Breast implant infection is a rare condition that can be difficult to diagnose. However, if you notice any symptoms of breast implant infection following plastic surgery then it’s important that you seek medical attention immediately. Your doctor will perform tests on both your breasts as well as other areas where there are wounds from surgery in order to determine whether or not there is an infection present and what type of treatment should be prescribed accordingly.
In this guide, we review the Symptoms Of Breast Implant Infection, can breast implant infection be cured, how to avoid infection after breast augmentation, and tissue expander infection treatment.
Symptoms Of Breast Implant Infection
Breast implant infection is a rare complication of plastic surgery. However, if you are concerned about breast implant infection or any other complications, it is important to report any symptoms to your doctor immediately. Here we will take a look at the symptoms of breast implant infection and how they can be treated.
Breast implant infection often presents with symptoms such as fever, swelling and redness.
If you have breast implants and are experiencing a fever, swelling and redness in the area of your surgery, it may be an indication of infection. Other symptoms include:
- Clear or bloody drainage from the surgical incision site
- Pain in the surgical area that is not relieved with rest or over-the-counter pain medications
If you notice any of these symptoms after having surgery on your chest wall or breasts, contact your doctor right away to determine what course of treatment is best for you.
The other common symptoms of breast implant infection include a clear or bloody drainage from the surgical incision.
If you notice a clear or yellow fluid coming out of your incision, this is normal. Some women may have a bit of blood in their discharge, but it’s not usually significant enough to be alarming. If the discharge has an unusual odor and/or looks thick and opaque, it could mean that there’s an infection present. In rare cases where the implant ruptures or deflates (the most common cause being trauma), there may also be some bleeding associated with implant rupture symptoms such as pain at rest or when lying down on one side; swelling around the surgical site; redness around incisional edges; increased tenderness overlying breast tissue due to inflammation caused by bacteria entering through open wounds created during surgery
If there are symptoms of breast implant infection, you may want to contact your doctor for a proper diagnosis and treatment.
If you have symptoms of breast implant infection, such as fever, chills and redness around the incision site or underneath your breasts, contact your doctor immediately. He or she will perform an examination to determine if you have an infection.
If an infection is found, it can be treated with antibiotics and/or drainage of fluid from around the implant(s) through aspiration (a needle inserted into each breast). If necessary, removal of all implants may be required in order for healing to occur properly and for pain relief–this is referred to as explantation surgery.
As each case is different, your doctor will be able to advise which treatment is most appropriate for your condition.
As each case is different, your doctor will be able to advise which treatment is most appropriate for your condition.
Your doctor will need to examine the patient and their medical history as well as their symptoms and condition. They may also ask about any previous or current treatments that have been tried. This will help them decide on the best course of action and whether an operation would be suitable in this instance.
In severe cases, surgery may be required to remove or replace the plastic implants in order to treat the infection.
If you have been diagnosed with a breast implant infection or if you suspect that you might be experiencing symptoms of an infection, it is important that you seek medical attention. In some cases, surgery may be required to remove or replace the plastic implants in order to treat the infection. However, this is a last resort and should only be done if all other methods fail to work. Surgery carries several risks including:
- Pain during recovery period
- Scarring (which can be permanent)
- Expense
If your doctor suspects that surgery will be necessary for treatment of an infected breast implant, they will likely recommend taking antibiotics before going under anesthesia so as not to increase risk of complications during surgery itself by having bacteria present on their skin surfaces when entering into operating room environment where sterile conditions are maintained at all times
Watch out for signs of breast implant infection whenever you are having plastic surgery.
Breast implant infection is a serious condition that can cause permanent damage to your body. If you are having plastic surgery, make sure you are aware of the risks and know how to prevent breast implant infections.
If you have symptoms of breast implant infection after surgery, contact your doctor immediately.
can breast implant infection be cured
Breast implants are commonly used in breast augmentation surgery. Made from either silicone or saline, they are used to reshape breasts into a fuller, firmer, and rounder form. But with all the beauty and confidence that implants can bring, it is still very important to know of any possible breast implant complications and risks.
This is not to scare you from getting breast implants. As a plastic surgeon, it is important for me to walk you through every step of the procedure. The goal of this article is to give you a gentle reminder that taking care of your body is still the number one priority when achieving your goals.
Breast Implants Infection Statistics
One Google search of this topic will probably send you away from plastic surgery forever. The cases that you may find online could be horrendous but in reality, infected breast implants are very rare. Less than 2% of cosmetic augmentations result in infection and more often than not, the situation can be addressed by an antibiotic.
Why Do Breast Implants Get Infected?
These silicone implants are foreign to your body which means that it is different from your own body tissues. Naturally, antibodies are delivered throughout your body. However, it only reaches the surface of the implant. This means that your breast implants, unlike the rest of your body, do not have an immune system that can fight infection naturally. This is the reason why implants can be prone to infection.
How to Prevent Breast Implant Infection
Once you notice any symptoms on your body, do not hesitate to schedule a consultation with your board-certified plastic surgeon. Antibiotics may be used as an initial treatment, but also keep in mind that the infection can lead to the removal of your implant.
It is never wrong to educate yourself about the potential risks and complications that may arise from your breast augmentation. I hope that this will make you more diligent with your body and more proactive when it comes to your overall healthcare.
how to avoid infection after breast augmentation
Evidences in aesthetic breast augmentation only derive from few randomized controlled trials comparing different types of implants and different techniques (3,4).
No high level of evidence conclusions about the best technique or the best implant to use for obtaining the best outcomes in aesthetic breast augmentation, with low complications and re-interventions rates exist from available literature.
The actual best evidence about silicone gel-filled breast implants derives from the US Food and Drug Administration (FDA) core-studies. We actually have the 10-year follow-up results about Natrelle 410 anatomical form-stable silicone-filled breast implants (Allergan Inc., Irvine, California) use in aesthetic and reconstructive breast surgery (5). The Allergan core-study investigated the safety and effectiveness of Natrelle 410 breast implants reporting complications and re-interventions rates, reporting the cumulative risk of a subject experiencing an adverse event at any time during the 10 years.
Capsular contracture rates (Baker scale grades III and IV) at 10-year follow-up were 9.2% for augmentation and 14.5% for reconstruction. The confirmed rupture rate was 9.4% without any report of extracapsular silicone gel migration. Other major complications (>5%) were implant malposition (4.7% for augmentation) and asymmetry (6.9%). The seroma rate was 1.6% for augmentation subjects, 0.6% occurring more than 1 year after implantation (late seroma). A single case of breast-implant associated anaplastic large cell lymphoma (BIA-ALCL) was reported.
The 410 Allergan core-study concludes the most commonly reported complication in breast implant surgery is capsular contracture, the risk of this complication increasing over time, even though capsular contracture rates being lower than those observed in the Natrelle round gel (fourth generation) core study, mostly including smooth implants (56.2%) (6).
Similarly the 6-year data about the form-stable Mentor Contour Profile Gel (CPG) implants (Mentor Worldwide LLC, Santa Barbara, California) showed lower contracture rates for the CPG implants when compared with predominantly smooth-surface round gel breast implants (7,8).
The 10-year data also show a very low rate of implant rippling or wrinkling (0.9% for augmentation, 6.2% for reconstruction).
In this paper we would like to present the actual evidences about the etiopathogenesis of main complications in aesthetic breast augmentation, trying to identify some basic rules to follow in order to reduce complication rates in our daily activity, minimizing re-interventions, obtaining long lasting results and high women’s satisfaction levels with their surgery.
Complications in breast augmentation
Potential surgical complications in breast implant surgery could be classified in pre- and intra-operative complications and early and late post-operative complications.
Pre-operative and intra-operative complications derive from poor planning (wrong choice of the surgical access, incorrect measurement) or poor surgical technique (over-dissection of the implant pocket, implant malpositioning, excessive bleeding).
Early post-operative complications are haematoma, seroma, infection, implant malposition and pain. Late post-operative complications are infection, seroma, capsular contracture, poor muscular animations (excessive, unusual, painful) or distortions, implant visibility, implant malposition (descent, double bubble, waterfall deformity, etc.), implant rippling, wrinkling and palpability, implant rupture, symmastia, poor scar healing or scar hypertrophy.
The role of bacterial biofilm in implant-associated infection, capsular contracture, late seromas and BIA-ALCL
Breast implants are placed in a potentially contaminated pocket, bacteria being present in breast ducts and glandular parenchyma (9,10).
Several in vitro studies demonstrated how bacteria could bind to breast implants’ surface despite the type of surface (11).
These bacteria could form a biofilm, that is a combination of glycoprotein and latent bacteria binding to the breast implant silicone envelope. When forming a biofilm, bacteria are resistant to antibiotics (12).
When overcoming the local host defenses, the biofilm will continue proliferating leading to local inflammation and fibrosis, causing capsular contracture (13).
An experimental model in pigs was presented by Hu and colleagues in 2015 (14), showing that capsular contracture Baker grade is directly linked to the number of bacteria for increasing and a threshold of bacterial biofilm exists above which host responses lead to capsular contracture, due to an inflammatory response leading to fibrosis.
A great T-cell response to the presence of bacteria has been described by Hu and colleagues, particularly in textured implants when compared with smooth implants, texturization representing a more ideal surface for biofilm formation. However the infectious hypothesis does not mean that textured implant will be necessarily associated with higher contracture rates, remaining determinant the threshold of infection above which local inflammation is initiated.
Chronic biofilm infection of breast implants and the predominant T-cell lymphocytic infiltrate could acquire a particular importance in the etiopathogenesis of late seromas and breast-implant associated Anaplastic Large Cell Lymphoma (BIA-ALCL) as well.
Chronic bacterial infection has been shown to be associated with the development of lymphomas (15) and similarly chronically infected breast implants could be extremely rarely linked with inflammatory processes leading to T-cell lymphoma development. Obviously this will be a multistep process with fundamental impact of patient genotypes and immunomediated factors contributing to BIA-ALCL development.
Double capsules
Double capsule could be defined as two distinct capsular layers around a breast implant with an intercapsular space: the inner layer adheres to the implant envelope and the outer one to the breast tissue. Between the two capsular layer could has been described the presence of seroma-like fluid. Double capsules could be partial or complete. When complete, double capsules could be linked to rotation of the implant due to the interface between the inner and the outer layers. In these cases the tissue in-growth into the textured surface could not prevent rotation, textured implants acting as smooth ones, due to the intercapsular space, where synovial metaplasia has been described.
The etiopathogenesis of double capsules is controversial with four main hypothesis. The first theory is based on movement of the implant within an oversized pocket, where adhesion of the implant with the surrounding tissues is precluded (17).
The second hypothesis propose a mechanical etiology: the detachment of the implant from the capsule would be determined by shear stresses applied to the implant-capsule complex, leading to the creation of a new inner layer of capsule over the implant, from seeding of cells coming from the seroma-like fluid accumulating between the implant and the original capsule (16).
The third hypothesis is based on seroma formation around the implant (from an infectious, allergic or hemorrhagic origin), subsequently leading to the development of a new inner capsule (18).
The fourth hypothesis also propose a mechanical etiology with shear forces causing detachment of the implant-capsule complex from the surrounding breast tissue, with a new capsular layer developing outside the original capsule (19,20).
A recent study by Giot and colleagues (21) observed that bacterial load and biofilm presence within the intercapsular space was lower or absent while bacteria could always be seen in the prosthesis interface, so the two spaces do not share the same initial fluid, as necessarily would be in the case of the first three hypotheses.
Moreover the histological findings reported in the same studies confirmed a layered appearance of the inner capsule and delamination at the more solicited locations of the capsule (outer breast quadrants), supporting the fourth hypothesis.
Late seromas
The term “seroma” is generic and describes collections of clear serous fluid developing in dissected spaces following surgery. The fluid could be defined as a serous effusion if on examination it appears acellular with small quantities of proteins (<2.0 g/dL), as an exudate if it contains cells and proteins (> 2.9 g/dL) and as an hematoma, if it predominantly contains red blood cells. Moreover it as an inflammatory effusion if the cells are predominantly white blood cells and a malignant effusion if it contains cancer cells.
Late seroma is defined as a periprosthetic fluid collection occurring more than 1 year following breast augmentation.
Few data exists about the epidemiology and etiology of this clinical entity in patients with breast implants.
Bengston and colleagues presented a literature review and a consensus panel recommendation about late periprosthetic seromas in patients with breast implants (22).
The exact epidemiology of late periprosthetic fluid collections in patients with breast implants is not defined with reported incidences ranging from 0.88 to 1.84% (23,24).
The cause and pathophysiology of late periprosthetic fluid collections could be linked with the infectious theory or deriving from mechanical shear forces or sliding surfaces generated by micromovements between the implant and the surrounding tissue, as for double capsule formation (25).
Breast Implant Associated Anaplastic Large Cell Lymphoma
Late periprosthetic fluid collections in patients with breast implants have also been reported in association with Breast Implant Associated Anaplastic Large Cell Lymphoma (BIA-ALCL).
This is why a correct diagnostic pathway should always be followed when dealing with late seromas. Late seroma does not represent a direct precursor of BIA-ALCL, but all late seromas should be thoroughly investigated with cytological examination through fine needle aspiration, flow cytometry and CD30 IHC of effusion.
Two-thirds of BIA-ALCL patients present as a malignant effusion associated with the fibrous capsule surrounding an implant occurring on average 8 to 10 years after implantation.
Therefore any seroma occurring greater than 1 year after implantation not readily explainable by infection or trauma should be considered suspicious for disease. One third of patients present with a mass which may indicate a more aggressive clinical course (26).
Any aspiration of peri-prosthetic fluid should be sent to pathology for cytologic evaluation and include a clinical history with the aim to “rule out BIA-ALCL”. Diagnosis by hematoxylin and eosin staining alone is nearly impossible: BIA-ALCL will demonstrate strong and uniform membranous expression of CD30 immunohistochemistry (27).
Ultrasound examination may help defining the extent of an effusion and identifying associated capsule masses. Clinical examination should include evaluation of regional lymph nodes. BIA-ALCL effusions are typically more viscous than a benign seroma due to the higher protein content and cellularity. The surrounding capsule may be thickened and fibrous or may be completely normal in appearance.
If a mass is present, it can protrude into the implant creating a mass effect distortion on imaging or the mass may protrude outward into the soft tissue (28).
Patients with biopsy-proven BI-ALCL must be referred to a lymphoma oncologist ideally prior to any surgical intervention to allow for proper oncologic evaluation. Surgical treatment of BI-ALCL includes removal of the implant, complete removal of any disease mass with negative margins and total capsulectomy. Because an implant capsule may drain to multiple regional lymph node basins, there does not appear to be a role for sentinel lymph node biopsy in the treatment of BI-ALCL. Excisional biopsies of any suspicious lymph nodes should be performed (29).
BIA-ALCL is distinct from primary breast lymphoma, that is a disease of the breast parenchyma and is predominantly a B-cell lymphoma (65–90%) (30,31). BIA-ALCL is a T-cell lymphoma arising either in an effusion surrounding the implant or in the scar capsule surrounding a breast implant, is ALK negative and express the CD30 cell surface protein (32).
Most cases are diagnosed during implant revision surgery performed for a late onset (> 1 year), persistent seroma and may be associated with symptoms of pain, breast lumps, swelling or breast asymmetry.
BIA-ALCL most commonly follows an indolent course when adequate surgical removal of the implant and surrounding capsule is performed, without any systemic therapy, but aggressive cases experiencing disease progression and death have been reported.
Implant rupture
Rupture is a long-recognized complication of all breast implants. Breast implants are not lifetime devices. MRI screenings are recommended 3 years after initial implant surgery and then every two years after to detect silent rupture. Among primary causes of implant rupture in the first 5 years after implantation, instrument damage by surgeon seems to be the is the principal cause (33).
A variety of methods have been used both to detect rupture and to estimate its incidence. Most ruptures are silent and detectable only by imaging techniques such as Magnetic Resonance Imaging (MRI), the current gold standard, or high-resolution ultrasound (34). Clinical examination detects only about 30% of the rupture found at MRI (35). As a result, any report of rupture incidence that is not based on screening of all patients with an imaging modality such as MRI or ultrasound will significantly underestimate the actual rupture rate. For this reason, rupture incidence should not be derived from combined populations of MRI-screened and non-MRI-screened patients. Although product complaint reporting has also been used for assessing the incidence of rupture, it is widely recognized that for nearly all device complications, such reports represent only a fraction of the actual complications occurring in patients. Incidence rates of rupture increase over time following implantation, so the follow-up is particularly important to be considered in any reported estimates of rupture rates. Rupture rates are very low in the first few years after implantation. A MRI-based study from Denmark reported a rupture-free survival of 98% at 5 years and 83% to 85% at 10 years (36).
When estimating rupture rates from prospective Core Clinical Study data, the most appropriate and rigorous method is to use follow-up data only through the patients’ last MRI exam, rather than through their last office visit, as most ruptures are detected via MRI as discussed earlier. This method of rupture calculation, however, is not yet standard, and until such methods are standardized, direct comparisons of rupture rates among studies are not reliable or meaningful.
Breast implant durability is a highly debated issue between surgeons, patients and regulators as FDA. To determine the useful life of a breast implant, it is necessary to determine the primary cause of failure (Figures 1-3); instrument damage seems to be an important “failure” factor (33).
tissue expander infection treatment
The options for breast reconstruction using either implants or expanders include the use of a temporary tissue expander exchanged for a permanent implant following serial expansion, permanent expander-type implant requiring only valve removal following full expansion, and latissimus dorsi muscle flap for coverage of an implant or expander.
Preoperative Details
Preoperative planning requires evaluation of the patient in the upright position. Breast ptosis, projection, and the location of the inframammary fold should be identified. The size of the tissue expander to be used is established by determining the base width and height of the intact breast and then allowing for overinflation of an additional one third of breast volume.
Ideally, the planned incision of the oncologic procedure is delineated if a standard periareolar skin-sparing mastectomy is not an option. If autologous coverage for the implant, such as the latissimus dorsi, is to be used, the donor site also should be marked. Routine preoperative precautions, such as antibiotic prophylaxis and deep vein thrombosis (DVT) prevention therapies, should be used as needed.
An intraoperative photograph is shown below.
Intraoperative Details
Following completion of the mastectomy, a submuscular pocket is created for placement of the implant. The pocket is created deep to the pectoralis major and the serratus anterior. The submuscular pocket can be entered by releasing the inferior origin of pectoralis major muscle and dividing the junction between the pectoralis major and serratus muscles. Care must be taken to preserve or recreate the inframammary fold, an important aesthetic landmark.
An intraoperative photograph is shown below.
The implant is placed to allow the superior two thirds of the implant to be covered by muscle; however, the inferior portion is usually left subcutaneous. The integrity of the inframammary fold is maintained as an important aesthetic landmark. If an isolated fill port is used, it should be positioned far enough from the implant to avoid inadvertent puncture of the implant during filling, yet left in an inconspicuous area that facilitates removal. As indicated previously, acellular dermal matrices can be used to provide coverage of the implant below the caudal edge of the pectoralis muscle. The dermal matrix is attached to the caudal border of the pectoralis major and then sutured to the inframammary fold, creating a sling for the implant. [25, 26, 23, 27]
If a skin-sparing mastectomy has been performed, the reconstructive surgeon must evaluate the skin margins and resect any that do not appear viable. The skin then can be closed in layers. Following complete expansion, the expander-implant is removed through a lateral incision of the mastectomy scar to expose the junction between the pectoralis major muscle and the periprosthetic capsule. The capsule is opened and the expander is delivered. If adjustments to the capsule pocket are needed, they are performed using the lighted retractor and electrocautery. The permanent implant is inserted and filled with saline. The wound should be closed in layers to minimize the appearance of rippling.
A view after wound closure is shown below.
Postoperative Details
After the operative site has healed, 4-6 weeks after surgery, expansion can be initiated. Saline is injected using either the surface port of the expander-implant or the distant port.
An implant is shown below.
Additional saline can be injected to achieve rapid expansion but minimize complications. Factors that must be considered while expanding include skin tightness, blanching, and patient discomfort.
The injection port can be placed in either the lower lateral thoracic position or, as has recently been described, in the parasternal position to facilitate the aesthetic outcome and decrease discomfort during needle placement or expansion.
Once the expander volume matches the contralateral breast, an additional 30-35% of volume should be added. This enlarges the implant pocket to help create a more natural ptotic breast. Removal of the expander and exchange for a permanent implant are delayed 8-12 weeks following complete expansion to prevent tissue recoil. Some reports describe the use of a single implant expander allowing a single-stage reconstruction.
Postoperative photos are shown below.
A study by Min et al found that in contrast to the use of a previous incision for replacement of an expander with a breast implant, the use of an inframammary fold incision for this purpose was associated with no cases of implant removal due to dehiscence or indeed any cases of wound dehiscence at all.
Follow-up
The incidence of locoregional recurrence is the same in breast cancer patients who undergo immediate, tissue expander/implant reconstruction as inpatients who do not undergo reconstruction. [31, 32] Cancer surveillance after breast reconstruction should be performed; however, mammographic imaging of the mastectomy site does not increase the detection of locally recurrent breast cancer. [33, 34] The presence of breast implants (placed for reconstructive or cosmetic purposes) does not interfere with mastectomy or breast reconstruction; however, they may compromise the outcome of breast conservation therapy.
For excellent patient education resources, see eMedicineHealth’s patient education articles Mastectomy, Breast Lumps and Pain, Breast Self-Exam, and Breast Cancer.
Complications
Exposure occurs most often at the site of the mastectomy scar, particularly if the implant is not fully covered with muscle. If the skin edges become necrotic, the wound can be treated with topical Betadine ointment. The wound either contracts and heals or progressively worsens. If intact muscle, such as a latissimus flap or a portion of the pectoralis, is present, the implant can usually be successfully left in place. If the muscle has retracted and the implant becomes exposed, removing the implant is preferable. If the reconstruction has been performed without the latissimus dorsi myocutaneous flap, the exposed implant should be removed and a delayed secondary reconstruction can be performed using the latissimus dorsi. The latissimus dorsi is effective to prevent not only exposure but also capsular contracture in the irradiated breast reconstruction. [36, 37]
Malposition of the implant usually occurs because the implant is set too high at the initial surgery and subsequent capsular contracture brings the implant even higher on the chest wall. Once this occurs, lowering the implant using nonoperative methods is difficult. The operative approach consists of dividing the capsule inferiorly and extending the pocket at least 2-3 cm below the desired postoperative level so that, as the capsular contracture reforms, the implant remains at the proper level.
In patients in whom the implant has been placed too low and the inframammary line is lower than the contralateral normal one, manual elevation and taping can successfully elevate the inframammary fold to the proper level. An effective but hazardous approach is the percutaneous closure of the excessive inferior pocket. This technique risks puncture of the implant and should be avoided. If taping and nonoperative methods fail, reopening the incision and then closing the pocket under direct visualization is preferable. A few nylon sutures are placed at the proper level to promote adherence of the capsule. Removal of the remainder of the capsule is not necessary.
In almost every patient, a certain amount of capsular contracture is expected and occurs. Severe capsular contracture (ie, Baker classes 3 and 4) does not occur as often when the latissimus dorsi myocutaneous flap has been used for coverage; however, it is much more common if reconstruction involves minimal subcutaneous coverage. In a patient who has undergone reconstruction with an expander and without the benefit of the latissimus dorsi myocutaneous flap, treatment of capsular contracture should include this transposition as a secondary procedure.
Conversely, in a patient who develops an asymptomatic capsular contracture despite having had a latissimus dorsi myocutaneous flap, no reoperation is indicated. More often than not, open capsulotomies or capsulectomies are followed by reformation of thicker capsules. Comparison of immediate reconstruction and delayed reconstruction using implants has indicated that no significant difference exists in capsular contraction in the 2 groups.
Infection is relatively rare in patients with implants. When it occurs, removing the implant is best. Although the literature indicates that an implant can be salvaged by continuous irrigation of saline and antibiotic solution, with increased hospitalization cost, this method of treatment is not cost-effective; it is better to remove the implant, support the patient, and wait a minimum of 6 months before undertaking another reconstruction.
A study by Woo et al indicated that in nonobese patients undergoing expander-implant breast reconstruction, mastectomy weight and adjuvant radiation are independent risk factors for complications. The study, which included 397 immediate expander-implant breast reconstructions (367 patients), reported an association between a 100 g increase in mastectomy weight and a 23% greater risk of overall complications, major complications, and skin flap complications and a 28% greater risk of seroma. Adjuvant radiation was associated with reconstruction failure.
A retrospective study by Manahan et al indicated that in women who undergo expander-implant breast reconstruction, the chance of infection is significantly increased by the presence of seroma, older age, larger mastectomy volume, smoking, vascular disorders, and hypertension, with a patient’s body mass index also influencing risk. The overall patient complication rate in the study was 30%, with infection occurring in association with 14% of tissue expanders.
A study by Chen et al indicated that in patients undergoing immediate expander-implant breast reconstruction, preoperative external beam radiation therapy increases the risk of reconstruction failure. The study included 76 patients, with the reconstruction failure rate being 13.3% in patients who underwent no external beam radiation therapy, versus 50.0% in the preoperative radiation patients and 26.3% in those who underwent postoperative radiation.
The occurrence of complications using expander-implants can exceed 40% in published studies. However, despite a significant rate, the complications themselves are usually minor and do not prevent completion of a satisfactory reconstruction. In experienced hands, good to excellent aesthetic outcomes can be obtained in more than 80% of patients.
A longitudinal, multicenter, prospective cohort study by Bennett et al indicated that in patients undergoing postmastectomy reconstruction, the expander-implant technique is associated with lower 2-year complication rates than other procedures. The study evaluated women who had undergone reconstruction with the expander-implant technique, direct-to-implant (DTI) technique, latissimus dorsi (LD) flap, pedicled transverse rectus abdominis myocutaneous (pTRAM) flap, free transverse rectus abdominis myocutaneous (fTRAM) flap, deep inferior epigastric perforator (DIEP) flap, or superficial inferior epigastric artery (SIEA) flap.
The investigators reported that the odds of developing any complication were significantly higher for the autologous reconstruction procedures than for the expander-implant technique. It was also found that compared with the expander-implant method, the odds for reoperative complication were greater in all flap procedures except LD flap reconstruction. Moreover, the odds for infection were not significantly lower in any of the autologous reconstruction techniques, with the exception of the DIEP flap procedure, than in expander-implant reconstruction. However, the failure rate for the expander-implant and DTI techniques (7.1%) was higher than for the pTRAM flap (1.2%), fTRAM flap (2.1%), DIEP flap (1.3%), LD flap (2.8%), and SIEA flap (0%) procedures.
In contrast to the above report, a study of 294 immediate breast reconstructions by Riggio et al found that the major complication rate associated with expander-based surgery was 12.5%, compared with 4.3% for DTI treatment. No clinical variables were found to be significantly associated with DTI complications, but multivariate analysis indicated that radiotherapy and body mass index have a significant impact on major complications in expander-based reconstruction.
A study by Dicuonzo et al indicated that whether a women undergoes breast reconstruction with a permanent implant or with a temporary expander that is subsequently exchanged with a permanent implant, postsurgical radiotherapy increases the risk of reconstruction failure. While such risk was apparently no greater in the expander-implant group than in the permanent implant patients, the investigators found that radiotherapy in patients with an expander was associated with a shorter time to failure than was radiation treatment to patients who underwent reconstruction with the permanent implant alone (109.2 mo vs 157.7 mo, respectively).
A study by Park et al indicated that in patients who have undergone immediate expander-implant breast reconstruction, contralateral augmentation mammaplasty can lead to higher complication rates in the reconstructed breast. In comparing patients who underwent contralateral revision with those who did not, the complication rates for the reconstructed breast were found to be 13.5% and 6.5%, respectively, while revision operation rates for the reconstructed breast after the second stage of reconstruction were 9.0% and 3.0%, respectively.
Note that all modalities of breast reconstruction usually require multiple procedures to achieve the final outcome; however, the use of implants may actually decrease the number of procedures needed. This may be partly attributed to complications at the donor site in autologous reconstruction.
Future and Controversies
Various types of implants have been developed. Although the fill material (saline or silicone) is the greatest difference in implant types, surface (smooth and textured) and shape (round or anatomic-shaped) also vary. The use of saline facilitates adjustment of the implant size, particularly when the expander-implant prosthesis is used. Silicone-filled implants provide a more natural feel and shape but may be less accepted by the public. Controversies exist over whether textured or smooth implants are best. [34, 45, 46] Currently, experience with the use of anatomic or biodimensional breast implants is not sufficient to evaluate their efficacy.
Because a capsule forms around the implant as it contracts, the surface area becomes smaller. Since the volume remains the same, the teardrop shape of the implants becomes spherical. A certain degree of spherical shape of the reconstructed breast must be accepted. To mask asymmetry, a small implant can be placed in the contralateral breast to create upper pole fullness. In the authors’ opinion, the smooth round implants offer reliable results in most patients, particularly when covered by a thick chest wall flap or a latissimus dorsi flap.
Another problem that can present in patients who have permanent implants placed is the development of visible implant rippling. Patients with very thin skin are prone to this problem. Increasing use of the acellular dermal matrix products offers an alternative. [47, 48] This dermal matrix has been demonstrated to incorporate with surrounding breast tissue. It can be used either to cover the implant completely or to provide extension of the muscle coverage, whether the latissimus or pectoralis muscle is used. This limited soft tissue coverage can be performed with a minimal increase in operative time and decreases morbidity as compared with more extensive procedures.
The use of expander-implants for immediate breast reconstruction and subsequent radiation of the chest wall has been evaluated. [49, 50] While the rate of capsular contracture formation is higher than in the nonirradiated breast, patient satisfaction remains high. Cordeiro and colleagues indicated that expander-implants in nonirradiated breasts resulted in acceptable aesthetic outcomes in 88% of patients compared to 80% in the irradiated group (P = not significant).
Another study of patients who underwent immediate reconstruction with expander-implants found a significantly higher rate of grade III and IV capsular contractures in irradiated breasts than in nonirradiated ones (21.7% vs 10%, respectively). Moreover, the chance of major complications was greater in the irradiated group (odds ratio of 4.2). However, the revision rate in the irradiated breasts was less than that in those that did not undergo postmastectomy radiation therapy (20.9% vs 30.2%). The investigators concluded that in the irradiated breasts, the capsular contracture rate was acceptable and the revision rates unexpectedly low, making immediate breast reconstruction with expander-implants a reasonable option even in patients undergoing radiation treatment.
The safety of implants with regard to postoperative cancer surveillance is another area of controversy. While patients with implants have demonstrated no increased risk of carcinogenesis, the implants themselves may preclude satisfactory radiologic evaluation for breast cancer. Most of the literature on this topic is from the early 1990s and was gleaned from patients who had silicone implants placed for breast augmentation.
More recent information indicates that even in patients who have silicone implants placed over the breast tissue, use of mammography (74% accuracy) and perhaps more importantly ultrasonography (91% accuracy) can yield effect cancer surveillance. In addition, following breast reconstruction, diagnostic evaluation with tools such as fine needle aspiration (FNA), ultrasonography, and MRI can be helpful to distinguish palpable masses from fatty necrosis (in autologous tissue reconstruction) and to identify silicone implant failure. However, others have indicated that the use of mammography is unnecessary in the reconstructed breast. In general, routine postmastectomy surveillance, including physical examination, should suffice in patients who have undergone implant-expander reconstruction.