- Email: [email protected]
Comparison of subcutaneous versus submuscular expander placement in the first stage of immediate breast reconstruction
Accepted Manuscript Comparison of Subcutaneous versus Submuscular Expander Placement in the First Stage of Immediate Breast Reconstruction Lin Zhu, MD, Anita Mohan, MRCS, MBBS, BSc, Jad M. Abdelsattar, MBBS, Zhen Wang, PhD, Aparna Vijayasekaran, MBBS, Michelle Hwang, MBBS, Nho V. Tran, MD, Michel Saint-Cyr, MD, FRCS (C), Director, Division of Plastic Surgery Wigley Professorship in Plastic Surgery PII:
S1748-6815(16)00018-8
DOI:
10.1016/j.bjps.2016.01.006
Reference:
PRAS 4881
To appear in:
Journal of Plastic, Reconstructive & Aesthetic Surgery
Received Date: 22 July 2015 Accepted Date: 6 January 2016
Please cite this article as: Zhu L, Mohan A, Abdelsattar JM, Wang Z, Vijayasekaran A, Hwang M, Tran NV, Saint-Cyr M, Comparison of Subcutaneous versus Submuscular Expander Placement in the First Stage of Immediate Breast Reconstruction, British Journal of Plastic Surgery (2016), doi: 10.1016/ j.bjps.2016.01.006. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Title: Comparison of Subcutaneous versus Submuscular Expander Placement in the First Stage of Immediate
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Breast Reconstruction
Authors: Lin Zhu1,2, MD
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Anita Mohan2,3, MRCS, MBBS, BSc Jad M. Abdelsattar2, MBBS
Aparna Vijayasekaran2, MBBS Michelle Hwang2, MBBS Nho V. Tran2, MD
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Michel Saint-Cyr2, MD, FRCS (C)
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Zhen Wang4,5, PhD
Affiliations:
Department of Plastic Surgery, Peking Union Medical College Hospital, Beijing, China
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Department of Plastic Surgery, Mayo Clinic, Rochester MN, USA
3
Restoration of Appearance and Function charitable Trust (RAFT), UK
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4 Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester MN, USA 5 Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester MN, USA
Meeting presentation: No 1
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Correspondence: Michel Saint-Cyr
Wigley Professorship in Plastic Surgery
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Director, Division of Plastic Surgery
Email: [email protected]; Tel: Office: 254-724-7017; Clinic: 254-724-2321; Fax: 254-724-0315
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Statements for Conflict of Interest, Funding and Ethical Approval Funding: None
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Conflicts of interest: Dr. Michel Saint-Cyr is a consultant for Pacira. All the other authors have no conflict of interest.
Ethical approval: This study was approved by the Institutional Review Board (IRB), Mayo Clinic,
Abbreviations: The latissimus dorsi flap: LD
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Rochester, MN (15-004601).
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The deep inferior epigastric perforator flap: DIEP
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The muscle sparing-transverse rectus abdominal myocutaneous flap: ms-TRAM The transverse upper gracilis flap: TUG The profunda artery perforator flap: PAP
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Comparison of Subcutaneous versus Submuscular Expander Placement in the First Stage of Immediate Breast Reconstruction
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Summary Background Tissue expander based two-stage reconstruction remains the most commonly used technique in immediate breast reconstruction. This study compares the subcutaneous expander
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placement to the traditional submuscular placement and describes our early experience with the expander insertion plane choosing algorithm. Methods A retrospective study of patients who
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underwent two-stage immediate breast reconstruction from May 2012 to October 2014 was performed. All expander insertion plane choosing was performed with the same algorithm. Expansion, pain and complications were compared between two groups. Results 88 patients (158 expanders) were included (50 subcutaneous and 108 submuscular). The subcutaneous group had a higher intraoperative expansion radio (p<0.001), high first postoperative expansion radio (p<0.001), shorter duration of
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expansion (p=0.02), less number of expansion visits (p=0.002), and less average pain during admission (p=0.004). Significant differences in intraoperative and first postoperative expansion ratios in patients with postmastectomy radiation therapy were also found between the two groups (p=0.005 and 0.01,
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respectively). Complications during expansion and after second-stage autologous flap reconstruction
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were comparable between two groups. Conclusion The subcutaneous expander placement was associated with greater intraoperative and first postoperative expansion, shorter expansion duration, less expansion visits and less pain. With the expander insertion plane choosing algorithm, the subcutaneous expander placement could be performed with comparable complications rates with the submuscular placement during expansion and after second-stage autologous flap reconstruction. With the lack of long-term complications following second-stage implant reconstruction on the subcutaneous approach, additional studies are needed. 3
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Keywords subcutaneous tissue expansion; submuscular tissue expansion; two-stage immediate breast
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reconstruction; tissue expander; breast reconstruction outcome
Level of Evidence
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III
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Introduction Breast reconstruction using the subcutaneous plane was first described by Snyderman in the 1970s.1 This procedure, however, was fraught with a high incidence of complications, including mastectomy skin
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flap necrosis, implant extrusion and capsular contracture.2,5 These problems led to the introduction of the submuscular plane, which has remained the most commonly used technique in two-stage postmastectomy breast reconstruction.3,6-14 The pectoralis major muscle provides a cushion with
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overlying healthy tissue, eliminating the problems of compromised wound healing, implant extrusion, rippling, and capsular contracture. However, there are some inherent limitations associated with
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submuscular tissue expander placement, such as pain or discomfort, limited expansion, expander dislocation and breast animation.10,15,16 If an autologous tissue breast reconstruction is anticipated, expander removal and pectoralis major muscle detachment from the overlying mastectomy skin flap is required during the autologous reconstruction8,9, therefore decreasing the overall benefit of the
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submuscular placement.
Over the past decade, mastectomy and breast reconstruction have witnessed significant innovations.
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Recent trends favoring nipple and skin sparing mastectomy have allowed for a better preserved skin envelope available for breast reconstruction.17-20 Adjuncts for intraoperative skin flap perfusion
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monitoring such as ICG fluorescence angiography, has allowed for earlier assessment of vascular compromise and reduced the rates of postoperative mastectomy skin flap.21-24 The use of ADM for implant coverage can decrease the risks of overstretching of the lower pole, implant rippling and capsular contracture, which makes it a useful adjunct in immediate expander implant breast reconstruction.25-29 These techniques have provided some justification to reconsider the use subcutaneous tissue expander placement.30, 31
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The aim of this study was to compare subcutaneously versus submuscularly placed tissue expanders in the first stage of two-stage immediate breast reconstruction. Two-stage reconstruction was defined as immediate expander placement and later conversion to permanent implants or autologous tissue
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reconstruction. The potential benefits of subcutaneous tissue expander placement in the setting of immediate breast reconstruction include faster and greater tissue expander fill volumes, faster time to final expansion, less pain and less postoperative expansion visits. To our knowledge, this is the first
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study comparing the two approaches in the setting of immediate breast reconstruction.
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Methods
A retrospective chart review was performed on all patients who underwent mastectomy and immediate two-stage breast reconstruction between May 2012 and October 2014 by two senior authors (M.S.C and N.V.T). Patients who underwent two-stage immediate breast reconstruction and had finished the
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expansion were included in this study. Expander placement was performed with the same decisionmaking algorithm (Figure 1) and surgical technique. A standardized postoperative care protocol was applied to all patients. This study was approved by the Institutional Review Board (IRB), Mayo Clinic,
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Rochester, MN.
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The primary outcomes of interest were expansion ratios, which were calculated by dividing the saline volume within the expander by the expander size at three time points: intraoperative, first postoperative expansion visit, and when the total expansion volume was reached. Secondary outcomes included the duration to reach total expansion volume, postoperative pain, and complications during the expansion process. Pain scores were measured with visual analogue scale and an average pain score was calculated in 24 hours. Complications were tracked within two time periods: during expansion (from the day of expander insertion to the day of expander removal and second-stage reconstruction) and 6
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after second-stage autologous flap reconstruction (from the day of second-stage reconstruction to the day of last clinical follow-up). Complication after implant reconstruction was not performed due to the short follow-up. Complications were characterized as minor or major depending on clinical severity and
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treatment required (Table 1). Major complications included those that lead to reoperation, rehospitalization or expander removal. Minor complications included minor infections, necrosis, and delayed wound healing.32 Number of expansion visits, duration of expansion and pain were analyzed per
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patients; all the other variables were analyzed per expanders.
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Intraoperative Decision-Making Algorithm
Figure1 shows the expander insertion plane choosing algorithm for immediate breast reconstruction. This algorithm also demonstrated our selection process for using ADM (AlloDerm, LifeCell Corp., Bridgewater, NJ) in combination with the tissue expanders. For active smokers (current smoker or those
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who stopped smoking less than 4 weeks), the submuscular plane was chosen. For former smokers (those who stopped smoking more than 4 weeks) and nonsmokers, the viability of the mastectomy skin flap was clinically accessed first. Good viability was defined as normal skin color, active bleeding at the fresh
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cut edges and thicker than 1 cm in the mastectomy flaps. Laser assisted indocyanine green angiograph (SPY® Elite System, Novadaq Inc., Bonita Springs, FL) was used as an adjuvant when performing the
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clinical assessment. If the viability of mastectomy skin flap was assessed as good, the subcutaneous plane was chosen, otherwise, the submuscular plane was chosen.
Factors that influenced the combined use of tissue expander and ADM included the planned final reconstruction, the expander insertion plane and the soft tissue coverage. In cases where an autologous flap reconstruction was planned, no ADM was used in either group. Wise pattern incision and inferior dermal flap were performed on larger breasts for additional soft tissue coverage in both subcutaneous 7
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and submuscular group. For subcutaneous expanders and aimed implant reconstruction, the lower pole of the expander was covered with an ADM sling to avoid the over stretching of the skin envelope, only if there was no inferior dermal flap. For submuscular expanders and aimed implant reconstruction, an
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ADM sling was used in circumstances where the lower pole coverage of the expander could not be
fascial flap.33,34
Surgical Technique and Post-Operative Care
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provided by an inferior dermal flap, adipofascial extension of the pectoralis muscle, or a lateral serratus
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All of the expanders used in this series were Natrelle-133 MV or MX (Allergan Corp., Irvine, CA). Any areas of poor perfusion in the mastectomy flap were excised; otherwise a 2 mm margin from the wound edge was routinely excised. The wound was closed in double layers with 3-0 and 4-0 Monocryl. Two Jackson-Pratt drains were placed sub-cutaneously in each breast and removed when the output was less
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than 30ml in 24 hours for two consecutive days (Figure 2). Intraoperative expansion volume was determined by both the viability of mastectomy skin flaps and the resulting wound closing tension. (Video 1 demonstrates the subcutaneous tissue expander placement without ADM or inferior dermal
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flap and Video 2 demonstrates the subcutaneous tissue expander placement with the inferior dermal flap). All patients received perioperative intravenous antibiotics that continued for 24 hours, then oral
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antibiotics until drain removal.
The first postoperative expansion was scheduled two weeks following discharge and expansion was started if the wound was well healed. Subsequent weekly expansions were planned and adjusted according to the patient reported level of discomfort and the breast skin laxity. Completion of expansion was judged by the two senior surgeons.
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Statistical Analysis We compared the baseline characteristics (patient demographics, comorbidities and operative information) between two groups using chi-squared test for dichotomized variables and nonparametric
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Wilcoxon rank-sum test for continuous variables. We also compared outcomes of interest between two groups using Wilcoxon rank-sum test. A subgroup analysis was also conducted for patients who received postoperative radiation therapy. Multiple linear regression models were constructed for the primary
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outcomes after adjusting for postoperative radiation and use of ADM. A two-tailed p-value<0.05 was considered statistically significant. All statistical analyses were conducted using STATA version 13.1
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(StataCorp, College Station, TX).
Results
Eighty-eight patients (158 expanders) were included, of which 29 patients (50 expanders) were
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subcutaneous and 59 patients (108 expanders) were submuscular. Patient demographics, comorbidities and operative information are summarized in Table 2. There were no statistical differences between the two groups in terms of age, body mass index (BMI), smokers, comorbidities, ASA score, preoperative or
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postoperative chemo-radiation therapy, mastectomy weight, mastectomy method and axillary lymph node dissection. ADM was used in 15 (30.00%) subcutaneous expanders and 50 (46.00%) submuscular
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expanders (p=0.05).
Comparison of expansion process and pain were detailed in Table 3. There was no statistical difference in the expander size between the two groups (p=0.19). Subcutaneous expanders had a higher intraoperative fill volume compared to the submuscular expanders (Mean=223.40(186.47) ml versus 101.22(161.15) ml respectively; p<0.001) and achieved a higher intraoperative fill ratio (0.40(0.33) versus 0.17(0.28); p<0.001). Expander volume after the first postoperative expansion was significantly 9
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higher in the subcutaneous group compared to the submuscular group (Mean(SD), 340.20(199.75) ml versus 195.20(155.02); p<0.001), as well as a higher first postoperative expansion fill ratio (Mean(SD), 0.60(0.32) versus 0.34(0.26); p<0.001). Patients in the subcutaneous group had less expansion visits than
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patients in the submuscular group (Mean(SD), 3.0(1.9) versus 4.3(2.1); p=0.002) and a shorter duration of expansion (Mean(SD), 79(90) days versus 90(127) days; p=0.02). Total expansion volume and total expansion ratio were comparable between the two groups. In multiple linear regression models,
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adjusting for ADM and postoperative radiation, subcutaneous expanders had a higher intraoperative expansion ratio and first postoperative expansion ratio (p<0.001) (Table 4). Patients with subcutaneous
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tissue expanders experienced lower average pain scores compared to submuscular tissue expanders during their admission (Mean(SD), 3.15(1.57) versus 4.05(0.95) respectively; p=0.004), but pain at discharge and at the first clinic visit were similar between the two groups.
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A summary of complications is listed in Table 5. The overall complications during the expansion process were comparable between subcutaneous and submuscular group (P=0.92). There were 3 cases of major infections which led to 6 expander removals (the contralateral expander was removed in all 3 cases) in
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the submuscular group. Two cases of major necrosis (1.85%) and 11 cases of minor necrosis (10.1%) occurred in the submuscular group, while only 2 minor necrosis (2.00%) occurred in the subcutaneous
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group. The overall seroma rate in the subcutaneous group (n=5, 10%) was higher than that in the submuscular group (n=2, 2.8%).
In terms of second-stage reconstruction, 28 breasts were reconstructed with implants and 23 breasts with autologous flaps (22 DIEP and 1 ms-TRAM) in the subcutaneous group. In the submuscular group, 65 breasts were reconstructed with implants and 39 breasts with autologous flaps (32 DIEP, 1 ms-TRAM, 2 LD, 2 PAP, and 2 TUG). Depending on thickness of the capsule, a capsulotomy or capsulectomy was 10
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routinely performed before autologous reconstruction in order to minimize tension over the flap. Four breasts in the subcutaneous group did not complete the second-stage reconstruction due to infection and expander removal. Complications after second-stage breast reconstruction with autologous flap
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were tracked. The follow-up time ranged from 2 to 34 months, with an average of 17.3 months. The total complications rates were comparable between the two groups (P=0.98). No major mastectomy
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skin necrosis occurred, with only 1 case of minor necrosis in each group.
Seventeen expanders in the subcutaneous group and 25 expanders in the submuscular group had
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postoperative radiation therapy (Table 6). Subgroup analysis of these expanders confirmed a higher intraoperative expansion ratio (Mean(SD), 0.44(0.34) versus 0.16(0.33); p=0.005) and a higher first postoperative expansion ratio (Mean(SD), 0.63(0.35) versus 0.37(0.28); p=0.01), however, there was no difference in number of expansion visits (Mean(SD), 3.40(2.72) verus 4.62(2.33); p=0.15) and duration of
Discussion
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expansion (Mean(SD), 111.00(97.20) days verus 115.92(186.88) days; p=0.76) between the two groups.
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The use of subcutaneous tissue expander placement in immediate breast reconstruction has been limited due to the concerns that the soft tissue coverage may be exacerbated when the mastectomy
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skin flaps have poor vascularity. However, in 2012, Engel et al30 reported the technique of subcutaneous tissue expansion and subsequent submuscular implant insertion for both immediate and delayed breast reconstruction. The results showed that subcutaneous tissue expansion was feasible in low body mass index (<29), nonsmoking, non-radiated patients with small and projective breasts, with an expansion complication rate of 8.6%. More recently, Reitsamer et al31 reported 22 cases of immediate direct-toimplant breast reconstruction utilizing completely porcine covered ADM and subcutaneous implants after nipple-sparing mastectomy. Two breasts received postoperative radiotherapy. No infection, 11
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implant dislocation, grade III and IV capsular contracture was observed during a mean follow-up period of 6 months.
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We developed the expander insertion plane choosing algorithm in an effort to lower complication rates in subcutaneous expander placement. Our study demonstrated that the subcutaneous placement could be performed safely in the selected patients, with no increased complication rates during expansion, compared to the submuscular placement. Subcutaneous expander placement results in faster
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postoperative filling with fewer clinic visits and less pain. This can be automatically translated into decreased costs, less time constrains for the patients and improved acceptance in the overall treatment
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plan. The greater early expansion volume and faster expansion process of subcutaneous expander placement offer the benefits of mastectomy skin preservation. This decreases the final skin requirements for the breast reconstruction and better overall cosmesis, especially following the mastectomy skin retraction and fibrosis. The subcutaneous expander placement allows the ability to
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position an expander more medially, which improves the medial cleavage and helps to better define the medial footprint of the breast (Figure 3,4). In terms of second-stage autologous reconstruction, it avoids the necessary detachment of the pectoralis major muscle from the overlying mastectomy skin flap,
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which means less bleeding and shorter operative time. (Figure 3C).
This cohort of patients with subcutaneous placement included those with variable body habitus (BMI ranged from 21.1 to 39.9) and breast volumes (mastectomy weight ranged from 102g to 1235g), as well as patients with pre or postoperative radiation. The two key points in deciding the plane of expander implant placement was smoking status and mastectomy flap perfusion. Smoking has long been implicated as a risk factor for complications in tissue expander–based reconstruction，with increased risk of complications, especially mastectomy flap necrosis.35-40 For active smokers, only the submuscular 12
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plane was used in this case series, which was coincident with the previous report.30 Although all of our cases were either skin- or nipple-sparing mastectomy, simply preserving the skin at the time of the mastectomy does not guarantee adequate perfusion of the skin. We recommended the careful
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attention be given to the evaluation of mastectomy skin flap perfusion prior to reconstruction. Clinical evaluation is critical as assessing mastectomy skin flap perfusion and can be combined with adjunct measures, such as ICG angiography. Even in the absence of poor mastectomy flap perfusion, we
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routinely excised 2mm margin along the mastectomy edges. Intraoperative over expansion was avoided
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in order to prevent undue pressure over the mastectomy flaps.41
The subgroup analysis of subcutaneous versus submuscular placed expanders in the context of postoperative radiation therapy confirmed a higher intraoperative and first postoperative expansion ratio without increased complication rates. There were no significant differences in number of
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expansion visits and duration of expansion between these two groups. Although in the setting of postoperative radiation therapy, subcutaneous tissue expander placement could not offer a faster expansion, it still has its unique benefits: The higher early expansion ratio (intraoperative and first
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postoperative expansion radio) allowed for early and better preservation of the skin envelope.
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In this study, we are hoping to reintroduce the concept of using a strict selection algorithm for choosing subcutaneous versus submuscular expander placement. The potential benefits, limitations and solutions of these two types of expander insertion planes are summarized in Table 7.
Limitations of this study include the following: This was a retrospective chart review with limited size of the cohort. However we presented our early experience of two senior plastic surgeons who shared similar operative technique and decision-making process. A larger multi-center prospective trial would 13
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provide better evidence to support our conclusions. The follow-up period of this study was limited to the first stage of the two staged breast reconstruction only. We are currently prospectively collecting
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data on the second stage reconstruction for this patient population.
Conclusion
The use of subcutaneous expander placement in immediate two stage breast reconstruction can be
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carried out safely in selected patients, with no increased complication rates compared to submuscularly placed expanders. Subcutaneous expander placement can provide faster expansion, faster final volume
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fill, less clinical visits, and overall decreased postoperative pain. This technique should be considered as a new strategy for the first stage of two-stage based immediate breast reconstruction, especially when a second-stage autologous flap reconstruction is anticipated.
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Acknowledgement
The authors are very grateful to the China Scholarship Council for the financial support of Dr. Lin Zhu as a research fellow and the Blond Royal College of Surgeons of England Research Fellowship 2015 for the
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financial support of Dr. Anita Mohan as a research fellow.
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29. Kim JY, Davila AA, Persing S, et al. A meta-analysis of human acellular dermis and submuscular tissue expander breast reconstruction. Plast Reconstr Surg. 2012; 129: 28-41.
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32. Miller ME, Czechura T, Martz B, et al. Operative risks associated with contralateral prophylactic mastectomy: a single institution experience. Ann Surg Oncol. 2013; 20: 4113-4120.
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33. Saint-Cyr M, Nagarkar P, Wong C, Thakar H, Dauwe P, Rohrich RJ. The pedicled subpectoral fascia flap for expander coverage in postmastectomy breast reconstruction: a novel technique. Plast Reconstr Surg. 2010; 125: 1328-1334.
34. Saint-Cyr M, Dauwe P, Wong C, Thakar H, Nagarkar P, Rohrich RJ. Use of the serratus anterior fascia
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flap for expander coverage in breast reconstruction. Plast Reconstr Surg. 2010; 125: 1057-1064. 35. Goodwin SJ, McCarthy CM, Pusic AL, et al. Complications in smokers after postmastectomy tissue expander/implant breast reconstruction. Ann Plast Surg. 2005; 55: 16-19; discussion 19-20.
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36. Chang DW, Reece GP, Wang B, et al. Effect of smoking on complications in patients undergoing free TRAM flap breast reconstruction. Plast Reconstr Surg. 2000; 105: 2374-2380.
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37. Padubidri AN, Yetman R, Browne E, et al. Complications of postmastectomy breast reconstructions in smokers, ex-smokers, and nonsmokers. Plast Reconstr Surg. 2001; 107: 342-349. 38. Pluvy I, Garrido I, Pauchot J, et al. Smoking and plastic surgery, part I. Pathophysiological aspects: Update and proposed recommendations. Ann Chir Plast Esthet. 2015; 60: e3-e13. 39. Pluvy I, Panouilleres M, Garrido I, et al. Smoking and plastic surgery, part II. Clinical implications: A systematic review with meta-analysis. Ann Chir Plast Esthet. 2015; 60: e15-49.
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40. Hage JJ, van der Heeden JF, Lankhorst KM, et al. Impact of combined skin sparing mastectomy and immediate subpectoral prosthetic reconstruction on the pectoralis major muscle function: a preoperative and postoperative comparative study. Ann Plast Surg. 2014; 72: 631-637.
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41. Newman MI, Swartz KA, Samson MC, Mahoney CB, Diab K. The true incidence of near-term postoperative complications in prosthetic breast reconstruction utilizing human acellular dermal
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matrices: a meta-analysis. Aesthetic Plast Surg. 2011; 35: 100-106.
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Table Legends Table 1: Definition of complications.
and submuscular tissue expander placed groups.
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Table 2: Patient demographics and procedure details, with no differences between the subcutaneous
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Table 3: Comparison of the expansion process and pain scores of the subcutaneous and submuscular
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groups.
Table 4: Multiple linear regression models of expansion process adjusted for ADM and post operation radiation therapy.
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Table 5: Complications during expansion and after breast reconstruction with autologous flaps. ⃰ Only complications of the breast included, complications of donor sites were excluded in this table.
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radiation therapy.
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Table 6: Subgroup analysis of comparison of expansion process in expanders which had postoperative
Table 7: Comparison of the benefits, limitations and solutions of the subcutaneous and submuscular tissue expander placement. * IMF, inframammary fold; §, ADM, acellular dermal matrix; #, PMM, pectoralis major muscle; ǂ, MSF, mastectomy skin flap.
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Figure Legends Figure 1: Decision-making algorithm of expander insertion plane and ADM usage. *ADM may be applied
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with the expander insertion or with the implant exchange.
Figure 2: Intraoperative views of subcutaneous expander placement. (A) The expander was inserted into the subcutaneous envelope. (B) View of wound closure and intraoperative expansion (intraoperative fill:
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300ml, expander size: 600ml).
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Figure 3: A 39-year-old woman who presented with left breast cancer and underwent left skin-sparing mastectomy, left axillary node dissection and immediate breast reconstruction with a subcutaneous placed tissue expander. The left breast underwent radiation without expander deflation. Six months following radiation, the left breast was reconstructed with a DIEP flap. Mastopexy was performed on the
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right side for symmetry. (A) Preoperative view. (B) 6 month following radiation (Total expansion: 590ml). (C) Intraoperative view showed easy and fasting anatomy of internal mammary vessels with no need of deflating the pectoralis major muscle as the submuscular placement. (D) Postoperative view showed the
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symmetric contour of bilateral breasts.
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Figure 4: A 64-year-old woman who presented with a history of right breast wide local excision consistent with lobular carcinoma in situ and left breast conserving therapy for DCIS with no evidence of recurrence. The patient underwent bilateral risk reduction nipple sparing mastectomy and immediate breast reconstruction with subcutaneously placed tissue expanders. (A) Preoperative view. (B) 6 months following bilateral capsulotomy, implant (Natrelle 410FF, 740ml) exchange and simultaneous fat grafting (right: 110 ml, left: 130 ml).
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Video Legends Video 1: Subcutaneous placement of tissue expander during immediate breast reconstruction.
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Video 2: Subcutaneous placement of tissue expander with the inferior dermal flap during immediate
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breast reconstruction.
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Table 1. Definition of Complications Minor
Infection
Culture proven; Intravenous antibiotics required; Surgical intervention required; Lead to expander removal
Clinical diagnosed; Oral antibiotics required;
Mastectomy skin necrosis
Full thickness skin necrosis; Full thickness wound edge necrosis; Surgical intervention required; Lead to expander removal
Split thickness skin necrosis; Split thickness wound edge necrosis; Superficial wound edge necrosis; Dress changing required
Seroma
Drainage or aspiration required
No intervention required
Fat necrosis
Surgical excision required
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Surgical aspirate required
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Table 2. Demographic and Procedure Details of Subcutaneous and Submuscular Groups
Age, year 2
BMI, Kg/m
Comorbidities Hypertension Diabetes Coronary artery disease Active smoker Preoperative chemotherapy
50
108
50.48 (8.83)
52.69 (12.18)
0.45
27.77 (5.35)
27.54 (6.55)
0.56
3(10.34%) 0(0%) 0(0%)
13 (22.03%) 2(3.40%) 3(5.08%)
0.18
0 (0%)
4 (6.78%)
0.10
14(23.73%)
0.17
16(14.81%)
0.23
11 (37.93%)
P value
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No. of expanders
Submuscular (SD) 59
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No. of patients
Subcutaneous (SD) 29
4 (8.00%)
Postoperative radiation
17 (34.00%)
25 (23.15%)
0.15
4(13.79%)
10 (16.95%)
0.18
29(58.00) 21(42.00)
71 (65.74%) 37 (34.26%)
479.87 (286.95)
477.21 (282.65)
Axillary lymph node dissection No Yes
5 (17.24%) 24 (82.76%)
7 (12.07%) 51 (87.93%)
ADM*
15 (30.00%)
50 (46.30%)
0.05
3 (6.00%)
18 (14.81%)
0.19
3(10.34%) 25(86.21%) 1(3.45%)
6 (10.17%) 50 (85.23%) 3 (5.08%)
Postoperative chemotherapy Mastectomy type Skin-sparing Nipple-sparing
Inferior dermal flap
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ASA§ grade I II III
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Mastectomy weight, g
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Preoperative radiation
0.99 0.51
0.94
*ADM, acellular dermal matrix; §ASA, American Society of Anesthesiology.
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0.35
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Table 3. Comparison of Expansion Process and Pain of Subcutaneous and Submuscular Groups
Expander size, ml
555.00 (136.74)
587.50 (151.49)
0.19
Intraoperative expansion, ml
223.40 (186.47)
101.22 (161.15)
<0.001
Intraoperative expansion ratio
0.40 (0.33)
0.17 (0.28)
<0.001
First postoperative expansion, ml
340.20 (199.75)
195.20 (155.02)
<0.001
First postoperative expansion ratio
0.60 (0.32)
0.34 (0.26)
<0.001
Total expansion ratio
0.86 (0.24)
Number of expansion visits
3.00 (1.90)
Duration of expansion, day
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470.20 (146.81)
521.52 (165.88)
0.07
0.89 (0.20)
0.29
4.31 (2.12)
0.002
79.38 (90.36)
90.36 (127.03)
0.02
3.15 (1.57) 3.14 (1.66)
4.05 (0.95) 3.80 (1.53)
0.004 0.06
2.31 (1.85)
2.59 (1.79)
0.38
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Total expansion, ml
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Submuscular(SD) (n=102*) 56
P value
Number of patients
Subcutaneous (SD) (n=50*) 29
Pain Score Average pain during admission Pain at discharge
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Pain at first clinic visit
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Table 4. Multiple Linear Regression Models of Expansion Process Adjusted for ADM and Postoperative Radiation Therapy 95% LCI
HCI
P value
Intraoperative expansion ratio
.27
.18
.37
<0.001
First postoperative expansion ratio
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.21
.39
<0.001
Total expansion ratio
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Coeff
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Outcome
0.48
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Table 5. Complications during Expansion and after Reconstruction with Autologous Flaps Variable
Subcutaneous (%)
Submuscular (%)
Complications during Expansion
n=50
n=108
Any complications Total major complications Infection Mastectomy skin necrosis Seroma Total minor complications Infection Mastectomy skin necrosis Seroma
8 1 0 0 1 7 1 2 4
18 6 3 2 1 12 0 11 1
Complications after Reconstruction Flaps⃰
n=23
Any complications Total major complications Infection Mastectomy skin necrosis
4 1 0 1
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0.92
n=39
6 2 0 2
0.98
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Total minor complications Infection Mastectomy skin necrosis Fat necrosis
P value
3 1 0 1
4 1 1 2
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⃰ Only complications of the breast included, complications of donor sites were excluded in this table.
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Table 6. Comparison of Expansion Process in Expanders with Postoperative Radiation Therapy
Expander size, ml
579.59 (114.64)
584.00 (164.39)
0.90
Intraoperative expansion, ml
261.18 (204.32)
101.6 (197.75)
0.006
Intraoperative expansion ratio
0.44 (0.34)
0.16 (0.33)
0.005
First postoperative expansion, ml
374.71 (229.51)
228.80 (189.02)
0.03
First postoperative expansion ratio
0.63 (0.35)
0.37 (0.28)
0.01
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Submuscular(SD) (n=25) 13
P value
Number of patients
Subcutaneous (SD) (n=17) 10
526.47 (115.94)
531.20 (165.79)
0.88
Total expansion ratio
0.94 (0.25)
0.92 (0.21)
0.89
Number of expansion visits
3.40 (2.72)
4.62 (2.33)
0.15
Duration of expansion, day
111.00 (97.20)
115.92 (186.88)
0.76
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Total expansion, ml
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Table 7. Comparison of the Potential Benefits, Tradeoffs and Resolving Methods of Subcutaneous and Submuscular Expander Placement Pocket
Potential Benefits
Tradeoffs
Resolving methods
Subcutaneous
1. Faster expansion, less expansion visit and less pain. 2. Less procedure duration and more rapid postoperative recovery.
1. Increased risk of implant edge visibility or palpability. 2. Possible increased risk of expander extrusion in the setting of compromised wound healing
Multiple fat grafting
3. No distortion with pectoralis contraction. 4. More natural breast shape.
3. Possible over stretching of the ski of lower pole. 4. Possible increased incidence of capsular contracture.
1. Less risk of palpable or visible implant edges on lower pole. 2. Possible decreased risk of capsular contracture. 3. Offer extra expander coverage in the setting of compromised wound healing
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1. Slower expansion, more expansion visit and more pain.
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Submuscular
Add ADM§ on the lower pole Add ADM and fat grafting
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5. Increased control of IMF* position.
Strictly following patient selection criterion, avoid over intraoperative expansion
2. Increased risk of superior implant malposition or displacement.
3. Less precise control of IMF fold and upper medial fill.
2. Add ADM or autologous fascial coverage.
Inherent problems
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4. More procedure time and prolonged recovery. 5. Lateral implant displacement over time, widening the space between the breasts.
1. Release PMM# along its inferior aspect extending toward the inferomedial border.
6. Distortion of breast shape with pectoralis contraction. 7. Need to be released from from MSFǂ during autologous flap reconstruction.
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*IMF, inframammary fold; §ADM, acellular dermal matrix; #PMM, pectoralis major muscle; ǂMSF, mastectomy skin flap.
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S1748-6815(16)00018-8
DOI:
10.1016/j.bjps.2016.01.006
Reference:
PRAS 4881
To appear in:
Journal of Plastic, Reconstructive & Aesthetic Surgery
Received Date: 22 July 2015 Accepted Date: 6 January 2016
Please cite this article as: Zhu L, Mohan A, Abdelsattar JM, Wang Z, Vijayasekaran A, Hwang M, Tran NV, Saint-Cyr M, Comparison of Subcutaneous versus Submuscular Expander Placement in the First Stage of Immediate Breast Reconstruction, British Journal of Plastic Surgery (2016), doi: 10.1016/ j.bjps.2016.01.006. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Title: Comparison of Subcutaneous versus Submuscular Expander Placement in the First Stage of Immediate
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Breast Reconstruction
Authors: Lin Zhu1,2, MD
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Anita Mohan2,3, MRCS, MBBS, BSc Jad M. Abdelsattar2, MBBS
Aparna Vijayasekaran2, MBBS Michelle Hwang2, MBBS Nho V. Tran2, MD
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Michel Saint-Cyr2, MD, FRCS (C)
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Zhen Wang4,5, PhD
Affiliations:
Department of Plastic Surgery, Peking Union Medical College Hospital, Beijing, China
2
Department of Plastic Surgery, Mayo Clinic, Rochester MN, USA
3
Restoration of Appearance and Function charitable Trust (RAFT), UK
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4 Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester MN, USA 5 Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester MN, USA
Meeting presentation: No 1
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Correspondence: Michel Saint-Cyr
Wigley Professorship in Plastic Surgery
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Director, Division of Plastic Surgery
Email: [email protected]; Tel: Office: 254-724-7017; Clinic: 254-724-2321; Fax: 254-724-0315
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Statements for Conflict of Interest, Funding and Ethical Approval Funding: None
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Conflicts of interest: Dr. Michel Saint-Cyr is a consultant for Pacira. All the other authors have no conflict of interest.
Ethical approval: This study was approved by the Institutional Review Board (IRB), Mayo Clinic,
Abbreviations: The latissimus dorsi flap: LD
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Rochester, MN (15-004601).
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The deep inferior epigastric perforator flap: DIEP
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The muscle sparing-transverse rectus abdominal myocutaneous flap: ms-TRAM The transverse upper gracilis flap: TUG The profunda artery perforator flap: PAP
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Comparison of Subcutaneous versus Submuscular Expander Placement in the First Stage of Immediate Breast Reconstruction
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Summary Background Tissue expander based two-stage reconstruction remains the most commonly used technique in immediate breast reconstruction. This study compares the subcutaneous expander
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placement to the traditional submuscular placement and describes our early experience with the expander insertion plane choosing algorithm. Methods A retrospective study of patients who
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underwent two-stage immediate breast reconstruction from May 2012 to October 2014 was performed. All expander insertion plane choosing was performed with the same algorithm. Expansion, pain and complications were compared between two groups. Results 88 patients (158 expanders) were included (50 subcutaneous and 108 submuscular). The subcutaneous group had a higher intraoperative expansion radio (p<0.001), high first postoperative expansion radio (p<0.001), shorter duration of
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expansion (p=0.02), less number of expansion visits (p=0.002), and less average pain during admission (p=0.004). Significant differences in intraoperative and first postoperative expansion ratios in patients with postmastectomy radiation therapy were also found between the two groups (p=0.005 and 0.01,
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respectively). Complications during expansion and after second-stage autologous flap reconstruction
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were comparable between two groups. Conclusion The subcutaneous expander placement was associated with greater intraoperative and first postoperative expansion, shorter expansion duration, less expansion visits and less pain. With the expander insertion plane choosing algorithm, the subcutaneous expander placement could be performed with comparable complications rates with the submuscular placement during expansion and after second-stage autologous flap reconstruction. With the lack of long-term complications following second-stage implant reconstruction on the subcutaneous approach, additional studies are needed. 3
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Keywords subcutaneous tissue expansion; submuscular tissue expansion; two-stage immediate breast
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reconstruction; tissue expander; breast reconstruction outcome
Level of Evidence
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III
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Introduction Breast reconstruction using the subcutaneous plane was first described by Snyderman in the 1970s.1 This procedure, however, was fraught with a high incidence of complications, including mastectomy skin
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flap necrosis, implant extrusion and capsular contracture.2,5 These problems led to the introduction of the submuscular plane, which has remained the most commonly used technique in two-stage postmastectomy breast reconstruction.3,6-14 The pectoralis major muscle provides a cushion with
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overlying healthy tissue, eliminating the problems of compromised wound healing, implant extrusion, rippling, and capsular contracture. However, there are some inherent limitations associated with
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submuscular tissue expander placement, such as pain or discomfort, limited expansion, expander dislocation and breast animation.10,15,16 If an autologous tissue breast reconstruction is anticipated, expander removal and pectoralis major muscle detachment from the overlying mastectomy skin flap is required during the autologous reconstruction8,9, therefore decreasing the overall benefit of the
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submuscular placement.
Over the past decade, mastectomy and breast reconstruction have witnessed significant innovations.
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Recent trends favoring nipple and skin sparing mastectomy have allowed for a better preserved skin envelope available for breast reconstruction.17-20 Adjuncts for intraoperative skin flap perfusion
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monitoring such as ICG fluorescence angiography, has allowed for earlier assessment of vascular compromise and reduced the rates of postoperative mastectomy skin flap.21-24 The use of ADM for implant coverage can decrease the risks of overstretching of the lower pole, implant rippling and capsular contracture, which makes it a useful adjunct in immediate expander implant breast reconstruction.25-29 These techniques have provided some justification to reconsider the use subcutaneous tissue expander placement.30, 31
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The aim of this study was to compare subcutaneously versus submuscularly placed tissue expanders in the first stage of two-stage immediate breast reconstruction. Two-stage reconstruction was defined as immediate expander placement and later conversion to permanent implants or autologous tissue
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reconstruction. The potential benefits of subcutaneous tissue expander placement in the setting of immediate breast reconstruction include faster and greater tissue expander fill volumes, faster time to final expansion, less pain and less postoperative expansion visits. To our knowledge, this is the first
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study comparing the two approaches in the setting of immediate breast reconstruction.
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Methods
A retrospective chart review was performed on all patients who underwent mastectomy and immediate two-stage breast reconstruction between May 2012 and October 2014 by two senior authors (M.S.C and N.V.T). Patients who underwent two-stage immediate breast reconstruction and had finished the
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expansion were included in this study. Expander placement was performed with the same decisionmaking algorithm (Figure 1) and surgical technique. A standardized postoperative care protocol was applied to all patients. This study was approved by the Institutional Review Board (IRB), Mayo Clinic,
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Rochester, MN.
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The primary outcomes of interest were expansion ratios, which were calculated by dividing the saline volume within the expander by the expander size at three time points: intraoperative, first postoperative expansion visit, and when the total expansion volume was reached. Secondary outcomes included the duration to reach total expansion volume, postoperative pain, and complications during the expansion process. Pain scores were measured with visual analogue scale and an average pain score was calculated in 24 hours. Complications were tracked within two time periods: during expansion (from the day of expander insertion to the day of expander removal and second-stage reconstruction) and 6
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after second-stage autologous flap reconstruction (from the day of second-stage reconstruction to the day of last clinical follow-up). Complication after implant reconstruction was not performed due to the short follow-up. Complications were characterized as minor or major depending on clinical severity and
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treatment required (Table 1). Major complications included those that lead to reoperation, rehospitalization or expander removal. Minor complications included minor infections, necrosis, and delayed wound healing.32 Number of expansion visits, duration of expansion and pain were analyzed per
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patients; all the other variables were analyzed per expanders.
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Intraoperative Decision-Making Algorithm
Figure1 shows the expander insertion plane choosing algorithm for immediate breast reconstruction. This algorithm also demonstrated our selection process for using ADM (AlloDerm, LifeCell Corp., Bridgewater, NJ) in combination with the tissue expanders. For active smokers (current smoker or those
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who stopped smoking less than 4 weeks), the submuscular plane was chosen. For former smokers (those who stopped smoking more than 4 weeks) and nonsmokers, the viability of the mastectomy skin flap was clinically accessed first. Good viability was defined as normal skin color, active bleeding at the fresh
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cut edges and thicker than 1 cm in the mastectomy flaps. Laser assisted indocyanine green angiograph (SPY® Elite System, Novadaq Inc., Bonita Springs, FL) was used as an adjuvant when performing the
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clinical assessment. If the viability of mastectomy skin flap was assessed as good, the subcutaneous plane was chosen, otherwise, the submuscular plane was chosen.
Factors that influenced the combined use of tissue expander and ADM included the planned final reconstruction, the expander insertion plane and the soft tissue coverage. In cases where an autologous flap reconstruction was planned, no ADM was used in either group. Wise pattern incision and inferior dermal flap were performed on larger breasts for additional soft tissue coverage in both subcutaneous 7
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and submuscular group. For subcutaneous expanders and aimed implant reconstruction, the lower pole of the expander was covered with an ADM sling to avoid the over stretching of the skin envelope, only if there was no inferior dermal flap. For submuscular expanders and aimed implant reconstruction, an
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ADM sling was used in circumstances where the lower pole coverage of the expander could not be
fascial flap.33,34
Surgical Technique and Post-Operative Care
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provided by an inferior dermal flap, adipofascial extension of the pectoralis muscle, or a lateral serratus
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All of the expanders used in this series were Natrelle-133 MV or MX (Allergan Corp., Irvine, CA). Any areas of poor perfusion in the mastectomy flap were excised; otherwise a 2 mm margin from the wound edge was routinely excised. The wound was closed in double layers with 3-0 and 4-0 Monocryl. Two Jackson-Pratt drains were placed sub-cutaneously in each breast and removed when the output was less
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than 30ml in 24 hours for two consecutive days (Figure 2). Intraoperative expansion volume was determined by both the viability of mastectomy skin flaps and the resulting wound closing tension. (Video 1 demonstrates the subcutaneous tissue expander placement without ADM or inferior dermal
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flap and Video 2 demonstrates the subcutaneous tissue expander placement with the inferior dermal flap). All patients received perioperative intravenous antibiotics that continued for 24 hours, then oral
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antibiotics until drain removal.
The first postoperative expansion was scheduled two weeks following discharge and expansion was started if the wound was well healed. Subsequent weekly expansions were planned and adjusted according to the patient reported level of discomfort and the breast skin laxity. Completion of expansion was judged by the two senior surgeons.
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Statistical Analysis We compared the baseline characteristics (patient demographics, comorbidities and operative information) between two groups using chi-squared test for dichotomized variables and nonparametric
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Wilcoxon rank-sum test for continuous variables. We also compared outcomes of interest between two groups using Wilcoxon rank-sum test. A subgroup analysis was also conducted for patients who received postoperative radiation therapy. Multiple linear regression models were constructed for the primary
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outcomes after adjusting for postoperative radiation and use of ADM. A two-tailed p-value<0.05 was considered statistically significant. All statistical analyses were conducted using STATA version 13.1
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Results
Eighty-eight patients (158 expanders) were included, of which 29 patients (50 expanders) were
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subcutaneous and 59 patients (108 expanders) were submuscular. Patient demographics, comorbidities and operative information are summarized in Table 2. There were no statistical differences between the two groups in terms of age, body mass index (BMI), smokers, comorbidities, ASA score, preoperative or
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postoperative chemo-radiation therapy, mastectomy weight, mastectomy method and axillary lymph node dissection. ADM was used in 15 (30.00%) subcutaneous expanders and 50 (46.00%) submuscular
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expanders (p=0.05).
Comparison of expansion process and pain were detailed in Table 3. There was no statistical difference in the expander size between the two groups (p=0.19). Subcutaneous expanders had a higher intraoperative fill volume compared to the submuscular expanders (Mean=223.40(186.47) ml versus 101.22(161.15) ml respectively; p<0.001) and achieved a higher intraoperative fill ratio (0.40(0.33) versus 0.17(0.28); p<0.001). Expander volume after the first postoperative expansion was significantly 9
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higher in the subcutaneous group compared to the submuscular group (Mean(SD), 340.20(199.75) ml versus 195.20(155.02); p<0.001), as well as a higher first postoperative expansion fill ratio (Mean(SD), 0.60(0.32) versus 0.34(0.26); p<0.001). Patients in the subcutaneous group had less expansion visits than
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patients in the submuscular group (Mean(SD), 3.0(1.9) versus 4.3(2.1); p=0.002) and a shorter duration of expansion (Mean(SD), 79(90) days versus 90(127) days; p=0.02). Total expansion volume and total expansion ratio were comparable between the two groups. In multiple linear regression models,
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tissue expanders experienced lower average pain scores compared to submuscular tissue expanders during their admission (Mean(SD), 3.15(1.57) versus 4.05(0.95) respectively; p=0.004), but pain at discharge and at the first clinic visit were similar between the two groups.
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A summary of complications is listed in Table 5. The overall complications during the expansion process were comparable between subcutaneous and submuscular group (P=0.92). There were 3 cases of major infections which led to 6 expander removals (the contralateral expander was removed in all 3 cases) in
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the submuscular group. Two cases of major necrosis (1.85%) and 11 cases of minor necrosis (10.1%) occurred in the submuscular group, while only 2 minor necrosis (2.00%) occurred in the subcutaneous
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group. The overall seroma rate in the subcutaneous group (n=5, 10%) was higher than that in the submuscular group (n=2, 2.8%).
In terms of second-stage reconstruction, 28 breasts were reconstructed with implants and 23 breasts with autologous flaps (22 DIEP and 1 ms-TRAM) in the subcutaneous group. In the submuscular group, 65 breasts were reconstructed with implants and 39 breasts with autologous flaps (32 DIEP, 1 ms-TRAM, 2 LD, 2 PAP, and 2 TUG). Depending on thickness of the capsule, a capsulotomy or capsulectomy was 10
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routinely performed before autologous reconstruction in order to minimize tension over the flap. Four breasts in the subcutaneous group did not complete the second-stage reconstruction due to infection and expander removal. Complications after second-stage breast reconstruction with autologous flap
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were tracked. The follow-up time ranged from 2 to 34 months, with an average of 17.3 months. The total complications rates were comparable between the two groups (P=0.98). No major mastectomy
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skin necrosis occurred, with only 1 case of minor necrosis in each group.
Seventeen expanders in the subcutaneous group and 25 expanders in the submuscular group had
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postoperative radiation therapy (Table 6). Subgroup analysis of these expanders confirmed a higher intraoperative expansion ratio (Mean(SD), 0.44(0.34) versus 0.16(0.33); p=0.005) and a higher first postoperative expansion ratio (Mean(SD), 0.63(0.35) versus 0.37(0.28); p=0.01), however, there was no difference in number of expansion visits (Mean(SD), 3.40(2.72) verus 4.62(2.33); p=0.15) and duration of
Discussion
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expansion (Mean(SD), 111.00(97.20) days verus 115.92(186.88) days; p=0.76) between the two groups.
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The use of subcutaneous tissue expander placement in immediate breast reconstruction has been limited due to the concerns that the soft tissue coverage may be exacerbated when the mastectomy
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skin flaps have poor vascularity. However, in 2012, Engel et al30 reported the technique of subcutaneous tissue expansion and subsequent submuscular implant insertion for both immediate and delayed breast reconstruction. The results showed that subcutaneous tissue expansion was feasible in low body mass index (<29), nonsmoking, non-radiated patients with small and projective breasts, with an expansion complication rate of 8.6%. More recently, Reitsamer et al31 reported 22 cases of immediate direct-toimplant breast reconstruction utilizing completely porcine covered ADM and subcutaneous implants after nipple-sparing mastectomy. Two breasts received postoperative radiotherapy. No infection, 11
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implant dislocation, grade III and IV capsular contracture was observed during a mean follow-up period of 6 months.
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We developed the expander insertion plane choosing algorithm in an effort to lower complication rates in subcutaneous expander placement. Our study demonstrated that the subcutaneous placement could be performed safely in the selected patients, with no increased complication rates during expansion, compared to the submuscular placement. Subcutaneous expander placement results in faster
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postoperative filling with fewer clinic visits and less pain. This can be automatically translated into decreased costs, less time constrains for the patients and improved acceptance in the overall treatment
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plan. The greater early expansion volume and faster expansion process of subcutaneous expander placement offer the benefits of mastectomy skin preservation. This decreases the final skin requirements for the breast reconstruction and better overall cosmesis, especially following the mastectomy skin retraction and fibrosis. The subcutaneous expander placement allows the ability to
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position an expander more medially, which improves the medial cleavage and helps to better define the medial footprint of the breast (Figure 3,4). In terms of second-stage autologous reconstruction, it avoids the necessary detachment of the pectoralis major muscle from the overlying mastectomy skin flap,
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which means less bleeding and shorter operative time. (Figure 3C).
This cohort of patients with subcutaneous placement included those with variable body habitus (BMI ranged from 21.1 to 39.9) and breast volumes (mastectomy weight ranged from 102g to 1235g), as well as patients with pre or postoperative radiation. The two key points in deciding the plane of expander implant placement was smoking status and mastectomy flap perfusion. Smoking has long been implicated as a risk factor for complications in tissue expander–based reconstruction，with increased risk of complications, especially mastectomy flap necrosis.35-40 For active smokers, only the submuscular 12
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plane was used in this case series, which was coincident with the previous report.30 Although all of our cases were either skin- or nipple-sparing mastectomy, simply preserving the skin at the time of the mastectomy does not guarantee adequate perfusion of the skin. We recommended the careful
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attention be given to the evaluation of mastectomy skin flap perfusion prior to reconstruction. Clinical evaluation is critical as assessing mastectomy skin flap perfusion and can be combined with adjunct measures, such as ICG angiography. Even in the absence of poor mastectomy flap perfusion, we
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routinely excised 2mm margin along the mastectomy edges. Intraoperative over expansion was avoided
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in order to prevent undue pressure over the mastectomy flaps.41
The subgroup analysis of subcutaneous versus submuscular placed expanders in the context of postoperative radiation therapy confirmed a higher intraoperative and first postoperative expansion ratio without increased complication rates. There were no significant differences in number of
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expansion visits and duration of expansion between these two groups. Although in the setting of postoperative radiation therapy, subcutaneous tissue expander placement could not offer a faster expansion, it still has its unique benefits: The higher early expansion ratio (intraoperative and first
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postoperative expansion radio) allowed for early and better preservation of the skin envelope.
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In this study, we are hoping to reintroduce the concept of using a strict selection algorithm for choosing subcutaneous versus submuscular expander placement. The potential benefits, limitations and solutions of these two types of expander insertion planes are summarized in Table 7.
Limitations of this study include the following: This was a retrospective chart review with limited size of the cohort. However we presented our early experience of two senior plastic surgeons who shared similar operative technique and decision-making process. A larger multi-center prospective trial would 13
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provide better evidence to support our conclusions. The follow-up period of this study was limited to the first stage of the two staged breast reconstruction only. We are currently prospectively collecting
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data on the second stage reconstruction for this patient population.
Conclusion
The use of subcutaneous expander placement in immediate two stage breast reconstruction can be
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carried out safely in selected patients, with no increased complication rates compared to submuscularly placed expanders. Subcutaneous expander placement can provide faster expansion, faster final volume
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fill, less clinical visits, and overall decreased postoperative pain. This technique should be considered as a new strategy for the first stage of two-stage based immediate breast reconstruction, especially when a second-stage autologous flap reconstruction is anticipated.
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Acknowledgement
The authors are very grateful to the China Scholarship Council for the financial support of Dr. Lin Zhu as a research fellow and the Blond Royal College of Surgeons of England Research Fellowship 2015 for the
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financial support of Dr. Anita Mohan as a research fellow.
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2. Radovan C. Breast reconstruction after mastectomy using the temporary expander. Plast Reconstr Surg. 1982; 69: 195-208.
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4. Lapin R, Elliott M, Juri H. The Use of an Integral Tissue Expander for Primary Breast Reconstruction.
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6. American Society of Plastic Surgeons. 2013 Plastic Surgery Statistics Report. Available at: http://www.plasticsurgery.org/Documents/news-resources/statistics/2013-statistics/breastreconstruction-procedures-by-age.pdf. Accessed January 26, 2015.
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7. Cemal Y, Albornoz CR, Disa JJ, et al. A paradigm shift in U.S. breast reconstruction: Part 2. The influence of changing mastectomy patterns on reconstructive rate and method. Plast Reconstr Surg.
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8. Kronowitz SJ. Delayed-immediate breast reconstruction: technical and timing considerations. Plast Reconstr Surg. 2010; 125: 463-474. 9. Kronowitz SJ, Hunt KK, Kuerer HM, et al. Delayed-immediate breast reconstruction. Plast Reconstr Surg. 2004; 113: 1617-1628. 10. Spear SL, Schwartz J, Dayan JH, Clemens MW. Outcome assessment of breast distortion following submuscular breast augmentation. Aesthetic Plast Surg. 2009; 33: 44-48. 15
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11. Albino FP, Patel KM, Nahabedian MY, Attinger CE, Bhanot P. Immediate, Multistaged Approach to Infected Synthetic Mesh: Outcomes After Abdominal Wall Reconstruction With Porcine Acellular Dermal Matrix. Ann Plast Surg. 2014.
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12. Khansa I, Hendrick RG, Jr., Shore A, Meyerson J, Yang M, Boehmler JHt. Breast reconstruction with tissue expanders: implementation of a standardized best-practices protocol to reduce infection rates. Plast Reconstr Surg. 2014; 134: 11-18.
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13. Strock LL. Two-stage expander implant reconstruction: recent experience. Plast Reconstr Surg. 2009; 124: 1429-1436.
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14. Gurunluoglu R, Gurunluoglu A, Williams SA, Tebockhorst S. Current trends in breast reconstruction: survey of American Society of Plastic Surgeons 2010. Ann Plast Surg. 2013; 70: 103-110. 15. Nguyen JT, Buchanan IA, Patel PP, Aljinovic N, Lee BT. Intercostal neuroma as a source of pain after aesthetic and reconstructive breast implant surgery. J Plast Reconstr Aesthet Surg. 2012; 65: 1199-1203.
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16. Ducic I, Seiboth LA, Iorio ML. Chronic postoperative breast pain: danger zones for nerve injuries. Plast Reconstr Surg. 2011; 127: 41-46.
17. Mallon P, Feron JG, Couturaud B, et al. The role of nipple-sparing mastectomy in breast cancer: a
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comprehensive review of the literature. Plast Reconstr Surg. 2013; 131: 969-984. 18. Ramos Boyero M. Skin-sparing mastectomy: an alternative to conventional mastectomy in breast
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cancer. Cir Esp. 2008; 84: 181-187.
19. Munhoz AM, Montag E, Filassi JR, Gemperli R. Immediate nipple-areola-sparing mastectomy reconstruction: An update on oncological and reconstruction techniques. World J Clin Oncol. 2014; 5: 478-494.
20. Murthy V, Chamberlain RS. Defining a place for nipple sparing mastectomy in modern breast care: an evidence based review. Breast J. 2013; 19: 571-581.
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21. Komorowska-Timek E, Gurtner GC. Intraoperative perfusion mapping with laser-assisted indocyanine green imaging can predict and prevent complications in immediate breast reconstruction. Plast Reconstr Surg. 2010; 125: 1065-1073.
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22. Newman MI, Samson MC, Tamburrino JF, Swartz KA. Intraoperative laser-assisted indocyanine green angiography for the evaluation of mastectomy flaps in immediate breast reconstruction. J Reconstr Microsurg. 2010; 26: 487-492.
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23. Phillips BT, Lanier ST, Conkling N, et al. Intraoperative perfusion techniques can accurately predict mastectomy skin flap necrosis in breast reconstruction: results of a prospective trial. Plast Reconstr Surg.
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2012; 129: 778e-788e.
24. Munabi NC, Olorunnipa OB, Goltsman D, Rohde CH, Ascherman JA. The ability of intra-operative perfusion mapping with laser-assisted indocyanine green angiography to predict mastectomy flap necrosis in breast reconstruction: a prospective trial. J Plast Reconstr Aesthet Surg. 2014; 67: 449-455.
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25. Clemens MW, Kronowitz SJ. Acellular dermal matrix in irradiated tissue expander/implant-based breast reconstruction: evidence-based review. Plast Reconstr Surg. 2012; 130: 27S-34S. 26. Basu CB, Jeffers L. The role of acellular dermal matrices in capsular contracture: a review of the
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evidence. Plast Reconstr Surg. 2012; 130: 118S-124S. 27. Cheng A, Lakhiani C, Saint-Cyr M. Treatment of capsular contracture using complete implant
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coverage by acellular dermal matrix: a novel technique. Plast Reconstr Surg. 2013; 132: 519-529. 28. Spear SL, Parikh PM, Reisin E, Menon NG. Acellular dermis-assisted breast reconstruction. Aesthetic Plast Surg. 2008; 32: 418-425.
29. Kim JY, Davila AA, Persing S, et al. A meta-analysis of human acellular dermis and submuscular tissue expander breast reconstruction. Plast Reconstr Surg. 2012; 129: 28-41.
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30. Engel H, Huang JJ, Lin CY, Lam WL, Gazyakan E, Cheng MH. Subcutaneous tissue expansion and subsequent subpectoral implantation for breast reconstruction in Asian patients: safety and outcome. Ann Plast Surg. 2013; 70: 135-143.
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31. Reitsamer R PF. Prepectoral implant placement and complete coverage with porcine acellular dermal matrix: A new technique for direct-to-implant breast reconstruction after nipple-sparing mastectomy. J Plast Reconstr Aesthet Surg. 2015; 68: 162-167.
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32. Miller ME, Czechura T, Martz B, et al. Operative risks associated with contralateral prophylactic mastectomy: a single institution experience. Ann Surg Oncol. 2013; 20: 4113-4120.
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33. Saint-Cyr M, Nagarkar P, Wong C, Thakar H, Dauwe P, Rohrich RJ. The pedicled subpectoral fascia flap for expander coverage in postmastectomy breast reconstruction: a novel technique. Plast Reconstr Surg. 2010; 125: 1328-1334.
34. Saint-Cyr M, Dauwe P, Wong C, Thakar H, Nagarkar P, Rohrich RJ. Use of the serratus anterior fascia
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flap for expander coverage in breast reconstruction. Plast Reconstr Surg. 2010; 125: 1057-1064. 35. Goodwin SJ, McCarthy CM, Pusic AL, et al. Complications in smokers after postmastectomy tissue expander/implant breast reconstruction. Ann Plast Surg. 2005; 55: 16-19; discussion 19-20.
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36. Chang DW, Reece GP, Wang B, et al. Effect of smoking on complications in patients undergoing free TRAM flap breast reconstruction. Plast Reconstr Surg. 2000; 105: 2374-2380.
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37. Padubidri AN, Yetman R, Browne E, et al. Complications of postmastectomy breast reconstructions in smokers, ex-smokers, and nonsmokers. Plast Reconstr Surg. 2001; 107: 342-349. 38. Pluvy I, Garrido I, Pauchot J, et al. Smoking and plastic surgery, part I. Pathophysiological aspects: Update and proposed recommendations. Ann Chir Plast Esthet. 2015; 60: e3-e13. 39. Pluvy I, Panouilleres M, Garrido I, et al. Smoking and plastic surgery, part II. Clinical implications: A systematic review with meta-analysis. Ann Chir Plast Esthet. 2015; 60: e15-49.
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40. Hage JJ, van der Heeden JF, Lankhorst KM, et al. Impact of combined skin sparing mastectomy and immediate subpectoral prosthetic reconstruction on the pectoralis major muscle function: a preoperative and postoperative comparative study. Ann Plast Surg. 2014; 72: 631-637.
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41. Newman MI, Swartz KA, Samson MC, Mahoney CB, Diab K. The true incidence of near-term postoperative complications in prosthetic breast reconstruction utilizing human acellular dermal
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matrices: a meta-analysis. Aesthetic Plast Surg. 2011; 35: 100-106.
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Table Legends Table 1: Definition of complications.
and submuscular tissue expander placed groups.
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Table 2: Patient demographics and procedure details, with no differences between the subcutaneous
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Table 3: Comparison of the expansion process and pain scores of the subcutaneous and submuscular
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groups.
Table 4: Multiple linear regression models of expansion process adjusted for ADM and post operation radiation therapy.
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Table 5: Complications during expansion and after breast reconstruction with autologous flaps. ⃰ Only complications of the breast included, complications of donor sites were excluded in this table.
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radiation therapy.
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Table 6: Subgroup analysis of comparison of expansion process in expanders which had postoperative
Table 7: Comparison of the benefits, limitations and solutions of the subcutaneous and submuscular tissue expander placement. * IMF, inframammary fold; §, ADM, acellular dermal matrix; #, PMM, pectoralis major muscle; ǂ, MSF, mastectomy skin flap.
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Figure Legends Figure 1: Decision-making algorithm of expander insertion plane and ADM usage. *ADM may be applied
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with the expander insertion or with the implant exchange.
Figure 2: Intraoperative views of subcutaneous expander placement. (A) The expander was inserted into the subcutaneous envelope. (B) View of wound closure and intraoperative expansion (intraoperative fill:
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300ml, expander size: 600ml).
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Figure 3: A 39-year-old woman who presented with left breast cancer and underwent left skin-sparing mastectomy, left axillary node dissection and immediate breast reconstruction with a subcutaneous placed tissue expander. The left breast underwent radiation without expander deflation. Six months following radiation, the left breast was reconstructed with a DIEP flap. Mastopexy was performed on the
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right side for symmetry. (A) Preoperative view. (B) 6 month following radiation (Total expansion: 590ml). (C) Intraoperative view showed easy and fasting anatomy of internal mammary vessels with no need of deflating the pectoralis major muscle as the submuscular placement. (D) Postoperative view showed the
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symmetric contour of bilateral breasts.
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Figure 4: A 64-year-old woman who presented with a history of right breast wide local excision consistent with lobular carcinoma in situ and left breast conserving therapy for DCIS with no evidence of recurrence. The patient underwent bilateral risk reduction nipple sparing mastectomy and immediate breast reconstruction with subcutaneously placed tissue expanders. (A) Preoperative view. (B) 6 months following bilateral capsulotomy, implant (Natrelle 410FF, 740ml) exchange and simultaneous fat grafting (right: 110 ml, left: 130 ml).
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Video Legends Video 1: Subcutaneous placement of tissue expander during immediate breast reconstruction.
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Video 2: Subcutaneous placement of tissue expander with the inferior dermal flap during immediate
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breast reconstruction.
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Table 1. Definition of Complications Minor
Infection
Culture proven; Intravenous antibiotics required; Surgical intervention required; Lead to expander removal
Clinical diagnosed; Oral antibiotics required;
Mastectomy skin necrosis
Full thickness skin necrosis; Full thickness wound edge necrosis; Surgical intervention required; Lead to expander removal
Split thickness skin necrosis; Split thickness wound edge necrosis; Superficial wound edge necrosis; Dress changing required
Seroma
Drainage or aspiration required
No intervention required
Fat necrosis
Surgical excision required
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Surgical aspirate required
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Table 2. Demographic and Procedure Details of Subcutaneous and Submuscular Groups
Age, year 2
BMI, Kg/m
Comorbidities Hypertension Diabetes Coronary artery disease Active smoker Preoperative chemotherapy
50
108
50.48 (8.83)
52.69 (12.18)
0.45
27.77 (5.35)
27.54 (6.55)
0.56
3(10.34%) 0(0%) 0(0%)
13 (22.03%) 2(3.40%) 3(5.08%)
0.18
0 (0%)
4 (6.78%)
0.10
14(23.73%)
0.17
16(14.81%)
0.23
11 (37.93%)
P value
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No. of expanders
Submuscular (SD) 59
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No. of patients
Subcutaneous (SD) 29
4 (8.00%)
Postoperative radiation
17 (34.00%)
25 (23.15%)
0.15
4(13.79%)
10 (16.95%)
0.18
29(58.00) 21(42.00)
71 (65.74%) 37 (34.26%)
479.87 (286.95)
477.21 (282.65)
Axillary lymph node dissection No Yes
5 (17.24%) 24 (82.76%)
7 (12.07%) 51 (87.93%)
ADM*
15 (30.00%)
50 (46.30%)
0.05
3 (6.00%)
18 (14.81%)
0.19
3(10.34%) 25(86.21%) 1(3.45%)
6 (10.17%) 50 (85.23%) 3 (5.08%)
Postoperative chemotherapy Mastectomy type Skin-sparing Nipple-sparing
Inferior dermal flap
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Mastectomy weight, g
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0.99 0.51
0.94
*ADM, acellular dermal matrix; §ASA, American Society of Anesthesiology.
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0.35
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Table 3. Comparison of Expansion Process and Pain of Subcutaneous and Submuscular Groups
Expander size, ml
555.00 (136.74)
587.50 (151.49)
0.19
Intraoperative expansion, ml
223.40 (186.47)
101.22 (161.15)
<0.001
Intraoperative expansion ratio
0.40 (0.33)
0.17 (0.28)
<0.001
First postoperative expansion, ml
340.20 (199.75)
195.20 (155.02)
<0.001
First postoperative expansion ratio
0.60 (0.32)
0.34 (0.26)
<0.001
Total expansion ratio
0.86 (0.24)
Number of expansion visits
3.00 (1.90)
Duration of expansion, day
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470.20 (146.81)
521.52 (165.88)
0.07
0.89 (0.20)
0.29
4.31 (2.12)
0.002
79.38 (90.36)
90.36 (127.03)
0.02
3.15 (1.57) 3.14 (1.66)
4.05 (0.95) 3.80 (1.53)
0.004 0.06
2.31 (1.85)
2.59 (1.79)
0.38
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Total expansion, ml
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Submuscular(SD) (n=102*) 56
P value
Number of patients
Subcutaneous (SD) (n=50*) 29
Pain Score Average pain during admission Pain at discharge
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Pain at first clinic visit
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Table 4. Multiple Linear Regression Models of Expansion Process Adjusted for ADM and Postoperative Radiation Therapy 95% LCI
HCI
P value
Intraoperative expansion ratio
.27
.18
.37
<0.001
First postoperative expansion ratio
.30
.21
.39
<0.001
Total expansion ratio
-.03
-.10
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Outcome
0.48
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Table 5. Complications during Expansion and after Reconstruction with Autologous Flaps Variable
Subcutaneous (%)
Submuscular (%)
Complications during Expansion
n=50
n=108
Any complications Total major complications Infection Mastectomy skin necrosis Seroma Total minor complications Infection Mastectomy skin necrosis Seroma
8 1 0 0 1 7 1 2 4
18 6 3 2 1 12 0 11 1
Complications after Reconstruction Flaps⃰
n=23
Any complications Total major complications Infection Mastectomy skin necrosis
4 1 0 1
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n=39
6 2 0 2
0.98
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P value
3 1 0 1
4 1 1 2
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Table 6. Comparison of Expansion Process in Expanders with Postoperative Radiation Therapy
Expander size, ml
579.59 (114.64)
584.00 (164.39)
0.90
Intraoperative expansion, ml
261.18 (204.32)
101.6 (197.75)
0.006
Intraoperative expansion ratio
0.44 (0.34)
0.16 (0.33)
0.005
First postoperative expansion, ml
374.71 (229.51)
228.80 (189.02)
0.03
First postoperative expansion ratio
0.63 (0.35)
0.37 (0.28)
0.01
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Submuscular(SD) (n=25) 13
P value
Number of patients
Subcutaneous (SD) (n=17) 10
526.47 (115.94)
531.20 (165.79)
0.88
Total expansion ratio
0.94 (0.25)
0.92 (0.21)
0.89
Number of expansion visits
3.40 (2.72)
4.62 (2.33)
0.15
Duration of expansion, day
111.00 (97.20)
115.92 (186.88)
0.76
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Table 7. Comparison of the Potential Benefits, Tradeoffs and Resolving Methods of Subcutaneous and Submuscular Expander Placement Pocket
Potential Benefits
Tradeoffs
Resolving methods
Subcutaneous
1. Faster expansion, less expansion visit and less pain. 2. Less procedure duration and more rapid postoperative recovery.
1. Increased risk of implant edge visibility or palpability. 2. Possible increased risk of expander extrusion in the setting of compromised wound healing
Multiple fat grafting
3. No distortion with pectoralis contraction. 4. More natural breast shape.
3. Possible over stretching of the ski of lower pole. 4. Possible increased incidence of capsular contracture.
1. Less risk of palpable or visible implant edges on lower pole. 2. Possible decreased risk of capsular contracture. 3. Offer extra expander coverage in the setting of compromised wound healing
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1. Slower expansion, more expansion visit and more pain.
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Submuscular
Add ADM§ on the lower pole Add ADM and fat grafting
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5. Increased control of IMF* position.
Strictly following patient selection criterion, avoid over intraoperative expansion
2. Increased risk of superior implant malposition or displacement.
3. Less precise control of IMF fold and upper medial fill.
2. Add ADM or autologous fascial coverage.
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4. More procedure time and prolonged recovery. 5. Lateral implant displacement over time, widening the space between the breasts.
1. Release PMM# along its inferior aspect extending toward the inferomedial border.
6. Distortion of breast shape with pectoralis contraction. 7. Need to be released from from MSFǂ during autologous flap reconstruction.
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*IMF, inframammary fold; §ADM, acellular dermal matrix; #PMM, pectoralis major muscle; ǂMSF, mastectomy skin flap.
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