Smooth Versus Textured Tissue Expander Breast Reconstruction: Complications and Efficacy

Abstract

Introduction Ongoing recognition of breast implant–associated anaplastic large cell lymphoma (BIA-ALCL) and its link with textured devices has brought a paradigm shift in prosthetic-based breast reconstruction. Many institutions no longer offer textured expansion devices for staged reconstruction. However, there is a paucity of data regarding the efficacy of smooth tissue expanders (TE). We hypothesized that the time to final reconstruction and complication profile between smooth and textured TEs would be similar in breast reconstruction patients. Methods A retrospective chart review was performed of all patients who underwent TE breast reconstruction during a 6-year period at the Penn State Hershey Medical Center. Rates of complications treated nonoperatively and those requiring reoperation were assessed. Mechanical complications, including expander malposition and rupture, were evaluated. Time to final breast reconstruction was quantified. Mixed-effects logistic regression and linear regression models, as appropriate, were used to compare textured to smooth TEs. Patient characteristics and anatomic plane placement were adjusted for in all analyses of outcomes. Results Data were collected on 389 patients, encompassing 140 smooth and 604 textured TEs. Textured devices had an increased incidence of complications treated nonsurgically (16.7% vs 10.7%; P = 0.14). However, smooth TEs had an increased incidence of reoperation (12.1% vs 7.6%; P = 0.06). Most noteworthy was that although smooth TEs had a 40-fold increase in malposition (13.6% vs 0.3%; P < 0.001), no reoperation for this complication was warranted. Further, the time to final reconstruction was comparable between the 2 devices (textured expanders: 221 days and smooth expanders: 234 days; P = 0.15). Conclusions Staged, implant-based reconstruction is the most common surgical approach to recreate the breast mound following mastectomy. Textured TEs were the cornerstone to this approach. Unfortunately, the association between textured devices and BIA-ALCL now mandates an alternative. We postulated that smooth expanders would compare favorably for breast reconstruction. Although our study suggests that smooth TEs suffer more malposition, this has a negligible impact on the reconstructive timeline. Thus, smooth TEs may prove beneficial when considering the risk of BIA-ALCL associated with textured devices.

Is It All about Surface Topography? An Intra-Individual Clinical Outcome Analysis of Two Different Implant Surfaces in Breast Reconstruction

“…Clinical studies suggest that these different surface architectures induce different foreign body immune responses and fibrosis [ 2 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 ]. Higher surface texture complexity leads to increased capsule disorganization, tissue ingrowth, and adherence; textured implants thus show a lower risk of malposition or rotation [ 48 , 51 , 52 ]. Importantly, macrotextured prostheses showed a higher risk of biofilm formation and they have been associated with the occurrence of anaplastic large cell lymphoma (BIA-ALCL) [ 53 , 54 , 55 , 56 ].…”

“…Hence, although tissue expanders are designated to be removed and exchanged for definite implants, their impact on the prosthesis environment must be considered beyond their period of use. Comparative studies on the clinical outcome of implant reconstruction after the use of different types of tissue expanders are scarce and they mainly focus on the evaluation of complications such as malposition, seroma formation, infections, capsular contracture, and reoperation rates [ 52 , 58 , 59 , 60 ]. In prior investigations, we analyzed the composition of peri-SMI connective tissue capsules only in women who received such implants for aesthetic reasons [ 31 , 61 , 62 ].…”

Practice Trends in the Management of Asymptomatic Breast Reconstruction Patients with Textured Implants: A Survey Analysis

“…Therefore, it is recommended that surgeons have a detailed conversation about the risks of surgical complications and benefits before proceeding with elective surgery for the asymptomatic patient, emphasizing the inconclusive evidence to support prophylactic implant exchange with or without capsulectomy as a riskreduction procedure. 2,6,26 Park et al emphasized four main themes during counseling that providers should focus on, which include weighing risks of BIA-ALCL, perceiving individual patients' psychosocial contexts, guiding by discussing benefits and risks of prophylactic treatment, and providing support through one-on-one consultation to strengthen the physician-patient relationship. 27 Finally, the use of ADM in breast implant reconstruction has increased significantly with the rising popularity of prepectoral implant-based breast reconstruction.…”

Is it all about Surface Topography? An Intraindividual Clinical Outcome Analysis of Two Different Implant Surfaces in Breast Reconstruction

“…Clinical studies suggest that these different surface architectures induce different foreign body immune responses and fibrosis [2,[42][43][44][45][46][47][48][49][50]. Higher surface texture complexity leads to increased capsule disorganization, tissue ingrowth, and adherence, therefore textured implants show a lower risk of malposition or rotation [51][52][53]. Importantly, macrotextured prostheses showed a higher risk of biofilm formation and they have been associated with the occurrence of anaplastic large cell lymphoma (BIA-ALCL) [54][55][56][57][58].…”

“…Hence, although tissue expanders are designated to be removed and exchanged for definite implants, their impact on the prosthesis environment must be considered beyond their period of use. Comparative studies on the clinical outcome of implant reconstruction after the use of different types of tissue expanders are scarce and they mainly focus on the evaluation of complications such as malposition, seroma formation, infections, capsular contracture, and reoperation rates [53,[60][61][62]. In prior investigations, we analyzed the composition of peri-SMI connective tissue capsules only in women who received such implants for aesthetic reasons [31,63,64].…”