Comparison of Immediate Implant-Based versus Staged Tissue Expander Breast Reconstruction Technique

Abstract

Sir:FigureWe had the great pleasure of reading the interesting article by Roostaeian et al. published recently in this Journal,1 and we congratulate the authors on their study. The two-stage tissue expander/implant technique is currently the most commonly performed procedure in breast reconstruction. A wide variety of procedures have been used for breast reconstruction, and the choice of technique depends on the needs, body habitus, general conditions, and preference of the patient. The advent of oncologically safe skin-sparing mastectomies and the improved cosmetic results achieved by these techniques have influenced and improved the aesthetic quality of breast reconstruction, especially from implants.2,3 The authors showed in their study that one-stage breast reconstruction is not burdened with more complications and a higher revision rate. In any event, the majority of their patients had grade 1 ptosis or less in approximately 80 percent and only 20 percent of large-breasted patients. Furthermore, they did not mention whether they had used total or partial muscular coverage of expander/implant, or acellular dermal matrices to achieve total muscular coverage, especially in the immediate implant-based breast reconstruction group. This information is extremely important for analyzing the possible complications and properly judging the aesthetic outcome. Finally, these factors might influence the results and explain why there is no difference in one-stage versus two-stage implant breast reconstruction groups. In our Unit, we always perform total muscular coverage of the device, and we think that with expanders there is a decreased risk of mastectomy skin flap necrosis because of less tension. Furthermore, immediate placement of large implants underneath the pectoralis major muscle without adequate expansion can be associated with increased postoperative pain and an inferior aesthetic result. Often, for immediate and adequate implant coverage, acellular dermal matrix is needed, and this yields an increased cost and greater risk of complications. Breast reconstruction using expanders/implants provides an excellent option for properly selected patients. We believe that patients with small, minimally ptotic breasts are the best candidates for implant reconstruction alone (Fig. 1), whereas patients with larger, more ptotic breasts should require a two-stage approach and a matching procedure to attain symmetry. The matching procedure can be a simple augmentation or mastopexy, or can involve a breast reduction (Fig. 2).Fig. 1: One-stage implant breast reconstruction after nipple-sparing mastectomy and contralateral augmentation mammaplasty in a 39-year-old patient.Fig. 2: A 44-year-old patient underwent skin-sparing mastectomy and two-stage breast reconstruction with an extraprojected implant, restoration of the inframammary fold, and contralateral reduction mammaplasty.For us, immediate one-stage reconstruction is limited to prophylactic and risk-reducing mastectomy, especially in small and nonptotic breasts, whereas with this two-stage technique, we are able to achieve good quality breast reconstruction using anatomically shaped expanders and implants in all types of patients, especially in those with large/ptotic breasts and in those requiring adjuvant chemotherapy, which can cause weight gain, which could be a cause of late breast asymmetry. Contralateral breast surgery can improve patient satisfaction and aesthetic outcome, especially in young patients. Our only concern is that the patients have to undergo two operations with the additional costs of two prostheses. The combined cost of the anatomically shaped expander and implant is over one and a half times the cost of a single mammary prosthesis. Despite these limitations, we consider the quality and aesthetic outcome of reconstruction justified in the use of two-stage technique. Stefano Bonomi, M.D. Fernanda Settembrini, M.D. Department of Plastic Reconstructive Surgery and Burn Unit Center, Ospedale Niguarda Ca' Granda, Milan, Italy DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication.