a total of 35 reconstructed breasts. Eighteen (90%) of these patients were treated for biopsy-proven breast cancer while 2 (10%) patients had prophylactic procedures. There was a mean of 9 years (range, 3Y19 years) from time of initial augmentation to breast cancer diagnosis. Mean patient age was 45.1 years (range, 37Y64 years). All patients were otherwise healthy and 8 (40%) reported a family history of breast cancer. Fourteen (70%) patients had grade 1 Baker contracture and 6 (30%) had grade 2. Two (10%) patients had grade 2 ptosis and 1 (5%) had grade 3 ptosis. Mean tumor size was 1.2 cm, and negative margins were achieved in all patients. Cancer was discovered in one of the prophylactic specimens. The majority of patients had stage I disease (80%), followed by stages 0 (15%) and II (5%). Eight patients (40%) received postoperative chemotherapy and 2 (10%) radiation. The mean weight of the mastectomy specimen was 321 g. The mean weight of the implants removed was 346 g with 75% being smooth saline; only one was found to be ruptured. The mean volume of the new implant inserted was 487 mL with 60% being moderate profile plus smooth gel and 40% being high-profile smooth gel. All patients underwent varying extents of capsulotomy; 100% had a superior capsulotomy, 85% had a medial capsulotomy, 30% inferior, and 5% lateral. Using these capsulotomies to manipulate and expand the capsule, we were able to increase the new implant size over the previous implant size by an average of 171%. Acellular dermal matrix was used in 1 patient to reinforce her pocket laterally as her original implant had shifted outward. Drains were used universally and removed on average on postoperative day 9. Mean operative time was less than 1 hour for bilateral reconstruction. Figures 2 and 3 show representative results for unilateral and bilateral cases, respectively. Mean follow-up was 25.6 months (range 6Y42 months). Two (10% of patients) patients were re-operated on for asymmetry (one for implant malposition and one for synmastia). Early complications within 30 days of operation included 1 (3% of breasts) implant loss due to infection, 1 (3% of breasts) drain placement for an infected subcutaneous collection with successful implant salvage, 1 hematoma * 2014 Lippincott Williams & Wilkins
that was recognized in the recovery room and evacuated, and 1 case of cellulitis treated successfully with intravenous antibiotics. There were no late complications and no capsular contractures. None of the patients have required further oncologic surgery and no cancer recurrences have been detected. To date, 25% have undergone nipple-areolar reconstruction and 10% tattooing.
DISCUSSION Treatment options for the previously augmented patient with breast cancer include breast conservation therapy, mastectomy with implant-based reconstruction, mastectomy with autologous reconstruction, or mastectomy with mixed autologous-implant reconstruction. Breast conservation therapy often results in reduced implant soft-tissue coverage, asymmetry, and poor cosmetic outcomes.3 Radiation associated with breast conservation increases the risk of contracture, breast discomfort, and overlying skin damage with the potential of implant extrusion. Additionally, the remaining breast tissue has to be continually surveyed with frequency.7,8 All of these factors are less of a concern when a mastectomy is performed as little, if any, breast tissue remains. Thus, mastectomy has become the treatment of choice in previously augmented patients.9,10 Autologous reconstruction is considered if the proposed mastectomy will result in significant skin resection, if prior radiation has damaged existing skin, if postoperative radiation is anticipated, or if the patient indicates preference. The transverse rectus abdominis myocutaneous and latissimus dorsi myocutaneous f laps are the most common choices and can result in satisfactory aesthetic outcomes.11 However, patients who have undergone prior augmentation mammaplasty tend toward a leaner body habitus often without adequate donor tissue to meet the full reconstructive needs. Also, because these patients already have breast implants, they tend to be less averse and more attracted to an implant-based reconstruction method. The combination of autologous f lap with expander reconstruction is an option, but subjects the patient to donor-site morbidity, multiple expansions, and future implant exchange and revisions. Carlson et al in 2001 discussed their initial experience with skin-sparing mastectomy with immediate reconstruction in 6 previously augmented patients. Based on tumor characteristics and implant position, a range of reconstructive methods including implant preservation and adjunctive autologous f laps were used.10 In Spear et al’s review of their institutional experience by the same year, 21 patients, of whom 9 had subpectoral augmentation, underwent a mixture of implant and/or latissimus flap reconstructions.12 This experience www.annalsplasticsurgery.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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was subsequently updated in 2008 to 32; half had subpectoral implants. Of the subpectoral group, 9 (56%) underwent prosthetic-only reconstruction; prosthetic/latissimus and TRAM flaps were used in the remaining cases.6 These earlier works focused largely on the analysis of cancer detection and oncologic features rather than description of the reconstructive technical details. More recently, Suber et al described retention of subpectoral implants in 10 patients during mastectomy without oncologic indication for explantation. These patients then underwent delayed implant reconstruction.13 The Emory group also updated their series last year. Within this series, 20 patients with submuscular implants had a variety of implant and/or autologous reconstructions, though two who had singlestage implant replacement required subsequent upsizing.5 Dedicated descriptions of single-step immediate implant reconstruction in augmented patients are very limited. A report of 12 patients from Italy last year concluded that this approach is a viable option with good aesthetic results, equivalent complications rates, and high patient satisfaction relative to results achieved in patients without prior augmentation.5 In this same paper, 3 additional patients who presented with subglandular implants were also treated with capsular preservation and direct implant reconstruction. However, our experience suggests that the capsule manipulation necessary to achieve adequate implant upsizing and positioning cannot be satisfactorily performed in patients with existing subglandular implants. To our knowledge, our study represents the largest series of cases of subpectoral augmented patients reconstructed in single-stage fashion. Although implant reconstruction can be as simple as leaving the existing implant in situ, this method rarely leads to an aesthetically pleasing result. It has been our experience that patients require an increase in implant size in order to achieve their desires that can only be accommodated with an increase in pre-existing capsule dimensions through the use of carefully applied capsulotomies. Using our procedure, the existing capsule is protected during mastectomy and used during the reconstruction to provide an autologous retaining envelope for the newer, often larger implant. Additionally, the capsule left in situ may aid in the prevention of future capsular formation around the new implant. Careful consideration must be taken in the preoperative planning to assess previous incisions, current implant type and position, preoperative breast size, and patient reconstructive goals. The volume discrepancy after mastectomy is addressed by selecting a new implant based on the weight of the mastectomy specimen and explanted implant. Following earlier experience with moderate profile plus implants, in the reconstructive setting we have evolved to almost uniform use of high profile devices. With well-controlled capsulotomies, natural results are achievable with smooth round gel implants; we do not routinely favor shaped, anatomic devices. Obviously, comparison with the contralateral side in unilateral mastectomy cases and adhering to the patients’ preoperative preference is of importance. Thirteen of our 18
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(72%) patients elected to have a contralateral procedure as a primary breast cancer places the patient at a 2- to 6-fold increase risk of developing contralateral disease.14 The skin-sparing technique using small incisions produced pleasing aesthetic results and does not compromise oncologic principals in selected patients. Overall, this operation is straightforward to perform and achieving a more symmetrical result is easier especially in the bilateral cases. Operative time is short, recovery is minimal, and aesthetic results are satisfactory in the absence of contractures or recurrences. In patients who desire prosthetic reconstruction similar to their original submuscular augmentation, preservation of the capsule and implant replacement with a larger prosthetic inserted within the old capsule is safe, fast, and aesthetically pleasing without compromising oncologic principles. REFERENCES 1. American Society of Plastic Surgeons. Plastic Surgery Statistics Report. Arlington Heights, IL: American Society of Plastic Surgeons; 2011. 2. National Cancer Institute. Surveillance Epidemiology and End Results. Bethesda, MD: National Cancer Institute; 2011. 3. Mark RJ, Zimmerman RP, Greif JM. Capsular contracture after lumpectomy and radiation therapy in patients who have undergone uncomplicated bilateral augmentation mammoplasty. Radiology. 1996;200:621Y625. 4. Handel N, Lewinsky B, Jensen JA, et al. Breast conservation therapy after augmentation mammaplasty: is it appropriate? Plast Reconstr Surg. 1996; 98:1216Y1224. 5. Singh KA, Saunders N, Carlson GW. Immediate breast reconstruction in the previously augmented patient. Ann Plast Surg. 2012;68:477Y480. 6. Spear SL, Clemens MW, Dayan JH. Considerations of previous augmentation in subsequent breast reconstruction. Aesthet Surg J. 2008;28:285Y293. 7. Krishnan L, Krishnan EC, Wolf CD, et al. Preservation of augmented breasts in patients with breast cancer. Radiographics. 1993;13:831Y839. 8. Guenther JM, Tokita KM, Giuliano AE. Breast-conserving surgery and radiation after augmentation mammoplasty. Cancer. 1994;73:2613Y2618. 9. Handel N. Conservation therapy for breast cancer following augmentation mammaplasty. Plast Reconstr Surg. 1999;104:867Y869; discussion 870Y861. 10. Carlson GW, Moore B, Thornton JF, et al. Breast cancer after augmentation mammaplasty: treatment by skin-sparing mastectomy and immediate reconstruction. Plast Reconstr Surg. 2001;107:687Y692. 11. Cahan AC, Ashikari R, Pressman P, et al. Breast cancer after breast augmentation with silicone implants. Ann Surg Oncol. 1995;2:121Y125. 12. Spear SL, Slack C, Howard MA. Postmastectomy reconstruction of the previously augmented breast: diagnosis, staging, methodology, and outcome. Plast Reconstr Surg. 2001;107:1167Y1176. 13. Suber J, Malafa M, Smith P, et al. Prosthetic breast reconstruction after implantsparing mastectomy in patients with submuscular implants. Ann Plast Surg. 2011;66:546Y550. 14. Chen Y, Thompson W, Semenciw R, et al. Epidemiology of contralateral breast cancer. Cancer Epidemiol Biomarkers Prev. 1999;8:855Y861.
* 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Immediate Permanent Implant Reconstruction Following Mastectomy With Capsule Preservation in Patients With Prior Augmentation Mammoplasty L. Franklyn Elliott, MD,*Þ Carrie K. Chu, MD,Þ Jarrod Daniel, MD,Þ Garrett Harper, MD,Þ and Patricia Bergey, PA-C* Abstract: Prior breast augmentation in patients desiring post-mastectomy reconstruction provides a unique opportunity for capsular preservation and immediate, single-step implant reconstruction. We report a case series of a single-surgeon experience with immediate implant reconstruction after skinsparing mastectomy in patients with prior subpectoral augmentation. Final implant volumes, complications, and outcomes were examined. Twenty patients (15 bilateral, total 35 breasts) were included. Eighteen (90%) patients were treated for cancer. Mean augmentation-to-reconstruction interval was 9 years (range, 3Y19 years). Mean patient age was 45.1 years (range, 37Y64 years). Eight patients (40%) received postoperative chemotherapy and two (10%) radiation. Mean mastectomy weight was 321 g. Mean weight of the implants removed was 346 g. Mean volume of new implants was 487 mL. All patients underwent capsulotomy (100% superior, 85% medial, 30% inferior, 5% lateral). Mean operative time was less than 1 hour for bilateral reconstruction. With average follow-up of 25.6 months, 2 patients were re-operated on for asymmetry (implant malposition, synmastia). Thirty-day complications included 1 implant loss due to infection, 1 drain placement with implant salvage, 1 hematoma requiring evacuation, and 1 cellulitis treated with antibiotics. There were no late complications and no capsular contractures. None have required further oncologic surgery. No cancer recurrences have been detected. In patients who desire prosthetic reconstruction similar to their original submuscular augmentation, capsule preservation and implant replacement with a larger prosthetic inserted within the old capsule is safe, fast, and aesthetically pleasing without compromising oncologic principles. Key Words: breast reconstruction, breast cancer, mastectomy, breast augmentation, implant, capsulotomy, capsule, immediate reconstruction (Ann Plast Surg 2014;72: S103YS106)
P
lastic surgeons are increasingly encountering patients with prior breast augmentation who now desire post-mastectomy reconstruction. Demand for augmentation mammaplasty, the most commonly performed cosmetic operation, continues to grow; the total number of procedures surpassed 300,000 in 2011 in the United States, representing an increase of 45% from 2000.1 Meanwhile, 1 in 8 women will be diagnosed with breast cancer during their lifetime.2 Breast reconstruction in previously augmented patients presents unique challenges. Younger age, lower body mass index, greater prevalence of smoking, ready acceptance of implant use, and reduced native breast tissue are all elements of consideration during reconstructive planning. Aesthetic emphasis may be of utmost importance Received November 8, 2013, and accepted for publication, after revision, November 13, 2013. From the *Atlanta Plastic Surgery, Atlanta, GA; and †Division of Plastic Surgery, Emory University School of Medicine, Atlanta, GA. Conflicts of interest and sources of funding: none declared. Reprints: Franklyn Elliott, MD, 975 Johnson Ferry Rd, NE, Suite 100, Atlanta, GA 30342. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0148-7043/14/7202-S103 DOI: 10.1097/SAP.0000000000000088
Annals of Plastic Surgery
& Volume 72, Supplement 2, June 2014
in this population. Total mastectomy is favored over breast conservation with radiation therapy as the latter approach may be associated with implant morbidity and poor cosmetic outcome.3,4 Skin-sparing mastectomy with immediate reconstruction has emerged as an attractive option. Though autologous tissue reconstruction has been described for previously augmented patients, the majority of approaches are implantbased procedures.5,6 Prior subpectoral augmentation has been proposed previously as a potentially advantageous scenario in which capsule preservation allows for in situ implant retention or immediate implant upsizing.6 However, no dedicated description of this technique and examination of its outcomes have been published. We present an experience with straight-to-implant reconstruction following capsule-preserving mastectomy in patients with pre-existing subpectoral augmentation.
METHODS Consecutive patients with prior augmentation who underwent immediate reconstruction by a single surgeon (L.F.E.) following mastectomy from January 2009 to September 2012 were identified for analysis in this retrospective case series. Patients with implants in the subglandular position were excluded, as the technique of capsule preservation was not possible. Data pertaining to demographics, familial history, pre-existing implant volume and type (saline, gel), preoperative ptosis (nipple-to-fold position), and contracture (Baker classification) were noted. Mastectomy indication and weight, implant-to-mastectomy interval, laterality, tumor staging, and adjuvant therapy were also examined. Capsulotomy extent and final implants features were observed. Outcomes of interest included reoperations and early (30-day) and late complications, inclusive of capsular contracture. Records were also reviewed for cancer recurrence and need for further oncologic surgery. Finally, completion of subsequent nipple-areolar reconstruction was noted.
Surgical Technique Skin-sparing mastectomy incisions are marked preoperatively after previous incisions and oncologic considerations are discussed with the general surgeon. Preoperative antibiotics are administered to all patients. Ample communication with the extirpative surgeon is key. The mastectomies must be performed with care not to disrupt or enter the implant capsule. Additionally, the mastectomy portion of this technique requires consideration of 3 major points. First, the dissection should start superiorly with adequate skin f laps raised until the pectoralis muscle is encountered. The breast can then be dissected off the muscle in a caudal direction with relative assurance that the capsule will not be entered (Fig. 1). Second, in a previously augmented patient, the inframammary fold is lowered away from the natural boundaries of the breast tissue. Tissue from the lower chest and upper abdomen is what is actually present in the new fold’s location, so with no actual breast tissue present, the resection can stop 2 to 3 cm cephalad to this existing fold. This helps prevent entering into the capsule inferiorly and preserves the inframammary fold, an www.annalsplasticsurgery.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
S103
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Elliott et al
& Volume 72, Supplement 2, June 2014
FIGURE 1. Mastectomy dissection begins with an inferior periareolar incision and continues cephalad to the pectoralis muscle inferiorly. The dissection stops 1 to 2 cm cephalad to the inframammary fold.
important aesthetic consideration. The care taken in this manner has allowed for us to limit the use of acellular dermal matrix inferiorly to reestablish the fold. Third, extra care should be focused on the lateral mastectomy dissection. At this point, the removal of breast tissue is directly over the capsule with no intervening muscle. The mastectomy is completed, and explantation of the implant is performed through an anterior capsulotomy just caudal to the inferior edge of the pectoralis muscle. The mastectomy specimen and the implant are weighed and a new implant size is selected based on these values and patient desires. Further capsulotomies and/or capsulectomies are performed as needed in sequential order. They are first performed superiorly
and next medially towards the sternal midline. If necessary, capsulotomies can be done inferiorly if the inframammary fold needs to be relocated caudally. It is generally not necessary or encouraged to perform a capsulotomy laterally as the capsule is often quite thin in this area. All done in the described order, the extent of these capsule releases depends on existing capsular state and the difference between the pre-existing implant size and the required new implant dimensions. Controlled and conservative treatment of the capsule in this manner has generally in our experience obviated the need for acellular dermal matrix and its associated expense and potential morbidities. The thin lateral capsule represents a rare exception where dermal matrix use prevents excess lateral implant migration.
FIGURE 2. A, Forty-eight-year-old with right breast cancer, 19 years after bilateral breast augmentation. B, Three months after nipple-sparing mastectomy and immediate reconstruction with 425 mL high-profile gel implant. No procedures were performed on the left. S104
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* 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Annals of Plastic Surgery
& Volume 72, Supplement 2, June 2014
Reconstruction After Augmentation
FIGURE 3. A, Forty-year-old with left breast cancer with planned bilateral mastectomy 11 years after augmentation. B, Four months after bilateral skin-sparing mastectomies and immediate reconstruction with removal of 283-mL implants and replacement with 400-mL high-profile implants.
An implant sizer then offers a preview of the adequacy of the capsular releases to accommodate the new, larger, implant.
RESULTS Twenty previously augmented patients underwent mastectomy by our technique with immediate implant reconstruction. Fifteen (75%) of the cases were bilateral and 5 (25%) unilateral for a total of 35 reconstructed breasts. Eighteen (90%) of these patients were treated for biopsy-proven breast cancer while 2 (10%) patients had prophylactic procedures. There was a mean of 9 years (range, 3Y19 years) from time of initial augmentation to breast cancer diagnosis. Mean patient age was 45.1 years (range, 37Y64 years). All patients were otherwise healthy and 8 (40%) reported a family history of breast cancer. Fourteen (70%) patients had grade 1 Baker contracture and 6 (30%) had grade 2. Two (10%) patients had grade 2 ptosis and 1 (5%) had grade 3 ptosis. Mean tumor size was 1.2 cm, and negative margins were achieved in all patients. Cancer was discovered in one of the prophylactic specimens. The majority of patients had stage I disease (80%), followed by stages 0 (15%) and II (5%). Eight patients (40%) received postoperative chemotherapy and 2 (10%) radiation. The mean weight of the mastectomy specimen was 321 g. The mean weight of the implants removed was 346 g with 75% being smooth saline; only one was found to be ruptured. The mean volume of the new implant inserted was 487 mL with 60% being moderate profile plus smooth gel and 40% being high-profile smooth gel. All patients underwent varying extents of capsulotomy; 100% had a superior capsulotomy, 85% had a medial capsulotomy, 30% inferior, and 5% lateral. Using these capsulotomies to manipulate and expand the capsule, we were able to increase the new implant size over the previous implant size by an average of 171%. Acellular dermal matrix was used in 1 patient to reinforce her pocket laterally as her original implant had shifted outward. Drains were used universally and removed on average on postoperative day 9. Mean operative time was less than 1 hour for bilateral reconstruction. Figures 2 and 3 show representative results for unilateral and bilateral cases, respectively. Mean follow-up was 25.6 months (range 6Y42 months). Two (10% of patients) patients were re-operated on for asymmetry (one for implant malposition and one for synmastia). Early complications within 30 days of operation included 1 (3% of breasts) implant loss due to infection, 1 (3% of breasts) drain placement for an infected subcutaneous collection with successful implant salvage, 1 hematoma * 2014 Lippincott Williams & Wilkins
that was recognized in the recovery room and evacuated, and 1 case of cellulitis treated successfully with intravenous antibiotics. There were no late complications and no capsular contractures. None of the patients have required further oncologic surgery and no cancer recurrences have been detected. To date, 25% have undergone nipple-areolar reconstruction and 10% tattooing.
DISCUSSION Treatment options for the previously augmented patient with breast cancer include breast conservation therapy, mastectomy with implant-based reconstruction, mastectomy with autologous reconstruction, or mastectomy with mixed autologous-implant reconstruction. Breast conservation therapy often results in reduced implant soft-tissue coverage, asymmetry, and poor cosmetic outcomes.3 Radiation associated with breast conservation increases the risk of contracture, breast discomfort, and overlying skin damage with the potential of implant extrusion. Additionally, the remaining breast tissue has to be continually surveyed with frequency.7,8 All of these factors are less of a concern when a mastectomy is performed as little, if any, breast tissue remains. Thus, mastectomy has become the treatment of choice in previously augmented patients.9,10 Autologous reconstruction is considered if the proposed mastectomy will result in significant skin resection, if prior radiation has damaged existing skin, if postoperative radiation is anticipated, or if the patient indicates preference. The transverse rectus abdominis myocutaneous and latissimus dorsi myocutaneous f laps are the most common choices and can result in satisfactory aesthetic outcomes.11 However, patients who have undergone prior augmentation mammaplasty tend toward a leaner body habitus often without adequate donor tissue to meet the full reconstructive needs. Also, because these patients already have breast implants, they tend to be less averse and more attracted to an implant-based reconstruction method. The combination of autologous f lap with expander reconstruction is an option, but subjects the patient to donor-site morbidity, multiple expansions, and future implant exchange and revisions. Carlson et al in 2001 discussed their initial experience with skin-sparing mastectomy with immediate reconstruction in 6 previously augmented patients. Based on tumor characteristics and implant position, a range of reconstructive methods including implant preservation and adjunctive autologous f laps were used.10 In Spear et al’s review of their institutional experience by the same year, 21 patients, of whom 9 had subpectoral augmentation, underwent a mixture of implant and/or latissimus flap reconstructions.12 This experience www.annalsplasticsurgery.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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Annals of Plastic Surgery
Elliott et al
was subsequently updated in 2008 to 32; half had subpectoral implants. Of the subpectoral group, 9 (56%) underwent prosthetic-only reconstruction; prosthetic/latissimus and TRAM flaps were used in the remaining cases.6 These earlier works focused largely on the analysis of cancer detection and oncologic features rather than description of the reconstructive technical details. More recently, Suber et al described retention of subpectoral implants in 10 patients during mastectomy without oncologic indication for explantation. These patients then underwent delayed implant reconstruction.13 The Emory group also updated their series last year. Within this series, 20 patients with submuscular implants had a variety of implant and/or autologous reconstructions, though two who had singlestage implant replacement required subsequent upsizing.5 Dedicated descriptions of single-step immediate implant reconstruction in augmented patients are very limited. A report of 12 patients from Italy last year concluded that this approach is a viable option with good aesthetic results, equivalent complications rates, and high patient satisfaction relative to results achieved in patients without prior augmentation.5 In this same paper, 3 additional patients who presented with subglandular implants were also treated with capsular preservation and direct implant reconstruction. However, our experience suggests that the capsule manipulation necessary to achieve adequate implant upsizing and positioning cannot be satisfactorily performed in patients with existing subglandular implants. To our knowledge, our study represents the largest series of cases of subpectoral augmented patients reconstructed in single-stage fashion. Although implant reconstruction can be as simple as leaving the existing implant in situ, this method rarely leads to an aesthetically pleasing result. It has been our experience that patients require an increase in implant size in order to achieve their desires that can only be accommodated with an increase in pre-existing capsule dimensions through the use of carefully applied capsulotomies. Using our procedure, the existing capsule is protected during mastectomy and used during the reconstruction to provide an autologous retaining envelope for the newer, often larger implant. Additionally, the capsule left in situ may aid in the prevention of future capsular formation around the new implant. Careful consideration must be taken in the preoperative planning to assess previous incisions, current implant type and position, preoperative breast size, and patient reconstructive goals. The volume discrepancy after mastectomy is addressed by selecting a new implant based on the weight of the mastectomy specimen and explanted implant. Following earlier experience with moderate profile plus implants, in the reconstructive setting we have evolved to almost uniform use of high profile devices. With well-controlled capsulotomies, natural results are achievable with smooth round gel implants; we do not routinely favor shaped, anatomic devices. Obviously, comparison with the contralateral side in unilateral mastectomy cases and adhering to the patients’ preoperative preference is of importance. Thirteen of our 18
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(72%) patients elected to have a contralateral procedure as a primary breast cancer places the patient at a 2- to 6-fold increase risk of developing contralateral disease.14 The skin-sparing technique using small incisions produced pleasing aesthetic results and does not compromise oncologic principals in selected patients. Overall, this operation is straightforward to perform and achieving a more symmetrical result is easier especially in the bilateral cases. Operative time is short, recovery is minimal, and aesthetic results are satisfactory in the absence of contractures or recurrences. In patients who desire prosthetic reconstruction similar to their original submuscular augmentation, preservation of the capsule and implant replacement with a larger prosthetic inserted within the old capsule is safe, fast, and aesthetically pleasing without compromising oncologic principles. REFERENCES 1. American Society of Plastic Surgeons. Plastic Surgery Statistics Report. Arlington Heights, IL: American Society of Plastic Surgeons; 2011. 2. National Cancer Institute. Surveillance Epidemiology and End Results. Bethesda, MD: National Cancer Institute; 2011. 3. Mark RJ, Zimmerman RP, Greif JM. Capsular contracture after lumpectomy and radiation therapy in patients who have undergone uncomplicated bilateral augmentation mammoplasty. Radiology. 1996;200:621Y625. 4. Handel N, Lewinsky B, Jensen JA, et al. Breast conservation therapy after augmentation mammaplasty: is it appropriate? Plast Reconstr Surg. 1996; 98:1216Y1224. 5. Singh KA, Saunders N, Carlson GW. Immediate breast reconstruction in the previously augmented patient. Ann Plast Surg. 2012;68:477Y480. 6. Spear SL, Clemens MW, Dayan JH. Considerations of previous augmentation in subsequent breast reconstruction. Aesthet Surg J. 2008;28:285Y293. 7. Krishnan L, Krishnan EC, Wolf CD, et al. Preservation of augmented breasts in patients with breast cancer. Radiographics. 1993;13:831Y839. 8. Guenther JM, Tokita KM, Giuliano AE. Breast-conserving surgery and radiation after augmentation mammoplasty. Cancer. 1994;73:2613Y2618. 9. Handel N. Conservation therapy for breast cancer following augmentation mammaplasty. Plast Reconstr Surg. 1999;104:867Y869; discussion 870Y861. 10. Carlson GW, Moore B, Thornton JF, et al. Breast cancer after augmentation mammaplasty: treatment by skin-sparing mastectomy and immediate reconstruction. Plast Reconstr Surg. 2001;107:687Y692. 11. Cahan AC, Ashikari R, Pressman P, et al. Breast cancer after breast augmentation with silicone implants. Ann Surg Oncol. 1995;2:121Y125. 12. Spear SL, Slack C, Howard MA. Postmastectomy reconstruction of the previously augmented breast: diagnosis, staging, methodology, and outcome. Plast Reconstr Surg. 2001;107:1167Y1176. 13. Suber J, Malafa M, Smith P, et al. Prosthetic breast reconstruction after implantsparing mastectomy in patients with submuscular implants. Ann Plast Surg. 2011;66:546Y550. 14. Chen Y, Thompson W, Semenciw R, et al. Epidemiology of contralateral breast cancer. Cancer Epidemiol Biomarkers Prev. 1999;8:855Y861.
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