title: Comparison of subcutaneous versus submuscular expander placement in the first stage of immediate breast reconstruction.
abstract: OBJECTIVE
  Tissue expander-based two-stage reconstruction remains the most commonly used technique in immediate breast reconstruction. This study compares the subcutaneous expander placement to the traditional submuscular placement and describes our early experience with the expander insertion plane-choosing algorithm.
  
  
  METHODS
  A retrospective study of patients who underwent two-stage immediate breast reconstruction from May 2012 to October 2014 was conducted. All expander insertion planes were chosen using the same algorithm. Expansion, pain, and complications were compared between two groups.
  
  
  RESULTS
  The study included 88 patients (158 expanders; 50 subcutaneous and 108 submuscular). The subcutaneous group had a higher intraoperative expansion ratio (p < 0.001), high first postoperative expansion ratio (p < 0.001), shorter duration of expansion (p = 0.02), less number of expansion visits (p = 0.002), and less average pain during admission (p = 0.004). Significant differences in the intraoperative and first postoperative expansion ratios in patients with postmastectomy radiation therapy were also found between the two groups (p = 0.005 and 0.01, respectively). Complications during expansion and after second-stage autologous flap reconstruction were comparable between two groups.
  
  
  CONCLUSIONS
  The subcutaneous expander placement was associated with greater intraoperative and first postoperative expansion, shorter expansion duration, less expansion visits, and less pain. With the expander insertion plane-choosing algorithm, subcutaneous expander placement could be performed with comparable complications rates with the submuscular placement during expansion and after second-stage autologous flap reconstruction. Further studies can be performed due to the lack of long-term complications following second-stage implant reconstruction in the subcutaneous approach.
authors.affiliation: Department of Plastic Surgery, Peking Union Medical College Hospital, Beijing, China; Division of Plastic Surgery, Mayo Clinic, Rochester, MN, USA.
authors.forename: Lin
authors.initials: L
authors.lastname: Zhu
authors.affiliation: Division of Plastic Surgery, Mayo Clinic, Rochester, MN, USA; Restoration of Appearance and Function charitable Trust (RAFT), UK.
authors.forename: Anita T
authors.initials: AT
authors.lastname: Mohan
authors.affiliation: Division of Plastic Surgery, Mayo Clinic, Rochester, MN, USA.
authors.forename: Jad M
authors.initials: JM
authors.lastname: Abdelsattar
authors.affiliation: Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA; Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA.
authors.forename: Zhen
authors.initials: Z
authors.lastname: Wang
authors.affiliation: Division of Plastic Surgery, Mayo Clinic, Rochester, MN, USA.
authors.forename: Aparna
authors.initials: A
authors.lastname: Vijayasekaran
authors.affiliation: Division of Plastic Surgery, Mayo Clinic, Rochester, MN, USA.
authors.forename: Soyun M
authors.initials: SM
authors.lastname: Hwang
authors.affiliation: Division of Plastic Surgery, Mayo Clinic, Rochester, MN, USA.
authors.forename: Nho V
authors.initials: NV
authors.lastname: Tran
authors.affiliation: Division of Plastic Surgery, Mayo Clinic, Rochester, MN, USA. Electronic address: Michel.SaintCyr@BSWHealth.org.
authors.forename: Michel
authors.initials: M
authors.lastname: Saint-Cyr
mesh_terms: D000465:Algorithms; D005260:Female; D006801:Humans; D016462:Mammaplasty / Q000379:methods*; D008408:Mastectomy; D008875:Middle Aged; D011183:Postoperative Complications; D012189:Retrospective Studies; D013524:Surgical Flaps; D015625:Tissue Expansion Devices; D016896:Treatment Outcome
keywords: Breast reconstruction outcome; Subcutaneous tissue expansion; Submuscular tissue expansion; Tissue expander; Two-stage immediate breast reconstruction