Immediate Breast Reconstruction with Implants

Abstract

Immediate breast reconstruction following mastectomy improves quality of life with benefits observed in body image and psychological health. An implant based reconstruction is one of the most common options utilised and a successful outcome relies on careful patient selection and technical decisions made intraoperatively. Significant technological adjuncts has advanced the role of direct to implant reconstruction by reducing rates of complications and implant failure. Understanding past techniques and variables in current practices facilitates operative management to provide an optimal implant based reconstructive outcome.

1. Introduction

Historically, reconstructions post mastectomy was not widely adopted and the predominant options for women were mostly limited to simple acceptance of breast loss or use of an external prosthesis. The introduction of silicone breast implants in the 1960s heralded the modern breast reconstruction era. Implant based reconstruction is now one of the most utilised breast reconstructive techniques and has evolved from a two staged operation to a single stage procedure.

2. History of direct to implant reconstruction

Breast reconstruction has developed hand in hand with breast oncological resection.

The Halsted radical mastectomy was devised only 36 years after the introduction of anaesthesia [1]. For almost a century it reigned as the gold standard treatment for breast cancer. The resection was radical, involving total removal of breast tissue, full en bloc dissection of level 1–3 lymph nodes and pectoralis muscle [2]. The extensive surgery left patients with a concaved chest wall and minimal excess skin coverage. Contemporaneous reconstruction techniques mostly described surgeries to reconstruct the resultant skin defect utilising skin grafts or the Halsted technique of wound healing by secondary intention thought to be a deterrent for local recurrence [3]. In 1906 Tanzini sought a more robust option for skin coverage and was the first to describe a musculocutaneous flap in breast reconstruction by harvesting pedicled latissimus dorsi muscle and overlying skin [4]. The understanding of breast reconstruction in regard to the breast mound was first reported by Vincent Czerny in 1895 who transplanted a fist-sized lipoma from the patient’s flank to their chest [5]. Similar attempts involving autologous tissue were described in the first half of the 20th Century with Ombredanne fashioning a new mound with pectoralis minor muscle while use of tubed pedicle flaps from the abdomen or gluteal tissue were pioneered by Gillies [6, 7]. None of these reconstructive options were widely adopted as they were lengthy multi-stage processes, expensive and associated with significant morbidity to donor and recipient sites. Advances in breast reconstruction were also limited during this time as Halsted believed it was a ‘violation of the local control of disease’ and actively discouraged the practice [3]. However in recent decades, breast cancer treatment has evolved towards breast conservation and ushered in modern reconstruction techniques ready to challenge traditional dogma.

The modern breast implant was developed by Cronin and Gerow in 1963 who recognised the resemblance of silicone gel within a plastic bag to a women’s breast [8]. Initially adopted for cosmetic augmentation, Synderman and Guthrie first reported its use for breast reconstruction in 1971 [9]. They described a delayed procedure of minimum 6 months post radical mastectomy by careful sharp dissection of skin from chest wall. Symmetrising surgery could also be performed on the contralateral breast via either augmentation or reduction. Immediate breast reconstruction was initially avoided due to perceived compromise of oncological management and concern of negative psychological impact on a patient’s body image. This was challenged by progressive reduction in the timing between resection and implant reconstruction until Noone et al. described a review of direct to implant surgeries [10]. This study demonstrated that direct to implant (DTI) reconstructions were safe operations which did not alter survival or recurrence rates nor impede adjunct treatments. Patient satisfaction with immediate reconstruction remained at a level consistent with delayed procedures and positively aided psychological acceptance of both mastectomy and aesthetic outcome.

Mastectomy practices similarly challenged the long established Halsted principles and less radical resections became accepted [11]. With the advent of skin and muscle sparing mastectomy, an opportunity arose for plastic surgeons to address issues with the subcutaneous implant reconstruction. Dissatisfactory appearance from capsular contraction and skin necrosis with subsequent risk to implant were both noted problems with often limited management options [12]. An immediate subpectoral implant reconstruction sought to remedy these concerns with an added benefit of providing additional soft tissue coverage to minimise the visible edge of an implant’s superior ridge [13]. Despite this, DTI reconstructions were ultimately less adaptive to address concerns with implant position, size and shape and was subsequently supplanted by two stage tissue expansion/implant reconstruction and autologous techniques. However, the last two decades have witnessed a resurgence of DTI surgery in light of innovations which help to shape the breast pocket, optimally position the implant and assess mastectomy skin vascularity.

3. Role of direct to implant reconstruction

The DTI reconstruction offers immediate restoration of breast appearance as a single-stage approach performed at the time of mastectomy [14]. This avoids the prior technique of tissue expansion and subsequent exchange to implants. While eliminating the need for multiple episodes of tissue expansion and an inevitable secondary operation, it also negates the risk of additional postoperative complications and potential delay of adjuvant treatment. Significantly, DTI reconstructions are associated with a lack of donor site morbidity in comparison with autologous reconstruction resulting in a shorter recovery time and quicker return to work [14]. Considering the majority of breast cancers occur in the elderly population the appeal of a less invasive, single-stage procedure with prompt return to normal activities should not be overstated. Increased awareness and more rigorous screening have also led to an increase in younger women requiring oncological surgery [14]. Autologous reconstruction may be avoided in this cohort due to donor site morbidity despite improved cosmetic appearance. Timing or irradiation also plays a role in choosing between DTI and other forms of reconstruction. DTIs are associated with increased complications such as capsular contraction and implant extrusion particularly in the setting of irradiation when compared to autologous reconstruction [15]. However regardless of reconstruction type, any immediate reconstruction is associated with improved physical and psychological well being leading to decreased distress and anxiety associated with their cancer treatment [16].

Timing reconstructive surgery to occur concurrently with oncological resection has potential drawbacks. It requires coordination between two surgical teams which can delay surgery if schedules are not compatible. With different surgical teams, more theatre nurses are required to accommodate and theatre complexes may not be able to staff this easily. Ultimately combined surgery leads to a longer cumulative operative time and the potential for increased complications causing delays in adjuvant therapy. Immediate reconstruction also results in significantly less decision-making time for the patient and introduces the potential for the patient to lack a full understanding of reconstructive options and details of the procedure.

3.1 Psychosocial benefits

A diagnosis of breast cancer is a devastating and psychologically morbid experience for women of any age. Not only do concerns of oncological survival exist, but the physical impact of treatment should not be understated. Distress regarding breast disfigurement and loss of hair dominate, and the loss of these tenets of traditional femininity underscores feelings of unattractiveness and sexual disinterest following diagnosis [17]. Understandably anxiety and depression are also found in significant numbers in this cohort [17, 18]. Immediate reconstruction post-mastectomy can play a role in alleviating this psychosocial impact. Women who undergo immediate reconstruction score higher on measures of body image, sexuality and health-related quality of life particularly in comparison with women who underwent delayed reconstruction [19]. This may be reflective of less advanced disease seen in immediate reconstructive patients who may not even require additional adjuvant treatment. Certainly, the duration of delay is a significant contributor to psychological distress as immediate reconstruction patients were much less likely to recall post-operative distress than the delayed patients [20]. The overall decrease in distress is thought to arise from the fact that these patients do not experience loss of the breast mound and the psychological burden that loss entails. Regardless of reconstruction, anxiety and depression were uniformly improved for any reconstruction compared to mastectomy alone patients [19, 20]. The favourable psychosocial outcomes for immediate reconstruction should encourage all surgeons to make every effort for immediate reconstruction in suitable patients.

4. Preoperative considerations

4.1 Patient selection

Patient selection is a key consideration for DTI reconstruction. An ideal candidate would be a non-smoker with small to moderate breast size who desires to be a similar implant size [21]. Careful evaluation of their past medical and surgical history is recommended and physical assessment of the patient’s features of weight, height, chest wall configuration and existing breast size and shape is essential. With any reconstructive surgery it is important to identify the aesthetic objective of the patient and to manage realistic expectations about the post operative breast. For patients seeking a significantly larger implant a two-stage expander to implant procedure may be more appropriate [22]. Breast characteristics of tissue laxity and resultant ptosis should prompt deliberation of concurrent mastopexy. Speculation of breast skin perfusion post mastectomy is required as scars, smoking and previous radiation can all affect mastectomy skin flap viability rendering DTI an unsuitable option. Conversely, in co-morbid patients who are not able to tolerate the operative burden of an autologous reconstruction, DTI may be the more appropriate surgery and careful patient evaluation is required in recommending the best reconstructive option [21, 22]. Communication with the patient is crucial to ensure they understand the long term ramifications of an implant reconstruction. Breast implants are not intended to last a lifetime and replacement, or removal is recommended 10–15 years after initial insertion [23]. This can be due to patient preference but most commonly due to long term sequelae of implants.

4.2 Implant selection

Choice of implant is an important component of DTI reconstruction and the goal for selection is to match the most appropriate implant to the patient. There exists multiple factors which contribute to an implant’s success and each factor should be considered in relation to the individual. DTI reconstructions are often recommended for patients wishing to achieve a small to moderate implant size [24]. Larger implants can be associated with a higher rate of complications arising from increased tensile force on surgical wounds and increased pressure on mastectomy flaps contributing to tissue ischaemia. They may also result in less desired cosmetic outcomes of inferior displacement and over expansion of the lower pole [25]. The challenges of implant reconstruction following mastectomy compared to a purely cosmetic augmentation is the loss of glandular tissue and subsequent reduced soft tissue coverage which presents as upper pole hollowing and contour rippling. Implant shape affects how best to manage the post mastectomy breast cavity. Anatomical implants offer both superior and inferior pole projection resulting in the colloquial term “tear-drop implant”. The ability to recreate a more natural appearing reconstructed breast has been suggested to reduce the need for subsequent symmetrising procedures on the contralateral breast.

However, the success of an anatomical implant relies on fixation of position which is difficult to maintain in the potential dead space following a mastectomy. The risks of malrotation can be mitigated with the use of a round implant which allows for more flexibility within the breast pocket [26, 27, 28]. Increasingly implant surface texture has been the pre-eminent focus on implant selection. Surface topography determines implant surface area and greater complexity of surface texture has a dramatic effect on cell-surface interactions and ultimately tissue integration [29]. This ability to determine tissue response resulted in highly textured implants which reduce risk of implant rotation and development of capsular contraction by adhering strongly to the breast pocket [30]. The trend of widespread textured implant use was abruptly albeit temporarily curtailed with the discovery of Breast Implant Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) [31]. Though the advent of micro-textured implants theoretically adopts the advantages of the previous macro-textured implant without the BIA-ALCL risk, continued adoption of any textured implants over smooth implants remains controversial following oncological breast cancer surgery.

5. Intraoperative technique

Advances in breast cancer surveillance and treatment modalities have dramatically transformed the landscape of mastectomy techniques. Though radical mastectomy was the mainstay of treatment for decades, breast conservation surgery has emerged as the contemporary preference. Skin sparing mastectomy was first described in 1991 and consists of removal of all breast parenchyma and nipple areola complex (NAC) with removal of overlying skin of a superficially located neoplasm [32]. This technique maximally preserves skin to facilitate breast reconstruction. The NAC is integral to the perception of a naturally appearing breast and its loss is associated with worse patient psychosocial and sexual well-being. Efforts to retain the NAC led to the development of the nipple sparing mastectomy which sought to remove all breast parenchyma with total preservation of skin and NAC [33].

This evolution in breast surgery has allowed for greater adoption of DTI reconstruction as soft tissue viability of the breast pocket is retained. Sharp dissection in the plane between the subcutaneous tissue and breast parenchyma avoids ischaemic injury to the subdermal plexus of the mastectomy flaps. A multidisciplinary approach is required between the breast and plastic surgery teams to ensure adequate excision for oncological clearance is achieved while preserving the mastectomy skin flap vascularity to accommodate for DTI reconstruction [34]. Particularly as implant reconstruction historically fell out of favour in setting of high complication rates of wound dehiscence and implant extrusion, identifying tissue hypoperfusion can significantly alter the reconstructive plan. If any concerns are raised intraoperatively regarding skin perfusion the plastics team traditionally opted for a tissue expander and delayed implant reconstruction while waiting for any tissue necrosis to declare itself [35]. The use of indocyanine green angiography (ICG-A) has removed a lot of the guesswork by aiding assessment of skin perfusion and viability to minimise necrosis risk. ICG-A allows for real time visualisation of blood vessels up to 10 mm deep to the skin surface by intravenous injection of indocyanine green dye which binds to plasma proteins. Utilised in combination with imaging systems which can detect fluorescence produced by near-infrared light illumination of the dye, visual assessment of blood flow can be achieved [36]. This technology has advanced to hand held portable imaging devices which can be easily operated in theatre and its use in breast reconstruction has been proven to reduce rates of mastectomy flap necrosis [37].

Once adequate mastectomy skin flap viability has been established, pocket formation and implant position need to be defined. A pocket can derive from either the submuscular or subcutaneous plane. A submuscular pocket is formed by dissection of the relatively avascular plane deep to the pectoralis major muscle. An implant placed in this plane ensures additional soft tissue coverage over the implant and eliminates contact between the implant and skin incision. The extent of subpectoral dissection should be closely controlled to prevent both over and under sizing of the pocket. A wide pocket can cause implant displacement and rotation, while aggressive division of the inferior pectoralis major insertion can result in animation deformity. Aesthetically a muscular layer camouflages implant edges and minimises the appearance of rippling particularly in leaner patients but an underdeveloped pocket may compress the implant and create a more pronounced rippling effect. The pectoralis muscle would often not be adequate to completely cover the implant and recruiting either serratus anterior or rectus abdominis would be required to provide lower pole coverage [38]. Importantly a submuscular plane was shown to have the lowest incidence of capsular contraction when compared to other implant pocket positions [39].

A subcutaneous or pre pectoral approach was once the only available implant placement however they were fraught with complications in setting of more aggressive mastectomy techniques resulting in sub-optimal skin flaps. Soft tissue deficiencies increased the risk of extrusion, infection of the implants and capsular contraction was a common occurrence [40]. Understandably patients often chose to remove the implant and it was accepted that a subcutaneous DTI was not a recommended reconstructive option. Even with a better understanding of mastectomy skin vascularity and changes to mastectomy technique, the subcutaneous placement of an implant was still considered high risk and surgeons often chose a submuscular pocket as the safer plane [41]. Yet it was increasingly observed that the submuscular implant could not optimise aesthetic outcome. Complete muscular coverage of an implant would restrict lower pole expansion and was unable to mimic the appearance of a contralateral naturally ptotic breast. Efforts to address this problem resulted in surgeons releasing the inferior edge of the pectoralis muscle as a partial muscle or dual plane technique. Though this allowed for expansion of the lower pole of the breast, the loss of inferior fixation could result in the free edge of the muscle moving superiorly and compressing the surface of the implant creating a visible line when contracting.

5.1 Acellular dermal matrices and synthetic mesh

The invention of acellular dermal matrices (ADMs) and synthetic mesh provided surgeons the tools to adapt the breast pocket and optimise it for implant use. First introduced for breast reconstruction in 2005 [42], these surgical adjuncts have been widely adopted to improve implant position regardless of plane and offer additional support (Figure 1).

Figure 1.

Implant reconstruction following a skin sparing mastectomy. Robust mastectomy flaps envelope an implant with synthetic mesh support. The implant is inserted into the pre-pectoral plane and a tension free closure is achieved to primarily close the breast pocket.

ADMs are extracellular matrix structures which can be of either human, bovine or porcine origin. Processing removes cellular antigens which can elicit an immune response while preserving the structural matrix that encourages angiogenesis and tissue regeneration [43]. This lack of immunologic response allows for integration of the matrix to native tissue without encapsulation or contracture. ADMs are available as flat sheets of material that can be fashioned as required and many different applications of ADM have been described.

For submuscular implants, ADMs can artificially elongate the pectoralis muscle to cover the inferolateral pole of the implant which would be otherwise exposed in a dual-plane reconstruction negating the need to raise surrounding muscle for implant coverage [44]. Its use for pre pectoral implant placement has revolutionised this plane as a viable option for reconstruction. ADM can be formed as an internal bra surrounding the implant and securing it to the chest wall [45]. This can occur as anterior coverage only with the pectoralis major muscle in contact with the posterior surface of the implant. This technique masks upper pole implant visibility however it is technically more challenging to fashion the pocket without risking implant herniation or rotation. Complete coverage of the pre-pectoral implant requires a large volume of product to be secured together and aids in implant position. This provides an additional layer of tissue coverage and the additional support can relieve pressure on the mastectomy flaps. For both submuscular and prepectoral implants the use of ADM also helps to define and secure the inframammary fold while optimising implant position and lower pole projection [46].

Various synthetic meshes are also available on the market, providing an alternative to ADM. These meshes are incorporated through fibroblastic and foreign body reactions. They can be available as a preformed pocket thereby reducing surgical time when insetting and avoids over-handling of the product (Figure 2) [47]. ADMs have a significant economic burden and can be a deterrent to use while the relative cost-effectiveness of synthetic meshes makes it an appealing alternative option [48]. Meshes are also associated with less frequent infections and seroma formation in comparison with ADMs [49]. It is important to understand that though offering similar support, synthetic meshes do not provide additional soft tissue coverage, which ADMs can provide, and caution should be exercised with thin mastectomy skin flaps.

Figure 2.

The breast implant is placed within a synthetic mesh pocket. The mesh is sutured together to completely encompass the implant and to create fixation tabs from the excess material to enable optimal placement within the breast pocket.

6. Radiotherapy

Radiotherapy is an essential part of the multidisciplinary approach towards treating breast cancer. Post mastectomy radiotherapy is indicated with large tumour size (>5 cm), a positive margin, >4 positive lymph nodes on axillary dissection or cutaneous involvement. Early stage cancers with 1–3 positive nodes are also considered for treatment however hormone treatment is a reasonable alternative in older patients with stage 1 hormone receptor positive tumours. With the advent of neoadjuvant chemotherapy, radiotherapy is also recommended if the patient remains node positive post operatively [50]. These guidelines are derived from the substantial mortality benefit from postmastectomy radiotherapy and multidisciplinary discussion is recommended in their implementation. As early stage cancers are detected and treated earlier resulting in improved overall survival rates, the choice of reconstruction becomes increasingly important for long term quality of life. Radiotherapy has long been associated with soft tissue injury and inhibition of angiogenesis. It compromises breast pocket viability and wound healing while in the long term, irradiation of an implant based reconstruction can develop complications of capsular contraction and implant rupture [51]. Radiotherapy following implant reconstruction has consistently been associated with higher rates of reoperation and failure within the literature. Zhang et al. reported the reoperation rate as 15.4% compared to 6.7% of the control group while Chetta et al. observed that implants were 11 times more likely to result in reconstructive failure post radiotherapy relative to autologous reconstruction [52, 53]. The Mastectomy Reconstruction Outcomes Consortium (MROC) study, the most comprehensive review of post mastectomy radiation therapy, also found that major complications rates occurred in 33.2% of irradiated implant based reconstructions [54]. With this high incidence of complications, post mastectomy radiation is a relative contra-indication for DTI reconstruction.

7. Conclusion

Direct to implant is an excellent reconstructive option for patients who are suitable for immediate reconstruction and wanting to either maintain a similar or smaller breast volume. The use of acellular dermal matrix and synthetic mesh provides good lower pole support for the implant. Development of other adjuncts to assess mastectomy flap perfusion also aids in implant success and reduces rates of failure. Immediate breast reconstruction has noted advantages compared to a delayed approach and the use of implant reconstruction in this setting is dependent on appropriate patient selection and surgical technique.

Conflict of interest

The authors declare no conflict of interest.