Secondary refinement procedures following prosthetic breast reconstruction


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Introduction

In the last few years, an increased demand for improvement in aesthetic results of breast reconstruction has pushed plastic and oncological surgeons to find new strategies.

A turning point in breast reconstruction was represented by Angelina Jolie’s New York Times article in May 2013, because from then on a growing number of patients were aware that they might potentially inherit a genetic mutation leading to an increased risk for developing cancer, and that there might be the potential for joining a strict follow-up schedule or the possibility of having a prophylactic mastectomy ( Fig. 26.1 ).

Figure 26.1, Front cover of Time in May 2013.

Although this subgroup of patients is at increased risk for developing breast cancer, they are currently disease free and thus they do not really consider complications, aesthetic defects or even small imperfections. Although risk reduction is the primary motivator, many patients consider prophylactic mastectomy and reconstruction as a means of improving the appearance of their breasts. Some patients will entitle the surgery as a reward for the unforeseen, untoward diagnosis, transforming a dream in to reality. It is therefore of paramount importance for the plastic surgeon to perform thorough preoperative counseling, psychological counseling and appropriate patient selection and setting proper expectations.

On the other hand, this has raised the bar for plastic surgeons as we have had to rethink breast reconstruction in order to obtain the best achievable results with the simplest procedure, according to the Veronesi philosophy. Entire generations of plastic surgeons have been trained with the dogma that “you can only place an implant in breast reconstruction in a submuscular plane”, and there was no discussion about that until few years ago, due to the high incidence of capsular contracture, mastectomy skin flap necrosis and implant dislocation, leading to high rate of immediate breast reconstruction (IBR) failure linked to prepectoral positioning.

It is known that the patient’s perception of result following mastectomy and reconstruction shifts during their journey according to the threat and psychological burden they are facing. After the initial diagnosis of breast cancer, the first 4–5 weeks are permeated with fear of death. This is then diverted and focused on the adjuvant treatment, like chemotherapy and radiotherapy. During these phases, the majority of patients are not evaluating their aesthetic results but focused more on the oncologic aspects of their care ( Fig. 26.2 ).

Figure 26.2, Patient fears and expectations after the diagnosis of breast cancer.

After those major life threats have passed, patients start to focus more on the aesthetic outcome; thus, this final phase is frequently the longest as it lasts for the rest of their life.

Patients with BRCA mutations present a specific pattern because in this group of patients the perceived risk of developing breast cancer should theoretically not be associated with the satisfaction inherent in the reconstructive outcome. Patients with an exaggerated fear of the risk of contracting cancer can experience more psychological stress that may undermine satisfaction regarding breast reconstruction.

Among the women who have had breast reconstruction, many have expectations that exceed their final result. This may be due to various factors such as the shape of the reconstructed breast, its consistency to touch and how much this could appear natural. These aspects should be discussed in more depth during the preoperative interview because it is important not to underestimate the importance of being emotionally prepared for these physical changes.

Even if a growing amount of literature exists evaluating patient outcomes after prosthetic breast reconstruction, only a minority of patients feel like making a high-quality and well-informed decision about breast reconstruction.

As surgeons, it is prudent for us to better inform patients and to engage them in a shared decision-making process. Shared decision-making is a process in which we bring together our expertise, likely treatment options, evidence, evaluations of risks and benefit along with the patient’s perceptions of them, their goals and preferences. It is a collaborative process that aims to support patients in reaching a well-informed decision about their treatment.

As stated by Dauplat et al ., mastectomy followed by IBR is a satisfactory tool to maintain quality of life score; however, this is only true if the reconstruction proposed is suitable for patients and if the cosmetic outcome is satisfactory.

The two major novelties of this new era that we are now facing are:

  • 1.

    Direct-to-implant (DTI) reconstruction since we have moved from the traditional two-stage breast reconstruction to direct-to-implant.

  • 2.

    Prepectoral breast reconstruction moving from the traditional retropectoral placement of implants for breast reconstruction.

DTI has proved to be cost-effective relative to two-stage breast reconstruction with a reduction of both direct costs that includes hospitalization and OR time, but also as means to reduce the psychosocial burden on the patient while at the same time posing a similar complication rate. The cosmetic outcome with DTI breast reconstruction is also thought to achieve a more natural-looking breast than can be created with the two-stage process by reducing incidence of nipple–areolar complex dislocation, inframammary fold (IMF) migration and severe asymmetry.

Generally speaking, DTI reconstruction provides the potential for structural, psychological, emotional, and sexual benefits to the patient. This includes reduction of trauma from mastectomy, feeling of wholeness with gain of femininity, liberty in dressing, extroversion with encouragement of sexual expressiveness, as well as elevation of self-esteem. This is in contrast to retropectoral DTI breast reconstruction where issues related to implant elevation remain unsolved. In addition, retropectoral placement has a higher incidence of functional impairment, chronic pain and implant-associated animation deformity, all of which will benefit from by converting the implant position from retropectoral to prepectoral. Animation deformity is a direct consequence of retropectoral placement rather than a true complication, because it is directly related to subpectoral implant placement. Animation is a phenomena that all patients will experience to some degree when the implant is under the pectoralis major muscle. Animation is due to the action of the pectoralis major muscle that contracts during flexion, adduction, and internal rotation of the humerus, thus forcing the implant to move cranially or caudally, and laterally as a single unit, causing implant displacement, distortion and discomfort. In some patients, muscle spasm resulting from retropectoral placement of the implant can cause severe discomfort. The extent and severity of animation deformity can vary due to surgical technique and thickness of mastectomy flap. A thin mastectomy flap can lead to tenacious adhesions and scarring of the cutaneous envelope to the underlying pectoralis muscle making the animation deformity more apparent ( Fig. 26.3 ; , ).

Figure 26.3, (A) Pre- and (B) postoperative frontal view of a patient who underwent implant exchange and change of plan from submuscular to prepectoral for a severe animation deformity.

There is a growing interest in the prepectoral placement of implants following mastectomy as demonstrated by the recent increase in the number of clinical studies. Between 2014 and 2015, there were only three studies; however, in 2019, there were 94, in 2020, there were 87 and during the first 6 months of 2021, there were 77 ( Fig. 26.4 ).

Figure 26.4, Published articles on PubMed related to prepectoral breast reconstruction.

Two-stage retropectoral breast reconstruction presented several issues, including:

  • 1.

    Nipple–areolar complex (NAC) dislocation.

  • 2.

    Pain-related complications, both at the shoulder girdle and chest wall, mainly related to elevation of both pectoralis major and/or serratus muscles.

The shift we are facing from retropectoral to prepectoral is related to various advancements with regard to nipple-sparing and skin-reducing mastectomy, new technologies for evaluating tissue perfusion and viability, as well as improvements in breast implants.

Another important advancement that better enables us toward prepectoral breast reconstruction has been made with the introduction of acellular dermal matrix (ADM) and synthetic meshes during the early 2000s. They have been used both in single-stage and in two- stage breast reconstruction to allow coverage of the inferior lateral aspect of the implant or the tissue expander, thus enabling the surgeon to spare the serratus muscle and/or its fascia, thereby reducing pain-related issues ( Fig. 26.5 ).

Figure 26.5, Improvements in imaging allowed surgeons to increase insight in preoperative evaluation of each patient.

In two-stage breast reconstruction, ADMs are used to overcome the low initial filling volume and the lack of total expander muscular coverage and inframammary fold dislocation; thus, reducing the number of outpatient visits for inflation and need for IMF repositioning.

In single-stage reconstruction, ADM and meshes allow the placement of an adequate prosthesis in a retropectoral fashion with appropriate lower pole projection. After detaching the pectoralis major from its lower insertion and choosing the appropriate implant with sizers, one must secure the inferolateral border to the ADM or mesh and then to the inframammary fold.

In both situations, a host response to the two different devices is initiated because both are foreign bodies. The inflammatory response initiated by the ADM is a necessary feature for host integration to occur. Thus, the advantages of using ADM are countered by the potential for an increased complication rate such as seroma, infection, hematoma, as well as minor and major wound necrosis that can potentially lead to reconstructive failure. In both situations, retropectoral placement of implants carries the additional complication of implant elevation and animation due to the action of the pectoralis major as well as functional impairment of the shoulder.

The next stage in this evolutionary process was to wrap the implant with ADM or mesh and fixing it at the pectoralis fascia; however, some feel that the presence of the ADM will increase the risk of a complication such as seroma, infection and wound dehiscence by 4–5-fold. As an alternative to ADM, some surgeon have used polyurethane-coated implants for prepectoral breast reconstruction. The basis for this is that the polyurethane coating is reabsorbed by the organism helping the formation of an ideal capsule, resulting in a softer implant, reduced upper-pole visibility and palpability and lower incidence of capsular contracture, resulting in a natural and softer breast. Unfortunately, the use of polyurethane implants vary around the world as regulations vary from country to country; thus polyurethane implants are not always available.

In either case, the goal of these reconstructions are to provide patients with results that are excellent, especially in the settings of IBR following skin-sparing mastectomy in a non-irradiated breast setting ( Fig. 26.6 ).

Figure 26.6, (A–F) Preoperative frontal, three-quarter and lateral view of a BRCA patient, postoperative images at 12 months’ follow-up after bilateral risk-reducing nipple-sparing mastectomy and prepectoral implant-based breast reconstruction.

Imperfections are continuously decreasing, but the one we are still facing are mainly related to:

  • Surgical approach and complications

  • Wrong implant choice

  • Wrong implant placement

  • Wrong pocket dissection.

Refinements procedures are represented by touch-ups or reoperation procedures like:

  • Autologous fat grafting

  • NAC reposition (both true misplacements situations and false ones)

  • Animation deformity correction

  • Contralateral breast symmetrization in unilateral prosthetic breast reconstruction.

Autologous fat grafting

Fat grafting for breast reconstruction was popularized by Spear et al . and has advanced in term of surgical technique and its wide range of applications. In 2007 Coleman and Saboeiro published their experience with long-term follow-up following 17 fat grafting procedures to the breast that was the impetus leading to the American Society of Plastic Surgeons changing their position statement and paving the way for the ongoing renaissance in fat grafting studies.

Safety of fat transfer in breast reconstruction has been evaluated by several authors and task forces and has been of paramount importance. Petit et al . in 2011 compared their experience with fat grafting following BCT and mastectomy and demonstrated a small increase of locoregional recurrence in the breast-conserving surgery group after lipofilling and no difference for the mastectomy group. Definitive conclusions were not provided; however, there was recognition of a higher risk of local recurrence in oncological patients undergoing autologous fat grafting. The main concerns were focused on the presence of adipose-derived stem cells within the lipoaspirate that after fat transfer, may activate a primary breast cancer or reactivate eventual dormant cells still present after breast-conserving therapy (BCT). Literature with clinical and animal studies report no conclusive data as whether lipofilling may rise the odds for local recurrence.

A later study from Kronowitz et al . in 2016 with 1024 breast undergoing lipofilling and a control group of 670 from the same institution found no significant differences in the rates of locoregional recurrence or systemic recurrence between breasts reconstructed with lipofilling and breasts reconstructed without lipofilling. Autologous fat grafting has now achieved widespread acceptance among surgeons and, more valuably, has been shown to have successful and safe patient outcomes. It represents one of the most important tools a plastic surgeon has in their armamentarium, making us able to enhance the reconstructive results.

Autologous fat grafting can be useful both in prepectoral and retropectoral breast reconstruction. It has been helpful to correct the step-off deformity at the upper pole and to correct contour deformity by reducing wrinkling and rippling. Those deformities can be classified in step-off, intrinsic and extrinsic, as done by Kanchwala.

In addition to improving the aesthetic results, autologous fat grafting (AFG) has also been used to treat postmastectomy pain syndrome and capsular contracture. Several articles have reviewed the indications for AFG in settings of previous radiotherapy, both in two-stage breast reconstruction as a preconditioning method, with different protocols, to reduce the grade of capsular contracture and to treat complications. Lipofilling is able to act on the main collateral effects of radiotherapy, such as fibrosis due to fibroblast injury, decreased microcirculation in the targeted areas. The principle factors responsible for this are stem cells, cytokines and growth factors that are all constituents of AFG.

Given the complexity associated with radiated tissues, more fat grafting sessions are usually necessary to achieve acceptable results in irradiated fields when compared with non-radiated. Khouri et al . demonstrated that 2.7 procedures were needed in non-irradiated breasts whereas 4.8 procedures were required in radiated breast to achieve an optimal result. Irradiated defects pose one of the most difficult situations for plastic surgeons. In these cases, the first two grafting sessions assist in reversing the radiation damage and the subsequent fat grafting sessions can allow for volume uptake.

Large volume fat grafting have been shown to be able to perform total breast reconstruction, even if they need several sessions and proper patient selection for adequate donor site, and should be considered in small to medium breast size.

Complications related to AFG include oil cyst formation and fat necrosis that can lead to calcification, poor and unpredictable retention rate, infections and palpable nodules.

Concerns about fat grafting have been raised that are primarily related to radiological follow-up of oncological patients and the alleged risk of local recurrence or increased risk of distance metastasis. Up-to-date knowledge has demonstrated that there is no higher risk for local or distant recurrence in lipofilling, and the radiological changes have been shown to be lower than a well-accepted procedure such as breast reduction. Rubin et al . in 2012 compared breast changes on radiological imaging such as scarring and masses that required biopsy, in two groups of patients, one after breast reduction and the other after fat grafting procedure. They demonstrated a higher Breast Imaging Reporting and Database System (BI-RADS) score and a significantly more common need for biopsy in the cohort of women that had breast reduction.

In order to achieve predictability and reproducibility, attention should be given for each step of lipofilling in order to achieve long-term success. This includes infiltration, fat harvesting, processing and infiltration. The goal is to respect both the adipocyte and the stromal vascular fraction through the entire process, while being able to remove the excessive liquid.

AFG represent a main interest in breast reconstruction with 77 clinical studies currently registered on ClinicalTrials.gov database (registered clinical trials: http://www.clinicaltrials.gov .), and with 20 of them specifically addressing its use in breast.

Up-to-date literature reviews show that several different protocols are being used, with a huge difference in comparative studies on fat grafting, proving that we are still looking for the perfect recipe. There is general consensus among the studies validating the use of either wet or tumescent liposuction, thus avoiding the major blood loss associated with dry liposuction, but the infiltration solution used varies from surgeon to surgeon. Our preference is to use adrenaline as a vasoconstrictor to reduce bleeding and the use Naropin for local anesthesia because lidocaine has been shown to inhibit the growth of adipocytes, altering their viability.

The donor site is chosen according to the patient’s habitus and preferences, as no anatomical site has proven better than another in terms of retention rate. After 10 min the adrenaline takes effect and aspiration with Coleman cannula connected to 10-cc syringe is started, thus applying a low aspirational pressure ( ).

The fat is then washed with Ringer’s lactate solution in a 50% dilution to the lipoaspirate. This is repeated three times prior to decantation. Following separation of fat and liquid, the fluids and debris are discarded. Fat obtained from this process is injected through 2-mm cannula and by means of a 10-cc syringe in a retrograde fashion on multiple planes and levels in order to maximize uptake ( ).

In case we are in a preconditioning method, at the time of the lipofilling session we always reduce the expansion volume by aspiring an amount of saline equal to the hypothetical amount of fat we are planning on injection, thus reducing the pressure on the graft in order to maximize the uptake rate.

Fat transfer is also useful for the pre-treatment of patients requiring a conversion of reconstruction plane, moving from retropectoral to prepectoral. This is especially true for patients with a central or apical scar due to the tenacious adherence of that area to the underlying pectoralis muscle. It is also useful for patients with a very thin mastectomy flap because they may require multiple preoperative sessions of lipofilling before being able to undergo the change of implant placement.

A different scenario we are facing is the loss of thickness of mastectomy flaps due to fat atrophy years after prosthetic breast reconstruction. The reason for this is the constant pressure of the implant on the mastectomy skin flaps, which, over time, can lead to thinning of the breast envelope with higher risk of rippling and wrinkling. Preemptive fat grafting in this cohort of patients helps to reduce the instances of asymmetry compared with patients not undergoing fat grafting in pre-conversion, lessening the development of capsular contracture and reducing the need for subsequent revision surgery.

Further refinements in prepectoral breast reconstruction in which rippling and wrinkling has occurred can be corrected with AFG in one or multiple sessions, as needed. The grafting technique is more accurate when the injection pattern is fan-shaped and then cross-hatched in order to improve the results. We like to cross-hatch the valley formed by rippling of the prosthesis with a 90° angle. Going parallel instead of perpendicular can aggravate rather than ameliorate the defect; thus, it is advisable at the end of injection procedure to check the result with the patient in a semi-sitting position in order to be sure the fat is in the most proper areas ( Fig. 26.7 ).

Figure 26.7, (A–F) Postoperative frontal, three-quarter and lateral views of a BRCA patient 12 months after bilateral nipple-sparing mastectomy and prepectoral breast reconstruction showing bilateral rippling; postoperative images at 6 months’ follow-up after two sessions of lipofilling.

As already stated, AFG represents a valuable tool in prosthetic breast reconstruction. It has been demonstrated to be a safe, simple procedure but highly effective as it helps the surgeon in the management of secondary contour deformity, irradiation-related issues and touch-ups for improving symmetrization. Fat grafting has been also effective in reducing breast discomfort or mastectomy-related pain syndrome, as evaluated by Juhl in a randomized controlled trial appraising the analgesic effect of AFG.

The outcome measures employed were obtained using DoloTest, the Visual Analogue Scale (VAS) pain score and the Neuropathic Pain Symptom Inventory (NPSI). They also performed the assessment of the scar with the Patient and Observer Scar Assessment Scale (POSAS) at baseline, at 3 and 6 months after baseline with one group treated with fat grafting and the other with medical standard of care according to the patient anesthesiologist or oncologist.

In this first randomized controlled trial evaluating fat grafting, lipofilling proved a significant analgesic effect, with an average pain reduction of 36 (54.9%) VAS pain points and also a significant clinical improvement of the scar after fat grafting. In a paper by Cogliandro et al . they evaluated with BREAST-Q as gold standard for patient-reported outcomes in breast surgery, patients undergoing AFG after IBR compared with only IBR. The authors were able to demonstrate significantly better results in the AFG group based on the ability to wear more fitted clothing, the softness of the reconstructed breast, breast symmetry, look and feel of the reconstructed breast, amount of implant rippling (wrinkling) perceived by patients, psychosocial well-being, and physical well-being of the chest and upper body.

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