**5. Tissue expander versus direct to implant reconstruction**

The two-stage tissue expander (TE) is the standard reconstruction technique following skinsparing or nipple-sparing mastectomy in most Western countries. TE is a safer option than direct to implant, particularly when there is uncertainty about the need for post-operative radiotherapy. Many surgeons continue to advocate the two-stage tissue expander reconstruction due to concerns about skin flap viability and risk of implant failure. Use of TE allows the mastectomy skin flap to heal without undue tension and risk of necrosis.

Two-stage tissue expander reconstruction is an option for women who wish to achieve larger cup size after breast reconstruction (**Figures 26** and **27**). The expander is replaced with a definitive implant as a second operation after completion of adjuvant therapy (such as chemotherapy). It is possible to deliver radiotherapy in women with tissue expanders or implants without compromising treatment. Patients need to be counselled about the increased risks of wound breakdown, implant infection and reconstruction failure in this setting. Use of adjustable expander-implants with a mini-remote port placed outside the radiotherapy field is helpful in reducing CT artefact during planning. There is a wide variation in the delivery of radiotherapy depending on centres. Many radiation oncologists are reluctant to deliver treatment in the presence of tissue expanders with integrated ports due to the large area of the metal backing in the port, uncertainty about treatment delivery in the area and concerns with raised temperatures and skin burn from treatment. Despite the higher risks, two-stage TE serves as a bridge to definitive reconstruction after

Oncoplastic Breast Surgery in the Treatment of Breast Cancer

http://dx.doi.org/10.5772/intechopen.77955

27

In patients who have not had radiotherapy, minor adjustments in the pocket or IMF is achievable in the second stage, but the basic footprint of the reconstruction is designed at the primary operation. Patients should be measured carefully in the clinic prior to surgery as a guide

Newer technology such as SPY *Elite* system for intraoperative monitoring of skin flap viability and vascular supply and use of newer diathermy devices such as PlasmaBlade (Medtronic plc. ®), which ensures lower tissue temperatures during dissection, can help minimise the risk of skin flap necrosis. Basic surgical principles of gentle tissue handling, avoiding undue traction of the skin flap or use of traumatic instruments at the skin edges, keeping the patient warm perioperatively, avoiding unnecessarily thin mastectomy skin flaps, resting the flap regularly and ensuring tension-free closure of the skin over the implant reconstruction; are

The safety of nipple-sparing mastectomy, depending on tumour location, has been adequately established for both in situ and early invasive breast cancer [28]. Careful preoperative assessment to ensure adequate clearance of the skin and nipple from the tumour site helps to ensure

completion of radiotherapy and helps preserve the mastectomy skin flap.

to ordering appropriate sized implants.

**Figure 27.** Final result replacement left TE with implant.

simple ways to avoid skin flap necrosis.

**6. Nipple-sparing and skin-sparing mastectomy**

reasonable margins and reduce the risk of recurrence.

**Figure 26.** Right two-stage TE and left prophylactic TE reconstruction.

**Figure 27.** Final result replacement left TE with implant.

Despite the significant global trend towards ADM and synthetic mesh-assisted implant reconstruction, recent years have also witnessed a resurgence in autologous tissue for inferior pole support, such as scar-less mini-LD flap and T-DAP flap. ADM associated 'red breast syndrome RBS', less than anticipated reduction in capsular contracture, higher seroma rates and secondary infection with implant loss; may account for this parallel rise in autologous tissue support. Some permanent synthetic meshes can result in higher rates of capsular contracture with firm tissue in the lower pole, resulting in long-term discomfort. Continued technological advances in lightweight synthetic mesh which integrate better with the host tissue, could help

The two-stage tissue expander (TE) is the standard reconstruction technique following skinsparing or nipple-sparing mastectomy in most Western countries. TE is a safer option than direct to implant, particularly when there is uncertainty about the need for post-operative radiotherapy. Many surgeons continue to advocate the two-stage tissue expander reconstruction due to concerns about skin flap viability and risk of implant failure. Use of TE allows the

Two-stage tissue expander reconstruction is an option for women who wish to achieve larger cup size after breast reconstruction (**Figures 26** and **27**). The expander is replaced with a definitive implant as a second operation after completion of adjuvant therapy (such as chemotherapy). It is possible to deliver radiotherapy in women with tissue expanders or implants without compromising treatment. Patients need to be counselled about the increased risks of wound breakdown, implant infection and reconstruction failure in this setting. Use of adjustable expander-implants with a mini-remote port placed outside the radiotherapy field is helpful in reducing CT artefact during planning. There is a wide variation in the delivery of radiotherapy depending on centres.

**5. Tissue expander versus direct to implant reconstruction**

mastectomy skin flap to heal without undue tension and risk of necrosis.

**Figure 26.** Right two-stage TE and left prophylactic TE reconstruction.

improve cosmetic outcomes for patients.

26 Breast Cancer and Surgery

Many radiation oncologists are reluctant to deliver treatment in the presence of tissue expanders with integrated ports due to the large area of the metal backing in the port, uncertainty about treatment delivery in the area and concerns with raised temperatures and skin burn from treatment. Despite the higher risks, two-stage TE serves as a bridge to definitive reconstruction after completion of radiotherapy and helps preserve the mastectomy skin flap.

In patients who have not had radiotherapy, minor adjustments in the pocket or IMF is achievable in the second stage, but the basic footprint of the reconstruction is designed at the primary operation. Patients should be measured carefully in the clinic prior to surgery as a guide to ordering appropriate sized implants.

Newer technology such as SPY *Elite* system for intraoperative monitoring of skin flap viability and vascular supply and use of newer diathermy devices such as PlasmaBlade (Medtronic plc. ®), which ensures lower tissue temperatures during dissection, can help minimise the risk of skin flap necrosis. Basic surgical principles of gentle tissue handling, avoiding undue traction of the skin flap or use of traumatic instruments at the skin edges, keeping the patient warm perioperatively, avoiding unnecessarily thin mastectomy skin flaps, resting the flap regularly and ensuring tension-free closure of the skin over the implant reconstruction; are simple ways to avoid skin flap necrosis.
