title: Trans-axillary approach for breast implant exchange in high risk cases of irradiated or attenuated skin.
abstract: BACKGROUND
  Breast reconstruction with implants after tissue expansion is one of the most common methods of reconstruction. Although this approach is generally reliable, exchange of breast tissue expander for implant through the standard anterior incision presents a challenge in cases with attenuated soft tissue envelope due to radiation, thin anatomy, prior surgery, or combination of the above. We propose that a trans-axillary approach is a safe and alternate approach for implant exchange in the high-risk patients.
  A case series of 16 patients with multiple risk factors for compromised soft tissue that underwent a trans-axillary approach for implant exchange is reported. The trans-axillary implant exchange technique involves use of a standard 4 cm axillary incision, removal of the expander, judicious capsulotomy, placement of permanent implant, and closure in three separate tissue layers.
  
  
  RESULTS
  All trans-axillary cases were successful and all incisions were well healed without dehiscence, infection, or seroma. The average patient age was 49.4 years, and 50% of patients had received or were scheduled to receive radiation therapy. Nine patients underwent unilateral trans-axillary expander exchange while 7 patients were bilateral. Median implant size was 360 cc (mean 369 cc, range 150-600 cc), and mean follow-up for all patients was over 24 months. There were no cases of implant extrusion, capsular contracture requiring re-operation, or lymphedema. Six patients underwent concurrent or subsequent nipple reconstruction.
  
  
  CONCLUSIONS
  This approach illustrates application of a technique commonly used in breast aesthetic augmentation to address a common reconstructive dilemma, which we believe to be a useful tool in prosthesis-based breast reconstruction, especially in patients with compromised soft tissue envelopes.
authors.affiliation: Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, United States.
authors.forename: Kyle R
authors.initials: KR
authors.lastname: Eberlin
authors.affiliation: Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, United States; Center for Regenerative Medicine, Harvard Stem Cell Institute, United States.
authors.forename: Lisa
authors.initials: L
authors.lastname: Gfrerer
authors.affiliation: Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, United States; Center for Regenerative Medicine, Harvard Stem Cell Institute, United States. Electronic address: cliao@partners.org.
authors.forename: Eric C
authors.initials: EC
authors.lastname: Liao
mesh_terms: D000328:Adult; D000368:Aged; D019928:Breast Implantation / Q000009:adverse effects / Q000379:methods*; D018427:Breast Implants; D001943:Breast Neoplasms / Q000532:radiotherapy / Q000601:surgery*; D020878:Device Removal / Q000009:adverse effects / Q000379:methods*; D005260:Female; D006801:Humans; D008408:Mastectomy; D008875:Middle Aged; D011832:Radiation Injuries / Q000209:etiology; D011878:Radiotherapy / Q000009:adverse effects; D012867:Skin / Q000528:radiation effects; D015625:Tissue Expansion Devices; D055815:Young Adult
keywords: Breast cancer; Implant reconstruction; Irradiated; Post-mastectomy radiation; Tissue expander; Trans-axillary