Two-Stage Prosthetic Breast Reconstruction With Integrated Versus Remote Port Expanders: A Comparison of Complication Rates

METHODS

A single-center retrospective review of 107 consecutive cases of 2-stage prosthetic reconstruction with remote versus integrated tissue expanders was conducted (Table 1). These 170 expanders were placed in 107 patients undergoing 2-stage breast reconstruction (Table 2). A total of 170 expanders were placed, with 64 patients with bilateral and 44 with unilateral breast reconstruction. Remote ports (Mentor Spectrum Remote; Mentor Corporation, Santa Barbara, Calif) were used in 21 patients and all were bilateral, for a total of 42 remote port expander reconstructions. Integrated ports (Mentor CPX3; Mentor Corporation) were used in 86 patients, with 42 bilateral and 44 unilateral, for a total of 128 expander reconstructions. Patients who had prior or planned radiation were excluded. Institutional preference was the determining factor for whether a patient received a remote tissue expander versus an integrated port expander; most of the remote port tissue expanders were performed earlier in the senior surgeon's practice, reflecting the preferences of the radiation oncology department at our institution at that time. Patient records were retrospectively reviewed for instances of complications and infection.

Given the small number of complications observed (1/4 expected cell frequencies <5), a Fisher exact test was used to compare the 2 groups. Overall complications were compared, followed by complications that were categorized as either mechanical or infectious.

RESULTS

Our review revealed a complication rate of 19% (8/42) associated with the use of remote port tissue expanders and a rate of 7% (9/128) with the use of integrated port expanders (Table 3). Five of the 8 complications associated with remote port expanders were due to infection. The remaining 3 complications were related to mechanical problems with the port that necessitated a re-operation, such as kinking and turnover of the port and port extrusion (Table 4). Eight of 9 complications in the integrated port expander group were due to infection, with the one remaining complication occurring secondary to expander deflation (mechanical). Comorbidities and other associated risk factors were examined and found not to be statistically significant between the 2 patient groups.

A Fisher exact test demonstrated that the increased rate of complications among remote port tissue expanders in immediate postmastectomy breast reconstruction was statistically significant (P = .024) (Table 3). Similarly, a statistically significant difference in the rate of mechanical complications between the 2 groups was found (7% in remote vs 0.8% in integrated, P = .047). When the rates of infectious complications were compared between the 2 groups, however (12% in remote vs 6% in integrated), no significant difference could be found (P = .312).

DISCUSSION

Advantages and disadvantages exist for both the remote and integrated port expanders. Remote port expanders confer the theoretical advantage of allowing the surgeon to select the site of injection in a place that is easily palpable and away from the tissue expander and the mastectomy flaps, thereby avoiding dependence on a magnet for port location and minimizing the risk of errant needle puncture in the case of thick overlying autologous flaps. Disadvantages include patient discomfort due to the port's location in the axillary region as well as the risks of mechanical complications (Table 5).

There are several advantages of integrated port tissue expanders. Integrated tissue expander insertion allows for the use of the existing mastectomy pocket and avoids having to create a tunnel and additional pocket for the port. Integrated expanders now have tabs to secure them in the proper position to avoid lateral displacement and axillary expansion. The newer expanders also have a wide self-sealing zone around the port to minimize the risk of leakage with errant needle access. Modern integrated port tissue expanders are more anatomically shaped, with increased distension at the lower pole producing expansion in the teardrop shape of the natural breast. The texturing present in these tissue expanders has been believed to lessen the risk of capsular contracture and facilitate the expansion process. While no rigorous head-to-head comparisons have been made, these observed benefits have led to the routine use of textured integrated port expanders over remote port expanders.

Certain theoretical disadvantages of integrated port expanders include attenuation of the radiation beam. Previous reports have suggested that regions of underdosing exist in the tissue surrounding the magnet.^6,14 More recent literature confirms the decreased dosing and increased heterogeneity of the radiation received, but the clinical significance of the small area of the underdosing remains unclear.^7,15 Most radiation protocols can now account for dosing heterogeneity introduced by the presence of the metallic port. At this time, the general consensus is that volume of attenuation is small and poses no contraindication to the use of an integrated port tissue expander.⁸

Our study indicates an increased rate of complications among these remote port expanders when compared with integrated port expanders. These complications are primarily mechanical in nature and include flipping, kinking, or extrusion of the port, as well as expander overlap of the port. While a statistical significance was not found between the rates of infection in the 2 groups, the data trended toward an increase in infections in the remote port (5/42 patients) versus integrated port (8/128) tissue expanders.

This study has several limitations, including its retrospective nature and the single center at which it was performed. This study is also limited by the fact that the number of integrated port placements exceeds the number of remote port expansions and that other variables such as shape and texturing were not accounted for.

Some of these limitations are a consequence of the current catalogue of devices offered by the 3 major device companies. While the options for textured integrated port expanders are abundant, the choices for remote port tissue expanders are much more limited. Invariably only one option exists: a round smooth tissue expander.

The rate of capsular contracture was not compared between the 2 groups in this study, although such a comparison would have potentially been meaningful. While the lack of a statistically significant difference in infection rate is, in part, due to the small patient population surveyed and the discrepancy in the number of remote and integrated ports implanted, certain patients, including obese patients, those undergoing combined autologous/prosthetic reconstruction, and those for whom an integrated port is contraindicated may benefit from the use of remote port expanders.