Immediate breast tissue expander-implant reconstruction with inferolateral AlloDerm hammock and postoperative radiation: a preliminary report

Abstract

Objective: To preserve the mastectomy skin envelope in select patients destined to receive radiation following mastectomy, we performed immediate tissue expander-implant reconstruction with a subpectoral tissue expander and an inferolateral AlloDerm hammock for complete implant coverage. We hypothesized that the AlloDerm hammock may allow greater intraoperative volume expansion and potentially avoid the need for an autologous construct.

Methods: Tissue expanders were filled to 75%-85% capacity intraoperatively and 85%-100% prior to radiation therapy. This allowed for maximum preservation of the mastectomy skin envelope prior to radiation therapy and provided a sizable breast mound immediately following mastectomy. Histology of irradiated and nonirradiated capsules was compared.

Results: Five patients aged 29-51 years had immediate implant (1) or expander-implant (4) breast reconstruction followed by postreconstruction radiation 2-6 months following the procedure. Patients were followed for 2.5-5.5 years following implant reconstruction and 2-5 years following radiation. No capsular contracture or implant loss was observed in any patient. No patients required or requested autologous reconstruction following radiation and all currently have silicone implants. Capsular biopsies from radiated and nonradiated implants showed identical collagen architecture on histology, confirming clinical observations.

Conclusion: Tissue expander-implant breast reconstruction following mastectomy preserves the skin envelope in patients who receive postmastectomy radiation. Further investigation is warranted to determine whether complete implant coverage with the pectoralis muscle and AlloDerm hammock mitigates the deleterious effects of radiation.

Figure 1

Immediate left-sided tissue expander-implant reconstruction following mastectomy and postoperative radiation. This 50-year-old woman received radiation 3 months after immediate tissue expander reconstruction. She subsequently underwent implant exchange and nipple construction and is shown 1 year following radiation.

Figure 2

Immediate left-sided tissue expander-implant reconstruction following mastectomy and postoperative radiation. This 46-year-old woman received radiation 4 months after immediate tissue expander reconstruction. She is shown here at her 1-year follow-up.

Figure 3

Immediate bilateral tissue expander-implant reconstruction following bilateral mastectomy and postoperative radiation to the right side. This patient had bilateral immediate tissue expander placement and then subsequently had radiation to the right side only. She then had an implant exchange and is shown here 1 year after radiation and after nipple areolar reconstruction and tattoo. The 2 sides are nearly indistinguishable.

Figure 4

Histology of tissue expander-AlloDerm capsule at the time of bilateral implant exchange. The upper photo shows the nonradiated left breast capsule and the bottom photo shows radiated capsule. The two capsules are indistinguishable (Verhoff stain).

Figure 5

Delayed breast reconstruction with TRAM flap in 2 patients after left-sided mastectomy and XRT. Despite good match in volume and shape, the aesthetic results are compromised because of visibility of TRAM skin island (scar and color mismatch) which can extend beyond the border of the bra.