Lessons Learned in Transition from Round to Shaped Implants in Immediate Breast Reconstruction Surgery

Goals/Purpose: Smooth round silicone implants predominate device-based breast reconstruction in the United States; despite their prevalence, complications include bottoming out, superior contour deformity, rippling, and/or lateral malposition. This complication profile increases the need for revision surgery and subsequent patient dissatisfaction.  With the resurgence of anatomic textured silicone implants in the United States, we report our senior author's success with these devices and tips to optimize outcomes in breast reconstruction surgery. 

Methods/Technique: A retrospective chart review was conducted on a prospectively-collected IRB-approved database of nipple sparing mastectomies (NSM) with immediate breast reconstruction with smooth round silicone implants (Group A) in 2011 in comparison to textured shaped silicone implants (Group B) in 2012. Changes in operative technique were highlighted and extrapolated (Figure 1).  Outcomes were reviewed.

Results/Complications: Demographics including age, BMI, smoking status, and diabetes history as well as operative time were statistically equivocal between the two groups. In Group A, 128 NSMs were performed in 76 patients. In Group B, 109 NSMs were performed in 59 patients.  15/128 (12%) had prior radiation therapy in Group A and 14/109 (13%) in Group B, p=0.816. 16/128 (13%) received a single-stage operation with permanent implants in Group A and 23/109 (21%) in Group B, p=0.099. 44/128 (34%) had acellular dermal matrix in Group A and 66/109 (61%) in Group B, p<0.0001. 23/128 (18%) breasts had post-operative NAC malposition in Group A and 0/109 (0%) in Group B, p<0.0001. 3/128 (2%) had post-operative NAC ischemia in Group A and 4/109 (4%) in Group B, p=0.362. 29/128 (23%) had post-operative capsular contracture in Group A and 10/109 (9%) in Group B, p=0.0039. 37/128(29%) had post-operative rippling in Group A and 0/109 (0%) in Group B, p<0.0001. 2/128(2%) had post-operative implant show in Group A and 4/109 (4%) in Group B, p = 0.362.  27/128 (21%) had revision reconstruction in Group A and 1/109 (0.9%) in Group B, p<0.0001. 1/128 (.7%) had implant loss in Group A and 3/109 (3%) in Group B, p=0.179. Patient/surgeon reported higher satisfaction despite increased firmness in Group B.

Conclusion:  With a few adaptations in surgical technique, the transition to textured shaped silicone devices for breast reconstruction can be seamless with superior breast contour, greater patient/surgeon satisfaction and decreased complication profile/revision rates.

Figure 1: Modifications in operative technique with textured shaped implants include:

(1) Precise pocked dissection for device placement (2) Selection of narrow Tissue Expander (TE) (3) Liberal use of ADM to control IMF (4) Filling of TE to eliminate folding of device intra-operatively (5) Post-operative under-expansion of TE to avoid permanent implant malposition (6) Selection of permanent implant based on width, height, and projection rather than volume (7) Use of entire length of mastectomy incision for exchange (8) Avoiding aggressive capsulorraphy/capsulotomy.