Breast reconstruction with Becker expanders : an analysis of 116 cases

Introduction: Breast expanders/implants were developed in the 1980s as a breast reconstruction alternative to pre-existing techniques. They were created to provide adequate shape and volume to the breast after one-stage surgery and they do not require replacement. To evaluate the long-term results of breast reconstruction performed with Becker expanders. Methods: This retrospective study evaluated patients who underwent breast reconstruction with implants/expanders between 2004 and 2012. Results: A total of 161 expanders were implanted. Major complications (those that led to the removal or replacement of the prosthesis) comprised 22.98% of the enrolled subjects. The expander was removed and replaced by another type of reconstruction implant in 21.74% of the cases. The main reasons for the replacement were capsular contracture (31.43%), patients’ desire (31.43%), and implant failure (20%). The surgical alternatives for the replaced expanders included prosthesis (91.43%), latissimus dorsi flap (5.71%), and TRAM flap (2.86%). Only few studies have evaluated the long-term effects of Becker expanders. In this study, the replacement rate was 28.57%. The study questions the use of Becker expanders as an adequate, onestage reconstruction technique. In spite of a high rate of optimal outcomes in the new surgical procedures (37%), its use is limited because of the high costs. The expanders are still useful for patients with comorbidities or other factors that limit the performance of other surgical procedures. Conclusion: The use of Becker expanders as an alternative for one-stage breast reconstruction technique is very limited. Therefore, these devices should only be used in selected cases. ■ ABSTRACT


INTRODUCTION
The first study on the use of expanders was published in 1957 by Neumann 1 and involved a case of a subauricular defect.Although Neumann's study has demonstrated the feasibility of the procedure, a greater interest in tissue expansion only occurred 20 years later, when Cledomir Radovan developed silicone tissue expanders 2 .In this context, breast expanders emerged as an alternative to autologous flaps, with the possibility of increasing skin coverage.Therefore, the purpose of the expanders' use in breast reconstruction was to allow the accommodation of a permanent implant, i.e., to provide tissue expansion that would accommodate the volume of a future prosthesis.
Breast expanders/implants were created to provide adequate shape and volume to the breast after one-stage surgery, no longer needing to be replaced by prosthesis because it allows for volume adjustment.These expanders were initially described by Hilton Becker [3][4][5] in the 1980s and could be left as permanent implants, once the desired volume was reached.
Therefore, it became an attractive alternative for the treatment of cases of breast reconstruction, particularly in patients with average volume breasts who underwent bilateral mastectomies, as well as in cases of breast asymmetry and congenital deformities.It presents several advantages 5 : the procedure is relatively simple and can be performed in a single-stage surgery, with the possibility of breast size adjustment, with reduced scarring, and without deformities and/or morbidity in the donor area, in addition to the shortened recovery period.Despite these advantages, some studies 6-8 have shown that in 30% to 68% of the patients who undergo this procedure, the implants need to be replaced.Therefore, its main advantage of being a one-stage and simple procedure is no longer a real argument.
The dome was removed in a second surgical procedure, simultaneously with the reconstruction of the nipple-areola complex and with additional procedures of homograft and contralateral mammoplasty, when necessary.
Patients were monitored weekly during the first month, and monthly for up to 4 months, and as needed until the removal of the medical valve or hospital discharge.
This study followed the criteria defined by the Declaration of Helsinki and its ethical principles, and no conflicts of interest are associated with this publication.

RESULTS
During the study period, 116 patients underwent permanent breast reconstruction using Becker expanders 50 .In 40 patients, the reconstruction was bilateral, resulting in 161 implanted expanders.The average age was 50.87 years (with a variation between 20 and 85 years).
The postoperative complications were divided into minor and major (Figure 1).Major complications were considered those that led to the removal or replacement of the expanders/implants, including major infections or necrosis with exposure of the expander, severe capsular contracture requiring implant replacement, expander failure, or major asymmetries that required the replacement of the expander.These complications totaled 22.98%.Minor complications (33.54%) were defined as seroma, hematoma, partial necrosis, contractures, and minor asymmetries (Table 1).

OBJECTIVE
This study aimed to evaluate the procedures for breast reconstruction with Becker expanders performed in the last eight years and to assess their long-term outcome.

METHODS
This retrospective study involved the review of medical records available between January 1 st 2004 and December 31 st 2012.The patients enrolled in this study included those who underwent total mastectomy with breast reconstruction (immediate or delayed) using expanders/implants.Those who underwent reconstruction with temporary expanders, local flaps, autologous tissue (TRAM or latissimus dorsi), and those with partial mastectomy were excluded.
The indications for the use of expanders included the patient's desire to undergo a simpler procedure, impossibility of performing other types of reconstruction, and high surgical risk for major surgeries (comorbidities and/or old age).
The data collected included age, postoperative complications, reasons for substitution of the expander and, in cases of expander removal, the new recommended therapy.
All reconstructions were performed by the same surgeon, closely following the same surgical technique.
In all cases included in this study, the Becker expander chosen was the Round BECKER™ 50 Expander/Breast Implant (50% gel) with a remote valve.Expander/implants present a textured surface with two inner shells made with layers of silicone, a gel-filled outer lumen and an adjustable salinefillable inner lumen.The outer lumen can account to up to 50% of the final volume, and the inner lumen is empty and can be expanded with normal saline until it reaches the desired breast volume.All patients underwent general anesthesia and the expander was placed in the submuscular pocket constructed with pectoralis major muscle flaps (on the upper and lower part), serratus anterior or its fascia (laterally), and the sheath of the rectus abdominis muscle (lower part).
The dome was placed subcutaneously in the axillary line at the height of the breast crease.The first expansion was made intraoperatively, with a volume dependent on the flap conditions at the mastectomy.However, in all cases, the expansion did not exceed 20% of the final volume.
The subsequent expansions were performed on an outpatient basis, after the wound was completely healed, after approximately 2-3 weeks, and every 2-3 weeks until the final volume was reached.Of the 28 patients with minor asymmetries, in 16 cases (9.93% of the total number of expanders used), a new surgical procedure was required for replacement of the expander; however, the expander was maintained and resulted in favorable esthetic outcomes.In the remaining cases of minor asymmetry, its correction was possible via fat grafting (Figure 2).
The expander was removed and replaced by another type of reconstruction in 21.74% cases, which comprised 35 expanders (Figure 3).The main reasons that led to the replacement of these expanders were:  severe capsular contracture in 11 cases (31.43% of the replaced implants), patient's desire to improve the symmetry or rigidity of the new breast in 11 cases (31.43%), implant failure in 7 cases (20%), severe asymmetry in 3 cases (8.57%), and infection in 3 cases (8.57%) (Figures 4 and 5).Infection led to the removal of the expanders in 8.69% cases (14 implants) and, in most of these cases, it was associated with flap necrosis.In 3 cases, after controlling the infection, the prosthesis was placed without complications.
All patients who had their expanders replaced did so in less than 5 years from the reconstruction.
The follow-up period varied between 3 and 60 months.
Figure 7 shows the postoperative outcome in one case.

DISCUSSION
Several studies 3,4,[9][10][11][12][13][14][15][16] have reported favorable outcomes after the use of expanders/implants in breast The first is related to the usual reasons for removal of implants: infections, capsular contracture, extrusion, and inadequate esthetic results, among others.The second reason is related to problems inherent to the expanders: breakage, leakage, changes in their compartments, dome displacement, and valve obstruction, among others.
We found no studies in the literature on the main reason of the implant failure: rupture of the inner bag with mixture of the components (Figure 8).These cases were discovered by chance during the follow-up on patients with cancer.It is not related to any symptomatology, but causes a lot of psychological discomfort in patients after they acknowledge that they have a ruptured implant.reconstruction surgeries, although most of these studies only report initial results because these devices had not been used long enough for a long-term evaluation by the subjects included in the studies.For this reason, to date, the actual longevity of the implant, which was designed to be permanent, has not been evaluated.Recently, Chew et al. 7 reported rates of replacement/removal of expanders/implants of more than 68% in a 5-year follow-up.This rate confirms our suspicion that most of these implants were being replaced.In our case-by-case analysis, the replacement rate was 28.57%.
According to our analysis, and in agreement with the results from previous studies, expanders/implants are subject to two main types of complications 6,17 .This study questions the use of expanders/ implants as a strategy for one -stage breast reconstruction, as well as about their longevity.The rate of new surgical procedures for repositioning of the implant of 9.9% combined with the rate of replacement and/or removal of approximately 28% in an 8-year period reinforces the hypothesis by Chew et al. 7 , that the use of these devices is severely limited because of their high cost.
In addition, nowadays, there is great pressure from health insurers, which restrict the authorization for high-cost procedures and materials, therefore commonly questioning the request for this material, with the justification of conducting a one-stage reconstruction.
In our analysis, of the 161 expanders implanted, only 25 implants (in 18 patients) underwent a one-stage intervention to achieve adequate esthetic results, and those units did not need any type of adjustment except the removal of the valve.
Fernandes et al. 18 evaluated the costs and resources associated with breast reconstruction surgery by comparing temporary expanders with permanent expanders/implants.For two-stage reconstruction, the medical fees were the main component of the final cost of treatment, corresponding to 28% of the total, followed by the temporary expander and the permanent implant used (13%).In one-stage reconstructions, the cost of the expanders/implants used corresponded to 46% of the total, followed by medical fees (19%).The budget impact analysis indicated significant savings from the perspective of the payer for reconstructions using Becker expanders, demonstrating that the higher unit costs of the expander would be offset by clear economic benefits, particularly with the lower utilization of funds due to the need to perform one-stage surgeries.
However, in 2012, Eriksen et al. 8 compared onestage with two-stage reconstructions and observed that the patients who underwent two-stage reconstructions had a lower surgical revision rate compared with those who underwent one-stage reconstructions, demonstrating that this technique is limited in achieving the desirable result as the single option.
The removal of the Becker expander and its replacement by breast implants does not cause any additional problems compared with the use of other models of expanders or implants 6 .The evaluation of patients with replaced expanders revealed that they also achieved favorable outcomes.The ultimate goal of all breast reconstructions should be to achieve the best possible aesthetic result, with the lowest number of surgeries.However, psychological stress and frustration caused by a new preoperative and postoperative routine and another period of absence from work in patients who believed they were undergoing a single procedure cannot be overlooked.
The need to perform a second procedure using temporary expanders or even prostheses is well accepted by patients because they have understood that this is part of a process aimed at achieving the best possible aesthetic outcome [19][20][21] .
It is important to note that Becker expanders continue to be a useful tool in some cases of breast reconstruction 22 .The evaluation of this study results allowed for a redirection of the indications concerning the use of these devices by our team.We restricted this technique to patients with comorbidities or other factors that limit the performance of other surgical procedures.In such cases, we assume the risk of proceeding concomitantly with mastectomy and symmetrization.The possibility of adjustment of the implant size becomes a favorable factor in achieving symmetry.

CONCLUSION
The use of Becker expanders as an alternative, one-stage technique for breast reconstruction is very limited.The increased need for replacement (approximately 28%) and/or associated corrections (approximately 85%) makes it costly and less efficient when compared with other, already established techniques.Therefore, these devices should be used in selected cases.

Figure 1 .
Figure 1.Postoperative complications -Graph showing the main complications.Major complications were defined as those that required replacement and/or removal of the expander.

Figure 2 .
Figure 2. Asymmetry correction -A, B, C: Preoperative left mastectomy.D, E, F: Postoperative period after implantation of the left expander.asymmetry was observed.G, H, I: Late post-operative period after correction of the left breast using fat grafting.

Figure 3 .
Figure 3. Eight-year evaluation of expanders.Graph showing the longevity of the expander.A rate of replacement of 21.74% was observed.

Figure 4 .
Figure 4. Reasons for replacing expanders.Among all expanders replaced and/or removed (n = 35), contractures and other factors (patient's desire) were the main reasons.

Figure 5 .
Figure 5. Failure of expanders.MRI showing the "component mixture" (mixture of silicone gel with the filling solution).

Figure 6 .
Figure 6.Replacement alternatives.The main alternative for replacement after the removal of the expander was reconstruction with prosthesis (in 91.43% cases).TRAM: Transverse Rectus Abdominis Myocutaneous.

Figure 7 .
Figure 7. Reconstruction with prosthesis -A: Preoperative period.B: Late postoperative period.Reconstruction with removal of the expander and implantation of bilateral prosthesis.

Figure 8 .
Figure 8. Component mixture of Becker expanders.MRI showing the component mixture with rupture of the internal capsule of the expander in the left breast, with mixture of the saline component with the silicone gel.

Table 1 .
Description of the complications.