Objective
To introduce the application of post-expansion prosthesis placement for breast reconstruction in patients with breast defects after modified radical breast cancer surgery, simple mastectomy and asymmetric breast deformity.
Results
Nine cases with 13 breasts were clinically applied, including two cases and two sides with breast defects after modified radical breast cancer surgery, four cases and eight sides with simple mastectomy, and three cases and three sides with asymmetric breast deformity, with satisfactory results at the longest follow-up of 2 years.
Conclusion
Post-expansion prosthesis placement for breast reconstruction allows patients to obtain a shape and size close to the contralateral breast without the trauma of additional donor area for reconstructive surgery. Radiotherapy can increase the incidence of complications, and this method should be used with caution in patients who require radiotherapy.
1.Surgical method
Local anesthesia with intravenous sedation is used. The patient is routinely disinfected and sheeted in the supine position. In the case of cystic hyperplasia, an incision of about 5-6 cm in length is designed on the lateral side of the inframammary fold to remove the cystic hyperplastic gland completely. The posterior space of the pectoralis major muscle is separated along the outer edge of the pectoralis major muscle, and part of the anterior serratus muscle is separated laterally under it to the anterior axillary line, forming a complete cavity under the pectoralis major muscle and behind the anterior serratus muscle, into which a 300-400 ml circular dilator is placed, and the injection pot is placed under the skin. During the operation, 100ml of water is injected, and after the removal of the stitches, water is continued to be injected until the volume is satisfactory or symmetrical with the contralateral side, and the total amount of water injected is recorded as the reference volume of the breast implant. Continue to inject 30%~50% of the excess volume of water, maintain it for more than 3 months, remove the expander again surgically and place the breast prosthesis. Patients with modified radical surgery for breast cancer utilize the original surgical incision. Patients with asymmetric breast deformity can take the areolar incision.
2. Typical cases
Case 1: Female patient, 38 years old. Diagnosis: cystic hyperplasia of the breast, bilateral. Bilateral simple mastectomy followed by expanded breast reconstruction was performed. During the operation, 300 ml of round expanders were placed in the posterior space of the pectoralis major muscle bilaterally, and water was injected for 5 months, totaling 450 ml, which was replaced with 300 ml of silicone gel breast prosthesis.
Case 2: Patient female, 21 years old. Diagnosis: right breast dysplasia, after radiotherapy. Hemangioma over the right nipple areola was detected right after birth and was treated with isotope at 10 months of age. Asymmetrical breast development during puberty, the right breast was significantly smaller in volume than the left. The right breast was reconstructed by expansion, 400 ml of expander was placed, water was injected for 3 and a half months, the total volume was 530 ml and replaced with 380 ml of silicone gel breast prosthesis, and both breasts were basically symmetrical after surgery.
3. Results
The interval between the two operations was 3 to 8 months, with an average of 5 months. One of the cases has been dilated for 2 years and has not been taken out so far. The total volume of water injected into the expander was 300~600 ml, with an average of 400 ml. 30%~50% of water was over-injected. The volume of breast implants ranged from 200 to 380 ml, with an average of 275 ml. The reconstructed breasts were natural, slightly droopy and symmetrical bilaterally. Five cases were followed up after the operation, and the follow-up time was 3~24 months, with satisfactory results.
4. Discussion
(1) Commonly used clinical breast reconstruction methods
The following methods are commonly used for breast reconstruction: ① abdominal flap free graft breast reconstruction with tissues or anastomotic vessels. The abdominal subcutaneous fat is thicker, and the amount of autologous tissue available is large. This method is suitable for patients who have undergone maternity, have a lax abdominal wall, and have a large contralateral breast. ②Breast reconstruction with latissimus dorsi muscle flap or additional breast prosthesis is also a very common method, mainly for young and infertile patients with small contralateral breast or old and weak patients who cannot tolerate larger surgery. ③Simple breast reconstruction with implant placement. ④Expansion breast reconstruction. The above methods have their advantages and disadvantages. Autologous tissue breast reconstruction has the advantages of good feel and tolerance to radiotherapy, but increases the trauma to the donor area, which most patients are not willing to accept. However, there are disadvantages such as mismatch between skin and pectoralis major muscle, limited size of reconstructed breast, lack of movement, and hardening of the breast due to contracture of the envelope. Expanded breast reconstruction overcomes some of the disadvantages of simple prosthesis placement and is especially suitable for patients with simple glandular excision and asymmetric breast deformity.
(2) Characteristics of simple mastectomy and asymmetrical breast development deformity.
For simple mastectomy, an areolar incision or inframammary fold incision is usually taken, preserving the surface skin of the breast and the nipple areola. After glandular excision, the local skin on the affected side is relaxed and wrinkled, and the healthy side of the breast is more saggy due to breastfeeding. If the prosthesis is placed behind the pectoralis major muscle in stage I, the prosthesis cannot support the loose and wrinkled skin on the surface due to the restriction of the pectoralis major muscle, and the reconstructed breast cannot form a natural protruding and slightly sagging effect. Asymmetrical breast deformity is characterized by a significantly smaller breast volume than the contralateral side, with a basically normal or small nipple areola development and normal contralateral breast development. If the implant is placed behind the pectoralis major muscle in stage I, it is also restricted by the pectoralis major muscle and its surface skin, and the reconstructed breast cannot exhibit a natural degree of droop. Expansion can counteract the elastic retraction of the pectoralis major muscle, so that it matches the surface skin and forms one piece. Continued over-expansion makes the prosthesis cavity of sufficient size, and the reconstructed breast will have a sense of sagging and achieve symmetry with the contralateral breast.
(3) Features of expanded breast reconstruction
The expansion can regenerate the tissues and also counteract the muscle retraction force. The expanded breast reconstruction solves the problems of insufficient soft tissue of the skin and insufficient size of the prosthesis cavity and postoperative contracture of the envelope. The expanded reconstructed breast is of appropriate size, natural shape, good feel and easy symmetry. The expansion should be done as soon as possible after the incision heals, so that the wrinkled skin can be smoothed out as soon as possible, reducing the difficulties caused by re-expansion after healing. It is very important to overdraw and overtime expansion, as the long time tension can counteract the elastic retraction of the tissue and reduce the occurrence of hardening of the breast due to contracture of the envelope. The water injection can exceed the actual amount needed by more than 50%, and the best result is achieved if it can be maintained for more than six months.
The disadvantages of this method are: ① Long and costly, although rapid expansion can save time, the postoperative effect is not stable enough and the breast shape is difficult to maintain. Only under the continuous action of tension for a long enough time can the tissue regenerate and fight against elastic retraction. ② The occurrence of hardening of the breast due to peri-implant contracture cannot be completely avoided. In addition to the surgical and implant-related factors that need attention, the oral administration of cumene tablets for six months has also been shown to inhibit the excessive proliferation of collagen fibers leading to peri-implant contracture.
(4) Indications for expanded breast reconstruction
The main indications for expanded breast reconstruction are: patients with intact skin and pectoralis major muscle, no need for postoperative radiotherapy, and not too large contralateral breast. This method can be applied to stage I or II breast reconstruction in patients with various breast defects, agenesis or bilateral breast asymmetry, but the complications during expansion increase in patients who need radiotherapy before and after surgery, Tallet AV et al. reported that this method has up to 3 times more complications than other procedures, which affects the postoperative results and comprehensive treatment, therefore, such patients must be used with caution. In patients after modified radical surgery, postoperative water injection should not be done too early or too fast to avoid hindering incisional healing. Patients with simple mastectomy are mostly benign lesions, the surgery preserves the normal skin of the breast and the nipple areola, and postoperative radiotherapy is not required; therefore, patients with simple mastectomy and asymmetric breast deformity are more suitable for this method.