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Implant-based ADM-aided breast reconstruction with fixed volume permanent implants

September 8th, 2013

Implant-based ADM-aided breast reconstruction with fixed volume permanent implants

In my previous blog, I alluded to the fact that ADM-based breast reconstruction is gaining popularity amongst oncoplastic breast surgeons and patients. It is a method of choice for breast reconstruction due its relative ease of use, good cosmetic results and quicker recovery. Surgeons, whilst performing implant-based ADM-aided breast reconstructions (IBAR), are using variable volume implants (expandable implants, a typical example being style 150 by Allergan of Beckers by Mentor). A fixed volume implant is seldom used and if it is, it tends to be in a highly selective group of patients. When I started performing IBAR, my preference was variable volume implants as they gave me control over the volume and addressed some of the unpredictability of my breast volume assessment. As I have gained more experience in this technique over the last three years, I feel very confident in using fixed volume permanent implants for my ADM-aided reconstructions. This confidence has been boosted after attending a master class in Stockholm with Per Hedén. The master class was about choosing the correct implant for breast augmentation and it relies mainly on dimensions rather than guessing the volume. While flying back to the UK, it suddenly hit me that this principle of measurement can easily applied to IBAR. Not all IBARs will be amenable to using fixed volume, but the majority will. Before I describe this technique, I want to discuss the merits and disadvantages of the use of variable volume implants.

Advantages of variable implants in ADM-aided reconstruction

Traditionally when performing IBARs, variable volume implants are used for the following reasons:

  •  It allows the surgeon to adjust the volume of the reconstructed breast to some extent, depending which implant has been used, e.g. Allergan style 150, Mentor Becker 50 or Becker 35. This is a good option, when you are concerned about the skin envelope and want to avoid excess pressure on the surrounding breast tissue.
  •  Preempting the precise volume of the final constructed breast has not been an exact science, and variable volume implants give the surgeon room to manipulate the volume for optimum cosmetic results.
  •  Conceptually it allows the surgeon to perform single-stage breast reconstruction.

Disadvantages of variable volume implants in ADM-aided breast reconstruction

  • Although the cosmetic outcome is acceptable, it may lack certain aspects of good breast reconstruction e.g. the distance between the nipple and inframammary fold (IMF) lacks definition and the desired dimension in some of the cases, as there is less control on this aspect when using variable volume.
  • Due to the fact that ADMs do not have give, they do not expand when variable volume implants are expanded, and as a result Pectoralis Major, which is more compliant, will expand and stretch. This, in 20-30% of cases, results in the thinning of the muscle and implant palpability over the upper pole.
  • Although variable volume implants are used with the intention of providing patients with one-stage reconstruction, unfortunately due to the above mentioned reasons, either the implant has to be changed to permanent fixed volume, or the palpability of the implant has to be corrected with an additional sheet of ADM on the upper pole. The revision surgery rate can be as high as 35%.

Advantages of fixed volume silicone implants in ADM-aided breast reconstruction

Fixed volume permanent implants address most of the above issues. When used in accordance with the Akademikliniken system (AK system), fixed volume implants provide excellent cosmetic results and do not cause the thinning of the Pectoralis Major muscle, as no expansion is required. It is half the price of the variable volume implant and does not require replacement in most cases.

How to measure for fixed volume implants in ADM-aided breast reconstruction

Traditionally, surgeons have taken approximate values of breast volume, breast height and width to determine the implant size to be inserted in the reconstructed breast. In most instances it works and produces a good cosmetic outcome because the majority of surgeons prefer using variable volume implants, allowing them some freedom of error and secondly, the majority of these patients undergo skin-sparing, nipple-sacrificing mastectomy, thus eliminating the need for the centralisation of the nipple areola complex. Conversely, when doing ultra skin-sparing mastectomy, the nipple areola complex position becomes more relevant, and thus there is a need for more accurate measurements. Although in most instances the traditional way of assessing volume is enough to give a good cosmetic result, an exact science to determine the proper implant to give the optimum result is desirable. It is very important to realise that IBAR works almost on the same principle as cosmetic breast augmentation. There are several systems available to assess implant size but the most accurate system backed by the science of numbers is, as previously mentioned, the Akademikliniken system (AK system), used and popularised by Per Hedén et al, plastic surgeons in Sweden.
I have been using the AK system for IBAR breast reconstruction with fixed volume permanent implants for some time now, and have been able to produce optimum results with minimum complications. I have been able to preserve the nipple areola complex in all of my patients. This obviates the need for multiple outpatient appointments to inflate an expander or variable volume implant. This also has the advantage of one-stage reconstruction eliminating the need for a second surgery to change the expander.

Pre-operative measurements start with measuring breast width.
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The next step is to ascertain the height of the implant. This is achieved by asking the patient to raise her arms above her head while the nipple level is marked on the sternum (A). Now arms are dropped down and the lower pole of the breast is marked in the midline (B). The distance measured between A and B is half of the height of the implant. This measurement is marked in the midline from point A, giving the superior pole of the implant.

_DSC0498_DSC0495The next step is to decide the desired projection. This depends on patients wishes and tissue give. All these measurements are used to determine the implant size. Allergan provides tables for all their implant products which makes this easy. The next step is to determine the site of incision under the breast, if doing ultra skin-sparing mastectomy through IMF approach. This is determined by calculating the lower ventral curvature (LVC) of the selected implant. This is taken on the anterior surface of the implant from the mid height point of the implant to the inferior edge. Again, this has been made easy by tables provided by Allergan, in which the LVC has been calculated for implants including style 410, 510 and Inspira. One centimetre (the thickness of the mastectomy flap) is added to the LVC of the implant to give u (C). Once again, the patient is asked to raise her arms above her head and C is taken from the nipple to the lower part of the breast: this is the site of the incision (figure). I use a vertical approach, I will double breast the incision by de-epithelisation of one of the edges.

The results of Implant-based ADM-aided breast reconstruction with fixed volume permanent implants are invariably optimum and reproducible. I strongly recommend this system to oncoplastic breast surgeons, who are doing ultra skin-sparing mastectomies with immediate implant-based ADM-aided reconstructions.

Filed in Augmentation / Mastopexy, Breast Augmentation, Breast Cancer Articles, Breast Enlargement, Breast Surgery, Cosmetic and Oncoplastic Breast Surgery, Cosmetic breast surgeon, Oncoplastic breast surgery.

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