Judging an Expander by Its Cover: A Propensity-Matched Analysis of the Impact of Tissue Expander Surface Texture on First-Stage Breast Reconstruction Outcomes

Safety Profile Comparison of 2 Smooth Tissue Expander Types: Artoura and CPX4

INTRODUCTION

With the recent transition to smooth tissue expanders (TEs), functional differences between TE subtypes have not been fully elucidated. This study evaluated the differences in TE characteristics and complications between 2 commonly used Mentor smooth TE models, Artoura and CPX4.

METHODS

A retrospective review of patients who received either smooth Mentor Artoura or CPX4 TE from 2012 to 2022 was conducted. Demographic data, perioperative information, pain scores, TE variables, cancer characteristics, and complications were collected. A multivariate analysis was used to evaluate the relationship between TE subtype and complications while controlling for demographic, TE characteristics, radiation, and chemotherapy exposure.

RESULTS

During the study period, 62 smooth Artoura TEs and 79 smooth CPX4 TEs were used. Patients who received CPX4 smooth implants tended to be older (51.09 vs 46.18 years old, P = 0.02) and have a higher body mass index (28.66 vs 23.50 kg/m 2 , P < 0.001). There were no differences among patient comorbidities. CPX4 required on average a greater total fill volume (422.23 vs 348.07 mL, P = 0.01) and had a greater drain duration (16.91 vs 14.33 days, P = 0.05). There were no differences in TE plane placement between Artoura and CPX4. Additionally, there were no differences in complication rates, including infection, hematomas, seromas, wound breakdown, TE replacement, and capsular contracture. When controlling for body mass index, diabetes, TE plane placement, acellular dermal matrix use, radiation exposure, and chemotherapy, there was no association between TE subtype and any individual complication.

DISCUSSION

Differences in total fill volume and drain duration were significantly different between Mentor Artoura and CPX4 implants, which may influence TE subtype selection. However, Artoura and CPX4 have excellent and equivalent safety profiles with similar complication rates, even when controlling for demographic and TE characteristics.

Impact of Tissue Expander Surface Texture on Two-Stage Breast Reconstruction Outcomes: A Combined Analysis

BACKGROUND

With ongoing investigations of the impact of device texturing on breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL), studies have begun comparing complication profiles of tissue expanders. However, there is a paucity of timing and severity data of complications. The aim of this study was to provide a comparative survival analysis of postoperative complications between smooth (STEs) and textured tissue expanders (TTEs) in breast reconstruction.

METHODS

A single-institution experience with tissue expander breast reconstruction was reviewed for complications up to 1 year after second-stage reconstruction from 2014 to 2020. Demographics, comorbidities, operation-related variables, and complications were evaluated. Kaplan-Meier curves, Cox proportional hazard models, and a consensus-based ordinal logistic regression model were used to compare complication profiles.

RESULTS

Of 919 total patients, 600 (65.3%) received TTEs and 319 (34.7%) received STEs. There was increased risk of infection ( P < 0.0001), seroma ( P = 0.046), expander malposition ( P < 0.0001), and wound dehiscence ( P = 0.019) in STEs compared with TTEs. However, there was also a decreased risk of capsular contracture ( P = 0.005) in STEs compared with TTEs. Failure of breast reconstruction ( P < 0.001) and wound dehiscence ( P = 0.018) occurred significantly earlier in STEs compared with TTEs. Predictors for significantly higher severity complications included the following: smooth tissue expander use ( P = 0.007), shorter time to complication ( P < 0.0001), higher body mass index ( P = 0.005), smoking history ( P = 0.025), and nipple-sparing mastectomy ( P = 0.012).

CONCLUSIONS

Differences in the timing and severity of complications contribute to the safety profiles of tissue expanders. STEs are associated with increased odds of higher severity and earlier complications. Therefore, tissue expander selection may depend on underlying risk factors and severity predictors.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Early Complications in Prepectoral Tissue Expander-Based Breast Reconstruction

BACKGROUND

Prepectoral implant placement for postmastectomy breast reconstruction has increased in recent years. Benefits of prepectoral reconstruction may include lack of animation deformities and reduced postoperative pain, but its complication profile is currently unclear. This study aimed to examine the complication profile of prepectoral tissue expanders (TEs) to determine factors associated with TE loss.

METHODS

A retrospective review was performed to identify all patients who underwent immediate prepectoral TE reconstruction from January 2018 to June 2021. The decision to use the prepectoral technique was based on mastectomy skin quality and patient comorbidities. Patient demographics, comorbidities, and operative details were evaluated. Outcomes of interest included TE loss, seroma, hematoma, infection/cellulitis, mastectomy skin flap necrosis requiring revision, and TE exposure. Logistic regression analysis was performed to identify factors associated with TE loss.

RESULTS

The study identified 1225 TEs. The most frequent complications were seroma (8.7%, n = 106), infection/cellulitis (8.2%, n = 101), and TE loss (4.2%, n = 51). Factors associated with TE loss in the univariate analysis included ethnicity, history of smoking, body mass index, mastectomy weight, and neoadjuvant chemotherapy. In the multivariate regression analysis, only mastectomy weight had a positive association with TE loss (odds ratio, 1.001; p = 0.016).

CONCLUSION

Prepectoral two-stage breast reconstruction can be performed safely with an acceptable early complication profile. The study data suggest that increasing mastectomy weight is the most significant factor associated with TE loss. Further research examining the quality of the soft tissue envelope and assessing patient-reported outcomes would prove beneficial.

Complication Profiles of Smooth vs Textured Tissue Expanders in Breast Reconstruction: A Systematic Review and Meta-Analysis

BACKGROUND

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a type of non-Hodgkin lymphoma first linked with breast implants in 2011. The correlation between BIA-ALCL and textured devices has led to increased use of smooth devices. However, much of the data surrounding smooth and textured devices investigates breast implants specifically and not tissue expanders.

OBJECTIVES

We performed a systematic review and a meta-analysis to compare surgical outcomes for smooth tissue expanders (STEs) and textured tissue expanders (TTEs).

METHODS

A search was performed on PubMed, including articles from 2016 to 2023 (n = 419). Studies comparing TTEs and STEs and reported complications were included. A random-effects model was utilized for meta-analysis.

RESULTS

A total of 5 articles met inclusion criteria, representing 1709 patients in the STE cohort and 1716 patients in the TTE cohort. The mean duration of tissue expansion with STEs was 221.25 days, while TTEs had a mean time of tissue expansion of 220.43 days.Our meta-analysis found no differences in all surgical outcomes except for explantation risk. STE use was associated with increased odds of explantation by over 50% compared to TTE use (odds ratio = 1.53; 95% CI = 1.15 to 2.02; P = .003).

CONCLUSIONS

Overall, STEs and TTEs had similar complication profiles. However, STEs had 1.5 times higher odds of explantation. The incidence of BIA-ALCL is low, and only a single case of BIA-ALCL has been reported with TTEs. This indicates that TTEs are safe and may lower the risk of early complications requiring explantation. Further studies are warranted to further define the relationship between tissue expanders and BIA-ALCL.

LEVEL OF EVIDENCE: 4

Textured versus Smooth Tissue Expanders: A Comparison of Complications in 3526 Breast Reconstructions

BACKGROUND

Increased understanding of breast implant-associated anaplastic large-cell lymphoma has led to a shift away from textured breast devices. A few small studies have compared the complication rates of textured and smooth tissue expanders (TEs). The aim of this study was to compare complication profiles in patients undergoing two-stage postmastectomy breast reconstruction with either textured or smooth TEs.

METHODS

The authors performed a retrospective review of female patients who underwent immediate breast reconstruction with textured or smooth TEs from 2018 to 2020 at their institution. Rates of seroma, infection/cellulitis, malposition/rotation, exposure, and TE loss were analyzed in the overall cohort and subgroups undergoing prepectoral and subpectoral TE placement. A propensity score-matched analysis was used to decrease the effects of confounders comparing textured and smooth TEs.

RESULTS

The authors analyzed 3526 TEs (1456 textured and 2070 smooth). More frequent use of acellular dermal matrix, SPY angiography, and prepectoral TE placement was noted in the smooth TE cohort ( P < 0.001). Univariate analysis suggested higher rates of infection/cellulitis, malposition/rotation, and exposure in smooth TEs (all P < 0.01). Rates of TE loss did not differ. After propensity matching, no differences were noted in infection or TE loss. Prepectoral smooth expanders had increased rates of malposition/rotation.

CONCLUSIONS

TE surface type did not affect rates of TE loss, although increased rates of expander malposition were noted in the smooth prepectoral cohort. Further research is needed to examine breast implant-associated anaplastic large-cell lymphoma risk with temporary textured TE exposure to improve decision-making.

CLINICAL QUESTION/LEVEL OF EVIDENCW

Therapeutic, III.

Smooth vs Textured Expanders: Patient Factors and Anatomic Plane Are Greater Factors in Determining First-Stage Breast Reconstruction Outcomes

BACKGROUND

Textured implants and expanders are associated with an increased risk of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). As a result, plastic surgeons are utilizing smooth expanders, but many perceive these produce undesirable outcomes including infection, seroma, and lateral displacement.

OBJECTIVES

The aim of this study was to compare clinical outcomes of smooth and textured expanders.

METHODS

Breast reconstruction patients from January 2018 to May 2021 were retrospectively reviewed. Included patients underwent placement of tissue expanders at the time of mastectomy. Primary outcomes included postoperative seroma, infection, malposition, days to final reconstruction, explantation, and the need for capsulorrhaphy.

RESULTS

In total, 233 patients were reviewed, of whom 167 met both inclusion and exclusion criteria. There was no statistically significant difference in poor outcomes comparing smooth and textured expanders. Days to final reconstruction was lower with smooth expanders per breast (P = .0424). The subpectoral group was associated with an increased likelihood of undergoing capsulorrhaphy (P = .004). Prepectoral placement was associated with more seromas (P = .0176) and infections (P = .0245). Demographic factors included older age as a protective factor for undergoing capsulorrhaphy (odds ratio [OR] = 0.962, P = .038), obesity increased the risk of infection (OR = 5.683, P = .0279) and malposition (OR = 6.208, P = .0222), and radiation was associated with malposition (OR = 3.408, P = .0246).

CONCLUSIONS

There was no significant difference in poor outcomes between smooth and textured expanders. Patient demographics and anatomical plane placement had greater effects on infection, seroma, and the need for capsulorrhaphy compared with tissue expander texturing.

LEVEL OF EVIDENCE: 3

Smooth versus Textured Tissue Expanders: Comparison of Outcomes and Complications in 536 Implants

Background  Increasing concerns regarding the safety of textured surface implants have resulted in surgeons transitioning from textured tissue expanders (TEs) to smooth TEs. Given this change has only recently occurred, this study evaluated outcomes between smooth and textured TEs. Methods  Women who underwent two-stage breast reconstruction using TEs from 2013 to 2022 were included. TE-specific variables, perioperative information, pain scores, and complications were collected. Chi-squared, t -test, and linear regression analyses were performed. Results  A total of 320 patients received a total of 384 textured and 152 smooth TEs. Note that 216 patients received bilateral reconstruction. TEs were removed in 9 cases. No significant differences existed between groups regarding comorbidities. Smooth TEs had a higher proportion of prepectoral placement ( p  < 0.001). Smooth TEs had less fills (3 ± 1 vs. 4 ± 2, p  < 0.001), shorter expansion periods (60 ± 44 vs. 90 ± 77 days, p  < 0.001), smaller expander fill volumes (390 ± 168 vs. 478 ± 177 mL, p  < 0.001), and shorter time to exchange (80 ± 43 vs. 104 ± 39 days, p  < 0.001). Complication rates between textured and smooth TEs were comparable. Smooth TE had a greater proportion of TE replacements ( p  = 0.030). On regression analysis, pain scores were more closely associated with age ( p  = 0.018) and TE texture ( p  = 0.046). Additional procedures at time of TE exchange ( p  < 0.001) and textured TE ( p  = 0.017) led to longer operative times. Conclusion  As many surgeons have transitioned away from textured implants, our study shows that smooth TEs have similar outcomes to the textured alternatives.

Seroma After Breast Reconstruction With Tissue Expanders: Outcomes and Management

BACKGROUND

Seroma is a relatively common complication after breast reconstruction with tissue expanders. The main risk in the presence of seroma is development of periprosthetic infection, which can lead to implant loss. Our goals were to identify risk factors for seroma, and to describe our protocol for managing fluid accumulation.

PATIENTS AND METHODS

An IRB approved breast reconstruction database was reviewed to identify patients who underwent tissue expander reconstruction. Patient characteristics, details of surgery, outcomes and treatment were recorded.

RESULTS

Two hundred nineteen tissue expander reconstructions were performed in 138 patients. Twenty-eight reconstructions developed seroma (12.8%), and 75 were identified to have prolonged drains (34.2%). Seroma was more common in patients with lymph node surgery ( P = 0.043), delayed reconstruction ( P = 0.049), and prepectoral reconstruction ( P = 0.002). Seroma and/or prolonged drains were more commonly noted in patients with higher body mass index ( P = 0.044) and larger breast size ( P = 0.001). Aspiration was the most common intervention (85.7%), which was performed in the clinic utilizing the expander port site. There was no difference in infection or explantation rate between seroma and no-seroma patients ( P = 0.546 and 0.167), whereas patients with any fluid concern (seroma and/or prolonged drains) were more prone to developing infection and undergoing explantation ( P = 0.041 and P < 0.005).

CONCLUSION

We recommend that prolonged drain placement longer than 3 weeks should be avoided, and patients should be screened for fluid accumulation after drain removal. Serial aspiration via expander port site and continuation of expansion provide a safe and effective method to manage seromas to avoid infection and expander loss.

A Propensity Score-Matched Comparison of Perioperative Outcomes in Prepectoral Smooth Versus Textured Tissue Expander Breast Reconstruction

INTRODUCTION

Textured tissue expanders (TEs) had previously gained popularity due to minimizing expander migration, rotation, and capsule migration. Recent studies, though, have revealed increased risk of anaplastic large-cell lymphoma associated with certain macrotextured implants, prompting surgeons at our institution to switch to smooth TEs; evaluation is thus required for specific viability and similarity of outcomes of smooth TEs. Our study aims to evaluate perioperative complications in prepectoral placement of smooth versus textured TEs.

METHODS

Our retrospective study evaluated perioperative outcomes of patients who underwent bilateral prepectoral TE placement, with either smooth or textured TE, at an academic institution between 2017 and 2021 performed by 2 reconstructive surgeons. The perioperative period was defined as the interval between expander placement until conversion to flap/implant or removal of TE due to complications. Our primary outcomes included hematoma, seroma, wounds, infection, unspecified redness, total number of complications, and returns to operating room secondary to complications. Secondary outcomes included time to drain removal, total number of expansions, hospital length of stay, length of time until the next breast reconstruction procedure, next breast reconstruction procedure, and number of expansions.

RESULTS

Two hundred twenty-two patients were evaluated in our study (141 textured, 81 smooth). After propensity matching (71 textured, 71 smooth), our univariate logistic regression showed no significant difference in perioperative complications between smooth and textured expanders (17.1% vs 21.1%; P = 0.396) or complications that required a return to the operating room (10.0% vs 9.2%; P = 0.809). No significant differences were noted for hematoma, seroma, infections, unspecified redness, or wounds between both groups. A significant difference was noted in days to drain out (18.57 ± 8.17 vs 20.13 ± 0.07, P = 0.001) and type of the next breast reconstruction procedure (P < 0.001). Our multivariate regression showed that breast surgeon, hypertension, smoking status, and mastectomy weight were significant for increased risk for complications.

CONCLUSION

Our study demonstrates similar rates and effectiveness of smooth versus textured TE when used for prepectoral placement, making smooth TEs a safe and valuable alternative for breast reconstruction because of their decreased risk of anaplastic large-cell lymphoma compared with textured TEs.

Is It All about Surface Topography? An Intra-Individual Clinical Outcome Analysis of Two Different Implant Surfaces in Breast Reconstruction

The most common long-term complication of silicone breast implants (SMI) remains capsular fibrosis. The etiology of this exaggerated implant encapsulation is multifactorial but primarily induced by the host response towards the foreign material silicone. Identified risk factors include specific implant topographies. Of note, breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) has only been observed in response to textured surface implants. We hypothesize that reduction of SMI surface roughness causes less host response and, hence, better cosmetic outcomes with fewer complications for the patient. A total of 7 patients received the routinely used CPX^®4 breast expander (~60 µM Ra) and the novel SmoothSilk^® (~4 µM Ra), fixed prepectoral with a titanized mesh pocket and randomized to the left or right breast after bilateral prophylactic NSME (nipple-sparing mastectomy). We aimed to compare the postoperative outcome regarding capsule thickness, seroma formation, rippling, implant dislocation as well as comfortability and practicability. Our analysis shows that surface roughness is an influential parameter in controlling fibrotic implant encapsulation. Compared intra-individually for the first time in patients, our data confirm an improved biocompatibility with minor capsule formation around SmoothSilk^® implants with an average shell roughness of 4 µM and in addition an amplification of host response by titanized implant pockets.

Smooth versus textured tissue expanders in breast reconstruction - A retrospective review of post-operative surgical site infections

BACKGROUND

Textured tissue expanders (TTEs) were introduced to limit migration and reduce capsular contracture, which were inherent to smooth tissue expanders (STEs). Previous reports suggest that textured devices have increased rates of bacterial contamination and biofilm formation in comparison with smooth devices. Recently, the relative increased association of anaplastic large cell lymphoma (ALCL) with textured versus smooth devices has led to increased adoption of smooth devices. The aim of our study is to evaluate the post-operative surgical site infection (SSI) rates of STEs versus TTEs.

METHODS

A retrospective case series was conducted at a single academic teaching hospital from April 2016 to December 2019. The primary outcome variable was the development of a post-operative SSI.

RESULTS

One hundred seventy-seven breasts underwent reconstruction with TTEs and 109 breasts underwent reconstruction with STE. In total, 54 SSIs were recorded (n = 34 TTE; n = 20 STE), with the majority of infections occurring within the first 30 post-operative days (TTE 65%, STE 70%). There was no statistically significant difference in overall post-operative infection rates between TTE and STE groups when broken down into the following time points: <30 day, 30-60 days, and >90 days (p = 0.924). There was no statistically significant difference between infection type (superficial vs. deep, p = 0.932), infection management (medical, surgical, or both, p = 0.409) or salvage results (p = 0.078) seen in STE versus TTE cohort. On multivariate analysis, seroma history was associated with SSI development (OR 3.18, p = 0.041).

CONCLUSION

There was no significant difference in the rate of post-operative SSI following breast reconstruction with STE relative to TTE.

Smooth Versus Textured Tissue Expander Breast Reconstruction: Complications and Efficacy

INTRODUCTION

Ongoing recognition of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) and its link with textured devices has brought a paradigm shift in prosthetic-based breast reconstruction. Many institutions no longer offer textured expansion devices for staged reconstruction. However, there is a paucity of data regarding the efficacy of smooth tissue expanders (TE). We hypothesized that the time to final reconstruction and complication profile between smooth and textured TEs would be similar in breast reconstruction patients.

METHODS

A retrospective chart review was performed of all patients who underwent TE breast reconstruction during a 6-year period at the Penn State Hershey Medical Center. Rates of complications treated nonoperatively and those requiring reoperation were assessed. Mechanical complications, including expander malposition and rupture, were evaluated. Time to final breast reconstruction was quantified. Mixed-effects logistic regression and linear regression models, as appropriate, were used to compare textured to smooth TEs. Patient characteristics and anatomic plane placement were adjusted for in all analyses of outcomes.

RESULTS

Data were collected on 389 patients, encompassing 140 smooth and 604 textured TEs. Textured devices had an increased incidence of complications treated nonsurgically (16.7% vs 10.7%; P = 0.14). However, smooth TEs had an increased incidence of reoperation (12.1% vs 7.6%; P = 0.06). Most noteworthy was that although smooth TEs had a 40-fold increase in malposition (13.6% vs 0.3%; P < 0.001), no reoperation for this complication was warranted. Further, the time to final reconstruction was comparable between the 2 devices (textured expanders: 221 days and smooth expanders: 234 days; P = 0.15).

CONCLUSIONS

Staged, implant-based reconstruction is the most common surgical approach to recreate the breast mound following mastectomy. Textured TEs were the cornerstone to this approach. Unfortunately, the association between textured devices and BIA-ALCL now mandates an alternative. We postulated that smooth expanders would compare favorably for breast reconstruction. Although our study suggests that smooth TEs suffer more malposition, this has a negligible impact on the reconstructive timeline. Thus, smooth TEs may prove beneficial when considering the risk of BIA-ALCL associated with textured devices.