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Concept: Tissue expansion

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Abstract Immediate breast reconstruction with tissue expander has become an increasingly popular procedure. Complete coverage of the expander by a musculofascial layer provides an additional well-vascularised layer, reducing the rate of possible complications of skin necrosis, prosthesis displacement, and the late capsular contracture. Complete expander coverage can be achieved by a combination of pectoralis major muscle and adjacent thoracic fascia in selected patients. Seventy-five breast mounds in 59 patients were reconstructed, in the first stage a temporary tissue expander inserted immediately after mastectomy and a musculofascial layer composed of the pectoralis major muscle, the serratus anterior fascia, and the superficial pectoral fascia were created to cover the expander. The first stage was followed months later by implant insertion. Minor and major complications were reported in a period of follow-up ranging from 24-42 months (mean 31 months). Complete musculofascial coverage of the tissue expander was a simple and easy to learn technique providing that the patient has a well-formed and intact superficial pectoral and serratus anterior fascia. From a total of 75 breast mounds reconstructed, major complications rate was 4% (overall rate of 19.8%), including major seroma (n = 4), haematoma (n = 1), partial skin loss (n = 3), wound dehiscence (n = 1), major infection (n = 2), severe capsule contracture (n = 1), and expander displacement (n = 3). The serratus anterior fascia and the superficial pectoral fascia flaps can be effectively used as an autologous tissue layer to cover the lower and the lateral aspect of tissue expanders in immediate breast reconstruction after mastectomy.

Concepts: Medial pectoral nerve, Muscles of the upper limb, Tissue expansion, Plastic surgery, Breast reconstruction, Breast, Pectoralis major muscle

25

The optimal method of reconstruction following mastectomy for breast cancer patients receiving radiation therapy (RT) is controversial. This study evaluated patient satisfaction and complication rates among patients who received implant-based breast reconstruction. The specific treatment algorithm analyzed included patients receiving mastectomy and immediate temporary tissue expander (TE), followed by placement of a permanent breast implant (PI). If indicated, RT was delivered to the fully expanded TE. Records of 218 consecutive patients with 222 invasive (85%) or in situ (15%) breast lesions from the Salt Lake City region treated between 1998 and 2009 were retrospectively reviewed, 28% of whom received RT. Median RT dose was 50.4 Gy, and 41% received a scar boost at a median dose of 10 Gy. Kaplan-Meier analyses were performed to evaluate the cumulative incidence of surgical complications, including permanent PI removal. Risk factors associated with surgical events were analyzed. To evaluate cosmetic results and patient satisfaction, an anonymous survey was administered. Mean follow-up was 44 months (range 6-144). Actuarial 5-year PI removal rates for non-RT and RT patients were 4% and 22%, respectively. On multivariate analysis (MVA), the only factor associated with PI removal was RT (p = 0.009). Surveys were returned describing the outcomes of 149 breasts. For the non-RT and RT groups, those who rated their breast appearance as good or better were 63% versus 62%, respectively. Under 1/3 of each group was dissatisfied with their reconstruction. RT did not significantly affect patient satisfaction scores, but on MVA RT was the only factor associated with increased PI removal. This reconstruction technique may be considered an acceptable option even if RT is needed, but the increased complication risk with RT must be recognized.

Concepts: Chemotherapy, Tissue expansion, Breast cancer, Breast implant, Breast reconstruction, Cancer, Plastic surgery, Breast

22

AeroForm is a new type of remote-controlled, needle-free, carbon dioxide-based expander involving a potentially faster method of tissue expansion. Results are presented here from the AirXpanders Patient Activated Controlled Tissue Expander pivotal trial comparing AeroForm to saline tissue expanders.

Concepts: Clinical trial, Tissue expansion, Plastic surgery, Breast reconstruction

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To prevent tissue expander (TE) exposure following mastectomy flap necrosis in immediate breast reconstruction, the TE is usually covered completely or partially with a musculofascial (MF) flap. This study compares the complications of the two coverage methods.

Concepts: Breast, Tissue expansion, Plastic surgery, Breast reconstruction

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Acute traumatic or surgical wounds that cannot be primarily closed often cause substantial morbidity and mortality. This often leads to increased costs from higher material expenses, more involved nursing care, and longer hospital stays. Advancements in soft tissue expansion has made it a popular alternative to facilitate early closure without the need for more complicated plastic surgical procedures. Areas Covered: In this review, we briefly elaborate on the history and biomechanics of tissue expansion and provide comprehensive descriptions of traditional internal tissue expanders and a variety of contemporary external tissue expanders. We describe their uses, advantages, disadvantages, and clinical outcomes. The majority of articles reviewed include case series with level IV evidence. Outcome data was collected for studies after 1990 using PubMed database. Expert Commentary: An overall reduction in cost, time-to-wound closure, hospital length-of-stay, and infection rate may be expected with most tissue expanders. However, further studies comparing outcomes and cost-effectiveness of various expanders may be beneficial. Surgeons should be aware of the wide array of tissue expanders that are commercially available to individualize treatment based on thorough understanding of their advantages and disadvantages to optimize outcomes. We predict the use of external expanders to increase in the future and the need for more invasive procedures such as flaps to decrease.

Concepts: Outcome, Orthopedic surgery, Game theory, Future, Costs, Plastic surgery, Surgery, Tissue expansion

0

The purpose of this research was to develop an experimental model of dosimetry using a breast phantom and evaluate the effects of the metallic port in tissue expanders on dose distribution in postmastectomy radiotherapy. Dose distribution was assessed using an experimental acrylic dosimetry simulator in the absence and presence of a metallic disc (MD), which is similar to that used in tissue expanders containing a magnetic port, by collecting coronal and sagittal radiochromic films. Dosimetry film analysis did not show any changes in dose distribution, except for a MD shadow in the sagittal film where the dose distribution rate was on average 14% lower than in other areas. This model very closely resembled actual breast reconstruction with a tissue expander containing a magnetic port. Scattering or attenuation of the irradiation dose due to interference of the MD was not evident in areas that could jeopardize the effectiveness of radiation therapy. Therefore, the presence of the MD inside the tissue expander does not likely have an impact on radiotherapy effectiveness during immediate breast reconstruction.

Concepts: Cobalt, Tissue expansion, Electron, Cancer, Plastic surgery, Radiobiology, Breast reconstruction, Radiation therapy

0

Prosthetic reconstruction utilizing a 2-stage saline tissue expander-to-implant procedure is the most common technique for breast reconstruction in the United States. For nearly the past 50 years, 2-stage breast reconstruction using saline tissue expanders has been the standard of care. However, in December 2016, a carbon dioxide-filled, remote-controlled tissue expander received U.S. Food and Drug Administration clearance. This tissue expander, known as the AeroForm Tissue Expander System (AirXpanders, Inc., Palo Alto, Calif.), is a novel, patient-controlled, needle-free expander operated by a wireless remote control device, which allows patients the comfort and convenience of home expansion, precluding the need for percutaneous saline injections. A multicenter, randomized, prospective clinical trial has revealed statistically significant shorter times to full expansion as well as shorter overall reconstructive times. It is the first tissue expander device designed successfully with an alternative filling medium to saline, namely carbon dioxide. This CO2-filled expander thus provides several potential advantages over previous expander designs, including patient-controlled expansion, obviation of saline injections, and shorter expansion times.

Concepts: Infrared, Wireless, Carbon dioxide, Tissue expansion, Plastic surgery, Breast reconstruction, United States, Remote control

0

A surgical case, in which inferior dermal flap was used to cover a tissue expander for breast reconstruction, is reported. In spite of the skin necrosis on the seventh postoperative day, flap coverage successfully protected the tissue expander from exposition.

Concepts: Breast implant, Palatal expander, Breast, Expander, Tissue expansion, Breast reconstruction, Skin, Plastic surgery

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Successful use of tissue expanders depends on the quality of expanded tissue. This study evaluates the impact of anisotropic self-inflating tissue expander (SITE) on the biomechanics of skin. Two different SITE were implanted subcutaneously on sheep scalps; SITE that requires 30days for maximum expansion (Group A; n=5), and SITE that requires 21days for maximum expansion (Group B; n=5). Control animals (n=5) were maintained without SITE implantation. Young’s Modulus, D-periodicity, overlap and gap region length, diameter, and height difference between overlap and gap regions on collagen fibrils were analyzed using atomic force microscopy. Histology showed no significant differences in dermal thickness between control and expanded skin of groups A and B. Furthermore, most parameters of expanded skin were similar to controls (p>0.05). However, the height difference between overlap and gap regions was significantly smaller in group B compared to both control and group A (p<0.01). Strong correlation was observed between Young's Modulus of overlap and gap regions of the control and group A, but not group B. Results suggest that a relatively slower SITE can be useful in reconstructive surgery to maintain the biomechanical properties of expanded skin.

Concepts: Skin, Difference, Tissue expansion, Orthopedic surgery, Young's modulus, Plastic surgery

0

With proven oncological safety and improved aesthetic outcomes, the Type IV or “Wise pattern” skin-sparing mastectomy (SSM) is a procedure that is being performed with increasing frequency. Unfortunately, it is also associated with an increased risk of complications. The purpose of this investigation was to determine the complications associated with direct-to-implant and two-step tissue-expander breast reconstruction following Wise pattern SSM.

Concepts: Breast implant, Tissue expansion, Plastic surgery, Breast reconstruction, Cancer, Breast