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Advertising Supplement to PSP Magazine, October 2014

Guide to the Natrelle® 410 Two-Stage
Breast Reconstruction System

First Stage:
Natrelle® 133
Shaped Tissue
Expander

Second Stage:
Matching
Natrelle ® 410
Shaped Gel
Breast Implant

Please see Indications and Important Safety Information inside.

Key Contributors

Allen Gabriel, MD

A board-certified plastic surgeon, Allen
Gabriel, MD, practices in Vancouver, WA,
with PeaceHealth Medical Group. Dr Gabriel
is chief of Plastic and Maxillofacial Surgery
at Southwest Washington Medical Center in
Vancouver, WA, and associate professor at
Loma Linda University, Department of Plastic
Surgery, in Loma Linda, CA. He obtained his
MD degree from the University of Nevada
School of Medicine and completed his
residency at the Integrated Plastic Surgery
Residency Program at Loma Linda University.
He completed advanced training in breast
and aesthetic surgery at Baptist Hospital in
Nashville, TN, and specializes in aesthetic and
breast surgery, including breast reconstruction
following mastectomy, breast augmentation,
and revisions. Since 1995, Dr Gabriel has
authored more than 3 dozen abstracts and
chapters in peer-reviewed publications.

Patricia McGuire, MD

Patricia McGuire, MD, is a board-certified
plastic surgeon in private practice with
Parkcrest Plastic Surgery in St Louis, MO.
She attended medical school at the University
of Missouri–Kansas City, did her general
surgery residency at Jewish Hospital,
Washington University in St Louis, and
completed her plastic surgery residency at
St Louis University. She specializes in cosmetic
and reconstructive surgery of the breast.
Dr McGuire was a principal investigator in the
Natrelle® 410 study and has performed over
600 surgeries using shaped devices in breast
augmentation and reconstruction, both in
primary and revision procedures.

James Namnoum, MD, FACS

James Namnoum, MD, FACS, is board-certified
in Plastic and Reconstructive Surgery and
practices in Atlanta, GA. He is codirector of the
Atlanta Breast Symposium, an executive council
board member for Allergan Breast Aesthetics,
an assistant clinical professor at Emory
University, and medical director of AYA Medical
Spa. Dr Namnoum has participated as an
investigator of Natrelle® 410 breast implants.
He is copresident of Innovative Biologics, a
research company investigating the development
of biologically integrated implants for use in
breast reconstruction.

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Guide to the Natrelle® 410 Two-Stage Breast Reconstruction System

The Natrelle® 410 Two-Stage Breast Reconstruction System
The Natrelle® 410 Two-Stage Breast
Reconstruction System is Made to Match
with the Natrelle® 133 Tissue Expander and
the Natrelle® 410 Highly Cohesive Anatomically
Shaped Silicone-Filled Breast Implant,
engineered with precision for a precise pocket
and a tight fit. Once in place, the Natrelle® 410
Shaped Gel Breast Implant is designed to
provide an anatomical look that holds its
shape and provides lasting satisfaction. The
Natrelle® 410 Two-Stage Breast Reconstruction
System requires a biodimensional method of
planning, which represents a paradigm shift
from the volumetric thinking previously used
with round implants, because shaped devices
are selected based on each patient’s unique
anatomic dimensions.1

Breast reconstruction with tissue expander and implant.2

The Natrelle 410 Two-Stage Breast
Reconstruction System offers an anatomically
shaped breast implant with a precisely matched
shaped tissue expander. The anatomical shape
of the Natrelle® 410 Shaped Gel Breast Implant
provides upper pole fullness, a gradual slope,
and lower pole contour to mirror the shape
(curve) of a woman’s breast.3,4
®

The Style 133 Tissue Expander has a
BIOCELL® textured surface, which, together
with suture tabs, helps anchor the device in
place to help minimize the chance of rotation.1,5

The tissue expander has an integrated port
that can be easily identified by its magnetic
finder, facilitating the filling process.6 After
expansion is complete and the expander is
exchanged for the permanent implant, patients
benefit from the Made to Match implant.
The Natrelle® 410 breast implant is composed
of a highly cohesive, form-stable gel that is
designed to be just firm enough to retain its
shape and prevent downward migration, or
migration out of the capsule, over time.7
Both the gel implant and its matching
expander are available in a wide variety of
sizes and projections that mirror many breast
shapes and chest dimensions.
By allowing preferential expansion of the lower
pole, the anatomical Style 133 Tissue Expander
provides a gradual contour to the upper pole.3
Its Made to Match Natrelle® 410 implant helps
patients achieve the aesthetic shape they seek,
with a look that is different from that produced
by round implants.
“I think that the design characteristics of the
Natrelle® 410 implants cut a maximal projection
probably a little lower than the nipple,” says
James Namnoum, MD, FACS, an Atlanta, GA,
plastic and reconstructive surgeon who has
worked extensively with the Natrelle® 410
Two-Stage Breast Reconstruction System.

Shaped gel
Gradually
tapered slope

Round gel
Fuller upper
breast contour

“I think the idea of a system is really
clever. I’ve always used it like a
‘team’. I know the dimensions of the
expanders, and with the Natrelle® 410
implant, you know you can get within
0.5 cm of the width of the expander.
It’s easy to remember, and it helps me
achieve consistent results.”
–Patricia McGuire, MD

Proven safety profile

The Natrelle® 410 implant has an excellent
safety profile, demonstrated by results through
7 years from the pivotal study that included a
cohort of 225 women who received primary
breast reconstruction.8 It is an ongoing
prospective, 10-year, multicenter, single-arm,
observational study designed to evaluate the
safety and effectiveness of the Natrelle® 410
in augmentation, reconstruction, and
revision surgery.9

Natrelle® Breast Implants Important Information
INDICATIONS
Natrelle® Breast Implants are indicated for women for the following:
• Breast reconstruction. Breast reconstruction includes primary reconstruction
to replace breast tissue that has been removed due to cancer or trauma or
that has failed to develop properly due to a severe breast abnormality. Breast
reconstruction also includes revision surgery to correct or improve the result
of a primary breast reconstruction surgery.
Please see Natrelle® Breast Implants Important Safety Information
on following pages.

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Reported Adverse Events Over 7 Years8
Complication

Kaplan-Meier Risk (%) (n = 225)

Palpability/Visibility

0.5%

Tissue/Skin necrosis

0.5%

Wrinkling/Rippling

3.1%

Malposition

3.6%

High satisfaction rate among
physicians and patients

Natrelle® 410 breast implants are the #1
selected shaped implants among surgeons in
the United States.9 Approved by the US Food
and Drug Administration in February 2013, for
use in the United States, the Natrelle® 410 has
been placed in 17,000 patients in clinical trials.9
Results of the pivotal trial show that 7 years
after implantation, the vast majority of patients
and physicians (95% and 94%, respectively)
remained satisfied with the Natrelle® 410.
Out of 149 primary reconstruction cases,
95.3% of patients who rated their satisfaction
at 7 years were still satisfied with their results.
Likewise, physicians were still satisfied with
results in 94.6% of cases at 7 years.8

Preoperative

“I ask my patients at every visit if they are
satisfied with the look of their breast,”
says Allen Gabriel, MD, chief of plastic and
maxillofacial surgery at Southwest Washington
Medical Center in Vancouver, WA, and
associate professor, Department of Plastic
Surgery, at Loma Linda University, “And they
say, ‘Yes.’”

Consistent results

Surgeons rely on tools and devices to help
them provide successful outcomes. Using a
system in which it is easy to match the tissue
expander to a corresponding breast implant
frees surgeons to focus on perfecting breast
reconstruction. The potential for variability is
particularly challenging in breast reconstruction,
given each patient’s unique disease
requirements and consequent effects on the

ability to preserve key anatomic landmarks.
It is helpful when, despite the wide range of
choices, there is a system engineered with
precision for a precise pocket and a tight fit.
Natrelle® 410 implants and Style 133 Tissue
Expanders, which make up the Natrelle®
Two-Stage Breast Reconstruction System,
are Made to Match. This begins with the
uniform anatomical shape of the Natrelle® 410
implant and its Made to Match Style 133
Tissue Expander—both of which are created
using similarly shaped molds. At the second
surgery, when the tissue expander is removed
from the expanded pocket, it is replaced with
a permanent implant designed to fit into the
precise pocket like a hand in a glove.1 When
the tissue expander is underexpanded, it
prepares a snug pocket that is designed to
minimize rotation of the expander to fit the
matched shape of the Natrelle® 410 implant.
As Patricia McGuire, MD, a board-certified
plastic surgeon in private practice with
Parkcrest Plastic Surgery in St Louis, MO, who
has conducted over 600 surgeries with shaped
implants, notes, “I think the idea of Made to
Match implants and expanders is really clever.
I’ve always used them like a ‘team’. I know
the dimensions of the expanders, and with the
Natrelle® 410 implant, you know you can get
within 0.5 cm of the width of the expander.
It’s easy to remember and it helps me achieve
consistent results. There are 45 options for size;
the design of the tissue expander and implant
working together makes that choice a little bit
easier. With this system, the tissue expander is
telling you what implant to use, and that’s a lot
less intimidating.”

After 2 years
Tissue Expander Selected: Natrelle® Style 133MV (600 cc); implanted for 4 months
Implant Selected: Natrelle® 410 Style MF 470
Photos provided by Scott Spear, MD. Individual results may vary.

Natrelle® Breast Implants IMPORTANT SAFETY
INFORMATION (continued)
CONTRAINDICATIONS
Breast implant surgery should not be performed in:
• Women with active infection anywhere in their body.
• Women with existing cancer or pre-cancer of their breast who
have not received adequate treatment for those conditions.
• Women who are currently pregnant or nursing.
WARNINGS
AVOID DAMAGE DURING SURGERY
• Care should be taken to avoid the use of excessive force and to minimize
handling of the implant during surgical insertion.
• Care should be taken when using surgical instruments in proximity with the
breast implant, including scalpel, sutures, and dissection instrumentation.

• Do not treat capsular contracture by closed capsulotomy or forceful external
compression, which will likely result in implant damage, rupture, folds,
and/or hematoma.
• Use care in subsequent procedures such as open capsulotomy, breast pocket
revision, hematoma/seroma aspiration, and biopsy/lumpectomy to avoid damage
to the implant.
• Do not place drugs or substances inside saline-filled implants other than sterile
saline for injection. Do not inject through the implant shell.
• Do not contact the implant with disposable, capacitor-type cautery devices.
• Do not alter the implants or attempt to repair or insert a damaged prosthesis.
• Do not immerse the implant in povidone-iodine solution. If povidone-iodine is
used in the pocket, ensure that it is rinsed thoroughly so no residual solution
remains in the pocket.
• Do not reuse or resterilize any product that has been previously implanted. Breast
implants are intended for single use only.

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Guide to the Natrelle® 410 Two-Stage Breast Reconstruction System

Case Study #1: Patricia McGuire, MD
Patient assessment

This 45-year old patient had invasive ductal
cancer of her right breast. As she had a
significant family history of cancer, she elected
to undergo bilateral mastectomy and requested
immediate reconstruction with a tissue
expander (TE) followed by permanent implants.
This was a great candidate for Natrelle® 410, as
she had small breasts with a proportionate BMI.
She wanted an anatomical look to her breasts
and said that she would love to not have to
wear a bra.
KEY PATIENT MEASUREMENT
• Breast base width (BW): 12.5 cm

Preoperative plan

• The patient wore a 36A bra size and wanted
to be a little bigger postoperatively. Because
of her 12.5 cm breast width, a 300 cc Style
133MV expander with a width of 12 cm was
chosen—slightly smaller than the implant,
so the implant would fit snugly in the pocket

• She did not require any acellular dermal
matrix (ADM) support in surgery
• The Natrelle® 133 TE was filled to 180 cc
in the operating room
• Drains were inserted in each side and left
in place for 11 days. They were removed
after the drainage was less than 30 cc
over a 24-hour period
• The patient wore a bra postoperatively
for comfort
I believe in an active recovery, so I encouraged
activity as long as she was comfortable.
She returned to work 12 days post operation.
• Two weeks post-op, the patient’s Natrelle®
133 TE was expanded to 300 cc.
Her expansions were worked around
sessions of postoperative chemotherapy.
Her expanders were then left in place until
she finished chemotherapy

Surgical technique

Surgical technique

SECOND STAGE: IMPLANT EXCHANGE

FIRST STAGE:
DELAYED RECONSTRUCTION
WITH TISSUE EXPANDER

Given that her expanders looked good, the
plan for her second stage was to place a
Natrelle® 410 Style FF 375 implant given her
preoperative breast width of 12.5 cm, which
was slightly wider than the expander.

• At surgery, this patient had total muscle
coverage of her expanders

I used a full-height device because (1) our
oncologic surgeons tend to skeletonize the
chest wall and (2) the taller implant with a
gradual slope fills the upper pole with a
gradual slope.
• At implant exchange, she had good
adherence of the expander to the tissue
capsule. The inside of the capsule had
developed in a “mirror image” capsule to the
BIOCELL® surface of her expander, so
no capsulectomy was necessary
• The patient had an inferior capsulotomy
with division of the pectoralis muscle insertion
and a superior capsulotomy to allow the
superior portion of the implant to lie smoothly
in the pocket
• Drains were placed in each breast for 7 days
• The Natrelle® 410 breast implant provided her
with the shape she desired with good lower
pole projection

Outcomes

The patient did not choose to undergo nipple areola reconstruction. She has since done well and is pleased with her appearance.
This is a straightforward case where I allowed the patient's anatomy to drive the decision-making. I used her BW to determine the TE and then the
known dimension of the TE to determine which style of Natrelle® 410 implant to use. I was able to meet this patient's wishes of an anatomically
shaped breast, slightly larger than her preoperative breast, and this result has held up for over 5 years.

Preoperative

TE

After 1 year

After 5 years

Individual results may vary.

“I think we’re very lucky right now to be in an era when there are choices for surgeons and patients. Several different implants are
available, with different shell characteristics, different textures, different fills, and different cohesiveness of the gels. There may be
advantages and disadvantages to each of these for different surgeons and patients. In my hands, I find that I can use the Natrelle®
Two-Stage Breast Reconstruction System in 90% of my patients. I haven’t used anything except the Style 133 Tissue Expander in about
17 years. I’ve been following patients for many years, and these results don’t just look good 6 months, a year, or 2 years after surgery—
we have postoperative results that still look good after 7 years.”

Natrelle® Breast Implants IMPORTANT SAFETY
INFORMATION (continued)
WARNINGS (continued)
• Do not place more than one implant per breast pocket.
• Do not use the periumbilical approach to place the implant.
Please see additional Natrelle® Breast Implants Important Safety
Information on pages 8 to 10.

5

Natrelle® 133 Tissue Expander BIOCELL® Texturing
The BIOCELL® shell covering the Style 133
Tissue Expander has an open-pore texture of
irregularly spaced cuboid wells.10 BIOCELL® is
a macrotextured surface that is created using a
lost salt technique.11,12
The cuboid depressions of the textured surface
vary in size from 200 µm to 500 µm wide and
100 µm to 200 µm deep.11
When viewed by electron microscopy, the
surface of the capsule is a mirror image of the
textured surface of the device.12
BIOCELL® textured surface facilitates tissue
expander adherence to the surrounding
tissue,11-13 as first demonstrated in Maxwell’s
landmark study on breast reconstruction with

BIOCELL® textured surface, integrated-valve,
anatomical tissue expanders.
Functionally, adherence of the BIOCELL®
textured surface to the periprosthetic breast
capsule promotes immobility of the expander.14
Adherence can be observed when the tissue
expander is exchanged for the implant
during the second stage of surgery.15 In the
Maxwell study, 98% of BIOCELL® textured
expanders, on average, adhered to the capsule
at 5 months.10 In order to remove the tissue
expander, the capsule must be carefully peeled
away from the tissue expander, disengaging
it in preparation for the pocket to receive the
permanent Natrelle® 410 implant.10

BIOCELL® pore depth

Tissue adherence at 4 months
Photo provided by Dr G. Patrick Maxwell.

Seven-year results from the pivotal trial of
the Natrelle® 410 Shaped Gel Breast Implant
demonstrated a 10.7% rate of capsular
contracture in primary breast reconstruction
patients.8 Malposition occurred infrequently in the
trial, at a rate of 3.6% in primary reconstruction.8
“The texture of the tissue expander plays an
important role,” says Dr. Gabriel. “I believe
that the texture is really important in helping to
minimize rotation, and, along with the tabs,
we can secure the tissue expander to
minimize rotation during the first stage.”

Biodimensional planning is key

Biodimensional planning takes the patient’s
unique anatomy and measurements into
consideration when selecting implant and
tissue expander size.8 The patient’s base
width is the key factor in selecting both the
shaped tissue expander and shaped
Natrelle® 410 implant. The tissue expander
creates a tight pocket for the anatomic
implant in order to help minimize rotation.
Once implanted, the Natrelle® 410 implant
creates an anatomic shape from the
beginning—that is maintained over time.

Natrelle® 133 Tissue Expanders with/without Suture Tabs and with
Magna-Site® Injection Sites Important Information
Indications
Natrelle® 133 Tissue Expanders are indicated for:
• Breast reconstruction following mastectomy.
• Treatment of underdeveloped breasts.
• Treatment of soft tissue deformities.
IMPORTANT SAFETY INFORMATION
CONTRAINDICATIONS
Natrelle® 133 Tissue Expanders SHOULD NOT be used in patients:
• Who already have implanted devices that would be affected by a magnetic field
(e.g., pacemakers, drug infusion devices, artificial sensing devices).
• Whose tissue at the expansion site is determined to be unsuitable.
• Who have an active infection or a residual gross tumor at the expansion site.
• Undergoing adjuvant radiation therapy.
• Whose physiological condition (e.g., sensitive over or underlying anatomy,
obesity, smoking, diabetes, autoimmune disease, hypertension, chronic lung

or severe cardiovascular disease, or osteogenesis imperfecta) or use of certain
drugs (including those that interfere with blood clotting or affect tissue viability)
poses an unduly high risk of surgical and/or postoperative complications.
• Who are psychologically unsuitable.
WARNINGS
• DO NOT use Natrelle® 133 Tissue Expanders in patients who already
have implanted devices that would be affected by a magnetic field (see
Contraindications), because the MAGNA-SITE® integrated injection site contains
a strong rare-earth, permanent magnet. Diagnostic testing with Magnetic
Resonance Imaging (MRI) is contraindicated in patients with Natrelle® 133 Tissue
Expanders in place.
• DO NOT alter the tissue expander or use adulterated fill. Fill only with sterile
saline for injection as described in INSTRUCTIONS FOR USE. DO NOT expose
to contaminants.
• DO NOT expand if the pressure will compromise wound healing or vasculature of
overlying tissue, or beyond patient or tissue tolerance. Stop filling immediately if
tissue damage, wound dehiscence, abnormal skin pallor, erythema, edema, pain,
or tenderness are observed.

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Guide to the Natrelle® 410 Two-Stage Breast Reconstruction System

The selected widths for both the tissue expander and the implant are determined by the base width of the
breast—the width of the expander should be 0.5 cm to 1 cm smaller than that of the intended implant.1,9 While
most surgeons select the size of the implant first and work backwards to select the size of the tissue expander,
the matched dimensions of both devices simplify this process.
0.5 cm or 1.0 cm
Natrelle ® 133
Natrelle ® 410
Precision Match
Shaped Tissue Expander
Shaped Gel Breast Implant
Base Width

Base Width

11.0 cm

11.5 cm or 12.0 cm

✔

12.0 cm

12.5 cm or 13.0 cm

✔

13.0 cm

13.5 cm or 14.0 cm

✔

14.0 cm

14.5 cm or 15.0 cm

✔

15.0 cm

15.5 cm

✔

Since anatomically shaped implants add a new
dimension of height to the existing dimensions
of base width and projection that define round
implants, biodimensional planning requires a
paradigm shift in surgeons’ thinking.1 It requires
calculating shape and dimension, in addition
to thinking in terms of volume and cup size.3

Biodimensional planning is a comprehensive
approach that begins with preoperative
planning and incorporates additional surgical
elements to achieve the best possible aesthetic
results. It is always advisable to include the
oncology surgeon in the patient’s reconstructive
surgery team in both preoperative planning
and postoperative management.4 This may
also facilitate the use of the latest skin and
nipple-sparing techniques in the mastectomy,
laying the groundwork for a good
reconstructive outcome.

Although first-stage breast reconstruction
establishes the blueprint for the final implant,
many surgeons find it helpful to envision the
final implant results first. Use the patient’s
breast width to determine the implant width.
The size of the tissue expander should be
0.5 cm to 1 cm smaller than the implant size.9
Final expansion should closely approximate
the desired result with the implant to ensure
that the implant will fit snugly within the
pocket. Avoid over expansion with the
tissue expander for a proper fit and to
help minimize device rotation.15

“I took a course by Dr Pat Maxwell on
biodimensional planning in the late 1990s
that completely changed how I approached
breast reconstruction: The focus of this
approach is using the patient’s anatomy to
choose the tissue expander, and doing a
precise dissection, just like you would in breast
augmentation,” says Dr McGuire. “Planning the

Natrelle® 133 Tissue Expanders
IMPORTANT SAFETY INFORMATION (continued)
WARNINGS (continued)
• Active infection anywhere may increase risk of periprosthetic infection.
Postoperative infections should be treated aggressively. Unresponsive or
necrotizing infection may require premature removal.
• Natrelle® 133 Tissue Expanders are temporary, single use only devices, and
are not to be used for permanent implantation or beyond 6 months. Tissue
expansion in breast reconstruction typically requires four to six months.
• When using suturing tabs be careful to avoid piercing the shell. Use a new one
if damage occurs.
PRECAUTIONS
Active infections may need to be treated and resolved before surgery. Allergan
relies on the surgeon to know and follow proper surgical procedures and carefully
evaluate patient suitability using standard practice and individual experience.

second stage carefully, educating the patient,
and using the patient’s dimensions to choose
the appropriate implant for her body really
makes a big difference in getting results that
look good—and look good for a long time.”

Which patients are appropriate
candidates for the Natrelle® 410
breast implants in two-stage
breast reconstruction?

The anatomically shaped Natrelle® 410
implant and its Made to Match Style 133
Tissue Expander are appropriate for almost
all candidates in implant-based breast
reconstruction who would otherwise receive
a round implant. The primary exception is the
patient with BMI ≥ 29, who usually requires
more pronounced projection and a wider base
width than is available, and may encounter
expansion difficulties.15

Avoid damage to the tissue expander and use a sterile back-up in case of damage.
Pay careful attention to tissue tolerance and hemostasis during surgery. Expansion
should proceed moderately and never beyond patient or tissue tolerance. Avoid
contamination in any postoperative procedure.
Please see additional Natrelle® 133 Tissue Expanders Important Safety
Information on back page.

7

Patients who may be appropriate
for a Natrelle® 410 shaped
implant include:

• Patients who desire a proportionate look with
less upper pole fullness7

• Patients with proportionate height/weight
and breast size15
• Patients for whom no radiation treatments
are planned6,16
• Patients who received either a unilateral

or a bilateral therapeutic or
prophylactic mastectomy15
• Patients who may especially benefit
aesthetically from an anatomically
shaped implant include those with
thoracic or chest wall deformities1

Case Study #2: Allen Gabriel, MD
Patient assessment

This 56-year old woman had a diagnosis of
left breast-infiltrating ductal carcinoma stage
IIIA. In the next month, she underwent a left
lumpectomy with left axillary node dissection
(in which 16 nodes were removed), followed by
adjuvant chemotherapy and radiation therapy,
which she completed 7 months later. As both
her mother and her aunt had breast cancer,
she decided that she did not wish to undergo
continued regular screening and decided on a
bilateral mastectomy.
A complicating factor was that she had severe
skin changes resulting from damage from
radiation therapy. Successful reconstruction
depended on developing a source of new
vascularized tissue.
KEY PATIENT MEASUREMENTS
• Sternal notch-to-nipple (SN-N) right
was 26.5 cm; left was 25 cm.
Breast base width (BW) was 16 cm

Preoperative plan

• Since the nipple areolar complex was going
to be removed on the left side, and to avoid

further shrinking of the skin envelope, the
plan was to replace the missing area with
new vascularized skin, using a latissimus flap
reconstruction with a tissue expander for her
left side
• Taking into consideration the patient’s
dimensions and her desire to stay close
to the same-size breasts, a Natrelle® 410
Style FF 740 implant was selected as most
appropriate for the final reconstruction
• A Natrelle® Style 133MV (600 cc) tissue
expander was chosen, as it was slightly
narrower and shorter in height than the
final implant

Surgical technique
FIRST STAGE: IMMEDIATE
RECONSTRUCTION WITH
TISSUE EXPANDER

• An 8 x 16 cm ADM was used bilaterally
for tissue support as well as in her left
latissimus dorsi myocutaneous flap
14 months later
• During the surgery, 240 cc of saline was
inserted in the TE. The expansion was
completed 4 weeks later at a final volume
of 600 cc

Surgical technique
SECOND STAGE: IMPLANT EXCHANGE
Bilateral breast reconstruction with
Natrelle® 410 Style FF (740 cc) implants
was performed on February 27, 2013.
• Fat was injected into the upper, medial,
and lateral poles
• Bilateral nipple reconstruction was
completed 16 months later

• The patient underwent a mastectomy that
spared her right nipple and skin on her left
breast. She then immediately had her breasts
reconstructed with Natrelle® Style 133MV
(600 cc) tissue expanders

Outcomes

Since then, the patient has been doing extremely well, given that she had received radiation prior to the reconstruction surgery on her left side.
She had an MRI in March 2014, following a car accident. The implant remained intact and continues to remain at Baker Grade I rating bilaterally.

Preoperative (3/4 view left)

Preoperative (profile view left)

5 months following right nipple–
sparing mastectomy, left skinsparing mastectomy and bilateral
breast reconstruction with tissue
expanders, ADM, and left latissimus
dorsi flap

5 months after surgery

16 months following bilateral
breast reconstruction with
Natrelle® 410 Style FF (740 cc)
implants, bilateral fat injection,
and left nipple reconstruction

16 months after surgery

MRI image of right breast at
12.5 months after surgery
Individual results may vary.

“What makes using the Natrelle 410 Two-Stage Breast Reconstruction System so much fun is the true artistry of plastic surgery. What
you’re doing is trying to reconstruct a breast from scratch, giving it the most anatomical shape with everything that you have at hand.
We can control the height, we can control the width, and we can control the projection. So we’re controlling all 3 dimensions of the
breast that we need to control to provide the best breast for that particular patient.”
®

Natrelle® Breast Implants IMPORTANT SAFETY
INFORMATION (continued)
WARNINGS (continued)
• Do not use microwave diathermy in patients with breast implants. Microwave
diathermy has been reported to cause tissue necrosis, skin erosion, and
implant extrusion.
PRECAUTIONS
Safety and effectiveness have not been established in patients with the following:
• Autoimmune diseases (e.g., lupus and scleroderma).

• A compromised immune system (for example, currently receiving
immunosuppressive therapy).
• Planned chemotherapy following breast implant placement.
• Planned radiation therapy to the breast following breast implant placement.
• Conditions or medications that interfere with wound healing and blood clotting.
• Reduced blood supply to breast tissue.
• Clinical diagnosis of depression or other mental health disorders, including body
dysmorphic disorder and eating disorders. Please discuss any history of mental
health disorders prior to surgery. Patients with a diagnosis of depression, or
other mental health disorders, should wait until resolution or stabilization of these
conditions prior to undergoing breast implantation surgery.

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Guide to the Natrelle® 410 Two-Stage Breast Reconstruction System

Caliper measurement of contralateral breast

surgeons prefer to complete the expansion in
as little as 2 weeks, with only a few inflations,
while others may coordinate expansion with the
patient’s chemotherapy schedule and comfort
level, postponing expansion until 4 to 6 months
after the first surgery. Generally, however,
expansion is completed within 2 to 4 months,
with approximately 4 inflations.4,10,15
The maximum recommended time for tissue
expansion with the Natrelle® 133 Tissue
Expander is 6 months.6

Precise pocket preparation

The primary goal in tissue expander placement
is creation of a snug pocket in the location
of the final implant. Precise dissection of the
pocket during the first stage minimizes the risk
of expander rotation and helps optimize pocket
creation.7,15 The precision of pocket dissection
is a key differentiator for anatomical implants.

Photo from Natrelle® 410 Interactive Surgery Planner.

“I wanted more consistency in my results, and that’s how I became interested
in an approach that could help me plan better. Dimensional planning gives you
an opportunity to think, so you can get more consistent results. It’s all in the
thinking.” –James Namnoum, MD, FACS

Selecting the appropriate tissue
expander and implant

Key to the success of the Natrelle® 410
Two-Stage Breast Reconstruction System is
how well the Made to Match Style 133 Tissue
Expander customizes the pocket for the
Natrelle® 410 implant. Appropriate implant
size is based on the patient’s individual
anatomy and desired aesthetic outcome.1
Tissue expander size is selected based on the
base width of the contralateral natural breast,
in the case of a unilateral mastectomy, which
is best measured using calipers.4,15 In the case
of a bilateral mastectomy, the patient’s chest
width is measured from the midsternum to
the anterior axillary line.15
There are 3 styles of tissue expanders available
for the Natrelle® 410 Two-Stage Breast
Reconstruction System: short, moderate, and

full, each with variable projections (Styles SV,
MV, and FV). The first letter refers to the height,
and the second refers to the projection. Several
sizes are available for each style, and each is
available with or without tabs. Altogether, there
are 36 tissue expander size options.

To achieve the best result, the shape of the
pocket should closely mirror the form of the
tissue expander and be both shorter and
narrower in size than the planned permanent
implant. Minimal dissection of the upper pole
allows the tissue expander to have maximal
surface contact with the tissues lining the
pocket, promoting mild tissue adherence to the
open pores of the BIOCELL® textured surface.5
As the expander is inflated, it will maintain
contact with the walls of the pocket, optimizing
the opportunity for adherence.

There are 4 available styles for the Natrelle® 410
implant (MM, MF, FM, FF). They are available
in 2 heights—moderate and full (the first letter
of the style represents the height), and each
height is available in 2 projections—moderate
and full projection (the second letter of the style
represents the projection).8 Several sizes are
available within each style, leading to a total of
45 Natrelle® 410 implant size options.

Expansion phase

The time it takes to reach full expansion will
vary depending upon physician preference
and patient treatment requirements. Some

Natrelle® Breast Implants IMPORTANT SAFETY
INFORMATION (continued)
ADVERSE EVENTS
Key adverse events are reoperation, implant removal with or without replacement,
implant rupture with silicone-filled implants, implant deflation with saline-filled
implants, and capsular contracture Baker Grade III/IV.
Please see additional Natrelle® Breast Implants Important Safety Information
on next page.

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Precise pocket dissection

to anatomical devices, may also help surgeons
optimize outcomes:
• Once the pocket is adequately dissected
during the first stage of surgery, confirm that
the tissue expander is secure in the pocket in
order to help minimize rotation8
• The size of the incision should be adequate
to insert the implant without deforming it or
fracturing the gel. The incision is usually larger
than that required for a round implant—
at least 5 cm wide8

Complete muscle coverage of the TE

• The dimensions of the pocket should
allow the implant to be placed flat on a
smooth surface8
• Avoiding overexpansion during the first stage
is key to creating a snug pocket
• Once the tissue expander is selected and the
pocket is expanded, there is still opportunity
to vary the choice of implant during secondstage surgery, particularly with respect to
height and projection. This is especially
important because a patient may change her
mind once she can react to her new shape

Photos courtesy of G. Patrick Maxwell, MD.

The entire condition of the pocket is important
for a successful outcome. Several other
elements of pocket preparation, unique

• Ensure hemostasis by visualization and
electrocautery, and irrigate the pocket with
antibiotics to reduce the risk of infection17

and potential rotation. The drains are best left
in place for 5 to 8 days, or until fluid volume is
reduced to < 30 cc per day.18,19
“I feel it is important to create a vascularized
tissue surface within the pocket for the
expander and implant,” says Dr Gabriel.
“At the expander stage, even though I have
the tab, I feel much better if I know the
vascularized surface is touching the expander.”

Conclusion

The Made to Match system simplifies
breast reconstruction planning by pairing
the Natrelle® 410 Shaped Gel Breast Implant
with its anatomically shaped Style 133
Tissue Expander. Using the principles
of biodimensional planning offers the
patients options based on their own
unique anatomic dimensions.1
The tissue expander and matched implant,
with their anatomical shapes and wide range
of sizes, help surgeons achieve an aesthetic
look for their patients. At the same time, the
Style 133 Tissue Expander, and the highly
cohesive, form-stable gel of the Natrelle® 410
Implant, are engineered with precision for a
precise pocket and a tight fit.

In the second stage, the use of drains is
recommended to reduce fluid accumulation

Natrelle® Breast Implants IMPORTANT SAFETY INFORMATION (continued)
ADVERSE EVENTS (continued)
Other potential adverse events that may occur with breast implant surgery include:
asymmetry, breast pain, breast/skin sensation changes, capsular calcification,
delayed wound healing, hematoma, hypertrophic scarring/scarring, implant
extrusion, implant malposition, implant palpability/visibility, infection, nipple
complications, redness, seroma, swelling, tissue/skin necrosis, wrinkling/rippling.

For more information see the full Directions for Use at www.allergan.com/labeling
/usa.htm or call the Allergan Product Support line at 1-800-433-8871.
To report a problem with Natrelle®, please call Allergan Product Surveillance at
1-800-624-4261.
Natrelle® Breast Implants are available by prescription only.

References: 1. Bengtson BP. The highly cohesive, style 410 form-stable gel implant for primary breast augmentation. In: Spear SL, ed. Surgery of the Breast: Principles and Art. 3rd ed. Philadelphia, PA: Lippincott
Williams & Wilkins; 2011:1346-1365. 2. Cordeiro PG. Breast reconstruction after surgery for breast cancer. N Engl J Med. 2008;359(15):1590-1601. 3. McGeorge DD, Mahdi S, Tsekouras A. Breast reconstruction with
anatomical expanders and implants: our early experience. Br J Plast Surg. 1996;49(6):352-357. 4. Spear SL, Spittler CJ. Breast reconstruction with implants and expanders. Plast Reconstr Surg. 2001;107(1):177-187.
5. Spear SL, Elmaraghy M, Hess C. Textured-surface saline-filled silicone breast implants for augmentation mammaplasty. Plast Reconstr Surg. 2000;105(4):1542-1552. 6. Natrelle® 133 Tissue Expanders with Suture
Tabs, with MAGNA-SITE® Injection Sites, MAGNA-FINDER® Xact & 21G Needle Infusion Set Directions for Use, 2009. 7. Brown MH, Shenker R, Silver SA. Cohesive silicone gel breast implants in aesthetic and
reconstructive breast surgery. Plast Reconstr Surg. 2005;116(3):768-779. 8. Natrelle® 410 Highly Cohesive Anatomically Shaped Silicone-Filled Breast Implants Directions for Use, 2013. 9. Data on file, Allergan, Inc.
10. Maxwell GP, Falcone PA. Eighty-four consecutive breast reconstructions using a textured silicone tissue expander. Plast Reconstr Surg. 1992;89(6):1022-1034. 11. Barr S, Hill E, Bayat A. Current implant surface
technology: an examination of their nanostructure and their influence on fibroblast alignment and biocompatibility. Eplasty. 2009;9:e22. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2698670/. Accessed July 30,
2014. 12. Danino AM, Basmacioglu P, Saito S, et al. Comparison of the capsular response to the BIOCELL® RTV and Mentor 1600 Siltex® breast implant surface texturing: a scanning electron microscopic study.
Plast Reconstr Surg. 2001;108(7):2047-2052. 13. Valencia-Lazcano AA, Alonso-Rasgado T, Bayat A. Characterisation of breast implant surfaces and correlation with fibroblast adhesion. J Mech Behav Biomed Mater.
2013;21:133-148. 14. Beasley ME. In discussion of: Maxwell GP, Falcone PA. Eighty-four consecutive breast reconstructions using a textured silicone tissue expander. Plast Reconstr Surg. 1992;89(6):1035-1036.
15. Isik FF. Delayed two-stage tissue expander-implant breast reconstruction. In: Spear SL, ed. Surgery of the Breast: Principles and Art. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2011:420-428.
16. Strock LL. Immediate two-stage breast reconstruction using a tissue expander and implant. In: Spear SL ed. Surgery of the Breast: Principles and Art. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins;
2011:388-405. 17. Adams WP Jr, Rios JL, Smith SJ. Enhancing patient outcomes in aesthetic and reconstructive breast surgery using triple antibiotic breast irrigation: six-year prospective clinical study. Plast
Reconstr Surg. 2006;117(1):30-36. 18. Sampaio Góes JC, Landecker A. Optimizing outcomes in breast augmentation: seven years of experience with the subfascial plane. Aesthetic Plast Surg. 2003;27(4):178-184.
19. Sampaio Góes JC. Breast implant stability in the subfascial plane and the new shaped silicone gel breast implants. Aesthetic Plast Surg. 2010;34(1):23-28.

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Guide to the Natrelle® 410 Two-Stage Breast Reconstruction System

11

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Natrelle® 133 Tissue Expanders IMPORTANT SAFETY INFORMATION (continued)
ADVERSE REACTIONS
Deflation, tissue damage, infection, extrusion, hematoma/seroma, capsular contracture, premature explantation, displacement, effects on bone, pain, sensation,
distortion, inadequate tissue flap, and inflammatory reaction.
To report a problem with Natrelle®, please call Allergan Product Surveillance at 1-800-624-4261.
For more information, please visit www.allergan.com/labeling/usa.htm or
call the Allergan Product Support line at 1-800-433-8871.
Natrelle® 133 Tissue Expanders are available by prescription only.

©2014 Allergan, Inc. ® marks owned by Allergan, Inc.
Siltex is a registered trademark of Mentor Worldwide LLC.
www.natrelle.com APC26VE14 141433

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