Breast Reconstruction with Expanders and Implants

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Breast reconstruction can be achieved through the use of tissue expanders followed by implants or by direct implant placement. Each approach has its specific advantages and considerations. 

Tissue expander-based reconstruction is often used when there is a need to gradually stretch the skin and soft tissue to accommodate an implant. 

This process begins with the placement of a temporary expander beneath the skin and muscle. Over time, the expander is gradually filled with saline to stretch the skin, creating enough space for a permanent implant.

This technique is particularly useful in cases where there isn’t sufficient skin after a mastectomy, or when additional expansion is needed to achieve the desired breast shape. 

Once the tissue has been adequately expanded, the expander is replaced with a permanent implant in a second surgery.

 In cases where there is enough skin and soft tissue, an implant can be placed directly without the need for an expander. This is the case with a skin sparing mastectomy.

The implant is positioned under the skin left from the mastectomy, often in front of the pectoral muscle (pre-pectoral position), which avoids the unnatural movement that can occur when the implant is placed under the muscle.

Implant-based reconstruction is a quick and straightforward procedure, offering good results when the nipple and areola are preserved, the remaining breast is not too large or droopy, and no radiotherapy is planned after the mastectomy.

 While implants provide a less invasive option with quicker recovery, the results may be less natural compared to autologous reconstruction methods. Over time, the implant may need to be replaced due to potential complications like rupture, infection, or capsular contracture (a hardening of the tissue around the implant).

Smoking is a significant risk factor, increasing the likelihood of complications such as skin necrosis. This makes it a contraindication for implant reconstruction. Additionally, in cases of cancer recurrence after conservative treatment, implant reconstruction is generally not recommended due to the increased risk of skin complications.

Breast reconstruction using flaps involves transferring tissue from one part of the body to the breast area to create a new breast mound. 

The transferred tissue, known as a flap, is made up of skin, fat, and sometimes muscle. 

Flaps can be classified into two main types: free flaps and pedicled flaps. 

Free flaps require microvascular surgery to connect the blood vessels, while pedicled flaps maintain their original blood supply. 

 DIEP (Deep Inferior Epigastric Perforator) flap is an advanced breast reconstruction technique that uses skin and fat from the lower abdomen to reconstruct the breast. This method provides the most natural and long-lasting results, without sacrificing any muscle, leading to a smoother recovery and reduced risk of abdominal weakness. It also tightens the skin laxity providing a smoother abdominal contour (like an abdominoplasty).

Key points:

• Uses abdominal skin and fat.
• Requires microvascular surgery.
• Can be performed immediately after mastectomy or as a secondary procedure.
• Not suitable for women with insufficient abdominal tissue or previous abdominal surgeries.

 The Latissimus Dorsi (LD) flap is a reliable breast reconstruction option that uses muscle, fat, and skin from the upper back. This flap remains attached to its original blood supply (pedicled), making it less complex than free flaps.

Key points:

• Uses muscle and tissue from the upper back.
• Often combined with an implant or lipofilling to achieve the desired breast size and shape.
• Ideal for patients who have undergone radiation therapy or lack sufficient abdominal tissue for a DIEP flap.
• Leaves a scar on the back but provides robust coverage for the reconstructed breast.

This technique is versatile and suitable for immediate or delayed reconstruction, especially in cases where other methods are not feasible.