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Reconstruction: Immediate

 
IMMEDIATE BREAST RECONSTRUCTION
USING THE EXPANDER/IMPLANT TECHNIQUE
STAGE I
  • Markings

Prior to mastectomy, the patient's inframammary folds and mid-line are marked. These markings will be used during surgery to help with dissection and correct placement of the expander.

  • Skin Flap Viability

Reconstruction proceeds directly following the mastectomy. The skin flaps remaining after the mastectomy are evaluated for viability. All potentially ischemic tissue is removed to avoid possible wound healing complications. If concern remains regarding the viability of the skin flaps, one ampule of flourescein may be given intravenously and a Woods Lamp can be used to help assess perfusion.

  • Selection of the Expander

The base width of the existing breast is the most important measurement in selecting the size and style of an expander. A plastic template supplied by the manufacturer (McGhan) is used to confirm the match. Once the measurements are confirmed, an appropriately matched McGhan style 133 anatomic textured tissue expander with an integral injection port is chosen.

  • Creation of the Muscle Pocket/Expander Placement

A muscle pocket is created for the tissue expander. The pectoralis major is elevated superiorly and medially, beginning at the lateral edge. The serratus anterior and anterior fascia of the rectus are elevated downward. It is possible the pocket may not be intact, particularly the lower portion, nonetheless it is crucial to provide a muscular separation between the expander and the skin/mastectomy incision. Prior to placement, all air is removed and the expander is filled with saline to check for leaks. Once the expander is cleared for leaks, it is filled with 50-100 cc of saline. The selected expander is then inserted with the integral injection port placed superiorly in the pocket (see Figure 1).

Reconstruction with expander

The muscle edges are approximated over the expander with interrupted 3-0 vicryl sutures.

  • Closure

A closed drainage system is recommended. A Jackson-Pratt 10 French fully perforated flat drain with bulb suction is used to prevent fluid accumulation. The drain is inserted into the pocket through a separate lateral stab incision and secured with 2-0 nylon sutures. The skin is approximated in layers using 3-0 vicryl sutures in the muscle and subcutaneous layers. A 4-0 prolene subcuticular running suture is used to approximate the skin edges.

  • Expansion

Tubing and attached 21 gauge needle are primed using saline to remove all air. The injection port is then palpated and a McGhan magnaport finder (magnet) is used to verify the location of the integral port. The needle is inserted into the integral injection port until the steel backing is struck and then aspirated to ensure proper positioning. A measured amount of saline is injected into the expander—50 to 200 cc is the standard amount injected during an expansion session. The volume injected is restricted by the point at which the patient begins to feel tightness or discomfort.

  • Expansion Process Overview

Breast expansion begins two weeks after the mastectomy if the incisions are healing well. Concerns regarding healing may postpone expansion until the status of the wound is satisfactory. Expansion occurs weekly until the expander is 10% larger than the native breast, at which point the process is stopped and the second stage implant exchange is planned four months later.


 
IMMEDIATE BREAST RECONSTRUCTION
USING THE EXPANDER/IMPLANT TECHNIQUE
STAGE II

 

  • Pre Expander/Implant Exchange

Prior to the expander/implant exchange, the status of the expanded breast mound is compared in relation to the patient’s native breast. Markings are once again made, identifying the mid-line and inframammary creases.

The previous incision is used to remove the expander. If necessary, adjustments are made in the capsule surrounding the expander to achieve symmetry with the contralateral breast. The inframammary crease may need to be lowered by incising the lower portion of the capsule, or elevated by using a 3-0 merselene suture to recreate a precise higher inframammary fold. Ideally, no alterations are necessary and the permanent implant can be placed immediately.

  • Implant Selection

The selection between the McGhan style 363 and the McGhan style 163 implant is made based upon the shape of the patient’s native breast. The implants differ in the design of the upper pole (see Figure 2).

Breast implants type

The McGhan style 163 is slightly taller than it is wide, with a contoured upper pole and projecting lower pole. While the McGhan style 363 implant has a projecting lower pole, but is shorter than it is wide. The style 363 implant creates a greater concavity of the upper pole of the reconstructed breast. Typically I use the style 163, but will on occasion select the style 363.

  • Implant Placement

Prior to its placement in the muscle pocket, the air should be removed from the implant and then filled to the appropriate volume with sterile saline and checked for leaks. The implants have very sensitive predetermined volume ranges. For example, underfilling can risk underinflation and rippling in the newly reconstructed breast. In addition, both overfilling and underfilling can result in implant rupture. Final judgment and correction of implant placement can be made by sitting the patient upright and making any necessary adjustments.

  • Closure

The wounds are closed in layers using 3-0 vicryl sutures on both the muscle and the subcutaneous layers. The skin is approximated with a subcuticular 4-0 prolene suture. To prevent fluid accumulation, a 10 French Jackson-Pratt flat-drain with bulb suction is used. The drain is brought out through a separate stab incision laterally and secured with a 2-0 nylon suture. Two-inch 3M microfoam tape is then placed in the inframammary crease to maintain its position. Sterile dressings and a surgical bra from Baxter are subsequently placed on the newly reconstructed breast.

  • Bilateral Breast Reconstruction

If the patient undergoes bilateral breast removal, care must be given to create symmetric inframammary folds.

 

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