Plastic Surgery Research Council

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Smooth Versus Textured Tissue Expanders in Breast Reconstruction Reduced Early Post-operative Complications
Ruth Tevlin, MB BAO BCh, MRCS, MD, Mimi R. Borrelli, MBBS, Amee Azad, BA, Victoria Posternak, RN, Derrick C. Wan, MD, Dung Nguyen, Pharm.D, MD, Rahim Nazerali, MD.
Stanford University, Stanford, CA, USA.

PURPOSE
Textured TEs (TTEs) were initially introduced to limit expander migration and reduce capsule formation, which are inherent to traditional smooth expanders. Recently, the addition of tabs on expander devices to reduce migration along with increasing concerns associated with textured implants and anaplastic large cell lymphoma (ALCL), has led to increased consideration of smooth TEs (STEs) in breast reconstruction. STEs reduce the theoretical risk of ALCL and migration can be addressed by fixation of suture tabs on the tissue expander to the chest wall. A comparative analysis of the outcomes of smooth and textured expanders is needed to ensure safety and equivalency. The aim of our study is to evaluate the early post-operative complications of smooth versus textured TEs.

METHODS
A retrospective case series was conducted across all female patients who underwent immediate breast reconstruction using TEs at a single academic teaching hospital from April 2017 to September 2018. Patients with a prior history of chest wall irradiation were excluded. The primary outcome variables were the presence early post-operative complications, namely infection, seroma, hematoma, or wound dehiscence, and failure of breast reconstruction.
RESULTS
53 patients with a total of 87 breasts met the inclusion criteria; TTEs were placed in 39 breasts and STEs in 48 breasts. Most patients studied had a therapeutic mastectomy (TTE n=15 (65.2%) versus STE n=20 (66.7%)), with nipple sparing mastectomy (NSM) being most commonly
performed (TTE n=31 (79.5%) versus STE n=34 (70.8%)). There were significantly more early post-operative complications in the TTE versus STE breast reconstruction group (p=0.001). We detected a significant increase in seroma formation in the TTE versus STE group (n=12 (30.8%) versus n=5 (10%), p=0.017). There were increased rates of infection and prosthetic failure in TTE versus STE, however these were not significant findings. At the univariate level, the factors predictive of having any complication were expander type (p<0.001), intraoperative filler (p<0.0001), and intraoperative TE expansion volume (p=0.0017), with complications being greater in TTEs than STEs (n=21 (70%) versus n=9 (30%)), and associated with a larger intraoperative TE expansion volume (249.6 178.7 versus 198.8 124). In multivariable regression analysis, implant type (p=0.006), mastectomy type (p=0.02), and TE filler (p=0.033) significantly predicted the risk of having a complication following TE insertion; where STEs, non-nipple sparing mastectomies, and saline TE filler were less likely to be associated with a postoperative complication.
CONCLUSIONS
STEs have increased their market share over the past year with no data supporting their equivalence in comparison to TTE. Here, we show that STEs had a reduced overall rate of early post-operative complications, and therefore are an acceptable and beneficial alternative to TTEs for immediate two-stage breast reconstruction with a known reduced incidence of ALCL development in smooth devices.


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