Reconstruction with Implant - GBCCgbcc.kr/upload/Hak Chang.pdf · 2020. 4. 7. · Autologous tissue versus breast implant Image from breastreconstruction.org Implant-based reconstruction

Panel Discussion 2: Issues with Mastectomy and Reconstruction

Reconstruction with Implant

Department of Plastic and Reconstructive Surgery

Seoul National University Hospital

Hak Chang

Conflict of InterestDisclosure Information

No financial relationships to disclose

Agenda

• 1. Implant based breast reconstruction

• 2. Perfusion status of mastectomy skin

• 3. Prevention mechanism of capsular contracture

by acellular dermal matrix(ADM)

Autologous tissue versus breast implant

Image from breastreconstruction.org

Implant-based reconstruction

Advantages

1. Minimal morbidity

2. Reduced operation time

3. No donor site morbidity

4. If the patient becomes dissatisfied with the result,

all pre-existing flaps are still available

Disadvantages

1. Complications related to implant

: implant deflation, capsular contracture

2. Contour irregularities

3. The implant will not behave like

normal vascularized tissue

: It will not develop natural ptosis

Direct-to-implant

(1 stage)Expander-implant

(2 stage)

Implant-based breast reconstruction

Breast tissue expander

Expander-implant breast reconstruction

Subpectoral plane versus prepectoral plane

Subpectoral technique

Prepectoral technique

Advantages

• Minimal visibility of the implant

• Minimal palpability and rippling

• Low risk of capsular contracture

Disadvantages

• Donor-site morbidity

• Postop painADM

Complications related to implant

Infection Implant exposure Implant rupture

Capsular contracture Capsule tissue

Mastectomy skin flap necrosis

Intraoperative perfusion mapping with SPY

3-4 mL of ICG (Indocyanine green, 2.5 gm/mL)

Nonperfused lat. skin (blue arrow)

was excised.

Tissue expander was filled with

250 ml

-> ischemia along the med.

incision line (blue arrow)

After the removal of 50 ml from

the tissue expander

-> the skin perfusion returned to

normal

Total cases: 24

Cx rate: 4 % (1 of 24 cases)

Cx rate in 206 cases without SPY: 15.1%

Case

F/54BMI: 23.01

Rt. breast cancer

CTx (-)

RTx (-)

HTx (-)



Postop 8 moImmediate postop

Postoperative result

1. After mastectomy, the

surgeon marked the area

of skin to be resected.

2. Then, the SPY imaging

was performed.

3. A 2-mm border of skin

was excised along the

incision edge regardless

of perfusion

4. Postoperatively, Pts were

assessed for necrosis.

5/31 patients, 8/55 breasts

developed necrosis

2 patients (3 breasts):

debridement alone

3 patients (5 breasts):

tissue expander removal and

replacement

Case

F/60BMI: 24.94

Rt. breast cancer

CTx (-)

RTx (-)

HTx (-)



POD #5Immediate postop


Case

F/37BMI: 26.96

Rt. breast cancer (2017-01)

Lt. breast cancer (2017-04)

CTx (+) : AC#4 -> D#4 (2017-06 ~ 2017-10)

RTx (-)

HTx (+) : TMX (2017-11 ~)



POD #5Immediate postop


Preop

No

rma

l p

erf

us

ion

Isc

he

mia

Immediate postop Postop 5 days

Comparison of nipples with normal perfusion and ischemia

No. Age BMI Nipple perfusion (%) Complication

1 39 19.78 14.8 Partial necrosis

2 47 23.71 99.0 None

3 36 19.24 31.0 None


5 60 24.94 98.0 None




Nipple perfusion status in nipple-sparing mastectomy

Complications related to implant

Infection Implant exposure Implant rupture

Capsular contracture Capsule tissue

Grading system of capsular contracture

Use of Acellular dermal matrices in implant-based breast reconstruction

Literatures regarding the role of ADM on capsular contracture

Basu CB et al. PRS. 2012.

ADM is widely used for expander-implant breast reconstruction

84.2%

The evidence against the use of ADM is weak

Basu CB et al. PRS. 2010.

∙ 20 patients

∙ Biopsy specimens were scored

by pathologist

Histological difference between subpectoral and ADM capsule

The effect of radiation on ADM and capsule formation

Moyer HR et al. PRS. 2014.

∙ 6 patients

∙ Significant differences in

cellular infiltration and elastin

Despite several efforts, the mechanism of how ADM inhibits

capsule formation is still unclear, especially in irradiated patients

1. Subpectoral and ADM capsule were analyzed

in cellular and molecular level

2. Non-irradiated and irradiated capsule were also compared

Patients and methods

1. Period: 2016. 5. 18 – 2017. 7. 18

2. Number of patients1) Radiotherapy (-): 10 patients

2) Radiotherapy (+): 10 patients (45-50 Gy)

3. Surgical techniqueExpander-implant breast reconstruction (immediate)

Complete coverage of expander with P. major m. and ADM (CG CryoDerm® )

Capsule tissue harvest at expander implant exchange surgery

4. Capsule tissue harvest1) Submuscular capsule: beneath the pectoralis major m.

2) ADM capsule: beneath ADM

5. Statistical analysisKruskal-Wallis test followed by Tukey’s HSD test with ranks

Mann-Whitney U test

6. IRB No. 1707-096-870

Comparative demographics

Nonirradiated

Group

Irradiated

Groupp

Age, yr 46.3 45.8 0.7051

BMI, kg/m2 22.6 22.7 0.9401

Mean interval for

expander-implant

exchange,

months

9.7 10.1 0.2191

Mean expander

volume, ml370 430 0.025*

Final expansion

volume, % of

capacity

103.9 107.7 0.4951

Comparison of capsule thickness

Submuscular capsule ADM capsule

Rad

iati

on

(-)

Rad

iati

on

(+

)

0

1000

3000

4000

Cap

su

le t

hic

kn

ess (

um

)

2000 **

***

*

Scale bar: 100 µm

a

b

Inhibition mechanism of ADM on capsule formation

Myofibroblasts

ECM

Fibrosis/capsule

1: play a central role

in tissue fibrosis

aSMA positive myofibroblasts


Ra

dia

tio

n (

-)R

ad

iati

on

(+

)

aS

MA

DA

PI

0

10

30

aS

MA

+ c

ell

s (

%)

20***

***

***

Scale bar: 100 µm


Myofibroblasts ↓

ECM ↓

Fibrosis

Capsule formation ↓

1

Fibroblasts2

Differentiation

Vimentin positive fibroblast


Ra

dia

tio

n (

-)R

ad

iati

on

(+

)

Vim

en

tinD

AP

I

Scale bar: 100 µm

0

10

40

Vim

en

tin

+ c

ell

s (

%)

20

***

***

***

30


Myofibroblasts ↓

ECM ↓

Fibrosis


1

Fibroblasts ↓2

Differentiation

Via blood vessels↓

3

Endothelial cells4

Endothelial-Mesenchymal Transition

Resident fibroblasts

Recruited fibroblasts

Endothelial-mesenchymal transition


Rad

iati

on

(-)

Rad

iati

on

(+

)

0

100

300

400

En

do

MT

(No

./m

m2)

200

***

***

Scale bar: 100 µm

aS

MA

CD

31

500


Myofibroblasts ↓

ECM ↓

Fibrosis


1

2

Differentiation

Proliferation

Via blood

vessels

3

4

Endothelial-Mesenchymal Transition ↓

5



Macrophages

Fibroblasts ↓ Endothelial cells

F4/80+ macrophage


Ra

dia

tio

n (

-)R

ad

iati

on

(+

)

F4

/80

DA

PI

Scale bar: 100 µm

0

16

F4

/80

ce

lls

(%

)

8 ***

***

***


Myofibroblasts ↓

ECM ↓

Fibrosis


1

Fibroblasts ↓2

Differentiation

Proliferation

Via blood

vessels

3

Endothelial cells ↓4


Macrophages ↓5

6TGFβ

PDGF

TGFβ



qRT-PCR

TGFβ1 PDGFb

0

Re

lati

ve

ge

ne

ex

pre

ssio

n

0.5

1.0

1.5

2.0

0

Re

lati

ve

ge

ne

ex

pre

ssio

n

0.5

1.0

1.5

*

2.0

0

Re

lati

ve

ge

ne

ex

pre

ssio

n

0.5

1.0

1.5

2.0

0

Re

lati

ve

ge

ne

ex

pre

ssio

n

0.5

1.0

1.5

*

2.0


Myofibroblasts ↓

ECM ↓

Fibrosis


Fibroblasts ↓

Differentiation

Proliferation

Via blood

vessels

Endothelial cells ↓


Macrophages ↓

TGFβ

PDGF ↓

TGFβ ↓



Summary

1. Intraoperative LASER angiography is useful for assessment of

mastectomy skin flap perfusion status

2. ADM decreases capsular contracture through the reduction of

myofibroblast, fibroblast and macrophage recruitment, vascularity,

EndoMT

3. Radiotherapy aggravates capsular contracture in submuscular

capsule but do not affect to subADM capsule

Thank you for your attention

Documents

Reconstruction with Implant - GBCCgbcc.kr/upload/Hak Chang.pdf · 2020. 4. 7. · Autologous tissue versus breast implant Image from breastreconstruction.org Implant-based reconstruction