Operative Technique in Plastic Surgery – Kevin C.Chung

■ Signs of systemic illness related to a periprosthetic infection indicate the need
for prompt implant removal.
Mastectomy Skin Necrosis
■ Superficial or partial-thickness flap necrosis is managed conservatively with
local wound care.
■ Small areas of full-thickness necrosis may also be managed with local wound
care if there is muscle or other vascularized tissue deep to the skin that will
allow secondary healing.
■ When ADM becomes exposed, salvage becomes much more challenging.
■ Larger areas of mastectomy skin flap necrosis require resection of the necrotic
skin with immediate wound closure.
■ Should consider removing fluid from the TE to allow for tension-free closure
of the mastectomy skin.
■ If skin defect is too large, the device may require removal and possibly skin
grafting over the pectoralis major muscle.
■ Secondary attempts at reconstruction may require autologous tissue flaps if
the chest skin cannot be expanded.
REFERENCES
1. D’Souza N, Darmanin G, Fedorowicz Z. Immediate versus delayed
reconstruction following surgery for breast cancer (Review). Cochrane
Database Syst Rev. 2011;(7):CD008674.
2. Fernandez-Delgado J, Lopez-Pedraza MJ, Blasco JA, et al. Satisfaction with
and psychological impact of immediate and deferred breast reconstruction. Ann
Oncol. 2008;19(8):1430-1434.
3. Seth AK, Silver HR, Hirsch EM, et al. Comparison of delayed and immediate
tissue expander breast reconstruction in the setting of postmastectomy
radiation therapy. Ann Plast Surg. 2015;75(5):503-507.

14
CHAPTER
Tissue Expander With
Acellular Dermal Matrix
Gabriel M. Kind
DEFINITION
■ Two-stage tissue expander-to-implant reconstruction with prosthetic implants
is the most common type of breast reconstruction in the United States.1,2
■ The use of acellular dermal matrix (ADM), originally described for direct-to-
implant reconstruction,3,4 has become increasingly common in two-stage
procedures as well.5–7
■ The potential benefits of this technique include more precise recreation of the
inframammary fold (IMF), control of the pectoralis major muscle, reduced risk
of implant palpability, reduction in capsular contracture rates, and a larger
initial expander volume (and consequently fewer office visits for tissue
expansion), with less dissection of the chest wall musculature when compared
to total muscle coverage of the tissue expander (TE).
■ All of these potential benefits would presumably improve aesthetic results
and, at least for the latter benefit, result in less morbidity.
■ Recently, there have been reports describing the placement of implants
wrapped with dermal allograft in the prepectoral position.
■ This technique has the potential to decrease the incidence of some of the
muscle-related complications associated with subpectoral placement, namely,
pain associated with manipulation of the muscle at the initial surgery,
discomfort associated with pectoralis major flexion postoperatively, and the
animation deformity seen in some patients with flexion of the pectoralis major
muscle.8
ANATOMY
■ The pectoralis major muscle has sternocostal, costal, and abdominal origins

and inserts on to the proximal humerus. It is a type V muscle, with a dominant
arterial pedicle from the thoracoacromial trunk and multiple secondary arterial
sources from parasternal perforators.
PATHOGENESIS
■ Breast cancer occurs in approximately 12% of women in the United States. It
is estimated that nearly 250 000 new cases of invasive breast cancer will be
diagnosed in 2016, along with 61 000 cases of in situ disease.
■ Although there are significant regional differences, mastectomy is performed
in approximately 35% of those newly diagnosed, and approximately 35% of
those women undergo breast reconstruction.
■ The rate of breast reconstruction has risen steadily, from 11.6% in 1998 to
36.4% in 2011.9
■ In 2014, of the 102 215 breast reconstructions performed in the United States,
74 694 (73%) used a TE and implant.2
PATIENT HISTORY AND PHYSICAL FINDINGS
■ The use of dermal allograft for soft tissue support at the time of mastectomy is
an intraoperative decision based on several factors, including the thickness of
the mastectomy skin flaps, the anatomy of the pectoralis major muscle, and the
desired initial volume of the TE.
■ If ADM is not used, either a total submuscular pocket is created or partial
muscle coverage of the expander is accepted.
IMAGING
■ Not indicated or necessary
SURGICAL MANAGEMENT
Preoperative Planning
■ The footprint of the breast is measured. The height and width of the breast are
used to determine which TE to order. Usually two or three differently sized
expanders are ordered for each case.
■ If mastectomy has already been performed, the pectoralis major muscle
function is assessed. Rarely, a paralytic or atretic muscle is identified
preoperatively. In such cases, a larger piece of ADM may be necessary.
Positioning

■ The patient is placed supine with both arms abducted and secured on well-
padded arm boards or tucked depending upon surgeon preference.
Approach
■ There are a number of different incisions used for mastectomy. TE insertion
can be performed via any of the incisions used.
■ In nipple-sparing procedures, care should be taken to avoid handling of the
nipple to decrease the chance of contamination. Adhesive plastic drapes can be
placed for this purpose.
T E C H N I Q U E S
■ Subpectoral Tissue Expander Placement With
Dermal Allograft
Markings
■ The footprint of the breast, including the IMF, is marked with the patient
standing and again under anesthesia.
■ Once the mastectomy is completed, hemostasis is confirmed.
Creation of Subpectoral Pocket
■ The pectoralis major muscle is elevated to create a subpectoral pocket across
the footprint of the breast (TECH FIG 1). The sternocostal origin is released
as necessary.
■ There is significant variability in the location of the origin of the pectoralis
major muscle.
■ Muscle attachments are preserved wherever possible. This will reduce the
size of the ADM required.
Preparation and Suturing of Dermal Allograft
■ A sheet of dermal allograft is prepared by irrigating it with normal saline
followed by antibiotic solution. ADM is provided in various sizes.
■ Generally 4 to 8 cm × 14 to 18 cm sheets are used; more recently shaped
pieces have become available.
■ Prefenestrated ADM is used, or fenestrations are cut into the ADM, to
encourage revascularization.

■ The use of thick or thin ADM also depends upon the preference of the
surgeon.
■ Care is taken to place the dermal (shiny) side of the ADM facing the
undersurface of the mastectomy flaps.
■ The dermal allograft is sutured to the chest wall along the desired position of
the IMF.
■ I prefer running absorbable barbed suture (2-0 PDO Quill) for this,
although other suture types have been described, perhaps most commonly
some type of an absorbable suture is used.
TECH FIG 1 • A,B. The pectoralis major muscle is
elevated across the footprint of the breast.

TECH FIG 2 • The dermal allograft is secured to the
IMF. The ADM is secured along the IMF to a point
equal or superior to the vertical midpoint of the breast.
■ The lateral extent of the ADM-IMF suture line should be at least to a point
equal to the vertical midpoint of the breast.
■ Patients with thin mastectomy flaps may benefit from continuing the ADM
further superolaterally, but this may tether the pectoralis major and is
generally not required (TECH FIG 2).
Preparation and Placement of Tissue Expander
■ A TE is selected based on the width of the breast footprint, the weight of the
mastectomy specimen, and the patient’s desired size.
■ The TE is prepared by removing the air and inserting 50 to 100 mL of saline.
■ Some prefer methylene blue–tinted saline, whereas others prefer to fill the
expander with air.
■ The TE is placed in the wound and secured in place using 2-0 PDS suture if

suture tabs are utilized. For expanders without tabs, precise pocket formation
will limit movement of the expander.
■ The ADM is trimmed to fit the defect in the inferolateral aspect of the
subpectoral pocket.
■ The upper border of the ADM is sutured to the lower border of the pectoralis
major muscle (TECH FIG 3).
■ Additional saline is injected into the TE.
■ In a total skin and nipple-sparing mastectomy, the expander is filled to
approximately 50% of its capacity.
■ In non–nipple-sparing mastectomies, the final volume is determined by the
limitation of the skin flaps.
Closure
■ Closed suction drains are placed through stab incisions in the lateral chest
wall.
■ For larger breasts and cases where axillary dissection is performed, two
drains are used. For smaller breasts, one drain is used.
TECH FIG 3 • Typical appearance of ADM secured to
the chest wall inferiorly and the pectoralis major
muscle superiorly.
■ The mastectomy flaps are debrided of nonviable skin and closed in layers.
■ Usually, 2-0 Vicryl is used in the deep tissues followed by 3-0 and 4-0
Monocryl in the skin.
■ The incision is dressed with dermal glue and a sterile dressing.

■ The chest is wrapped with an Ace wrap.
■ Prepectoral Tissue Expander Placement With
Dermal Allograft
■ As in the subpectoral technique, markings are made of the breast footprint
and IMF, and following mastectomy, hemostasis is confirmed.
■ The prepectoral technique is not recommended in patients with excessively
thin or poorly vascularized flaps.
■ A large sheet of dermal allograft (16 × 20 cm) is secured across the chest
wall, several centimeters superior to the desired position of the IMF.
■ The ADM is draped inferiorly and sutured to the chest wall slightly inferior
to the desired position of the IMF.
■ The TE is placed, and the ADM is folded over the tissue expander and then
secured superiorly to the chest wall.
■ The ADM is trimmed to the shape of the expander and then secured
medially and laterally to the chest wall (TECH FIG 4).

TECH FIG 4 • Dermal allograft secured to the chest
wall with the implant in the prepectoral position.
PEARLS AND PITFALLS
Symmetry of
the IMF
■ Begins with symmetrical skin markings. In a bilateral case, leaving
the first side open after placing the TE and ADM allows for visual
confirmation of symmetrical placement of the TE and ADM along
the IMF on the second side.
Symmetry of
tissue
expander
placement
■ The patient can be brought to a sitting position after inserting the
TE(s) to confirm adequate symmetry.
Proper
■ Care must be taken to place the TE in the appropriate location and

placement of
the tissue
expander
orientation. It is common to leave it too far superior and/or lateral
on the chest wall.
Inset of the
ADM
■ The ADM should be trimmed so that there are no folds or corners.
If there is a palpable fold, it should be excised and closed (similar to
a “dog-ear” excision). Redundancy of the ADM should be
minimized. This can sometimes be accomplished by filling the
expander. If the muscle or skin does not permit enough filling to
eliminate significant redundancy, the ADM needs to be trimmed
further.
Seroma
management
■ Seromas can be safely aspirated superficial to the expander port.
Tissue expansion can proceed as scheduled during seroma
aspiration. Oral antibiotics should be considered if a seroma
requires multiple aspirations.
POSTOPERATIVE CARE
■ Oral antibiotics are continued until drains are removed.
■ Drains are removed when the output is less than 30 mL/
24 hours for 2 consecutive days.
■ Tissue expansion is usually started 2 to 3 weeks postoperatively.
■ Expansion volume can vary but typically ranges from 30 to 120 cc per fill.
■ Overexpansion is avoided, as that can lead to a more redundant pocket and
more visible rippling.
OUTCOMES
■ Many of the benefits of ADM use in breast reconstruction are subjective and
surgeon dependent. Several authors have reported favorable aesthetic
outcomes.3–6
■ With regard to more objective measures of outcomes, there are multiple
retrospective series that report increased TE fill at the time of mastectomy plus
TE/ADM and fewer postoperative visits for expansion.4,10–14
■ There are several retrospective series that report diminished pain with ADM
use.4,5,15
■ There are several reports of an absence of capsular contracture in breasts
reconstructed with ADM, with follow-up times ranging from 6.5 to 52
months.3–5,16 This compares favorably with reported rates of capsular
contracture as high as 14% in patients undergoing reconstruction without

ADM.17
■ There are also published data showing lower rates of capsular contracture in
radiated breasts reconstructed with TE/ADM compared to historical
controls.13,18,19
■ Published reports describing prepectoral reconstruction with ADM are
encouraging, but preliminary, as there is only short-term follow-up available at
this time. A large series reports low complication rates at 6 to 26 months but
gives no data regarding aesthetic results or pain compared to the subpectoral
approach.8
■ Questions remain regarding the role of fat grafting to mask rippling and the
visibility of the upper pole of the implant, as well as the long-term
complication rates using the prepectoral technique.
COMPLICATIONS
■ Complications associated with ADM use in breast reconstruction are similar to
those reconstructed without ADM. Published series comparing ADM use with
TE reconstruction generally do not show statistically relevant differences in
overall complication rates.
■ The overall complication rates for reconstructions using ADM range from 3%
to 49%.20–23 Two studies show statistically significantly higher incidences of
seroma,12,21 but several other studies do not show an increased rate of seroma
with ADM use.13,14,22,24 A recent review showed that the use of dermal
allograft has a pooled relative risk of seroma of 1.85.25
■ Mastectomy flap necrosis was shown in two reports to be higher in patients
undergoing TE/ADM reconstruction.14,21 However, in both series, there was a
higher TE volume, which is known to cause a higher rate of mastectomy skin
necrosis.
■ Caution should be taken when filling TEs at the time of mastectomy, as
increased TE volume has been shown to correlate with mastectomy skin
necrosis, with or without the use of ADM.
■ There are multiple conflicting reports regarding the use of ADM and infection,
with authors concluding both an increased risk and no increased risk of
infection. Meta-analyses have shown increased relative risk of infection with
ADM use in breast reconstruction of 2.47 and 2.7.26,27
REFERENCES
1. Albornoz CR, Bach PB, Mehrara BJ, et al. A paradigm shift in U.S. breast

reconstruction: increasing implant rates. Plast Reconstr Surg. 2013;131:1,15-
23.
2. American Society of Plastic Surgeons. National Clearinghouse of Plastic
Surgery Procedural Statistics. 2014 Plastic Surgery Statistics Report. Available
at
statistics/plastic-surgery-statsitics-full-report.pdf
3. Breuing KH, Warren SM. Immediate bilateral breast reconstruction with
implants and inferolateral AlloDerm slings. Ann Plast Surg. 2005;55:232-239.
4. Salzberg CA. Nonexpansive immediate breast reconstruction using human
acellular tissue matrix graft (AlloDerm). Ann Plast Surg. 2006;57:1-5.
5. Bindingnavele V, Gaon M, Ota KS, et al. Use of acellular cadaveric dermis
and tissue expansion in postmastectomy breast reconstruction. J Plast Reconstr
Aesthet Surg. 2007;60(11):1214-1218.
6. Spear SL, Parikh PM, Reisin E, Menon NG. Acellular dermis-assisted breast
reconstruction. Aesthetic Plast Surg. 2008;32(3):418-425.
7. Sbitany H, Serletti JM. Acellular dermis–assisted prosthetic breast
reconstruction: a systematic and critical review of efficacy and associated
morbidity. Plast Reconstr Surg. 2011;128(6):1162-1169.
8. Sigalove S, Maxwell GP, Sigalove NM, et al. Prepectoral implant-based breast
reconstruction: rationale, indications, and preliminary results. Plast Reconstr
Surg. 2017;139:287-294.
9. Kummerow KL, Du L, Penson DF, et al. Nationwide trends in mastectomy for
early-stage breast cancer. JAMA Surg. 2015;150(1):9-16.
10. Sbitany H, Sandeen SN, Amalfi AN, et al. Acellular dermis assisted
prosthetic breast reconstruction versus complete submuscular coverage: a
head-to-head comparison of outcomes. Plast Reconstr Surg. 2009;124(6):735-
1740.
11. Zienowicz RJ, Karacaoglu E. Implant-based breast reconstruction with
allograft. Plast Reconstr Surg. 2007,120(2):373-381.
12. Parks JR, Hammond SE, Walsh WW, et al. Human acellular dermis (ACD)
vs. No-ACD in tissue expansion breast reconstruction. Plast Reconstr Surg.
2012;130(4):739-746.
13. Seth AK, Hirsch EM, Fine NA, Kim JY. Utility of acellular dermis-assisted
breast reconstruction in the setting of radiation: a comparative analysis. Plast
Reconstr Surg. 2012;130(4):750-758.
14. Weichman KE, Wilson SC, Weinstein AL, et al. The use of acellular dermal
matrix in immediate two-stage tissue expander breast reconstruction. Plast

Reconstr Surg. 2012;129(5):1049-1058.
15. Namnoum JD. Expander/implant reconstruction with AlloDerm: recent
experience. Plast Reconstr Surg. 2009;124(2):387-394.
16. Baxter RA. Intracapsular allogenic dermal grafts for breast implant-related
problems. Plast Reconstr Surg. 2003;112(6):1692-1696.
17. Spear SL, Newman MK, Bedford MS, et al. A retrospective analysis of
outcomes using three common methods for immediate breast reconstruction.
Plast Reconstr Surg. 2008;122(2):340-347.
18. Spear SL, Seruya M, Rao SS, et al. Two-stage prosthetic breast reconstruction
using AlloDerm including outcomes of different timings of radiotherapy. Plast
Reconstr Surg. 2012;130(1):1-9.
19. Breuing KH, Colwell AS. Immediate breast tissue expander-implant
reconstruction with inferolateral AlloDerm hammock and postoperative
radiation: a preliminary report. Eplasty. 2009;9:e16.
20. Rawlani V, Buck DW II, Johnson SA, et al. Tissue expander breast
reconstruction using prehydrated human acellular dermis. Ann Plast Surg.
2011;66(6):593-597.
21. Chun YS, Verma K, Rosen H, et al. Implant-based breast reconstruction using
acellular dermal matrix and the risk of postoperative complications. Plast
Reconstr Surg. 2010;125(2):429-436.
22. Antony AK, McCarthy CM, Cordeiro PG, et al. Acellular human dermis
implantation in 153 immediate two-stage tissue expander breast
reconstructions: determining the incidence and significant predictors of
complications. Plast Reconstr Surg. 2010;125(6):1606-1614.
23. Losken A. Early results using sterilized acellular human dermis (Neoform) in
post-mastectomy tissue expander breast reconstruction. Plast Reconstr Surg.
2009;123(6):1654-1658.
24. Vardanian AJ, Clayton JL, Roostaeian J, et al. Comparison of implant-based
immediate breast reconstruction with and without acellular dermal matrix.
Plast Reconstr Surg. 2011;128(5):403e-410e.
25. Jordan SW, Khavanin N, Kim JY. Seroma in prosthetic breast reconstruction.
Plast Reconstr Surg. 2016;137(4):1104-1116.
26. Kim JYS, Davila AA, Persing S, et al. A meta-analysis of human acellular
dermis and submuscular tissue expander breast reconstruction. Plast Reconstr
Surg. 2012;129:1.
27. Ho G, Nguyen TJ, Shahabi A, et al. A systematic review and meta-analysis of
complications associated with acellular dermal matrix-assisted breast

reconstruction. Ann Plast Surg. 2012;68:4,346-356.

15
CHAPTERImmediate Tissue Expander
Eric G. Halvorson and Joseph J. Disa
DEFINITION
■ Immediate tissue expander placement is performed following skin-sparing or
nipple-sparing mastectomy as a prelude to either two-stage implant
reconstruction or “delayed-immediate” autologous reconstruction.
■ The advantages of expander placement (compared to immediate autologous
reconstruction) include shorter operation, lack of donor site, shorter hospital
stay, shorter recovery, ability to adjust final volume, and a “perkier” result.
■ The disadvantages of expander placement include multiple postoperative
office visits for expansions, discomfort associated with the expansion process,
a second (albeit outpatient) surgery if proceeding with two-stage implant
reconstruction, and the permanent risks of implants (capsular contracture,
rupture, rotation, rippling, infection, malposition, and exposure).
PATIENT HISTORY AND PHYSICAL FINDINGS
■ It is beneficial for the initial consultation to occur separate from
multidisciplinary clinic visits focused on cancer care. Patients presenting to the
plastic surgeon after such visits are often overloaded with information and
overwhelmed by all the options and information related to reconstruction.
■ It is critical to determine the patient’s goals for reconstruction and to ascertain
their preferences with respect to breast size, breast shape, willingness to accept
surgical risk, willingness to accept donor-site morbidity, operative length,
hospital stay, recovery process, postoperative follow-up protocol, secondary
surgeries, and long-term complications.
■ Having a physician extender well versed in reconstructive options to meet with
patients and show them patient photographs is an incredibly helpful prelude to

the physician-patient consultation.
■ Physical examination of the breasts is performed to evaluate any masses and
whether or not skin involvement or peau d’orange is present. The overall size
and degree of ptosis are noted.
■ Patients with skin involvement or significant ptosis will typically require skin
excision. If performed as an inverted “T” or Wise pattern, the risk of
mastectomy flap necrosis is increased.
■ Alternatively, one can perform a generous horizontal, oblique, or vertical
ellipse or two-stage Wise pattern excision with the vertical closure first and a
horizontal excision at the inframammary fold (IMF) 3 to 6 months later.
■ The breast width, height, and projection are measured in centimeters. These
measurements are used for selecting a tissue expander (as described in the
following text).
SURGICAL MANAGEMENT
■ Ideal candidates for expander placement are thin nonsmokers undergoing
bilateral mastectomy who have not, and will not, receive radiotherapy.
■ Smokers are prone to mastectomy flap necrosis and infection.
■ Radiotherapy increases the risk of infection, implant exposure, and capsular
contracture.
■ Previously radiated skin will not expand well.
■ Although obesity increases the risk of complication for any type of
reconstruction, heavier patients tend to have better cosmetic results with
autologous reconstruction than with implants, as it can be difficult to match the
opposite breast after a unilateral mastectomy or give adequate volume/ptosis
after a bilateral mastectomy.
■ Patients with very large breasts who require skin removal during mastectomy
are at risk for mastectomy flap necrosis and tend to require secondary
procedures to address residual excess skin. These patients often have ample
donor sites for autologous reconstruction, which may be a better option.
■ Patients with small breasts who want them to be larger can achieve that goal
through expansion.
■ Patients who have minimal ptosis and want their breasts to be slightly smaller
are candidates for single-stage implant reconstruction.
■ Using a tissue expander as a bridge to autologous reconstruction, so-called
delayed-immediate reconstruction, is considered when the patient is likely to
receive postoperative radiation therapy, as radiating autologous flaps can result

in fat necrosis, firmness, and shrinkage.
■ A minority of surgeons prefer to accept the risks of radiating an autologous
flap when compared to the risks of performing delayed reconstruction in a
radiated field.
■ Other reasons to consider delayed-immediate reconstruction are to gain
control of the skin envelope, to expedite surgery and adjuvant therapy, and to
modify risk factors (smoking, obesity) and when patients are undecided.
Preoperative Planning and Implant Selection
■ Good communication with the breast surgeon is important to ensure oncologic
goals are maintained and that reconstruction is appropriately staged.
■ Patients with advanced disease, requirement for immediate postoperative
adjuvant therapy, unstable social environment, and/or uncertainty regarding
goals for reconstruction may be better served by delayed reconstruction.
■ Prior to mastectomy, the patient must be marked in the standing position. The
IMF is marked on each side, and the midline is drawn between the sternal
notch and xiphoid process. The overall outline of the breasts is marked.
■ Although a transverse ellipse around the nipple-areolar complex (NAC) is
commonly used for the mastectomy incision, the authors’ preference is an
oblique ellipse parallel to the pectoralis major fibers (FIG 1). This renders the
medial scar less visible in clothing, allows for better subincisional muscular
coverage, and facilitates a stair-step approach during the exchange procedure
(as described in the following chapter).
■ Tissue expanders are selected preoperatively based on the width of the
patient’s breast. There are many different tissue expanders to choose from, but
most are textured and anatomic, providing lower pole projection.
■ Some are taller than they are wide, some are wider than they are tall, and
some are semicircular or crescentic and focus on lower pole expansion.
■ Some have tabs to secure the expander.
■ Most have integrated metal ports that are located with magnets, although a
remote port is useful when placing the expander under a thick flap (such as a
latissimus dorsi flap in an obese patient). In such patients, finding the port
with a magnet can be difficult and a longer needle is required, placing the
expander at risk for rupture.

FIG 1 • An oblique mastectomy incision is used. (From:
Halvorson EG. Two-stage implant breast reconstruction.
In: Mulholland MW, ed. Operative Techniques in
Surgery. Vol. 2. Philadelphia, PA: Wolters Kluwer,
2000.)
Positioning
■ Patients are placed in the supine position under a general anesthetic with arms
padded circumferentially and abducted at 80 to 90 degrees.
■ Following mastectomy, the patient is positioned such that the sternum is
parallel to the floor (via head elevation or reverse Trendelenburg).
T E C H N I Q U E S
■ Tissue Expander Placement
First Step—Wound Assessment
■ Following mastectomy, the wounds are irrigated and hemostasis is obtained.
■ The mastectomy flaps are evaluated by examining their thickness and
assessing color and capillary refill.
■ Areas where dermis is exposed internally should be carefully evaluated
externally.
■ Areas where the external skin is pale without capillary refill should be
excised.

■ Laser-assisted indocyanine green fluoroscopy has been promoted to assess
mastectomy flap perfusion; however, guidelines for its use and interpretation
have not been firmly established.1
■ Use of tumescent solution by the extirpative surgeon makes assessment of
mastectomy flaps difficult and has been shown in some studies to be
associated with a higher rate of mastectomy flap necrosis.2–4
■ When there is significant concern for mastectomy flap necrosis, or if
debridement of questionable tissue will lead to closure under tension or an
open wound, then aborting reconstruction is strongly advised.
■ If necessary, the IMF can be recreated with interrupted suture; however, the
position of the inferior edge of the expander will ultimately determine the
IMF, which can be adjusted further during an exchange procedure if desired.
■ Some surgeons try to establish the native IMF during this initial procedure
(which may make the exchange procedure simpler), whereas others
intentionally place the expander lower than the IMF to increase lower pole
expansion and projection (which requires recreation of the IMF with suture
during the exchange procedure).
■ The author’s preference is to preserve the native IMF when performing
single-stage implant reconstruction, when placing a significant initial fill
volume in the expander, or when the IMF is already low.
■ When performing delayed two-stage implant reconstruction or when
placing minimal initial fill volume in the expander, placing the implant
below the IMF will preferentially expand the lower pole and permit the
surgeon to create minimal ptosis at the exchange procedure (as described in
the following chapter).
■ Another reason to consider placing the expander lower than the native IMF
is when adjuvant radiotherapy is expected. Radiotherapy almost always
causes fibrosis and contracture of the pectoralis major and soft tissue
surrounding the implant, with superior migration of the expander.
Second Step—Creation of Implant Pocket
■ The tissue expander cannot be covered by the mastectomy flaps alone, which
are thin and offer poor soft tissue coverage. Ideally, the surgeon should
provide complete musculofascial coverage with the pectoralis major and
serratus anterior muscles (TECH FIG 1A) or use an acellular dermal
allograft (ADM) or other product in addition to the pectoralis major muscle.
■ An emerging technique is to use complete acellular dermal matrix (ADM)

coverage with adjuvant fat grafting at the time of implant exchange, which
is beyond the scope of this chapter.
■ The lateral edge of the pectoralis major muscle is pinched between the
surgeon’s index finger and thumb and pulled away from the chest, revealing a
loose areolar plane between the pectoralis major and minor muscles.
Dissection in this plane commences with Bovie cautery, but once the
subpectoral space is entered, much of the superior and medial implant pocket
can be created via blunt digital dissection before using lighted retractors for
direct visualization.
■ A lighted retractor is quite helpful to finish medial dissection, as great care
must be taken to ligate or cauterize the intercostal perforators (TECH FIG
1B,C).
■ The medial boundary is defined externally by the preoperative markings that
define the patient’s native breast form. Internally, it is quite common to
release the medial and inferomedial origins of the pectoralis major muscle. It
is important not to release this area excessively, as symmastia can result and
is difficult to correct.
■ After the subpectoral plane is developed, the inferior insertion of the
pectoralis major muscle is examined (TECH FIG 1D).
■ If the patient’s muscle reaches the IMF, then a submuscular pocket can be
created down to the IMF with supple and adequate soft tissue coverage that
will respond well to expansion (TECH FIG 1E).
■ More commonly, however, the pectoralis major inserts above the IMF. In
this scenario, to provide autologous implant coverage inferiorly, one must
continue dissection past the pectoralis major insertion and under the
anterior rectus sheath until just below the IMF.
■ Transitioning from the subpectoral plane to underneath the anterior rectus
sheath is sometimes technically difficult and may result in a few gaps in
coverage that can be closed after the pocket is fully created. A lighted
retractor is necessary for this portion of the procedure.

D Mastectomy flaps Inferior Superior Pectoralis major Abdominal skin TE pocket Rectus abdominis Ribs

Rectus abdominis muscle Subcutaneous plane Bridge of anterior rectus sheath TE pocket Releasing incision Rib Pectoralis major muscle HI - Pectoralis major muscle Cut edges of anterior rectus sheath Rectus abdominis muscle fibers

TECH FIG 1 • A. Following mastectomy, the pectoralis
major and serratus anterior muscles are visualized as
these are the muscles used for expander coverage. If
these muscles have been affected by mastectomy,
using an ADM in their place is considered. (From:
Halvorson EG. Two-stage implant breast
reconstruction. In: Mulholland MW, ed. Operative
Techniques in Surgery. Vol. 2. Philadelphia, PA:
Wolters Kluwer, 2000.) B, C. A lighted retractor is very
helpful for both expander placement and the implant
exchange procedure. Here, the lighted retractor is
shown during creation of the subpectoral pocket
superomedially, where dissection proceeds carefully

so intercostal perforators can be visualized and
carefully ligated if necessary. (From: Halvorson EG.
Two-stage implant breast reconstruction. In:
Mulholland MW, ed. Operative Techniques in Surgery.
Vol. 2. Philadelphia, PA: Wolters Kluwer, 2000.) D.
The relationship between the most caudal extent of
the pectoralis major muscle and the IMF determines
whether or not the anterior rectus sheath will be
necessary to provide complete submusculofascial
coverage of the expander. If the muscle originates at
or below the IMF, as shown in this figure, then there is
no need to elevate the anterior rectus sheath. (From:
Halvorson EG. Two-stage implant breast
reconstruction. In: Mulholland MW, ed. Operative
Techniques in Surgery. Vol. 2. Philadelphia, PA:
Wolters Kluwer, 2000.) E. Schematic diagram patient
anatomy when the pectoralis major originates at or
below the IMF. In this case, a submuscular pocket can
be created down to the IMF that will be supple and
respond well to expansion. TE, tissue expander.
(From: Halvorson EG. Two-stage implant breast
reconstruction. In: Mulholland MW, ed. Operative
Techniques in Surgery. Vol. 2. Philadelphia, PA:
Wolters Kluwer, 2000.) F. At or just below the IMF, the
anterior rectus sheath is divided horizontally to enter
the subcutaneous plane. If this is not performed, lower
pole expansion will be limited by the stiff anterior
rectus sheath. (From: Halvorson EG. Two-stage
implant breast reconstruction. In: Mulholland MW, ed.
Operative Techniques in Surgery. Vol. 2. Philadelphia,
PA: Wolters Kluwer, 2000.) G. Schematic diagram
patient anatomy when the pectoralis major muscle
originates above the IMF. In this case, the gap

between the caudal border of the pectoralis and IMF
must be bridged by elevating the anterior rectus
sheath. At or just below the IMF, the sheath must be
incised horizontally to enter the subcutaneous space;
otherwise, the inferior pocket will not expand well.
Alternatively, an ADM can be used to bridge this gap.
TE, tissue expander. (From: Halvorson EG. Two-stage
implant breast reconstruction. In: Mulholland MW, ed.
Operative Techniques in Surgery. Vol. 2. Philadelphia,
PA: Wolters Kluwer, 2000.) H. For lateral and
inferolateral coverage, a partial-thickness serratus
anterior muscle flap is elevated and shown in this
photograph. If the fascia is robust and intact, that can
be used alone; however, this is seldom the case. An
incision in the muscle parallel to the inferolateral edge
of the pectoralis major muscle is made and the flap is
elevated laterally until the anterior axillary line or
sufficiently to create the desired pocket width for the
chosen expander. (From: Halvorson EG. Two-stage
implant breast reconstruction. In: Mulholland MW, ed.
Operative Techniques in Surgery. Vol. 2. Philadelphia,
PA: Wolters Kluwer, 2000.) I. Following elevation of
the serratus anterior muscle, the inferolateral aspect
of the implant pocket will still be adherent to the chest
wall. If retractors are placed under the pectoralis major
and serratus anterior muscles, this area of adhesion
will be exposed and inferolateral dissection will
elevate the serratus anterior and external oblique
muscles off the chest wall to complete implant pocket
dissection. (From: Halvorson EG. Two-stage implant
breast reconstruction. In: Mulholland MW, ed.
Operative Techniques in Surgery. Vol. 2. Philadelphia,
PA: Wolters Kluwer, 2000.) J. If an ADM is used, the

pectoralis major muscle is elevated from the chest
wall by dividing its inferior and inferomedial origin.
(From: Halvorson EG. Two-stage implant breast
reconstruction. In: Mulholland MW, ed. Operative
Techniques in Surgery. Vol. 2. Philadelphia, PA:
Wolters Kluwer, 2000.) K. A piece of ADM is prepared
appropriately, according to the manufacturer’s
recommendations, and is sewn in with the epidermis
side facing the implant. A 6- × 16-cm piece is usually
sufficient. The inferomedial and inferolateral corners of
the ADM are trimmed to create a curved inferior
border, and it is secured to the IMF and lateral pocket
using a running 2-0 monofilament slowly absorbing
suture. The transition from the IMF to the lateral
pocket must be a gentle arc that mimics the opposite
side. (From: Halvorson EG. Two-stage implant breast
reconstruction. In: Mulholland MW, ed. Operative
Techniques in Surgery. Vol. 2. Philadelphia, PA:
Wolters Kluwer, 2000.) L. A ruler is used to measure
the width of the surgically created pocket. The proper
pocket width can be determined by either patient
anatomy (eg, the anterior axillary line) or the
dimensions of the expander desired. (From: Halvorson
EG. Two-stage implant breast reconstruction. In:
Mulholland MW, ed. Operative Techniques in Surgery.
Vol. 2. Philadelphia, PA: Wolters Kluwer, 2000.) M.
Algorithm to determine when to use ADM. IMF,
inframammary fold. (From: Halvorson EG. Two-stage
implant breast reconstruction. In: Mulholland MW, ed.
Operative Techniques in Surgery. Vol. 2. Philadelphia,
PA: Wolters Kluwer, 2000.)
■ The anterior rectus sheath is quite stiff and will not expand well unless an

incision is made transversely across the sheath just below the IMF, entering
the subcutaneous plane (TECH FIG 1F,G).
■ If the anterior rectus sheath is released above the IMF, one would
obviously enter the implant pocket. The goal is to provide complete and
supple submusculofascial coverage without gap between the pectoralis
major and the IMF.
■ Alternatively, the pectoralis major can be released from the chest wall and
a piece of ADM (or other product) can be sewn to the IMF inferiorly using
a running 2-0 absorbable braided suture.
■ Following creation of a subpectoral pocket with or without elevation of the
anterior rectus sheath, inferolateral coverage must be provided.
■ Autologous coverage is provided by elevating the serratus anterior fascia if
robust, or more commonly a partial-thickness muscle flap if the fascia is
thin or traumatized from the mastectomy.
■ An incision in the serratus anterior is made at the level of, and parallel to,
the inferolateral edge of the pectoralis major muscle, and a fascial or
musculofascial flap is elevated to the anterior axillary line (TECH FIG
1H).
■ Alternatively, one can determine the width of the implant pocket based on
the width of the desired tissue expander and stop lateral dissection when a
sufficient pocket width is achieved (usually 1 cm wider than tissue
expander).
■ At this point, the inferior and lateral dissections will be complete, but the
inferior serratus and superolateral external oblique muscles will still be
attached to the chest wall. By retracting inferiorly and laterally, this plane is
exposed and the muscles can be elevated off the chest wall to open the
inferolateral pocket (TECH FIG 1I).
■ If an ADM is used, the origin of the pectoralis major is taken down starting
inferolaterally and extending medially and then superiorly along the sternal
origin to approximately the 4th rib (TECH FIG 1J).
■ The ADM will provide inferolateral implant coverage, and there is no need
to elevate the serratus anterior. In this case, the IMF and anterior axillary
line are marked internally and the ADM is sutured along a line that
transitions in an arc from the IMF to the anterior axillary line using a
running 2-0 absorbable braided suture (TECH FIG 1K).
■ Alternatively, one can mark the lateral mammary fold based on the width
of the desired tissue expander and suture the ADM to this line (TECH FIG

1L).
■ One can tailor the surgically created IMF to match the contralateral native
IMF during unilateral reconstruction. If performing bilateral reconstruction,
then it is imperative to create symmetric IMFs.
■ The advantages of using an ADM are that it avoids any morbidity associated
with elevation of the rectus sheath and serratus anterior, it allows for a greater
initial fill volume (and thus fewer postoperative expansions), it allows precise
control of the IMF, it may reduce operative time, and it may preserve lower
pole fullness.
■ Disadvantages include cost and an increased incidence of seroma, infection,
and reconstructive failure in patients with risk factors such as obesity,
smoking, and/or radiation.5
■ Although some surgeons use an ADM routinely and others do not, the
author’s preference is to use ADM selectively (TECH FIG 1M).
■ If the pectoralis major muscle extends to the IMF and the patient does not
desire a large breast reconstruction, then complete submusculofascial
coverage is performed. In most other cases, ADM is utilized unless the
patient has significant risk factors (obesity, radiation, tobacco use).
Third Step—Preparation of Tissue Expander
■ Intraoperatively, a ruler is used to measure the width of the surgically created
implant pocket, which ultimately determines the expander to be used.
Alternatively, one can create a pocket wide enough to accommodate the
desired expander.
■ The authors’ preference is to measure the surgically created pocket based on
native patient anatomy and choose an expander that is 1 cm narrower in
width (the expander is always wider than its base when expanded).
■ Tissue expanders come with air in them to prevent the inner shell from
sticking to itself. There are usually markings for orientation, but it is helpful
to draw a vertical line on the expander with a marking pen to assist with
positioning the expander in the pocket.
■ A needle (usually 23 gauge) is inserted into the port, and all air is removed.
■ The most commonly used tissue expanders are anatomic (creating lower
pole expansion), and thus, they are textured (to prevent rotation). There is
typically more shell inferiorly, and while deflating the expander, it is
important to fold excess shell inward as opposed to folding it upward and

on to itself, where it might cover the port and get punctured (TECH FIG
2).
■ The authors’ preference is to place 60 to 180 mL of sterile saline in the tissue
expander prior to placement, which allows the anterior shell to move away
from the rigid backing. It is important to control positioning of this backing
as it is what determines final expander position.
TECH FIG 2 • The tissue expander is marked with a
vertical line for orientation. All air is removed with the
excess inferior implant folded inward as shown to
avoid puncturing the inferior implant while placing
needles for expansion in clinic postoperatively. A
minimum of 60 mL of saline is instilled. (From:
Halvorson EG. Two-stage implant breast
reconstruction. In: Mulholland MW, ed. Operative
Techniques in Surgery. Vol. 2. Philadelphia, PA:
Wolters Kluwer, 2000.)
■ It can be helpful to put 1 mL of methylene blue in 1 L of injectable saline
and use this for the initial expander fluid. If the expander is punctured during
closure, it will be evident due to the dye. Additionally, during expansions in
clinic, the blue dye will confirm when the port is accessed.
Fourth Step—Placement of Tissue Expander and Closure
■ The pectoralis is retracted away from the chest wall and the expander is

placed into the pocket taking great care to orient it correctly.
■ It is important to note the rigid backing of the expander and place the
caudal edge at the IMF or below if desired. Be sure to unfold all edges of
the expander and ensure it is as medial as desired.
■ If performing bilateral reconstruction, symmetry in expander placement
should be confirmed by palpating the expander ports on each side and
ensuring symmetric horizontal and vertical positioning.
■ If an expander requires adjustment in positioning, it is critical to grasp the
rigid backing of the implant and then adjust the position. If only the ports
or anterior shell are adjusted, this usually has no effect on the position of
the backing, which determines implant position once fully inflated.
■ The inferolateral edge of the pectoralis major muscle is sutured to the
anteromedial edge of the serratus anterior muscle with running absorbable 2-
0 braided suture, closing the pocket. A small opening is left superolaterally to
allow egress of fluid.
■ Alternatively, if an ADM is used, the pectoralis major muscle is sewn to
the ADM with interrupted figure-of-8 braided absorbable 2-0 suture
(TECH FIG 3A).
■ The author’s preference is to inflate the tissue expander with sterile saline as
much as the soft tissue (muscle/skin) will allow without creating tension.
This is typically 120 to 240 mL.
■ It is important to do this prior to skin closure, as placing the needle through
the muscle will occasionally cause bleeding, which can be controlled
directly. Otherwise, a hematoma could expand in the subcutaneous space
without notice until the patient is out of surgery.
TECH FIG 3 • A. The inferolateral edge of the
pectoralis major is sewn to the superomedial edge of

the serratus anterior with a running 2-0 absorbable
polyfilament suture to cover the implant. The expander
can then be subsequently filled further depending
upon the tolerance of the submuscular pocket and the
mastectomy skin flaps. (From: Halvorson EG. Two-
stage implant breast reconstruction. In: Mulholland
MW, ed. Operative Techniques in Surgery. Vol. 2.
Philadelphia, PA: Wolters Kluwer, 2000.) B. The
patient is shown following placement of tissue
expanders and closure over closed suction drains.
Internal absorbable sutures are used, with skin glue
as the only dressing. No bra is applied, which might
apply pressure to tenuous mastectomy flaps. (From:
Halvorson EG. Two-stage implant breast
reconstruction. In: Mulholland MW, ed. Operative
Techniques in Surgery. Vol. 2. Philadelphia, PA:
Wolters Kluwer, 2000.)
■ In cases where there is significant concern regarding the cutaneous
circulation, then only 0 to 60 mL of inflation is advisable.
■ Two closed suction drains are placed in the subcutaneous space. One is
oriented superiorly and the other inferiorly.
■ In low-risk patients with smaller breasts, a single drain may be placed via
the axilla and extending inferiorly along the lateral border and then across
the IMF toward the midline.
■ The skin is closed with interrupted 3-0 absorbable monofilament suture for
the dermis and a running 4-0 absorbable monofilament suture for
subcuticular closure (TECH FIG 3B).
■ The authors’ preference is to use skin glue alone as a dressing, without
placement of a surgical bra, which applies pressure to the tenuous
mastectomy flaps and is an impediment to physical examination.
■ Antibiotics are continued parenterally for at least 24 hours postoperatively.
■ Although some studies support the use of postoperative prophylactic
antibiotics until the drains are removed6, others have shown no difference

between this regimen and 24 hours alone.7
■ Drains are removed when output is less than 30 mL per 24 hours and
expansion is begun typically 2 weeks postoperatively. Expansion can
continue on a weekly basis, adding as much fluid as the patient will tolerate
without discomfort (usually 60 to 120 mL).
■ Once expansion is complete according to patient preference and surgeon’s
satisfaction, the author’s preference is to perform one additional
overexpansion, which can provide some additional tissue to create minimal
ptosis at the exchange procedure at least 1 month later (as described in the
following chapter).
PEARLS AND PITFALLS
Indications
■ Patients with a history of radiation are poor candidates for implant
reconstruction.
■ Risk factors for infection and wound healing complications include
smoking, radiation, and obesity.
Incision
placement
■ An oblique incision parallel to the pectoralis muscle fibers provides
the best appearance and easiest approach for the exchange procedure.
■ Excess skin can be excised through a linear incision only, as
additional incisions will compromise circulation and risk mastectomy
flap necrosis. Secondary procedures are frequently necessary in
patients with excess skin.
Expander
selection
■ Expanders are selected based on breast width, not volume.
Expander
placement
■ Marking the expander assists in correct orientation.
■ Remove all air and place saline dyed with methylene blue to allow
detection of implant rupture as well as confirmation of port access for
staff performing expansions.
■ Provide 24 hours of postoperative antibiotics.
POSTOPERATIVE CARE
■ Following the mastectomy and tissue expander placement, the patient is
maintained on antibiotics for at least 24 hours.

■ Drains remain in place at least 3 days and then are removed when output is
less than 30 mL/d.
■ Only one drain from each side should be removed at a time, as sometimes the
output of the second drain will increase after the first drain is removed.
■ The author’s preference is to allow patients to shower with drains in place.
■ The patient should be seen within 1 week to evaluate for postoperative
infection and/or mastectomy flap necrosis and to remove drains if appropriate.
■ Range of motion is limited to 90 degrees of shoulder abduction for 2 weeks,
and then full range of motion is permitted. Heavy lifting (greater than 10 lb) is
avoided for 1 month.
■ Expansion is begun 2 weeks after surgery and continued on a weekly basis
thereafter until the patient and surgeon are happy with the final volume.
■ One additional “overexpansion” is performed, and the exchange procedure is
scheduled at least 1 month later to allow the tissues to soften.
OUTCOMES
■ Please see the chapter on implant exchange for a discussion of the outcomes of
implant reconstruction in general.
■ Although patients are typically happy to have “something there” following
mastectomy, expanders are often uncomfortable, and the process of tissue
expansion can cause discomfort, especially after each expansion.
■ Many patients will describe the expander as a “rock under my arm,” and it is
important to reassure them that this improves dramatically following the
exchange procedure.
■ The overall success rate of expander reconstruction is roughly 95% to 98%,
with a 2% to 5% risk of implant loss due to necrosis and infection.
COMPLICATIONS
■ Bleeding
■ Infection
■ Injury to surrounding structures (eg, cutaneous nerves)
■ Mastectomy flap necrosis
■ Seroma
■ Asymmetry, imperfect cosmetic result
REFERENCES
1. Moyer HR, Losken A. Predicting mastectomy skin flap necrosis with

indocyanine green angiography: the gray area defined. Plast Reconstr Surg.
2012;129(5):1043-1048.
2. Abbott AM, Miller BT, Tuttle TM. Outcomes after tumescence technique
versus electrocautery mastectomy. Ann Surg Oncol. 2012; 19(8):2607-2611.
3. Seth AK, Hirsch EM, Fine NA, et al. Additive risk of tumescent technique in
patients undergoing mastectomy with immediate reconstruction. Ann Surg
Oncol. 2011;18(11):3041-3046.
4. Chun YS, Verma K, Rosen H, et al. Use of tumescent mastectomy technique
as a risk factor for native breast skin flap necrosis following immediate breast
reconstruction. Am J Surg. 2011;201(2):160-165.
5. Ho G, Nguyen TJ, Shahabi A, et al. A systematic review and meta-analysis of
complications associated with acellular dermal matrix-assisted breast
reconstruction. Ann Plast Surg. 2012;68(4):346-356.
6. Clayton JL, Bazakas A, Lee CN, et al. Once is not enough: withholding
postoperative prophylactic antibiotics in prosthetic breast reconstruction is
associated with an increased risk of infection. Plast Reconstr Surg.
2012;130(3):495-502.
7. Phillips BT, et al. Are prophylactic postoperative antibiotics necessary for
immediate breast reconstruction? Results of a prospective randomized clinical
trial. J Am Coll Surg. 2016;222(6):1116-1124.

16
CHAPTER
Replacement of Expander
With Permanent Implant
Eric G. Halvorson and Joseph J. Disa
DEFINITION
■ Exchange of an expander for a permanent implant is performed as the second
stage in two-stage implant breast reconstruction, following mastectomy and
tissue expander placement (covered in previous chapter).
■ The advantages of two-stage implant reconstruction (compared to autologous
reconstruction) include shorter operation, lack of donor site, shorter hospital
stay, shorter recovery, patient control over final volume, and a “perkier” result.
■ The disadvantages of two-stage implant reconstruction include multiple
postoperative office visits for expansions, discomfort associated with the
expansion process, a second (albeit outpatient) surgery, and the permanent risks
of implants (capsular contracture, rupture, rippling, infection, malposition, and
exposure).
PATIENT HISTORY AND PHYSICAL FINDINGS
■ The initial consultation will have taken place prior to mastectomy and tissue
expander placement; however, it is important to review the patient’s interim
medical history prior to the exchange procedure, as interim changes are not
uncommon as a patient progresses through breast cancer treatment, and their
medical problems to assess risk factors for wound healing complications, for
example, diabetes, radiation therapy, obesity, and smoking.
■ If patients have had radiotherapy, then waiting 3 to 6 months before
performing the exchange procedure is advised.
■ Physical examination of the breasts is performed to evaluate expander size and
position as well as the soft tissue envelope.
■ Implants often require position adjustment using capsulotomy and/or

capsulorrhaphy.
■ Radiation changes are noted (if applicable), and if the skin and soft tissue
surrounding the mastectomy scar are very thin, then an IMF approach to the
exchange procedure should strongly be considered. Cutaneous recurrence
should always be excluded.
■ Areas of soft tissue deficiency are evaluated for possible autologous fat
grafting. This is fairly common in the upper pole.
■ Donor sites are also assessed. The medial thighs and hips are good donor sites.
The abdomen should be spared as a possible future donor site for autologous
reconstruction, if appropriate.
■ Expander size and volume is reviewed and determines implant selection
(covered in the following text).
SURGICAL MANAGEMENT
■ Ideal candidates for two-stage implant reconstruction are thin, nonsmokers
undergoing bilateral mastectomy who have not, and will not, receive
radiotherapy.
■ Smokers are prone to wound healing complications and infection.
■ Radiotherapy increases the risk of infection, implant exposure, and capsular
contracture.
■ Although obesity increases the risk of complications for most procedures,
unless other risk factors are present, the exchange procedure on obese patients
is very safe. Most of their risk will have occurred during the mastectomy and
expander placement.
■ The exchange procedure can be an opportunity to modify implant position and
also address some excess skin via lenticular excision.
Preoperative Planning and Implant Selection
■ Good communication with the breast surgeon and medical oncologist ensures
oncologic goals are maintained and that reconstruction is appropriately staged.
■ The exchange procedure is typically delayed until one month following
chemotherapy.
■ If radiotherapy is planned, the exchange procedure can be performed between
chemotherapy and radiation, or 3 to 6 months following radiation. This is
often determined by the preferences of the medical oncologist and radiation
oncologist.
■ Patients on extended adjuvant therapy can safely undergo the exchange

procedure; however, the specific agent must be assessed for risk of wound
healing complications and/or thromboembolic events, and a discussion with
the medical oncologist is advised.
■ Prior to the exchange procedure, the patient must be marked in the standing
position.
■ The IMF is marked on each side and the midline is drawn between the sternal
notch and xiphoid process.
■ A horizontal line is drawn from the lowest point of the IMF on each side to
the midline, which helps identify vertical asymmetries in expander position.
■ The medial silhouette of each expander is marked, which helps identify
horizontal asymmetries in expander position.
■ The ideal contour for the final implants is marked, revealing areas where
capsulotomy will need to be performed to adjust the implant pocket.
■ If applicable, areas of soft tissue deficiency are outlined for autologous fat
grafting, and the donor sites are marked.
■ Final implants are selected primarily based on volume, although width should
be taken into consideration. A full discussion of implant types is beyond the
scope of this chapter.
■ The majority of surgeons use smooth, round, high-profile silicone implants
for reconstructive purposes, although textured anatomic silicone implants are
also available.
■ Patients with very wide chests may require a moderate-profile implant that
will have a larger base diameter for a given volume (although less
projection).
■ A comparison of saline vs silicone implants is also beyond the scope of this
chapter, but suffice it to say that the issue is controversial. The authors’
preference is to offer both types to patients noting the following advantages
and disadvantages for each implant type:
■ Saline
• Advantages: Implant rupture is immediately detected; removal/replacement
of a ruptured implant is simple and quick.
• Disadvantages: Re-expansion may be required if implant ruptures and is not
replaced expeditiously; firmer than silicone, although this difference is
negligible when good soft tissue coverage is present; higher potential for
rippling if underfilled.
■ Silicone

• Advantages: Softer, more “natural” feel
• Disadvantages: Rupture is often clinically silent until capsular contracture
and/or extracapsular rupture occurs, removal of a ruptured implant is a
difficult operation that can involve removal of native tissue thus
compromising subsequent reconstruction, and monitoring for silent implant
rupture using magnetic resonance imaging (MRI) is not proven and has a
definite risk of false positives and unnecessary surgeries.
Positioning
■ Patients are placed in the supine position under a general anesthetic with arms
padded circumferentially and abducted at 80 to 90 degrees. The patient is
positioned such that the sternum is parallel to the floor via head elevation or
reverse Trendelenburg.
T E C H N I Q U E S
■ Implant Exchange
First Step—Removal of Tissue Expander
■ As noted earlier, the patient is marked in the standing position. Asymmetries
are noted, and the ideal contour for the final implants is marked.
■ If performing fat grafting, the donor sites should be injected with tumescent
solution at the beginning of the case to allow the epinephrine to take effect.
■ The mastectomy scars have often widened during expansion and these can
be excised.
■ A stair-step approach to the implant pocket is usually performed, so any
wound breakdown in one layer does not expose the suture line of the other
layer.
■ If the scar is oriented obliquely (TECH FIG 1A), 2 to 4 cm of
superomedial skin elevation will expose the pectoralis major, which can be
incised parallel to the muscle fibers.
■ If a transverse approach was used, then superolateral and inferomedial skin
elevation is required to expose the pectoralis major and allow for an
incision parallel to the muscle fibers.
■ The implant pocket is entered and the capsule is bluntly separated from the

expander, which is removed. If the expander is too large, it can be ruptured
with a needle or scalpel to assist in removal. If there was any doubt about the
final expander volume, it can be measured at this point (TECH FIG 1B).
Second Step—Creation of Implant Pocket
■ Ideally, the expanders can be removed and the permanent implants placed
without further intervention; however, this is rarely the case. Superior and
superomedial capsulotomy is often required to soften the transition from the
chest wall to the implant (TECH FIG 2A,B).
TECH FIG 1 • A. If the oblique incision is used for
mastectomy, it is easy at the exchange procedure to
elevate a superomedial flap exposing the pectoralis
major muscle where it tends to be thicker. This will
allow a “stair-step” approach to the implant pocket.
Any wound healing issue at one level will not expose
the suture line at the other level. (From Halvorson EG.
Two-stage implant breast reconstruction. In:
Mulholland MW, ed. Operative Techniques in Surgery.
Vol 2. Philadelphia, PA: Wolters Kluwer; 2014.) B. A
muscular incision is made parallel to the pectoralis
major muscle fibers to access the implant pocket. The
capsule is also incised with cautery, and the expander
is bluntly separated from the capsule. (From
Halvorson EG. Two-stage implant breast
reconstruction. In: Mulholland MW, ed. Operative

Techniques in Surgery. Vol 2. Philadelphia, PA:
Wolters Kluwer; 2014.)
■ The pocket may need to be medialized, lateralized, elevated, or displaced
inferiorly. These can all be accomplished through capsulotomy.
■ If the final implant is roughly the same width as the expander, then a
corresponding capsulorrhaphy at the opposite side of the pocket is
necessary using figure-of-eight interrupted 0 suture.
■ If the implant is wider than the expander, this may not be necessary as the
capsulotomy will increase pocket diameter.
■ If the expander was placed below the IMF, or if the IMF needs to be
elevated, this is accomplished with figure-of-eight interrupted 0 suture.
■ The patient is sat upright (TECH FIG 2C,D) and the inferior mastectomy
flap is lifted away from the chest wall.
■ Usually, the old IMF can be visualized and marked; otherwise, the desired
IMF can be marked.
■ The needle is passed through the capsule and the IMF marking externally
is visualized. The needle tip should just catch the deep dermis, resulting in
a small indentation when tied. These indentations will resolve in several
weeks.
■ After passing the needle through the capsule/dermis, tension can be
adjusted by examining the fold externally and elevating it as desired.
■ Internal inspection with the suture still under tension will indicate where
the corresponding suture throw in the chest wall must be made. Suturing
into the rib should be avoided, as this results in pain.
■ The first suture is placed at the center of the IMF and then one to two
sutures are placed medially and laterally until an adequate fold is created
(TECH FIG 2E).
■ Some surgeons prefer to establish the IMF at the initial operation, potentially
with an acellular dermal matrix (ADM), which has the added benefit of
permitting a higher initial fill volume. A greater initial fill volume has the
potential to better preserve lower pole fullness.
■ No time is spent reconstructing the IMF at the exchange procedure.
Although this may be a simpler approach, it may result in a blunted IMF.
■ The authors’ preference is to treat each case individually and surgically
create a crisp IMF at the exchange procedure if necessary. For example,

patients undergoing delayed reconstruction will benefit from significant
lower pole expansion and thus the expander is placed inferior to the desired
IMF and the IMF is reconstructed at the exchange procedure.
■ A patient with minimal excess skin and ptosis undergoing immediate
reconstruction may benefit from an ADM to maximize the initial fill
volume (preserve lower pole fullness), establish the IMF, and avoid inferior
capsulorrhaphy at the exchange procedure.
■ To further expand the lower pole and create minimal ptosis, capsulotomy of
the inferior pocket is then performed. A horizontal capsulotomy half way up
the inferior mastectomy flap, at least 4 cm off the chest wall, will expand the
lower pole of the pocket. Additional radial capsulotomies can be added for
further lower pole expansion or elsewhere to create symmetric pockets.
■ During pocket creation, it is helpful to have a temporary sizer inflated (with
air or saline) to roughly the desired implant volume, which can be placed into
the implant pocket to assess position, shape, and volume. This is particularly
important in bilateral reconstructions, where two sizers are required to
confirm pocket symmetry.
TECH FIG 2 • A,B. A superomedial and superior
capsulotomy is made just above the chest wall using a
lighted retractor. This will soften the transition from
chest wall to implant and allow for more implant
mobility within the pocket. (From Halvorson EG. Two-

stage implant breast reconstruction. In: Mulholland
MW, ed. Operative Techniques in Surgery. Vol 2.
Philadelphia, PA: Wolters Kluwer; 2014.) C,D. The
patient is positioned upright with both upper
extremities well padded and secured to the operating
room table or arm boards. E. Inframammary fold
and/or lateral mammary fold sutures are place to
define the fold and adjust pocket dimensions as
needed. (From Halvorson EG. Two-stage implant
breast reconstruction. In: Mulholland MW, ed.
Operative Techniques in Surgery. Vol 2. Philadelphia,
PA: Wolters Kluwer; 2014.)
■ If the sizer is loose and slips laterally, lateral capsulorrhaphy sutures should
be placed.
■ If autologous fat grafting is to be performed, the authors’ preference is to do
it while the temporary sizers are in place to avoid inadvertent rupture of the
permanent implants.
■ Fat grafts are harvested, processed, and injected into the subcutaneous,
intramuscular, and submuscular planes via the incision or small stab
incisions as determined by preoperative examination and markings.
■ The sizers are removed, and the implant pocket is once again irrigated to
remove any possible fat grafts that have been placed into the implant
pocket. A full description of fat grafting techniques is beyond the scope of
this chapter.
Third Step—Implant Selection and Closure
■ When ordering implants for the exchange procedure, it is wise to order
implants that are one size smaller and one size larger than the implant size
determined by the patient’s final expansion volume (prior to final
overexpansion). As mentioned earlier, temporary sizers are usually used and
can be adjusted to determine an acceptable final implant volume.
■ Inflating the sizer beyond the final expander volume usually results in
excessive upper pole fullness, a noticeable step-off between the chest and
implant, and tight closure. The chest should transition to the implant
smoothly, and the breast mound should have slight ptosis.

■ When placing saline implants, choose an implant that has the desired volume
as the upper end of its volume range. For example, if 380 mL is the desired
implant volume, use an implant with a volume range of 360 to 390 mL.
■ This avoids rippling at the expense of making the implant slightly firmer.
Some surgeons will in fact overfill the implant by 10% to avoid rippling.
■ Disposable sizers can be used prior to final implant placement (TECH FIG
3A).
TECH FIG 3 • A. Disposable sizers are used to
determine the optimal implant. The patient is viewed in
the upright position. (From Halvorson EG. Two-stage

implant breast reconstruction. In: Mulholland MW, ed.
Operative Techniques in Surgery. Vol 2. Philadelphia,
PA: Wolters Kluwer; 2014.) B –D. Next, the permanent
implant is selected. The field is surrounded by clean
sterile drapes and clean gloves are used to place the
implant. Care is taken to avoid implant contact with
the skin. (Credit: Halvorson EG. Two-stage implant
breast reconstruction. In: Mulholland MW, ed.
Operative Techniques in Surgery. Vol 2. Philadelphia,
PA: Wolters Kluwer, 2014.) E,F. The pectoralis is
reapproximated with an absorbable suture, and the
wound is closed in layers. (From Halvorson EG. Two-
stage implant breast reconstruction. In: Mulholland
MW, ed. Operative Techniques in Surgery. Vol 2.
Philadelphia, PA: Wolters Kluwer; 2014.)
■ The pockets are irrigated, hemostasis is obtained, and the final implants are
opened.
■ Although many surgeons will reprep the patient, place new drapes, dip
retractors in prep solution, and handle the implants with fresh gloves, there
is no data to support these practices. The authors do not take any special
precautions, as the procedure is a clean, sterile procedure (TECH FIG 3B–
D).
■ The implants are placed and the muscular closure is performed with a
running 2-0 braided absorbable suture. The capsule is not included in this
closure if possible, thus creating an anterior capsulotomy (made upon initial
approach to the implant pocket).
■ No drains are placed. The skin is closed with interrupted deep dermal 3-0
monofilament absorbable suture and a running 4-0 subcuticular absorbable
suture (TECH FIG 3E,F). A skin glue is applied, and a brassiere is only used
if supporting the implant in a particular position is desired.
PEARLS AND PITFALLS

Implant
selection
■ Implants are selected based on volume primarily, taking breast width
into consideration. High-profile implants are typically used, except in
patients with wide chests who benefit from moderate-profile, wider
implants.
Adjunct
procedures
■ Consider fat grafting to address contour deformities, improve the soft
tissue, and soften the contours of the implant.
Patient
expectation
■ Two-stage implant breast reconstruction is typically a year-long
process.
■ Symmetry in the nude is always the goal but is seldom achieved.
Symmetry in clothing is the most reasonable expectation.
POSTOPERATIVE CARE
■ Following the exchange procedure, patients may shower after 48 hours. The
exchange procedure is sterile, and the mastectomy flaps have been delayed and
have robust perfusion. No postoperative antibiotics are given. Range of motion
is limited to 90 degrees of shoulder abduction for 2 weeks, and then full range
of motion is permitted. Heavy lifting (greater than 10 lb) is avoided for 1
month.
OUTCOMES
■ Patient satisfaction with implant breast reconstruction is high, provided the
preoperative consultation appropriately identified the patient’s priorities, goals,
and preferences with respect to reconstructive options, and realistic
expectations were discussed.
■ Although some studies have indicated that patients undergoing prosthetic
reconstruction are less satisfied than are those undergoing autologous tissue
reconstruction,1,2 other studies have shown significant improvements in
psychosocial outcomes regardless of the type of reconstruction.3
■ It is common to tell patients undergoing implant reconstruction that, on
average, they will require some form of surgery every 10 years. These could be
procedures for symmetry, infection, rupture, or capsular contracture. Although
some surgeons exchange silicone implants every 10 years to avoid
extracapsular ruptures, most only offer surgery if a problem is identified.
■ One study evaluated long-term outcomes of autologous vs implant
reconstruction and noted stable survival of 90% of autologous reconstructions

vs a gradual decline to 70% survival of implant reconstructions.4 In general,
autologous reconstructions improve or remain stable with time, whereas
implant reconstructions tend to worsen slightly over time.
■ There is no increased risk of breast cancer recurrence in patients undergoing
therapeutic mastectomy and implant reconstruction. Detection of recurrence
and outcome when recurrence is detected are not affected by the presence of an
implant reconstruction.5
COMPLICATIONS
■ Bleeding
■ Infection
■ Long-term risks of implants: capsular contracture, rupture, rippling, infection,
malposition, and exposure
■ Asymmetry, imperfect cosmetic result
REFERENCES
1. Alderman AK, Wilkins EG, Lowery JC, et al. Determinants of patient
satisfaction in postmastectomy breast reconstruction. Plast Reconstr Surg.
2000;106:769-776.
2. Christensen BO, Overgaard J, Kettner LO, et al. Long-term evaluation of
postmastectomy breast reconstruction. Acta Oncol. 2011;50(7):1053-1061.
3. Wilkins EG, Cederna PS, Lowery JC, et al. Prospective analysis of
psychosocial outcomes in breast reconstruction: one-year postoperative results
from the Michigan Breast Reconstruction Outcome Study. Plast Reconstr Surg.
2000;106(5):1014-1025.
4. Rusby JE, Waters RA, Nightingale PG, et al. Immediate breast reconstruction
after mastectomy: what are the long-term prospects? Ann R Coll Surg Engl.
2010;92(3):193-197.
5. McCarthy CM, Pusic AL, Sclafani L, et al. Breast cancer recurrence following
prosthetic, postmastectomy reconstruction: incidence, detection, and treatment.
Plast Reconstr Surg. 2008;121(2):381-388.

17
CHAPTER
Direct-to-Implant Breast
Reconstruction
Amy S. Colwell and Eric J. Wright
DEFINITION
■ Following mastectomy, the reconstructive goal is to recreate a natural-
appearing breast, which may improve quality of life and body image.
■ Direct-to-implant (DTI) reconstruction involves placement of the permanent
implant at the time of mastectomy in one stage.
■ DTI reconstruction is a cost-effective, low complication rate procedure with
outcomes similar to two-stage tissue expander/implant reconstruction in
experienced centers.1
■ Alternatives to DTI include no reconstruction, two-stage tissue
expander/implant reconstruction and autologous reconstruction with flaps or
fat.
■ In comparison with tissue expander reconstruction, there are fewer office visits
and one less surgical procedure. Compared to autologous reconstruction, there
is no donor site morbidity.
ANATOMY
■ The breast skin is preserved or reduced to accommodate an appropriate-size
implant.
■ Skin-sparing or nipple-sparing mastectomy keeps the native breast skin
envelope intact by crafting a natural shape with immediate round or shaped
implant insertion. In nipple-sparing procedures, the nipple ducts are removed
with the mastectomy and the outer epidermis and dermis are retained with the
rest of the breast skin.
■ Ideal candidates for nipple-sparing mastectomy have grade 1 to grade 2 nipple
ptosis.

■ Patients with grade 3 ptosis may be better candidates for skin-sparing
mastectomy or mastopexy prior to mastectomy.
■ The implant has total, partial, or no muscle coverage under the breast skin.
■ The pectoralis major muscle most commonly covers the implant superiorly.
Inferiorly, acellular dermal matrix (ADM) or mesh serves as an extension of
the pectoralis major muscle to cover the implant inferiorly.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ DTI reconstruction can be performed in unilateral or bilateral mastectomies
and in reconstruction for cancer or prophylaxis.
■ Ideal candidates for DTI reconstruction are otherwise healthy patients, with
moderate size breasts, who desire to retain approximately the same breast size.
■ Patients who desire a significantly larger size are more safely treated with
tissue expander/implant reconstruction.
■ Relative contraindications to DTI include active smoking, uncontrolled
diabetes, and immunosuppressive medications.
■ Planned postoperative radiation, obesity, prior breast scars, and previous
lumpectomy/radiation may increase the risk of complications, but they are not
absolute contraindications to performing DTI reconstruction.
■ The breasts are assessed for volume, symmetry, nipple position,
inframammary fold (IMF) position, and breast base width.
■ Patients with very small (less than 100 g) or very large (greater than 900 g)
breasts are typically better candidates for tissue expander/implant
reconstruction.
■ If a patient has asymmetry, a better cosmetic outcome may be achieved in two
stages for bilateral reconstructions.
IMAGING
■ Preoperative mammogram or MRI can determine the oncologic safety of
proceeding with a nipple-sparing vs skin-sparing mastectomy based upon the
proximity of the cancer to the nipple.
SURGICAL MANAGEMENT
■ Surgical management requires either a team approach with the surgical
oncologist and plastic surgeon or an oncoplastic surgeon experienced in both
mastectomy and reconstruction.
■ During the preoperative visit, patients are to be counseled on the possibility of

a two-stage tissue expander/implant reconstruction or delayed reconstruction
depending on the intraoperative mastectomy skin viability.
■ Though saline implants can be used, silicone implants are used more
commonly to create a more nature look and feel.
■ Smooth round implants are softer than are anatomic implants and typically
provide more superior pole fullness.
■ Textured anatomic implants are firmer than round implants and typically have
reduced risk of rippling. These implants may better match a contralateral breast
in unilateral reconstructions and may have less contracture after
postmastectomy radiation.
■ Partial pectoralis muscle coverage of the implant is the most common
technique with an inferior sling of ADM or synthetic mesh.
■ Compared to total muscle coverage, partial muscle coverage gives more
natural breast shape and can accommodate a larger size implant.
■ Compared to no muscle coverage, partial muscle coverage has better soft
tissue coverage in the upper pole, and it is less expensive.
■ Human ADM is the most common material used to provide an inferior sling.2
Alternative materials include porcine skin, bovine skin, and synthetic meshes
made from silk, Vicryl, and titanium. These products provide precise control of
the lateral and inframammary pocket borders along with the lower pole
projection. They also support the implant and help keep the pectoralis muscle
on stretch.
■ The authors describe their preferred technique using partial muscle coverage
with an inferior pole sling of human ADM.
Preoperative Planning
■ A paravertebral block can be performed for perioperative and postoperative
analgesia.
■ Reference markings are placed including the IMF bilaterally and planned
lateral border of the breasts.
■ For skin-sparing procedures, the incision is placed around the areola, with or
without small medial and lateral extensions.
■ For nipple-sparing procedures, an inferolateral IMF incision optimizes
mastectomy, lymph node sampling, and reconstruction.
■ Alternative incisions in NSM include lateral radial, vertical, or extension of a
nonradiated scar (FIG 1).