Curs Postuniv Reconstructie Sini

INTERNAL versus EXTERNAL
Tissue Expansion
in Breast Reconstruction
experience in 63 patients with
long-term follow up
Prof. Teodor STAMATE, M.D., Ph.D
.
University of Medicine and Pharmacy “Gr.T. Popa” IASI
Head of Plastic and Reconstructive Surgery Departament
IASI - ROMANIA
Introduction
 we present our clinical experience and
results in breast reconstruction using
autologous fat transfer associated with
external tissue expander BRAVA System
in pre- and postoperative care
 comparative with classical methods –
internal expander associated with other
techniques for breast reconstruction.
1- VOLUME RESTAURATION OF THE
ABSENT OR AMPUTATED BREAST
2- SYMMETRISATION
WITH THE OPPOSITE BREAST
3- NAC RECONSTRUCTION
Prof. Teodor STAMATE, M.D., Ph.D.

= Absence of the mammary gland + NAC
=MG exists bu UNdeveloped (uni ,bi) ; NAC present
* unilateral amasty +PAM smaller or ectopic
** amasty + partial agenesis SCM,MP,mP,
Serratus + II – VI rib hipoplasy
amasty + other anomalies
*** amasty + homolat. hand and forearm hipoplasia
+ shorter phalanx ; possible syndactyly
2

A
Conf. Dr. Teodor STAMATE

Prof. Th.Stamate MD, Ph.D.
B
•Irregular thickness of the soft tissue
•Local / partial stiffness
•There are no stress zones unevenly distributed
•Two steps breast reconstruction :

a) - expander placement :- base equal to the base of the implant
- remote valve + inflation 2 x/week
b) – final implant placement :-no over-inflation 10%
-no infra-mammary fold sustentation
Prof.
Conf.Th.Stamate,
Dr. TeodorMD,Ph.D.
STAMATE
C
Fascio-cutaneous flaps don’t provide enough thickness
Conf. Dr. Teodor STAMATE

Prof.Th.Stamate,MD,Ph.D.
63 Clinical cases
In the 48 operated patients we found:
• absence of the pectoralis major in all cases,
• absence of the pectoralis minor in 6 cases;
• NAC
• lateral to the midclavial line in 2 cases
• Inferior to the normal position in 1 case
• Skeletal malformation of the thorax

•pectus excavatum = 5 cases.
•pectus carrinatum = 7 cases.
•Deformed costal arches = 4 cases
• Diminished axillary pilosity = 4 cazuri;
• Malformations in the ipsilateral upper limb included:

• syndactylia (6 cases),
• brahydactylia (7 cases) and
•shortness of the forearm bones (2 cases).
 7 amasties
 14 severe unilateral mammary hypoplasies

(V<50%) (major asymmetry)
 27 minor mammary hypoplasies (V>50%)
 48 cases
Poland
Syndrome
45
40
35 POLAND
30
Major
25 Hypotrophy
20 Minor
Hypotrophy
15
AMASTIA
10
5
0

Internal Tissue Expander
 insufficient
quantity after
mastectomy or
Poland Syndrome
 ITE is mandatory to
be placed into a
musculo-
cutaneous
pocket
Internal Tissue Expander
ITE are two types :
 temporary, replaced after

expansion with a definitive
implant
 definitively - type Becker

left
mammary
agenesia
 Pectoralis
Major
hypotrophia
 NAC 2,5 cm
above the
controlateral one

Two steps surgical approach
Breast reconstruction
First step :
a) Placing a tissue
expander to create extra
– skin and to expand
the hypotrophic
pectoralis major
b) Incision in the VIth

intercostal space, 2 cm
lower than the opposite
inframammary fold,
c) 380ml tissue expander

(bigger than the
opposite breast) placed
under the pectoralis
major.

Tratament
Breast reconstruction
First step:
d) Two weeks
postoperatively
expander inflation
begins (20-40 ml
/ week).
e) Elastic strapping
to maintain
constant pressure
over the myo-
cutaneous
structures
situated under the
horizontal plane
that passes
through the
opposite nipple .

Two steps breast reconstruction
Second step
a) 3 months
postoperatively
the expander is
withdrawn and
the final 250 ml
implant is
inserted.
b) Wound closure in
separate planes

Two steps breast reconstruction
3 days postoperatively
2 months postoperatively
 FINAL OUTCOME
 Right
mammary
agenesia
 Absence of
pectoralis
major
 Hypoplasia
of pectoralis
minor
 Prominence
of the 3rd
costo-sternal
cartilage
 NAC < 2,5
cm +
malposition

1. Placing a 300ml
expander in the
upper pole of
the future
breast, over the
NAC, through
axillary
approach
2. Inflation 30-40
ml weekly.

3 EXPANDERS
 2 a 300 and 350 ml
expander in the inferior and
superior half of the future
breast
 1 a 500 ml expander in the
cleavage space between
serratus anterior and latissimus
dorsi.
Combined expansion of the

belly of latissimus dorsi
and the skin in the inferior
half of the breast

 Expander
withdrawal
 Tailoring the
latissimus
dorsi flap

 LDF is fixed to the
future infra-
mammary fold
 A hammock is
created to support
the final implant
 Insertion of the
final implant
supported by the
muscular flap

 Placing the
final implant
 Closure in
separate
planes 24 hours
 Drainage postoperative

After Mastectomy

Musculocutaneous LD Flap + ITE
Techniques Points
 The preliminary expansion of the flap avoid the prelevation of o
big size cutaneous palette and the direct closing for the donor
site
 This procedure have the inconvenient to the supplementary
surgery time but the important advantage is the tessellate
infusion
Breast reconstruction by
Musculo-cutaneous pedicled L.D. Flap
MCLD Flap Technique

 The flap is crossing the
subcutaneous tunnel ahead of
big pectoral muscle tendon
 The flap must have no tension
Delaporte T., Sinna R.,. Perol D, Garson S., Vasseur C. and E. Delay . Bilateral breast
reconstruction with the autologous latissimus dorsi flap (a retrospective study of 31
consecutive cases) . Annales de Chirurgie Plastique Esthétique. Vol. 51, nr. 6,
December 2006, Pages 482-493
musculo-cutaneous pedicled L.D. Flap
associate with Internal Tissue Expander




 Definitively ITE
- type Becker

 ...laborious operation


 10 days after – the first expansion
 good result after three months

muscular pedicled L.D. Flap
 2 Temporary ITE
 2 Temporary ITE
 First step
Tissue
Expander
 Expander 2
 2 Temporary ITE
 After three
months
 Muscular LD Flap after expansion
M LD Flap = hammock for the

mammary implant
EXTERNAL TISSUE EXPANSION
 BRAVA System
External Tissue Expander
 BRAVA System
 Miami 14.02.2010
Roger Khouri
BRAVA System
Breast Reconstruction after Mastectomy
 Initial aspect

 BRAVA System – pre op 2 weeks

 BRAVA System – after 2 weeks

LIPOSUCTION
 preparation for
centrifugation
 FAT TRANSFER +
BRAVA System

 FAT TRANSFER +
BRAVA System

 FAT TRANSFER +
BRAVA System

 FAT TRANSFER +
BRAVA System
“orange skin”

 Subdermal skin
RIGOTOMY expansion
 FAT TRANSFER
+ BRAVA System

 FAT TRANSFER +
BRAVA System

 FAT TRANSFER + BRAVA System

 Results


 Results

 Initial aspect


 Results

 Results
 After 3 Fat Transfer stages

Breast Augmentation by Fat Transfer


 Results


 Results


 Dificult liposuction (skinny woman)
 Results


 Dificult liposuction
 Results

Complications
 oedema and bruising of both donor and

recipient sites are common
- can be reduced by abdominal compression garments
- 4-6 months: the volume of the breast appears to
stabilize
 donor site contour irregularities and

hypersensitivity
 sepsis - following fat grafting for bilateral breast
augmentation (*)
* Valdatta L, Thione A, Buoro M, et al. A case of life-threatening sepsis after breast augmentation by fat
injection. Aesthetic Plast Surg 2001;25:347-9
Complications
 LIPONECROSIS CYSTS – most cysts appeared:

 3-6 months after grafting
 palpable masses after 23 months
 mammography :
 benign calcifications, typically thin-walled calcifications surrounding
oil cysts or coarse irregular calcifications(*)
 is mandatory to 6 and 12 months and annually after
 Ultrasound
 MRI
 Localization : majority of cysts occurred in the

subglandular plane and subcutaneous
- over-injection in the subglandular plane can result
ischaemia with fat necrosis (**)
*C.W. Chan , S.J. McCulley , R.D. Macmillan. Autologous fat transfer e a review of the literature with a focus
on breast cancer surgery. Journal of Plastic, Reconstructive & Aesthetic Surgery (2008) 61, 1438-1448
**Zheng DN, Li QF, Lei H, et al. Autologous fat grafting to the
breast for cosmetic enhancement: experience in 66 patients with long-term follow up. J Plast Reconstr
Aesthet Surg 2008; 61:792-8
LIPONECROSIS CYSTS
6,5 X 5,5 mm

LIPONECROSIS
CYSTS
 skin puncture
aspiration

Complications
 7.8% developed liponecrosis cysts (*)
3 cases liponecrosis cysts of 19 (15,7%)
 fat injection into the breast could result in:
 fat necrosis - cyst formation
 hyperchrome scars ( 1 case )
 delayed mastitis at 6 months after fat grafting
 indurations that could be mistaken as cancerous
calcifications
*C.W. Chan , S.J. McCulley , R.D. Macmillan. Autologous fat transfer e a review of the literature
with a focus on breast cancer surgery. Journal of Plastic, Reconstructive & Aesthetic Surgery (2008) 61, 143-1448
Hyperchrome scars
 Tubular breast asymmetry – BRAVA Syst + Fat transfer

RESULTS = 94% VG+G
19 cases with
Fat Transfer in
Breast
Reconstruction
 3 cases with
liponecrosis
cysts (15,7%)
 1 case with
hyperchrome
scars

FAT TRANSFER STAGES
 68,4% = Was sufficient ONE FAT TRANSFER STAGE
STAGES QUANTITY OF INJECTED FAT

FAT INJ (cc) CASES ( 19 )
(CC)
FAT 1
13 60-180 cc
TRANSFER
STAGES
2
4 80-150 cc
3
2 80-100 cc

Comparative study of
ITE vs ETE
Comparative study of INTERNAL TISSUE EXPANDER EXTERNAL TISSUE EXPANDER
ITE vs ETE (ITE) (ETE)
TIMING OF SURGERY 2 STAGES: 1 STAGE

a) 1 hour 2 -3 hours
b) 4-5 hours
ANESTHESIA general Spinal + local anesthesia

HOSPITALIZATION a) 3 - 4 days One day surgery
b) 5 - 7 days
POSTOPERATIVE CARE a) 3 weeks 3rd day: change the dressing (HERSELF)

b) expandation: until 3 months Start using BRAVA 3 weeks
ADVANTAGES OFFERS A LARGE VOLUME AND A LIPOASPIRATION - Body Contour Surgery

IMPORTANT CUTANEOUS ISLAND NON-INVASIVE SURGERY
DISADVANTAGES 2 SURGICAL STAGES 1 SINGLE STAGE OPERATION

FINAL RESULT: 3-4 MONTHS (FAT TRANSFER > 150 ML)
SIZE OF AUGMENTATION: DEMANDING
PSYCHOLOGICAL PSYCHOLOGIC DIFFICULTY AFTER NON-INVASIVE

MASTECTOMY SKIN PUNCTION
2 STAGES LARGE OPERATION LIPOASPIRATION
SOCIAL REINTEGRATION 3 MONTHS IMMEDIATELY - max 1 week

CONCLUSIONS
Internal Tissue Expansion in Breast reconstruction
 The preliminary expansion of the LD flap avoid the

prelevation of o big size cutaneous palette and the
direct closing for the donor site
 This procedure have the inconvenient to the

supplementary surgery time but the important
advantage is the tessellate infusion
CONCLUSIONS
External Tissue Expansion in Breast reconstruction
 external tissue expander BRAVA associate with autologous fat

graft is a useful, modern and non- invasive procedure for
breast reconstruction
 internal expander and complex breast reconstruction is

mandatory to obtain a skin envelope large enough for a
tension free closure.

THANK YOU !
Roger Khouri

University of Medicine and Pharmacy “Gr.T. Popa” IASI
Head of Plastic and Reconstructive Surgery Departament
IASI – ROMANIA
www.stamate-teodor.ro

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INTERNAL versus EXTERNAL

Prof. Teodor STAMATE, M.D., Ph.D.

Prof. Teodor STAMATE, M.D., Ph.D.

Conf. Dr. Teodor STAMATE

•Two steps breast reconstruction :

Fascio-cutaneous flaps don’t provide enough thickness

Conf. Dr. Teodor STAMATE

• absence of the pectoralis major in all cases,

• absence of the pectoralis minor in 6 cases;

• Skeletal malformation of the thorax

• Diminished axillary pilosity = 4 cazuri;

• Malformations in the ipsilateral upper limb included:

 14 severe unilateral mammary hypoplasies

 27 minor mammary hypoplasies (V>50%)

Prof. Teodor STAMATE, M.D., Ph.D.

 temporary, replaced after

 definitively - type Becker

Prof. Teodor STAMATE, M.D., Ph.D.

b) Incision in the VIth

c) 380ml tissue expander

Prof. Teodor STAMATE, M.D., Ph.D.

Prof. Teodor STAMATE, M.D., Ph.D.

Prof. Teodor STAMATE, M.D., Ph.D.

Prof. Teodor STAMATE, M.D., Ph.D.

Prof. Teodor STAMATE, M.D., Ph.D.

Combined expansion of the

Prof. Teodor STAMATE, M.D., Ph.D.

Prof. Teodor STAMATE, M.D., Ph.D.

Prof. Teodor STAMATE, M.D., Ph.D.

Prof. Teodor STAMATE, M.D., Ph.D.

Prof. Teodor STAMATE, M.D., Ph.D.

MCLD Flap Technique

 The flap must have no tension

Prof. Teodor STAMATE, M.D., Ph.D.

Prof. Teodor STAMATE, M.D., Ph.D.

Prof. Teodor STAMATE, M.D., Ph.D.

Prof. Teodor STAMATE, M.D., Ph.D.

Prof. Teodor STAMATE, M.D., Ph.D.

Prof. Teodor STAMATE, M.D., Ph.D.

Prof. Teodor STAMATE, M.D., Ph.D.

Prof. Teodor STAMATE, M.D., Ph.D.

M LD Flap = hammock for the

Prof. Teodor STAMATE, M.D., Ph.D.

 BRAVA System – pre op 2 weeks

Prof. Teodor STAMATE, M.D., Ph.D.

 BRAVA System – after 2 weeks

Prof. Teodor STAMATE, M.D., Ph.D.

Prof. Teodor STAMATE, M.D., Ph.D.

Prof. Teodor STAMATE, M.D., Ph.D.

Prof. Teodor STAMATE, M.D., Ph.D.

Prof. Teodor STAMATE, M.D., Ph.D.

Prof. Teodor STAMATE, M.D., Ph.D.

Prof. Teodor STAMATE, M.D., Ph.D.

 FAT TRANSFER + BRAVA System

Prof. Teodor STAMATE, M.D., Ph.D.

 FAT TRANSFER + BRAVA System

Prof. Teodor STAMATE, M.D., Ph.D.

Prof. Teodor STAMATE, M.D., Ph.D.

 FAT TRANSFER + BRAVA System

Prof. Teodor STAMATE, M.D., Ph.D.

Prof. Teodor STAMATE, M.D., Ph.D.

Prof. Teodor STAMATE, M.D., Ph.D.

 FAT TRANSFER + BRAVA System

Prof. Teodor STAMATE, M.D., Ph.D.