New options for immediate reconstruction: Achieving optimal results with adjustable implants in a single stage

Background: With the wide acceptance of immediate reconstruction and skin-sparing mastectomy and the precipitous decline in reimbursement for all types of breast reconstruction techniques, it is appropriate to revisit a technique that can achieve optimal reconstruction goals with a single general anesthetic operation. Methods: A total of 322 consecutive cases in 14 years are reviewed. The mean patient age was 46 years (range, 20 to 76 years). Although this is not the first time a single-stage technique with adjustable implants has been reported, it is the largest series, and the technique was used in all consecutive patients during the past 14 years who were candidates for immediate implant reconstruction. The placement of a smooth-walled, permanently adjustable implant (Spectrum or Becker) entirely subcutaneously in the lower half of the breast, the use of shaping sutures initially, the careful placement of biopsy incisions, and aggressive initial debridement of mastectomy flaps are the keys to obtaining reliable results. Because of the partial or total subcutaneous placement of the implant, this method preserves the ptotic shape of the original breast without the need for subsequent expansion to obtain ptosis. Results: Complications requiring major general anesthesia reoperations were capsular contracture [n = 61 (19 percent)], significant mastectomy flap necrosis ([n = 6 (1.9 percent)] seroma or hematoma. [n = 16 (5 percent)], and periprosthetic infection [n = 7 (2.1 percent)]. Four infected implants were salvaged and three were removed and replaced at a later date. Most mastectomy flap necrosis was marginal and revised in the office under local anesthesia [n = 23 (7.1 percent)]. The rate of major necrosis requiring debridement in the operating room was 1.9 percent (n = 6). Aesthetic results were rated by patient and physician report to be excellent (78 percent), good (17 percent), or poor (5 percent). Conclusions: This technique achieves the goals of providing a ptotic reconstruction in one operation without the use of latissimus flaps or tissue expansion. The complication rate was low and the author discusses several methods for avoiding complications historically associated with immediate implant reconstruction.