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| IMMEDIATE BREAST RECONSTRUCTION |
| USING THE EXPANDER/IMPLANT TECHNIQUE |
| STAGE
I |
Prior to mastectomy, the patient's inframammary
folds and mid-line are marked. These markings will be
used during surgery to help with dissection and
correct placement of the expander.
Reconstruction proceeds directly following the
mastectomy. The skin flaps remaining after the
mastectomy are evaluated for viability. All
potentially ischemic tissue is removed to avoid
possible wound healing complications. If concern
remains regarding the viability of the skin flaps,
one ampule of flourescein may be given intravenously
and a Woods Lamp can be used to help assess
perfusion.
- Selection of the Expander
The base width of the existing breast is the most
important measurement in selecting the size and style
of an expander. A plastic template supplied by the
manufacturer (McGhan) is used to confirm the match.
Once the measurements are confirmed, an appropriately
matched McGhan style 133 anatomic textured tissue
expander with an integral injection port is chosen.
- Creation of the Muscle
Pocket/Expander Placement
A muscle pocket is created for the tissue
expander. The pectoralis major is elevated superiorly
and medially, beginning at the lateral edge. The
serratus anterior and anterior fascia of the rectus
are elevated downward. It is possible the pocket may
not be intact, particularly the lower portion,
nonetheless it is crucial to provide a muscular
separation between the expander and the
skin/mastectomy incision. Prior to placement, all air
is removed and the expander is filled with saline to
check for leaks. Once the expander is cleared for
leaks, it is filled with 50-100 cc of saline. The
selected expander is then inserted with the integral
injection port placed superiorly in the pocket (see
Figure 1).
The muscle edges are approximated over the
expander with interrupted 3-0 vicryl sutures.
A closed drainage system is recommended. A
Jackson-Pratt 10 French fully perforated flat drain
with bulb suction is used to prevent fluid
accumulation. The drain is inserted into the pocket
through a separate lateral stab incision and secured
with 2-0 nylon sutures. The skin is approximated in
layers using 3-0 vicryl sutures in the muscle and
subcutaneous layers. A 4-0 prolene subcuticular
running suture is used to approximate the skin edges.
Tubing and attached 21 gauge needle are primed
using saline to remove all air. The injection port is
then palpated and a McGhan magnaport finder (magnet)
is used to verify the location of the integral port.
The needle is inserted into the integral injection
port until the steel backing is struck and then
aspirated to ensure proper positioning. A measured
amount of saline is injected into the
expander—50 to 200 cc is the standard amount
injected during an expansion session. The volume
injected is restricted by the point at which the
patient begins to feel tightness or discomfort.
- Expansion Process Overview
Breast expansion begins two weeks after the
mastectomy if the incisions are healing well.
Concerns regarding healing may postpone expansion
until the status of the wound is satisfactory.
Expansion occurs weekly until the expander is 10%
larger than the native breast, at which point the
process is stopped and the second stage implant
exchange is planned four months later.
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| IMMEDIATE BREAST RECONSTRUCTION |
| USING THE EXPANDER/IMPLANT TECHNIQUE |
| STAGE
II |
- Pre Expander/Implant
Exchange
Prior to the expander/implant exchange, the status
of the expanded breast mound is compared in relation
to the patient’s native breast. Markings are
once again made, identifying the mid-line and
inframammary creases.
The previous incision is used to remove the
expander. If necessary, adjustments are made in the
capsule surrounding the expander to achieve symmetry
with the contralateral breast. The inframammary
crease may need to be lowered by incising the lower
portion of the capsule, or elevated by using a 3-0
merselene suture to recreate a precise higher
inframammary fold. Ideally, no alterations are
necessary and the permanent implant can be placed
immediately.
The selection between the McGhan style 363 and the
McGhan style 163 implant is made based upon the shape
of the patient’s native breast. The implants
differ in the design of the upper pole (see Figure
2).
The McGhan style 163 is slightly taller than it is
wide, with a contoured upper pole and projecting
lower pole. While the McGhan style 363 implant has a
projecting lower pole, but is shorter than it is
wide. The style 363 implant creates a greater
concavity of the upper pole of the reconstructed
breast. Typically I use the style 163, but will on
occasion select the style 363.
Prior to its placement in the muscle pocket, the
air should be removed from the implant and then
filled to the appropriate volume with sterile saline
and checked for leaks. The implants have very
sensitive predetermined volume ranges. For example,
underfilling can risk underinflation and rippling in
the newly reconstructed breast. In addition, both
overfilling and underfilling can result in implant
rupture. Final judgment and correction of implant
placement can be made by sitting the patient upright
and making any necessary adjustments.
The wounds are closed in layers using 3-0 vicryl
sutures on both the muscle and the subcutaneous
layers. The skin is approximated with a subcuticular
4-0 prolene suture. To prevent fluid accumulation, a
10 French Jackson-Pratt flat-drain with bulb suction
is used. The drain is brought out through a separate
stab incision laterally and secured with a 2-0 nylon
suture. Two-inch 3M microfoam tape is then placed in
the inframammary crease to maintain its position.
Sterile dressings and a surgical bra from Baxter are
subsequently placed on the newly reconstructed
breast.
- Bilateral Breast
Reconstruction
If the patient undergoes bilateral breast removal,
care must be given to create symmetric inframammary
folds.
© 1997 - TRANSMED
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