d

CME

Recent Advances in Implant-Based

Breast Reconstruction
Amy S. Colwell, M.D.
Learning Objectives: After reading this article, the participant should be able
Erin M. Taylor, M.D.
to: 1. Understand the indications for implant-based breast reconstruction
Boston, Mass. and the indications for nipple preservation compared to skin-sparing or skin-
reducing patterns. 2. Understand the indications for direct-to-implant breast
reconstruction versus tissue expander/implant breast reconstruction and the
advantages and disadvantages of total, partial, or no muscle coverage. 3. Un-
derstand the role of acellular dermal matrix or mesh in reconstruction. 4.
Learn the advantages and disadvantages of different types and styles of im-
Downloaded from http://journals.lww.com/plasreconsurg by BhDMf5ePHKbH4TTImqenVLeEdd5NVDXpz4d3Xl00ogTSbYyQ5Qa7ilHixqSUCykJwxb0eTfTw3o= on 02/02/2020

plants and develop a postoperative plan for care and pain management.
Summary: Breast reconstruction with implants has seen a decade of advances
leading to more natural breast reconstructions and lower rates of complica-
tions. (Plast. Reconstr. Surg. 145: 421e, 2020.)

I
n the past 10 years, the field of breast recon-
struction has undergone tremendous changes
that have resulted in our ability to more closely
mimic the native breast. Our success is attribut-
able in large part to the improved mastectomy
techniques with nipple preservation and efforts to
preserve a well-perfused skin flap following breast
removal. In addition, there has been evolution and
advancement in the tools surgeons have to recre-
ate the breast, including supplemental fat graft-
ing. This article outlines important components
of successful implant-based breast reconstruction.
INDICATIONS
All women who have a mastectomy should
be counseled on their options for breast recon-
struction. Important components of the history
include the general health of the patient and the
ability to withstand the extra time of anesthesia
attributable to the reconstruction. Consultations
with other specialists are necessary to deter-
mine whether it is safe to hold anticoagulation
medications and whether immunosuppressants/
antimetabolites can be held. Diabetes should be
controlled and smoking discontinued. In patients
with prior breast irradiation, individual assessment
of risk factors may help determine candidacy for
immediate implant reconstruction. In general, a
From the Division of Plastic Surgery, Massachusetts General
Hospital, Harvard Medical School.
Received for publication January 1, 2019; accepted May 10,
2019.
Copyright © 2020 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000006510
higher incidence of risk factors is associated with a
higher chance for complications. Obesity is not a
contraindication to immediate breast reconstruc-
tion; however, these patients are likely at higher
risk for complications.1,2 If two or more risk factors
exist, delayed reconstruction or a Goldilocks pro-
cedure to control the skin envelope and create a
small breast are considered.3 Compared to autolo-
gous reconstruction, implant reconstruction has a
lower rate of complications and reoperations but
a higher rate of failure.4
Postmastectomy radiation therapy is the
risk factor that adversely affects outcomes and
increases complications more than any other in
implant-based reconstruction.5–8 Although we do
not understand the entire mechanism of injury, it
is likely influenced by the health and vascularity
of the mastectomy skin envelope and the dose/
delivery of radiation. Other contributing factors
to radiation injury include a possible advantage
of acellular dermal matrix and textured devices
and a potential negative role for pectoralis muscle
contraction. Timing of radiotherapy continues
to be debated. Lower rates of complications are
reported with radiotherapy to the implant, and
better cosmesis is reported with radiotherapy to
the expander.9
Disclosure: The authors have no financial disclo-
sures.
Related digital media are available in the full-text
version of the article on www.PRSJournal.com.

www.PRSJournal.com 421e
 Plastic and Reconstructive Surgery • February 2020

INCISIONS WITH NIPPLE also excellent candidates; however, if they would

PRESERVATION OR REMOVAL
Nipple-sparing mastectomy procedures have
become the default operation in many large cen-
ters, with preference over skin-sparing or skin-
reducing procedures. Oncologic indications for
nipple removal include involvement of the nipple
on clinical or radiologic examination.10 From a
plastic surgery standpoint, nipple preservation
is considered if it will end up in the correct ana-
tomical position postoperatively or for patient
preference.11,12 Prior incisions on the breast are
not contraindications to nipple-sparing mastec-
tomy.13,14 The most common incisions include
an inferolateral inframammary fold incision for
the best cosmesis (Figs. 1 through 3), a vertical
incision for the ptotic breast, and a lateral radial
incision for the best preservation of nipple blood
supply. A full-thickness incision around the areola
is largely avoided to minimize nipple ischemia. A
technical pearl for optimization of nipple posi-
tion in the first-stage surgery is to choose a wider
expander or implant than would typically be used
in skin-sparing procedures to try to keep the nip-
ple centered. Patients with grade I breast ptosis are
universally good candidates to preserve the nip-
ple. Most patients with grade II breast ptosis are
like a smaller, more uplifted breast, skin or areola
sparing is sometimes preferred. With severe grade
II and grade III ptosis, several options exist for
nipple preservation, depending on therapeutic
versus prophylactic, desire for number of opera-
tions, and patient preference for uplift of breast
(Table 1 and Fig. 4).15 If a staged approach is cho-
sen, it is best to wait 3 months after a superior/
medial pedicle and 9 to 12 months after an infe-
rior pedicle with a Wise pattern before mastec-
tomy, which can be problematic for therapeutic
procedures.
When nipple preservation is not possible, an
areola-sparing procedure can be considered. This
preserves more skin at the time of the mastectomy
compared with skin-sparing procedures, which
has advantages for direct-to-implant reconstruc-
tion, and may obviate the desire for nipple recon-
struction. If nipple reconstruction is performed,
the thickened pigmented areola makes an excel-
lent nipple. Standard skin-sparing or skin-reduc-
ing mastectomies are typically closed horizontally;
however, a vertical closure provides better shape
in a large breast. Although a Wise pattern pro-
vides the best control of the skin envelope and the
best cosmesis if it is successful, it is also associated

Fig. 1. Nipple-sparing mastectomy can be performed using these incisions. (Reprinted

with permission from Colwell AS, Tessler O, Lin AM, et al. Breast reconstruction following
nipple-sparing mastectomy: Predictors of complications, reconstruction outcomes, and
5-year trends. Plast Reconstr Surg. 2014;133:496–506.)

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Volume 145, Number 2 • Implant-Based Breast Reconstruction
Fig. 2. This patient underwent bilateral direct-to-implant reconstruction through an inframammary incision
using large contour acellular dermal matrix and subpectoral/dual-plane, smooth, round, full, 560-cc implants.
with the most complications. If a Wise pattern is
chosen, the inferior skin is typically deepitheli-
alized to provide implant support and to act an
additional barrier with skin breakdown.
DIRECT-TO-IMPLANT VERSUS
TISSUE EXPANDER/IMPLANT
RECONSTRUCTION
Implant reconstruction can be performed in
one stage or two stages. In a one-stage direct-to-
implant reconstruction, the final implant is placed
at the time of the mastectomy, whereas in a two-
stage approach, a tissue expander is placed imme-
diately and then exchanged to the final implant
in a second surgical procedure (tissue-expander/
implant).16 With experience, there is no dif-
ference in complication rates or revision rates
between direct-to-implant and tissue-expander/
implant reconstruction.15,17
Direct-to-implant reconstruction is considered
for patients desiring to stay approximately the
same size, although with experience, some degree
of size change is commonly possible.16,18,19 It is
most frequently performed in nipple-sparing pro-
cedures. Patients in general are otherwise healthy
with relatively symmetric breasts and volume less
than 900 cc. The most critical component of suc-
cessful direct-to-implant procedures is the health
and vascularity of the mastectomy skin flap. With
experience, physical examination alone is suffi-
cient for assessing the flap; however, a perfusion
assessment device gives additional objective infor-
mation that may be particularly helpful for inex-
perienced surgeons or those working with many
oncologic breast surgeons. To safely increase size
in direct-to-implant reconstruction, the mastec-
tomy technique must be perfect in its ability to
remove all the breast tissue yet leave a well-per-
fused flap. In the senior author’s experience, this
type of flap is only routinely seen with one breast
surgeon, and the size increase is typically limited
to 50 to 100 cc greater than breast volume. How-
ever, with continued improvement in technique,
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 Plastic and Reconstructive Surgery • February 2020

Fig. 3. This patient desired an enhancement in size with her mastectomy. She underwent bilateral nipple-spar-
ing mastectomy using an inframammary fold incision and subpectoral/dual-plane, 600-cc, moderate height,
variable projecting expanders and acellular dermal matrix. She underwent exchange to smooth, round, extra-
full, 750-cc implants with 30 cc of fat transfer to the upper pole of each reconstruction.

Table 1. Reconstructive Options for Nipple-Sparing Mastectomy and Severe Grade II or III Breast Ptosis
Choice Advantages Disadvantages
Fill/overfill skin envelope Any incision, DTI often possible Less lift compared to other techniques
Vertical incision Better centralization and lift than IMF DTI less likely secondary to more tension
incision, mastopexy at second stage and ischemia to skin flap
Staged mastopexy or reduction before Best lift and contour Delay in treatment, need for lumpectomy
mastectomy with first-stage surgery, insurance
coverage
Skin-sparing/skin-reducing mastectomy One of best options for size reduc- Loss of native nipple
tion, avoids delay
DTI, direct-to-implant; IMF, inframammary fold.

larger volume changes may be possible. Advan-
tages to direct-to-implant reconstruction include
the potential for one less operation and recovery
period compared to tissue-expander/implant
reconstruction.20 Furthermore, there is less
thinning of the skin envelope, resulting in less
need for fat grafting and more control of nipple
position. At our center, direct-to-implant recon-
struction is the procedure of choice if a patient
needs postmastectomy radiotherapy secondary to

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Volume 145, Number 2 • Implant-Based Breast Reconstruction
Fig. 4. One option for a patient with ptosis who desires to stay the same size and shape is to fill or overfill
the skin envelope using an inframammary fold incision and in this case subpectoral/dual-plane direct-to-
implant reconstruction (preoperative and postoperative images).
decreased complication rates compared with tis-
sue-expander/implant reconstruction.
Tissue expander/implant reconstruction is
indicated for significant size changes, very large or
very small native breast volumes, asymmetry, or if
the vascularity of the skin envelope is insufficient
to support a full-sized implant. In addition, for
inexperienced surgeons, tissue expander/implant
reconstruction is a safer choice until experience
is gained determining skin perfusion. Advocates
of tissue expander/implant reconstruction cite
the ability to more precisely control symmetry and
implant position when given two operations com-
pared to one and the ability to fat graft at the sec-
ond stage. At the first stage, it is important to avoid
overfilling the tissue expander, which can lead to
tension-induced ischemia. A technical pearl at
the second-stage operation is to perform superior
and medial capsulotomies if needed to accommo-
date an implant approximately 50 cc greater than
the volume of the tissue expander at the time of
exchange. This gives a nice hand-in-glove fit and
makes up for the loss of projection seen with
exchange to a softer, more mobile device.
With either direct-to-implant or tissue-
expander/implant surgery, fat grafting has
emerged as an integral tool for filling in upper
pole divots and for masking contour irregulari-
ties. Fat is injected at the second-stage surgery
or as a revision procedure. The optimal way to
enhance fat graft take remains elusive but is likely
influenced by the quantity injected, quality of the
lipoaspirate, and vascularity of the recipient site.
SOFT-TISSUE SUPPORT OF THE
BREAST RECONSTRUCTION
Options for soft-tissue support and cover-
age of the breast implant reconstruction include
the pectoralis major muscle, serratus anterior
muscle or fascia, rectus abdominis fascia, acellu-
lar dermal matrix products, and synthetic mesh.
Excellent recent reviews of the support matrix
materials available for breast reconstruction have
been published.15,21 The ideal material should be
flexible and soft, yet durable for long-term soft-
tissue support. In addition, it is advantageous for
the material to thicken the soft-tissue envelope
for implant coverage without inducing capsu-
lar contracture. Finally, if the support matrix is
biointegrated, it minimizes risk for matrix expo-
sure and facilitates bacterial clearance in the set-
ting of infection. Acellular dermal matrix is the
most commonly used material for breast recon-
struction; however, synthetic meshes have been
used in attempts to reduce overall costs of the
procedure either alone or in combination with
acellular dermal matrix.22,23 Short-term absorb-
able mesh has inconsistent outcomes, as the
soft tissues struggle to maintain support, which
may result in either excessive scar/capsular con-
tracture or bottoming-out from lack of support.
Titanium mesh appears promising for its ease of
use, long-term support, and stability. However,
performance with smooth round implants in the
prepectoral space and in the setting of radiother-
apy is lacking.
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 Plastic and Reconstructive Surgery • February 2020
TOTAL MUSCLE COVERAGE
In the technique of total or nearly total mus-
cle coverage, the pectoralis major muscle covers
the majority of the device, whereas the serra-
tus anterior muscle or fascia covers the lateral
aspect of the device. This is reserved in general
for tissue-expander/implant reconstruction. The
advantages of this technique are in having healthy
muscle as a barrier over the device and reduced
material cost. This technique has fallen out of
favor secondary to poor shape of the reconstruc-
tion with lack of inferior pole projection and
painful expansion. However, with technical exper-
tise, this technique can give excellent results in
selected patients.24
PARTIAL MUSCLE COVERAGE
(SUBPECTORAL OR DUAL-PLANE
RECONSTRUCTION)
Partial muscle coverage offers a more natural
shape by releasing the inferior pole constriction
of the pectoralis muscle. Control of pectoralis
muscle contraction and “window shading” may
be achieved by sewing the pectoralis muscle to
the inferior skin flap or with spanning sutures to
the chest wall. Lateral control of implant position
may be obtained by minimizing lateral dissection
of the mastectomy with soft-tissue contouring to
the chest wall. However, partial muscle coverage
with acellular dermal matrix offers more control,
predictability, and reliability and is therefore the
most common technique performed currently for
one- or two-stage surgery25 (Fig. 5). [See Video 1
(online), which displays subpectoral (partial mus-
cle coverage) tissue expander reconstruction.
See Video 2 (online), which displays subpecto-
ral (partial muscle coverage) direct-to-implant
Fig. 5. The subpectoral dual plane/partial muscle coverage tech-
nique has pectoralis muscle coverage of the superior implant
and acellular dermal matrix coverage of the inferior implant.
426e
pocket creation. See Video 3 (online), which
displays subpectoral (partial muscle coverage)
direct-to-implant placement of implant and clo-
sure.] This is routinely referred to as “subpec-
toral” or “dual-plane” reconstruction. In this
procedure, the pectoralis muscle is raised from
its lateral and inferior border to approximately
the 4- or 8-o’clock position on the chest wall.
This allows simultaneous upper pole soft-tissue
coverage with muscle and inferior pole expan-
sion. To avoid pectoralis muscle retraction defor-
mity, the muscle is held on stretch with acellular
dermal matrix, which acts as an inferior exten-
sion of the pectoralis muscle to the chest wall
or inframammary fold. The lateral dissection of
the mastectomy often proceeds to the latissimus
dorsi muscle. To control the lateral border of the
reconstruction, acellular dermal matrix is sewn
to the chest wall at the desired position. If the
lateral skin flap is of adequate thickness, quilting
sutures may be placed from the skin flap to the
chest wall to close off dead space and improve lat-
eral contour. However, if the skin flaps are thin,
these sutures are typically avoided, as they lead
to skin puckering that may be permanent. The
advantages of subpectoral partial muscle cover-
age reconstruction include excellent soft-tissue
coverage of the superior pole of the breast, which
is most visible in clothing. The subpectoral recon-
struction tends to lift the breast, analogous to a
dual-plane breast augmentation, and has excel-
lent long-term cosmetic and functional results.
Compared to prepectoral reconstruction with
acellular dermal matrix (Table 2), the costs of the
reconstruction are lower. The main disadvantage
is potential animation, which refers to distortion
or movement of the implant with flexion of the
pectoralis muscle. In the senior author’s (A.S.C.)
personal experience of more than 1500 sub-
pectoral implant reconstructions, most patient
animation is minor and present only with pecto-
ralis activity. However, in select patients, it can be
severe and bothersome.
NO MUSCLE COVERAGE
(PREPECTORAL RECONSTRUCTION)
As the quality of mastectomy skin flaps began
to improve, a movement began to place implants
on top of the muscle (Figs. 6 and 7).26,27 In these
“prepectoral” or “subcutaneous” reconstructions,
implants may be supported by soft tissue alone
(no external support), anterior coverage with
acellular dermal matrix/mesh, or anterior and
posterior coverage of the device.
Volume 145, Number 2 • Implant-Based Breast Reconstruction

Table 2. Comparison of Subpectoral Partial Muscle Coverage and Prepectoral Breast Reconstruction
Characteristic Subpectoral Prepectoral
Soft-tissue coverage Better soft-tissue coverage upper pole More implant visibility, rippling, and contour
irregularity upper pole
Animation More animation Less animation (implant may still move)
Symmetry Good symmetry for unilateral grade 1 ptosis; symme- Good symmetry for unilateral grade I to grade III
try not as good for grade II to grade III ptosis ptosis
Uplift More uplift of breasts Less uplift of breasts
Pain More acute pain than prepectoral (variable) Less acute pain than subpectoral (variable)
Follow-up Long-term follow-up Short-term follow-up
Cost-effectiveness More cost-effective Higher material cost
Implant size No limit on implant size No limit on implant size
Outcome with Variable outcome with radiation therapy Variable outcome with radiation therapy; avoids
radiotherapy pectoralis contracture
Projection Lack of projection in very large breasts Better projection in very large breasts
Medial position Excellent medial position of implants attainable Excellent medial position of implants attainable
except with wide sternalis muscle in all cases, more risk for symmastia

Fig. 6. This patient had a right nipple-sparing mastectomy using an inframammary fold incision and prepec-
toral placement of a full-height, moderate projecting shaped implant and anterior coverage with porcine acel-
lular dermal matrix. She had no fat grafting.

In reconstructions with no external support, acellular dermal matrix is typically used to cover
control of the device comes from soft tissue and the entire anterior surface of the device, with or
tabbed expanders or textured devices. To increase without posterior coverage. [See Video 4 (online),
predictability and for long-term tissue support, which displays prepectoral implant reconstruction

427e
 Plastic and Reconstructive Surgery • February 2020

Fig. 7. Prepectoral two-stage reconstruction with anterior acellular dermal matrix coverage was performed in
this patient who desired increased size. She had exchange to full-height, extra-full projecting shaped implants
and 35 cc of fat transfer to bilateral upper poles of the reconstruction.

with two sheets of acellular dermal matrix: pocket gutter of acellular dermal matrix inferiorly for
creation. See Video 5 (online), which displays pre- enhanced protection against inferior descent.
pectoral implant reconstruction with two sheets of These modifications are particularly important
acellular dermal matrix: implant placement and in direct-to-implant reconstruction with smooth
closure. See Video 6 (online), which displays pre- round implants.
pectoral implant reconstruction with a 16 × 20-cm Anterior and posterior device coverage is com-
sheet of acellular dermal matrix.] Anterior cover- monly known as the acellular dermal matrix wrap.
age uses two contour pieces of acellular dermal
matrix sewn together centrally or a single 16 ×
20-cm piece (Figs. 8 and 9). A slip of muscle may
be raised superiorly to allow enhanced superior
support for the device, a smoother chest wall/
implant transition in patients with a paucity of soft
tissue, and less acellular dermal matrix for device
coverage.28,29 Another modification includes a

Fig. 9. The prepectoral anterior coverage technique may be per-

Fig. 8. The prepectoral anterior coverage technique may use
one large piece of acellular dermal matrix for soft-tissue sup-
port. The superior portion may be anchored to a slip of released
pectoralis muscle for enhanced support. In addition, an inferior
gutter of acellular dermal matrix may offer inframammary fold
support.
formed with two sheets of acellular dermal matrix. The inferior
acellular dermal matrix is sewn to the inframammary fold and
chest wall similar to subpectoral dual-plane reconstruction. The
superior acellular dermal matrix is sewn to the chest wall and/
or a superior slip of released pectoralis muscle. If desired, the
implant may be inserted centrally and the tension adjusted.
Alternatively, the two pieces may be sewn together before
insertion into the breast pocket and the tension adjusted inferi-
orly and laterally around the implant.

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Volume 145, Number 2 • Implant-Based Breast Reconstruction

The acellular dermal matrix wrap is an off-label
use of the material. The acellular dermal matrix
wrap is the easiest, fastest way to perform the
reconstruction and may be performed with one
or two pieces of acellular dermal matrix. If the
posterior acellular dermal matrix integrates into
the muscle, it may enhance long-term support of
the device and prevention of bottoming-out, but
there may also be animation/movement of the
device with pectoralis flexion. The greatest disad-
vantages are increased material cost and possible
device malposition when only limited points of
fixation to the chest wall are used. Furthermore,
an excess of acellular dermal matrix material may
increase seroma rates.
Initial safety results with the prepectoral tech-
nique are promising for similar rates of compli-
cations compared to subpectoral techniques.30–32
The main advantage of the prepectoral technique
is avoiding distorting animation. Prepectoral
reconstruction may also improve projection for
the large breast, where an 800-cc implant replaces
only a portion of the breast size. Depending on
the technique, prepectoral reconstruction may
decrease surgeon operative time, which is likely
one of the reasons for the increasing popularity of
the procedure. The greatest disadvantages are in
more superior pole implant visibility and rippling
and greater material cost. The implant visibility can
often be improved with fat grafting in subsequent
procedures. With the prepectoral technique, the
implant tends to sit lower on the chest wall com-
pared with subpectoral implants. This can be an
important advantage in unilateral breast recon-
structions in patients with ptotic breasts. However,
it can be a disadvantage in bilateral reconstruc-
tions. The senior author’s (P.D.N.) general prefer-
ences are subpectoral/acellular dermal matrix for
bilateral and prepectoral acellular dermal matrix
anterior coverage for unilateral reconstructions,
with some notable exceptions (Fig. 10).
Many comparisons of prepectoral versus sub-
pectoral reconstruction continue to be debated,
including whether there is a difference in over-
all pain and recovery, and long-term outcomes of
stability and capsular contracture. In their large

Fig. 10. Algorithm for partial muscle coverage (subpectoral) or prepectoral implant placement. The
senior author (A.S.C.) generally prefers the prepectoral position for unilateral reconstruction because the
implant sits lower on the chest wall, similar to the native breast. However, in patients with grade I ptosis,
the symmetry is excellent with subpectoral implant placement and there is less implant visibility and
rippling. The senior author generally prefers subpectoral implant placement for bilateral reconstructions
secondary to a better lift of the breasts and smoother result. However, prepectoral reconstruction is con-
sidered if postmastectomy radiotherapy is needed, particularly if the patient has a thin skin envelope.

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 Plastic and Reconstructive Surgery • February 2020
series, Sigalove et al. discuss that patients have
“less pain and a faster recovery” with prepectoral
reconstruction,26 and in a small series of tissue
expanders, Walia et al. found decreased pain with
prepectoral placement.33 Conversely, Baker et al.
measured pain scores and length of stay in their
prospective study and found no difference in pain
or length of stay between subpectoral and prepec-
toral procedures.34 Most likely, pectoralis muscle
elevation contributes to pain in some but not all
patients. Overall pain in both techniques may be
secondary to nerve pain from excessive traction or
dissection during mastectomy, which can be modi-
fied by enhanced recovery protocols including
nerve blocks, gabapentin, and acetaminophen.
Long-term outcomes may be influenced by tech-
nique and material.
TISSUE EXPANDERS
Advances in tissue expander design have
included texturing of devices for improved capsule
quality and avoiding malposition. An integrated
valve has eliminated remote valve dysfunction fail-
ures. Tissue expanders now focus on lower pole
expansion for more natural shape. A new device
(AeroForm; AirXpander, Inc., San Jose, Calif.)
uses carbon dioxide instead of saline for con-
trolled expansion. The advantages of patient and
physician convenience for this device are offset
by disadvantages of device bulk, permeation, and
cost. With knowledge of breast implant–associ-
ated anaplastic large cell lymphoma (BIA-ALCL)
and its association with textured implants, new
smooth-walled tabbed expanders have resurfaced.
The question remains of whether the new smooth-
walled expanders can improve on problems of
poor capsule quality and device malposition
seen in the earlier generations of smooth-walled
expanders.
IMPLANTS
Silicone gel implants have the advantage of
a more natural appearance and feel compared
with saline implants with similar safety profiles.
Implants are chosen based on breast base diam-
eter and breast implant volume. Lower projecting
implants have a larger diameter-to-volume ratio,
whereas higher projecting implants have a more
narrow diameter. Cohesive shaped anatomical
implants offer a stiffer gel to help minimize rip-
pling. These implants also have a better cosmetic
result in the prepectoral position compared to
round implants and may have an advantage with
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postmastectomy radiation therapy. The main dis-
advantage includes the risk of BIA-ALCL, which
is a rare low-grade lymphoma associated primarily
with textured implants.35 Although uncommon,
the risk of BIA-ALCL has led many surgeons in
the United States to offer exclusively the smooth
round implants. Other disadvantages for some
patients include a risk of rotation and lack of
upper pole projection. Modifications have sub-
sequently been made to round devices to make
them more cohesive. The first modification
includes an increased fill ratio using the same gel,
which makes the implant slightly stiffer to help
minimize rippling. The second modification is
a cohesive round silicone gel implant with all of
the advantages of the cohesive shaped implants
but without the risks of texturing. However, these
implants naturally flip in the anterior/posterior
position. With the highest projecting cohesive
round implants, a posterior flip presents as a
noticeable new flatness of the device. The device
can often be flipped anterior in the office, but it
may be a recurring problem for the patient, only
treatable by exchange to a different device style.
POSTOPERATIVE MANAGEMENT AND
OUTCOMES
Skin edges are trimmed or deepithelialized
and meticulously closed in layers. Surgical glue
seals the incisions and Tegaderm (3M, Maple-
wood, Minn.) coverage allows patients to shower.
Drains sites are covered by BioPatches (Ethicon,
Inc., Somerville, N.J.) or sterile gauze and Tega-
derm to help prevent bacterial contamination.
Devices may be stabilized by the addition of
Microfoam (3M) tape or a foam dressing. Patients
are followed weekly until drains are removed.
The typical criteria for drain removal is less than
20 to 30 cc/24 hours. A light compressive bra or
wrap is placed following surgery or before patient
discharge.
Pain management planning begins before sur-
gery. Enhanced recovery after surgery pathways
using multimodal pain therapy are gaining trac-
tion and offer patients nonnarcotic options for
pain control.36 A typical regimen includes 900 mg
of acetaminophen and 600 mg of gabapentin
given before surgery and a postoperative regimen
of gabapentin 100 mg or 200 mg twice daily for
1 week or more after surgery. Furthermore, para-
vertebral or local nerve blocks may help minimize
intraoperative and postoperative opioid use.
Controversy remains regarding continuation
of postoperative antibiotics with literature support
Volume 145, Number 2 • Implant-Based Breast Reconstruction
for and against.37,38 The authors promote risk strat-
ification with potential advantages in prepectoral
or partial muscle coverage techniques with drains
in contact with devices or acellular dermal matrix
and in high-risk patients or poor flap perfusion;
conversely, there may be no advantage and even
disadvantage in patients with total muscle cover-
age and an axillary drain without any specific risk
factors. Good outcomes can be achieved with
implant-based reconstruction, although complica-
tions can occur. The most common acute compli-
cations include skin and nipple necrosis, infection,
and seroma. Acute complications are best man-
aged aggressively with excision of necrotic tissue,
drainage of seromas, and treatment of infections
with antibiotics and/or device removal or replace-
ment. Surgeons should strive for infection rates
and explantation rates to be less than 5 percent.
CONCLUSIONS
Now more than ever, we have the ability to
reconstruct breasts that often appear as good as
or, in some cases, better than the native breast
with implant-based reconstruction. Together with
the patients, we can tailor the incision, device, and
technique to meet their reconstructive goals.
Amy S. Colwell, M.D.
Division of Plastic Surgery
Massachusetts General Hospital
15 Parkman Street, WACC 435
Boston, Mass. 02114
acolwell@mgh.harvard.edu
@DrAmyColwell
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