Indications and Controversies for Implant-Only Based Breast Reconstruction.

Today's demographic of the breast reconstruction patient is younger, often prophylactic or at an early stage of diagnosis, and is more likely to be bilateral. These factors combined with an increase in breast implant options, internal support matrices, fat transfer, technologies for intraoperative real time assessment of tissue perfusion, and an increasing appreciation for morbidity associated with autogenous procedures have resulted in an increase in the percentage of women seeking alloplastic breast reconstruction. This article discusses the indications for implant-only reconstruction and reviews the authors' approach to the use of adjunctive techniques that are used in most of their patients.

Autologous Fat Transfer: The Progenitor Cell Response to Different Recipient Environments.

BACKGROUND: Autologous fat transfer is a common procedure; however, results are variable and unpredictable. OBJECTIVES: Stem cell responses to hypoxic environments need to be elucidated to determine which cell types contribute to graft survival. METHODS: Acellular dermal matrix (ADM) envelopes were implanted in the subcutaneous tissues of 4 swine. In each swine, 2 envelopes were inserted as controls (ADM group), and 2 were placed and injected with 5 mL of autologous fat (ADM/fat group). Two additional envelopes were inserted and filled with 5 mL of fat and an omental pedicle (A/F/O group). Animals were sacrificed and the envelopes excised at 1, 2, 4, and 16 weeks. Specimens were analyzed histologically and/or with flow cytometry. RESULTS: Fat was retained in ADM envelopes with and without a pedicle blood supply, although the percentage of volume retention was greater in the pedicled group. The peak number of mesenchymal progenitor cells within the ADM/fat group was significantly greater than the peak in the A/F/O group (P =.044), whereas endothelial progenitor cells in the ADM/fat group showed a prolonged increase through 4 weeks (P =.015 vs the A/F/O group at week 4). At 16 weeks, the interior surface of the matrix in the ADM/fat group had significantly more blood vessels than that of the ADM or A/F/O group (P = .0021 and .0036, respectively). CONCLUSIONS: Injecting fat into hypoxic environments significantly increases the mesenchymal and endothelial progenitor cell responses and enhances the formation of blood vessels.

Primary breast augmentation clinical trial outcomes stratified by surgical incision, anatomical placement and implant device type.

BACKGROUND: Clinical evidence concerning the potential risks and benefits associated with surgical incision, anatomical pocket and implant device type in primary breast augmentation is lacking. OBJECTIVES: This study assesses relative risk (RR) of adverse events stratified by surgical incision, anatomical pocket and breast implant device in primary augmentation patients enrolled in Core (NCT00689871, round/silicone devices) and 410 (NCT00690339, anatomically shaped/highly cohesive silicone devices) long-term clinical trials. METHODS: RR for time-to-first-event of Baker grade 3-4 capsular contracture (CC), moderate-severe malposition, and secondary procedure were calculated using multivariate time-to-event regression analysis. RESULTS: Risk of CC was increased with periareolar (unadjusted model only) and with axillary (adjusted model) versus inframammary incision. Risk of CC was significantly reduced with subpectoral versus subglandular placement (adjusted model), and with textured surface/round/silicone-filled devices and textured surface/shaped/highly cohesive silicone-filled devices versus smooth surface/round/silicone-filled devices (adjusted model). Risk of CC was significantly reduced with textured surface devices independent of subpectoral or subglandular placement (adjusted model). In a number-needed-to-treat analysis, 7-9 patients needed to be treated with a textured surface device to prevent one Baker grade 3-4 CC over 10 years. Risk of moderate-severe malposition was significantly increased with periareolar (adjusted model) and axillary (adjusted model) versus inframammary incision; and significantly lower with textured surface/shaped/highly cohesive silicone-filled devices than with smooth surface/round/silicone-filled devices (adjusted model). Risk of secondary procedures was significantly increased with periareolar (adjusted model) and axillary (adjusted model) versus inframammary incision; and significantly reduced with textured surface/shaped/highly cohesive silicone-filled devices versus smooth surface/round/silicone-filled devices (adjusted model). CONCLUSIONS: In primary breast augmentation, surgical incision, anatomical pocket, and device were significant predictors of clinical outcomes: capsular contracture, malposition and secondary procedure.

The role of acellular dermal matrix in the treatment of capsular contracture.

Capsular contracture is one of the most common complications following breast surgery with implants and is a common cause for reoperation. Many techniques have been described to treat or prevent recurrent capsular contracture with varying success. Acellular dermal matrix (ADM), in combination with periprosthetic capsulectomy, is a powerful tool to delay or prevent recurrent contracture. Excellent results have been obtained when this approach has been used in patients with capsular contracture, but at increased cost.

Expander/implant reconstruction with AlloDerm: recent experience.

BACKGROUND: Expander/implant reconstruction with acellular dermal matrix (AlloDerm) has become an increasingly popular technique. Potential advantages include lengthening of the pectoralis major muscle, preventing "window-shading" after muscle release; precise control of the inframammary fold and lateral breast border; and complete coverage of the device without resorting to additional muscle or fascial elevation. METHODS: Patients undergoing immediate breast reconstruction with tissue expanders underwent acellular dermal matrix augmentation of the pectoralis major muscle. After inferior pectoralis muscle release and creation of a subpectoral pocket, the acellular dermal matrix was draped out to length and sutured to the inframammary fold. An integral port, low-height tissue expander was placed into the pocket and the acellular dermal matrix was sewn to the cut edge of the muscle inferiorly. Subsequent placement of either a smooth-walled silicone gel implant or anatomically shaped cohesive gel device was performed secondarily. RESULTS: Twenty consecutive patients (29 breasts) undergoing immediate breast reconstruction with tissue expanders had acellular dermal matrix augmentation of the pectoralis major muscle. Follow-up averaged 21 months (range, 3 to 32 months). Infection occurred in one of 29 breasts (3.4 percent). One patient had a small area of suture line necrosis requiring revision. CONCLUSIONS: Acellular dermal matrix augmentation of the pectoralis major muscle in the setting of prosthetic breast reconstruction improves the soft-tissue drapery around devices without resorting to additional muscle or fascial flaps. Total device coverage and precise control of the pocket dimensions permit more predictably superior results in these patients.