1. CRITICAL QUESTIONS -
REFINEMENTS IN IMPLANT BASED
BREAST RECONSTRUCTION
Stamatis Sapountzis M.D
Division of Plastic Surgery
China Medical University Hospital
Department of Plastic and Reconstructive Surgery
Seoul National University Hospital
ssapountzis@yahoo.com

2. Goals of Breast Reconstruction
 Provide permanent breast contour
 Make the breasts look balanced
 Avoid the need for external prosthesis
 Re-establish normalcy and confidence

3. Breast Reconstruction
 Implant Based
 Autologous Tissue
 Implant + Autologous Tissue

4. 80 % of Women in 2010
received Implant- Based Breast
Reconstruction

5. Plastic and Reconstructive Surgery • December 2009
The 70% of women Plastic Surgeon prefer Implant
Based Reconstruction for themselves

6. Immediate Vs Delayed Breast
reconstruction – Benefits &
Risks

7. •Better aesthetic result •Lower complication rate
•Better psychological effect •Less optimal result
•Lower cost
•High percentage of anxiety,
•Higher risk of complications depression and impairment
independently the method of their sexual attractiveness
of reconstruction
•Higher cost (2 operations,
hospital stays)

8. Comparison Immediate- Delayed Reconstruction to the same patient
Preoperative with previous right Result of delayed right breast
mastectomy reconstruction and immediate left breast
reconstruction with bilateral deep inferior
epigastric perforator (DIEP) flaps shown 21
months postoperatively

9. 80 % of breast reconstructions are immediate

10. What is the effect of
radiation on Implant based
breast reconstruction?

11. The objective of this meta -analysis is to examine:
whether patients requiring post-mastectomy
radiotherapy should have an immediate or delayed
reconstruction
whether a prosthesis or autologous reconstruction is
associated with the optimum outcome in terms of
postoperative morbidity

14. conclusion
 Post-mastectomy radiation, irrespective of the method of
reconstruction, increases the incidence of postoperative
complications; however, this study demonstrates that an
autologous flap offers a more favorable outcome in terms of
morbidity than expander/implant reconstruction

15. Can we always know if RT is
going to be followed?

16. Indication for Post-mastectomy RT Many decisions regarding radiation
therapy are made after mastectomy
•T3 or T4 tumors or four or more •sentinel lymph node biopsy cannot
positive axillary lymph nodes needs RT detect lymph node micrometastases
•fine-needle aspiration instead of open
•Radiation in T1 or T2 tumors and one to excisional biopsy techniques, has
three positive axillary nodes is limited the ability to diagnose the
controversial. amount of invasive tumor within the
breast parenchyma compared to the
permanent section

17. Delayed-Immediate Breast Reconstruction
2 weeks
2 weeks
4 to 6 months

18. Benefits of Delayed-Immediate Breast
Reconstruction
Aesthetic outcomes similar to immediate
Patients who do not require PMRT:
reconstruction
Avoid problems associated with PMRT after an
Patients who require PMRT :
immediate breast reconstruction.
Better aesthetic outcome than is achieved with
standard delayed reconstruction. Specifically, re-
expansion of the mastectomy skin after PMRT
provides additional usable breast skin to perform
delayed breast reconstruction.
Provides an additional option that broadens
patients’ treatment choices and allows patients to
participate fully in treatment and reconstruction
decisions.

19. 151 patients , TE/I Reconstruction
followed by PMRT.
7-year Follow-Up:
• PIRR rate was 29%.
•Reasons for PIRR included infection
(15),implant extrusion, shift, leak, or
rupture (4), patient request (1), or
multifactorial (17)

20. What is the role of Fat Grafting in
Implant Based Reconstruction in the
presence of Radiotherapy?
Does it Affect the Follow-up?
Are there Pharmacologic agents to prevent
the PR fibrosis?

21. 65 mastectomized patients who had received radiotherapy.
In the 1st operation Tissue expander under the pectoralis major + 150 (+- 25 cc) of
fat in the upper quadrants between the skin and the muscle
and also inside the muscle
After 3 months, removal of expander, insertion of the
In the 2nd operation
cohesive silicone prosthesis, and injection of 150 (+-30 cc) of
fat in the lower quadrants

22. Mean follow-up was 1 year.
No complications were recorded with the fat
injections.
Patients’ mean satisfaction rating was 4 on
a scale of 1 (low) to 5 (high), and the capsular
contracture was never above 1 on the Baker
classification

23. Plastic and Reconstructive Surgery • August 2011
From 2000 to 2010, the authors reviewed 646 lipofilling procedures from
513 patients
The average follow-up time from the last lipofilling procedure to the last visit
was 19.2 months (range, 1 to 107 months)
7: Benign calcifications
12 radiologic images appeared
2: Benign opacity masses
after lipofilling:
3 :Suspicious lesions
5: Benign lesion
From 7 histopathologic reports:
2: Local breast relapse

24. Conclusion
 Lipofilling following breast cancer treatment leads to a
very low rate of complications
 Does not affect the radiologic follow-up
 There is no proof of the safety of lipofilling in terms of
cancer recurrence or distant metastasis
 Lipofilling should be performed in experienced hands,
and a cautious oncologic follow-up protocol is advised

25. Pharmacologic Agents
Leukotriene antagonists (LTRAs) have emerged as
effective prophylactic agents in the management of
reactive airway diseases
Montelukast and Zfirlukast have “Off-Label” use
in Breast Augmentation
They seem to prevent and improve the Capsular
Contracture
There are no series of using these agents in
breast reconstruction with RT

26. Pharmacologic Agents
S.Sapountzis, JH Kim, DF Veiga, LM Ferreira
Impact Factor: 1.389
In our Hypotheses we suggest that the Zafirlukast is able to prevent the
post-radiation capsular contracture by blocking the TGF which plays key
role in radiation induced fibrosis

27. Human Acellular Dermal
Matrix: Why? Effective?
Infection?

28. Limitation of Other Implant Techniques
 Total Muscle Cover  Partial Muscle Cover
 Difficult  Implant migration
 Painful  More infections?
 Bloody  More contractures?
 Limited space  More exposures?
 Poor shape  More explantation
 Poor IMF definition
 Superior malposition

29. Benefits of AlloDerm
•Technically easier than total muscle
cover
•Less morbidity than total muscle
•Better shape than total muscle
•Better control of folds and shape
than total muscle only
•Less capsular contraction

30. Plastic and Reconstructive Surgery • December 2010
Twenty patients underwent tissue expander
reconstruction using the “dual-plane” acellular
cadaveric dermis technique (AlloDerm).
During implant exchange, intraoperative
biopsy specimens were obtained of (1)
biointegrated acellular cadaveric dermis and
(2) native subpectoral capsule (internal
control).

31. Review Study of 9
Articles

32. (Plast.Reconstr. Surg. 128: 403e, 2011.)
A total of 203 patients underwent 337
immediate TE/I Breast reconstructions :
•With acellular dermal matrix: 208 (61.7 %)
•Without 129 (38.3 %)

34. The key points of our technique are:
• advantages of Alloderm
•eliminate the “Step- off” deformity
•Recreate the normal tail of the breast
toward the axilla

35. 1st Stage:
Tissue Expander +
Alloderm
33 Patients/ 36 3 months later
Breast
Reconstructions
2nd Stage:
Permanent Silicone
Implant + Fat
grafting :134cc (21cc
to 228)

36. Results
 7 patients required surgical intervention to the contralateral breast
for symmetry achievement.
Mean follow-up was 1 years (ranged from 6 to 17 months)
 Two patients with infection in the early postoperative period
required expander removal (5.4%).
 No complications were noticed after fat injection.
 During the follow-up period the capsular contracture was never
above 1 on the Baker classification

37. Plastic Surgery
female 40 years old, prior to total mastectomy b) 3 months after immediate reconstruction with 275cc tall
height profile tissue expander and 12x4 cm AlloDerm c) 1 years after the second stage of reconstruction
with 265cc smooth round implant, moderate plus and 91cc of fat grafting
Plastic Surgery
female 48 years old, 3 months after immediate breast reconstruction with 450cc tall height expander
and 16X4cm AlloDerm b) 1 year after the second stage of reconstruction with 350cc smooth round high
profile implant and 141cc of fat grafting c) profile view: note the fullness of the upper pole and the
absence of “step-off” deformity between the reconstructed breast and the chest wall