PURPOSE:
The ideal natural-appearing reconstructed breast has more fullness in the lower pole and a tapered appearance. Historically, the limitations of tissue expander breast reconstruction have been superior pole fullness and lower pole deficiency. Previous attempts at increasing lower pole projection have focused on the use of anatomically shaped implants. However, without an appropriately expanded pocket, anatomic implants cannot manifest their intended shape. Additionally, if appropriate pockets which have preferential expansion of the lower pole are created, a wider range of implants can be used to give the reconstructed breast a natural, aesthetically pleasing contour.
METHODS:
We performed a 6 year retrospective review of 242 consecutive patients who underwent placement of INAMED Style 133 LV tissue expanders. All reconstructions were performed by a single surgeon. Office charts were examined for demographics, time course, complications and revisions.

RESULTS:
From January 2000 through December 2005, a total of 242 patients underwent 190 breast reconstructions (140 bilateral, 102 unilateral). The average length of follow-up was 3.8 years (range 0.6 to 6.5 years). 196 patients underwent immediate reconstruction after mastectomy, 12 patients had failed previous reconstructions, 34 patients had delayed reconstruction. 13 patients had pre-operative radiation therapy, 14 patients underwent radiation during their time of expansion, and 7 received radiation after expander/implant exchange. The average length of time from initial expander placement to implant exchange was 172 days (range 45-502 days). Alloderm was utilized at the time of expander insertion in 26 patients to obtain complete coverage of the expander Expander complications included leaks (9 patients, 3.7%) of which 4 patients required early exchange, exposure (6 patients, 2.4%), infection (3 patient, 1.2%), rotational malalignment (3 patients, 0.9%), migration (2 patient, 0.9%), and hematoma (3 patient, 1.2%). A total of 23 patients (9.5%) required revisional surgery for the following reasons: incorrect size (8 patients, 3.3%), incorrect style (8 patients, 3.3%), malposition (5 patient, 2.1%), or infection (2 patients, .8%).
CONCLUSION:
Preferential tissue expansion of the lower pole in breast reconstruction after mastectomy allows for creation of an appropriate, anatomically shaped pocket. This allows for a more natural-appearing reconstructed breast using either anatomically shaped or smooth round implants.. Complications with LV expanders are similar to those reported with expander styles and are increased by aggressive expansion, radiation therapy, and poor soft tissue coverage. LV tissue expanders are relatively easy to place due to their small size, however, they do require a superior capsulotomy at the time of exchange. Lower pole tissue expansion is a safe and effective method of implant based breast reconstruction and when used appropriately can provide superior aesthetic results.