Long-term advantages of permanent expandable implants in breast aesthetic surgery

Outcome of single-stage breast reconstruction using the Natrelle 150 expander implant

The Natrelle 150 offers the advantage of single-stage reconstruction. However, there is lack of published data on its long term outcomes, which does not allow for definitive conclusions as to whether it truly meets its design objective of a lasting single stage breast reconstruction. This is a retrospective review of all Natrelle 150 reconstructions by a single surgeon over 5 years. A total of 143 procedures were performed in 125 patients with a mean follow-up of 33 months (range, 3-65 months). Most (120, 84%) received the implant after oncological mastectomies, 22 (15%) after risk-reducing mastectomies, and 1 (0.8%) for hypoplasia. Fifty-one (35.7%) implants were explanted an average of 12.9 months after implantation. A Kaplan-Meier survival analysis demonstrates an explantation rate of 25% by 11 months. Explantation was more likely after subpectoral placement compared to reconstructions in combination with latissimus dorsi flaps (P<0.05). Risk-reducing reconstructions were also more likely to undergo explantation (P<0.05) compared to reconstructions for oncological reasons. Our data suggest that this prosthesis is only successful as a 1-stage procedure in certain patients, and has led to more careful patient selection and counseling.

Comparison of breast implant deflation for mentor anterior and posterior valve designs in aesthetic and reconstructive patients

BACKGROUND

Saline breast implant rupture remains problematic after implantation. Company reports and previous studies implicate the valve as a common site of implant failure. This study evaluates the rupture rate of the Mentor posterior valve compared with the anterior valve in breast augmentation and reconstruction.

METHODS

This is a retrospective analysis of consecutive breast implantations performed between 1992 and 2004 by two surgeons. All but two implants were filled at or above the manufacturer-recommended volume. Data were collected by chart review, telephone survey, and Mentor Corp. reports. Kaplan-Meier and Mantel-Haenszel analyses were used to compare rupture rate and relative risks, respectively.

RESULTS

Sufficient data were available for 516 implants in 325 women (average follow-up, 6.04 years). Overall, those implants with posterior valves had a lower rupture rate (0.007 versus 0.022). In the reconstructive cohort, the posterior valve implants had a lower rupture rate (0.011 versus 0.036), and the relative risk of rupture using an anterior valve versus a posterior valve was 3.387 (p = 0.0154). There was no significant difference in rupture rate between valve types in breast augmentation. A multivariate analysis showed that implant texture did not affect rupture rate.

CONCLUSIONS

The authors found a statistically significant decrease in implant rupture for Mentor posterior valve implants in the reconstructive cohort and no difference in the augmentation cohort. Thus, the authors conclude that at worst, the posterior valve is not more prone to rupture than the anterior valve model. Furthermore, the authors believe that the postoperative flexibility of the posterior valve implants makes them more useful clinically.

Breast implants as a preventive factor

After a large number of patients with silicone breast implants worldwide had been evaluated [2, 9], it was concluded that such implants were not carcinogenic. This allowed for experimentation with rats to determine the benefits and potential risks associated with implants. By means of a high-precision monitor, temperature measurements were obtained from 100 silicone-implanted rats. These measurements then were divided into various groups to compare the reaction of their implanted and nonimplanted mammary glands at different hormone levels. The temperature measurements were analyzed and compared. Dysthermia was detected in the skin area immediately overlying the implant. The results also demonstrated that at high hormone levels, implants act as neutralizing agents. By contrast, glandular alterations with severe signs of anisocytosis and anisokoryosis were observed in nonimplanted glands.

One-stage breast reconstruction using McGhan Style 150 biodimensional expanders: A review of 107 implants with six years experience

Permanent expanders have revolutionised breast reconstructive surgery, allowing one-stage procedures and the development of increasingly sophisticated implants (textured, anatomically shaped) has played an important role in enhancing the aesthetic outcomes. It is important to evaluate the tolerability of the implant. The aim of this present study was to evaluate the survival curves for McGhan Style 150 permanent expanders, in a consecutive series of breast reconstructions. Complications rates were also examined. Between April 1997 and May 2003, 107 McGhan Style 150 expanders (either full height or short height depending on patients' requirements) were used in 97 consecutive patients for a variety of breast reconstructive procedures. Overall, 46 devices were used for immediate reconstruction, 15 for delayed reconstruction and 46 for implant exchange, respectively. The mean age at implantation was 48 years (min: 26; max: 71). The mean follow-up was 60 months (min: 12; max: 72). Explantation was considered the most objective outcome variable, therefore this parameter was carefully monitored and then analysed using the Kaplan-Meier method of survival analysis. Different curves were compared using the log-rank test. Long term complications were also recorded. Among complications the most frequent finding was Baker 3-4 capsular contracture, occurring in 26% of immediate reconstructions at six years. Explantations increased in an almost linear fashion, with an overall rate of 25%, with a statistically significant difference among immediate reconstruction group and the implant exchange group. The rate of explantations was high, if compared with other series, because the sample included patients undergoing strong adjuvant therapies, particularly in the immediate group (locally advanced disease). The overall rate of explantations and of capsular contracture was found to be significantly lower in the delayed and substitution groups, than the immediate group (p<0.05). In our hands, the McGhan Style 150 anatomically shaped permanent expanders were associated with acceptable results, especially when used as 'permanent prostheses' for second stage procedures.

Decision making in the treatment of tuberous and tubular breasts: volume adjustment as a crucial stage in the surgical strategy

Tuberous and tubular breasts, two distinct deformities based on the same anatomic anomaly, are characterized by several morphologic alterations with a wide spectrum of expression. The classifications reported in the literature are based primarily on deformity of shape, but other parameters such as breast volume and symmetry often are underrated. This study aimed to define tuberous and tubular breasts and their management accurately on the basis of multiple anatomic alterations involving breast volume and symmetry as well as shape. The records of 30 patients affected by tubular and tuberous breast were reviewed. Surgical strategy included correction of breast shape through areola and gland alterations, correction of volume asymmetry through parenchyma resection, and volume augmentation through permanent expandable breast implant insertion. All the patients were treated bilaterally. Evaluation using a visual analogic scale confirmed high patient satisfaction with a mean value of 92.6% in the assessment of shape, volume, and symmetry. Correct diagnosis, careful preoperative evaluation, and a comprehensive surgical strategy can achieve, in one surgical procedure, good and long-lasting outcomes in terms of breast shape and volume symmetry.

Breast reconstruction by tissue expansion. A retrospective technical review of 197 two-stage delayed reconstructions following mastectomy for malignant breast disease in 189 patients

Despite the advent of free tissue transfer, breast reconstruction by tissue expansion is an important technique in the armamentarium of the reconstructive breast surgeon. The concept is deceptively simple and yet in reality can produce difficult complications and poor results. A database was compiled of all the patients receiving tissue expanders and/or implants for cosmetic, congenital and reconstructive purposes between 1986 and 1998. 189 patients had 197 delayed two-stage tissue expansion breast reconstructions following mastectomies for malignant breast disease between 1986 and 1997. 103 breasts (52%) had two uncomplicated stages. The remainder had one or more complications, revisional procedures for complications or alterations to the reconstruction for size, position or shape. Overall each breast reconstruction required 2.9 procedures (range 2-9). The complications and additional procedures are discussed. In particular, capsular contracture of the definitive implant (12%) was related to implant type and not to the speed of tissue expansion or the degree or duration of over-expansion. Although 17% of patients received radiotherapy, none of those who developed contracture around the definitive implant had this adjuvant therapy, P< 0.05. Twelve reconstructions (6%) totally failed due to complications of which six underwent secondary flap reconstruction. Twenty-one patients have subsequently developed metastatic disease of which 15 have died to date. Breast reconstruction by tissue expansion is still an important technique. It should be used carefully and thoughtfully by surgeons trained to deal with any complications. Patients need to be carefully selected and counselled prior to undertaking this process.